Background. Independent carcinogenic effects of alcohol drinking and tobacco smoking as well as their interaction can be usefully studied in a population of heavy drinkers and smokers. Methods. A hospital‐based case‐control study was conducted during 1972 to 1983 in a large Veterans hospital in East Orange, New Jersey. A total of 359 oral cavity‐oropharynx cancer cases and 2280 controls were interviewed according to tobacco smoking, use of smokeless tobacco, alcoholic beverage, coffee and tea drinking, race, family origin, religion, and occupation as bartender. Results. Odds ratio of oral cancer increased up to the level of 35 cigarettes per day and 21 whiskey equivalents per day: no further increase was found for higher level of exposure to either factor. A protective effect of quitting smoking was found, but the number of former smokers was small. No difference occurred in oral cancer risk according to type of alcoholic beverage drunk. An interaction effect compatible with a multiplicative model was found between the two exposures. Blacks were at lower risk than whites, and, in the latter group, individuals of Italian origin were at lower risk than individuals from northern or central European countries. Conclusions. Alcohol drinking and tobacco smoking were responsible for the majority of oral cancer cases in this population of US Veterans.

An examination of the oral cavity and oropharynx in asymptomatic patients at high risk requires an orderly visual inspection of the entire oral and oropharyngeal mucosa with particular attention to the tongue, floor of mouth, soft palate, uvula, tonsillar pillars, and the lingual aspects of the retromolar trigones. Completion and clear documentation of the entire examination should be recorded. Detected lesions that do not resolve in a reasonable length of time--two to three weeks--require intense and assiduous investigation. The following specifics should be considered. 1. Alcohol drinkers and cigarette smokers, especially those 40 years of age and older, are at very high risk for the development of upper aerodigestive tract and lung squamous carcinomas. 2. The floor of the mouth, the ventrolateral tongue, and the soft palate complex are the high-risk sites within the oral cavity and oropharynx. 3. Persistent mucosal erythroplasia rather than leukoplakia is the earliest visual sign of oral and oropharyngeal carcinoma. These lesions should not be regarded merely as precancerous changes. The evidence indicates that these lesions in high-risk sites should be considered to be invasive carcinoma or carcinoma in situ unless proven otherwise by biopsy. 4. Toluidine blue staining is a useful diagnostic adjunct, particularly as a method of ruling out false-negative clinical impressions. It may also be used as a rinse in high-risk patients to encompass the entire oral mucosa after a negative clinical examination and as a guide to improve biopsy yields. 5. If oral or oropharyngeal cancer is identified, evaluations of the larynx, hypopharynx, esophagus, and lungs should be performed to rule out multiple primary cancers.(ABSTRACT TRUNCATED AT 250 WORDS)

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A series of 359 male patients with 424 cancer lesions of the oral cavity and oropharynx identified at a US Department of Veterans Affairs Medical Center were divided according to site of origin of the lesion and compared with 2,280 controls from the same hospital with respect to exposure to tobacco smoking and alcohol drinking. Sites of origin were: floor of the mouth (I 53), oral tongue (50), anterior tonsillar pillar (49), soft palate (44), lingual aspect of retromolar trigone ( I I), alveolar ridge (5), buccal mucosa (4), and hard palate (2). Forty-one patients had cancers in multiple sites. Tobacco smoking was more strongly associated with soft-palate lesions than with lesions in more anterior sites. Patients with cancer of floor of the mouth and oral tongue had higher odds ratios for alcohol drinking than subjects with cancers of other sites. This study supports the hypothesis of the carcinogenic effect of tobacco smoke and alcoholic beverages on the oral mucosa through direct contact.

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