Oral‐cancer knowledge, practice, and attitude assessment of dentists in Upper Egypt: A cross‐sectional study

Abstract The aims of this study were to investigate the knowledge, attitude, and practice of dentists in Upper Egypt with regard to oral cancer (OC). Out of 1,200 licensed dental practitioners list, 424 dentists were randomly selected from three governorates in Upper Egypt (Minia, Assuit, and Sohag). The sample size was calculated using the equation considering the knowledge of dentists about OC, confidence level, and margins of error; then, an additional number of dentists were added to guard against nonresponse. Data were collected by face‐to‐face interview using 44 items divided into four sections; first part demonstrates sociodemographic. The second part concerned with the knowledge about OC clinical presentation and diagnosis (12 multiple‐choice questions) as well as its risk factors (17 close‐end questions). The third part consists of six questions focused on the practice of participants, and finally, the last part measures attitude of dentists. The chi‐square test was used to compare between the two or more proportions. A correlation was used for describing the relationship or association between two mutually numerical dependent variables. p < 0.05 was considered to indicate significance. Rate of response was 94.3%. The overall knowledge level in the current study was 31.8%. The awareness about OC risk factors was high especially, smoking tobacco and alcohol consumption. Also, over 80% of dentists identified family history and human papillomavirus (HPV) as risk factors. Only 37.5% of participants performed regular screening of oral mucosa, and 26.5% reported lymph‐node examination. Regarding attitude, only one quarter of dentists attended continuing educating programs about OC. A statistically significant relation (p < 0.0001) between knowledge level and most demographic variables was detected. There was a fair positive correlation (r = 0.47) between practice and knowledge scores. A predominant trouble among dentists in Upper Egypt was regarding OC knowledge and practice. Continues education and training programs are highly recommended.


| STUDY SAMPLE
Before the study has started, the number of recorded licensed dentists in dentists association in each governorate was 1,200 dentists (450 dentists in Minia,425 in Assuit,and 325 in Sohag). The study included 424 dentists who were randomly selected from the lists of licensed dental practitioners in three governorates in Upper Egypt (Minia, Assuit, and Sohag) using the computer-generated simple randomization.
The sample size was calculated using the equation considering the knowledge of dentists about OC, confidence level, and margins of error; then, an additional number of dentists were added to guard against nonresponse. The used equation is n = t 2 × p (1 − p)/m 2 where n is the required sample size, t is the confidence interval at 95% (standard value of 1.96), p is the estimated dentists knowledge (50%), and m is the margin of error at 5% (standard value of 0.05).

| DATA COLLECTION
Data were collected by using a 44-item anonymous questionnaire to ensure confidentiality. Four hundred forty questionnaires (16 for the pilot study and 424 for the main study) were prepared in English and assessed and revised by a specialist, which have been used for conducting face-to-face interview. The questionnaire was pretested by conducting a pilot study with 16 dentists. After the pretest data were analyzed, Cronbach's α correlation coefficient, α = 0.91, indicating the survey had a high degree of internal consistency. The results of a pilot study were not included in the results of the current study. The time of the interview was about 20 min. The questionnaire consisted of four parts. First part demonstrates sociodemographic and work characteristics data of the participants that were covered through six items including age, gender, school and date of graduation, experience years, last academic degree, and specialty. The second part concerned with the knowledge about the OC clinical presentation and diagnosis (12 multiple-choice questions) as well as its risk factors (17 close-end questions). For each question, a score of either 0 = incorrect or 1 = correct was obtained. A total score of nine or higher correct responses out of the 12 questions (75%) were considered high OC level of knowledge (Khakbaz et al., 2017). The third part consists of six questions focused on the practice of the participants. The total score of practice was classified either good when at least four questions have positive answers. The last part measures the attitude of dentists and composed of six close-ended questions. Attitude is considered favorable when a positive response was recorded for at least one half of the questions.
The questionnaire used in this study was long. Therefore, it is available at https://drive.google.com/open?id=1AmUSmCiCDm8z0A t55aG8IZ8Fx9kOm2wZ.

| STATISTICAL METHODS
Statistical Program Statistical Package for the Social Sciences (SPSS) 19 was used for data entry and analysis. Quantitative data were presented by mean and standard deviation, whereas qualitative data were presented by frequency distribution. The chi-square test was used to compare between two or more proportions. A correlation was used for describing the relationship or association between two mutually numerical dependent variables. p < 0.05 was considered to indicate significance.

| RESULTS
Out of 424 questionnaires, 400 fulfilled questionnaires were adopted for statistical analysis whereas 24 incomplete questionnaires have been excluded. The response rate in this study was high, 400 (94.3%). Approximately about 284 (71%) of dentists enrolled were working in general hospitals of Egyptian Ministry of Health at the time of study performing. Most of the participants are general dental practitioners, below the age of 35 years, and work for more than 6 hr daily.
There is no sex predilection (Table 1). Although the overall knowledge level in the current study was 127 (31.8%), which considered low (Table 2), the awareness of our dentist about OC risk factors was high as all of them recorded that smoking, tobacco, and alcohol consumption and over 80% mentioned that family history, HPV, poorly fitted dentures, sun exposure, and consumption of hot beverages and foods are risk factors. The participants' practice evaluation clarified that only 106 (26.5%) of dentists' behaviors were good. Practice characteristics such as routine screening of oral mucosa and lymph-node examination were only done by 150 (37.5%) and 106 (26.5%), respectively, (Table 3). More than 206 (50%) of the respondents demonstrated a favorable attitude, and 79% of them thought that OC should be a part of the routine examination. Only 156 (39%) of them convinced that they were qualified in performing diagnostic procedures. Also, 116 (29%) of the participants considered that the university provided training in OC examination during their undergraduate program, and 100 (25%) attended a continuing education program. However, 336 (84%) of dentists were interested in attending education courses on OC in the future. There was a statistically significant relationship between knowledge level and all demographic variables except the   (20) More common gender 220 (55) 180 (45) Common condition associated to OC 238 (59.5) 162 (40.5) Initial OC most common aspect 292 (73) 108 (27) Most frequent anatomical region 312 (78) 88 (22) Most  Referral of a patient to which specialty 184 (46) 216 (54) gender, p < 0.0001. Also, a statistically significant difference was obvious between dentists' practice and age, experience years, scientific degree, university of graduation, and working hours ( Table 4). The correlation between practice and knowledge level was measured and showed fair positive correlation r = 0.47 between knowledge and practice scores ( Figure 1).

| DISCUSSION
This study type is an observational cross sectional. An anonymous questionnaire was used in this quest, and this encouraged many participants to write down their actual behavior regarding the different questionnaire items. This had an impact on reducing the effect of information bias. Several methods were used in similar investigations such as email, postal service, or phone interviews, but the one-toone interview has been chosen to perform this study because this method has been accredited to achieve a high quality of data and obtain more accurate results (Holman et al., 2018 Motallebnejad & Hedayati, 2006). There was not a big difference between positive answers to the common age of OC, the initial aspect of OC, leukoplakia as a common condition associated with OC, and the characteristics of metastasized lymph nodes among our participants, and surveys were done in Italy, Brazil, and Iran (Colella et al., 2008;Pavao Spaulonci et al., 2018;Razavi et al., 2013). There was a wide variation among studies regarding the common site of the OC. In the current study, the tongue was selected by 78% of dentists, which is comparable with Kujan et al. who reported 85% correct answers (Kujan et al., 2014). On the other hand, an only 34% dentists in Jeddah in Saudi Arabia identified the correct answer (Eltelety et al., 2014). When asking about the OC common stage in Egypt, 76.25% of our participants identified the stage whereas only 24% of respondents awarded the relation between the size of the swelling and OC stage. Only 37.5% of our dentists reported that they perform a routine oral examination during dental visits. This is an indication of inadequate practice when compared with the study done in Spain by Seoane et al. and that is done in Cairo by Labib et al. (Labib, Elraghi, Shoman, & Othman, 2012;Seoane et al., 2016) as more than one half of the respondents in these studies reported that they were conducting the routine oral examination. Moreover, studies of Gajendra et al. and Vazquez-Mayoral et al. recorded higher percentages than the current study; they were 85% and 52%, respectively, (Gajendra, Cruz, & Kumar, 2006;Vazquez-Mayoral, Sanchez-Perez, Olguin-Barreto, & Acosta-Gio, 2008). This could be considered as logical consequences, for weak knowledge level of our participants or their decision on the full-mouth screening was influenced by the patient complaining of an oral health problem. There is a problem in response to most of the practice items, especially routine lymph-node examination and qualified training to take a biopsy of the suspicious lesion (27%  (Forrest, Drury, & Horowitz, 2001). Regarding the practice of dentists in this study, there was a statistically significant difference in their practice and their age, last scientific degree, and hours of work. This direct proportional relationship is a logical consequence of the participants' level of knowledge. In another aspect, the correlation between participants' attitude and their demographic data was statistically insignificant except for different age groups.

| CONCLUSIONS
It can be concluded from the results of this study that dentists in Upper Egypt have obvious problems in the knowledge of OC diagnosis. Routine screening of oral mucosa is another poor sign of practicing among dentists. Unfortunately, these shortages in knowledge and practice are a real threat against prevention and early detection of the disease and subsequently reducing its burden. Practicing was significantly improved in correlation with age, university of graduation, and hours of daily work. The good news was that most of the respondents were interested in improving their knowledge and practice levels. It is highly recommended to apply continues education and training programs in the form of lectures, courses, or workshops through cooperation between universities especially, in Upper Egypt and Egyptian Ministry of Health. Revising and updating the current OC educational curricula in dental schools especially those in Upper Egypt.