|Year : 2019 | Volume
| Issue : 1 | Page : 25-30
Oral cancer awareness, knowledge, and practices among Saudi general dentists
Zayed Ali Assiri1, Abdulrahman Ahmed Alshehri1, Alia Khalid Alfadhel2
1 Department of Dental Administration, Saudi Ministry of Health, General Directorate of Health Affairs in Aseer Region, Riyadh, Saudi Arabia
2 Department of Dental, Al-Farabi College for Dentistry and Nursing, Riyadh, Saudi Arabia
|Date of Web Publication||12-Mar-2019|
Alia Khalid Alfadhel
Al-Farabi College for Dentistry and Nursing, Riyadh
Source of Support: None, Conflict of Interest: None
Objectives: The present study aimed to investigate oral cancer (OC) awareness, knowledge, and practices among Saudi general dentists.
Materials and Methods: We included dentists who were recognized and licensed by the Saudi Commission for Health Specialties. They were e-mailed officially with a 28-item questionnaire and constructed to investigate the study objectives.
Results: The final sample included 326 dentists. About 85.6% of the participants reported their awareness; this was confirmed when similar percentage (87.4%) stated that there are etiological factors other than tobacco and alcohol for OC. Only 34.7% of the participants had sufficient knowledge concerning the prevention and detection of OC. Concerning the referral, 53.4% referred their patients to oral medicine specialist.
Conclusions: Our findings revealed that chances exist to improve the knowledge, increase awareness, and develop right practices toward OC. Furthermore, our results revealed that dentists believed their knowledge was insufficient to detect OCs, although most of them showed reasonable level of knowledge about some aspects of diagnosing OCs. All these emphasize general dentists' role in the prevention and diagnosis and the need to improve dentists' knowledge and practices toward OC.
Keywords: Awareness, cancer, dentist, knowledge, oral, Saudi
|How to cite this article:|
Assiri ZA, Alshehri AA, Alfadhel AK. Oral cancer awareness, knowledge, and practices among Saudi general dentists. Saudi J Oral Sci 2019;6:25-30
|How to cite this URL:|
Assiri ZA, Alshehri AA, Alfadhel AK. Oral cancer awareness, knowledge, and practices among Saudi general dentists. Saudi J Oral Sci [serial online] 2019 [cited 2019 Jul 24];6:25-30. Available from: http://www.saudijos.org/text.asp?2019/6/1/25/254031
| Introduction|| |
Oral cancer (OC) is the neoplasm involving oral cavity and mainly starts at the lips and ends at the anterior pillars of the fauces. In the United States, OC is the cause of more than 8000 deaths annually as a second leading cause of death. It causes deaths in percentages higher than cervical cancer or other melanomas. Global prevalence of OC shows diversity with geographical distribution. Around 370,000 new cases of OC were reported over the world in 2012; more than 60% of these cases were diagnosed in the developing countries. Moreover, oral cavity cancers were ranked the seventh most common cancer according to the World Cancer Report.
Among the known risk factors for oral cancer, tobacco in its many different forms and alcohol consumption remains major causes all over the world. Fortunately, OC is a known high-risk factors' disease. Established etiological factors for oral cancerous lesions include both duration of alcohol and tobacco consumption, as well as their intensity. Sadri and Mahjub conducted a meta-analysis of epidemiological studies investigating the magnitude of the relationship between tobacco smoking and oral cancer. They investigated original articles published from 1990 to 2007. They concluded that tobacco smokers are at increased risk of OC that can be reduced by altering the tobacco smoking habit in different countries. Goldstein et al. reviewed the literature from 1988 to 2009 to study the relationship between alcohol consumption and cancer of the oral cavity and pharynx. They found sufficient evidence confirming the International Agency for Research on Cancer 1988 Working Group's conclusion that alcohol consumption is carcinogenic and can cause oral and pharyngeal cancer. Other risk factors include poor nutrition, genetic factors, mate drinking, viruses, and chronic trauma.
Düzlü et al. reported that during a 20-year period between the years 1993 and 2013, around 230 malignancies were detected originated from the oral cavity. From 1992 to 2006, the 5-year survival had improved by more than 11 percentage points. Recently, from 2008 to 2010, it enhanced around 65 percentage points., In Eastern Asia, the 5-year survival ranges between 30% and 60%; in India, it is <40%., According to the World Health Organization, the mortality rate of OC is approximately two per 100,000 in the Middle East. For that, the American Cancer Society recommends a comprehensive OC examination annually for people 40 years or older. This, therefore, places dentists in a unique position to contribute to the examination of oral cancer, based on their job's nature. They see their patients frequently and regularly, compared to other primary care providers.
Several studies around the world as well as in the Arab and Gulf countries assessed dentists' knowledge, awareness, and practices regarding oral cancers; all of these studies emphasized the dentists' role and need for improving their knowledge and practices toward OC.,,,, In Saudi Arabia, there is a lack of studies, aimed to investigate dentists' knowledge, awareness, and practice to determine where deficiencies may exist in oral cancer's diagnostic knowledge. Therefore, the present study aimed to investigate OC awareness, knowledge, and practices among Saudi general dentists.
| Materials and Methods|| |
In the present study, we included dentists and recognized and licensed by the Saudi Commission for Health Specialties (SCHSs) as general dentists. We excluded dentists and licensed to practice in oral pathology or oral medicine clinics because they were known to be less likely to diagnose or treat patients clinically. We recruited a random sample of eligible dentists registered in SCHS. Furthermore, we excluded non-Saudi dentists.
We developed a survey tool from a 28-item questionnaire, designed by Jnaneswar et al., modified minimally for readability. The questions encompassed the following: participants' demographic characteristics, practices regarding performing OC examinations in daily practice, and their assessment of patients' risk factors; their knowledge about signs, symptoms, and characteristics of OC lesions; and dentists' opinions of their knowledge level regarding the OC examination. We sent the questionnaire by e-mail. For this official dentists' e-mails had reached from SCHS records. Along with the questionnaire was an introductory letter end with a question requesting participation. The questionnaire was pretested on twenty randomly selected participants by sending it to their e-mails. We sent it again to them. They were not involved in the study results. All twenty participants agreed that the questions were clear and straightforward. We included one question asking for agreement to participate. On receiving negative answer, the questionnaire was excluded immediately. We used internal split-half method to assess the reliability for selected questions. The correlation coefficient was +0.89 (89%). Further, to ensure the questionnaire's validity, we showed it to an expert asking him to give a score of 100% for each question. Then, the average congruency percentage was 100%.
The ethical approval and facilitating letter of this study were obtained from the Department of Studies and Researches at King Fahad Medical City, and the research has been conducted in full accordance with the World Medical Association Declaration of Helsinki.
Written consent was obtained from all participants in the study. The study design and the consent procedure were reviewed and approved by the Ethics Committee of the Department of Studies and Researches at King Fahad Medical City represented in its Institutional Review Board.
Sample size calculation
For our study, Applebaum et al.'s design was used as a guide to estimate the effect size and pooled standard deviation. Then, we used G* power software, the Faculty of Experimental Psychology at Heinrich-Heine University, Dusseldorf, Germany to calculate the sample size. Given an alpha error of 0.05, a power of 0.95 and estimated effect size of 0.2, the minimum sample size required for this study was 314.
Data findings were organized into different sections based on the research study's objectives as below. These sections transferred the data on 326 dentists into results presented in two sections. First, the descriptive analysis section reported number and percentage for categorical variables and means ± standard deviation for continuous variables, presented in [Table 1], [Table 2], [Table 3], besides [Figure 1] and [Figure 2]. Second, the inferential analysis section is presented in [Table 4] in terms of the univariate analysis and [Table 5] in terms of the multivariate analysis; this result interpreted in detail the study population's characteristics and the association between sociodemographic characteristics versus knowledge about OC.
|Table 1: Descriptive analysis for sociodemographic characteristics (n=326)|
Click here to view
|Table 2: Participants' characteristics on oral cancer awareness, knowledge, and practices (n=326)|
Click here to view
|Table 3: Participants' information about the referral for suspected oral malignancy (n=326)|
Click here to view
|Table 4: Univariate analysis for the association between sociodemographic characteristics versus awareness about oral cancer (n=326)|
Click here to view
|Table 5: Multivariate analysis predicting the awareness about oral cancer as aware versus not aware from the sociodemographic characteristics (n=326)|
Click here to view
| Results|| |
Results were presented in accordance with the dentists' positive (yes) response, voluntarily enrolled in the study. Results were gathered from 326 dentists, randomized, and voluntarily enrolled in the study.
[Table 1] shows the descriptive analysis of sociodemographic characteristics. Number and percentage were used to summarize each variable. Results show 221 (67.8%) of the participants aged <30, 83 (25.5%) aged between 31 and 40, 13 (04.0%) aged 41–50, and 9 (02.8%) aged >50 [Figure 1]. Among these, 204 (62.6%) were males whereas 122 (37.4%) were females [Figure 2].
[Table 2] shows participants' characteristics on OC awareness, knowledge, and practices. Number and percentage were used to summarize all categorical variables. Results revealed that 296 (90.8%) were aware of OC whereas 30 (9.2%) were unaware. The following responses were obtained for questions that sought to test dentists' knowledge, awareness, and practices about OC. The awareness of dentists regarding different OC risk factors accounted for 85.6% (279), alcohol and tobacco constituted the sole OC etiological factors and accounted for 12.6% (41), the harmful effect arising from the consumption of both alcohol and smoking accounted for 86.8% (283), knowledge of OC symptoms accounted for 80.1% (264), initial and common symptomatic OC lesions accounted for 26.4% (86), the lateral border of the tongue as the prevalent site for the existence of OC accounted for 71.2% (232), many OCs could not be diagnosed within initial phase accounted for 46.6% (152), OC as a genetic disease accounted for 18.4% (60), risk for OC escalation with age accounted for 84.4% (275), comprehension of investigative procedures undertaken for initial identification of OC accounted for 67.2% (219), OC as a disease that could be prevented accounted for 73.0% (238), lesions linked to the decision of quitting tobacco smoking following halting of products accounted for 59.8% (195), most essential feature for OC metastasis constitute hard painless permanent lymph nodes accounted for 84.4% (275), initial identification enhances 5-year survival rates within OC accounted for 83.7% (273), annual screening for OC must be done to individuals aged over 40 years accounted for 73.6% (240), well trained to educate people alcohol cessation accounted for 33.1% (108), trained to conduct palpation of patients' lymph nodes accounted 67.2% (219), require more training or information on OC accounted for 34.7% (113), time wastage on educating patients to cease their behavior accounted 19.3% (63), patients with cancerous lesions in the mouth must seek specialist's treatment accounted for 93.3% (304), routine screening of patients' oral mucosa accounted for 66.9% (218), alcohol and tobacco use record within personal history accounted for 71.2% (232), oral cavity screening practices accounted for 51.8% (169), whereas biopsy among patients with suspected lesions accounted for 43.9% (143).
[Table 3] shows participants' information about referral for suspected oral malignancy. The results constituted a summary of the construct and expressed in percentages and numbers. Most of the referrals were for oral medicine as 174 (53.4%), oral and maxillofacial surgery had 133 (40.8%), general surgery had 13 (04.0%), whereas dentists had 6 (01.8%).
Research investigators applied Chi-square test for [Table 4] reporting the comparison between aware and not aware related to participants' sociodemographic characteristics with P values, indicating whether the association is statistically significant. Researchers dealt with Chi-square test as univariate because it tests single predictor at a time (individually) versus the outcome. Results revealed that gender (P = 0.004) was statistically significant, given the level of significance when the value of P is < 0.05 [Figure 3].
|Figure 3: Percentage comparison of gender versus awareness of oral cancer|
Click here to view
[Table 5] shows multivariate regression analyses predicting awareness about participants' sociodemographic characteristics. Logistic regression analysis estimated factors, which influenced OCs awareness for the two groups of dentists: aware and not aware. Sociodemographic factors were controlled in the model, such as age group (in years) and gender. The odds ratio for the age group shows 1.150, interpreting that for patients 30 years and older, there will be 15% increase in awareness in OC compared to patients below 30 years. The odds ratio for gender shows 4.406, interpreting that males are four times females in their level of awareness. Results showed that gender was statistically significant given the level of significance when P value is P < 0.05.
| Discussion|| |
Early detection of oral cancers is considered the cornerstone, enhancing the survival rate of oral cancers. Furthermore, it is believed to be the best method of reducing morbidity as well as mortality rates of these diseases. On the other hand, these enhance the dentists' role in reducing and preventing oral cancers.
In the present study, vast majority of participants (90.8%) answered “Yes” in response to the question regarding their awareness of oral cancers, indicating that they believed that they are aware of OC. Subsequent questions investigated dentists' knowledge, awareness, and practices about OC. By examining OCs various risk factors, 85.6% of participants reported their awareness, confirming when similar percentage (87.4%) stated that there were etiological factors other than tobacco and alcohol for OC. Besides, 46.6% believed that the most OCs could not be diagnosed in early stage. This finding could interpret to some extent why some general dentists do not perform any diagnosis for oral cancerous lesions. In fact, our findings showed more favorable results when compared to findings reported by Applebaum et al. and Ahmed and Naidoo., Applebaum et al. found 50% of their participants correctly identified high-risk factors for OC, whereas Ahmed and Naidoo found only 38.9%. Compared to our results, López-Jornet et al. reported that more than 95% of their participants correctly identified high-risk factors for OC. Collectively, the awareness was statistically significant when related to gender (males are four times females in their level of awareness); most participants showed awareness toward OC in general and risk factors, which might predispose any oral cancerous lesion.
Moreover, more than 83% of the participants were aware about the hard painless fixed lymph node being OCs common characteristic, early detection improving 5-year survival rates in OC, and importance of educating patients to quit their habits; however, majority of them (90.5%) reported the need for more information or training on OC. Meanwhile, 67.2% of participants received training to perform patient's lymph node palpation. It is worth mentioning that only 34.7% of them had sufficient knowledge concerning OCs prevention and detection. This finding could be another interpretation why some general dentists do not perform any diagnosis of oral cancerous lesions. Our study's results were similar to the findings reported in different studies. Razavi et al. reported that only 34% of dentists were at an acceptable level of knowledge regarding OC. In another review, the authors stated that only 34% of dentists could identify erythroplakia and leukoplakia as the two most common conditions likely to be associated with OC. Furthermore, Alaizari et al. reported different findings. Collectively, most participants knew some aspects of diagnosing, but believed it was not sufficient to detect OCs clinically.
Our results showed that 66.9% of participants used to examine patients' oral mucosa routinely; 93.3% referred these lesions to a specialist. Compared to findings reported by Ahmed and Naidoo (52.2%), our participants performed more referrals; 53.4% referred their patients to oral medicine specialist, while rest attributed to oral and maxillofacial surgeon (40.8%), general surgeon, and other dentists. This finding could indicate the presence of misunderstanding among general dentists of referral system for these diseases.
| Conclusions|| |
There is no complete human work. Some limitations of our work should be addressed in future studies. Larger sample size, other reliability measures, and study tools are preferred to be applied in future works. With these limitations, we can conclude the following. We found our dentists' awareness was high regarding OC and their risk factors with males were four times more than females. Taking into consideration, the correlation's strength between mortality resulting from OC and stage of detection emphasizes general dentists' role in the prevention and diagnosis. Our findings revealed that chances exist to improve the knowledge, increase awareness, and develop right practices toward OC, further revealing that dentists believed their knowledge was insufficient to detect OCs although most of them showed reasonable level of knowledge about some aspects of diagnosing OCs. Finally, our data showed that vast majority of dentists refer patients with suspicious cancerous lesions to specialists, mainly oral medicine specialist.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Neville B, Damm D, Allen C, Bouquot J. Oral and Maxillofacial Pathology. 2nd
ed. Philadelphia (PA): Saunders; 2002.
National Cancer Institute. Cancer Statistics Review 1973-1987. Washington, D.C.: Government Printing Office, Department of Health and Human Services, Public Health Service, National Institutes of Health. NIH Publication; 1989. p. 2788-9.
American Cancer Society. Cancer Facts and Figures 1992. Atlanta: American Cancer Society, Inc.; 1992.
Ghantous Y, Abu Elnaaj I. Global incidence and risk factors of oral cancer. Harefuah 2017;156:645-9.
Stewart BW, Wild CP. World Cancer Report. Lyon: International Agency for Research on Cancer; 2014.
Gillison ML. Current topics in the epidemiology of oral cavity and oropharyngeal cancers. Head Neck 2007;29:779-92.
Sadri G, Mahjub H. Tobacco smoking and oral cancer: A meta-analysis. J Res Health Sci 2007;7:18-23.
Goldstein BY, Chang SC, Hashibe M, La Vecchia C, Zhang ZF. Alcohol consumption and cancers of the oral cavity and pharynx from 1988 to 2009: An update. Eur J Cancer Prev 2010;19:431-65.
Al-Jaber A, Al-Nasser L, El-Metwally A. Epidemiology of oral cancer in Arab countries. Saudi Med J 2016;37:249-55.
Düzlü M, Karamert R, Bakkal FK, Cevizci R, Tutar H, Zorlu ME, et al.
The demographics and histopathological features of oral cavity cancers in Turkey. Turk J Med Sci 2016;46:1672-6.
Pulte D, Brenner H. Changes in survival in head and neck cancers in the late 20th
and early 21st
century: A period analysis. Oncologist 2010;15:994-1001.
Ries LA, Melbert D, Krapcho M, Stinchcomb DG, Howlader N, Horner MJ. Cancer Statistics Review, 1975-2005. Bethesda, MD: National Cancer Institute; 2008.
Howlader N, Ries LA, Mariotto AB, Reichman ME, Ruhl J, Cronin KA, et al.
Improved estimates of cancer-specific survival rates from population-based data. J Natl Cancer Inst 2010;102:1584-98.
Sankaranarayanan R, Swaminathan R, Brenner H, Chen K, Chia KS, Chen JG, et al.
Cancer survival in Africa, Asia, and central America: A population-based study. Lancet Oncol 2010;11:165-73.
Lambert R, Sauvaget C, de Camargo Cancela M, Sankaranarayanan R. Epidemiology of cancer from the oral cavity and oropharynx. Eur J Gastroenterol Hepatol 2011;23:633-41.
Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. GLOBCAN 2010. Cancer Incidence and Mortality Worldwide: IARC CancerBase No 10. Lyon (FR): International Agency for Research on Cancer; 2010-2029.
Smith RA, Cokkinides V, Eyre HJ. Cancer screening in the United States, 2007: A review of current guidelines, practices, and prospects. CA Cancer J Clin 2007;57:90-104.
Victoroff KZ, Lewis R, Ellis E, Ntragatakis M. Patient receptivity to tobacco cessation counseling in an academic dental clinic: A patient survey. J Public Health Dent 2006;66:209-11.
Applebaum E, Ruhlen TN, Kronenberg FR, Hayes C, Peters ES. Oral cancer knowledge, attitudes and practices: A survey of dentists and primary care physicians in Massachusetts. J Am Dent Assoc 2009;140:461-7.
López-Jornet P, Camacho-Alonso F, Molina-Miñano F. Knowledge and attitudes about oral cancer among dentists in Spain. J Eval Clin Pract 2010;16:129-33.
Ahmed NH, Naidoo S. Oral cancer knowledge, attitudes, and practices among dentists in Khartoum state, Sudan. J Cancer Educ 2017. DOI: 10.1007/s13187-017-1300-x. [Epub ahead of print].
Razavi SM, Zolfaghari B, Foroohandeh M, Doost ME, Tahani B. Dentists' knowledge, attitude, and practice regarding oral cancer in Iran. J Cancer Educ 2013;28:335-41.
Alaizari NA, Al-Maweri SA. Oral cancer: Knowledge, practices and opinions of dentists in Yemen. Asian Pac J Cancer Prev 2014;15:5627-31.
Jnaneswar A, Goutham BS, Pathi J, Jha K, Suresan V, Kumar G, et al.
Across-sectional survey assessing knowledge, attitude, and practice regarding oral cancer among private medical and dental practitioners in Bhubaneswar city. Indian J Med Paediatr Oncol 2017;38:133-9.
] [Full text]
Yellowitz JA, Horowitz AM, Drury TF, Goodman HS. Survey of U.S. Dentists' knowledge and opinions about oral pharyngeal cancer. J Am Dent Assoc 2000;131:653-61.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]