Missing and decayed teeth, oral hygiene and dental staining in relation to esophageal cancer risk: ESCCAPE case-control study in Kilimanjaro, Tanzania

Blandina T Mmbaga 1 2 , Amos Mwasamwaja 1 , Godfrey Mushi 1 , Alex Mremi 1 2 , Gissela Nyakunga 1 2 , Ireen Kiwelu 1 2 , Remigi Swai 1 , Godwin Kiwelu 3 , Sophia Mustapha 3 , Eliawawomy Mghase 3 , Amana Mchome 4 , Redfan Shao 5 , Evarista Mallya 6 , Deogratias S Rwakatema 1 2 , Kajiru Kilonzo 1 2 , Oresto Michael Munishi 1 , Behnoush Abedi-Ardekani 7 , Daniel Middleton 8 , Joachim Schüz 8 , Valerie McCormack 8
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In the African esophageal squamous cell carcinoma (ESCC) corridor, recent work from Kenya found increased ESCC risk associated with poor oral health, including an ill-understood association with dental fluorosis. We examined these associations in a Tanzanian study, which included examination of potential biases influencing the latter association. This age and sex frequency-matched case-control study included 310 ESCC cases and 313 hospital visitor/patient controls. Exposures included self-reported oral hygiene and nondental observer assessed decayed+missing+filled tooth count (DMFT index) and the Thylstrup-Fejerskov dental fluorosis index (TFI). Blind to this nondental observer TFI, a dentist independently assessed fluorosis on photographs of 75 participants. Odds ratios (ORs) are adjusted for demographic factors, alcohol and tobacco. ESCC risk was associated with using a chewed stick to brush teeth (OR 2.3 [95% CI: 1.3-4.1]), using charcoal to whiten teeth (OR 2.13 [95% CI: 1.3, 4.1]) and linearly with the DMFT index (OR 3.3 95% CI: [1.8, 6.0] for ≥10 vs 0). Nondental observer-assessed fluorosis was strongly associated with ESCC risk (OR 13.5 [95% CI: 5.7-31.9] for TFI 5+ v 0). However, the professional dentist's assessment indicated that only 43% (10/23) of participants assessed as TFI 5+ actually had fluorosis. In summary, using oral charcoal, brushing with a chewed stick and missing/decayed teeth may be risk factors for ESCC in Tanzania, for which dose-response and mechanistic research is needed. Links of ESCC with "dental fluorosis" suffered from severe exposure misclassification, rendering it impossible to disentangle any effects of fluorosis, extrinsic staining or reverse causality.