Ameena F.doc J Bagh College Dentistry Vol. 25(3), September 2013 Awareness and knowledge Oral Diagnosis 69 Awareness and knowledge of oral cancer among final year undergraduate dental students in Baghdad-Iraq Ameena R. Diajil, B.D.S., M.Sc., Ph.D. (1) ABSTRACT Background: The incidence of oral cancers is increasing all over the world. Early detection ofthis important public health matter makes them more amenable to treatment and allows the greatest chance of cure.The aim of this study was to investigate the awareness and knowledge on oral cancer among final -year dental students in Iraq. Materials and methods: Questionnaires were delivered to 160 final–year dental students in the College of Dentistry in Baghdad. The questionnaire focused on the awareness/knowledge of oral cancer, earlyand common clinical signs and symptoms andassociated risk factors. Results: It was found that 87% of students were aware of oral cancer. The followings were recognized as signs and symptoms of oral cancer: persistent ulcer and lymphadenopathy (71 %, 70%), followed by presence of white patch (63%). A satisfactory knowledge was observed on; smoking (86%), family history (84%), old age (63%), sun light exposure (59%), smokeless tobacco (57%), alcohol consumption (55%) and Immunosuppression (54%).Considering dilatory risk-factors, a satisfactory knowledge was identified on hot and spicy food (57%), but not on the other factors. Although satisfactory knowledge of dental risk-factors including premalignant disorders (84%) and previous history of oral cancer (70%) was observed, inadequate knowledge about other factors was observed.91% of future dentists indicated that oral cancer can be cured when detected early. Conclusion: This study highlighted the need for more education in dental schools to enhance dental professionals’ awareness and knowledge of oral cancer, aiding in early diagnosis and treatment of patients. Keywords: Oral cancer, undergraduate dental students, awareness, knowledge. (J Bagh Coll Dentistry 2013; 25(3):69-79). INTRODUCTION Oral cancer is a potentially fatal disease that usually presents late and has a poor prognosis. The most common oral cancer is squamous cell carcinoma (OSCC) which affects significant numbers of people around the world. OSCC represents more than 90% of head and neck cancers (1, 2) with approximately two thirds are diagnosed at advanced stages (2-4). Despite advances in the therapeutic management and increased understanding of the molecular basis of the disease, the proportion of oral cancer cases diagnosed at an early and localized stage is still below 50% (5,6) ; and the five-year survival rate has not improved in recent years (7). OSCC may be preceded by Potentially Malignant Disorders (PMDs), which can be detected morphologically as leukoplakia, erythroplakia or erythroleukoplakia, reflecting the multi-step process of oral cancer development (8- 10). It has been estimated that one-third of oral PMDs progress to cancer (11) and most of them are asymptomatic or present with few symptoms and they are regarded as an intermediate stage between normal and malignant tissues (12). Thus, it is important to identify patients at risk of developing PMDs and to detect these disorders as early as possible. Several risk factors have been associated with the aetiology of PMDs and OSCCs, but tobacco smoking and alcohol consumption (13) are the most important. (1) Lecturer, Department of Oral Diagnosis, College of Dentistry, University of Baghdad. They are independently and synergistically associated with high risk in a dose-dependent pattern (14.15). Age, sex (16) and environmental carcinogens such as chemicals, radiation and viruses (17) have been considered significant prognostic and important promoting factors in the development of oral cancer. Oral cancer is largely preventable (18) with early diagnosis is greatly increase survival rates as the mouth is easily accessible for self or clinical examination. Contrary, the late diagnosis of a significant number of OSCCs is mostly attributable to delays in patients seeking treatment, insufficient patient awareness, asymptomatic clinical states and/or inappropriate investigation (19,20). According to Hollows et al. and McLeod et al. (21,22), lack of public knowledge and awareness is the most significant factor in delaying diagnosis and treatment of oral cancer. Some oral cancers are asymptomatic (23) or may experience symptoms differently (21) therefore lack of awareness and /or knowledge of early signs and symptoms of oral cancer among general dental practitioners may also contribute to delays in diagnosis and treatment of oral cancer (24,25). Epidemiological studies showed that the incidence of oral cancer varies considerably between different parts of the world with the highest levels in the Indian subcontinent and the lower ones in Western Europe and North America (26, 27). In the UK, oral cancer accounting for over 2% of all new cases of cancer in males and responsible for more than 1% of all new cases of cancer in females (27). In high-risk countries such J Bagh College Dentistry Vol. 25(3), September 2013 Awareness and knowledge Oral Diagnosis 70 as Sri Lanka, India, Pakistan and Bangladesh, cancer of the lip and oral cavity is either the most common or second most common cancer in men, accounting for up to 15% of all new cases of cancer in males (27). In Iraq, oral cancer account for about 4.5% of all cancer cases according to Iraqi cancer registry and it represent about 37% of the head and neck cancer (28). Awareness and knowledge of oral cancer among Iraqi dental student is not well documented. There is a lack of studies in Iraq about oral cancer and pre-cancer knowledge among final year university dental students. Thus the aim of the current study was to assess the oral cancer knowledge and awareness of future general dental practitioners by assessing 5th year undergraduate dental students' knowledge of prevention and early detection of oral cancer. MATERIALS AND METHODS Study design and population This cross sectional study was conducted among 160 dental students in the college of dentistry in Baghdad University. They were approached during seminars after permission was obtained from program coordinators and lecturers. Instruments and data collection Data were collected by using a self- administered questionnaire which included four sections: Section 1 included questions related to participant socio-demographics. These data included questions on age, gender, marital status, monthly household income class, residence and family history of oral cancer (table 1and figure 1). Section 2 consisted of 6 close- ended questions, which focused onawareness of oral cancer. Awareness was assessed by one question ‘did you hear about oral cancer (table 2). Section 3 assessed the knowledge of the final year students by questions on the signs and symptoms of oral cancer with the mostly mentioned manifestations of this disease (table 3). Section 4 focused on the associated risk factors and one question about the curability of oral cancer (Table 4 and figure 4). The questionnaire was distributed in English language and based on previous work by one of the authors (25, 30 and 31). The questions were mainly closed –ended rather than open questions. A description about the purpose and aim of the study along with the study questionnaires explanation was performed for all participants. See appendix A for questioners. Statistical analysis Data analysis was performed using Statistical Package of Social Sciences (SPSS) software, version 17.0. Descriptive statistics were obtained for all variables in the study with means and standard deviations were applied as appropriate. RESULTS Socio-demographic characteristics of the participants The mean age of respondents was 22.74 years (SD ± 0.87) and age range was 21-25 years with the majority aged 22 years (42%), followed by 23 years (38%), 24 years (14%) and 25 and 21years (3%) equally . Most of the students were females (66%) with remaining 34% were males, being in collage for around 5 years. Most of the respondents were singles (96%) and residing in urban area (76%). Seventy-seven percent had a middle monthly income, 13 % had high class and 10% with low household income. Only 9% of the final year students had a family history of oral cancer. Table 1 shows the social and demographic features of the participants. Awareness and knowledge of oral cancer The majority of the 5th year dental students were aware of oral cancer (87%) and all of them agreed that early detection can improve the treatment. Thirty –nine percent of the final year students knew that lifestyle can influence risk of oral cancer; fruit and vegetable intake 66%; good and frequency oral hygiene 81% and regular check-up and dental visits 93% (Table 2). As can be shown in Table 3, the majority of students recognized the followings as signs and symptoms of oral cancer; persistent ulcer (71%), lymphadenopathy (70%), presence of white patch (63%), colour changes to white and red (54%) and fixation to underlying tissue (51%). Whilst half of the students agreed that a lump of leukoplakia is a well-recognized sign of oral cancer, less than half of the dental students considered the followings as signs of oral cancers; Erythroplakia mass (45%), Erythroleukoplakia growth (43%), red patch (39%), swelling (37%), altered sensation (34%), induration /necrosis (32%) and oral bleeding was the least recognized symptom (28%). The mostly mentioned manifestations of oral cancer were also investigated and showed that ulcer that does not heal was the most common (79%) , followed by persistent white or red patch (78%) and lump or tissue overgrow (59%). Less than half of the students identified the followings as mostly identified manifestations of oral cancer; difficulty in swallowing (48%), difficulty in open the mouth (30%), Haemorrhage (30%), Abscess, boil, or infection (23%) and prosthesis that fails to fit (22%). Regarding the Knowledge of risk factors, most of the undergraduate students in this study agreed J Bagh College Dentistry Vol. 25(3), September 2013 Awareness and knowledge Oral Diagnosis 71 that tobacco smoking (86%) was the major risk factor associated with oral cancer, followed by family history of oral cancer (84%), old age (63%), sun light exposure (59%), smokeless tobacco- oral tobacco use (57%), alcohol (55%), Immunosuppression (54%) and occupation hazard (50%). Whilst less than half of the 5th year dental students considered the following factors as risk for oral cancer; viral infection (41%), gender (37%), chronic trauma (33%), chronic infection (30%) and betel quid chewing (30%). Taking in consideration the dietary factor, more than half of the participants (57%) agreed that hot and spicy food was a risk factor of oral cancer and less than half of the students regarded the followings as dietary risk factors for oral cancer; diet low in iron (39%), diet low in vitamin A (33%), low intake of fruit and vegetables (31%), diet low in vitamin C (31%) and high fat diet (7%). The majority of students agreed that the presence of precancerous lesions (84%) and previous history of oral cancer (70%) were risk factors for oral cancer. Less than half of students considered the followings as dental risk factor for oral cancer; poor oral hygiene (40%), poor dental condition (30%) and poor fitting dentures (27%). The curability of oral cancer has been investigated with 91% of students agreed that oral cancer can be cured if detected early; Table 3. DISCUSSION There is a paucity of information regarding undergraduate dental student oral cancer awareness in Iraq. In this study, we conducted a questionnaire survey among 160 final -year undergraduate dental students in collage of dentistry -university of Baghdad to investigate oral cancer awareness and knowledge of the future dental practitioners in Iraq, regarding early detection, clinical presentation, associated risk factors and curability of oral cancer. In Iraq, according to Iraqi cancer registry oral cancer account for about 4.5% of all cancer cases and it represent about 91.5% of all oral cancer and 37% of the head and neck cancer (28). Researchers in the field of oral oncology believe that early detection and diagnosis of oral cancer greatly increases the chance of cure and survival rates in addition to minimizing impairment and deformity (32, 33). Lack of public awareness has been reported to be the most significant factor in delaying referral and treatment of oral cancer (21,22). Delay in presentation and patient referral has a significant impact on the associated morbidity and mortality. The rate of awareness among dental student in this study (87%) was in line with a study conducted by Al Dubai among university students in Malaysia (29), which found that the majority of respondents were aware of oral cancer (92 %). This finding was higher than that among UK medical students (24) and also higher than that found among general population from UK (56 %) (33) and Iran (10.6 %) (6). Authors concluded that there is a need to introduce various educational programs to increase awareness of oral cancer. In this study, persistent ulcer, lymphadenopathy and presence of white patch were the most commonly identified signs and symptoms, were recognized by more than 60% of the final year students. However erythroplakia mass, erythroleukoplakia growth, red patch, swelling, altered sensation, induration and oral bleeding were only known by less than half of the dental students. The current study showed that almost half of the undergraduatestudents agreed that the presence of red or white plaques was not associated with oral cancer, is in accordance with other studies (6,31).This finding may be problematic because in addition of being an early signs of oral cancer,red/white lesions can correspond to oral potentially malignant disorders which should be early detected and treated to reduce the risk of malignant transformation and to have a good prognosis. The results of the present study have confirmed that there was an overall deficiency in oral cancer awareness and knowledge amongst undergraduate dental students regarding early signs and symptoms with clinical presentation. This finding was similar to that of previous studies conducted in Nigeria (34), United Kingdom (24) and amongst undergraduate dental students of Lahore – Pakistan (35). Thus, there is a vital need for increase awareness and knowledge about oral cancer for an early detection with subsequent effective management and eventually improvement in quality of life for patient. Regarding oral cancer risk factors, our study showed that 95 % of respondents identified smoking as the most common risk factor for oral cancer which is consistent with other studies from different countries (24,33,35), followed by family history of oral cancer. In this study, other risk factors such as old age (63%), sun light exposure (59%), smokeless tobacco, alcohol drinking, immunosuppression and occupation hazard were commonly recognized by more than half of the students, whilst viral infection, gender, chronic trauma/infection and betel quid chewing were J Bagh College Dentistry Vol. 25(3), September 2013 Awareness and knowledge Oral Diagnosis 72 recognized by less than half of the students. These risk factors were also reported among medical and dental students in various studies as well as in general population (24, 35-37). Tobacco smoking as a risk factor for oral cancer was realized by the majority of the final year students. However, alcohol was identified to a lesser degree as a risk factor. Knowledge on the increased cancer risks by alcohol use should be included in future health promotion strategies, such as lectures and seminars. This study found that more than 50% of the final year students agreed that hot and spicy food was a risk factor of oral cancer, less than one-third of students were able to recognize diet low in iron, vitamin A, C, low intake of fruit and vegetables and high fat diet as dilatory risk factors of oral cancer. In addition, the majority of the 5th year students agreed that the presence of premalignant disorders and previous history of oral cancer were well-recognized dental risk factors of oral cancer. However, poor oral hygiene, poor dental condition and poor fitting dentures as oral cancer risk factors were only known by less than half of students in this study. The unsatisfactory knowledge of some oral cancer risk factors found in this study, is in agreement with previous studies (24, 33). Therefore, there is a vital need to introduce and focus on these factors in the final year dental students’ educational programme and events. The majority of the respondents in this study were aware about oral cancer with 91% of them agreed that this type of cancer could be cured if detected early. In conclusion, awareness and knowledge about key signs and symptoms among final-year Iraqi dental students and its major risk factor were found satisfactory. However, there was inadequate knowledge observed regardingother associated risk factors. Therefore, it is suggested that efforts should be made to introduce oral cancer education for future general dental practitioners on clinical presentation, early manifestation, early referral and possible associated risk factors to cultivate positive attitude towards prevention of oral cancer. Since this study is limited by its small sample size, studies with larger samples are recommended to confirm the findings which may help to expand the knowledge base for future dentists in Iraq to help in early detection and diagnosis of oral cancer. 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An alarming lack of public awareness towards oral cancer. Br Dent J 1999; 187(6): 319-22. 34. Uti OG, Fashina AA. Oral cancer education in dental schools: knowledge and experience of Nigerian undergraduate students. J Dent Educ 2006; 70(6): 676-80. 35. Kazmi F, Chaudhar Ma, Mumtaz M, Bhatti Mud and Khawaja N. Oral cancer knowledge and awareness amongst undergraduate dental students of lahore– pakistan. Pakistan Oral & Dental Journal 2011; 31(1): 64-7. 36. Khalili J. Oral cancer: risk factors, prevention and diagnostic. Exp Oncol 2008; 30(4): 259-64. 37. ZainRB. Cultural and dietary risk factors of oral cancer and precancer--a brief overview. Oral Oncol 2001; 37(3): 205-10. http://www.cancerresearchuk.org/cancer J Bagh College Dentistry Vol. 25(3), September 2013 Awareness and knowledge Oral Diagnosis 74 Table 1. Socio-demographic characteristics of the respondents (n=160). Socio-demographic Characteristics of the Respondents Characteristics Number % Age (21-25) years Gender Male 48 30% Female 112 70% Marital status Single 156 96% Married 5 3% Divorced 1 1% Year of study 5th Household income class Low 16 10% Middle 123 77% High 21 13% Residence Urban 122 76% Rural 38 24% Family history of oral cancer Yes 15 9% No 145 91% Figure 1. Socio-demographic Characteristics of the Respondents (n=160). J Bagh College Dentistry Vol. 25(3), September 2013 Awareness and knowledge Oral Diagnosis 75 Table 2. Awareness of oral cancer amongrespondents (160). Awareness of oral cancer Number % Have you heard about mouth cancer? Yes 139 87% No 7 4% No idea / I don’t know 14 12% Early detection can improve treatment Yes 160 100% No 0 0% Lifestyle influence risk of oral cancer Yes 148 93% No 12 8% Fruit and vegetables Yes 105 66% No 55 34% Good and frequency oral hygiene Yes 130 81% No 30 19% Regular dentist visits and check up Yes 148 93% No 12 7% Table 3. Knowledge of oral cancer among respondents (n=160). Knowledge of Oral Cancer Among Respondents (n=160) Clinical Signs of Oral Cancer Number % Swelling 42 37% White patch 37 63% Red patch 45 39% Persistent ulcer 82 71% Oral bleeding 32 28% Colour changes to white and red 62 54% Erythroplakia Mass (red lesion) 52 45% Leukoplakia Lump (white lesion) 58 50% Erythroleukoplakia Growth (white and red lesion) 49 43% Induration /Necrosis 37 32% Fixation to underlying tissue 59 51% Lymphadenopathy 80 70% Altered sensation 39 34% Mostly mentioned manifestations of oral cancer Sore (ulcer) that does not heal 91 79% Lump or tissue overgrow 68 59% Difficulty in swallowing 55 48% Difficulty in opening the mouth 34 30% Prosthesis that fails to fit 25 22% Persistent white or red patch 91 78% J Bagh College Dentistry Vol. 25(3), September 2013 Awareness and knowledge Oral Diagnosis 76 Table 4. Recognised risk factors of oral cancer. Recognised risk factors of oral cancer Number % Sex 43 37% Old age 73 63% Tobacco smoking 99 86% Oral tobacco use/ Smokeless tobacco use 65 57% Betel quid chewing 35 30% Drinking alcohol 63 55% Family history of oral cancer 97 84% Obesity 5 4% Chronic trauma 38 33% Sun (UV light) exposure 68 59% Viral infection 47 41% Immunosuppression 62 54% Chronic infection 35 30% Occupation 57 50% Car smoke 29 25% Don’t know 0 0% Dietary factors Reduced intake of fruit and vegetables 36 31% Diet low in iron 45 39% Diet low in vitamin A 38 33% Diet low in vitamin C 36 31% High fat diet 8 7% Hot & spicy flood 66 57% Dental factors Chronic irritation from jagged (sharp) teeth 46 40% Infections in the teeth 15 13% Poor dental condition 35 30% High number of missing teeth 8 7% Poor oral hygiene 53 40% Poor fitting dentures 31 27% Pre-cancerous conditions/lesions 97 84% Previous history of oral cancer 80 70% No idea 1 1% I don’t know 2 2% Curability Oral cancer can be cured if detected early Yes 146 91% No 14 9% J Bagh College Dentistry Vol. 25(3), September 2013 Awareness and knowledge Oral Diagnosis 77 Figure 4. Recognised risk factors of oral cancer. J Bagh College Dentistry Vol. 25(3), September 2013 Awareness and knowledge Oral Diagnosis 78 Appendix (A) Oral Cancer Knowledge and Awareness amongst Undergraduate Dental Students in Baghdad University-College of Dentistry Please circle as appropriate Socio-demographic Characteristics Year of study Gender Male Female Age Marital status Single Married Divorced Household income class Low Middle High Residency Rural Urban Family history of oral cancer Yes No Knowledge of Oral Cancer Clinical signs/ Oral changes associated with Oral Cancer /Recognised early signs of mouth cancer Swelling White patch Red patch Persistent ulcer Oral bleeding Colour changes to white and red Ulceration Exophytosis Erythroplakia Mass (red lesion) Leukoplakia Lump (white lesion) Erythroleukoplakia Growth (white and red lesion) Induration /Necrosis Fixation to underlying tissue Lymphadenopathy Altered sensation Recognised risk factors of oral cancer Sex Old age Tobacco smoking Oral tobacco use/ Smokeless tobacco use Betel quid chewing Drinking alcohol Family history of oral cancer Obesity Chronic trauma Sun (UV light) exposure Viral factors Immunosuppression Chronic infection Occupation Car smoke Close contact with another cancer patient Don’t know Dietary factors Reduced intake of fruit and vegetables Diet low in iron Diet low in vitamin A Diet low in vitamin C High fat diet Hot & spicy flood Dental factors: Chronic irritation from jagged (sharp) teeth Infections in the teeth J Bagh College Dentistry Vol. 25(3), September 2013 Awareness and knowledge Oral Diagnosis 79 Poor dental condition High number of missing teeth Poor oral hygiene Poor fitting dentures Pre-cancerous conditions/lesions Previous history of oral cancer No idea/ I don’t know Mostly mentioned manifestations of oral cancer- Signs and symptoms Sore (ulcer) that does not heal Lump or tissue overgrow Difficulty in swallowing Haemorrhage Abscess, boil, or infection Difficulty in open the mouth Persistent white or red patch Prosthesis that fails to fit Curability Oral cancer can be cured if detected early Yes No Awareness of oral cancer Have you heard about mouth cancer? Yes No No idea / I don’t know Early detection can improve treatment Yes No Lifestyle influence risk of oral cancer Yes No Fruit and vegetables Yes No Good and frequency oral hygiene Yes No Regular dentist visits and check-up Yes No THANKS VERY MUCH FOR YOUR PARTICIPATION