The graphic images that appear on cigarette packages have been found to work when it comes to encouraging smokers to quit and discouraging nonsmokers from starting. If anyone needs any further convincing about the negative health effects of nicotine, they might want to sit down with Dr. Eitan Prisman, an otorhinolaryngologist at Vancouver General Hospital who specializes in treating head and neck cancer.

Prisman regularly performs surgery on people with oral cancer, procedures that range from the removal of malignant lesions inside a person’s mouth to a total glossectomy or mandibulectomy, which involves, respectively, taking out the entire tongue or segments of the jaw, with or without neck “dissection”, in which lymph nodes or tissue from the collarbone to the jawbone is excised.

“There’s early-stage tongue cancer, where surgery involves removing the cancer and a small cuff of normal tissue with limited impact on tongue function, followed by a course of close follow-up of the patient,” says Prisman, who’s also an assistant professor at UBC, in an interview at his office. “More extensive surgeries are those where cancer invades the surrounding structures like the jaw or the sinuses or the nose. Removing these cancers results in large facial defects that significantly impact not only facial cosmetics but also the ability to eat and speak.

“When you lose more than one-third of the tongue, or segments of the jaw, we start talking about reconstruction,” he adds. “What we do in those cases is we rebuild the jaw or tongue by transplanting a vascularized piece of their tissue from the arm, thigh, or leg in the shoulder.”

Sometimes chemotherapy and radiation are needed as well.

Smoking is the leading cause of oral cancer.

In about 10 percent of people with oral cancer, the cause is unknown.

Yet there are other risk factors for the disease, which strikes approximately 3,200 Canadians each year, according to the B.C. Cancer Agency (BCCA). They include heavy alcohol use, which the BCCA describes as more than two or three drinks a day. Put smoking and drinking together and the risk of oral cancer skyrockets. Age, a history of head and neck cancer, immunosuppression, poor oral hygiene, and sun damage are other contributors, as is occupational exposure to inhaled wood dust, paint fumes, and certain chemicals.

Then there is the human papilloma virus (HPV), the same virus that causes cervical cancer. It’s highly associated with developing cancer at the back of the tongue and throat, namely cancer of the oropharynx. This is the type of cancer that Michael Douglas went public with and that affects the base and back part of the tongue and the tonsils. The actor’s disclosure helped raise awareness of oral cancer in general, a disease that’s poorly understood by the public despite its prevalence.

“Greater than 90 percent of the malignancies we see in the oral cavity are related to smoking,” Prisman says. “Smoking alone is a risk factor, and heavy drinking alone a risk factor. If you’re a smoker and a drinker, it’s multiplied.”

In B.C., 545 people (357 men and 188 women) were diagnosed with oral cancer in 2011, the last year for which statistics are available from the BCCA. There were more oral-cancer cases diagnosed in B.C. in 2003 than, separately, Hodgkin’s lymphoma, multiple myeloma, and cancers of the cervix, ovary, testicle, brain, and kidney.

Prisman explains that 30 years ago, the patient populations for oral cancer and oropharyngeal cancer were similar: about 80 percent smokers and drinkers. But the face of oropharyngeal cancer is changing.

“Now it [the patient population for cancer of the oropharynx] is about 20 percent smokers and drinkers,” Prisman says. “They’re younger, wealthier, and more educated. It used to be older men. Now it’s younger men and women, mostly men, without a significant smoking or drinking history but who have been infected with the HPV virus. This is the same virus that causes nearly 100 percent of cervical cancer. In the last couple of years in North America, there are more HPV-induced oropharyngeal cancers than cervical cancers.”

A publicly funded vaccine for HPV is available to girls in B.C. born in or after 1994, but not boys.

Routine Pap smears have led to early detection of cervical cancer, and screening for initial signs of oral cancer is becoming more common in B.C. That’s where regular trips to the dentist could be not just one more commitment but a life-saving task.

Oral cancer has been associated with high mortality and morbidity rates, largely because of late diagnosis. To change that, the BCCA has developed the B.C. Oral Cancer Prevention Program, working closely with the B.C. Dental Association and other health agencies. It’s a provincewide screening network that aims to detect the disease at the earliest possible stage, achieve better cure rates through more effective treatments, and improve early detection of recurrences.

“Dentists have taken on oral screening very seriously,” Prisman says. “They’re the perfect professional for frontline screening. We see cancer much earlier than we did 20 or 30 years ago.”

Signs of oral cancer include: an ulcer, sore, or swelling in the mouth that doesn’t heal; a lump, thickening, or rough spot in the mouth that doesn’t go away or gets bigger; the appearance of white or red spots in the mouth or on the lips; trouble chewing or swallowing; pain, numbness, or tenderness of the lips, mouth, jaw, or ear; changes in the way your teeth fit together or how your voice sounds; and a painless lump in the neck that doesn’t go away.

Many dentists now use devices that allow them to see changes in the mouth that may be associated with cancer that are not visible to the naked eye. According to the BCCA, oral-cancer screening takes less than two minutes.