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BRITISH BROADCASTING CORPORATION
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Programme 5. - Oral Health
RADIO 4
THURSDAY 09/03/06 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
IAIN HUTCHISON
PRODUCER:
PAULA MCGRATH
NOT CHECKED AS BROADCAST
MYERS
Hello. Tongue, cheeks, gums, teeth, soft palate - the mouth is very complex, structurally as well as functionally. It allows us to eat, to speak and to put a smile on our face. Fortunately our mouths last a lifetime but during that time things can go wrong. Ulcers, blocked salivary glands, abscesses, infections and worse. So if your oral health is causing concern call us now - 08700 100 444 or you can e-mail checkup@bbc.co.uk and put your questions today to our expert, he's Iain Hutchison, consultant oral and maxillofacial surgeon at Barts and The London hospitals.
Iain, I mentioned there worse things that can happen, I guess the worse thing is mouth cancer and yet that's something that people don't know a great deal about do they.
HUTCHISON
Absolutely Barbara, thank you for inviting me on. The worst thing about mouth cancer is that patients themselves delay seeking advice because it's normally caused - it appears as an ulcer and of course ulcers in the mouth are incredibly common. And patients themselves, very often, don't know that cancer can occur in the mouth, so they have this ulcer for four, five, six weeks and they don't seek advice. If they sought advice early they'd have a 90, almost 100% cure rate for mouth cancer and that's the biggest problem - if we can get people to know that cancer occurs in the mouth and see a doctor or dentist the moment they have an ulcer that lasts for four weeks we'd win the game.
MYERS
A very clear and important message right at the top in that case. We do have some questions I know about ulcers. I've had a lot of e-mails. And our first caller Liz has ulcers. Liz, your question about your ulcers.
LIZ
Yes, I have quite a few ulcers for the first time in my life, I'm 55. They appeared maybe three months ago and when I saw my dentist I mentioned it to her and she just said oh you're probably stressed. And I wondered if stress can cause ulcers and how one gets rid of them apart from getting rid of the stress?
MYERS
If only, yes. Iain, what about that, I mean you've obviously put up a clear warning about the dangers of ulcers going on and perhaps being a first early sign of mouth cancer but what about Liz, she hasn't had them before and now she's getting a crop and someone says it's stress?
HUTCHISON
Liz, can I ask you a question first? These are ulcers that come and go and that occur in different parts of your mouth and come at different times and ...?
LIZ
No these have arrived and stayed.
HUTCHISON
These have arrived and stayed and how many of them are there?
LIZ
Well they're all over the place.
HUTCHISON
So you've got lots of ulcers all over your mouth?
LIZ
Yeah.
HUTCHISON
And they haven't gone away at all?
LIZ
Not at all.
HUTCHISON
And you've had them for how long?
LIZ
Three months?
HUTCHISON
Three months. Well lots of thoughts go through my head but it's very difficult to judge them without seeing you and then without doing investigations on you. But I would say absolutely because these haven't gone away, the key is that ulcers are meant to go away. We get ulcers if we bite our tongue or bite our cheek or burn ourselves, we get ulcers - these aphthous ulcers occur not particularly associated with stress but around hormonal surges, so adolescents get them a lot, ulcers that come and go, they're called aphthous ulcers and that aphthous means - is the Greek for I don't know, which means we don't know what causes them. And they also occur around the menopause as well, for men and for women, at that kind of age when our hormones are starting to die down. They also occur when we're low in iron or vitamin B12 or folic acid. But those ulcers tend to come and go. So the fact that yours have stayed means that you should ask your dentist to refer to your local oral and maxillofacial surgeon. It doesn't sound at all like cancer because they are occurring all over your mouth but it does sound like things like pemphigous or all sorts of oddities and without seeing you and without investigating you it would be impossible say.
LIZ
So mouth washes - I mean I've tried absolutely everything ...?
HUTCHISON
No, ask for a referral to your local oral and maxillofacial surgeon, to your local friendly oral and maxillofacial surgeon - we're all friendly.
MYERS
That's a very clear directive Liz, thank you for that, I hope you'll follow that up, in short order too. Let's move though to another caller, who's been waiting for us, Beryl is in Chesterfield, with a question about lichen planus. Am I pronouncing that correctly, is that what you've got?
BERYL
Yes it is, lichen planus.
MYERS
And what is it?
BERYL
It's kind of a fungus in the mouth and it almost looks like cobwebs - spiders little webs - white.
MYERS
Does it cause you problems?
BERYL
Oh horrendous. I've had it for three years, I had systemic steroids initially to try and kick start it to get it away and so every day I do steroidal mouth washes, up to four a day. But I've just had a major flare up, it's lasting about six weeks this time, so bad I've not really been able to eat properly or even talk ...
MYERS
I'm just thinking you do sound a little bit as though it's hurting to talk. Let's get some advice then from the expert. Iain, what would you say about it?
HUTCHISON
Well I think unfortunately I've already said I don't know necessarily what's causing Liz's problem, although I have some clues, and the problem with lichen planus is it's yet another condition where we don't know what the cause is. Lichen planus is called that because of what it appears like under the microscope. It's actually not caused by a fungus, it's - there's a dense infiltrate of lymph cells under the - under the surface layer, the mucus lining of the mouth and we think that it's caused by some kind of maybe allergic phenomenon. So there's been some dentist go and take out all sorts of amalgam fillings and put in white fillings, that helps some patients. But the truth is we don't know what causes lichen planus. We do know that giving steroids does help some cases, we do know that if the person is deficient in all sorts of vitamins and minerals that again, as I mentioned before with Liz, iron, B12 and folic acid are the main culprits that we know about, or zinc. And if you have those tested and if you're found to be mildly deficient in one or other of them and treating them that won't get rid of the lichen planus but it may get rid of the soreness that you're experiencing.
MYERS
Is there a danger that this could actually become cancerous, is that's what's behind this?
HUTCHISON
Right, are you see any hospital specialist regularly?
BERYL
Yes, I'm with the hospital. At the moment he's given me a stronger steroidal mouth wash to try and get this away a little bit.
HUTCHISON
Are you seeing an oral and maxillofacial surgeon?
BERYL
I am yes.
HUTCHISON
Yeah okay.
BERYL
I just wondered is there any other treatment, has there been any research gone into it?
HUTCHISON
Well I mean my wife gets very angry with me when I say this but I started a charity five years ago and it was built out of failure not out of success, out of the many things we don't know and that we can't treat effectively and lichen planus falls into that category. And so the facial surgery research charity Saving Faces was started to fund research to try and find what causes these diseases, how to treat them better because there are so many things we don't know. All I can say is that it's highly unlikely that your lichen planus will ever turn into cancer but you need to be monitored regularly. There are two aspects to it. First of all you need to be monitored regularly by your surgeon to check that it isn't transforming to cancer. But I would say there's a 1 in 10,000 chance of it turning into cancer, lichen planus. The second thing is that he should be trying to treat you systematically with things like steroids and the like to try and make things better. There is one thing and I have no idea why it works but it works in some patients, which is if you take the antibiotic tetracycline and break up a capsule in some water and rinse that around your mouth it helps some patients symptomatically, in the same way that a steroid mouthwash can help.
MYERS
We'll leave it at that if we may but thanks for that call. We've got a call about mouthwashes in general. Mr Gamble is on the line. What's your question about mouthwashes, do you use them?
GAMBLE
Well I've been using an alcoholic mouthwash for quite a while but I was recommended it by my dentist but this time I've been to a hygienist, she says that the alcohol in the mouthwash is damaging my teeth. And what I'm interested - I'm not using one at the moment because I don't know what to do and I wonder what mouthwashes you can recommend.
MYERS
And why are you using them anyway isn't tooth brushing enough?
GAMBLE
Well although I floss and clean my teeth regular I seem to build up plague for some reason.
MYERS
Okay, well let's get a ruling on mouthwashes because certainly they are heavily advertised and sold. Do they have a real place in oral hygiene would you say?
HUTCHISON
Well can I - well Barbara, thanks for asking that question. I think the point that Mr Gamble makes, about the plague building up, the alcohol mouthwash isn't going to help get rid of the plague, it's your tooth brushing technique and your hygienist is absolutely the person to show you how to clean your teeth. I mean it sounds ridiculous because ...
MYERS
We think we know don't we.
HUTCHISON
But actually it's very important - the tooth brushing technique, and your hygienist is absolutely the person to guide you on that. And the alcohol mouthwash won't help get rid of the plague. What the alcohol mouthwash or what any mouthwash does is make your mouth feel good. And the point about the alcohol is it kind of gives you a hit in your mouth to - at the beginning of the day to wake you up. We don't know whether alcohol mouthwashes do harm but we know that alcohol, if you drink it socially, does do harm, so why wouldn't alcohol mouthwashes do harm as well? So most manufacturers now market mouthwashes that don't contain alcohol.
MYERS
So - just pick up a little bit further on that because I've said earlier in one of the trails that the second biggest risk factor for mouth cancer is alcohol, drinking excess alcohol, obviously it's second to smoking. What's going on in the mouth if you smoke and/or drink, why should that be so damaging?
HUTCHISON
Well the absolute answer is we don't know but if you want my hypothesis - I mean for a surgeon it's very exciting if we say we don't know, it means there's lots of research to do. For the patients it's not very reassuring. Can I reassure all the patients or people out there that actually we do know a lot as well and we can cure a lot of diseases and help a lot of people, it's just in the situations where we can't that it's frustrating for both us and the patients. The - I think what's going on is that if you smoke there are carcinogens in smoke but the lining of your mouth is intact and so the carcinogens can't get through. But interestingly if you take steroid inhalers for asthma they can damage the lining and if you smoke as well then you can get cancers where the steroid inhaler hits your mucus membranes because that's an area of weakness that the smoke attacks and the carcinogens and smoke attack. So the steroid inhaler doesn't do harm but the combination of the two. And I think the same happens with alcohol - if you drink a glass of whisky neat it burns your mouth and it's burning your mouth that's a sign that it is actually damaging the lining of your mouth slightly. And so that damage allows the ingress of the carcinogens. I think that that's why alcohol and tobacco are carcinogistic and why they really cause a problem, more than just one - alcohol alone or tobacco alone.
MYERS
Thank you very much. And thanks for setting us off down that track Mr Gamble. Let's go to Lulu now who is wanting to talk about thrush. What are your symptoms of thrush Lulu?
LULU
Hi I get a creamy unpleasant fur on my tongue and like one of your last callers I also floss and see my dentist regularly and as I floss in the morning and night I can see the creamy build up building up between the teeth as well. And there are little sore patches at the back of the tongue. My doctor has been treating me with Nystatin oral suspension but that only clears it up really while I'm using - under treatment, which only lasts about a week and then it just comes back very quickly.
MYERS
Well let's see what Iain has to say about thrush and whether there's anything you can suggest that Lulu might try for her thrush.
HUTCHISON
Right. Thank you for ringing Lulu. There are a few questions I want to ask you and I hope you don't think I'm being very personal. You sound very young.
LULU
No, 49.
HUTCHISON
Forty nine, okay. Alright. Thrush is caused by a fungus called candida albicans and it's in our mouths, I've got candida albicans in my mouth, Barbara has, everybody has.
MYERS
Have we got furry tongues though?
HUTCHISON
No we haven't got furry tongues, no. So the question is why have you got a furry tongue? Now it may be that you're on some medications which predispose you to have overgrowth of thrush or overgrowth of candida, the organism candida, compared with the many other organisms that are in your mouth. Or it may be that you're under the weather. But what I would do is there are two things: first of all are you seeing a specialist about it?
LULU
No.
HUTCHISON
Well I would get a referral to a specialist because there may be something - there may be some blood tests that need to be done to check whether you're a bit run down and that's why you're getting it. The second thing is that symptomatically what you can do, absolutely the best thing you can do, the tongue is a brilliant crater for catching all sorts of bits of debris because it's - if you look at it under the microscope, we have a scanning microscope that we use to look at the tongue, it looks like the mountains, it looks live Everest ...
MYERS
Mountains of the moon.
HUTCHISON
Yeah, yeah exactly. And so what you can do is get a very, very soft tooth brush and dilute vinegar and just use that to brush your tooth - your tongue night and morning.
LULU
Well since I was a teenager I was using my brush to brush my teeth and when ...
HUTCHISON
Tongue.
LULU
Tongue - so I've been using a tooth brush and then as soon as I saw tongue scrapers on the market I went and got one of those and I use it religiously several times a day but I don't use the vinegar but I have been scraping away and you scrape away the most horrible garbage.
HUTCHISON
Well of course - well the honest truth is that I don't scrape my tongue at all. Well it may be that if I scrape my tongue I would bring out all sorts of garbage and it may be that actually you're tongue is very healthy but because you're scraping it a lot you're actually removing protective layers and you're getting all sorts of debris building up. So what I would do - I would get a referral to a specialist who can have a look at the tongue and say to you either stop scraping because you're scraping too much or scrape more with dilute vinegar...
LULU
Well I often forget to scrap but I mean it builds - so I'm giving the picture of manically scraping ...
MYERS
It sounds as though you need some advice on this.
LULU
... creamy build up. Okay I will.
MYERS
Thank you though for the question. And just generally speaking, for people who don't have thrush but have perhaps again seen the adverts for tongue scrapers, I mean the - there are plenty of things out there you can buy in terms of oral hygiene and the manufacturers are very happy to sell them to us, do you need to scrape your tongue?
HUTCHISON
I think very few people need to scrape their tongue. But I think when people do have problems with their tongues sometimes a soft tooth brush with dilute vinegar is better than a scraper.
MYERS
Thank you. We'll go to Bedfordshire and Brian Padgett is waiting to speak to us, Brian your question please.
PADGETT
Oh hello. A little while ago, about a year ago, I must have lost a filling in one of my teeth towards the corner of the mouth and over a period a little white lump has built up from the edge of the tongue, it looked quite innocent at the beginning and I almost thought I'd cut off with a pair of scissors. But it's now about an eighth of inch diameter and sticks out about an eighth of an inch. And I think I don't know it's abrasion again that's caused it, occasional bleeding from it but I wondered if it was serious. I've seen my dentist this week and he's referred me to the local hospital in Bedford.
HUTCHISON
Right, well I think your dentist has done exactly the right thing. It probably is nothing at all and you're probably right that it's a kind of callous from constant rubbing on the sharp tooth. In the old days, before I qualified, and I'm a very old man now -Methuselah - that they said that cancer was caused by chronic trauma. We don't believe that nowadays, so I think it's highly unlikely that it's cancer but nonetheless you're far better off getting an urgent referral and your dentist has referred you urgently to the local oral and maxillofacial surgeon?
PADGETT
I think it's the oral part of the Bedford hospital, I don't know ...
HUTCHISON
Yes. Yes, okay, well they're excellent, they're absolutely excellent, there are some very, very nice people there, very friendly oral and maxillofacial surgeons and they'll look after you. Now is it an urgent appointment?
PADGETT
I don't know because it hasn't come through yet, it was on Monday when I went to see the dentist.
HUTCHISON
Well I think you should ask your dentist did he write down urgent because you know if you're got an urgent appointment you'll get an appointment within two weeks and then you'll be reassured and they'll be able to say to you don't worry about it, it's nothing at all and you can relax.
PADGETT
I am in BUPA, I don't know if that makes any difference.
MYERS
That's another story.
HUTCHISON
The point is that if - if your dentist puts down urgent on it you will be seen within two weeks.
MYERS
Brian, good luck with that, follow that up as soon as possible. And it's a good example of how a dentist actually can be the right person if you go for a regular check, can spot not just things going wrong with your teeth and gums but anything else within the mouth - quite important.
HUTCHISON
Well dentists are trained in examination of the whole mouth and the neck as well, so that they should be used as regularly as doctors.
MYERS
Okay, good let's go to Edward now who's waiting in Croydon with a lump under his tongue, tell us a little bit about that Edward.
EDWARD
Hello. I discovered this lump under the side of my tongue and it's been there for I think a couple of months, it was very small at the beginning, so I didn't obviously notice it. And it's gradually become larger and larger and it's now the size of a cherry tomato and it's becoming a bit uncomfortable because there's little space left for it to go. It's completely painless, it's red - the same colour as my tongue - with a sort of bluish tinge to it. I'm just wondering what it is.
HUTCHISON
Right okay. Now the bluish tinge I think gives the clue to it, it's - the bluish tinge probably means that it's got fluid in it and it's probably saliva that you've got in there and you may have what's called a ranula which means a frog's belly. I'm sorry to say you've got a frog's belly in your mouth. What all these funny Greek and Latin terms - what has happened is you have thousands and thousands of minor salivary glands producing saliva in your mouth and you have three major glands on each side, you have the one in front of the ear called the parotid, you've got the one under your jaw called the submandibular and you've got the one in the floor of your mouth called the sublingual gland, meaning sub - under - lingual - the tongue. So that sounds like exactly the right place. And the key is the bluish tinge and the fact that it's slow growing but expanding out. And what has probably happened is one of the ducts of the sublingual gland has got blocked, it probably happened shortly after a visit to the dentist when they may have used a sucker to suck around your mouth and you need to see an oral and maxillofacial surgeon fairly rapidly to get it sorted out because it needs some surgical treatment, not very major surgical treatment but it needs some surgical treatment.
MYERS
Very clear, very straightforward, thank you very much, glad you called about that Edward. And we'll go to Brian Rawlings in Warwickshire who is raising I think a question about the salivary ducts. What's the story Brian?
RAWLINGS
Well actually it's about my wife. She's had several operations - she's had a submandibular gland removed, she's a ranula removed ...
MYERS
Just what we were talking about okay.
RAWLINGS
Yes exactly. She's had all these bits and pieces done to her, she's had I think at the most three or four operations now, she's had saliva stone removed from under the tongue as well. But she's still, after all this time, is getting dreadful tastes in her mouth and a terrible amount of saliva build up in her mouth itself, it seems to build up over the day, particularly when she does a lot of talking, she's a senior social worker and obviously has a lot of phone calls and things to make and the more talking she does over the day the worse it gets and by the evening or whatever she's got this terrible taste and in some respects it does get quite painful. But she has seen oral surgeons and dentists, they've made her a special plate she has to wear at night because they think it may be her bite is too severe, through grinding her teeth. But she's almost at her wit's end.
MYERS
Right okay. Quite a complex story, is there anything further you could offer Iain if you - if she was a patient of yours for example, I know you do pretty cutting edge stuff?
HUTCHISON
Well I'm at a loss to help you out Brian really because it sounds so complex. The big problem is the bad taste rather than the pain, which is the biggest problem?
RAWLINGS
The bad taste really.
HUTCHISON
The bad taste.
RAWLINGS
The pain has subsided over - with the recent operations that she's had but ...
HUTCHISON
When did she start having operations?
RAWLINGS
Two years ago now.
HUTCHISON
Two years ago. And when was the last operation?
RAWLINGS
The last one was about June, July time.
HUTCHISON
So nine months ago. It's - bad tastes are very, very difficult, I mean we have to assume that the bad taste relates to her salivary glands but of course bad taste can also be due - the commonest cause of bad taste is problems with the nose and the sinuses and post-nasal drips coming down the back or even stuff coming up from the stomach - acid regurgitation from the stomach. Or you can have crips in your tonsil which mean that they get blocked and get a bit smelly and give a bad taste. So there are all sorts of myriad causes of bad taste.
RAWLINGS
She's also had several teeth removed as well, to try and alleviate - she's had ulcers and all sorts of things.
MYERS
Sorry to hear about all that and I'm not sure that we've got very much more to offer at this point. If you don't mind I would like to try and squeeze in another last call. But thanks for that one Brian. Robert Ross in Oxford wants to have a quick word, Robert.
ROSS
Hi.
MYERS
Hi there. What do you want to tell us about?
ROSS
Ten years ago I was diagnosed with cancer of the tongue, I had half of it removed but as you can hear I regained the power of speech and I can eat reasonably normally. I used to drink too much so it may well be linked to the cancer. My main point is I have a rare and slow growing variety of cancer and it raises the possibility can I do something to slow it down further?
MYERS
Okay, well thanks for telling us, I mean you're obviously a survivor, anything to ...
HUTCHISON
There are wonderful - presumably the cancer's gone away, you haven't got the cancer still have you?
ROSS
No, it has popped up in two other locations.
HUTCHISON
Right. Well there are all sorts of wonderful new things happening, there's Erbitux, a new drug; there are injections of [indistinct words] to recurrent tumours, many, many things that are happening that will help prolong your life and quality of life.
MYERS
But no more news on this programme. That's it for today. Thank you very much to everyone who called and to Iain Hutchison. Next week we're back taking calls on asthma.
ENDS
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