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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 5  |  Page : 735-746

Knowledge and behavioral assessment of dentists toward screening and managing patients with head and neck cancer in Saudi Arabia


Department of Oral Biology, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Submission25-Jun-2020
Date of Acceptance28-Aug-2020
Date of Web Publication20-May-2021

Correspondence Address:
Dr. T Y Alhazzazi
Department of Oral Biology, King Abdulaziz University, Faculty of Dentistry, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_392_20

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   Abstract 


Background: Widening the breadth of dentists' responsibilities to include screening all patients for life-threatening diseases, such as head and neck cancer (HNC), is crucial to improve survival rates and decrease morbidity. Aims: The study aimed to assess the knowledge and behavior of dentists toward screening and managing patients with HNC in Daudi Arabia. Thus, this study aimed to assess the knowledge and behavior of dentists toward screening and managing patients with HNC in Saudi Arabia. Methods: This cross-sectional study comprised a closed-ended electronic questionnaire sent to dentists including general practitioners, specialists, and consultants (n = 723). The e-questionnaire included questions that assessed dentists' behavior and knowledge toward screening and managing patients with HNC. The Chi-square test was used to establish relationships between categorical variables. Results: The response rate was 28.5%. Dentists obtained the dental and medical histories of 74% and 80% of their cases, respectively. Only 55% and 14% of dentists routinely ask their patients about smoking habits and family history of cancer, respectively. Additionally, only 13% and 12% always screen for HNC and were familiar with adjunct HNC screening tools, respectively. Approximately 75% of respondents identified HPV as a risk factor, whereas 54% and 41% identified human immunodeficiency virus (HIV) and poor oral hygiene as risk factors, respectively. Conclusions: There is an apparent lack of essential concepts of the behavior and knowledge in our dental community with respect to screening and managing patients with HNC. More emphasis should be placed on updating information on clinical practices and having dentists familiarize themselves with HNC screening methods and tools. Ultimately, the role of the dentist should include screening and detecting systemic diseases in dental settings.

Keywords: Behavior, dentists, knowledge, head and neck cancer, oral cancer, Saudi Arabia


How to cite this article:
Alhazzazi T Y. Knowledge and behavioral assessment of dentists toward screening and managing patients with head and neck cancer in Saudi Arabia. Niger J Clin Pract 2021;24:735-46

How to cite this URL:
Alhazzazi T Y. Knowledge and behavioral assessment of dentists toward screening and managing patients with head and neck cancer in Saudi Arabia. Niger J Clin Pract [serial online] 2021 [cited 2022 Dec 3];24:735-46. Available from: https://www.njcponline.com/text.asp?2021/24/5/735/316467




   Introduction Top


Dentists can play an important role in maintaining the general health of their patients by not only performing high-quality dental work but also by screening for life-threatening diseases such as head and neck cancer (HNC).[1],[2],[3] Unfortunately, there remains a lack of knowledge and awareness worldwide surrounding this consideration that warrants further study.

HNC encompasses malignancies developed in the nasal cavity, sinuses, lips, salivary glands, throat, oral cavity, and larynx.[4] HNC is one of the most common worldwide cancer types and represents a global burden.[5] It is estimated that more than 650,000 cases and 330,000 death are reported annually.[5] In the United States, HNC represents about 3% of all types of cancer, with an estimate of 53,000 new cases and 10,750 annual deaths.[6] Geographically, HNC seems to have a greater impact on other areas around the world such as India, East Asia, Eastern Europe, and South America.[7]

According to the latest cancer report in Saudi Arabia, HNC accounts for approximately 6% of all malignancies.[8] Interestingly, because Saudi Arabia constitutes the bulk of the Arabian peninsula, with a landmass spanning more than 2 million km2, the incidence of HNC varies according to geography, with a ~30-fold difference in the age-standardized rate (ASR) between the lowest and highest prevalence rate.[9] For instance, Jazan (Gizan) ranked highest in HNC prevalence in Saudi Arabia; more specifically, oral cancer ranked first among females and second among males.[9] After Jazan, HNC was most prevalent in Najran.[9] Furthermore, Allord et al. reported that 35% of oral cancer referrals in their study originated from Jazan,[10] and Al-Ghamdi et al. reported that oral cancer was the second most common form of HNC in males from the Asir region after skin cancer and the third most common in females after thyroid and skin cancers.[11]

All of the above regions are located in the south of Saudi Arabia and in close proximity to Yemen. In these areas, the use of smokeless tobacco (shammah) was identified as a major risk factor associated with oral cancer, which may partly explain the high prevalence of oral cancer in theses regions relative to other types of cancer.[10],[12],[13] This illustrates that oral cancer is a significant public health problem in these regions, especially given that they are considered developing regions of Saudi Arabia.

The fact that dentists are the first in line to locate abnormalities in the head and neck region, and specifically in the oral cavity, makes them uniquely poised to help screen, diagnose, and refer such patients to the appropriate medical specialists; only then can we consider that the highest standard of care is being met. Accordingly, prevention and early detection of such cancers are two key determinants of survival and treatment outcomes.[7] Most studies to date have focused on evaluating the knowledge, awareness, and behavior of dental students, healthcare providers, dental hygienists, and general society with regards to HNC.[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34] However, few reports have assessed practicing dentists, and specifically in Saudi Arabia.[28],[34],[35],[36],[37],[38],[39] Thus, this study aimed to assess the current knowledge and behavior of dentists toward screening and managing patients with HNC in Saudi Arabia.


   Materials and Methods Top


The e-questionnaire protocol

This cross-sectional study comprised a closed-ended electronic questionnaire. The e-questionnaire includes questions about the participants' knowledge and behavior toward screening and managing patients with HNC.

The questionnaire was created and then reviewed by three experts in the field to ensure its validity. We piloted that initial version of the questionnaire on 25 participants to assess the questions' clarity. This version was modified following participant feedback, and the final version of the e-questionnaire was sent to dentists in major regions of Saudi Arabia, including general practitioners, specialists, and consultants (n = 723), using known and established dentistry-related social media groups in Saudi Arabia. All participants confirmed that they answered the questions to the best of their knowledge and according to their daily dental routine, and they consented to have their responses used for research and educational purposes.

Statistical methodology

The IBM SPSS software version 23 was used for statistical analysis. Simple descriptive statistics were used to define the characteristics of the study variables through counts and percentages for categorical variables. To establish a relation between categorical variables, the Chi-square test was used, where a P value <0.05 was defined as statistically significant. Two domains were used during the analysis, namely; Behavior and Knowledge, with each domain calculated by converting the answers of the (7) behavior-related questions and those of the (11) knowledge-related questions into points as follows:

For behavioral questions: “No” = 0; “Yes, sometimes” or “Only for patients with risk factors” = 1; and “Yes, always” = 2. Possible scores ranged from 0 to 14 points, which were categorized as follows:

  • 0-8 = Poor Behaviors
  • 9-11 = Acceptable Behaviors
  • 12-14 = Excellent Behaviors


For knowledge questions: correct answer = 1; incorrect answer = 0. Possible scores ranged from 0 to 10 points, which were categorized as follows:

  • 0-5 = Less Knowledgeable
  • 6-7 = Slightly Knowledgeable
  • 8-10 = Knowledgeable.


Human subjects statement

The e-questionnaire included written informed consent that was obtained from all participants. The e-questionnaire was approved by the ethics committee review board (Ref. No. 22-03-2020) from King Abdulaziz University Faculty of Dentistry (KAUFD) and was in full accordance with the World Medical Association Declaration of Helsinki.


   Results Top


Of the 723 questionnaires that were sent, 206 were completed, indicating a response rate of 28.5%. Of those respondents, 60.7% were male and 39.3% were female. The majority of respondents were general dentists (57.8%), followed by consultants (23.8%). Approximately 46.6% of respondents were new graduates, whereas 29.6% have been practicing for >10 years. The characteristics of all 206 participants are presented in [Table 1]. Dentists' behavior toward obtaining proper dental and medical records was then assessed. Dentists that obtained full dental and medical histories for all patients including past and present illness were 74% and 80%, respectively [Figure 1]a and [Figure 1]b, [Table 2]. [Figure 1]a and [Figure 1]b, [Table 2]. Additionally, 55% of participants routinely inquire about smoking habits; however, only 14% routinely ask about family history of cancer, compared to the 53% of respondents who indicated never asking such questions [Figure 1]c and [Figure 1]d, [Table 2].
Table 1: Characteristics of the 206 respondents

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Figure 1: Dentists' behavior toward obtaining proper dental and medical records. Percentage of dentists obtaining (a) Full dental records; (b) Full medical records; (c) Smoking history; (d) Family history of Cance

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Table 2: Survey questions and response percentages

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Afterward, dentists were assessed for their behavior and knowledge toward HNC screening in the dental clinic. Approximately 67% of respondents reported that they routinely screen their patients for problems other than the chief complaint [Figure 2]a, [Table 2]. In addition, 50% of respondents indicated always taking panoramic radiographs, while only 13% indicated always screening for HNC as part of their daily examination protocol [Figure 2]b and [Figure 2]c, [Table 2]. When participants were asked whether they knew how to perform HNC screening, only 28% said “yes” [Figure 2]d, [Table 2], and only 12% were fully familiar with the adjunct HNC screening tools such as brush biopsy, TBlue, and VELscope [Figure 2]e. Only 65% of the participants knew that the tongue and the floor of the mouth are the most common locations of oral cancer [Figure 2]f, [Table 2].
Figure 2: Dentists' behavior and knowledge toward HNC screening in dental clinic. Percentage of dentists (a) Screening for problems other than the chief complaint; (b) Routinely taking panoramic radiographs; (c) Always screening for HNC; (d) Knew how to perform HNC screening; (e) Knew adjunct HNC screening tools; (f) Knowing tongue and the floor of the mouth are the two most common areas of HNC

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Respondents were then evaluated on their knowledge of important HNC-related areas including HNC risk factors. Approximately 84% of participants responded that HNC is not always painful, and 90% accurately responded that squamous cell carcinoma (SCC) is the predominant form of HNC [Figure 3]a and [Figure 3]b, [Table 2]. With respect to risk factors, 75% of respondents knew that human papillomavirus (HPV) is a risk factor for HNC, whereas only 54% accurately identified human immunodeficiency virus (HIV) as a risk factor [Figure 3]c and [Figure 3]d, [Table 2]. Surprisingly, there were divided responses regarding whether poor oral hygiene is a risk factor for HNC: 41% of respondents answered “yes” and 41% answered “no” [Figure 3]e, [Table 2]. In addition, only 17% of respondents knew the overall 5-year survival rate of HNC [Figure 3]f, [Table 2].
Figure 3: Dentists' knowledge on HNC-related topics. Percentage of dentists knowledge about (a) HNC representation with pain; (b) Most common type of HNC; (c) If HPV is a risk factor; (d) If HIV is a risk factor; (e) If poor oral hygiene is a risk factor; (f) The correct overall 5-year survival rate of HNC

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Finally, the dentists' management protocol for HNC patients was assessed. Approximately 78% of respondents believed that dentists are responsible for screening each patient for HNC and, indeed, 55% of them did detect patients with HNC or suspicious lesions requiring further attention at some point during their career [Table 2], which differed significantly between males and female dentists [69.3% vs 30.7%; *P < 0.05; [Table 3]]. However, no significant difference was found between years since graduation or profession title (data not shown). Moreover, 64% of participants preferred referring patients with suspicious lesions to oral and maxillofacial surgeons, whereas 18% preferred referring to a colleague known to deal with such cases [Figure 4]a and [Figure 4]b, [Table 2]. When participants were asked about the follow-up period for a diagnosed HNC patient, the majority agreed on a lifetime period (57%), followed by a 5-year period [14%; [Figure 4]c and [Figure 4]d, [Table 2].
Table 3: Comparison of male and female dentists on lesion detection

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Figure 4: Dentists' management protocols for HNC patients. Percentage of dentists (a) Believing that they should screen for HNC; (b) Detecting patients with HNC or suspicious lesions; (c) Referral of HNC patients; (d) Agreement about the proper follow-up period for HNC patients

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Analysis of the summed behavior and knowledge scores is summarized in [Table 4]. Surprisingly, only eight of the 206 participants answered all behavior-related questions correctly, and none answered all knowledge-related questions correctly [Figure 5]a and [Figure 5]b. However, both scores were normally distributed, as shown in the histogram graph [Figure 5]a and [Figure 5]b. [Figure 6]a and [Figure 6]b show the mean score and percentage distribution of the behavior and knowledge questions to illustrate the participants' areas of strengths and weaknesses.
Table 4: Summary of dentists' behavior and knowledge scores

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Figure 5: Summary of dentist's behavior (a) and knowledge (b) scores

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Figure 6: The mean score and percentage distribution of the behavior and knowledge questions illustrating participants' areas of strengths and weaknesses. (a) Behavior questions; (b) Knowledge questions

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For example, scores of 1.8 and 1.73 demonstrate that the majority of the respondents routinely inquire about present and past medical and dental histories of their patients, respectively, compared to the score of 0.77 and 0.61, which reflect that dentists, unfortunately, perform less HNC screening as part of their daily examination protocol, and seldom ask for cancer family history, respectively [Figure 6]a. On the other hand, 90.3% and 84.5% of participants were knowledgeable about the common type of HNC and knew that HNC is not always painful, respectively, compared to only 27.7% and 17% who confidently knew how to perform HNC screening and knew the overall 5-year survival rate of HNC, [Figure 6]b. The survey questions and a summary of the frequency of responses are listed in [Table 2].


   Discussion Top


Prevention and screening for oral and systemic health issues is the ultimate goal to promote a better quality of life and decrease the burden of these diseases on the healthcare system. One important parameter to achieve this goal is raising awareness and knowledge about the relationship between oral health and systemic diseases in the general population and healthcare providers alike.[14],[15],[40],[41],[42],[43],[44],[45],[46],[47] Therefore, broadening dentists' responsibilities to include participating in the screening process for these diseases as part of their daily routine is imperative to overcome the sociological and economic burden imposed by these diseases and to ensure better quality and standard of care for all patients.[1],[45],[48]

Interestingly, numerous worldwide reports have investigated the awareness, knowledge, and behavior toward HNC within the general society,[15],[18],[19],[20],[22],[33] dental students,[25],[26],[27],[29],[30],[31],[32] and hygienists.[16],[23],[24] However, few studies have as of yet assessed these topics among practicing dentists, and fewer still among dentists practicing in Saudi Arabia. Therefore, the aim of this study was to assess the current knowledge and behavior of dentists in Saudi Arabia toward screening and managing patients with HNC.

Our results revealed a clear lack of essential knowledge and behavioral practice concepts among dentists with regards to HNC screening and management approaches. We expected to see a 100% compliance rate for obtaining full dental and medical histories. Reviewing dental and medical histories will not only prevent unexpected treatment outcomes and complications such as excessive bleeding and fainting,[49],[50],[51] but will also facilitate reaching an accurate diagnosis, especially in cases of systemic diseases[52],[53],[54] or referred pain.[55],[56] In addition, smoking and a family history of cancer have been associated with an increased risk of developing HNC.[57] Surprisingly, only 55% and 14% ask their patients about smoking and a family history of cancer, respectively. These results are alarming and suggest that dentists could miss important precipitating factors of HNC.

Dentists were then assessed for their knowledge and behavior with respect to HNC screening in dental settings. Acknowledging and treating the patient's chief complaint is an important component of the dentist–patient relationship and helps build trust. However, it is our contention that the dentist should be responsible for screening patients for other oral or systemic health problems during dental visits to prevent potential disease progression and direct them to the appropriate dental or medical specialist. By doing so, dentists will ensure better oral and general health for all patients.[42],[58] This should be a routine practice goal for all dental specialties and general practitioners.[45] The poor average percentage (67%) of dentists who reported routinely screening their patients for issues other than the chief complaint indicated that some difficulty may be faced in achieving this goal.

Screening and early detection of HNC have been established as two important key players in determining the survival rate of HNC patients.[2],[59],[60] Moreover, obtaining digital radiographs (e.g., panoramic radiographs), screening all patients for HNC, and being familiar with adjunct HNC screening tools are all important factors that will help in the screening and early detection of HNC patients.[61],[62],[63],[64] In a systematic review by Uribe et al., panoramic radiographs were found to be a cost-effective and reliable method for detecting bone defects of patients with oral SCC, with a specificity of 91.7%, compared to more invasive and expensive methods such as computed tomography (CT) and magnetic resonance imaging (MRI) scans (100% specificity).[65]

Our data reveal a clear deficiency in these areas, as only half of the respondents indicated performing routine panoramic radiographs, and only 13% reported screening all patients for HNC. Moreover, only a few were knowledgeable on how to perform HNC screening and were familiar with some of the HNC adjunct screenings tools (e.g., brush biopsy, TBlue, VELscope). Familiarizing with such tools has been shown to be an effective method for the early detection of HNC patients in dental clinics.[66],[67]

SCC accounts for more than 90% of all head and neck malignancies, and oral cancer represents the majority of HNC cases, wherein the tongue, followed by the floor of the mouth, are the most common sites of oral cancer.[59],[68] The 5-year survival rate of HNC depends on several factors including early detection, location, and stage; nevertheless, the overall 5-year survival rate of HNC averages 50% and has only marginally improved over the past decade.[69] This type of cancer is not always painful during its early stages,[68],[70] which may contribute to the delay in diagnosis and thereby affecting the survival rate.

Participants' knowledge towards important HNC-related information, including HNC risk factors, was then queried. The majority of our participants reported that they knew that SCC is the predominant form of HNC and that pain is not always present in early HNC. However, only 65% of respondents were knowledgeable about the common sites of oral cancer, compared to 17% who thought that the tongue and lips are the most commonly affected sites. Regarding risk factors, studies have shown that smoking, alcohol, and HPV are among the most common factors that can cause HNC.[71],[72] In addition, other emerging HNC risk factors have emerged, such as HIV and poor oral hygiene.[73],[74],[75],[76],[77],[78] Our data show that an appreciable proportion (75%) of respondents knew that HPV is a risk factor for HNC, relative to the mere 54% who thought that HIV is a risk factor. However, only 41% of participants believed that poor oral hygiene is a risk factor for oral cancer, compared to 18% who did not know the correct answer and 41% who answered “no.” These factors have recently evolved and our data demonstrate that the participants' knowledge in these areas is not up to date.

Surprisingly, only 17% were knowledgeable about the correct answer to the overall 5-year survival rate of HNC, whereas 50% answered that they “do not know.” This indicated a clear lack of knowledge on such important information and further emphasizes the importance of keeping up to date on emerging information. Thus, educating patients about risk factors and survival rates are two important parameters when it comes to patient motivation and prevention.

Next, dentists' management protocol for HNC patients was evaluated. Interestingly, although the majority of the participants believed that dentists are responsible for screening each patient for HNC, this was not reflected in their self-reported behavior. As our results demonstrate, only 13% of respondents always screen for HNC as part of their daily examination protocol.

Regarding the follow-up period, more than half of respondents believed that these patients should be followed up for life, followed by 14% who believed that 5 years is a satisfactory follow-up period. Nonetheless, there remain no common and clear recommendations or guidelines for an appropriate follow up-period for HNC patients, which can vary depending on multidisciplinary team decisions made on a case-by-case basis.[79] A study by Joshi et al. reported that 56% of participating clinicians would follow-up their patients for a minimum of 5 years, while 22% would do so for life. The latter statistic came mostly from maxillofacial surgeons.[80] Therefore, while a lifetime follow-up period, which was suggested by the majority of our respondents, seems daunting, it should nevertheless be attempted. Follow-up visits would entail screening for treatment complications, recurrence, metastasis, and patient support.[80]

In general, our data seem to agree with those of other international studies in which deficits in the knowledge and clinical practices of dental practitioners were noted and educational reinforcement was needed in regards to HNC screening and management.[28],[35],[36],[37],[38],[39] Finally, our analysis of the summed behavior and knowledge scores revealed areas of strengths and weaknesses among our participants.

It is worth highlighting that there is a clear gap between what the dentists in our study believe and what they actually do in their daily practice. In addition, the loss of confidence in how to perform a proper HNC screening in the clinic on a daily basis may underlie its lack of application in our cohort. Moreover, the general lack of knowledge that poor oral hygiene can be an important emerging risk factor for HNC is an alarming sign that dental practitioners should invest more time in updating their general knowledge about critical information that will improve and enrich the standards of care they provide. This can be easily done by attending conferences or even webinars from home.

One of our study limitations may be the low response rate. The study was conducted during the Covid-19 pandemic; thus, we expected respondents to be at home more than usual. Considering that three reminders were sent to the participants to answer the questionnaire, a higher response rate was expected. In addition, we would have wanted to include more questions that specifically targeted risk factors and related topics, but it is well known that lengthy questionnaires are poorly received and yield a lower response rate than brief questionnaires.


   Conclusions Top


There is a clear lack of essential concepts of behavior and knowledge aspects in the Saudi Arabian dental community in regard to screening and managing patients with HNC. The gap between the perceived knowledge and the actual practice in daily basis is alarming. More emphasis should be placed on updating information on clinical practices and having dentists familiarize themselves with HNC screening methods and tools. No significant difference was found between the year since graduation and employment position in our study, which highlights the importance of dentists in the early screening and detection of systemic diseases in dental settings. Only then can dentists provide patients with the highest quality of care and decrease the burden of non-communicable diseases and risk factors, such as hypertension, diabetes, and HNC.

Financial support and sponsorship

This project was funded by the Deanship of Scientific Research (DSR) King Abdulaziz University, Jeddah, Saudi Arabia, under grant no. G-720-165-38. The author, therefore, acknowledge with thanks DSR for their technical and financial support.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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