Oral and oropharyngeal cancer: Knowledge, attitude and practices among medical and dental practitioners

Abstract Background Oral and oropharyngeal cancer are significant health problems. They are both life‐threatening conditions usually diagnosed at an advanced stage causing survival rates to decline. Aim To assess and compare practices, knowledge and attitude regarding oral and oropharyngeal cancer between dental and medical practitioners. Methods A cross‐sectional study was conducted to assess knowledge, attitude and practices of oral and oropharyngeal cancer among dental and medical practitioners at King Abdulaziz Medical City, Riyadh, Saudi Arabia. 360 participants were included in the study using a convenient sampling technique. Participants were approached in their clinics and printed self‐administered questionnaire were handed over to them after signing a written consent form. Frequency distribution and Chi‐Square test were used for the statistical analysis and the level of significance was set at P value of .05 or less. Results A total of 174 participants responded. Assessment of oral and oropharyngeal cancer knowledge between dental practitioners and medical practitioners showed comparable results. Regarding practices, a significant difference was seen between medical practitioners and dental practitioners in determining the duration of intra‐oral ulcer to consider urgent referral (P = .006) and in number of referrals made in relation to suspicious oral lesions (P = .002). Moreover, a significant difference (P = .006) was seen between medical practitioners and dental practitioners in determining the duration of intra‐oral ulcer to consider urgent referral. Conclusion Medical and dental practitioners showed areas of differences in practice, attitude and knowledge of oral and oropharyngeal cancer that when addressed would lead to improved survival rates.


| INTRODUCTION
Oral and Oropharyngeal Cancers (OC/OPC) are both considered significant health problems. When OC/OPC are grouped together they have ranked the fifteenth most common cancers worldwide. 1 Despite the oral cavity being an accessible site for self and professional examinations and in spite of better understanding and development of new therapeutic interventions, OC/OPC continues to carry a poor survival rate due to late diagnosis. The overall survival rate for OC/OPC is 65%, however, the majority of OC/OPC are diagnosed at an advanced stage having a survival rate of 39%. [2][3][4] Screening and early detection can lead to a reduction in mortality rate of OC/OPC as in other cancers with well-developed screening protocols, like breast, lung and colorectal cancers. [5][6][7][8] Oral cancer refers to any cancerous tissue inside the mouth involving the front two-thirds of the tongue, floor of the mouth, buccal mucosa, gingiva, lips, retromolar trigone and hard palate. Oropharyngeal Cancers involve the base of tongue, soft palate, tonsils and posterior pharyngeal wall. Most of OC/OPC lesions are squamous cell carcinoma (SSC). 3 Tumours may arise as a primary lesion in the oral cavity or a metastatic tumour arising from a distant site. Risk factors include smoking, chewing habits (including Areca nut, Shamma/ tobacco chewing, Qat, and Toombac), sun exposure, and human papilloma virus (HPV) 16 and 18. 9-17 Globally OC is more common in males but cultural habits have shown to play a role in some regions of the world. An example is the acceptance of women to use shamma (form of smokeless tobacco) in the south western region of Saudi Arabia leading to a higher rate of OC in females in that region with the sites most affected being the gingiva and alveolus (in direct contact with the shamma), whereas the tongue and lips are the most affected sites in other areas of the world. [9][10][11][12][13][14][15][16][17][18] Cancer patients would benefit from early diagnosis and detection of lesions, with immediate referral to specialist care centres. Early diagnosis and referral will ultimately improve survival rates, reduce morbidity and lead to better treatment outcomes. 4,19 Dental practitioners (DP) and medical practitioners (MP) are all part of the health care profession but it is likely that the nature of practice would differ between these two groups. 4,20,21 As far as the authors knowledge, this has been looked at only in the UK, and no other published data comparing the role of medical and dental health care providers with regards to detection of OC/OPC was found. 20,21 The aim of this study was to assess OC/OCP knowledge, attitude and practices among medical and dental practitioners.

| METHODS
A cross-sectional study was conducted in order to assess knowledge, attitude and practices of OC/OPC among DP and MP at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia. KAMC has more than 1500 beds and comprised of multiple campuses providing primary, secondary and tertiary care for national guard military and hospital employees and their families. The study inclusion criteria included dentists, dental interns, general medical practitioners, medical interns, family medicine specialists and otorhinolaryngologists who are registered and practicing health care workers. Dental students, dental assistants and dental hygienists are excluded from the study. The study sample could be representative of health care providers in Saudi Arabia as it was performed in a major hospital and all associated primary care centres. An ethics statement was conducted in full accordance with the World Medical Association Declaration of Helsinki. It was independently reviewed and approved by the ethics committee at King Abdullah International Medical Research Centre (KAIMRC), (IRBC/0512/18) study number (SP18/011/R). Written consent form was considered as an agreement for participation in the study and data were collected using a hard copy questionnaire developed by Macpherson et al. 21 The questionnaire composed of 6 domains: demographics, knowledge of OC/OPC, pattern of referral, preventive role, training needs and examination habits with a total of 37 questions.
Knowledge was defined if the participant selected the right option for the prevalence of oral cancer, risk factors, sites and predisposing oral condition. Attitude was assessed by questions about the participants' belief of having a role in several aspects including: prevention, participants' confidence in detecting any premalignant\malignant lesion and pattern of referral of required cases. Practices were based on questions involving routine examination of sign and symptoms, factors influencing decision to undertake examination, sites to focus on during examination, predisposing oral conditions and barriers precluding routine examinations. The questionnaire was estimated to take between 7 to 10 minutes in order to be completed. Participants were selected using convenience sampling technique. The participants were approached in their clinics and after that a brief introduction of the current study was provided. Participants who agreed to participate were handed over the printed selfadministered questionnaire to be filled on the spot. The participants' personal information was anonymously treated for privacy and confidentiality. The data collection process started on 1/1/2019 until 30/4/2019. Statistical analysis was completed by using SAS version 9.4 (SAS Institute, Cary, NC, USA). Frequency and percentages were used to display categorical variables. Chi-square test was used to test for the presence of association between categorical variables. Level of significance was set at .05.

| RESULTS
Questionnaires were distributed among DP and MP; 174, out of 360, completed questionnaires were received representing 48% response rate. The response rate was higher among the DP (56.9%) of the completed questionnaires compared to the MP (43%).

| DEMOGRAPHIC CHARACTERISTICS
More than half of the respondents were male (64%) while (36%) were female. Half of the DP (50%) had been qualified for less than 5 years, 16% between 6 to 10 years, 6.1% between 11 to 15, 12.1% between 16 to 20 and 16.2% had been qualified for more than 20 years. Similarly, for the MP, about half of (48%) graduated within the last 5 years, 9% between 6 to 10 years, 9% between 11 to 15 years, 11% between 16 to 20 years, and 23% had more than 20 years experience.
(  and DP was observed in the perception of bacterial infection as an etiology of OC (P = .04). In addition, a significant difference between MP and DP was noticed in the perception of sun exposure as an etiology of OC (P = .05). No significant difference between MP and DP was observed in perception of age, alcohol, smoking, trauma, HPV, fungal infection, and family history as an etiology of OC. Table 3 displays the respondents perceptions of perceived importance of OPC risk factors. A significant difference between MP and DP was observed only in perception of trauma as an etiology of OPC (P = .05). No significant difference between MP and DP was seen in perception of age, alcohol, smoking, trauma, HPV, sun exposure, fungal infection, and family history as an etiology of OPC.

| Examination habits
Significantly higher proportion of the MP (47%) would never examine the patient in the course of the initial examination of a patient greater than 16 years of age for signs of OC/OPC when compared to DP (17%). Most of the participants considered pre-existing lesion, alcohol and smoking as factors that would influence their decision to undertake an examination for OC/OPC screening.
Lateral borders of the tongue (74%), floor of the mouth (65.5%), pharyngeal wall (60%) and lips (62%) were the sites that the participants mostly focus on when they examined the oral cavity for Abbreviations: DP, dental practitioners; MP, medical practitioners.
OC/OPC. Only 47% considered soft palate important to be examined.
More DP would consider lateral tongue (83%) and floor of the mouth (79%) examination highly important when compared to MP (63%, 48%), respectively. On the other hand, MP (55%) would consider gingival examination highly important more than the DP (25%).
Lack of training and lack of time were the main barriers to routinely undertake OC/OPC examinations. More MP (53%) perceived lack of time as a very important barrier to OC/OPC examinations when compared to DP (36%).
In which, about 69% of the DP considered erythroplakia to be very important predisposing condition while only 39% of the MP considered it to be very important. Geographic tongue is considered as an important predisposing condition by MP (43%) more than DP (29%).
Similarly, smoker's keratosis considered to be very important by MP (68%), while less DP (47%) perceived it to be very important. In regards to the recall of patients with predisposing oral conditions, DP (73%) would do significantly more than MP (55%). and 77.8% respectively. Figure 1 illustrates the difference between MP and DP in duration for intra-oral ulcer to consider urgent referral. A significant difference (P = .006) was seen between MP and DP in determining the duration of intra-oral ulcer to consider urgent referral. Majority of DP (52.5%) consider 2 to 3 weeks as maximum duration for intra-oral ulcer to do urgent referral whereas 28% of MP would refer the patient after 2 to 3 weeks. F I G U R E 1 Difference between medical practitioner and dental practitioner in duration for intra-oral ulcer to consider urgent referral be distance learning (58%), and 51% of participants would also like to attend courses and 54% would prefer in-service training.

| DISCUSSION
The current study was performed to assess knowledge, current practices and training needs of DP and MP with regards to the detection of OC/OPC. Usually, OC/OPC are diagnosed at an advanced stage leading to increased mortality. It is well established that the early diagnosis and management of these patients could increase the survival rate. 22 In addition, although OC/OPC is known to be diseases of the elderly and mostly with a history of many years of smoking and alcohol consumption, now there is an alarming increase of incidence among young adults. 23 The increase in incidence has mostly been noted in OPC over the past three decades attributed to HPV. 16  knowledge about OC risk factors coincided with many studies conducted in Saudi Arabia, Australia, and Kuwait. 25,28,29 An example of regional discrepancies can be seen in Saudi Arabia, where there is an increase in the incidence of OC as in the southern region (Gizan), due to frequent use of special types of smokeless tobacco like Shamma and Qat in the southern region of Saudi Arabia. [30][31][32] OC/OPC is associated with smoking and alcohol but HPV infections have been found to be an independent risk factor for OPC. [33][34][35] Nearly a third of the practitioners did not identify HPV as a risk factor for OPC. On the other hand, according to a study conducted on Canadian physicians, only 5% of primary care physicians revealed any doubt regarding the evidence supporting HPV associated head and neck cancer. 36 Although a significant difference was not found, more DP identified HPV as a risk factor for OPC, when compared to MP. Similarly, dentists showed higher overall HPV related knowledge than dental hygienists in a study examining knowledge of HPV among dentists and dental hygienists attending a regional dental conference in Florida, United States. 37 This may be due to a more focused training involving the head and neck area.
Practitioners showed areas of differences as both groups, DP and MP, have a good knowledge about OC/OPC risk factors but DP would consider OC/OPC examination and referral more than MP. In the current study, a significantly higher proportion of DP would routinely examine the patients for OC/OPC than MP. That coincides with several studies done in the UK, USA, Italy, and Saudi Arabia. 20,21,[38][39][40] Macpherson et al stated that MP has a general feeling that OC examination is beyond their limits and the DP should do it routinely; this belief was supported also by American dentists and physicians. 21,41 It is logical that the DP is responsible for OC/OPC screening but there are concerns about how often the patients will visit a dentist. There is evidence that even if the patients were to have oral symptoms, they would visit MP not DP. A British dental survey in 2009 proved that only 58% of the participants visited a dentist in the past 3 years which showed that a large number of the population did not visit their dentists regularly. As a result, dependence on DP to screen patients for OC/OPC might lead to delayed and/or misdiagnosing OC/OPC. 42 Similar to our findings other studies completed in Saudi Arabia and UK, found that a lack of time and training were reported by both participants as the main barriers to examine patients for OC/OPC. 21,29 These findings further highlight the need of developing more training opportunities including courses and in-service training. In addition, by increasing awareness, the hope would be to justify the benefit of time spent when completing these examinations.
High-risk areas for OC are the posterolateral surfaces of the tongue and the floor of the mouth. 43 Buccal mucosa is a common OC site in some countries in Asia due to tobacco chewing habit. 44 In the current study, when the participants were asked about high-risk sites to focus on during their examination, 74% reported lateral borders of the tongue, 66% floor of the mouth and 54% buccal mucosa. A significantly higher number of DP identified the lateral boarder of the tongue and floor of the mouth as important sites while more MP identified the gingiva as an important site to be examined when compared to DP. This was consistent with a study done in the US; less than 10% of MP and 39% of DP identified the most common site for OC. 41 These findings indicate that MP who are more likely to see patients first would not be wary of high-risk sites. In this study, more participants identified leukoplakia (65%) to be a very important predisposing condition when compared to erythroplakia (56%). erythroplakia was significantly identified by DP to be of more risk than MP. Applebaum et al in the US reported that less than 10% of MP and 34% of DP recognized leukoplakia and erythroplakia as the two oral changes associated with OC. 41 In addition, Carter et al in UK reported that a significantly lower number of MP identified leukoplakia and erythroplakia as the two predisposing conditions for OC. 20 When we compare our results to the previous studies, our participants identified the two predisposing conditions more than participants in the UK and US but were similar in that DP was able to identify the two conditions more than the MP. Literature reviews 45,46 reported that the rate of malignancy transformation of erythroplakia (9%-40%) is much more than leukoplakia (2%-6%) and at time of biopsy (91%) of erythroplakias were found to be dysplastic to carcinoma in situ when compared to (20%) of leukoplakias at time of biopsy. 47 care physician more than their dentist. In addition, the community pharmacist could play a role in detecting oral lesions. Furthermore, dental hygienists are considered as prevention specialists; they might spend more time with the patients and see higher number of patients compared to DP. 37 As a result, awareness must be raised for all health care providers especially primary care providers with regards to known risk factors, most common sites and early signs for OC/OPC. 21 In our study, MP received more training than DP regarding smoking and alcohol counselling. Majority of both practitioners need further information and training on sources of counselling patients regarding smoking, alcohol consumption, cancer prevention, detection of oral cancer/ pre-cancer and patient referral.
Distance learning, courses and in-service training are the preferred methods of training by our participants. Carter et al in UK similarly reported that the majority of DP and MP needed further training in OC but they preferred information pack rather than courses or meetings. 20 The limitations of the current study included a low response rate which may have been due to the lengthy questionnaire and practitioners' busy schedules. Second, the study was done in an institution that continually provides training and education in all aspects of cancer and may have affected the results of our study positively.

| CONCLUSION
Knowledge, attitude and training with regards to OC/OPC were all found to be deficient. DP was found to be more knowledgeable about the high OC/OPC risk sites and predisposing factors than MP. In addition, DP perform routine OC/OPC examination and proper referral more than MP. More education and training with regards to OC/OPC examination and referral should be addressed, through systemic educational updates.
This would lead to improved patient care and outcomes by leading to early diagnosis and immediate referrals to specialist care.

ACKNOWLEDGEMENT
We thank the medical and dental practitioners who participated in the study.

CONFLICT OF INTEREST
The author declare that they have no conflict of interest.

AUTHOR CONTRIBUTIONS
All authors had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the data analy-

CONSENT TO PARTICIPATE
Written consent form was considered as an agreement for participation in the study.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.