Assessment of the Factors Influencing Early Detection Practices of Oral Carcinomas by Dentists: A Cross-Sectional Study Open Access

Oral carcinoma (OC), the 16th most common type of cancer, is a significant health problem worldwide. Globally, the incidence of this malignancy is 8/100,000, with a mortality rate of 3.8/100,000 of the population [1]. Oral cancers (OCs) are a substantial component of the global burden of cancers [2]. GLOBOCAN data revealed that 377,713 new cases of OC were reported worldwide in 2020 [3]. There are extensive geographical variations in distribution of oral carcinomas among countries. The number of OC cases is much higher in countries with low socioeconomic status. Almost two-thirds of all new cases are reported in developing countries, and 25% of them are from Pakistan, India, Bangladesh, and Sri Lanka. Conversely, in France, which has the highest OC incidence in European Union, OC accounts for only 5.5% of all cancer cases. Moreover in USA, the American Cancer Society estimated that in 2019, approximately 53,000 people were diagnosed with OCs (about 3% of all cancers diagnosed in USA) [4]. This comparison highlights that while Pakistan and other developing countries face a higher burden of OCs with limited early detection, western countries like France and USA benefit from better screening and healthcare systems, leading to improved outcomes. Moreover, 5-year survival rates of these carcinomas are very low in low- and middle-income countries. Lip and OCs are ranked as 2nd most common cancers in South Asian countries [5]. These global variations in the prevalence of oral carcinomas are mainly due to a lack of access to healthcare services and early detection practices. Hence, most oral carcinoma cases are diagnosed at advanced stages in developing countries, thus placing a huge economic burden on their health systems. According to Global Burden of Disease (GBD) data, the number of deaths related to oral carcinomas in Asian countries has increased by 148.76% in the last 3 decades. In 2019, the countries in Asia with the highest age-standardized rates of incidence, death and disability adjusted life years (DALYs) related to oral carcinomas were Pakistan, China, India, and Taiwan. However, the countries that showed significant downward trends in these indicators were Mongolia, Singapore, and Bahrain. The incidence of OCs was related to gross domestic product per capita with negative correlation in countries with gross domestic product per capita above USD 10,000. A downward trend of age standardized death rate was observed in high-income Asia Pacific countries from 1990 to 2019. This decline in death rates was attributable to improved treatments and advances in early diagnosis. However, in Pakistan and other developing countries, OCs were diagnosed in advanced stages, leading to poor prognosis. Hence, socioeconomic factors have a strong influence on early diagnosis and lead to a lower burden of OC in high-income countries [6].

A total of 75% of oral carcinoma cases are diagnosed among people who have a history of smoking, smokeless tobacco consumption, alcohol intake, and sunlight exposure. Moreover, according to a global systematic review, the risk of OC increases with the use of chewable tobacco compared with non-chewable tobacco [7]. Hence, the incidence of these malignancies is increasing in countries with high smokeless tobacco consumption. The use of areca nuts has been reported in many countries, especially China, Cambodia, India, Pakistan, Taiwan, Malaysia, Sri Lanka, and Thailand [8]. However, in the past few years, the number of new cases of OC associated with human papillomavirus (HPV) has been increasing [9]. Hence, in countries with low socioeconomic status, the risk further increases due to infections (HPV) coupled with poor oral hygiene. Some OCs originate from potentially malignant oral disorders. In this regard, dentists should be mindful of the clinical presentation and must intercept at earlier stages to reduce the likelihood of transformation to malignancy [10].

As some oral carcinomas develop from precancerous lesions, early detection can counter the development of OC. In a dental setting, the oral cavity can be easily observed without any discomfort to the patient. Conventional tests (visual oral examination) include visual inspection and palpation of the oral mucosa to detect abnormalities [11]. Evidence suggests that early diagnosis of these carcinomas leads to less complex and cost-effective treatments, thus reducing the economic burden. The clinical presentation of OC varies, ranging from visible nonhealing ulcerations, erythroplakia (red patches), and leukoplakia (white patches) to Lichenoid lesions [12]. It is important to mention that a number of such cancers arise from formerly asymptomatic mucosa while others can emerge from existing lesions; therefore, they are considered potentially malignant lesions [13]. At the advanced stages, there is metastasis in cervical lymph nodes, and manual palpations can be done to establish pretreatment staging [14]. The survival rate of patients increases significantly if cancer is detected in the early stages. The 5-year survival rate from OC, if not detected at an early stage, remains very poor (approximately 50%). However, it improves to 80% in the case of early diagnosis [13]. Therefore, to reduce the incidence and mortality of this carcinoma, emphasis should be placed on the detailed screening of the oral cavity by dentists. Any persistent abnormalities in the oral mucosa and cervical lymph nodes require immediate referral for definitive diagnosis [13]. Both the prevention and early detection practices are important because early diagnosis not only increases the 5-year survival rates but also reduces the chances of recurrence.

In Pakistan, OCs are the second most common cancers and the primary cause of cancer-related deaths. In 2020, 16,959 new cases and 10,617 deaths due to these carcinomas were reported in Pakistan [3]. According to WHO-EMRO, almost 75% of OCs in Pakistan are diagnosed at the last stage [15]. Among the Pakistani population, the main risk factors for these carcinomas include the use of smokeless tobacco, poor oral hygiene, genetic predisposition, and lower socioeconomic status [16]. Unfortunately, there is no comprehensive OC control strategy or any initiative for health education concentrated in the country. Multiple studies in Pakistan have shown poor knowledge related to oral health and cancers among the general population [17]. However, none of these studies have evaluated the factors that could influence early detection practices of oral carcinomas among dentists. Several studies have been conducted to evaluate knowledge, awareness, and attitudes regarding OCs among the general population and dentists in Pakistan. However, there is limited evidence regarding the dental examination skills among dentists. OCs remain a neglected disease in Pakistan owing to multiple factors, including lack of cancer registries, human and financial resources, and appropriate referral pathways. The rapidly increasing number of cases can be reduced by comprehensive efforts done by the government regarding oral hygiene practices and the importance of early detection [18]. This study is novel in Pakistan to evaluate dentists “practices related to early detection of OCs” and to identify key factors influencing these practices. Its findings offer baseline data to inform future training and policy development.

Therefore, the present study aimed to assess the knowledge and opinions of dentists towards OCs and to identify and evaluate the factors that could influence early detection practices among dentists. This study also intended to explore the potential educational needs of dentists. Identification and assessment of different factors that could influence performing oral mucosal examinations among dentists would provide baseline information that could help in removing the potential barriers to performing OC detection practices. Moreover, this information could also be used for the future planning of continuous professional education programs and undergraduate training programs for OCs. The objective of this study was to assess the knowledge, opinions, and practices toward early detection of oral carcinomas and to assess the vital factors influencing screening practices among dentists.

The cross-sectional study recruited participants from 202 dental care facilities in Islamabad (ICT), out of which 186 are private clinics and 13 are dental hospitals [19]. There are three Rural Health Centers in ICT [20], which also provide dental care services. Data for this study were collected digitally from both hospitals and clinical settings. The study population included registered dentists (valid license holders of the Pakistan Medical Council [PMC]) practicing in ICT. There were 7,670 registered and practicing dentists in both the public and private sectors of ICT, Pakistan [21]. A random sampling technique was used in this study. The sampling framework for this study consisted of all dentists who were registered with the PMC and practiced in ICT dental care facilities. The anticipated prevalence of early detection practices was 84.9%, taken from a study conducted in Karachi, Pakistan [22].

Based on this prevalence, a sample size of 235 was calculated using 5% margin of error, a design effect of 1.2 and population size of N = 7,670. The dentists who had a valid registration with PMDC but were nonpracticing or in a nonclinical setting were excluded from the study. A team of six general dentists collected in-person data from the study participants. The electronic data collection forms were self-administered to the participants. Written consent was obtained from all participants prior to this activity. The study participants were requested to self-fill all sections of the questionnaire except “practices related to early detection of oral carcinomas.”

The study tool was developed using three previously validated tools (online suppl. material A1; for all online suppl. material, see https://doi.org/10.1159/000546971). The section “practices related to early detection of oral carcinomas” was taken from a tool already used in a study in Jordan [23]. The sections about the “knowledge related to clinical presentation of oral cancers,” “knowledge related to risk factors of oral cancers,” and “opinions related to oral cancers” were taken from a pre-validated tool used in a study conducted in Qatar [24]. The section “perceived barriers to checking oral mucosa” was taken from a tool used in a multicountry study [25]. The survey questionnaire consisted of 62 closed-ended items divided into eight different sections: (1) sociodemographic factors; (2) work-related factors; (3) health facility-related factors; (4) practices related to early detection; (5) knowledge related to clinical presentation; (6) knowledge related to risk factors; (7) opinions; and (8) perceived barriers. The questionnaire was pretested with 5% of the sample population. The content validity of the questionnaire from field specialists was also conducted. The primary outcome (dependent) variable in the current analyses was “practices related to early detection of oral cancers” among dentists (house officers, general dentists, FCPS trainees, and dental specialists). The independent variables included sociodemographics, work and health facility-related variables, knowledge related to clinical presentation and risk factors, perceived barriers, and opinions related to oral carcinomas.

Once the data collection was completed, data were downloaded to Excel and cleaned by removing any irrelevant raw data. Data analysis was performed using the IBM SPSS Statistics 21 for Windows 10. Statistical analysis was divided into two parts: (1) descriptive and (2) inferential. The total score for “early detection practices” was calculated by assigning points to each response as Yes = 1 and No = 0. There were 14 items on the knowledge of the clinical presentation of oral carcinomas. One point was given for each correct response, and the knowledge score was categorized by the number of correct responses (low = 0–9 scores, medium = 10–11, high = 12–14). There were 16 items on knowledge of risk factors for oral carcinomas. One point was given for each correct response, and the score was categorized as (low = 0–8, medium = 9–10, and high = 11–16).

In the descriptive analysis, frequencies and percentages were calculated for demographic characteristics, work and health facility-related factors, and knowledge scores. The mean and standard deviation were calculated for the early detection practice scores.

In univariate analysis, an independent sample t test was conducted between the outcome variable (early detection practices) and dichotomous variables. An analysis of variance test was performed between the outcome variable and variables with more than two responses. All those variables with p < 0.05 in univariate analysis were entered into multivariate analysis. Multiple regression statistical analysis and multiple linear regression were used to determine the association between explanatory variables and the outcome variable.

A total of 235 dentists were included in the study. Among the respondents, 163 (69.4%) were females, and 72 (30.6%) were males. A total of 160 (68.1%) dentists were between the ages of 23–29 years, and 62 (26.4%) were between the ages of 30–39 years. Of the 235 participating dentists, 45 (19.1%) were dental specialists, and 80 (34%) were general dentists (BDS only). Among the respondents, only 65 (27.7%) had attended a professional development course (PDC) during the past 2 years. The majority of participants, 182 (77.4%), were working full time.

Regarding health facility-related factors, 153 (65.1%) participants practiced in the private setup and 43 (18.3%) were working in the government setup. Advanced procedures were performed in almost half (54.5%) of the 128 facilities. Moreover, half of the facilities 133 (56.6%) had written guidelines on OC examinations (Table 1).

The mean score for knowledge related to clinical presentation of oral carcinomas is 7.5 (SD = 2.2). The majority of the dentists, 192 (81.7%) had low knowledge related to clinical presentation. The mean score for knowledge related to the risk factors of oral carcinomas was 10.4 (SD = 2.06). Nearly half 130 (55.3%) had high scores for knowledge of risk factors. Only 30 (12.8%) of the study participants knew that the patient is asymptomatic during the early stages of oral carcinomas, while the majority of the participants 169 (71.9%) recognized the tongue as the most common site of oral carcinomas. A very low percentage of 73 (31.1%) participants identified low consumption of fruits and vegetables as a risk factor, while only 54 (23%) could correctly recognize poor-fitting dentures as a non-risk factor (Table 2).

The mean score for practices related to detection of oral carcinomas among dentists was 5.4 (SD = 2.04). The majority of respondents, 224 (95.3%), had a history of smoking habits. However, only half of the participants, 112 (47.7%), underwent lymph node palpation. Moreover, only 107 (54.5%) dentists examined the tonsils/oropharynx (Table 3).

Among the participants, 142 (60%) strongly agreed that OC screening should be provided each year to individuals aged ≥40 years. A high percentage of respondents 74%, strongly agreed that they were comfortable referring their patients to specialists when they inspected a suspicious lesion in the oral cavity (shown in Fig. 1).

Regarding perceived barriers, 112 (47.7%) participants agreed that lack of clinical time is a barrier to performing OC examinations. However, 122 (51.9%) participants agreed that lack of training for OC screening is a barrier for examining oral mucosa (shown in Fig. 2).

Sociodemographic Factors. In univariate analysis, t tests or analysis of variance tests with a confidence interval of 95% were performed where appropriate. The results revealed that there was no statistically significant association between age (p = 0.4), monthly salary (p = 0.9), and sex (p = 0.5) with early detection practice mean scores (Table 4).

Work and Facility-Related Factors. Table 4 illustrates that the variable “duration since attended Professional development course” was significantly associated with early detection practice scores (F(3, 231) = 8.6, p < 0.0001). For multiple comparisons, Tukey’s post hoc test was performed. The results revealed that the participants who attended the PDC during the past 2 years had significantly higher mean scores of early detection practices (mean = 6.5, SD = 1.6) than those who had attended within the last to 2–5 years (mean = 5.1, SD = 2.3, p = 0.02), attended 5 years ago (mean = 5.2, SD = 1.9, p = 0.015), and had never attended the PDC (mean = 5, SD = 2, p < 0.001). Similarly, the dentists who had completed certification had significantly higher mean scores (mean = 6.6, SD = 1.2) than those who had not completed any certification (mean = 5.4, SD = 2) (t(232) = 2, p = 0.14). The test results revealed that the variable “who owns health facility” was significantly associated (F(4, 230) = 2.5, p = 0.04) with early detection practices scores. However, the results of Tukey’s post hoc test revealed that there were no statistically significant differences in the mean scores of different groups within the variable. The mean scores for early detection practices were significantly higher in the health facilities where written guidelines about the examination of oral carcinomas were present (mean = 6.1, SD = 1.8) than in those where no written guidelines were present (mean = 4.7, SD = 2.1) (p < 0.001). The ANOVA test for “Types of the procedures done” revealed that there were significant differences in the mean scores of practices between the groups (F(2, 232) = 4.1, p = 0.017). Multiple comparisons revealed that the mean scores in the health facilities where basic procedures were performed were significantly higher (mean = 6.6, SD = 1.6) than those in facilities where advanced procedures were performed (mean = 5.3, SD = 2, p = 0.013).

Knowledge Related to Clinical Presentation and Risk Factors of Oral Carcinomas. There was no statistically significant difference in the mean scores of practices between groups of “knowledge related to clinical presentation” (F(2, 232) = 0.62, p = 0.54) and “knowledge related to risk factors” (F(2, 232) = 0.76, p = 0.468) was observed.

Opinions Related to Oral Carcinomas. Among the six variables relating to opinions, only two variables were found to be statistically associated with early detection practices scores.

• 1.

  The screening practice scores among the participants were significantly associated with the comfort of the dentists in referring their patients (having suspicious oral lesions) to the specialists (F(4, 230) = 2.8, p = 0.026).

• 2.

  Similarly, NOT confidence in the ability to perform an OC exam was significantly associated with early detection practice scores (F(4, 230) = 2.7, p = 0.03).

Multiple linear regression was conducted to examine the effects of “duration since attending PDC,” “types of procedures performed,” “certification,” and “guidelines” on early detection practice scores. All variables with p < 0.05 in univariate analysis were entered into the model through a priori criteria. The results revealed that the duration since the attended PDC was significantly associated with early detection practice scores. Those who attended PDC within 2 years had 1.2 units higher mean scores (p < 0.001, 95% CI = −1.9 to −0.55) compared to those who attended within 2–5 years, 0.87 units higher scores (p = 0.038, 95% CI = −1.6 to −0.04) compared to those who attended more than 5 years ago and 1.02 units higher scores (p = 0.001, 95% CI = −1.6 to −0.4) compared to those who never attended. Facilities where written guidelines about OCs were present had 1.12 units higher mean scores of early detection practices compared to those with no written guidelines (p < 0.001, 95% CI = 0.62–1.6). Facilities where basic procedures were performed had 1.01(p = 0.08, 95% CI = −1.9 to −0.19) and 1.09 (p = 0.015, 95% CI = −1.9 to −0.2) units higher mean scores of practices compared to facilities where intermediate or advanced level procedures were performed (Table 5).

Unlike previous studies, that focused primarily on knowledge and awareness of OCs, this study offers new insights into the early detection practices of dentist and highlights the specific factors that influence these behaviors in context of Pakistan. These findings help bridge a critical gap in existing literature and provide direction for targeted professional development initiatives. The study’s findings contribute to expanding our understanding in the following areas.

The results of this study have shown that most dentists are capable of identifying tobacco, alcohol, Ghutka, and HPV as risk factors for OCs. Although dentists are well aware of the adverse effects of alcohol consumption on the oral mucosa, only a minority inquired about alcohol consumption. Dentists should be encouraged to take medical histories and provide counseling regarding risk factors, such as alcohol consumption. This practice is particularly crucial in conservative populations such as Pakistan, where individuals are unable to disclose their alcohol consumption habits due to religious or cultural norms. This study revealed that the overall knowledge of dentists regarding the risk factors was high. However, the majority of dentists were unable to identify the association between low consumption of fruits and vegetables and OCs, indicating the need to educate dentists about the importance of healthy food in reducing the incidence of carcinomas. The majority of participants could not recognize poor oral hygiene, use of marijuana, poor-fitting dentures, and spicy food as non-risk factors for oral carcinoma. Hence, this knowledge gap may affect their ability to correctly identify high-risk patients. Hence, to enhance their diagnostic abilities, there is a dire need for Continuous Professional Development courses (CPD), as is evident from a study conducted previously [26]. This could lead to increased awareness in the population, which plays an important role in the prevention of OC. The overall score of the participants regarding knowledge related to the clinical presentation of OC was low. Only 12.8% of participating dentists knew that OCs were asymptomatic in the early stages, which is even lower than the percentages reported in studies conducted in Qatar (21%) [24] and Kuwait (31.1%) [27]. Less than one-fourth of the participants knew that OC was mostly diagnosed in individuals aged 60 years and above. The results of this study also indicated that CPD courses are associated with improved screening practices. This further emphasizes the need for a CPD course to keep the knowledge of dentists updated.

Delay in OC diagnosis and management is a crucial factor contributing to the poor prognosis of the disease [28]. Previous studies have shown that opportunistic screening of the oral mucosa by dentists or oral healthcare professionals may lead to earlier identification, thus increasing survival rates [29].

In this study, a series of questions was asked to investigate the specific steps of the examination. The results revealed that only a minority of participants performed all steps. Moreover, the inspection of tonsils and palpation of the lymph nodes are most commonly overlooked during examinations, and these practices can be improved with continuous training and guidelines. This is further emphasized by the results of the present study that the screening practices are better in settings where written guidelines are present, compared to settings where guidelines are not available. This indicates that comprehensive education material should be provided to dentists to improve their knowledge and diagnostic abilities.

In this study, a high percentage of dentists, more than the percentages reported in previous studies, emphasized the importance of annual OC examinations for individuals 40 years or above [24]. This was evident from their attitudes, as 60% of the dentists strongly agreed that OC examinations should be conducted annually. Similarly, a high proportion of dentists revealed good knowledge regarding the steps involved in oral cavity examination. A relatively low percentage of dentists were confident in their ability to perform oral examinations. The majority of dentists in the present study agreed that 5-year survival rates of oral carcinomas can be improved with early detection practices, as it is evident from the literature that 3/4th of the cases are diagnosed in late stages of the disease, when the prognosis is very poor [15]. Hence, regular training should be provided to enhance knowledge and skills. This will not only improve their confidence but will also lead to more positive attitudes toward OC screening.

Almost half of the participants agreed that lack of clinical skills, practice time, training and knowledge are barriers in executing OC examinations. These findings further highlighted the importance of continuous education for dentists. Unfortunately, there is no comprehensive education system for dentists in Pakistan. Healthcare authorities should put collaborative efforts to implement a continuous dental education system that should be tailored according to the needs of dentists in Pakistan.

Above discussion suggests absence of a comprehensive approach for academic and professional capacity building of dentists to counter OC at the initial stage. In this regard multipronged strategy is suggested, including incorporating targeted OC education in dental curriculum, offering CPD programs and utilizing digital learning platforms for dentists. National dental bodies may also consider implementing routine screening protocols and awareness campaigns. Further large-scale studies with nationally representative samples of dentists are recommended to gain a more comprehensive understanding of the differential factors influencing early detection practices of oral carcinomas among dentists.

A team of six dentists were trained before data collection to reduce interpersonal error. A self-administered electronic questionnaire was provided to the participants to make it easy for them to answer. Although this method is time-consuming, it improved the response rate and overcame the accessibility barrier. However, the section on “practices related to oral carcinomas” was not self-administered to avoid response bias. Self-reporting in that section could have led participants to over report adherence by marking all practices as “yes.” Instead, participants were interviewed to describe the specific practices they routinely perform for OC detection. Only those practices explicitly mentioned were recorded as “yes” and all others were marked as “no.” This approach was intended to enhance the accuracy and validity of reported practices.

The present study has several limitations. Though the characteristics of the participants were similar to the national dentists’ profile, the findings may not completely reveal the practices and knowledge of all dental practitioners in the country. Further large-scale studies are thus suggested. Another limitation of the study is nonresponse bias. The dentists who refused to participate in the study might have different knowledge or practice scores compared to nonparticipants.

This study demonstrated poor early detection practices among the participating dentists, particularly, palpation of the oral mucosa and lymph nodes. Moreover, they had inadequate knowledge, particularly related to the clinical presentation of oral carcinomas. Owing to the high burden of oral carcinomas in Pakistan, these poor practices can have serious consequences for suffering patients. Hence, intervention must be done to improve the knowledge and practices of dentists. This can be achieved by improving the curriculum at the undergraduate levels and by providing continuous PDCs to dentists. These interventions are specifically important in South Asian countries, where OC cases are increasing day by day, along with the lack of awareness among the population.

The authors would like to express their gratitude to the Health Services Academy Pakistan and the Department of Global Health Research, Juntendo University, for providing an invaluable platform for research. The academic support offered by the institution significantly contributed to the successful completion of this study.

This study was performed in accordance with the Declaration of Helsinki. This human study was approved by the Internal Review Committee of Health Services Academy – approval: 000136/HSA/MSPH-2021. All adult participants provided written informed consent to participate in this study. Requests were made to seek Informed Consent from the Participating dentists in the study. Their written permissions were also taken on the consent forms before conducting the survey (online suppl. material A2). Identities of the participating dentists were preserved by using alpha-numeric codes for respondents during data collection and analysis. During the conduct of interviews, privacy and confidentiality of the interview setting were managed carefully.

The authors declare no conflicts of interest.

This research received no external funding.

Conceptualization, project administration, and design: Zoofa Talha and Mariyam Sarfraz. Methodology: Zoofa Talha, Mariyam Sarfraz, and Ishtiaq Ahmad. Validation, formal analysis, investigation, writing – original draft preparation, and data curation: Zoofa Talha and Ishtiaq Ahmad. Writing – review and editing: Zoofa Talha, Mariyam Sarfraz, Ishtiaq Ahmad, and Aida Uzakova. Visualization: Zoofa Talha and Aida Uzakova. Supervision: Mariyam Sarfraz, and Ishtiaq Ahmad. All authors have read and agreed to the published version of the manuscript.

The data that support the findings of this study are not publicly available due to privacy reasons but are available from the corresponding author upon reasonable request.