Your Dentist, The Explorer

FOUR YEARS AGO, Rosemary Hansen had a toothache that may have saved her life. There were no visible signs of infection or decay in her mouth, but the 30-year-old woman complained of stabbing pains around her upper-right wisdom tooth. X-rays revealed that the jawbone around the root of the tooth was completely destroyed.

Usually, this kind of bone loss around a tooth would be an indication of gum, or periodontal, disease. But this case was different—the bone destruction was too localized, affecting only one tooth. The dentist suspected that the problem did not originate in the patient's mouth: The bone damage was the sign of another, perhaps more serious, problem.

A sample of the diseased tissue was sent to the oral pathology laboratory; twenty-four hours later, an answer came back: Malignancy. The cancer in Mrs. Hansen's jaw had spread from another part of her body, and the source had to be found.

A subsequent medical examination revealed that Mrs. Hansen had a previously undetected malignant tumor in one of her breasts. Both malignancies were removed: the breast cancer by a surgeon, the secondary jaw cancer by a dentist. Since that time, Mrs. Hansen has regained her health and, last year, gave birth to her third child.

Mrs. Hansen's experience is unusual but not unique. Most dentists don't find cancer when they are examining a patient's mouth—but that doesn't mean they aren't looking. Today, dentists examine the mouth not only for signs of decayed teeth and diseased gums but also for symptoms of blood disorders, rheumatic fever, vitamin deficiencies, diabetes, kidney and digestive disorders, cancer, and even venereal disease.

"Mouths do not walk around by themselves but are connected to bodies," says Robert A. Goepp, D.D.S., associate professor of oral pathology at the University of Chicago and radiologist at the university's Walter G. Zoller Memorial Dental Clinic. "Bodies will have problems that happen in the mouth, and the mouth will manifest problems that are occurring in the rest of the body."

The mouth is like a laboratory of the body where a dentist can detect any number of health problems. For example:

• Softening of the jawbone may be an indication of an overactive parathyroid functioning. (The parathyroid glands, located in the thyroid, produce hormones which control the amounts of calcium and phosphorus in the bones and blood.) A patient with a thyroid condition also may be excessively nervous or have bulging eyes. "As part of his training, the dentist should be taught not just to look at the mouth, but at the whole patient," says Lawrence Cohen, M.D., D.D.S. "Even if he cannot examine the heart and chest, he certainly should look at the entire face."

• A 7-year-old girl who had been diagnosed as an epileptic because of apparent seizures was sent to a university dental clinic with abnormalities in the surfaces of her teeth. An examination there revealed that the tooth problem was caused by an underactive para thyroid condition which, in turn, also had produced the child's apparent seizures.

Dry mouth and the sudden development of periodontal disease without prior warning signs may mean that the patient is suffering from diabetes, explains Dr. Cohen, head of the department of oral diagnosis at the University of Illinois College of Dentistry. If diabetes is suspected, the dentist can take a blood sampling from the patient's finger for a simple diabetes test.

• A dry mouth, burning tongue, and mouth sores could be a sign of a vitamin deficiency. Bleeding gums, primarily a warning signal for developing gum disease, also could be a sign of scurvy, a disease caused by lack of ascorbic acid, vitamin C. In most instances, a proper diet, and perhaps a vita min prescription, will correct the problem.

• Swollen, pale, and bleeding gums can be a symptom of leukemia. If there are no oral causes for the symptoms, the dentist should then refer the patient to a hematologist for a diagnosis.

"The dentist has a unique opportunity to spot many types of blood disorders, such as leukemia or an anemia," says Dr. Goepp. "If a patient has an acute case of anemia, it's probably been diagnosed already. But in borderline cases, a dentist taking an X-ray examination can note the bone changes in the skull and/or jaw that indicate anemia. He may wish additional information from blood tests. If these show a low hemoglobin count, the dentist should send the patient to a physician."

• If the jawbone doesn't heal properly after a tooth is pulled, the patient could have a digestive or kidney disorder—and the dentist could be the first to know.

"Since tooth extraction is probably the most common form of bone injury," explains Dr. Coepp, "the occurrence of 'socket sclerosis' (hardening of the socket) provides the dentist with the evidence needed to detect such systemic diseases early."

• A change in the ligament that attaches the root of the tooth to the jawbone can point to scleroderma of the internal organs. (Scleroderma refers to a skin dis ease in which subcutaneous tissues harden and thicken, and can affect connective tissue elsewhere in the body.) One patient who had been bothered with stomach pains for some time found the cause of his discomfort following a visit to his dentist. Mouth X-rays revealed changes in the jawbone and the dentist, suspecting scleroderma, sent the man to a physician.

• An ulcerated lip or an enlarged lymph node in the neck (usually common and nonalarming) may be signs of syphilis. There also are oral forms of gonorrhea (evidenced by mouth ulcers or an inflamed pharynx) that may first be noticed by a dentist.

• A toothache could be mistaken for sinusitis, inflammation of the sinus cavity. "The upper molar teeth and the sinuses located on either side of the nose are intimately related to the roots of the upper teeth," explains Dr. Coepp. "It's not unusual for a patient to come to the dentist complaining of a toothache when he really has a sinus problem—or to see a doctor for what he thinks is a sinus problem when he has a toothache."

• A sore throat or strep infection can result in rheumatic fever in young children. To prevent serious complications, the dentist should refer the child to a physician for treatment.

• Mouth ulcers or sore gums, in rare cases, can be signs of tuberculosis. The disease may be concentrated in the lungs, with symptoms manifested in the mouth, or it may be localized in the mouth.

Susan's parents became concerned when their daughter, a fifth-grader in a Chicago grammar school, started losing weight, perspiring abnormally even on cool days, and complaining constantly of being tired. It was part of growing up, they thought. Then one day, Susan noticed a few sores in her mouth, and she was sent to the family dentist.

After questioning the girl about her general health, the dentist referred her to a physician for chest X-rays. The doctor discovered that Susan had tuberculosis in one lung. After the TB was treated, the mouth ulcers disappeared.

But the main emphasis in oral diagnosis, beyond the treatment of ordinary dental problems such as cavities and gum disease, is on detecting cancer.

"It is very desirable to find cancer early or when it is small. This is a primary concern of the dentist," says Dr. Goepp. "The dentist has a thorough knowledge about the mouth and is the person most often examining mouths. Thus, he is quite likely to find small, early cancers."

Cancer found in the mouth may be either primary or secondary (metastatic) cancer. Primary oral cancer begins in the mouth. The main sign is a lesion or sore. Secondary cancer is a manifestation of a cancerous growth in another part of the body; it is cancer that has spread, or metastasized, from the point of origin to another organ. The usual symptoms of metastatic oral cancer are loose teeth, a swollen jawbone or palate, tingling or numb lips, and unusual bumps anywhere in the mouth.

Every year, an estimated 15,000 people in the United States develop primary oral cancer. Every year, 7,000 die because of it. One patient came to the University of Illinois College of Dentistry complaining that his dentures didn't fit properly. The roof of his mouth had swollen. The cause: A cancerous tumor in the sinus cavity had worked its way through the palate. In another case, a 48-year-old woman told the dentist her entire mouth was sore. The pain was due to a cancerous area covering the floor of her mouth.

"We can treat oral cancer with radiation therapy or surgery or both," explains Dr. Coepp. "And early detection is vital. The survival rate for a patient with a small primary tumor is very good. But the prognosis is more bleak if the cancer has advanced to the bone."

The cause, as for all cancer, remains elusive. But dentists say that chronic irritation—such as that caused by ill-fitting dentures —often is a common contributing factor to primary oral cancer. Studies also link smoking and the excessive use of alcohol to the disease.

Although most mouth cancer is primary oral cancer, there are indications that secondary jaw cancer may be on the increase. Cancer traditionally had metastasized to such organs as the lungs, liver, and kidney. But there is a rise in the incidence of carcinoma of the lungs, a type of cancer that originates from the cells lining the lungs. "New statistics," says Henry M. Cherrick, D.D.S., of the University of California at Los Angeles School of Dentistry, "probably will reveal that carcinoma of the lungs is the most common tumor to metastasize to the jaws."

Rosemary Hansen was lucky. "We occasionally find an unsuspected malignant disease be cause of a metastatic lesion in the mouth," says Dr. Goepp. "But usually the cancer has been detected before it spreads to the jaw."

Jim Fergusen, a 42-year-old truck driver, had a kidney removed because of a malignancy; then he began developing mouth trouble. Three molar teeth were loose, and Fergusen complained of pain m the right jaw. A biopsy was performed, confirming the presence of metastatic cancer in the jaw.

When cancer is suspected and there is an obvious lesion in the mouth, the dentist cuts away a small section of the affected area for analysis. This is called a biopsy or tissue sampling. If, however, a biopsy is not warranted, a more general test can be performed. A smear, similar to the Pap smear taken for cervical cancer, is given to screen the cells in a region of the mouth. This is called oral cytology. All dentists are qualified to perform either the biopsy or the oral cytology test.

As the dentist's role of diagnostician expands, he will be able to do even more toward detecting health problems that affect his patients. Dr. Cohen, for ex ample, suggests that dentists can easily screen patients for suspected diabetes, right in the office, with either a one-minute blood glucose test or by testing a patient's tear drop.

And in Bergen County, New Jersey, Charles L. Berman, D.D.S., the local dental and medical societies, and the county health department are doing something about high blood pressure. In a pilot Program started by Dr. Berman, 17 dentists agreed to check their patients' blood pressures and re fer those who had high readings to a Physician. Of the 1,343 patients tested, 4 to 5 percent of the adult Patients had high blood pressure. On the dentists' recommendations, 88 percent of them made follow-up visits to their own doctors.

To the dentist, however, the mouth remains most important. A loose tooth may be a sign of gum disease; a sore on the lip, a fever blister; a bleeding gum, the result of a too stiff toothbrush. But in some rare cases each could mean much more—the difference between illness and health for someone like Susan, and the difference between life and death for a woman like Rosemary Mansen.