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Year : 2021  |  Volume : 12  |  Issue : 2  |  Page : 79-86

Patient Awareness of Oral Health and Periodontal Disease as a Potential Risk Factor of Breast Cancer

1 Periodontics Division, Dentistry Program, Batterjee Medical College, Jeddah, Saudi Arabia
2 General Dentist, Graduate of Dentistry Program, Batterjee Medical College, Jeddah, Saudi Arabia

Date of Submission02-Nov-2020
Date of Decision02-Dec-2020
Date of Acceptance28-May-2021
Date of Web Publication26-Jul-2021

Correspondence Address:
Mohamed Roshdy
Dentistry Program, P.O. Box 6231, Batterjee Medical College, Jeddah 21442
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/denthyp.denthyp_172_20

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Introduction: Breast cancer (BC) is a public health problem and the most frequent malignancy among women. Oral health is important and directly related to the overall general health of the body; it is dependent and related to oral health knowledge and oral hygiene behavior. Several studies have associated links between BC and periodontal disease (PD). The aim of the study was to assess oral health and periodontal disease awareness and potential risk factors of BC in a sample of Jeddah residents. Materials and Methods: A cross-sectional study was conducted on 106 adults with a self-answered questionnaire in the framework of a community service initiative sponsored by the Ministry of Health on the occasion of the world BC month, where the college students participated in. Results: In our study population, 68.68% of participants expressed proper oral hygiene awareness, while merely 42.72% identified the correct risk factors of BC. Only 12.3% had awareness of PD as a potential risk factor of BC, and their awareness was measured against their oral hygiene and periodontal health awareness, where 92.3% acknowledged the negative effect of oral hygiene neglect on the overall body health, 76.9% heard of dental plaque biofilm, and only 23.1% identified it as the causative of PD. Finally, 61.5% cleaned their teeth twice a day in accordance with the recommendations of the Saudi Dental Society. Conclusion: There is an urgent need for comprehensive educational programs to promote correct oral hygiene practice and educate on its positive impact on the overall body health. The knowledge and awareness on BC and PD can still rise by community services and awareness campaigns throughout the city of Jeddah.

Keywords: Awareness, breast cancer, oral hygiene, periodontal disease, risk factors

How to cite this article:
Fouad A, Patel F, Al-Thagafi M, Yahya M, Roshdy M. Patient Awareness of Oral Health and Periodontal Disease as a Potential Risk Factor of Breast Cancer. Dent Hypotheses 2021;12:79-86

How to cite this URL:
Fouad A, Patel F, Al-Thagafi M, Yahya M, Roshdy M. Patient Awareness of Oral Health and Periodontal Disease as a Potential Risk Factor of Breast Cancer. Dent Hypotheses [serial online] 2021 [cited 2022 Jul 3];12:79-86. Available from:

  Introduction Top

One of the leading causes of death in the world including Saudi Arabia (SA) is cancer; breast cancer (BC) tops the list from among several other malignancies. While BC is more common in females, males are more prone to prostate cancer. In 2008, of all deaths, 13% were due to cancer and its burden will continue to increase in the next decades.[1],[2]

In SA, it was established that BC ranked first among females accounting for 27.4% of all newly diagnosed female cancers (5378) in the year 2010. Despite the incidence of BC being similar among USA and SA, the difference is found in the age of patient (younger than 50 years of age in SA) and the stage of disease upon clinical presentation.[3]

As many other diseases, cancer is multifactorial including age, gender, alcohol, smoking, pregnancy, chronic inflammation, oxidative stress or shared genetic factors that contribute to host susceptibility. Furthermore, BC has been found to be associated with early menarche, late menopause, and ethnicity in addition to the previously mentioned factors.[2],[3],[4],[5]

Oral health is important and directly related to the overall general health of the body. Worldwide, the most common oral inflammatory processes are caries and periodontal diseases (PD), which emanate from an undisturbed growth of oral bacteria colonizing the tooth surfaces and forming oral biofilms.[1],[2],[3],[4],[5]

Indeed, infection-driven inflammations have been projected to be involved in the pathogenesis of approximately 15% to 20% of human tumors. Studies in particular on gastrointestinal malignancies have shown that the large amounts of cytokines, inflammatory mediators, and growth factors released during inflammation by immune and nonimmune cells may influence the process of carcinogenesis.[2],[5]

Several studies have associated links between BC and PD among both genders.[1],[2],[3],[4],[5],[6] Smoking is also the most important risk factor for periodontal health and immune response, and the epidemiological and clinical consequences of this have been extensively reviewed.[1],[5] Current and former smokers being immunocompromised are at a higher risk of having BC. As in the case of PD, the cytokine receptor activator of nuclear factor-κB (RANK) and its ligand (RANKL) may be important in breast carcinogenesis and metastasis as well. Blood and salivary RANKL are increased in PD, especially among smokers.[5]

Periodontitis is the main cause of tooth loss in middle-aged and elderly people and counts for 28% of extractions.[1],[2],[4],[5] Bacteria can also enter the blood stream during activities such as tooth brushing, flossing, and chewing, particularly among those with PD.[5] This emphasizes the importance of oral health to general health and role of oral cavity as a source of systemic infections also linked to carcinogenesis.[1],[7]

Periodontal pathogens can directly affect carcinogenesis because of the exposure of breast ductal tissues to bacteria and viruses during lactation. Also, human milk contains a complex and variable array of microbes.[5] The origins of microbes in breast tissues and tumors are not known but the oral cavity and gut might contribute as similar strains of oral bacteria are found in the tumors. Use of certain antibiotics may alter this flora and make them more resistant to treatment, hence increasing mortality.[5]

The findings of an experimental study on a mouse model supported the idea that periodontal inflammation promoted metastasis of 4T1 BC cells and defined the role for interleukin (IL)-1β in the metastatic progression of BC, highlighting the need to control periodontitis as a prevalent inflammatory condition in older patients.[8]

Owing to the important role of inflammation in the progression of periodontitis, there has been an increasing concern in therapies that could improve the effects of scaling and root planing (SRP) or adjuvant therapies by specifically reducing the inflammatory mediators. This was demonstrated by Isola et al.,[9] who analyzed and compared a new nutraceutical agent compound (Baicalin and Palmitoylethanolamide) as an adjunct to SRP versus SRP alone for the treatment of periodontitis patients followed for a 6-month period for clinical parameters, pain experience, and measurement of inflammatory mediators IL-1β, and IL-10, and tumor necrosis factor-α.

The overall meta-analysis of 11 studies by Shao et al.[4] suggested that the risk of developing female-specific BC was 1.22 times greater among patients with PD than those without PD. Contrarily, Jia et al.[10] observed no clear association between PD and overall BC risk in a large prospective cohort study following 49,968 women aged 35 to 74 years without prior BC from 2003 to 2017.

To date, the best method to prevent BC is by knowledge and to have early detection by self-examination.[11] Treatment of BC is based on the tumor stage and biomarkers; this typically includes surgery, followed by systemic therapy (chemotherapy and antiestrogen therapy) plus or minus radiation. Nevertheless, these have deleterious effects on oral and general health acutely and chronically in addition to compliance with treatment.[6]

Personalized periodontics and epigenetics are innovative approaches that take into account individual differences in genes, environments, lifestyle, and behavior. Thus, personalized periodontics could be defined as separation of patients into different groups, with clinical decisions, practices, and products being customized to an individual patient.[12]

Therefore, knowing the patient’s genetic profile or their predisposition to disease could be very useful in diagnosing PD and in defining a personalized therapeutic plan. In addition, it could give prognostic indications of the outcome of the disease.[13]

Saliva-based diagnosis surfaced as a promising clinical scheme, allowing correlations between salivary diagnostics and a tangible disease.[14] López-Jornet et al.[15] evaluated the diagnostic value of salivary biomarkers in BC and concluded that the biomarkers CA125 and sFas were significantly increased in saliva of patients with BC.[16] Although BC is on the rise, previous studies at several regions of SA (Buraidah, Riyadh, Jeddah, Ahsa, Qassim) or other countries such as Egypt, Iran, Jordan, Nigeria, and Turkey have reported low levels of awareness even among university educated participants and health care professionals.[6],[11],[17],[18],[19]

Interventions are needed to spread awareness about early prevention of BC and its effects on oral health, including a BC self-examination (BSE) and hence reporting to an available medical facility. As BSE is the single most effective and cost-efficient method of early detection in comparison to a mammogram, targeted persons should include, apart from general public, medical professionals and students who can be faster and cheaper outlets of awareness spread in order to overcome an ever-increasing burden of this disease among Saudis.[6],[11],[17]

Consequently, the aim of this study was to assess oral health and PD awareness as a potential risk factor for BC in a sample of Jeddah residents. Moreover, we specifically proposed the hypothesis that the level of awareness about the role of PD as a potential risk factor in the pathogenesis of BC is still low despite the rise in documented cases of the disease and the increased number of targeted community media campaigns addressing this malignancy.

  Participants and Methods Top

A cross-sectional study was conducted on 106 adults during a community service event sponsored by the Ministry of Health (MOH) on the occasion of the world BC month. Study protocol approved by ethics review committee of the Batterjee Medical College.

An informed nonverbal consent was obtained from the visitors who participated via a self-answered questionnaire. The questionnaire was formulated by review of articles and the World Health Organization (WHO) guidelines and translated into the local language, that is, Arabic, by a certified translator. Arabic translation was pretested for validity and reliability and modified accordingly.

The questionnaire consisted of 26 close-ended questions divided as follows: demographic data (four questions), oral hygiene awareness (OHA) (five questions), periodontal health awareness (five questions), BC risk awareness (11 questions), and PD as a potential risk factor BC (one question). The participants responded to each question according to the response format provided.

Each questionnaire was revised after it was filled out to eliminate incomplete answers; data entry was performed by members of the research team. To preserve privacy, participants’ data were saved in a private computer accessible by the research team only.

Data were analyzed using IBM Statistical Package for the Social Sciences (SPSS) software version 20.0 (IBM Corp., Armonk, NY). Qualitative data were described using number and percent, while quantitative data were described using range (minimum and maximum), mean, standard deviation, and median. Significance of the obtained results was judged at the 5% level. Comparisons between groups for categorical variables were assessed using chi-square test (Fisher or Monte Carlo).

  Results Top

A total of 106 participants responded to the questionnaire on site. Of them, a majority were females (n = 93, 87.7%) compared to males (n = 13, 12.3%). Majority of the participants were young adults between the age group from 20 to 29 years (n = 55, 51.9%), and the next major age group was from 30 to 39 years (n = 22, 20.8%). None of the participants were illiterate; rather, they (n = 66, 62.3%) had a graduate degree [Table 1].
Table 1 Distribution of the studied cases according to demographic data

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The majority of the participants agreed that oral hygiene is important for the well-being of the overall health (n = 102, 96.2%). Furthermore, n = 69 (65.1%) cleaned their teeth twice a day and n = 59 (55.7%) changed their toothbrush once in 3 months in accordance with the American Dental Association recommendations. An over-meticulous group had the habit of changing their brushes every month as well as using it thrice or more a day, that is, n = 26 (24.5%) and n = 24 (22.6%), respectively.

Interdental cleaning was done majorly by floss (n = 57, 53.8%). Next common use was of the wooden dental stick (n =18, 17%) and then the interdental brush (n = 12, 11.3%). But n = 19 (17.9%) were not using any means of interdental cleaning aids [Table 2].Plaque and calculus were commonly heard about terms (n = 80, 75.5%) and (n = 90, 84.9%), respectively; nevertheless, the etiology of PD was attributed more to calculus (n = 36, 34%) than to the main etiologic factor, that is, plaque (n = 30, 28.3%) [Table 3].
Table 2 Distribution of the studied cases according to oral hygiene awareness (n = 106)

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Table 3 Distribution of the studied cases according to periodontal health awareness (n = 106)

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The distribution of the participants’ awareness levels to the detailed BC risk factors is shown in [Figure 1]. Only n = 13 (12.3%) participants had awareness of PD as the potential risk factor of BC, and their awareness was measured against their oral hygiene and periodontal health awareness, where n = 12 (92.3%) acknowledged the negative effect of oral hygiene neglect on the overall body health, n = 10 (76.9%) heard of dental plaque biofilm, and only n = 3 (23.1%) identified it as the causative of PD. Finally, n = 8 (61.5%) participants cleaned their teeth twice a day in accordance with the recommendations of the Saudi Dental Society [Table 4].
Figure 1 Distribution of the participants (n = 106) according to breast cancer risk factors reflecting awareness levels in percentage (%)

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Table 4 Correlation between knowledge of periodontal diseases could be a potential risk factor for breast cancer and parameters of oral hygiene and periodontal awareness (n = 106)

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  Discussion Top

Health - being as precious as it is - must be guarded from vicious diseases like cancers. Our interest was specific to BC due to several studies linking it to PD. Hence, we aimed toward creating awareness among patients attending a community service program on the occasion of the World Breast Cancer month of October in association with the MOH at a charity hospital, in the city of Jeddah.

Time trends in prevalence of risk factors can be directly correlated with time trends in BC incidence.[20] Approximately 10 years ago, the WHO predicted that an increase in life expectancy and drastic changes in lifestyle are expected to lead to an epidemic of BC in majority of the developing countries by the first quarter of the 20th century (i.e., 2020).[21]

Well-known risk factors include gender, age, genetics, and smoking as well as certain gynecologic and endocrine factors such as early menarche and late menopause. Early diagnosis and treatment are important steps in prevention of the disease.[22] Moreover, bacterial-induced inflammations such as PD also have a role in the pathogenesis of some cases of BC.[7]

Of the 106 participants of our study, the majority were single young adults with 100% literacy rate, minimum being high school and as high as a college graduate unlike any previous studies. The most popular risk factors known by our study population were age, genetics, smoking, and alcohol consumption (averaging 54%). Oral contraceptive (37.7%) use came next in line, but PD was least of a concern (12.3%). A higher percentage (28%) was rather affirmative that PD is not a risk factor.

Age is an associative factor to several diseases, combined with the long-term effects of lifestyle aspects like diet and fitness levels; hence, early awareness and prevention are vital. If well aware of preventive measures, young adults could lead a healthier life later on. Our results revealed that 57% accepted increased age to be a risk factor, which is lesser than the study by Al-Suroj et al.[17] at 85% and contradicting to the study by Suleiman[18] at 16% in Jordan.

Our results showed that only one-third of the participants considered early menarche a risk factor, despite 88% of our participants being females, similar to residents of Ahsa,[17] furthermore, nearly the same percentage considered late menopause to be a factor too.

We studied correlations between the oral hygiene practices and the OHA. The largest number of people (n = 57, 60%) used floss as an interdental cleansing aid, and of this group of flossers, n = 38 (59.6%) were changing their toothbrush once in 3 months and n = 34 (66.7%) were brushing twice a day. Furthermore, five out of the 12 people who used the interdental brush were also replacing their main brushes within 1 to 3 months. Although these results were significant within the results of our study, it infers that OHA and its practice are still deficient and many people might be on the path to PD.

Lack of knowledge has been previously reported in the literature by Garber[23] and Lewis et al.[24] apart from social and cultural beliefs and lack of cooperation. Plaque is the chief cause of any oral disease as proven by science. Of the number of people who have heard about plaque (n = 30, 71%), they either do not consider it to be an etiology or have no knowledge about it, while among those who have heard about calculus (n = 36), 89% attribute it to be an etiology, hence displaying a dire lack of knowledge, especially that dental plaque is the main etiological reason for gingival and periodontal disease. Moreover, controlling plaque is an integral step in prevention of PD and crucial goal of periodontal therapy in periodontitis patients.[9]

Although 28% are in no doubt that PD is a risk factor of BC, 60% of our study population either do not know or are not sure about it. These are similar to the previous reported studies by Al Otaibi et al.[11] and Al-Suroj et al.,[17] but larger than the Turkish study[19] in which 23.4% had no knowledge of BC. Furthermore, young adults who have undiagnosed and/or untreated oral infections are more likely to develop systemic disorders, including cancer.[2]

Awareness of both risk factors and the disease is low in general in our study as in previous studies, but higher in the population who have had a personal experience by self, family, or peers (i.e., primary or secondary exposure). There is a need to increase the educational material about BC survivorship issues in dental hygiene and continue educational programs. Public and private sectors should collaborate through comprehensive educational programs that promote awareness, good oral hygiene practice and overall wellbeing. Interventions are also needed to spread awareness about early prevention of BC including a BSE and the effects of oral health on the overall well-being.[23],[24],[25],[26]Recently, the scope of using saliva as a complementary tool to improve medical evaluations has been thoroughly investigated; this renders saliva an optimum choice for the detection of BC since saliva sampling is noninvasive and safe and is relatively simple to perform.[15]

The causal relationship between inflammation, innate immunity, and cancer is nowadays widely accepted; however, many of the molecular and cellular mechanisms mediating this relationship remain unresolved. Even more, evidence supports the mutual interactions between host cells and the oral microbiome in the course of chronic periodontal inflammation that likely creates a tumor-favorable microenvironment that may promote cancer development and progression.[27],[28],[29]

Finally, the direction toward personalized dentistry as an ongoing multidisciplinary model aimed at tailoring health care with dental research, practice, and decisions specifically customized for the single patient is eminent, with the reliance on diagnostic tests and appropriate therapies specific to the patient based on personal genetic, physiological, epidemiological, and molecular analyses.[30]

The limitations of our study include the gathered data being self-reported and that no measures of disease presence had been used. Furthermore, in future studies, data may be collected, including full medical history and physical examination, and follow-up of the same cohort group of patients for 3 to 5 years may be of added value.

  Conclusion Top

Irrespective of the nature of the relationship, whether causal or co-occurrence, a definite relationship between these two diseases would help informing health promotion initiatives and enterprises for women at higher risk of BC or those who already have been diagnosed with the disease.

The advances in salivary biomarkers and personalized periodontics offer themselves as future candidates for periodontal diagnostics and therapy.

There is an urgent need for comprehensive educational programs to promote correct oral hygiene practices and educate on their positive impact on the overall body health. The knowledge of BC can still benefit from community services and campaigns throughout the city of Jeddah.

The present study indicated that oral health and PD awareness levels as a potential risk factor for BC are low. However, further studies with a larger sample and different design are needed in order to analyze the actual reasons of such awareness levels.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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