Monthly Archives: October 2008

Cerebrovascular disease risk in older head and neck cancer patients after radiotherapy

Source: Journal of Clinical Oncology, Vol 26, No 31 (November 1), 2008: pp. 5119-5125
Authors: Grace L. Smith et al.

Cerebrovascular disease is common in head and neck cancer patients, but it is unknown whether radiotherapy increases the cerebrovascular disease risk in this population.

Patients and Methods:
We identified 6,862 patients (age > 65 years) from the Surveillance, Epidemiology, and End Results (SEER) –Medicare cohort diagnosed with nonmetastatic head and neck cancer between 1992 and 2002. Using proportional hazards regression, we compared risk of cerebrovascular events (stroke, carotid revascularization, or stroke death) after treatment with radiotherapy alone, surgery plus radiotherapy, or surgery alone. To further validate whether treatment groups had equivalent baseline risk of vascular disease, we compared the risks of developing a control diagnosis, cardiac events (myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft, or cardiac death). Unlike cerebrovascular risk, no difference in cardiac risk was hypothesized.

Mean age was 76 ± 7 years. Ten-year incidence of cerebrovascular events was 34% in patients treated with radiotherapy alone compared with 25% in patients treated with surgery plus radiotherapy and 26% in patients treated with surgery alone (P < .001). After adjusting for covariates, patients treated with radiotherapy alone had increased cerebrovascular risk compared with surgery plus radiotherapy (hazard ratio [HR] = 1.42; 95% CI, 1.14 to 1.77) and surgery alone (HR = 1.50; 95% CI, 1.18 to 1.90). However, no difference was found for surgery plus radiotherapy versus surgery alone (P = .60). As expected, patients treated with radiotherapy alone had no increased cardiac risk compared with the other treatment groups (P = .63 and P = .81). Conclusion: Definitive radiotherapy for head and neck cancer, but not postoperative radiotherapy, was associated with excess cerebrovascular disease risk in older patients. Authors: Grace L. Smith, Benjamin D. Smith, Thomas A. Buchholz, Sharon H. Giordano, Adam S. Garden, Wendy A. Woodward, Harlan M. Krumholz, Randal S. Weber, K.-Kian Ang, David I. Rosenthal Authors' affiliations: From the Departments of Radiation Oncology, Breast Medical Oncology, and Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, TX; and the Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT

October, 2008|Oral Cancer News|

Oral rinses used for tracking HPV-positive head and neck cancers holds promise for cancer screening

Author: staff

A study published in the journal Clinical Cancer Research, a journal of the American Association for Cancer Research, validates a non-invasive screening method with future potential for detection of human papillomavirus (HPV)-positive head and neck cancers.

In the study, researchers at Johns Hopkins University used oral rinses and targeted DNA amplification to track and identify oral HPV infections in patients with HPV16-positive and negative head and neck carcinomas (HNSCC) before and after therapy.

Findings showed detection of high-risk HPV infections in patients with HPV16-positive HNSCC for up to five years after therapy, indicating a high rate of persistent infection and reaffirming the connection between high-risk types of HPV and HPV-positive head and neck cancer.

“There is no question of cause,” said the study’s co-author Maura Gillison, M.D., Ph.D. associate professor of oncology. “It has now become a question of tracking the infection over time to identify those at risk of developing HPV-positive cancer, and for those who have had it, the risk of recurrence and risk of transmission. This is the first study in which we have been able to track the disease and related oral infections for an extended period of time.”

Researchers obtained oral rinse samples from a group of 135 patients with head and neck carcinomas. Tissue analysis showed that 44 of these patients had HPV16-positive tumors. Both the tissue and oral rinse samples were genetically sequenced to specify the HPV variants in each. Patients with HPV16-positive tumors were significantly more likely to have oral HPV16 infections, with an almost ten-fold increase prior to therapy and a fourteen-fold increase after. Patients with high-risk oral HPV infections prior to therapy also had a 44-fold increase of post-treatment infection.

Findings showed no significant odds of tumor recurrence among those with post treatment infections and no association between these infections and the development of second primary tumors at two years. However, this possibility cannot be excluded as longer observation may be needed.

Future studies will be able to use the data and methodology to further explore the connection between HPV and head and neck cancer formation, as well as the biological factors, such as HLA type, that are involved, Gillison said.

“The big question in HPV research is centered on biological factors that cause one person to have a medical consequence from an oral HPV infection and another to be able to clear the infection without any consequences,” Gillison said.

October, 2008|Oral Cancer News|

Coffee consumption and the risk of oral, pharyngeal and esophageal cancers in Japan

Source: American Journal of Epidemiology, doi:10.1093/aje/kwn282
Authors: Toru Naganuma et al.

An inverse association between coffee consumption and the risk of oral, pharyngeal, and esophageal cancers has been suggested in case-control studies, but few results from prospective studies are available. Data from the Miyagi Cohort Study in Japan were used to clarify the association between coffee consumption and the risk of these cancers.

Information about coffee consumption was obtained from self-administered food frequency questionnaires in 1990. Among 38,679 subjects aged 40–64 years with no previous history of cancer, 157 cases of oral, pharyngeal, and esophageal cancers were identified during 13.6 years of follow-up. Hazard ratios were estimated by the Cox proportional hazards regression model.

The risk of oral, pharyngeal, and esophageal cancers was inversely associated with coffee consumption. The multivariate-adjusted hazard ratio of these cancers for ≥1 cups of coffee per day compared with no consumption was 0.51 (95% confidence interval: 0.33, 0.77). This inverse association was consistent regardless of sex and cancer site and was observed both for subjects who did not drink or smoke and for those who currently drank or smoked at baseline.

In conclusion, coffee consumption was associated with a lower risk of oral, pharyngeal, and esophageal cancers, even in the group at high risk of these cancers.

Toru Naganuma, Shinichi Kuriyama, Masako Kakizaki, Toshimasa Sone, Naoki Nakaya, Kaori Ohmori-Matsuda, Yoshikazu Nishino, Akira Fukao and Ichiro Tsuji

Authors’ affiliation:
Division of Epidemiology, Department of Public Health and Forensic Medicine, Tohoku University School of Medicine, 2-1 Seiryo-machi Aoba-ku Sendai, 980-8575, Japan

October, 2008|Oral Cancer News|

Nobel laureate calls for HPV vaccine for boys

Author: Andrew Innis

The Nobel Prize winning pioneer of human papilloma virus (HPV) research is calling for the vaccination of boys against HPV.

Speaking at the MaRS Centre in Toronto on Oct 21, Dr Harald zur Hausen argued that vaccination against the viruses, which can lead to cervical cancer in women, is also important to men since they too are susceptible to developing cancers related to HPV.

Zur Hausen said men, like women, need to be protected from the more dangerous strains of the virus, HPV-16 and -18, which can contribute to the development of anal and penile cancer.

The announcement came hours before the release of a report by the US Centers for Disease Control and Prevention (CDC), which confirmed that after two years of clinical usage Gardasil remains safe for human use, citing no elevated risk for neurological complications. The vaccine was approved for use in both Canada and the United States two years ago.

Philippe Brideau, media relations officer for Public Health Agency Canada, said Gardasil has been found to be, “effective and the vaccine is safe, and should be used.” He said there have been no major reactions reported.

Health Canada estimates nearly 75 percent of sexually active men and women will be infected with HPV at least once in their lifetime. While most strains of the virus are of little danger, mainly producing genital warts, it can lead to the development of cancer in both males and females.

Men who have sex with men are at even higher risk, according to studies by the CDC that claim gay and bisexual men may be up to 17 times more likely to develop anal cancer than heterosexual men.

There is also an increased risk of developing cancers of the throat. A 2007 study published in the New England Journal of Medicine found a link between the presence of HPV and a development of oropharyngeal cancer, showing those with HPV had a 32 times higher risk of development.

Most people will eventually eliminate HPV from their body, but those who are HIV-positive or have a compromised immune system are at a greater risk from the virus, making treatment for things like genital warts more difficult.

But the HPV vaccine is not approved for use in males, though Merck, the manufacturer, is holding clinical trials to determine the effectiveness of Gardasil on men.

Sheila Murphy, a spokesperson for Merck, said she is hopeful that preliminary data for the study will be available soon.

“There is going to be a [peer reviewed] meeting in Europe in November, and I was hoping there would be some data presented there, and I still haven’t heard weather that is going to be the case or not,” Murphy said on Oct 27.

When asked if the study could become bogged down by bureaucracy, Murphy was clear that public interest was high.

“We’re talking about a vaccine that prevents cancer, and that will prevent cancer in men… so there’s no question,” she says.

“People are waiting for these results, people like yourselves are clamouring for them.”

But even after the release of preliminary data from the female study, Murphy said it took, “another two years before we had approval of the vaccine, so I would imagine we’re another two or three years away.”

Other countries have allowed boys to be given the vaccine, she said, based on the initial studies on Gardasil. “In Canada… they want us to do the efficacy studies, to show in fact that the vaccine, not only does it cause an immune response recognition, but it actually prevents a disease.”

October, 2008|Oral Cancer News|

Periodic CT detects pulmonary metastases among head and neck cancer patients

Author: staff

Among patients with head and neck cancer who are at a high risk for metastases, periodic computed tomography (CT) scans can be highly effective for detecting pulmonary metastases.

Head and neck cancers originate in the oral cavity (lip, mouth, tongue), salivary glands, paranasal sinuses, nasal cavity, pharynx (upper back part of the throat), larynx (voice box), and lymph nodes in the upper part of the neck. Worldwide, head and neck cancer is diagnosed in approximately 640,000 people annually and is responsible for approximately 350,000 deaths each year.

Some patients with head and neck cancer are at a higher risk of developing cancer spread (metastasis). One of the common places of metastasis is to the lung, referred to as pulmonary metastasis. Researchers continue to evaluate ways in which to detect metastasis so that detection and treatment may occur in its earliest phases.

Researchers from Taiwan recently conducted a clinical study to evaluate the effectiveness of chest CT scans in early detection of pulmonary metastases among patients with head and neck cancer. This trial included 192 patients over nearly 4 years, during which time CT scans of the chest were intermittently performed.

Approximately one-third of patients had abnormal chest CT scans. Nearly 70% of patients with an abnormal scan ultimately demonstrated disease progression.

The researchers concluded that patients with head and neck cancer who are at a high risk of developing pulmonary metastases may benefit from intermittent chest CT scans for early detection of pulmonary metastases. Patients with head and neck cancer may wish to speak with their physician regarding their individual risks and benefits of chest CT scans.

Hsu Y, Chu P, Liu J, et al. Role of Chest Computed Tomography in Head and Neck Cancer. Arch Otolaryngol Head Neck Surg. 2008;134:1050-1054.

October, 2008|Oral Cancer News|

How eating fruit and vegetables can improve cancer patients’ response to chemotherapy

Author: staff

UC Riverside study describes how naturally occurring apigenin facilitates the death of cancer cells

The leading cause of death in all cancer patients continues to be the resistance of tumor cells to chemotherapy, a form of treatment in which chemicals are used to kill cells.

Now a study by UC Riverside biochemists that focuses on cancer cells reports that ingesting apigenin – a naturally occurring dietary agent found in vegetables and fruit – improves cancer cells’ response to chemotherapy.

Xuan Liu, a professor of biochemistry, and Xin Cai, a postdoctoral researcher working in her lab, found that apigenin localizes tumor suppressor p53, a protein, in the cell nucleus – a necessary step for killing the cell that results in some tumor cells responding to chemotherapy.

The study, published this week in the online early edition of the Proceedings of the National Academy of Sciences, provides a novel approach to conquer tumor resistance to chemotherapy, and suggests an avenue for developing safe chemotherapy via naturally occurring agents.

Normally, cells have low levels of p53 diffused in their cytoplasm and nucleus. When DNA in the nucleus is damaged, p53 moves to the nucleus where it activates genes that stop cell growth and cause cell death. In this way, p53 ensures that cells with damaged DNA are killed.

In many cancers, p53 is rendered inactive by a process called cytoplasmic sequestration. Apigenin is able to activate p53 and transport it into the nucleus, resulting in a stop to cell growth and cell death.

“In therapy you want to kill cancer cells,” explained Cai, the first author of the research paper. “But to stop cell growth and to kill the cell, p53 first needs to be moved to the cell’s nucleus to function. Apigenin is very effective in localizing p53 this way.”

Apigenin is mainly found in fruit (including apples, cherries, grapes), vegetables (including parsley, artichoke, basil, celery), nuts and plant-derived beverages (including tea and wine). It has been shown by researchers to have growth inhibitory properties in several cancer lines, including breast, colon, skin, thyroid and leukemia cells. It has also been shown to inhibit pancreatic cancer cell proliferation.

“Our study advocates the inclusion of vegetables and fruit in our daily diet to help prevent cancer,” said Liu, the research paper’s coauthor.

1. The National Institutes of Health supported the five-year study.
2. Next in their research Liu and Cai plan to design therapies for cancer by finding compounds that are like, but perform better than, apigenin.

University of California – Riverside

October, 2008|Oral Cancer News|

Bevacizumab better than gold standard imaging at detecting tumors

Author: staff

Scientists have developed a new imaging agent that can be used in scanning for tumours, and which gives a much clearer and more precise image than existing methods. The discovery has the potential to revolutionise pre-clinical cancer research and clinical diagnostic practice, and it makes use of compounds that have already been approved for treating patients: the anti-cancer drug bevacizumab (Avastin) and Copper-64, a radioactive copper nuclide, which is approved by the US Food and Drug Administration (FDA) for some clinical trials.

Dr Zheng Jim Wang told the 20th EORTC-NCI-AACR [1] Symposium on Molecular Targets and Cancer Therapeutics in Geneva today (Wednesday 22 October) that he and his colleagues had attached bevacizumab to a molecule called DOTA (a cyclic compound) and tagged it with a radioactive tracer, Copper-64 (64Cu). Bevacizumab is an antibody that targets vascular endothelial growth factor (VEGF), a signalling protein released by tumour cells and which plays an important role in angiogenesis (the process by which a growing tumour creates its own blood supply). Currently, bevacizumab is being used to treat patients with advanced colorectal cancer and is being tested in several other metastatic cancers.

When the researchers injected the compound (64Cu-bevacizumab) into mice with breast, lung and pancreatic cancers and then used PET/CT imaging to scan the animals, they found that it successfully targeted the cancer cells, accumulating in high concentrations in the tumours, and that it enabled clear and well-defined images of the tumours to be detected during scanning.

When compared with images of the same tumours in the same animals taken the day before, using the current gold standard imaging probe for tumours (18-Fluoro-Deoxy-Glucose (18FDG)), they found that not only were the 64Cu-bevacizumab images better, but also that they could detect tumours in earlier stages and at smaller sizes than with 18FDG. In addition, the 64Cu-bevacizumab images had none of the conventional “hot spots” that tend to appear in 18FDG images and which affect the accuracy of the imaging; “hot spots” occur where the compound has accumulated not just in tumours but also in key organs (such as the heart, brain, kidneys and bladder) which give false positive signals.

Dr Wang, Director of Molecular Imaging at MPI Research Inc (Michigan, USA) and an adjunct assistant professor at University of Texas Health Science Center at San Antonio, said: “Our collaborative research reveals and verifies a new imaging agent for the next generation of tumour detection imaging probes. 64Cu-bevacizumab is highly sensitive in pancreatic, breast and lung cancer models, detecting tumours earlier than 18FDG, with much better contrast between the tumour and the surrounding tissue and with fewer non-tumour-related hot spots. Because it uses different biological mechanisms compared with 18FDG, it could detect a broader range of tumour types than 18FDG.

“Since bevacizumab has been approved by the FDA for treating patients and Copper-64 for clinical trials, the conjugated compound has a much higher chance of being applied to clinical use faster than other, newly developed bimolecular compounds.

“VEGF-related angiogenesis is almost a universal phenomenon for most types of solid tumours. We are testing this probe in different cancers (lung, pancreatic, ovarian, prostate, breast, and colon cancer) and bone metastasis models to verify our assumption. Once it’s been verified and validated, we are planning to test it in clinical trials.”

Dr Wang and his group are the first to show that it is possible to use bevacizumab as a diagnostic imaging agent to detect early tumours in animal models and that it is better than the gold standard 18FDG. However, he said that when he and his colleagues first started the project, some scientists and doctors in the cancer field did not believe their idea could work because VEGF is diffusible and breaks down very quickly. “They highly doubted the research goal and some of them refused to believe the first imaging result, which was thought too good to be true,” he said.

The group persisted, and last year, another research group in The Netherlands independently published similar results in an ovarian tumour model. “Eventually we found out that while some types of VEGF are diffusible, other types of VEGF are located at the tumour cell surface and very near the extra cellular matrix. That is why the radiolabeled bevacizumab targets VEGF on the angiogenesis site around the tumour and demonstrates excellent imaging of the tumour. Since we are targeting early stage of angiogenesis we are able to see the tumour when it is still very small or in other words, in a very early stage.”

Once researchers have obtained the necessary confirmation of their results in further studies and clinical trials, imaging with 64Cu-bevacizumab could be used in both pre-clinical and clinical work.

Dr Wang said: “In pre-clinical research it could be used for the following:

1. Tumour detection It could help researchers detect and observe the growth of the tumours located at greater depth in the body and offers better sensitivity and contrast.
2. Estimate the tumour size and monitor the therapeutic effect According to our results, bevacizumab imaging offers clearer contours of the tumours than other probes. With appropriate image analysis and experiment design, it could help researchers estimate the size of the tumour and further monitor the therapeutic effect of certain treatments.
3. Observe angiogenesis-related events The release of VEGF is highly related to angiogenesis. This compound can provide information about the distribution and the change of VEGF at different time points. Furthermore, this information can be used for evaluation of the functional effect of other anti-angiogenesis drugs. Also, it can tell the researcher which part of the tumour is actively undergoing angiogenesis at certain time point. VEGF is related to hypoxia and inflammation as well. Therefore, this probe may be used to obtain indirect information of hypoxia and inflammation.
4. The pharmacokinetics and distribution of bevacizumab itself and other anti-cancer antibodies It could offer information on the percentage of the total injection dose of bevacizumab accumulated in the tumour, also for other organs. The distribution of bevacizumab in the tumour could be revealed by this technique. All the imaging information is important for using bevacizumab more accurately and to optimise the drug dosing. The same imaging strategy can be used to evaluate the pharmacokinetics and distribution of other anti-cancer antibody candidates.

“In clinical work with patients, the superior imaging will enable us to detect and diagnose tumours at earlier stages, to monitor the effects of therapy on the patients’ cancers, and, because the contour of tumour is so much clearer with 64Cu-bevacizumab, it will help physicians to decide the size of the tumour and may be able to help the radiation oncologist decide the clinical treatment volume.”

He said it was possible that other, targeted cancer therapies could be used for imaging in a similar way, but this depended on the type, biological distribution, specificity, and pharmacokinetics of the drug. “Some targeted drugs may be too specific to be used as the first-line imaging agent for the diagnosis of a broad spectrum of cancers. However, once the cancer is detected by the first-line imaging agent, other targeted cancer therapies may be useful as imaging agents when monitoring whether the drugs are sufficiently targeted at the tumour site. This will offer valuable information in deciding treatment strategy, such as dosing optimisation and personalised medicine.”


[1] EORTC [European Organisation for Research and Treatment of Cancer, NCI [National Cancer Institute], AACR [American Association for Cancer Research]. Abstract no: 33

October, 2008|Oral Cancer News|

‘A second opinion saved our lives’ say the patients who refused to accept their GP’s diagnosis

Author: Marianne Power

We all trust our GPs to give the correct diagnosis. But doctors CAN get it wrong – with potentially disastrous consequences. These patients prove you should never be too embarrassed to ask for a second opinion.

We all want to believe what doctors tell us, especially when they’re assuring us that nothing is wrong. But sometimes there remains that niggling doubt – something tells you all is not right.

‘Trusting your instinct is important. Doctors do make mistakes and sometimes you know your body better than anyone else,’ says Dr Graham Archard, vice chairman of the Royal College of GPs.

‘I can remember a patient who was convinced he had bowel cancer, but all the tests came back clear. He wanted a second opinion so we referred him to another consultant for more tests, which showed that he did have cancer.

‘I don’t know if the cancer developed between the first and second appointment or if the first consultant missed it, but the patient’s instincts were right. As a GP I don’t take it personally if someone asks for a second opinion. If any doctor does take offence, they are too full of themselves, and it’s time to stop practising.

‘If you are concerned, first talk to your GP, and allow them to explain how they came to their diagnosis. Sometimes this alone can make you feel better.

‘If it doesn’t, ask to see another GP in the practice or to be referred to a specialist. Do not feel anxious about doing this, it is your right on the NHS to have a second opinion – and no good doctor would stand in your way.’

From the post-natal depression that turned out to be cancer, to the childhood bug that
actually a tumour in the brain, here we tell the stories that prove you should always get a second opinion if you’re in doubt.

Fiona Kennon, a patient liaison officer, 35, lives in Poynton, Cheshire, with her husband, Steve, an engineer, and children Duncan, 11, Donald, nine, and Alice, five. Fiona says:

My GP assured me that as a non-drinker and non-smoker the painful ulcerated rash on my tongue couldn’t be mouth cancer.

But having seen my husband battle testicular cancer in his 30s and my mother die of ovarian cancer, I was worried. Three years before, in 1999, I’d been diagnosed with a benign skin condition, Lichen Planus, which caused rashes in my mouth.

Over the years, whenever a new rash would appear I’d managed it with steroid mouthwash, but shortly after my third child was born, it changed – it looked like a white dab of Tip-Ex. The mouthwash no longer helped and it had become uncomfortable when I ate and brushed my teeth.

Still concerned after six weeks, I saw my GP. I broke down when I told her about my fears that this condition had turned to cancer. I know it sounds dramatic, but I was terrified I would not see my three-month-old baby grow up.

She thought I was suffering from post-natal depression and referred me to a counsellor, and a dermatologist to assess my tongue. By the time I saw the counsellor, after a three-month wait on the NHS, the pain in my tongue was worse.

The counsellor, however, thought it was all in my mind. She told me I didn’t have post-natal depression, I was suffering from ‘health anxiety’ and she referred me for Cognitive Behavioural Therapy. I left feeling confused. Part of me thought ‘Maybe she’s right, maybe this is just in my head’ – but then the other part of me refused to believe it was nothing.

Three weeks later I saw the dermatologist and showed her the small white marks and ulcers on my tongue. By this stage, eating was agony and I had lost more than half a stone. She said it was nothing to worry about, she’d seen a lot of Lichen Planus cases and prescribed a steroid cream – if it didn’t improve in a month, she’d do a biopsy.

Again, I was conflicted. Another doctor was telling me it was nothing and my husband was telling me I was worried unnecessarily. Why, then, was I so paranoid?

As a last-ditch attempt, I made an appointment with my old dentist in Edinburgh. He had diagnosed the original Lichen Planus and knew I wouldn’t make a fuss over nothing.

The minute he saw my mouth, he said my condition had changed considerably and I needed to be seen by an oral surgeon immediately. By that time I’d been waking up with blood on the pillow, but thought I was biting my tongue in my sleep.

He told me to demand a biopsy from my GP. Then, nine weeks later, after biopsies and an MRI scan, I was at Manchester’s Wythenshaw Hospital, having a nine-hour operation to remove half my tongue and several lymph nodes from the left side of my neck.

The biopsy had confirmed a cancerous tumour in my tongue, which had started to spread to my lymph nodes. My worst fears had been confirmed – five months after I first went to my doctor. It turns out the steroid cream that the dermatologist gave me might actually have speeded up the growth of the tumour.

It was a massive operation, but I had complete faith in my surgeon, Mr Manu Patel. It was a few days after the operation before they removed the tracheotomy and I was able to speak. I was expecting my tongue to feel strange, but it didn’t, and after weeks of pureed foods I started to eat solids.

Just four months later, after three weeks of radiotherapy, I was back at work as a language teacher. My speech is 98 per cent the same and you couldn’t tell I’d had half my tongue removed.

It’s now almost five years since I was diagnosed. I never went back to my old GP, even though she did apologise.

My confidence in doctors has certainly been dented. I am paranoid about every ache and pain, but fortunately my history means that I now get checked out fully every few months – and I’m taken seriously. If a time comes when I feel someg is being missed, I’ll insist on a second, third or fourth opinion – whatever it takes.

October, 2008|Oral Cancer News|

Prevention vs. prosecution

Author: Dianne Glasscoe-Waterson

Malpractice. The very word strikes fear in the hearts and minds of all health-care providers. In fact, according to risk management statistics, every dentist can expect at least one malpractice lawsuit in his or her practice lifetime. What about dental hygienists? Are they at risk? Should dental hygienists invest in their own malpractice insurance? Read on to learn of the unpleasant circumstances surrounding four dental hygienists.

Limits of Malpractice Coverage
Carol practiced dental hygiene for 25 years without carrying malpractice insurance. She reasoned that there was no need since the doctor’s malpractice insurance covered her.

When Carol’s employer was sued for failure to diagnose oral cancer, Carol was named as a codefendant in the suit, as she had seen the patient for a preventive care appointment within the past year. While being named in any lawsuit was unsettling, Carol figured she really had nothing to worry about. She knew the doctor had malpractice insurance.

What Carol did not know was that lawsuits can actually exceed the limits of the doctor’s malpractice coverage. According to Jeff Tonner, JD, monetary awards for failure to diagnose oral cancer are the most common lawsuits to exceed the limits of coverage. If a lawsuit is successful and the limits of coverage are exceeded, codefendants can be saddled with monetary damages, because the doctor is the primary defendant.

False Security
Jan chose not to carry malpractice insurance. She felt it was really a waste of money, since she knew her employer’s malpractice insurance covered her.

One day, Jan accidentally sliced her patient’s tongue when she slipped with a sharp instrument. The patient had to go to the hospital and get his tongue sutured. The patient subsequently sued the hygienist for damages.

The doctor’s malpractice insurance paid out a monetary settlement to the patient for damages. That should have been the end of the story, but unfortunately there was more to come. Since the doctor was not named in the suit, the insurance company sued the hygienist to recover what it had paid out on her behalf.

The concept of respondeat superior is a Latin phrase that means let the master answer. It means that the owner/doctor of the practice is responsible for the acts of omission and commission of employees while engaging in delivery of dentistry. It is also called “vicarious liability,” meaning that although the doctor may not have been involved in an injury to a patient (such as when a hygienist accidentally injures a patient), the doctor is still responsible. However, there is nothing to prevent a malpractice carrier from suing a staff member to recover the monetary amounts paid out on a staff member’s behalf.

Surprise, Surprise!
Mona had practiced dental hygiene in Texas for 15 years without malpractice insurance. One day, she accidentally spilled a chemical on her patient that caused a burn to the patient’s lip. The patient had to see a plastic surgeon and endure pain and suffering associated with the accident. The patient was left with a scar, and she sued Mona.

What a surprise it was to Mona to find out that her employer did not have any malpractice insurance! She did not realize that the state of Texas does not require doctors to carry malpractice insurance.

Policy Stipulations
It was a day like any other in the office where Mary had worked for one year. However, Mary would never forget this day. As her elderly patient stood up to exit the treatment room, he cut a gash in his scalp when he staggered and hit his head on the overhead light. He lashed out at Mary that it was her fault, that she should have pushed it out of the way. After a trip to the emergency room, the patient had nine stitches in his scalp.

After consulting an attorney, the patient decided to sue Mary. She had no malpractice insurance of her own, and the doctor’s policy carried a stipulation that employees would be covered only if the dentist was named in the suit. The patient chose not to name the dentist. Some policies state that if both employer and dental hygienist are named in a suit and the employer’s name is later dropped, the insurance policy may not cover the dental hygienist. In this case, Mary may have to countersue her employer’s malpractice carrier or even her employer to get relief.

Types of Malpractice Coverage
It is true that hygienists are not sued nearly as often as dentists, but the above examples point to the necessity of additional malpractice coverage for dental hygienists. The good news is that malpractice coverage is very reasonably priced for hygienists, typically less than $100 per year for coverage.

There are two types of professional liability insurance. The first and most comprehensive coverage is called an occurrence policy. This type of policy protects the clinician for any alleged malpractice that occurs during the policy period. It does not matter when the claim is filed. With an occurrence policy, the clinician is afforded protection after leaving clinical practice even if the policy is not still in force at the time a claim is made. The coverage extends to the period after the clinician retires, so no additional coverage is needed.

The second (and most common) type of liability insurance is called claims-made policy. The policy protects the clinician against claims made only while the policy is active and the clinician is actively engaged in clinical practice. If a clinician retires or leaves practice and a claim is filed after the policy is no longer in force, the clinician has no coverage. With this type of coverage, it may be prudent for the clinician to purchase an additional policy (called “tail coverage”) to protect for a limited period of time after leaving practice. For example, consider that a dental hygienist retires or leaves clinical practice in June. In July, a patient files a malpractice suit claiming the hygienist injured him or practiced in a negligent manner during an appointment one month before she left practice. If the hygienist had purchased a “tail coverage” policy to extend her coverage for a time, she would be protected.

Before purchasing any type of policy, be sure that you understand any exclusions set forth (sometimes in small print) in the policy. Also, ask for availability of additional coverage should you be contemplating leaving practice.

Ten Areas of Potential Liability for Dental Hygienists
1. Failure to update medical history —
High-quality chart records are the most important aspect of preventing a patient lawsuit from ever reaching the courts, and the medical history update is of primary importance. According to information provided to the ADA from malpractice carriers, failure to update the medical history is among the top five record-keeping errors. In fact, the medical history should be updated at every patient visit.

One thing every clinician should be clear about is that responsibility for completing the medical history does not rest entirely on the patient. Rather, it is the clinician’s responsibility to obtain the medical history. So, when patients balk or express consternation about filling out their medical history, the clinician should take over the responsibility and go through the questions one-on-one. Consider that, according to the U.S. Department of Education National Adult Literacy Survey, almost half of the U.S. population is either functionally illiterate or only marginally literate.

2. Failure to detect oral cancer —
Attorney Jeff Tonner posits that, in his experience, the failure to detect oral cancer is the primary reason hygienists are named as codefendants when the doctor is sued for failure to diagnose. By virtue of their education, hygienists are trained to spot abnormalities in the oral cavity. Too many hygienists operate in the “run and gun” mode and omit the most important aspect of the patient visit.

Common causes of liability for failure to diagnose or delayed diagnosis of oral cancer fall into four major categories: errors in clinical judgment, failure to follow up, failure to screen patients appropriately, and evaluation delays. Screening for oral cancer should include a thorough history and physical examination of the head and neck region, including a visual inspection and palpation of the head, neck, oral, and pharyngeal areas. It should also include a review of the social, familial, and medical history of the patient along with risk behaviors (tobacco and alcohol usage — people who drink and smoke are 15 times more likely to have oral cancer), a history of head and neck radiotherapy, familial history of head and neck cancer, and a personal history of cancer. All patients over 40 years of age should be considered at a higher risk for oral cancer than patients younger than age 40.

The bottom line is this: any patient with a suspicious lesion should be kept under a “magnifying glass” until the clinician is certain of the diagnosis or the lesion resolves.

3. Failure to detect periodontal disease —
Hygienists typically are in a codiagnosis role in discovering periodontal disease through periodontal charting, tissue assessment, and radiographs. It is incumbent upon the hygienist to perform timely periodontal assessments and keep radiographs current. The standard of care is one full-mouth probing with all numbers recorded once per year. Radiographs should be taken at an interval appropriate to the patient. (See ADA document

4. Injury to a patient —
Unfortunately, accidents usually occur when we least expect them to happen. It is our responsibility to practice according to established standards that minimize the chance of an untoward event. It has been noted by some risk management experts that apologizing to a patient who has been injured is an important part of keeping the lines of communication open and preventing lawsuits.

5. Failure to record thorough documentation in the patient chart —
Records are the backbone of the clinician’s defense in any malpractice claim. Make sure you record all the pertinent events in the appointment, including materials used and instructions given to the patient.

6. Not protecting patient privacy/divulging confidential patient information —
Never, never discuss patient information outside the confines of the office, even with your spouse unless your spouse works in the practice.

7. Failure to ask if the patient has premedicated —
According to the newest premedication guidelines published in April 2007, many people who formerly required premedication are exempt from taking antibiotics before the dental visit. It is in the clinician’s best interest to require that physicians prescribe antibiotics if they desire certain patients to premedicate prior to dental procedures. This prevents the dentist from being sued if the patient experiences an antibiotic reaction.

8. Failure to inform about treatment options and consequences of nontreatment —
The hygienist must ensure that the patient understands the proposed treatment and the ramifications of nontreatment.

9. Practicing outside the legal scope of practice —
Practice acts differ from state to state, so dental hygienists must be fully informed of the practice act in the state where she or he practices.

10. Fraud —
Dental hygienists have a legal and moral responsibility to report their services truthfully. To do otherwise puts the hygienist at risk for lengthy court proceedings and possible jail time.
Where To Purchase Malpractice Insurance

Malpractice insurance may be purchased through Marsh at the following Web site: Click on the dropdown box that says, “Select Your Profession,” then click on “Dental Assistant/Hygienist.” You will be prompted to answer some questions.

About the Author
Dianne Glasscoe-Watterson, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe-Watterson for speaking or consulting, call (301) 874-5240 or e-mail Visit her Web site at

October, 2008|Oral Cancer News|

Public knowledge and attitudes towards Human Papilloma Virus (HPV) vaccination

Source: 7th Space (Johns Hopkins Medical Letter)
Author: Charlotte Devereaux et al.

Human Papilloma Virus (HPV) vaccine has undergone successful trials and has recently been approved for use for the primary prevention of cervical cancer. The aim of this study was to determine knowledge and attitudes towards HPV vaccination.

Semi-structured interview and questionnaire delivered in a street survey. Standardised HPV-related statements used to measure HPV knowledge and attitudes to vaccination. The setting was three different areas of Birmingham, to target a mix of social class and ethnicity. The sample population was composed of 16-54 year olds.

A total of 420 participants were recruited. Poor knowledge of HPV and its links with cervical cancer were observed. 81% had a knowledge score of zero. Knowledge about HPV was associated with different ethnic group and socio-economic group. The majority (88%) of participants were in favour of vaccination, with 83.6% indicating that they would allow a child under their care to be vaccinated.

Initial responses to the proposed HPV vaccination within the UK public are favourable. However, knowledge levels are poor and media and health professional promotion are required to raise awareness.

Charlotte Devereaux Walsh, Aradhana Gera, Meeraj Shah, Amit Sharma, Judy E Powell and Sue Wilson

BMC Public Health 2008, 8:368

October, 2008|Oral Cancer News|