|Year : 2014 | Volume
| Issue : 4 | Page : 903-907
Assessing oral cancer knowledge and awareness among Malaysian dental and medical students
Kamran Habib Awan1, Tan W Khang2, Tye K Yee2, Rosnah B Zain3
1 Department of Oral Medicine and Diagnostic Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia; Dental Research and Training Unit, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
2 Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
3 Department of Oro-Maxillofacial Surgical and Medical Sciences, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
|Date of Web Publication||9-Jan-2015|
Kamran Habib Awan
Department of Oral Medicine and Diagnostic Sciences, College of Dentistry, King Saud University, P.O. Box 60169, Riyadh 11545, Saudi Arabia
Source of Support: None, Conflict of Interest: None
Background: Oral cancer is a foremost health dilemma in several regions of the world. General dental practitioners and general medical practitioners play a major role in recognition of oral mucosal changes that may lead to malignancy. Their knowledge in oral cancer itself and the risk factors associated with the disease need to be sufficient.
Objective: The objective of the present study was to investigate awareness and knowledge of undergraduate dental and medical students in early detection and prevention of oral cancer.
Materials and Methods: Dental and medical students were invited to participate by answering a questionnaire on their habits of the oral mucosa examination and history taking, knowledge on risk factors and changes related with oral cancer, referral of patients as well as their desire to receive further information on oral cancer. Chi-square test was carried out to analyze knowledge and awareness between undergraduate dental and medical students.
Results: Undergraduate dental students were more likely to examine oral mucosa (96.7%) and advice risk habits to patients (93.9%) compared to medical students (60.6% and 79.8% respectively). Significantly more dental students considered smoking (84.4%), betel quid chewing (76.1%), and alcohol drinking (35%) as risk factors. Clinical changes of oral cancer were better identified by dental students (leukoplakia - 52.8%, erythroplakia - 45%, and non-healing ulcer - 40%) compared to medical students (leukoplakia - 12.9%, erythroplakia - 4.6%, and non-healing ulcer - 10.3%). Both dental and medicals students reported the desire to receive further information in relation to oral cancer.
Conclusion: Dental students have better knowledge and awareness in prevention and early detection of oral cancer compared to medical students.
Keywords: Awareness, early detection, oral cancer, potentially malignant disorders, risk factors
|How to cite this article:|
Awan KH, Khang TW, Yee TK, Zain RB. Assessing oral cancer knowledge and awareness among Malaysian dental and medical students. J Can Res Ther 2014;10:903-7
| > Introduction|| |
In Malaysia, the prevalence of oral cancer varies by gender and ethnic group, with the highest prevalence among Indians and indigenous groups.  It is reported to be sixth and third most common cancer among Indian males and females respectively, in Malaysia.  Regarding gender distribution, oral cancer was the 19 th and 16 th leading cancers among men and women respectively.  In the recent years, even with the advancement in the surgical and non-surgical management of oral cancer, little improvement has occurred in the 5-year survival rate.
Majority of the oral cancers are squamous cell carcinoma and are linked with preventable risk factors.  Use of tobacco, excessive alcohol and betel quid have been reported to be major individual etiological factors resulting in around 90% of oral cancers with the oral cancer risk increasing further if these risk factors are used together. , Early detection of oral potentially malignant disorders (OPMDs) and oral cancers is very important in achieving a good prognosis and as a result reducing the morbidity and mortality rates. ,
Delays in the diagnosis of oral cancers have been reported to be associated with both health care professionals and patients. , Published literature has demonstrated a strong association between patient's lack of knowledge and understanding of oral cancer and delay. , Health care professionals should have sufficient awareness and knowledge of oral cancer and its associated risk factors and appropriate clinical skills to properly perform a systematic oral cancer examination.  Studies carried out on medical and dental students, dentists, dental hygienists, physicians, and nurse practitioners have shown their lack of oral cancer awareness and inability to perform a standardized preventive and diagnostic procedures. 
Medical and dental practitioners both have responsibilities in the prevention and detection of oral mucosal changes in the early stages. Medical and dental undergraduate students are future practitioners and therefore their knowledge and awareness of oral cancer need to be appropriate. The aim of the current study was to assess the oral cancer awareness of undergraduate medical and dental students by evaluating their knowledge of prevention and early detection of oral cancer.
| > Materials and methods|| |
The cross-sectional survey was conducted among medical and dental undergraduate students. The questionnaires were distributed to 3 rd , 4 th , and 5 th year medical and dental students during routine lectures. These students were selected on the basis that they had received teaching on oral diseases including oral cancer.
The questionnaire comprised of questions on socio-demographic data, knowledge and awareness of oral cancer. Socio-demographic data included questions on age, gender, year of study, race, family history of oral cancer, monthly household income and residence. Oral cancer knowledge and awareness was assessed by questions on examination of oral mucosal habits, capability to detect high-risk patients, understanding and ability to provide assistance on risk factors, understanding of clinical appearances or oral mucosal changes associated with oral cancer, opportunity to examine oral mucosa of patients, preferred pathway of referral for suspected lesions, and desire to have further information regarding oral cancer. Pretesting of the questionnaire was carried out to assure that all the questions are clear and understandable to the participants. Approval of the study was obtained from both medical and dental research and ethics committees.
Data collected were entered through the IBM Statistical Package for the Social Sciences. Released 2009. PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc. for analysis. The responses were coded as numeric in order to facilitate the data entry. The results were analyzed using the Pearson Chi-square (χ2 ) test with the level of significance set as P < 0.05.
| > Results|| |
A total of 302 medical and 180 dental students responded to the questionnaire. Socio-demographic data including the age, gender distribution, number of students per year of course and other characteristics are shown in [Table 1].
Significantly, more dental students (96.7%) routinely examine the oral mucosa of the patient as compare to medical students (60.6%) (χ2 = 76.393, df = 1, P < 0.001). Furthermore, majority of the dental students (95.6%) recognized the necessity of history taking in identifying high-risk habit of patients, whereas only 60% of medical students did so.
When asked about the risk factors of oral cancer, significantly less number of medical students recognized smoking (medical 49.3%, dental 84.4%; χ2 = 59.274, df = 1, P < 0.001) and betel quid chewing (medical 43%, dental 76.1%; χ2 = 49.901, df = 1, P < 0.001) as risk factors. Furthermore, alarmingly lesser number of medical and dental students (35%) recognized alcohol (medical 7.2%, dental 35%, χ2 = 59.642, P < 0.001) as a risk factor. Since this was an open-ended question, other replies including those associated to dental and diet factors were also stated by the students and shown in [Table 2]. Encouragingly, majority of both medical and dental students (79.8%, and 93.9% respectively) reported that after graduation, they would offer advice to patients about risk factors of oral cancer.
Significantly, more dental students reported having had the opportunity to examine the oral mucosa of patients compared to medical students (dental 77.8%, medical 13.2%, χ2 = 200.728, df = 1, P ≤ 0.001). Likewise, more dental students reported that they feel very well or well educated about the clinical appearance of oral cancer in comparison to their medical counterparts (dental 96.7%, medical 53.3 and χ2 = 129.946, df = 3, P < 0.001).
When asked about the oral changes that are associated with oral cancer, dental students recognized a greater number of oral mucosal changes than the medical students. Since it was again an open-ended question, a range of responses were reported by the students. [Table 3] shows the list of the oral changes accepted and other responses. Significantly, more dental students identified leukoplakia (χ2 = 89.29, df = 1, P < 0.001) and erythroplakia (χ2 = 116.114, df = 1, P < 0.001) as oral mucosal changes related to oral cancer. Worryingly, around a quarter of the medical students reported that they are not aware of oral cancer associated mucosal changes. When asked about the point of referral of an oral cancer patient, bulk of the medical and dental students reported that they would refer these patients to oral and maxillofacial surgery and oral medicine specialists.
|Table 3: Oral cancer related mucosal changes reported by the participants|
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Overall, more dental than medical students reported of having adequate knowledge about prevention and early detection of oral cancer (χ2 = 95.268, df = 1, P < 0.001). However, interestingly, greater percent of final year medical and dental students (88.7% and 31.3%, respectively) reported that they lack adequate knowledge about prevention and early detection of oral cancer. Majority of both medical and dental students reported that they need more information on prevention and early detection of oral cancer (χ2 = 1.256, df = 1, P = 0.262) and preferred an information pack to be the mode of that information. [Table 4] summarizes the results of all the questions.
| > Discussion|| |
In our study, medical students were significantly younger than dental students. The reason for this was that medical students graduate 5 months earlier to the dental students. It is pertinent to mention that both the medical and dental students had clinical experience with patients who had either oral cancer or OPMDs. This experience ranged from clinical observation at the initial stages of the academic year to direct clinical examination under the supervision at later stages. In terms of gender distribution, both the medical and dental respondents show similarity as both groups have more female than male students who participate in the study. This is in line with the trends that more female students attending medical and dental colleges compared with male counterparts. 
Significantly, more dental students reported to routinely examine the patient's oral mucosa. In comparison, medical students were less likely to examine the oral mucosa and may do so in the background of a problem, for example, a patient presenting with an oral-related problem. High-risk patients for oral cancer are more prone to be seen by the general medical practitioners (GMPs). , Similarly, these high-risk patients are also more likely to be seen by medical than dental students, yet in our study only 60% of medical students reported that they routinely examine the patients' oral mucosa in contrast to more than 96% of dental students who would do so.
Majority of the dental students were able to identify smoking (84.4%) and betel quid chewing (76.1%) as risk factors for oral cancer. But unfortunately, only 35% of dental students reported alcohol to be a known risk factor. Similar trend was seen among the medical students where most of them also identified smoking as a risk factor but very few medical students (7.2%) identified alcohol as a known risk factor. Similar findings have been reported in the published literature by other studies on medical practitioners. ,,, Therefore, it is imperative to emphasize the role of alcohol as an established risk factor in future education and training of undergraduate medical students. A trend toward better identification of the risk factors is noticeable as the students' progress in their academic years. It was difficult to compare the level of knowledge of risk factors among different year students because a number of factors such as curriculum, changes in faculty and community awareness campaigns may influence their knowledge and awareness of the risk factors.
In our study, majority of the dental (93.9%) and medical (79.8%) students reported that they would offer advice to patients about oral cancer and associated risk factors after graduation. These findings are similar to a previous study performed on dental students to evaluate their ability to deliver advice on smoking cessation and may be linked to greater knowledge of risk factors, but are in conflict to other studies carried out on GMPs about the counselling of oral cancer risk factors. ,, It is crucial for both medical and dental officers to take the responsibility of advising the patient on high-risk habits as well as teaching them self-examination of the oral mucosa to not only enhance their knowledge of oral cancer, but also help in early detection of changes in the mouth. 
Significantly, more dental students were able to identify oral cancer associated mucosal changes such as leukoplakia and erythroplakia than their medical counterparts. Despite these lesions being potentially malignant, medical students were far less frequent in identifying erythroplakia whereas both medical and dental students poorly identified erythroleukoplakia. In a questionnaire based study to evaluate the ability of the general population to identify early signs of oral cancer, the authors' reported that approximately 33.8% were able to recognize white patches (leukoplakia) and even lesser (24.5%) identified red patches (erythroplakia).  Poor knowledge of oral changes shown by the students can be linked to the level of education offered to them as more than two-third (86.8%) of medical students reported that they did not have the opportunity to examine patients' oral mucosa, and significantly more medical students reported that they are not well informed about the clinical appearance of oral cancer. The importance of identifying OPMDs requires emphasis in the future education of dental and medical students.
Approximately, half of the dental students appeared to have adequate knowledge about prevention and early detection of oral cancer in contrast to only 10% of the medical counterparts. These findings are consistent with previous studies where the authors' reported lack of confidence among GMPs about their knowledge of oral cancer and attributed this to lack of clinical training.  Both the medical and dental students showed interest to acquire more information and teaching regarding oral cancer. Awareness and knowledge of oral cancer for medical students can be enhanced by including teaching and clinical training on oral disorders. This may be difficult in already crowded medical curricula; however a collaborative approach from different specialties such as oral and maxillofacial surgery, otorhinolaryngology, plastic surgery or clinical oncology may provide support in clinical teaching about oral cancer. In addition, inter-professional collaboration with dental faculty members has also been recommended for both teaching and assessment. 
| > Conclusion|| |
With the increase in global incidence of oral cancer, the responsibilities of medical practitioners along with dental counterparts in the prevention and detection of oral cancer assumes even more importance. The level of awareness and knowledge about oral cancer among undergraduate medical and dental students is less than acceptable and need improvement and reforms in the teaching curricula.
| > References|| |
Zain RB, Ghazali N. A review of epidemiological studies of oral cancer and pre-cancer in Malaysia. Ann Dent Univ Malaysia 2001;8:50-6.
National Cancer Registry. Second report of the national cancer registry cancer incidence in Malaysia 2003. Kuala Lumpur: Ministry of Health, Malaysia 2003:1675-8870.
Johnson NW, Warnakulasuriya KA. Epidemiology and aetiology of oral cancer in the United Kingdom. Community Dent Health 1993;10 Suppl 1:13-29.
Mishra GA, Shastri SS, Uplap PA, Majmudar PV, Rane PS, Gupta SD. Establishing a model workplace tobacco cessation program in India. Indian J Occup Environ Med 2009;13:97-103.
Gupta PC, Ray CS. Epidemiology of betel quid usage. Ann Acad Med Singapore 2004;33:31-6.
Speight PM, Morgan PR. The natural history and pathology of oral cancer and precancer. Community Dent Health 1993;10 Suppl 1:31-41.
McGurk M, Chan C, Jones J, O′regan E, Sherriff M. Delay in diagnosis and its effect on outcome in head and neck cancer. Br J Oral Maxillofac Surg 2005;43:281-4.
Donnell A, Jin S, Zavras AI. Delay in the diagnosis of oral cancer. J Stomatol Invest 2008;2:15-26.
McLeod NM, Saeed NR, Ali EA. Oral cancer: Delays in referral and diagnosis persist. Br Dent J 2005;198:681-4.
Hollows P, McAndrew PG, Perini MG. Delays in the referral and treatment of oral squamous cell carcinoma. Br Dent J 2000;188:262-5.
Preventing and controlling oral and pharyngeal cancer. Recommendations from a National Strategic Planning Conference. MMWR Recomm Rep 1998;47:1-12.
Burzynski NJ, Rankin KV, Silverman S Jr, Scheetz JP, Jones DL. Graduating dental students′ perceptions of oral cancer education: Results of an exit survey of seven dental schools. J Cancer Educ 2002;17:83-4.
Mortazavi SM, Nejad RH. Serious gender imbalance in medical and dentistry majors: How to prevent a crisis. J Med Educ 2005;8:11-6.
Yellowitz JA, Goodman HS. Assessing physicians′ and dentists′ oral cancer knowledge, opinions and practices. J Am Dent Assoc 1995;126:53-60.
Goodman HS, Yellowitz JA, Horowitz AM. Oral cancer prevention. The role of family practitioners. Arch Fam Med 1995;4:628-36.
Greenwood M, Lowry RJ. Primary care clinicians′ knowledge of oral cancer: A study of dentists and doctors in the North East of England. Br Dent J 2001;191:510-2.
Carter LM, Ogden GR. Oral cancer awareness of general medical and general dental practitioners. Br Dent J 2007;203:E10.
Macpherson LM, McCann MF, Gibson J, Binnie VI, Stephen KW. The role of primary healthcare professionals in oral cancer prevention and detection. Br Dent J 2003;195:277-81.
McCunniff MD, Barker GJ, Barker BE, Williams K. Health professionals′ baseline knowledge of oral/pharyngeal cancers. J Cancer Educ 2000;15:79-81.
Rikard-Bell G, Groenlund C, Ward J. Australian dental students′ views about smoking cessation counseling and their skills as counselors. J Public Health Dent 2003;63:200-6.
Rikard-Bell G, Ward J. Australian dentists′ educational needs for smoking cessation counseling. J Cancer Educ 2001;16:80-4.
West R, Alkhatib MN, McNeill A, Bedi R. Awareness of mouth cancer in Great Britain. Br Dent J 2006;200:167-9.
Ogden GR, Green M, Ker JS. The use of interprofessional peer examiners in an objective structured clinical examination: Can dental students act as examiners? Br Dent J 2000;189:160-4.
[Table 1], [Table 2], [Table 3], [Table 4]