Assessment of Dental Students and Dentists’ Awareness and Management Toward Head and Neck Cancer Patients: A Cross-sectional Study in Makkah (Saudi Arabia)

1. INTRODUCTION

Head and neck cancer (HNC) describes any type of cancer growing in the oral cavity, nasal cavity, paranasal sinuses, larynx, pharynx, salivary glands, or lymph nodes of the head and neck, it is considered the 9th most common cancer globally [1]. Approximately 380,000 new cancer cases and 180,000 deaths were registered worldwide in the year 2020 [2]. Most of the recent HNC cases are found in developing countries [3]. Kujan et al. expected that by 2030, the number of new cases and deaths of oral cancer will double in the Middle East and North Africa, as a majority of countries in this region are from the developing world [4]. Oral cancer represents about 26% of HNC in Saudi Arabia, and unfortunately most cases are diagnosed at a late stage [5].

Most of oral cancers are found on the lateral border of the tongue, the floor of the mouth, and the lower lip. They are predominantly affecting elderly and middle-aged men with the highest incidence located between the sixth to eighth eras of life [4]. Many factors contribute to oral cancer in the middle east such as: the use of smokeless tobacco products (Shammah) [6, 7], Alqaat chewing [8], and evergreen shrub masticated for its amphetamine-like effects [9]. Additionally, viral infections by the human papillomavirus, industrial and environmental risk factors, and genetic instability contribute to oral cancer [10-14].

HNC can be treated by various methods, including supportive care measures (e.g., antiresorptive therapies), chemotherapy (neoadjuvant, adjuvant, and/or concurrent), surgery and hematopoietic stem cell transplantation, and radiotherapy [15]. These methods have an effect on the teeth and the surrounding tissues, thus management of teeth and surrounding tissue is crucial for the HNC patient. For instance, 90% of patients undertaking radiotherapy may experience xerostomia; while about 60% may suffer from mucositis, 40% are affected by candidiasis, more than 50% can be affected by caries post-radiotherapy, and 15% of patients may suffer from osteoradionecrosis [16-20].

Cancer therapy has unavoidable chronic or acute oral side effects, proper management of these complications has the potential to reduce morbidity and improve prognosis if noticed early on [21]. Undeniably, there are substantial short- and long-term effects of cancer therapy on oral health. This requires increasing preventive measures, patient awareness, and managing the case by multidisciplinary healthcare providers including oncologists, otorhinolaryngologists, dentists, and other oral healthcare givers. The main role of the dentist treating patients with HNC is to care for the patient’s oral cavity before, during, and after cancer therapy [22]. Although HNC has aggressive behavior and poor prognosis [23, 24], they are commonly associated with good prognosis if they are diagnosed early [25]. In the initial phases of the disease, the five-year survival rate varies from 30-70% with adequate treatment [26]. Unfortunately, a systematic review by Grafton-Clarke et al. [27] showed that oral cancers are frequently overlooked by healthcare providers and the subsequent postponement in diagnosis and referrals is a main contributor to the disease’s late stages. Dental practitioners perform a crucial role in the early detection and prevention of oral cancer due to their facial contact with patients [28].

Many papers showed that dentists’ attitudes, knowledge, and practice towards HNC were inadequate. Guneri et al. [22] conducted a study at the University of Izmir (Turkey) to measure the knowledge of under- graduate students about HNC, the results showed that more than half of all participants were unaware that dental interventions should be done for HNC patients. In a cross-sectional investigation including general dentists and medical practitioners in Qazvin (Iran), dentists had adequate information which ranged from 38% - 68% of the 16 knowledge questions asked [29]. Another study of all dentists and dental specialists working in the South Khorasan Province (Iran) stated that dentists had correct responses between 51% and 83% of the 11 knowledge questions that they were asked [30]. Carter et al. compared the differences in awareness of oral cancer between the future doctors of medicine and dentistry in Great Britain, the 12-question survey explored participant’s knowledge of risk factors, the possibility of advising patients, as well as signs and symptoms of oral cancer. The authors concluded that participants didn’t have adequate knowledge [31]. Similarly, Clovis et al. [32] reported a negative correlation between knowledge and years of practice among a random sample of Canadian dentists in British Columbia and Nova Scotia. Kujan et al. [28] stated that about 87% of undergraduate dental students in Saudi Arabia felt confident about carrying out an intraoral examination to look for HNC lesions. However, awareness and knowledge of HNC are low among the general community of Saudi Arabia in the Makkah region [33, 34]. Two-thirds of Saudi people are unfamiliar with the early signs and symptoms of HNC, and just 12% have learned about oral cancer from their dentists [35, 36]. This lack of awareness is directly related to late recognition in 50% of HNC cases.

Therefore, this study was designed to assess HNC knowledge and awareness among dental students and dentists in Makkah (Saudi Arabia). The null hypothesis is that there is no difference in knowledge, practices, and attitudes toward HNC early detection and prevention between participants.

2. METHODS

3. RESULTS

Out of the 310 questionnaires that were electronically distributed, 160 were completed, representing a response rate of 52.1%. Most respondents were females (63.1%) while the male percentage was (36.8%), with a mean age of 26.4 ± 7.3 years old. The majority of participants were dental students (77.5%). Most of the dentists who completed the survey had less than five years of work experience (86.3%). The demographic data of the participants are presented in Table 1. Participants were asked about their knowledge regarding oral cancer risk factors, management and complications as shown in Table 2. The majority of the participants had an acceptable knowledge level about orofacial cancers and its associated complications. However, there was a lack of knowledge regarding oral cancer complications and their association with cancer and cancer therapy such as exacerbation of oral or perioral herpes simplex virus or varicella-zoster virus among patients undergoing therapies for cancer, caries association and oral cancer therapy, and that intraoral soft tissues become easily damaged and infected (31.9%,21.9%, 17.5%), respectively. Osteoradionecrosis of the jaw is one of the major side effects that had both low and lack of awareness (28.8%). More than half of the participants were not sure or gave wrong answers about endodontic treatment timing for an oncology patient.

Dentists were asked about their management approach for an oncology patient undergoing therapy in the head and neck region as shown in Table 3. The majority of the participants agreed to consult the oncologist before starting invasive treatments (88.8%) and to apply preventive measures such as fluoride application before radiation therapy (80%). However, for the rest of the management questions, there was an obvious lack of knowledge regarding the proper approach to dealing with such patients.

There was no significant difference between males and females in the knowledge score (p=0.82) or attitude score regarding oncology patients (p=0.5). There was a significant difference in the overall knowledge depending on their rank (p=.0.04) where consultants had better knowledge compared to students and general dentists. Dentists with working experience of more than 5 years had better knowledge than those with less experience (p=0.03) and those with (5-10 years) of experience had significantly better attitudes compared to the rest (p=0.001).

4. DISCUSSION

In dental practice, intraoral and extraoral examination is a crucial phase during the examination of a new patient [41]. Proper examination is the main aiding tool in the early detection of HNC through early detection, the mortality rate could be significantly minimized in the population, however, that cannot be possible without proper knowledge. This cross-sectional study was designed to evaluate awareness and management toward HNC among students and dentists working in different sectors in Makkah City, Saudi Arabia, and to explore issues that may affect HNC diagnosis or prevention. “Cancer Therapies and Dental Considerations” are available on the ADA website, which acts as a guide for dentists and patients, upon which we built this questionnaire [38].

The response rate observed in this study amounted to 51.2% aligning closely with the response rate conducted in a previous study conducted in Saudi Arabia which reported a rate of 54.2% [26]. However, it is noteworthy that this figure falls notably short compared to another study conducted at Jazan University in Saudi Arabia which achieved a response rate of 90% [42]. The majority of respondents were undergraduate students (77.5%) and dentists or consultants with less than 5 years of work experience (78.8%). It appears that students are more eager to answer questionnaires or more eager to examine their knowledge, while on the other hand, general dentists and consultants are either uninterested in finishing questionnaires or overloaded with dental practices and have no appeal to spend time on surveys. Authors anticipated the opposite i.e.; the undergraduate students could give fewer responses due to being overburdened with studying and learning, while professionalists would be more willing to respond. Our research disclosed that the level of HNC awareness and management among the majority of the surveyed participants is considered acceptable. These results are similar to the results of earlier studies conducted in Saudi Arabia [28, 42], Kuwait [39], and India [43] which showed good to excellent general knowledge of HNC among interns and undergraduate students. It is in contrast to other studies in Saudi Arabia [26, 33], and the United Arab Emirates [44], where the studies showed poor knowledge and awareness among similar groups of participants.

Regarding the level of knowledge of orofacial cancers and their associated complications, this study showed an adequate level of knowledge among the participants. This is in agreement with the results of a local study conducted in Jeddah [33]. However, it is in conflict with another cross-sectional study conducted at Jazan in Saudi Arabia [26]. In this study, there was some defective knowledge on when and how to treat the oral complications that appear after patients get cancer therapy. This may be due to the majority of respondents being undergraduate students with limited involvement in treating cancer patients and just attending theoretical lectures about cancer, which affects the responses. These conclusions are in agreement with previous studies that revealed dentists’ sufficient fundamental knowledge about HNC, but the shortage of awareness about dental treatment of cancer therapy-related complications [22].

The survey answers showed that there was deficient knowledge regarding certain points of the relationship between viruses and cancer. The most involved viruses in oral cancerous changes are human papillomavirus, herpes group viruses, hepatitis C viruses, and adenoviruses [45, 46]. The herpes viruses that are related to HNC are the human herpes virus, Epstein-Barr virus, and cytomega- lovirus [45]. It is anticipated that worldwide between 15%-20% of carcinomas attaching the oropharynx are coinfected by the human papillomavirus and herpes. But the coinfection rates of squamous cell carcinomas affecting the base of the tongue and tonsils increased between 25% - 70% [47]. Secondly, there was an existing deficiency in awareness regarding osteoradionecrosis as a potential risk associated with oral cancer. Osteo- radionecrosis is the consequence of ischemic necrosis of the bones combined with soft tissue necrosis without the occurrence of the tumor lesion [48, 49]. Osteo- radionecrosis of the lower jaw is a chronic late complication of radiotherapy in HNC patients, and several studies have stated its incidence to range between 4 and 9.7% [50-52], however, Studer et al. and Ben-David et al. [53, 54] stated in different articles that osteoradionecrosis incidents decreased over the past few decades due to the availability of more conformal techniques of intensity-modulated radiotherapy (IMRT). Dealing with active oral diseases and motivating oral health before and after cancer therapy may reduce the risk of osteoradionecrosis. The goal is to reduce the demand for invasive interventions such as extraction [55]. The lack of awareness in our sample might be related to low retention of the information about the topic itself or due to the way the question was directed in the survey in a way in which the correct answers were supposed to be (disagree) and the participants were tempted to pick (agree) as the correct answer.

There was a great variation in the answers about the relation between caries and radiotherapy as well as endodontic treatment before radiotherapy. Patients with HNC who will be exposed to radiotherapy should preferably obtain endodontic treatment before radiotherapy to remove any disease present on the mucosa or teeth as following radiotherapy, infection foci progress may become more aggressive [56]. After radiotherapy, patients are at high risk of dental caries due to hyposalivation, and intra-oral microbial and chemical changes that occur which will result in cariogenic environments [57]. More than 50% of patients might develop caries over time with a prevalence of 6% monthly [58]. This is known as “radiation caries” which appear after head and neck radiotherapy [59]. Radiation caries happens even in non-exposed teeth to radiation, and if left untreated can continue leading to losing all teeth after three years [60].

This study found that the educational level and tenure greatly affect the overall HNC knowledge since the specialists and consultants had substantially better knowledge compared to the undergraduate dental students. This finding is in agreement with the Shubayr et al. study [26], but it is in contrast to the results of Keser et al. [61] that proved no relation between educational level and knowledge of risk factors of oral cancer. This may be attributed to the fact that the “Saudi Commission for Health Specialties” and the licensing association for healthcare practices in Saudi Arabia mandate that all dental graduates should attend various continuous education courses so they can apply to the “Saudi dental specialty post-graduate program” and to renew their present registration.

This is a cross-sectional study that permits researchers to take a snapshot of the target population regarding the knowledge and awareness of HNC. Cross-sectional studies offer a quick approach to collecting valuable data in specific areas. Additionally, this study is especially useful for advising the organization of educational HNC courses and practicing for undergraduate students, specialists, and consultants. The majority of respondents were female [62]. Moreover, the results might not be generalizable because of the participants’ size and the distribution of the respondents.

There is a need to emphasize and expand HNC educational programs mostly in diagnosis, management, and prevention. The workshops and education programs are greatly advised to improve dentists’ awareness of the diagnosis and risk factors of HNC.

Educating graduate dentists about orofacial head and neck cancer involves several key approaches:

(1) Didactic Education: Provide comprehensive lectures, seminars, or workshops covering the epidemiology, etiology, risk factors, signs and symptoms, diagnostic techniques, and management of orofacial head and neck cancer.

(2) Clinical Training: Offer hands-on clinical experiences where graduate dentists can observe, diagnose, and manage cases of orofacial head and neck cancer under supervision.

(3) Interdisciplinary Collaboration: Emphasize the importance of interdisciplinary collaboration with oncologists, radiologists, pathologists, and other healthcare professionals involved in the care of patients with orofacial head and neck cancer.

(4) Continuing Education: Encourage ongoing learning through continuing education courses, conferences, webinars, and journal subscriptions to stay updated on the latest advancements in the field.

(5) Case Studies and Problem-Based Learning: Utilize case studies and problem-based learning approaches to enhance critical thinking and decision-making skills in diagnosing and managing orofacial head and neck cancer cases.

(6) Patient Communication Skills: Train dentists in effectively communicating with patients about the risk factors, the importance of early detection, treatment options, and supportive care measures for orofacial head and neck cancer.

(7) Screening Programs: Implement screening programs in dental clinics to facilitate early detection of orofacial head and neck cancer among patients.

By employing these strategies, graduate dentists can be better equipped to recognize, diagnose, and manage orofacial head and neck cancer, ultimately improving patient outcomes and survival rates.

CONCLUSION

Participants in this study proved to have good general knowledge of HNC, but they lacked knowledge about oral complications of cancer-associated therapy which must be emphasized through educational programs.

REFERENCES