The Mouth as Body's Mirror 
by Judy Folkenberg 

The mouth:  Lovers kiss with it, babies coo with it, fighters curl it in
rage, winners lift it up in victory, and the doctor looks into it.

In fact, approximately 20 percent of visits to the doctor are because of
mouth or throat complaints.   But by peering into the mouth the doctor may
discover more than a strep infection or a canker sore.  It is a truism in 
medical circles that the mouth is the mirror of the body.  "The mouth is
affected by many bodily processes," says  Jerome Goldstein, M.D., executive 
vice president of the American Academy of Otolaryngology--Head and Neck 
Surgery.

When the doctor asks you to stick out your tongue and say "aah," he or she
may discover tell-tale clues that reflect underlying disorders elsewhere in 
the body.  Stories are legendary of physicians who looked carefully at a
patient's tongue and cleverly diagnosed disorders in other areas of the 
body. 

Donald R. Haggerty, D.D.S., M.D., a medical officer with the Food and Drug
Administration, recalls a patient who complained of a persistent bad taste
in her mouth.  Haggerty discovered multiple telangiectasis (little red spots
formed by dilated blood vessels) in her mouth.  Further evaluation revealed 
difficulty in swallowing and cold hands, leading to a diagnosis of a
particular connective tissue disease--a serious chronic disease of the skin 
and internal organs.

Other disorders may also signal their presence by oral symptoms.  Gums that 
have grown over the teeth may mean a patient has leukemia.   A red or furry 
tongue may indicate scarlet fever; a tongue covered with brownish sores,
typhoid fever; and a pale, smooth glossy tongue, pernicious anemia.  A fine 
black line that appears on the gums is an important diagnostic sign of
chronic lead poisoning, while spongy gums signal chronic mercury
poisoning.

A doctor can also find diagnostic clues to Addison's disease (a disease of
the adrenal glands that afflicted the late President John F. Kennedy),
diabetes mellitus, vitamin B deficiency, scurvy, Sjogren's syndrome (an 
autoimmune disorder described in the February l989 FDA Consumer article 
"Eyes Too Dry to Cry:  How Sjogren's Syndrome Makes the Body a 'Desert'"),
inflammatory bowel disease, and multiple sclerosis by examining the oral
cavity.   Foul breath may indicate a lung abscess.  Pain in the jaw may mean
a patient is suffering from angina.  And an extended tongue that bends to 
one side may indicate a stroke. 

"The mouth is a valuable reflection of what's going on elsewhere in the 
body," says Goldstein.

Common Complaints 

Although the condition of the mouth can provide a wealth of information 
about disorders elsewhere in the body, in most cases, complaints about the
mouth or throat are usually more mundane.  Following are some of the most 
common reasons people visit the doctor for mouth problems.

Fever Blisters or Cold Sores-- Painful little blisters about the size of a
dime that usually form on the lips, cold sores are caused by herpes simplex 
virus type-one or HSV-1.  (Genital herpes is caused by a cousin, known as 
HSV-2.)   Most people have been infected by the virus (40 percent of
Americans acquire the virus by age 30), but it lies dormant in the body,
flaring up from time to time with a cold or fever, exposure to excessive
sunlight, or during periods of stress.   People with cold sores should avoid
kissing others and making skin contact with newborns or people with weakened
immune systems--who are particularly vulnerable to infection. 

There is no cure for cold sores; they must run their course.  Keeping the 
affected area clean or using a protective cream may help relieve the pain.
Over-the-counter products usually contain astringents that dry tissues, but 
these products do not necessarily speed healing.  People who are susceptible
to cold sores brought on by sun exposure should use a sunscreen on their
lips.  Persons experiencing recurring cold sores should consult their 
doctors.  One drug for treating herpes, Zovirax (acyclovir), is available by
prescription as either an ointment or capsule.

Canker Sores-- Not to be confused with cold sores, these sores are ulcers 
that occur in the mucous membrane inside the mouth.  They can range from the
size of a pinhead to the size of a quarter and may appear alone or in 
clusters.  Most canker sores heal within two weeks, although recurrent
canker sores may afflict some people.  One out of every two people will have
at least one episode during their lifetimes.

The cause of canker sores remains a mystery,  although stress may be a
factor.  For example, college students are most often afflicted before exam 
time.  Certain foods, such as nuts, or sweet and acidic foods may cause 
canker sores.  They may also result from deficiencies of folic acid, iron,
or vitamin B12.  Even genetics play a role:  A predisposition to canker 
sores runs in families. 

There is no treatment that speeds healing, but antiseptic mouthwashes may 
prevent their spread.  "Washing the infected area with hydrogen peroxide may
also relieve the symptoms," says Jean Rippere, a microbiologist with FDA. 

Xerostomia (dry mouth)-- There are many disorders that can cause a dry
mouth, such as  diabetes, anemia, Sjogren's syndrome, infection of the
salivary glands, stress, even aging.   Treatment falls into two categories: 
saliva substitutes and saliva stimulators.   Demulcents such as glycerin
solution soothe and coat the dry area.   And a simple remedy such as
sugarless lemon drops may temporarily stimulate some salivary flow.  For
some persons, a dry throat may simply be the result of not drinking enough
water.  The remedy, of course, is to drink more water.

Sore Throats-- A sore throat is a common medical complaint that can be
caused by allergies or irritations such as industrial pollutants, tobacco 
smoke, dry heat during the cold winter months, and cheering too loudly at a 
sports event. 

Viruses and Infections

The most common causes of sore throats are viral illnesses (such as the 
"flu," the "common cold," or mononucleosis) or bacteria (such as
Streptococcus).  A viral sore throat can be a symptom of measles, chicken 
pox, or whooping cough.  Antibiotics can be used to treat bacterial 
infections but have no effect against sore throats caused by viral illness. 
The body heals itself of a viral infection by building up antibodies that 
destroy the virus.

Such over-the-counter remedies as throat lozenges or anesthetic sprays may
bring some relief.  Increasing liquid intake (warm tea with honey is a
favorite), gargling with warm salt water, and using a humidifier or mild
pain relievers may also offer temporary relief. 

Bacterial infections in the nose and sinuses can cause sore throats because 
mucus drains down into the throat, carrying the infection with it.  One of
the more serious kinds of bacterial infection is caused by Streptococcus
bacteria.  As many as 1 out of l0 Americans develops "strep throat" every 
year, and 40 million adults will see a doctor for it, according to the
American Academy of Otolaryngology.  Complications of streptococcal 
infections include tonsillitis, pneumonia, scarlet fever, and ear 
infections.  A strep test approved by FDA a few years ago for use in a
doctor's office detects an infection in about 15 minutes rather than the 24 
hours usually required for a throat culture.  Antibiotics can be
administered if the test results are positive.

FDA is currently evaluating over-the-counter mouth remedies to make sure the
ingredients are safe and effective.  "If we discover that some ingredients
do not live up to their billing or are unsafe, we will request that the 
manufacturer reformulate the product," said FDA's Rippere.

Role of Emotions

Not only does the mouth reflect what is happening elsewhere in the body, but
changing the posture of the mouth can elicit bodily changes.  Even a mere 
smile or frown can affect the nervous system.  Researchers from the 
University of Michigan and the University of California Medical School at 
San Francisco have shown that lifting the corners of the lips in a smile or 
puckering the lips in a frown can affect the temperature of the blood 
flowing to the brain and change heart and breath rate.

In a series of experiments, participants were told to arrange their face and
mouth in different poses.  But the volunteers were not told what emotion
they were mimicking or even that the study was testing the relationship 
between facial expressions and emotions.  Volunteers reported feeling the 
emotion their expressions portrayed.  For instance, when volunteers puckered
their lips and mouthed  the word "few" they reported feeling depressed or 
"down" even though they didn't know they were expressing a "down" mood.  In 
other words, facial expressions are not only a sign of an emotion but 
actually contribute to the feeling itself.

Although people may pay little heed to their mouths except when something 
goes wrong, the importance of the mouth cannot be underestimated. Its 
condition provides clues to disease elsewhere in the body, and its
posturings can affect a person's emotions so that just as the eyes are a
window to the soul, so the mouth is a mirror of the body. 

Judy Folkenberg is a member of FDA's public affairs staff.

FDA Consumer
Dec89-Jan90 

Oral Cancer on Rise 

The seventh most common cancer--oral cancer--may be on the rise because of
the increased use of snuff and chewing tobacco, or "smokeless tobacco," 
among teenage boys. 

Oral cancer occurs on the lip, tongue, or floor of the mouth.  Smoking and
drinking also increase the risk of oral cancer, but smokeless tobacco is of 
special concern because of its appeal to teenage boys.

Smokeless tobacco comes in two basic forms:  finely ground tobacco or snuff,
and loose leaf tobacco sold in pouches or plugs.    An estimated 16 million 
Americans use smokeless tobacco, 3 million of whom are under 21.   Sixteen
percent of all males between the ages of 12 and 17 used smokeless tobacco in
1985, according to the American Academy of Otolaryngology--Head and Neck
Surgery.  The habit has filtered down to even younger ages in some
localities:  A University of North Carolina study showed that one-third of
the first-grade boys in rural North Carolina had tried smokeless tobacco. 
And according to another study, 21 percent of 112 Arkansas kindergartners 
had indulged. 

Chewing tobacco, a habit commonly associated with elderly gentlemen and 
southern farmers, caught on among teenagers in the mid-1970s when U.S.
Tobacco Company (the major manufacturer of smokeless tobacco) began an
aggressive ad campaign especially targeted towards young men.  Endorsements 
by such sports heroes as Catfish Hunter (a former New York Yankee pitcher), 
Earl Campbell (former running back for the Houston Oilers), and Walt
Garrison (former running back, Dallas Cowboys) promoted smokeless tobacco 
and changed its image.   In a growing number of youthful circles, smokeless 
tobacco became a socially acceptable symbol of virility, machismo and 
coolness. 

In a further bid to attract teenagers, U.S. Tobacco Co. offered free samples
of smokeless tobacco and concocted low-nicotine and fruit-flavored brands.
(One "adult" brand, for instance, has seven times the amount of nicotine as 
the "junior brands," and most young boys who might first experiment with the
adult brand would end up nauseous.) 

By 1985, tobacco's opponents began striking back.  In that year,
Massachusetts became the first state to require   warning labels on 
smokeless tobacco.  Other states considered similar action.  Federal
legislation requiring uniform labeling was passed in l986.   Dentist Greg 
Connolly, D.M.D., a leading opponent of smokeless tobacco and director of 
the Office for Nonsmoking and Health in Massachusetts, pressured U.S. 
Tobacco to stop using current sports heroes to endorse smokeless tobacco
products. 

Though proponents claim that smokeless tobacco is a safe alternative to 
smoking, the 1986 Report of the Advisory Committee to the Surgeon General 
doesn't see it that way.   Smokeless tobacco is causally related to oral
cancer, says the report.  In fact, the report says that the increased risk
of cancer of the cheek and gums may reach nearly fiftyfold among long-term
snuff users.

Nitrosamines, the chief cancer-causing compounds in smokeless tobacco, are
contained in the tobacco.    A dip of snuff, for instance, delivers 10 times
more nitrosamines than a cigarette. 

Despite this risk, the habit is attractive for many users.  Jared Taylor of 
Menlo Park, Calif., a fourth-generation chewer who quit after 15 years
because of his concern over the link between chewing tobacco and cancer,
nevertheless admits he misses his habit.  "We were always a very religious
family and thought smoking was a sin--it had to be a sin to burn up anything
that tasted that good," says Taylor wryly.

Precancerous signs, such as leukoplakia (a white plaque on the gums, cheek
or roof of the mouth) may appear after only one year of use.  Once oral 
cancer strikes, it can spread rapidly--and "the first stop is the neck,"
says  Jerome Goldstein, M.D., executive vice president of the American
Academy of Otolaryngology.

"Head and neck surgery can mutilate and affect function," says Connolly.
"If the cancer is not caught early enough, a person can lose his teeth, 
salivary glands, portions of his jaw, or sections of the neck or cheek."
The tongue may also have to be cut out--and the person is rendered
speechless or speaks in a garbled manner, according to Connolly.

Although sports heroes no longer endorse smokeless tobacco products,
baseball players remain major users.  A recent survey of 282 major league 
baseball players published in the )INew England Journal of Medicine )Rshowed
that over half were past or current users of smokeless tobacco.  In a 
baseball tradition going back to Babe Ruth, who was a heavy snuff dipper, 
the bulge in the back pocket--a tin of snuff or chewing tobacco--is a 
familiar sight on the baseball field.  (Ruth, who also smoked, died of
throat cancer.) 

The American Academy of Otolaryngology has launched a campaign to warn the
public--and especially teenage boys--about the dangers of smokeless 
tobacco.   The academy has also formed an organization called "Athletes 
Through With Chew,"  whose spokesmen are all-star pitcher Nolan Ryan of the 
Texas Rangers and Bobby Brown, M.D., president of the American Baseball 
League. 

The teenage set is at risk.  William Frederick McGuirt, M.D., a head and
neck surgeon at the Bowman Gray School of Medicine in Winston-Salem, N.C.,
says he is seeing more and younger smokeless tobacco users with either
pre-malignant signs of cancer or dental problems such as receding gums. 

Most scientists predict that though it will take 20 or 30 years for the rate
of oral cancer to increase due to current smokeless tobacco use, such an
increase is inevitable. 

As Connolly says, "oral cancer is a time bomb ticking away in the mouths of 
adolescents." 

--J.F.