Alcohol-containing mouthwash and oropharyngeal cancer: A review of the epidemiology

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ABSTRACT

Background

There has been concern that the use of alcohol-containing mouthwash may increase the risk of developing oropharyngeal cancer, or OPC. The authors examine the epidemiologic literature relating to this issue.

Types of Studies Reviewed

The authors identified all nine English-language epidemiologic studies of OPC that made reference to mouthwash. The findings and major strengths and limitations of each study are described. In addition, the authors reanalyzed data from one of the studies.

Results

The results of six of the studies reviewed are negative and provide no support for the hypothesis that use of alcohol-containing mouthwash increases the risk of OPC. One of the three studies with positive results was a case series and included a follow-up case-control study, the results of which were negative. The authors reanalyzed the study with the most positive results. This analysis found that the study results were just as positive for nonmucosal cancers developing in the mouth as they were for the usual type of OPC. The authors concluded that this study’s positive finding resulted from recall bias.

Clinical Implications

It is unlikely that the use of mouthwashes that contain alcohol increases the risk of developing OPC.

Section snippets

GENERAL CONSIDERATIONS

In 1979, a combined case-series report and case-control study raised concern that use of alcohol-containing mouthwash, or ACM, also causes oropharyngeal cancer, or OPC.6 We review that report below, as well as all of the other available epidemiologic studies. In addition, we describe four general considerations that bear on epidemiologic studies of the ACM-OPC relationship.

First, relative risks, or RRs, for OPC up to 5 commonly are seen for smoking7 and up to 15 for the synergistic effect of

OVERVIEW OF EPIDEMIOLOGIC STUDIES

Nine epidemiologic studies relating to mouthwash use and OPC have appeared in the literature since 1979. Three included some positive results and six had results that were entirely negative. Eight of the studies are reviewed in chronological order. The ninth, a large and broadly based study, has been seen as providing some support for a causal relationship between ACM and OPC. We review it in detail in the next section of this report.

In 1979, Weaver and colleagues6 first suggested a link

THE NATIONAL CANCER INSTITUTE STUDY

Investigators at the National Cancer Institute, or NCI, and at four cancer registries in the United States conducted a large, population-based case-control study of OPC. The purpose of the study was to describe in quantitative terms the effects of known and strongly suspected causes of OPC. The study also attempted to identify new causes of the disease. Cases were diagnosed between January 1984 and March 1985. Control subjects younger than age 65 years were selected via random-digit dialing of

A REASSESSMENT OF THE NATIONAL CANCER INSTITUTE STUDY

After publication of the report by Winn and colleagues,20 an oral pathologist reviewed the histologic appearance of the subjects’ diseases. He found that among men, the histologic appearance of 38 (6.6 percent) of the tumors was nonmucosal, while among women, the histologic appearance of 37 (12.6 percent) of the tumors was nonmucosal. The 75 nonmucosal cases consisted of 11 adenocarcinomas, 12 adenoid cystic carcinomas, 17 mucoepidermoid carcinomas, 13 sarcomas and 22 cases of Hodgkin’s disease

CONCLUSION

During the past 25 years, nine epidemiologic studies have been conducted of the relationship between alcohol-containing mouthwash use and the risk of developing OPC. While two of these studies include some positive findings, the weight of the evidence strongly suggests that use of ACM does not increase the risk of OPC.

Practicing dentists may recommend to their patients that they use the mouthwashes of their choice, including those that contain alcohol.

References (21)

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Dr. Cole received financial support for this study from the Warner-Lambert Company, Morris Plains, N.J., a Pfizer company.

The authors are grateful to Jack Vincent, D.D.S., Ph.D., for his assistance in performing the histologic review of the case material.

1

Dr. Cole is a professor emeritus at the Department of Epidemiology, School of Public Health, The University of Alabama at Birmingham, 1665 University Blvd., Birmingham, Ala. 35294-0022.

2

Dr. Rodu is a professor, Department of Pathology, School of Medicine, The University of Alabama at Birmingham.

3

At the time of this study, Dr. Mathisen was a biostatistician at the Warner-Lambert Company. She now lives in Ambler, Pa.

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