A NEW QUESTIONNAIRE FOR ORAL AND LARYNX...

A NEW QUESTIONNAIRE FOR ORAL AND LARYNX CANCER SCREENING. INVESTIGATION AND PRELIMANARY RESULTS ON LARYNGECTOMEES

-DUCA, MASSIMO PHYSICIAN, ENT - INST.CLINIC.PERF .BUZZI (MILANO) ITALY

PHONE 39 3392277584: MAIL ADDRESS [email protected]

-MENICAGLI ROBERTO. SENIOR RESEARCHER BIOLOGICAL AND BIOCHEMISTRY

SCIENCE (MILANO) ITALY - PHONE 390290661201; MAIL ADDRESS: [email protected]

-MAROTTA ORTENSIO. PHYSICIAN DIR U.O ENT. S. Anna SAN SEBASTIAN HOSPITAL

CASERTA ITALY -PHONE 39 3396681590: MAIL ADDRESS, ortensio.marotta @ alice.it

- RANCOITA PAOLA MARIA VITTORIA;. UNIVERSITY RESEARCHER “CENTRE FOR

BIOMEDICAL SCIENCES STATISTIC” HOSPITAL SAN RAFFAELE (MILAN), ITALY,

PHONE 390 226 433 844. MAIL ADDRESS: [email protected]

KEY WORDS:

LARYNGEAL CANCER

MUCIN

QUESTIONNAIRE

SIALIC ACID

AUTOIMMUNE DISEASE

mailto:[email protected]

mailto:ITALY

mailto:[email protected]

ABSTRACT

The aim of this work was to verify the application of a new anamnestic questionnaire , also with

the possibility of self-evaluation, for preliminary screening in the identification of possible cancer

of the oral cavity and larynx.

-For the oral cavity and larynx there are not effective methods of screening for early detection of

cancer, there are not criteria for self-evaluation, detectable with questionnaires, as is the case for

example for cardiovascular disease, lacking both the identification of almost all risk factors, both

biological structure their main target. From this analysis of are proposed ten specific risk factors,

and their main target was found in the protein component of saliva, especially in secreted by glands

salivariMUC5B mucins, MUC7

- .It is proposed a questionnaire and submitted it tothe laryngectomees patients, and healthy control.

Questions are eleven, relating to the report and the knowledge that the patient has with what the

main hypothesis of this work is indicated as the main "natural defence" — that is, the set of

"MUC5B mucins and MUC 7. Every question aimed to assess the impact of each risk factor,

provides answers to which are assigned a score from zero to three, meaning based on literature data

if is absent or implemented a partial and/or total impairment of the protective functions of salivary

mucins; maximum score compatible with sufficient integrity of mucous mucin system was

established within eight points. Analysis of the results has been evaluated statistically using the

Fischer Exact Test

The results indicate that ,66 %of laryngectomees before diagnosis would have exceeded the

established threshold limit value, while the data on the control was 15%.The results also show that

the presence of autoimmune disease is a risk factor for the onset of cancers of the oral cavity, (p =

0.0163), as well as the feedback from the men of xerostomia, (p = 0.0563).

These data indicate that the cancer of the larynx, are in strong correlation to smoking and sex, but

also the presence of autoimmune diseases, and between the anamnesis indicators must be

considered essential for a non-explainable xerostomia. The questionnaire proposed can be an

effective tool in predictive screening, and this study also proposes making at least to those that

exceed the value of eight an analysis of saliva to determine the salivary sialic acid/protein that

would make it possible to identify with certainty all the good people at risk for which establish a

protocol for monitoring and care

INTRODUCTION AND BACKGROUND

At present, cancer research has made many advances in the study and in the fight against cancer,

especially in the field of molecular genetics, but from observation and analysis of epidemiological

data concerning the values for incidence of malignancies in all the districts of the human body you

can certainly say that in the field of prevention and early detection the way is still long. An example

of this comes from the analysis of the results obtained from the cancer genetics research relating to

the head-neck; According to a recent review (1) were highlighted been 601 regulatory genes tumour

tissue growth and 25 that control, significantly, the process of its activation. These data on the one

hand, confirm a significant difficulty in identifying with certainty the causes that bring cancer

education wing second indicate how for this district, so far, are not the only comprehensive

precautionary directions concerning the consumption of alcohol and tobacco, as a control for the

onset of various cancers. .In fact, for the oral cavity and larynx, there is a real program of

monitoring and screening, nor a self-evaluation mechanism as it does to any other sites, to which

this work proposes a different approach to the problem by directing efforts to the study and

knowledge of natural defences, by patients and medical specialists in Ent.This way you can reach

both the perception and the identification of a threshold of risk. The main natural defence for oral

cavity and larynx was identified based on clinical practice and review of the literature, in the protein

fraction of saliva and salivary mucins in mucins, secreted mainly by the sublingual glands and

mandible are glycosylated proteins or (2): in particular we refer in this connection to the hamlets

MUC5B, and MUC77).The glycosylation of salivary mucins, plays a fundamental role in protein

function as:

a) Is changed its chemical-physical structure

b) you have the protection of protein sites

c) creating loci of molecular recognition

d) the polysaccharide chain gives to the protein surface is very elastic.

It is believed that these mucins are absorbed into a protein layer at the interface of liquid saliva-air,

to form the so-called salivary film layer, which has an average thickness of 70-100 microns (3)

ensuring the fundamental rheological properties when the glycosylation process occurs regularly

(4), In this case is given to the typical appearance viscous saliva just lubricating substances. In this

way it Stratify, evenly, throughout the oral cavity allowing for effective protection of the mucosa

from different toxic agents, whether they be chemical, physical and biological, facilitates the first

phase of swallowing of food bolus, and due to its high lubricant, reduces friction between the vocal

cords, allowing regular phonation..A shortage of mucins, more or less strong and cronical , their

structural change, or their total privation from the entire oral cavity, exposing it to possible insults

chemical, physical and biological long-term can induce the formation of

4 page

the effects of cancer a total deprivation is largely verified (5), when you introduce in your mouth

food preparations like Bethel, a custom that has become entrenched in some Asian countries; this

food bolus contains large amounts of tannins (6) and in the concentrations lead to total precipitation

of salivary proteins consumer perception is expressed with a very strong sense of astringency

throughout the oral cavity and the consequences are of an absolute gravity so that in some countries

there is talk of health emergency for the very high incidence of cancers of the oral cavity (6) (7).We

speak in General of astringency when, the oral cavity is exposed to astringent (molecules, (3) and

more precisely it is referred to as the "complex of sensations caused by contraction, stretch, crimp

epithelium, as a result of exposure to substances such as alum and tannins In the seizure of mucin

from tannins, is because it is rich in PROLINE and this results in the formation of a very stable and

insoluble in water as a result of the formation of ties OH-groups, present in tannins, with oxygen

ketoimidic peptic bond (-CO-NH-) PROLINE, mucin inside (5) it is considered that these

mucins are absorbed into a protein layer at the interface of liquid saliva-air, to form the so called

salivary film, ensuring the entire oral cavity and larynx lubrication protection This function is

ensured only under certain conditions rheology mucin-mucosa, which prevents the salivary film, in

the process of scrolling and renewal, abrasion phenomena laceration, (8) (9)) .In final mucins are

critical in maintaining the lubricity, adhering strongly to the surface in layers, formed with repulsive

areas, both in the sense that steric electrostatic. (10). (11). These introductory remarks are necessary

to understand, how likely mechanisms involving chronic albeit slight astringency, can be crucial in

establishing hazardous conditions around the mouth .For this reason during the discussion of this

work we focus on the possible causes that may lead to a structural change and / or a functional

deficit even slight, of these elements salivary protein, whose chronicity can however facilitate the

onset of tumors, in our case those of the larynx

MATERIALS AND METHODS

As will be explained in the results and discussion section, was formulated an eleven questionnaire

multiple choice questions each of which is assigned a score from zero to three minimum value

indicating the absence of symptoms and/or illnesses and/or lack of habits, like smoking and alcohol.

The questionnaire was presented in the Milan section laryngectomees patients and in this first test

fifty were collected of which forty-six for men and four for women the average age of the male

population, as at the date of the intervention of laryngectomees is 61 years while that for women is

72.The same questionnaire was submitted to fifty volunteers visiting ENT, aged over 40 years: 30

women (average age 55 years) and 20 men (average age 66 years)

ANAMNESTICO-SURVEY QUESTIONNAIRE FOR LARYNGEAL CANCER

EPIDEMIOLOGICAL.

LAST NAME FIRST NAME

SEX M F AGE

AGE OF TOTAL LARYNGECTOMIE

SMOKE NOT

YES

HABITS SCORE

HABITUALLY 2-3

EX SMOKING/

1

TOTAL

ALCOHOL NOT (0)

YES

CONSUMPTION SCORE

MEAL GLASS 0

MODERATE 0-1

HABITUALLY 2

TOTAL

NORMAL SALIVATION YES (0)

NOT

XEROSTOMIA SCORE

LOW 1

HIGH 2

TOTAL

HYPOGEUSIA (NORMAL) SCORE

0

IPOGEUSIA (ALTERATED) SCORE

1

FAMILIARITY CANCER NOT(0)

YES

FAMILY SCORE

SISTER BROTHER 1-2

ONE PARENT 1

TWO PARENT 2

TOTAL

FOOD INTOLLERANCE SCORE

YES 1

FOOD INTOLLERANCE SCORE

NOT 0

LIFESTYLE

PHYSICAL ACTIVITY NOT (SEDENTARY) (3)

YES

INTENSITY SCORE

HIGH 0

LOW AND CONTINUE’ 1 0-1

LOW 2

TOTAL

BALANCED AND VARIED DIET ( YES (0)

NOT

HABITS SCORE

SWEET BREAD DOUGH MILK (PLENTY) 2-3

SWEET BREAD DOUGH MILK (no

PLENTY)

2

TOTAL

BLOOD GROUPS

A B AB O

SCORE 1 SCORE 1 SCORE 0 SCORE 0

AUTOIMMUNE DISEASES NOT

YES (1)

DISEASES SCORE

DIABETES

THYROIDITIS

REUMATOID ARTHRITIS

CELIAC DISEASE

LUPUS

ULCERATIVE COLITIS

PERNICIOUS ANEMIA

SCLERODERMIA

OTHER

TOTAL

STATISTICAL ANALYSIS: The questionnaire response data were analyzed using the Fisher

Exact Test that is the best test to verify a hypothesis that is used in the context of non-parametric

statistics, with two nominal variables and for small champion

RESULTS

The study and elaboration of bibliographic data made it possible to fill out a questionnaire for which

responses have been assigned a variable risk score, and was found a maximum threshold value

(score ≥ 8). The questionnaire was then given to two populations: 50 patients for laryngectomees

patients the result, see table 1, indicates that the threshold limit value was exceeded by 66% of the

population interviewed the results also indicate, as on 50pazienti who have completed the

questionnaire, 33 of them (66 percent), including one woman, at the time of diagnosis have

exceeded this value. Table 2 shows the results for the people, of the same population, they have

reached the 8 specifying individual parameters and how to, Percentagewise, have been overcome

risk thresholds given and accepted in the questionnaire, with particular emphasis on the age of onset

(61 percent), smoke (87%) diet (69%), and Xerostomia (57%) Autoimmune Diseases (53 per cent),

blood (64).The 22% of them also recognises, at the time of diagnosis the presence of all these

factors. In absolute terms, it can be seen from table 1 that the data confirm the role on the incidence

of laryngeal Ca, smoking, gender, as well as of the contribution resulting from the presence of

autoimmune diseases, mainly diabetes, (20% of people), and nonspecific symptom, relative to the

dry mouth (32.It should be noted that the percentage of patients with oral cancer that has an

autoimmune disease is significantly higher than for the general population in Italy (34% vs 1%, p

0.0001 test < proportions). Also, in the same patients, smoking and the presence of an autoimmune

disease are two associated risk factors (p = 0.1211 with Fisher exact test). Population data are given

in tables 3 and 4, and as you can see at the moment of the presentation and the formulation of the

questionnaire only 7 patients have surpassed the score of eight points without manifesting any

symptoms indicative of a laryngeal pathology can be present, as confirmed by physical

examination. Of these seven patients, six are men, all heavy smokers, drinkers, not usual careful

diets or lifestyles details, and all with aged over 65 years, to which the achievement of the eight-

point score is attributable mainly to assigned parameters. In any case, this population subgroup

((seven persons) both have autoimmune diseases that a smoker and all these patients was strongly

recommended a radical lifestyle change and a checkups after six months. From the results, we see

that the presence of an autoimmune disease is a significant risk factor for cancer of the oral cavity

(34% vs. 12% in the laryngectomees patients in controls, p = 0.0163 with Fisher exact test). In

addition, the data suggest that could be individual risk factors hypogeusia and also xerostomia (p =

0.0563 and p = 0.0559, respectively) and that the latter might be a specific risk factor for men

(32.6% in men vs. 5% in the laryngectomees patients men of control, p = 0.0260 with Fisher exact

test). Globally, with a threshold value of 8, the survey has obtained a sensitivity of 66% and a

specificity of 86% for predicting the risk of cancer of the oral cavity (0.0001 p < with logistic

regression).

DISCUSSION

The score by eight points, beyond which is established the beginning of risk threshold corresponds

to 2/3 of the questions in the questionnaire, with a positive response (1 value) for each question, and

half of this score can be reached with only three patients individual factors that, statistically, occur

in most cases of the larynx cancers age, smoking and sex. Literature data, it is clear that in the

development of laryngeal, Ca a preponderant role is attributed to age, smoking and another to sex:

for this evidence was assigned a risk 1 value for the male only and a score of 3 (as maximum) for

heavy smokers. It is also clear; these three parameters alone cannot be the cause of a possible

outbreak of the larynx tumours, which are, of course, as well as other factors, as has been

sufficiently explained in the discussion of this work. Their single contribution anyway, except in

rare cases, like familiarity for tumours, multiple autoimmune diseases, nutrition and the type B

blood group and/or does not exceed the value of 1 (maximum 2) to evaluate and examine in detail

the results of the questionnaire answers. it must be said that the idea of preventive approach

regarding the defences of the oral cavity and larynx in particular ,was determined not only by

increasing indications of literature but also from clinical and anamnestic feedback on patients

laryngectomees patients, functional changes to the mucous mucin. Many of them in the checkups,

stimulated to remember details symptoms before diagnosis remembered well the feeling of dryness

in the mouth, a phenomenon that mostly was intermittent and not exacerbated by particular eating

habits...This anamnestico, allowed to present the hypothesis of xerostomia tied to functional

changes of salivary mucins and/or a shortage, such as to modify the lubricity of the spittle. The

study of literature data show that this can happen when at the stage of glycosylation, the ratio is

varied in substituent’s O-linked carbohydrates with protein amino acids, and in particular the

concentration of sialic acid. Literature data agree in attributing to sialic acid a given concentration

range in glycosylated mucin, in comparison with the other sugars, (4), between the 5 and the 9%

mole/mole which ensures the appropriate quality lubricants mucins, and/or protective, fundamental

to the defence of oral biotope. However this doesn't happen for a flaw in the concentration of

protein-bound sialic acid, regardless of the conditions that created it. ..These conditions can be

realized for various reasons, the main of which are generally due to an increase of the activity of the

enzyme sialinidasi, mechanism not yet explained, and probably multifactorial, as we shall see, or,

for an increase of oxidative stress. In the first case in the saliva will be an increase in the

concentration of sialic acid free while in the second we will have an increase in the amount of

malondialdehyde, generated over that compound from lipid per oxidation of membrane, also from

the same degradation related to sialic acid mucins (12). In both cases the saliva increases its

viscosity (9)), it inhibits the same lubricating capacity, and the spatial structure changed, prepares,

the oral cavity to various diseases. Ultimately mucins are crucial in maintaining the protective

power and lubricant, if their glycosylation defines a spatially correct structure. In this case it may be

properly solvated by water molecules and form a mobile film but able to adhere strongly to the

surface of the mucous membrane with subsequent layers, with repulsive areas, both electrostatic

and steric.(13).(14). Recent work has shown a strong correlation between glycosylation, bad acid

concentration

Salivary sialic and laryngeal Ca (15) (16) (17), confirming the correct investigative approach in

formulating the questionnaire and propose a subsequent investigation that finds the sialic acid in

saliva. In fact, high levels of sialic acid in saliva and blood were detected in patients with laryngeal

cancer and precancerous conditions of the oral cavity (18). This figure, in some cases, it is

suggested to increase proteins and sugars in serum and in saliva (19)) in patients with squamous cell

carcinoma. The question of the questionnaire concerning the presence of autoimmune diseases also

take account of these findings in literature: in autoimmune diseases in addition to present itself very

often a dry mouth, you have high serum concentrations of sialic acid (20) (21). Other topics

covered, on the consumption and/or abuse of alcohol and tobacco, are also suspects in the logic of

negative interactions with the natural defences of the mouth and larynx, particularly mucin. Also in

This case the most recent literature data (22) (23) (24), predispose to store the initial hypothesis of

this work. The questionnaire has been submitted the application for possible involvement of genetic

nature. In Medical Genetics, cancers of the oral cavity and larynx are not at present included in that

5-10% of "hereditary neoplasia".These are cases in which a single gene alterations able to confer a

high risk of cancer even at a young age, usually less than 40 – 45 years. In any case, the geneticist

has to rebuild a family tree with the neoplastic diseases for all family members, possibly in addition

to first degree relatives, also those of the second degree (maternal and paternal uncles, cousins,

grandparents).In our case it was consciously simplified the question, by adapting the concept of

"familiar" in situations where multiple tumours were found in younger than 45-50 years of tumours

and, in the family of the patient, including in it the paternal and maternal grandparents. In the

questionnaire then there is a question concerning the identification of patients, of possible food

intolerances, that argument is particularly delicate because of its complexity, but worthy of study.

The first factor to consider is the biochemical evidence that correlates type autoimmune diseases

statistically with immune reactions triggered by allergens present in certain foods (especially dairy

products and cereals such as lactose and gliadin.The second factor, no less important, concerns the

effects arising from the elimination by the diet of those foods where the person is intolerant. With a

power source, budget to avoid allergic reactions are less in the daily diet, many of those compounds

needed for the normal life cycle of the intestinal flora that are important in the immune system.(25).

This stems from the fact that the cycle immune defence depends essentially by metabolites that

bacteria produce compounds alimentary that once formed the bind "sensing proteins", e.g., GPR43,

which in turn being coupled to specific receptors modulate the immune response).The lack of

certain metabolites that could come from the breakdown of certain foods responsible for allergies

very often those rich in fibres, can stop this cycle, reducing the immune system: According to

epidemiological data, the increase in diabetes in Western countries is attributable to these factors. It

is clear, therefore, how in the face of this eventuality, you can bind even the concept of a balanced

diet, not excessive in some parts, components, and backed by a good physical activity. Regarding

the question about blood groups, there is to say at the outset that recent epidemiological studies

showed that the incidence of tumours in various districts head neck and blood group function (26).

We also noted that the glycosylation of mucins, saliva, and in particular, the relationship between

sialic acid and other sugars, reflect the distinct gene expression on blood groups (27), assigning a

score equal to 1, and for Group B, the most significant risk for cancer of the larynx is to group A,

oral cavity and salivary glands, of only three individual factors that, statistically, occur in

most cases of cancer in the larynx, i.e. age, sex and smoking. Literature data, it is clear that in the

development of laryngeal, Ca a preponderant role is attributed to age, smoking and another to sex:

for this evidence was assigned a risk 1 value for the male only and a score of 3 (as maximum) for

heavy smokers. It is also clear that these three parameters alone cannot be the cause of a possible

outbreak of the larynx cancers, which are, of course, as well as other factors, whose single

contribution anyway, except in rare cases, like familiarity for tumours, multiple autoimmune

diseases, nutrition and the type B blood group and/or, does not exceed the value of 1 (maximum 2)

recent literature data concerning epidemiological research (28) (29), indicative of possible

correlation with cancers of the larynx and mouth. From the observation of the results points out

finally as there is a different tumour incidence as a function of sex, whose role in the development

of cancers of the mouth, larynx and more generally of the district head neck (HNC), is still under

discussion. The last and most significant data, analyzed in a recent review, (30) show that in a large

series of patients with HNC, estrogens levels in females play a protective role in the development of

cancer, unlike the males that have a lower level of them so they are predisposed. .This hypothesis

appears to be supported by experimental evidence that the destruction of the liver function in

alcoholic’s leads to a substantial alteration in the metabolism of sex hormones, estrogens and

testosterone, and this would explain why the many alcoholics are high-risk individuals in the

development of cancers of the oral cavity and larynx. The results obtained confirm the possibility of

easy and useful application of the questionnaire. In outpatient scope, such as screening for all

patients visiting ENT, to identify people at risk. The authors also consider plausible all assumptions

made at the onset of laryngeal Ca, including even the newer one, which calls into question the HPV

(31), hypothesis that ultimately does not conflict at all with the role of mucins in the prevention of

cancer of the larynx. With this work, however, is thought to have identified a possible new and

innovative approach to the problem. The questionnaire, in fact designed, to the knowledge of

natural defences it is then structured, until the final definition, with the survey history on patients

already undergoing of laryngectomees, coypu are thus obtained the results to "rear", which would

have indicated how il66 cables% of them if he had prepared the questionnaire, would have been at

serious risk, while another 25% borderline Probably though on the latter population sample, he

could maintain a salivary analysis prior to the determination of sialic acid, or rather (21), total

protein ratio/sialic acid, you would have found a 91% of people at high risk. In figures 1 and 2, we

finally tried to outline the numerous physical and chemical processes-biological that might

somehow interact in both stages of salivary mucins or after altering substantially more or less their

inherent properties.

CONCLUSIONS

This work, while not contradicting any of the cases related to cancer, especially those genetic,

emphasizes the need to structure more productively the preventive approach to all patients visiting

ENT. enhancing the current knowledge of the natural defenses and making participants and

protagonists physician and patient in the outpatient setting, the questionnaire, may well become a

valuable aid for one first screening for all patients, regardless of ENT pathology for which is required

to visit .In this way on a large segment of the population can be identified, all the people who exceeded

the score of eight points, must be evaluated for a possible risk factor for diseases of the oral cavity

and in particular of larynx..Per these patients the physician should immediately establish a prevention

protocol designed to eliminate and / or reduce risk factors: smoking cessation, varied and balanced

diet, good lifestyle, metabolic control relative to any autoimmune diseases, and dosage of salivary

protein ratio total / sialic acid are the first factors intervention .The physician can then determine on

the basis of the results after the completion of the second questionnaire, the chronology of the

subsequent follow-up.

TABLE 1 RESULTS - TOTAL LARINGECTOMEES

RISK FACTORS

M ≥65

YEARS

% F ≥60

YEARS % TOTAL %

AGE 30 65.2 1 25 31 62

SMOKE 33 71.3 1 25 34 68

ALCOHOL 3 6.5 0 0 3 6

CANCER FAMIL 2 4 1 50 3 6

XEROSTOMIA. 15 32.6 1 25 16 32

HYPOGEUSIA 4 8.7 1 25 5 10

PHYSICAL

ACTIVITY 10 21.7 3 75 13 26

DIET 15 32.6 2 50 17 34

FOOD

INTOLLERANCE 4 8.7 1 25 5 10

BLOOD GROUPS 14 30.4 3 75 17 34

AUTOIMMUNE

DISEASES 16 34.8 1 25 17 34

TABLE 2 (DATA PROCESSING QUESTIONNAIRE)

FINAL ELABORATION (for 33 patient over 8 score)

RISK

FACTORS

%

IMPACT

AGE 'ONSET CANCER 61

SMOKE RS 87

ALCOHOL 9

FAMILY 'CANCER 3

XEROSTOMIA 57

HYPOGEUSIA 22

FOOD INTOLLERANCE 15

PHYSIC ACTIVITY 35

DIET 69

BLOOD GROUPS 53

AUTOIMMUNE DISEASES 64

TABLE 3 - CONTROL POPULATION

30 WOMENS 20 MENS

RISK FACTORS M ≥65

YEARS %

F ≥60

YEARS % TOTAL %

FISHER EXACT

TEST

COMPLIANCE

CHECKS

AGE 13 65 10 33 23 60

SMOKE 15 75 10 33 25 50 0.1033

ALCOHOL 5 25 1 3 6 12 0.4870

CANCER FAM 1 5 2 23 3 20 0.7150

XEROSTOMIA. 1 5 6 20 7 14 0.0559

HYPOGEUSIA . 0 0 0 0 0 0 0.0563

PHYSICAL

ACTIVITY 7 35 12 36 19 38 0.2837

DIET 7 35 9 27 16 32 1.0000

FOOD

INTOLLERANCE 1 5 2 7 3 6 0.7150

BLOOD

GROUPS 2 10 7 23 9 18 0.1095

AUTOIMMUNE

DISEASES 1 5 5 17 6 13 0.0163

TABLE 4 CONTROL GROUP NUMBER 7 PEOPLE

SCORE POINTS OVER 8

RISK FACTORS NUM %

AGE 6 86

SMOKERS 6 86

ALCOHOL 4 57

FAMILY CANCER 1 14

XEROSTOMIA 1 14

HYPOGEUSIA 0 0

FOOD INTOLERANCE 1 14

PHYSIC ACTIVITY 4 57

DIET 5 71

BLOOD GROUPS 1 14

AUTOIMMUNE DUSEASES 2 29

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