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MINI SYMPOSIUM: HEAD AND NECK
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Year : 2012  |  Volume : 49  |  Issue : 1  |  Page : 33--38

Knowledge, attitude and screening practices of general dentists concerning oral cancer in Bangalore city

KV Vijay Kumar1, V Suresan2,  
1 Department of Public Health Dentistry, RIMS Dental College and Hospital, Kadapa, Andhra Pradesh, India
2 Hitkarini Dental College and Hospital, Jabalpur, Madhya Pradesh, India

Correspondence Address:
V Suresan
Hitkarini Dental College and Hospital, Jabalpur, Madhya Pradesh
India

Abstract

Context: Oral cancer presents with high mortality rates, and the likelihood of survival is remarkably better when detected early. The dental profession shares an important responsibility toward early screening, prompt referral and treatment. Aims: The aim of the present study was to assess the oral cancer knowledge, attitude and screening practices among dental practitioners in Bangalore city. Materials and Methods: This descriptive cross-sectional study was conducted using a 24-item self-administered questionnaire involving private dental practitioners of Bangalore city. A total of 1556 private dental practitioners of Bangalore made up the sampling frame of the study, and a sample of 250 dentists was found to be sufficient. Two hundred and fifty dentists were selected by cluster random sampling. The institutional review committee approved the study. Data were entered using SPSS 13.01. Results: A total of 250 practicing dentists were approached, of which 240 participated in the study. Among the various risk factors for causing oral cancer, the use of alcohol was identified as a major risk factor by 238 (99%) dentists. The high-risk age group for oral cancer was identified as the fourth and fifth decades by 143 (59%) dentists. Adequate training for providing oral cancer examinations was acquired by 164 (68%) of the dentists. Two hundred and thirty-seven (98%) dentists strongly agreed that patients should be referred to specialists if they suspected oral cancer in any lesion. No more than 37% of the dentists routinely practiced complete oral cavity examination on all patients who attended their practice. A mere 31% of the dentists educated their patients on the adverse effects of these habits and assisted them in cessation programmes. Conclusions: These findings concerning dentists«SQ» knowledge and opinions related to oral and pharyngeal cancer suggest strongly that educational interventions for practitioners and dental students are necessary. We contend that an offering of continuing dental education programs would go a long way to enhance the prevention and early diagnosis of oral cancer.



How to cite this article:
Vijay Kumar K V, Suresan V. Knowledge, attitude and screening practices of general dentists concerning oral cancer in Bangalore city.Indian J Cancer 2012;49:33-38


How to cite this URL:
Vijay Kumar K V, Suresan V. Knowledge, attitude and screening practices of general dentists concerning oral cancer in Bangalore city. Indian J Cancer [serial online] 2012 [cited 2020 Oct 24 ];49:33-38
Available from: https://www.indianjcancer.com/text.asp?2012/49/1/33/98915


Full Text

 Introduction



Most epidemiological studies have revealed that heavy smoking and alcohol intake are the most important risk factors for oral cavity cancer. [1] Occupational exposure to carcinogens, [2] infections with certain papilloma viruses [3],[4] and nutritional status [5] are additional risk factors that have been associated with an increased cancer risk. Poor dental hygiene, accompanied by tooth loss, [6] is another suspected risk factor. Smokeless tobacco use, a common practice in the Indian sub-continent, has also been shown to be a significant risk factor for oral and pharyngeal cancer, particularly for oral sites that come into contact with the product. [7]

Primary prevention of oral cancer includes avoidance of tobacco use, alcohol abuse as well as appropriate intake of fruits and vegetables. Secondary prevention of oral cancer consists of a visual and tactile examination of the oral cavity, the head and the neck, which is essential for early detection. Regular dental visits are associated with diagnosis of oral cancer at an earlier stage.

Typically, oral pharyngeal cancers take several years to progress to advanced stages. The oral cavity is easily accessible for examination and thus offers the potential for opportunistic screening for intraoral cancer. Dentists have ready access to the oral cavity and hence arguably bear the largest share of responsibility in detecting and diagnosing oral cancer. [8],[9]

Supporting this statement, evidence was found 20 years ago, when a British Columbia study [10] of people with oral cancer found that 70% of those who had regular dental visits were diagnosed late (stage I or II cancers), while only 40% of those who did not have regular dental visits were diagnosed at an early stage.

Treatment of oral cancer at an earlier stage is less complicated and is associated with higher survival rates. In addition, the cost of treatment for a stage IV oral cancer patient is more than three-times the cost of treatment for a stage I patient according to a study conducted in Greece, [11] and a similar fallout was observed in Italy. [12],[13] Hence, oral cancer screening by dentists may both improve prognosis and reduce the costs associated with this disease.

It is estimated that about nine million new cancer cases are diagnosed and over 4.5 million people die from cancer each year in the world. [14] The estimated number of new cancers in India is about seven lakhs, and over 3.5 lakhs people die of cancer each year. [14] There would be about 1.5 lakhs cancer cases at any given time in Karnataka, and about 35,000 new cancer cases are added to this pool each year. [14] The Hospital Based Cancer Registry (HBCR) collects information on each and every patient diagnosed of cancer as devised by the National Cancer Registry Programme, a Project of the Indian Council of Medical Research. The data from the registry provide the incidence/magnitude and type of various cancers in patients attending their outpatient department. [14]

Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, is one such hospital that has maintained a Population Based Cancer Registry since the year 1981. [14] The registry covers the resident population of Bangalore Urban Agglomeration, which has an area of 741 sq. kms, and has an estimated population of seven million as of 2007. On an average, about 5000 new cancer cases are registered in the registry area per year.­ [14]

The data from HBCRs of India has shown that cancer of cervix (28%) and breast (16%) in women are most common and cancer of the head and neck region (30%) constitute the third most common type of all cancer in males and females. [14] Tobacco-related cancers accounted for 34% of all cancers in males and 16% of all cancers in females. These malignancies are among the most debilitating and disfiguring of all cancers. [14]

In general, no major prognostic improvement can be observed. This is mainly caused by the often advanced tumor stage at the time of diagnosis. Although diagnostic possibilities and therapy have improved the mortality, yet 5-year survival rates are still unsatisfactory. Thus, early diagnosis and identification of risk patients is essential for better response to therapy and improved prognosis. [15]

To the best of our knowledge, there is no information available on the abilities of dental practitioners in Bangalore city with regard to early detection, diagnosis and referral of oral cancer cases. Hence, it was found to be appropriate to access this information prior to designing an appropriate educational programme for dental health care workers. The aim of the present study was to assess the oral cancer knowledge, attitude and screening practices among dental practitioners in Bangalore city.

 Materials and Methods



This descriptive, cross-sectional study was conducted using a self-administered questionnaire involving private dental practitioners of Bangalore city. A list of private dental practitioners in Bangalore city was obtained from the dental directory. [16] This directory enlists all the dentists practicing in Bangalore. A total of 1556 private dental practitioners of Bangalore made up the sampling frame of the study and a sample of 250 dentists was selected by cluster random sampling. Bangalore is geographically divided into five different zones, and these different zones formed the clusters for sampling. From each cluster, 50 dentists were randomly selected. After random selection, all these dentists were telephonically contacted for consent of participation in the study, and none refused.

This sample of 250 private dental practitioners was personally approached by the investigators and requested to complete a comprehensive closed-ended, self-administered questionnaire. Two hundred and forty dentists participated in the study. The common reason to refuse participation was time constraint.

This 24-item questionnaire included the background characteristics, knowledge items (signs, symptoms and risk factors, examination techniques for oral cancer), attitude items (significance of knowledge needed for oral cancer examinations and its perceived utility) and practice items (methods of oral cancer examination, management of suspicious lesions, identifying the use of tobacco and alcohol in patients medical history).

The questionnaire was pilot tested on 25 private dental practitioners and was assessed for the uniformity of interpretation. No major corrections were necessary. This data gathered during the pilot survey was not included in the main study. The questionnaire took about 25 min to complete. The institutional review committee approved the study. Data was entered using SPSS 13.01.­ [17]

 Results



The background characteristics are shown in [Table 1]. Majority (55%) of the dentists was male, and most of the dentists were only graduates. Forty-four percent of the dentists were solo practitioners.{Table 1}

Response to knowledge questions on oral cancer

Among the various risk factors for causing oral cancer; the use of alcohol was identified as a major risk factor by 238 (99%) dentists [Figure 1]. The high-risk age group for oral cancer was identified as the fourth and fifth decades by 143 (59%) dentists. Early signs of oral cancer present with varied patterns of manifestations, of which 197 (82%) dentists stated a non-scrapable white patch as the most common form of manifestation [Figure 2]. Squamous cell carcinoma was identified as the most common form of oral cancer by 231 (96%) of the dentists, and the common site for oral cancer was selected as the buccal mucosa by 198 (83%) dentists.{Figure 1}{Figure 2}

Response to attitude questions on oral cancer

The dentists' attitude toward oral cancer screening is shown in [Table 2]. Concerning this, 138 (57%) dentists agreed that their knowledge about oral cancer is not up-to-date. Adequate training for providing oral cancer examinations was acquired by 164 (68%) of the dentists. Two hundred and thirty-seven (98%) dentists strongly agreed that patients should be referred to specialists if they suspected oral cancer in any lesion.{Table 2}

Response to questions on oral cancer screening practices

[Table 3] shows the response to questions on oral cancer screening practices. No more than 37% of the dentists routinely practiced complete oral cavity examination on all patients who attended their practice. Twenty-four percent of the dentists were able to identify patients with suspicious lesions and take biopsies. The habits related to tobacco and alcohol use was recorded by 68% dentists, whereas a mere 31% of the dentists educated their patients on the adverse effects of these habits and assisted them in cessation programmes. {Table 3}

 Discussion



A comprehensive oral cancer examination and risk assessment are measures that may lead to early detection and prevention of oral cancer. Many experts agree that the key is not necessarily identifying oral cancer but identifying tissue that is not normal and taking appropriate action. An oral cancer examination could take as little as 90 s to perform. [18] Overall, we found that this group of dentists was knowledgeable about oral cancer risk factors and about signs and symptoms.

Nearly 94 (39%) dentists claim that their knowledge on oral cancer was current; pertinently, 143 (59%) dentists were able to identify the risk age group of oral cancer as the fourth and fifth decades of life.

One hundred and sixty-three (68%) dentists in the present study agreed that all patients aged 40 years or older should be provided oral cancer examinations annually. Similarly, in dentists practicing along the Texas-Mexico border, [19] 90% agreed that oral cancer examinations should be provided annually for patients 40 years of age and older. Respondents expressed diverse opinions about oral cancer prevention and early detection. Positive acquaintance on oral cancer knowledge was associated with performance of oral cancer examination, as implied by Alonge and Narendran. [19] Lack of up-to-date knowledge is known to effect inconsistencies or unacceptable procedures for oral cancer examinations.

The greater part of dentists' (68%) agreed that they are adequately trained to provide an oral cancer examination; conversely, they do not do so in all cases. This was also noticed in dentists of Maryland, [8] wherein all participants said that they provided comprehensive oral cancer examinations regularly. However, their descriptions revealed variations in the comprehensiveness of the examinations. A mere 37% of the dentists declare palpating the lymph nodes during the complete oral cavity examination. Thus, a greater part of the sample did not complete the critical component of comprehensive oral cancer examination. This variation and lack of routineness is in stark contrast to the guide provided by the National Institutes of Health, [20] which stresses the importance of following a definitive step-by-step protocol. Similarly, in Brazil, [21] 36% of the dentists reported that they did not palpate the lymph nodes. The authors also state that oral cancer examinations performed seemed to depend on a number of factors, the most pertinent of which were time and the comfort level and training of the dentist.

Being able to routinely detect oral cancer at an early stage and counsel patients in prevention is a continuous challenge for the dental profession. [22] Dentists must be familiar with the risk factors, clinical signs and symptoms of oral cancer if they are to be effective in identifying, referring and counseling high-risk patients. The present study indicated that only 12% of the dentists referred patients with suspicious lesions to a specialist's clinic for further evaluation. Only 24% of the clinicians who attended to patients with possible malignant oral disease indicated that they would undertake a biopsy of the affected lesion. This is notably worrisome as dental surgeons do not wish to undertake invasive procedures due to lack of clinical knowledge and exposure to such cases.

Identifying patients' tobacco and alcohol use, whether current or past, is pivotal for a practitioner to be informed about his or her patient's risk of developing oral cancer. Sixty-eight percent of the dentists reported recording only the current tobacco and alcohol use of their patients. This sort of a practice can easily underestimate a patient's risk of attaining oral cancer, especially for those patients who have recently stopped using tobacco and alcohol.

However, only 12% refer patients to de-addiction centers. A previous study [23] has shown that many dentists do not feel comfortable with the idea of counseling patients on matters such as smoking or alcohol cessation. In one study, however, [24] the majority of dentists felt that they had a role in counseling of patients to stop smoking and excessive alcohol consumption.

These findings concerning dentists' knowledge and attitudes related to oral and pharyngeal cancer suggest strongly that educational interventions for practitioners and dental students are necessary. We believe that there are missed opportunities in the dental office. First, with dentists' focus limited to the oral cavity, it is reasonable to believe that they might be able to easily obtain a focused medical and behavioral history, including the key risk factors for oral cancer. Second, multiple opportunities exist during a patient's visit to a dental office for tobacco-use intervention services, as it has been established that dental patients traditionally are receptive to preventive health messages. [25]

The next task is to use this information to help improve levels of knowledge and practices among Bangalorean dentists concerning early detection and prevention of oral cancer. The participants' responses suggest the need to develop continuing education opportunities that suit the needs and wants of these dentists.

Given the level of inconsistencies between the dentists' knowledge about oral cancer and their screening practice behaviors, it is apparent that further study is needed to understand the barriers dentist experience to implement this knowledge.

The present study adds a growing body of evidence suggesting that educational interventions are needed for dentists in the areas of oral cancer detection, screening and prevention.

We contend that an offering of continuing dental education programs would go a long way to enhance the prevention and early diagnosis of oral cancer. Optimally, educational programs should focus on risk factor screening, behavior modification counseling, physical examination of the oral cavity and a review of the criteria for referral to a specialist for a biopsy, definitive diagnosis and treatment.

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