Enamel erosion and esophageal cancer: What you should know

As dental hygienists, we can save patients’ lives. We have heard this phrase hundreds of times, but do we honestly believe it? Although the general public may view us as glorified tooth scrubbers, the truth is we do have the ability to save lives—it just comes down to whether or not we seize that opportunity.

I want to share my heart with you in hopes of empowering you to step outside your comfort zone and be a leader in bridging the gap between oral and systemic health. I know, wow, get out of your comfort zone! I know that is scary to many people, but growth comes when we get uncomfortable.

Let me start by sharing from my heart. Early in 2016, my family was dealt some terrible news. My dad was diagnosed with stage III esophageal cancer, which quickly progressed to stage IV. Although we are taught the ins and outs of cancer, nothing prepares us for a loved one’s fight with cancer. The researcher in me kicked in. I found comfort digging into why my “Daddy-o” was having to fight esophageal cancer. Frequently, I researched topics through the Mayo Clinic. What I found was enlightening.

There are two main types of esophageal cancer: squamous cell carcinoma and adenocarcinoma with a precancerous stage called Barrett’s esophagus. According to the Mayo Clinic, “squamous cell carcinoma develops in the flat cells that line the esophagus and is found in the upper to middle parts of the esophagus. Adenocarcinoma forms in glandular cells in the lining of the esophagus that releases mucus, and develops in the lower part of the esophagus, closer to the stomach. The precancerous stage is called Barrett’s esophagus, a condition in which the cells lining the lower part of the esophagus have changed or been replaced with abnormal cells that could lead to esophageal cancer.”1

The most common form of esophageal cancer is adenocarcinoma. This will be the focus of our attention in this article. According to the Mayo Clinic, some of the risk factors for adenocarcinoma include gastroesophageal reflux disease (GERD), smoking, Barrett’s esophagus, obesity, poor diet, and having an esophageal sphincter that won’t relax.1 There is an abundance of information about the cancer that I could share, but I want to stay focused on how we can save patients’ lives, improve their quality of life, or both.

Around the same time as my dad’s diagnosis, I was noticing an increase in acid erosion on the palatal surfaces of the maxillary anterior teeth in many of my patients. This clinical finding resembled the effects that bulimia has on dental enamel, but these patients did not have bulimia. That led my doctor and me to believe that GERD was the contributing factor. We discussed these findings with the patients, took intraoral pictures, and recommended that they speak to their primary care doctors about GERD and its treatment.

Microscopic view of the epithelial lining of the esophagus

After my dad’s diagnosis, he and I began bonding during chemo and radiation visits. I realized that his esophageal cancer was adenocarcinoma that was caused by his poorly treated chronic GERD. My dad thought it was just “heartburn, no big deal,” then popped some Rolaids or Tums.

As I lay in bed one night thinking about the day’s events, it hit me like a ton of bricks: I had missed the opportunity to detect my dad’s cancer four years earlier, when he mentioned needing partials to chew his food. I was shocked because my father never went to the dentist. I mean never. That day, I had taken a quick peek in his mouth and noticed that his teeth presented with severe erosion. I explained to him that this was not decay; something might be going on in his body, and he needed to speak to his medical doctor about it. This occurred during my first month of dental hygiene school.

Well, let’s face it: hygiene school takes over our lives. It didn’t help that I had a three-hour daily commute, three young children to raise, and a firefighter husband who was on duty 24 hours at a time. That very brief conversation with my dad quickly slipped my mind. It wasn’t until a tumor in his esophagus became so large that it was difficult to swallow, causing food to become lodged in his esophagus, that he sought medical advice.

The realization that I missed an opportunity to save, or at least improve, the quality of life of someone I loved so dearly has been one of the most difficult things I’ve had to deal with. After a year and a half of fighting cancer, my dad’s body couldn’t fight any longer and I lost my sweet “Daddy-o” on June 26, 2017. I’m thankful that I was able to care for him as much as I did, but it was a slow and horrible death. Although the pain of this loss is unbearable at times, I wholeheartedly believe that everything happens for a reason. I mean everything.

So, you remember that comfort zone I was talking about? Well, nothing changes inside that zone. Now is the time to break down those walls and get so uncomfortable that it feels like you’re lying in a bed of cacti. Getting outside of my comfort zone includes writing this article. What would my dad’s battle with esophageal cancer and its early signs of enamel erosion teach anyone if I didn’t get uncomfortable by spreading awareness and empowering dental hygienists to bridge the gap between oral and systemic health?

Let’s build the bridge that will connect oral and systemic health. When discussing medical history changes during recare appointments, I followed up with the at-risk patients to find out if they had discussed GERD with their physicians. To my surprise, they actually did, and some began treatment. But that was it. No tests were run. No endoscopies or biopsies were taken to check the patient for esophageal cancer or Barrett’s esophagus. That’s like getting on birth control without a pregnancy test to verify that you are not pregnant.

It was time to change how we referred. We designed our own referral slip that outlined the severity of erosion and explained our concern for esophageal cancer or Barrett’s esophagus. Here comes the really uncomfortable part: interviewing local gastroenterologists in hopes that they would be receptive to the concerns that the dental health-care team had about erosion linked to esophageal cancer. The referral form was reviewed with the physician, and thankfully we were on the same page about the concerns. If GERD can cause severe erosion on the hardest substance in the body (enamel), then I could only imagine the destruction of the soft tissue in the esophagus.

The American Cancer Society estimates about 17,290 new cases of esophageal cancer will be diagnosed in the US in 2018 (13,480 men; 3,810 women), resulting in about 15,850 deaths (12,850 men; 3,000 women).2 As you can see, the survival rates are very low.

As hygienists, we are in a position to impact and possibly save patients’ lives with the early detection of enamel erosion and the risk factors for esophageal cancer. Together, let’s bridge the gap between oral and systemic health by referring patients to a gastroenterologist when moderate to severe enamel erosion is noted.

Editor’s note: This article previously appeared in a March 2018 issue of RDH eVillage. Next month, the author will share in more detail how her practice refers at-risk patients to gastroenterologists. Don’t miss it!

References

1. Esophageal cancer. Mayo Clinic website. https://www.mayoclinic.org/diseases-conditions/esophageal-cancer/symptoms-causes/syc-20356084. Accessed December 22, 2017.

2. Key statistics for esophageal cancer. American Cancer Society website. https://www.cancer.org/cancer/esophagus-cancer/about/key-statistics.html. Accessed January 4, 2018.

Rebecca Klaus, RDH, fell in love with dental hygiene after she became a dental assistant. This newfound passion led her to attend Coastal Bend College, where she graduated with honors in 2012 and was awarded the Hu-Friedy Golden Scaler Award, which symbolizes clinical excellence and compassionate service. Becky practices dental hygiene in Seguin, Texas.