Mouth & Oral Care for the Dependent Adult

older adult

Mouth & Oral Care for the Dependent Adult  by Ann Ossinger, RDH, BSDH, EPP 11/22/2013

Good oral care is essential. Not just to reduce dental or oral disease, but to provide comfort, for quality of life, to enable healthy eating, to reduce pain, to reduce infection, to reduce inflammation and, maybe most importantly for the dependent adult, to reduce pneumonia which is one of the leading causes of hospitalization and death among this special population. We also know that poor oral care can exacerbate diabetes, heart disease and other health issues.

OK, so now we know it is important. What does providing good oral care mean? And how do you do it?

Did you know that it takes about 14 separate steps to brush and floss your teeth? Most of us do this almost unconsciously. We hardly think about it since we just follow our habits at bedtime and when we wake up.

For a patient who might forget, or has difficulty with the dexterity required, or who might choke easily, or is completely dependent –we need to provide assistance of some sort. Maybe we just need to remind them to brush. Maybe we need to remind them for each step of the process. Maybe we need to provide all the care needed. Whatever level is required though, we need to let the adult do as much as they can on their own, while still making sure the job has been done thoroughly. That is tough! It isn’t easy to provide care if the care isn’t wanted, or if there is active resistance.

Well I’m here to help! I’m here to provide some answers and provide a list of tips, tricks, and products to try.

First, I’m going to talk about products. There are SO MANY PRODUCTS out there!! Here is a partial list of products that I like and that my patients like. Pick and choose as needed, depending on YOUR PATIENT, I will give recommendations for different scenarios. Every patient is unique, and what works for one person won’t necessarily work for another.
Brushes: A somewhat independent adult may just use the brush they have always used. Fine! If they like a power brush, then that is great! Just make sure the head is replaced at least every 3 months. Do they prefer a manual brush? Make sure it is a brush with a small head, large handle and SOFT bristles. They also need replacing at least every 3 months.
If the patient has dementia, they may not be able to tolerate a power toothbrush. The power brush may make them think there is a bee inside their mouth! You can either use a soft-bristled brush that you and the patient like, or use the 3-D brush: the Benefit 3-D Benedent toothbrush.

Benefit TB Benefit TB-2

These toothbrushes have 3 sides and have a perfect angle to the gumline for the inside, the cheek-side, and the chewing side of the teeth. The bristles are soft and flexible and are comfortable for even fragile tissues. The large handle makes it easy for a caregiver to hold. Due to the unique use of the brush though, I don’t recommend the patient brush their own teeth with this 3-D brush unless you can see they use it correctly. The caregiver gently presses the brush head down onto the teeth so all sides are in contact with the bristles as in the picture.

Interdental cleaning “Flossing”: There are numerous products to clean between the teeth, floss being only one of them. Here are samples of floss alternative products I like.

Pictured: Reach Access Flosser, GUM Soft-Picks, Sulcabrush, GUM rubber tip Stimulator, and Water Pik oral irrigator.


Mouthwash: Use a mild, non-alcoholic, non-burning antiseptic mouthwash. Good examples are Biotene and Closys rinse.

Biotene MW ClosysMW

Toothpaste: This can be either a fluoride toothpaste with a mild flavor (many older adults do not like the strong taste of mint -try a children’s flavor if they like) OR they can use a prescription strength toothpaste you can obtain from your dentist or hygienist. You only need a little bit- a small pea-sized amount.

Other great products: Xylitol and oral moisturizers: Use a spray xylitol (I like RAIN by Spry) and spritz ~3 times several times a day throughout the day to fight cavities and gum disease. Patients often also have dry mouth and you can alternate this with Biotene oral moisturizer spray (liquid or gel) as well. Use these either after snacks or after the patient uses the toilet for you to remember.

Spry RAIN Biotene OM

If the patient can brush their own teeth:
Make sure they have the tools they need to do the job. Do they like a power toothbrush? Make sure the head is replaced at least every 3 months. Do they prefer a manual brush? Make sure it is a brush with a small head, large handle and SOFT bristles and replaced every 3 months.

Is flossing becoming more difficult? There are several “floss alternatives” out there that I like, again, depending on the patient. For someone who is still somewhat independent, they may be able to handle a water irrigator (Water Pik) which is easier than a string of floss, or they may like a flosser with a long handle such as the Reach Access Flosser, -no need to hold the string or put hands in the mouth, and GUM Soft Picks are easier to use (and more gentle) than toothpicks. If dexterity is an issue, the Sulcabrush wins, hands down, and cleans not only between teeth, but around crowns, implants and under bridges.

Sulcabrush Sulcabrush2

As a caregiver, you will need to check how your patient does on their own by occasionally inspecting their mouth and teeth. If you see a decline in their own care, you will need to provide additional care.

One method of care is called guidance: You may need to prompt someone at each step along the way. Are they forgetting to brush? Get their supplies out for them and remind them. Are they forgetting to use the toothpaste? Are they only brushing their front teeth? Or maybe only brushing one side? You can help by prompting and reminding them.
Hand over hand guidance: If they still are missing areas, even with prompts, you can gently place your hand on top of their hand and help guide their hand to the area missed.
If they are able to brush, but not clean between their teeth, you can use the Sulcabrush too to get some of the nooks and crannies that were missed. It is easy for both patient AND caregiver to handle and deliver oral interdental care. (And no hands between teeth!) See below for great pictures of how to use the brush:

For the Co-operative and Dependent Adult:
For an adult who is cooperative, but who is unable to brush, just follow these steps:
Assuming your patient is not in the bathroom next to the sink:
1. Have the patient sit up, either in bed, in a chair, or in a wheelchair.
2. Get out all your supplies you will need (brush, paste, cup of water, interdental cleaning device/floss, cup with mouth wash, clean disposable gloves, small towel and a kidney basin). Optional: small flashlight.
3. Put on your clean disposable gloves.
4. Sit or kneel in front of your patient at eye level. Do not hover over them.
5. Ask the patient to rinse their mouth with water, if they are able to swish and rinse. If not, they may be able to rinse and swallow. Do not use this step if they might choke!
6. Check the inside of the cheeks for food debris. Use a gloved finger wrapped in gauze to remove, or a tooth swab.
7. Now INSPECT the mouth: Look at the lips, cheeks, the tongue, the palate, and the teeth.
8. If there are any broken teeth, areas of decay or abscesses or if you notice any cracking, lumps, white or red lesions, or sores that do not heal within 2 weeks, you should consult a dentist or doctor.
9. Dip the toothbrush in a mouthwash, shake, and use the brush to clean the mouth of major food particles first.
10. Once the mouth is clear of major particles, place a small, pea-sized amount of toothpaste on the brush and brush gently. Gums are more fragile in older people so go slow and steady! Brush each tooth with a small circular motion and gentle pressure. If using a traditional brush, angle the brush towards the gums as you brush the outside, inside, and chewing surface of each tooth. Optimal is to brush for two minutes, twice a day.
11. Rinse with water or have patient sip water if possible.
12. Gently brush the tongue, start at the middle back and stroke forward.
13. Cleaning between the teeth: Use the Sulcabrush (pictures above) to brush between the teeth, or use Soft Piks or other flosser to clean between the teeth.
14. If patient is able, have them rinse with a mild mouthwash such as Biotene or Closys. If they are likely to swallow or choke, omit this step.

Denture care:
Dentures must be removed daily and soak for at least 4 hours a day. The tissues of the mouth need to breath and recover from the dentures at least 4 hours a day. Best time to do this is at night. Dentures are VERY fragile and can break if you drop them in the sink, so line the sink with 2 layers of paper towels. Do not use regular toothpaste as it is too abrasive. Brush the dentures and soak in either plain water (changed daily!) or in a denture soak such as Polident.

INSPECT the mouth: Look at the lips, cheeks, the tongue, the palate, and the teeth. If there are any broken teeth, areas of decay or abscesses or if you notice any cracking, lumps, white or red lesions, or sores that do not heal within 2 weeks, you should consult a dentist or doctor.

Brush the gums with a gentle, soft bristle toothbrush.

After meals or snacks:
If safe, ask the patient to rinse, spit or swallow a cup of plain water (they can spit back into the cup). Frequent sips of water throughout the day will help cleanse the mouth.

Xylitol and oral moisturizers: Use a spray xylitol (I like RAIN by Spry) and spritz ~3 times several times a day throughout the day to fight cavities and gum disease. Patients often also have dry mouth and you can alternate this with Biotene oral moisturizer spray as well. Use these either after snacks or after the patient uses the toilet for you to remember.

For the RESISTANT and Dependent Adult:
This is the tougher task, no doubt about it. Here is a list of tips and tricks to make this easier.
1. Try to know the reason behind the resistance. Remember that for a dementia patient the only way they can communicate is through behavior. Are they in pain? Is it a bad time for them? Are they tired? Are they afraid?
2. If they are in pain, EVERYTHING will be more difficult! Make sure they are not in pain, make sure they don’t have broken teeth, abscessed teeth, infection or other problem.
3. Always approach from the front. Dementia patients have difficulty seeing to the side of them. They have “tunnel vision” and you can startle them from the side.
4. Smile! Introduce yourself! Put your hand out and hold their hand. This reassures them and helps gain trust.
5. Complement them. Tell them they have beautiful teeth and you are there to keep them beautiful.
6. Tell them you will make their mouth more comfortable. You are there to get that food out from between their teeth.
7. Focus on the person, not the task.
8. Explain each step.
9. Be patient and repeat.
10. Give positive feedback and encouragement. ALWAYS say “Thank you” when they open their mouth.
11. Try singing, music that they like and is calming, say silly things, tell a joke, try gentle laughing. Remember when they sing, they open their mouth. When they laugh, they open their mouth! Tell them “thank you” every time they make your job easier!
12. Give them a stuffed animal to hold (or a doll, blanket, pillow, etc.) to comfort them.
13. Phase in oral care. Start with just clearing the mouth of debris and work your way up.
14. Tap the lower lip with the brush to prompt opening the mouth.
15. Massage the jaw and jaw joint.
16. If they grab at your arm or brush, hand them the brush and invite them to brush.
17. Come back at another time. Pick another time of day. Maybe morning, maybe evening.
18. Slide your finger inside the cheek (but NOT between the teeth!).
19. If they bite the brush, just be patient and gently wiggle the brush.
20. Have another caregiver hold their hands to reassure them.
21. Change the flavor of the products. Many older folks don’t like the strong flavor of mint.
22. Try a different toothbrush. Soft and small!
23. Never use a mouth prop to force the mouth open. It just doesn’t work. Props are only for people who want to “rest their teeth and jaw”. Otherwise it feels like handcuffs.
24. Establish a routine. The more this is done, the more familiar it is.

Professional Dental Care:
Have a mobile hygienist come visit at least twice a year. The hygienist may recommend three or four cleanings a year, depending on the patient.

At least ONCE a year (and more often if there are problems) the patient should see a dentist. Ask the hygienist for a referral. Even those that only wear dentures need an annual exam.

older adult with CG

Ann Ossinger is a Registered Dental Hygienist who owns DoorStep DentalHygiene, LLC, a mobile dental hygiene service that provides dental hygiene services to people who would otherwise be unable to go to a regular dental clinic in the Linn-Benton Counties of Oregon. 541-990-0814. Please contact Ann if you have any questions!


I’m starting a new hashtag, even if it isn’t a new concept. Put the mouth back in the body.  Dentists and oral health is considered to be on “one side” of a cultural divide, while medicine and wellness is on yet “another”.  This is crazy, as our teeth and mouth is actually attached to our body. Our mouth is the beginning of our digestive system. Healthy food  (like fruits, vegetables, and nuts) are much easier to eat when we have a full complement of teeth. Our mouth is where we express ourselves through speech and facial expressions. Our facial structure depends upon our teeth and the bone they are set in. As stated by at least a couple of surgeon generals, we can’t be considered “healthy” unless we have good oral health too.

We know there are connections between oral health and overall health; with positive associations to heart disease, diabetes, pneumonia & lung disease, arthritis, obesity, complications of pregnancy, dementia & Alzheimer’s, and yes, even erectile dysfunction.  A few people in the U.S. die every year due to untreated cavities as infection spreads to their brain. (Are you flossing yet??) A lot of it has to do with inflammation (periodontal disease is primarily a disease of inflammation) but there are also bacterial implications as well and links that we have yet to uncover. No, the reason for our smile is not just for cosmetic reasons.

My dad was a medical doctor, my mom a nurse, a sister a nurse, a brother a pharmacological researcher. Medicine is in my DNA.  I decided to become a dental hygienist as a way to bridge the gap between these two cultures that SHOULD be on the same side, but sadly are not.

At least not yet.  I’m working on it!

Ann Ossinger is a Registered Dental Hygienist who owns DoorStep DentalHygiene, LLC, a mobile dental hygiene service that provides dental hygiene services to people who would otherwise be unable to go to a regular dental clinic in the Linn-Benton Counties of Oregon. 541-990-0814. Please contact Ann if you have any questions!

MTI Dental Van Volunteer

Images are from Medical Teams International, please visit their website at

April and June 2013


I enjoy volunteering with Medical Teams International a few times a year, which is about as often as I can. I think I “get” as much as I “give”. So many of the patients are in so much chronic pain!

During a normal volunteer stint I will review the medical history with the patient, find out “where it hurts”,  take the radiographs (x-rays), start cleaning the teeth like mad, and sometime prep the patient for the doctor by giving the patient their local anesthesia injections.

Most of the time we treat adults who don’t have the money or the dental insurance for dental treatment in a dental office.  Our priority is to get the adults “out of pain” and treat any infection. Generally, children are taken care of through Oregon Health Plan, but some kids do fall through the cracks given their specific circumstances.

I had the pleasure of taking care of one 14 year old. When I placed the lead apron on him prior to the radiographs he asked “why are you putting this on me?” I answered, “to protect you”, he freaked out and asked “to protect me from WHAT?!?”  It then dawned on me that he had never been in a dental office EVER. He had no idea what we do, how we do it and what it entailed. I stopped what I was doing to explain EVERYTHING that was around him – from the air/water syringe, the suction, the chair positioning, the light, the x-rays, the mirror, etc… and I saw that he started to calm down. The X-rays were easy now. Then the doctor asked me to anesthetize him for an extraction.  While I’m confident in my ability to provide a comfortable injection to my patients, in the back of my mind I thought “great! I get to be the bad guy!” and I was a little nervous that I would be this patient’s first experience. So many patients are traumatized by dental experiences and we work so hard for them to be as comfortable as possible!  I explained to my patient exactly what I was going to do, what he would feel and how it would happen.  I could tell he was nervous, and I explained that while he would feel a slight pinch, to trust me, he would much rather have a local anesthetic injection than NOT, for his extraction.  I followed all the protocol that had been drilled into us in hygiene school, to go SLOWLY, take our time and give an “atraumatic injection”. I told my patient to close his eyes, he followed all my instructions and after it was all over he was “wow, that wasn’t bad at all!”, then he was amazed at how fat his lip started to feel! I had to give him a mirror to convince him that his lip wasn’t changing shape.

After the doctor performed the extraction, I asked him how his total experience was. He shrugged his shoulders and said “not too bad” through the gauze packed between his teeth! That made my day! While I would always want patients to have a GREAT experience, if a 14 year old kid’s very first dental experience is an extraction and if it “wasn’t too bad”, then I guess we have to celebrate that as a success!

One day we won’t need Dental Vans to help get people out of pain, because in my ever optimistic view, we will find a way to avoid all oral diseases and find a way to keep people healthy- mouth included!


Ann Ossinger is a Registered Dental Hygienist who owns DoorStep DentalHygiene, LLC, a mobile dental hygiene service that provides dental hygiene services to people who would otherwise be unable to go to a regular dental clinic in the Linn-Benton Counties of Oregon. 541-990-0814. Please contact Ann if you have any questions!


EPDH Conference

EPDH conference (Expanded Practice Dental Hygiene)

Every year ODHA (Oregon Dental Hygiene Association) sponsors a conference tailored to the EPDH hygienists (Expanded Practice Dental Hygiene). This year, just like last year, I had a hard time deciding which classes to take –they all sounded great and it was a hard choice! It was held in Springfield, Oregon May 3 & 4, 2013.

The first class I took was “Management of Early Childhood Caries” taught by Karen Hall, RDH, BSDH.  She has spearheaded the “First Tooth” project here in Oregon.  Children need to be seen by a dental professional when they start to get their primary (baby) teeth.  Primary teeth are important! They help guide the permanent teeth -so you want to keep the primary teeth until they naturally wiggle and fall out. Children will have difficult time learning in school if they are in dental pain. If they become decayed years earlier the permanent teeth are more likely to come in crooked and needing orthodontia work to maintain dental health as an adult.  The ADA recommends children have their first visit by 12 months old. It is all about prevention! How to halt the disease process we call caries (and you probably know of as “Cavities”).   Contact me if you have any questions about how to prevent your children from developing decay.

The second class I took was “Use of Silver Nitrate for Non-Surgical Management of Dental Caries” taught by Dr. Gary Allen, DMD, MS. This is an exciting time to be in the dental field! We can now start to treat Caries as a disease, much like we treat any disease in the medical model. Caries is an INFECTION that is TRANSMISSIBLE. Silver nitrate is a promising new treatment protocol that can halt the disease. Drilling and filling only treat the symptoms of dental caries and they do NOT treat the underlying infection.

The third class was “Farming or Hunting? Marketing in a Social Media Age” by Rosalea Peters, BS Ed. Even though I didn’t learn a lot of new information in this class, I did learn that I am doing everything right! About the only thing I’m not using to reach my audience is Twitter.  This is all an evolution of tools we have to help teach people about what we do and how we can help our patients.

The last class was invaluable! “Managing Medical Emergencies for Dental Patients in Alternative Practice Settings” by Gail Aamodt, RDH, MS and Bill Laird, EMT-P. What a great team!  Although I’ve taken several classes on medical emergencies, they have all assumed to be taken place in a regular dental clinic. In this class we assumed we were “out in the field”, away from a dentist and our traditional medical emergency kit. Lots of great ideas and creative solutions were discussed.  My patients are safer!

Thank you ODHA for sponsoring this great opportunity to network, trade ideas, and get valuable information on being better providers!

Ann Ossinger is a Registered Dental Hygienist who owns DoorStep DentalHygiene, LLC, a mobile dental hygiene service that provides dental hygiene services to people who would otherwise be unable to go to a regular dental clinic in the Linn-Benton Counties of Oregon. 541-990-0814. Please contact Ann if you have any questions!

A New E.N.D.S. Provider!


A few months ago I began the process of becoming an ENDS provider and a few weeks ago I was finally officially credentialed as a provider. It was a long process, but I think it will be worth it for many reasons; the most important is that it will extend the reach of the number of people ENDS will be able to help in the Mid-Willamette Valley.

What is “ENDS”? The acronym stands for Exceptional Needs Dental Service. It started in 1995 when several dental care organizations (Capitol Dental Care, Willamette Dental, Multnomah County and Managed Dental Care of Oregon) partnered to provide mobile and hospital based dental services to patients in group homes, foster care, and long term care facilities.  Patients must be non-ambulatory or have a severe developmental disability or a mental impairment to qualify for the ENDS program (i.e. have special needs).  Patients must be unable to access dental care in the traditional clinical setting.  Most patients are on the Oregon Health Plan (OHP/Medicaid) for basic dental services.  Patients are generally referred to ENDS from one of the above partner dental care organizations. If you aren’t an OHP recipient but would like to receive services via ENDS, contact ENDS directly for more information.  Call 800-644-1859, email or visit their website at

I shadowed Dr. James Hayden and his assistant Lori for one day and it was a real learning experience to see how they provided dental care apart from the dental hygiene care I am used to providing in an “alternative” setting. I am happy to be a part of a team for total dental care for people who have a difficult, if not impossible time, getting to a dental clinic.

Ann Ossinger is a Registered Dental Hygienist who owns DoorStep DentalHygiene, LLC, a mobile dental hygiene service that provides dental hygiene services to people who would otherwise be unable to go to a regular dental clinic in the Linn-Benton Counties of Oregon. 541-990-0814. Please contact Ann if you have any questions!

Reflections: The Power of Touch & Validation

Reflections on the oral cancer screening event at the Live Well Age Well Expo:
People need to be touched. I had one woman (older, widow) break down in tears while I was examining (and palpating her head and neck) because it had been so long since someone had just touched her. Why are we so afraid to reach out to each other? After the five minute exam she held out her arms and asked for a hug. I’m so glad she did and I hope she will get more hugs soon.

Two other women (separately) stopped by my booth for exams. One had been experiencing difficulty in swallowing for the last few months. She had not seen a doctor for this. As I was examining her head and neck, I felt a mass/thickening over a large area in her neck. I told her she needed to see a doctor immediately and wrote her a referral letter. I had the sense she needed validation from me for what she was noticing herself to see a doctor. I wish she had seen a doctor as soon as she noticed the difficulty in swallowing. The second woman had a swelling between her orbit and her nose. Again, she had noticed this for the last few months but had not yet seen a doctor.

When we notice something out the ordinary or out of what is ordinary for us, we need to have it checked out by our doctors.  Please don’t wait!  Please don’t feel you need validation by someone else to go to your doctor! I hope all  goes well for both these women and that they will have both these conditions resolved soon. I’m only glad if I can help people access their doctors and can give referrals.

Ann Ossinger is a Registered Dental Hygienist who owns DoorStep DentalHygiene, LLC, a mobile dental hygiene service that provides dental hygiene services to people who would otherwise be unable to go to a regular dental clinic in the Linn-Benton Counties of Oregon. 541-990-0814. Please contact Ann if you have any questions!


Live Well Age Well Expo Oral Cancer Screening


The Cascades West Senior Services Foundation did an excellent job of pulling together, yet again, a wonderful health, information and services fair! Thank you to Jill Ingalls, the coordinator for her work.

I provided free oral cancer screenings (head, neck and intraoral) for over 20 people today! Based on need, I also gave several people referrals to dentists and oral surgeons. Additionally, I answered LOTS of questions on an incredibly wide variety of dental subjects. Overall it was a great day, connected with a lot of people in the community as well as other health professionals.

Oral Cancer Screening in Albany, Oregon

Oral Cancer Screening in Albany, Oregon

Here are some facts regarding oral cancer from the Oral Cancer Foundation:

Rates of occurrence in the United States

Close to 42,000 Americans will be diagnosed with oral or pharyngeal cancer this year. It will cause over 8,000 deaths, killing roughly 1 person per hour, 24 hours per day. Of those 42,000 newly diagnosed individuals, only slightly more than half will be alive in 5 years. (Approximately 57%) This is a number which has not significantly improved in decades. The death rate for oral cancer is higher than that of cancers which we hear about routinely such as cervical cancer, Hodgkin’s lymphoma, laryngeal cancer, cancer of the testes, and endocrine system cancers such as thyroid, or skin cancer (malignant melanoma). If you expand the definition of oral cancers to include cancer of the larynx, for which the risk factors are the same, the numbers of diagnosed cases grow to approximately 54,000 individuals, and 13,500 deaths per year in the U.S. alone. Worldwide the problem is much greater, with over 640,000 new cases being found each year.  Oral cancers are part of a group of cancers commonly referred to as head and neck cancers, and of all head and neck cancers they comprise about 85% of that category. Brain cancer is a cancer category unto itself, and is not included in the head and neck cancer group.

Historically the death rate associated with this cancer is particularly high not because it is hard to discover or diagnose, but due to the cancer being routinely discovered late in its development. Today, (2013) that statement is still true, as there is not a comprehensive program in the US to opportunistically screen for the disease, and without that; late stage discovery is more common. Another obstacle to early discovery (and resulting better outcomes) is the advent of a virus, HPV16, contributing more to the incidence rate of oral cancers, particularly in the posterior part of the mouth (the oropharynx, the tonsils, the base of tongue areas) which many times does not produce visible lesions or discolorations that have historically been the early warning signs of the disease process.

Often oral cancer is only discovered when the cancer has metastasized to another location, most likely the lymph nodes of the neck. Prognosis at this stage of discovery is significantly worse than when it is caught in a localized intraoral area. Besides the metastasis, at these later stages, the primary tumor has had time to invade deep into local structures. Oral cancer is particularly dangerous because in its early stages it may not be noticed by the patient, as it can frequently prosper without producing pain or symptoms they might readily recognize, and because it has a high risk of producing second, primary tumors. This means that patients who survive a first encounter with the disease, have up to a 20 times higher risk of developing a second cancer. This heightened risk factor can last for 5 to 10 years after the first occurrence. There are several types of oral cancers, but around 90% are squamous cell carcinomas. It is estimated that approximately $3.2 billion is spent in the United States each year on treatment of head and neck cancers. (2010 numbers)

The demographics of those who develop this cancer have been consistent for some time. While historically the majority of people are over the age of 40 at the time of discovery, it is now occurring more frequently in those under this age. Exact causes for those affected at a younger age are now becoming clearer in peer reviewed research, revealing a viral etiology (cause), the human papilloma virus number 16. There are also links to young men and women who use conventional “smokeless” chewing or spit tobacco. Promoted by some as a safer alternative to smoking, it has in actuality not proven to be any safer to those who use it when referring to oral cancers. Campaigns to promote the safety of smokeless are being initiated, but it is clear that while it may reduce lung cancers, it has a negative effect on the rates of oral cancers, pancreatic cancer, periodontal disease, and the chronic infections that it produces may even link it to heart disease as well. The gains against lung cancers may occur, but there will be new losses in other areas. The jury is out on other new smokeless tobacco dissolvable products, and until their use has acceptable research behind it we recommend avoiding it.

It is also now confirmed that  in a younger age group, including those who have never used any tobacco products, have a cause which is HPV16 viral based. The human papilloma virus, particularly version 16, has now been shown to be sexually transmitted between partners, and is conclusively implicated in the increasing incidence of young non-smoking oral cancer patients. This is the same virus that is the causative agent, along with other versions of the virus, in more than 90% of all cervical cancers. It is the foundation’s belief, based on recent revelations in peer reviewed published data in the last few years, that in people under the age of 50, HPV16 may even be replacing tobacco as the primary causative agent in the initiation of the disease process.

From a gender perspective, for decades this has been a cancer which affected 6 men for every woman. That ratio has now become 2 men to each woman. Again, while published studies do not exist to draw finite conclusions, we will probably find that this increase is due to lifestyle changes, primarily the increased number of women smokers over the last few decades. It is a cancer which occurs twice as often in the black population as in whites, and survival statistics for blacks over five years are also poorer at 33%, versus 55% for whites. As in the above examples, it is unlikely we will find a genetic reason for this. Lifestyle choices still remain the biggest cause. These published statistics do not consider such socio-economic factors as income levels, education, availability of proper health care, and the increased use of both tobacco and alcohol by different ethnic populations, but all these factors likely play a role in who develops the disease.

Risk Factors

Understanding the causative factors of cancer will contribute to prevention of the disease. Age is frequently named as a risk factor for oral cancer, as historically it occurs in those over the age of 40. The age of diagnosed patients may indicate a time component in the biochemical or biophysical processes of aging cells that allows malignant transformation, or  perhaps, immune system competence diminishes with age. Very recent data (late 2008-2011) lead us to believe that the fastest growing segment of the oral cancer population are non-smokers under the age of fifty, which would indicate a paradigm shift in the cause of the disease, and in the locations where it most frequently occurs in the oral environment. The anterior of the mouth, tobacco and alcohol associated cancers have declined along with a corresponding decline in smoking, and posterior of the oral cavity sites associated with the HPV16 viral cause are increasing.

However, it is likely that the accumulative damage from other factors, such as tobacco use, alcohol consumption, and persistent viral infections such as HPV, are the real culprits. It may take several decades of smoking for instance, to precipitate the development of a cancer. Having said that, tobacco use in all its forms is number one on the list of risk factors in individuals over 50. Historically at least 75% of those diagnosed at 50 and older have been tobacco users. This percentage is now changing, and exact percentages are yet to be definitively determined and published, as new data related to viral causes are changing the demographics very rapidly. When you combine tobacco with heavy use of alcohol, your risk is significantly increased, as the two act synergistically. Those who both smoke and drink, have a 15 times greater risk of developing oral cancer than others. It does not appear that the HPV16 viral cause acts synergistically with tobacco or alcohol, and HPV16 represents a completely unique and independent disease process.

Tobacco and alcohol are essentially chemical factors, but they can also be considered lifestyle factors, since we have some control over them. Besides these, there are physical factors such as exposure to ultraviolet radiation. This is a causative agent in cancers of the lip, as well as other skin cancers. Cancer of the lip is one oral cancer whose numbers have declined in the last few decades. This is likely due to the increased awareness of the damaging effects of prolonged exposure to sunlight, and the use of sunscreens for protection. Another physical factor is exposure to x-rays. Radiographs regularly taken during examinations, and at the dental office, are safe, but remember that radiation exposure is accumulative over a lifetime. It has been implicated in several head and neck cancers.

Biological factors include viruses and fungi, which have been found in association with oral cancers. The human papilloma virus, particularly HPV16, has been definitively implicated in oral cancers, particularly those that occur in the back of the mouth. (Oropharynx, base of tongue, tonsillar pillars and crypt, as well as the tonsils themselves.) HPV is a common, sexually transmitted virus, which infects about 40 million Americans today. There are over 130 strains of HPV, the majority of which are thought to be harmless. Most Americans will have some version of HPV in their lifetimes, and even be exposed to the oncogenic / cancer causing versions of it. But  only approximately 1% of those infected, have a lack of immune response to the HPV16 strain which is a primary causative agent in cervical cancer (with HPV18), cancers of the anus and penis, and now is a known cause of oral cancer as well. So we wish to be clear. Infection with even a high risk HPV virus does not mean that you will develope oral cancer. Most people’s immune systems will clear the infection before a malignancy has the opportunity to occur. It is likely that the changes in sexual behaviors of young adults over the last few decades, and which are continuing today, are increasing the spread of HPV, and the oncogenic versions of it. There are other minor risk factors which have been associated with oral cancers, but have not yet been definitively shown to participate in their development. These include lichen planus, an inflammatory disease of the oral soft tissues, and genetic predispositions.

There are studies which indicate a diet low in fruits and vegetables could be a risk factor, and that conversely, one high in these foods may have a protective value against many types of cancer.  Clearly cancer is a very complex group of diseases, and diet alone should not be considered a stand alone causative factor for initiation of the cascade of cellular events that changes a cell from normal to malignant.

Possible signs and symptoms

One of the real dangers of this cancer, is that in its early stages, it can go unnoticed. It can be painless, and little in the way of physical changes may be obvious. The good news is however, that your dentist or doctor can, in many cases, see or feel the precursor tissue changes, or the actual cancer while it is still very small, or in its earliest stages.   It may appear as a white or red patch of tissue in the mouth, or a small indurated ulcer which looks like a common canker sore. Because there are so many benign tissue changes that occur normally in your mouth, and some things as simple as a bite on the inside of your cheek may mimic the look of a dangerous tissue change, it is important to have any sore or discolored area of your mouth, which does not heal within 14 days, looked at by a professional. Other symptoms include; a lump or mass which can be felt inside the mouth or neck, pain or difficulty in swallowing, speaking, or chewing, any wart like masses, hoarseness which lasts for a long time, or any numbness in the oral/facial region. Unilateral persistent ear ache can also be a warning sign.

Other than the lips which are not a major site for occurrence any longer, common areas for oral cancer to develop in the anterior (front) of the mouth are on the tongue and the floor of the mouth. Individuals that use chewing tobacco, are likely to have them develop in the sulcus between the lip or cheek and the soft tissue (gingiva) covering the lower jaw (mandible) where the plug of tobacco is held repeatedly. There are also a small number of cancers that are unique to the salivary glands, as well as the very dangerous melanoma. While the occurrence of these are dwarfed by the other oral cancers, they are a small percentage of the total incidence rate. In the US, cancers of the hard palate are uncommon, though not unknown. The base of the tongue at the back of the mouth, the oropharynx (the back of the throat) and on the pillars of the tonsils, and the tonsillar crypt and the tonsil itself, are other sites where it is now more commonly found, particularly in young non smoking individuals. If your dentist or doctor decides that an area is suspicious, the only way to know for sure if it is something dangerous, is to do a biopsy of the area. This is not painful, is inexpensive, and takes little time. It is important to have a firm diagnosis as early as possible. It is possible that your general dentist or medical doctor, may refer you to a specialist to have the biopsy performed. This is not cause for alarm, but a normal part of referring that happens between doctors of different specialties.

How oral cancer develops

We know that all cancers (neoplastic transformations) result from changes (mutations) in genes which control cell behaviors. Mutated genes may result in a cell which grows and proliferates at an uncontrolled rate, is unable to repair DNA damage within itself, or refuses to self destruct or die (apoptosis). It takes more than one mutation to turn a cell cancerous. Specific classes of genes must be mutated several times to result in a neoplastic cell, which then grows in an uncontrolled manner. When a cell does become mutated to this point, it is capable of passing on the mutations to all of its progeny when it divides. Genetic mistakes randomly happen each day in the course of our bodies replacing billions of cells. Besides these random occurrences, genetic errors can be inherited, be caused by viruses, or develop as a result of exposure to chemicals or radiation. Our bodies normally have mechanisms that destroy these abnormal cells. We are now discovering some of the reasons this fails to take place, and cancers occur.


After a definitive diagnosis has been made and the cancer has been staged, treatment may begin. Treatment of oral cancers is ideally a multidisciplinary approach involving the efforts of surgeons, radiation oncologists, chemotherapy oncologists, dental practitioners, nutritionists, and rehabilitation and restorative specialists. The actual curative treatment modalities are usually chemotherapy with concurrent radiation, sometimes combined with surgery. Chemotherapy while able to kill cancer cells itself is currently not used as a monotherapy for oral cancers. Added to decrease the possibility of metastasis, to sensitize the malignant cells to radiation, to reduce the size of any malignancy prior to surgery, or for those patients who have confirmed distant metastasis of the disease, it is a powerful component of treatment.

Prior to the commencement of curative treatment, it is likely that other oral health needs will be addressed. The purpose is to decrease the likelihood of developing post therapeutic complications. Teeth with poor prognosis from periodontal problems, caries, etc. may be extracted. This avoidance of post radiotherapy surgery is important as it can sometimes induce osteonecrosis, a condition which can develop when tissue damaged by radiation exposes the underlying bone and remains chronically non healing. The bone, which has lost its ability to efficiently repair itself due to reduced blood supply, from radiation exposure, yields a chronic and difficult to treat situation. A thorough prophylaxis, or cleaning will likely be done as well prior to beginning treatments.

Whether a patient has surgery, radiation and surgery, or radiation, surgery, and chemotherapy, is dependent on the stage of development of the cancer. Each case is individual. Patients with cancers treated in their early stages, may have little in the way of post treatment disfigurement. For those whose cancer is caught at a later stage, the results of surgical removal of the disease may require reconstruction of portions of their oral cavity or facial features. There may be adjunctive therapy required to assist in speech, chewing and swallowing of foods, the problems associated with the lack of salivary function, as well as the fabrication of dental or facial prostheses.

Ann Ossinger is a Registered Dental Hygienist who owns DoorStep DentalHygiene, LLC, a mobile dental hygiene service that provides dental hygiene services to people who would otherwise be unable to go to a regular dental clinic in the Linn-Benton Counties of Oregon. 541-990-0814. Please contact Ann if you have any questions!



Autism Resource Fair in Corvallis Oregon

Just participated at the Autism Resource Fair at the Linus Pauling Middle School here in Corvallis. Met a lot of people who have Asperger and or Autism, or work with, are parents of, or otherwise support people with Asperger or Autism Spectrum disorders. They were very welcoming given I sort of “crashed” their party! My hope is, of course, to help people prevent the variety of oral diseases that can affect this particularly vulnerable population. I enjoyed giving “tips and tricks” with specially designed 3 sided toothbrushes and explaining how I can visit patients in their own home for maximum comfort, reduced anxiety and ultimately for better oral health.

Ann Ossinger is a Registered Dental Hygienist who owns DoorStep DentalHygiene, LLC, a mobile dental hygiene service that provides dental hygiene services to people who would otherwise be unable to go to a regular dental clinic in the Linn-Benton Counties of Oregon. 541-990-0814. Please contact Ann if you have any questions!