A Survey About Awareness of Oral Cancer Among The Undergraduate Dental Students

Anushya P1, Keerthi Sasanka L*2, Jothi Priya A3 1Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai-600077, Tamilnadu, India 2Department of Prosthodontics, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai-600077, Tamilnadu, India 3Department of Physiology, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai-600077, Tamilnadu, India


INTRODUCTION
Recently the incidence of oral cancer is increasing to an alarming level, especially in developing countries. Epithelial cell carcinoma (SCC) makes about 95% of oral cancers (Soares et al., 2014). Tobacco consumption, unhealthy diet, physical inactivity, and infections are the foremost common causes of cancer. The risk factor for development of carcinoma increases when tobacco is employed in combination with alcohol or betel nut (Sandeepa, 2018). Oral cancer affects the anterior tongue, cheek, loor of mouth, gingiva or the other a part of the mouth. The commonest risk factors liable for carcinoma are chemical factors like tobacco and alcohol, oro-dental factors, biological factors like Human papillomavirus (HPV), syphilis, dietary de iciencies, chronic candidiasis and viruses (Ram et al., 2011;Ramaswamy et al., 2014). Carcinoma occurs more often in males, in people from the lower socioeconomic scale and in ethnic group groups, although rates in females are on the increase (Scully and Felix, 2006). Early detection of oral potentially malignant disorders (OPMDS) and oral cancers is extremely important in achieving an honest prognosis and as a result reducing the morbidity and mortality rates (Speight et al., 1996;Johnson et al., 2000). Dentists have a prominent role within the prevention and early diagnosis of carcinoma because they could be the primary clinicians to encounter a patient with oral cancer. Therefore, they're ready to perform screening for oral cancers, advice interventions and recommend avoiding risky habits and behaviours. Delays within the diagnosis of oral cancers are reported to be related to both healthcare professionals and patients (Pitiphat et al., 2002;McGurk et al., 2005). However, the awareness among academics & professionals is additionally decreasing due to the shortage of proper knowledge about some risk factors, oral lesions that result in oral carcinoma and prevention of carcinoma. Multimedia, videos, podcasts, wikis, social network programs like "Facebook", are all now available on computers and mobiles, and they will collectively play a huge role in increasing awareness with regards to the importance of early detection & prevention of cancer (Elgazzar, 2018). Research on correlation of width of maxillary anterior teeth using extraoral and intraoral factors (Ariga et al., 2018), Periodontal health of three different groups wearing temporary denture (Jyothi et al., 2017), evaluations of microgap at the implant-Abutment interface with original and non original Abutments (Duraisamy et al., 2019), ef icacy of ifth generation of cephalosporins against methicillin-resistant staphylococcus aureus (Selvan and Ganapathy, 2016), effect of resin bonded luting agents , effect of burn plant in oral health (Subasree et al., 2016), cervical and incisal marginal discrepancy in ceramic laminate veneering materials (Jain et al., 2017), medical management of cellulitis (Vijayalakshmi and Ganapathy, 2016), effect of coated surfaces which in luencing screw loosening in implants , ceramic restoration (Ashok and Suvitha, 2016), Lip bumper prosthesis for an acromegaly patient (Ashok et al., 2014), magnetically retained silicone facial prosthesis (Venugopalan et al., 2014), effect of use of impregnated retraction cords on gingiva (Kannan and Venugopalan, 2018), Oral hygiene status among pregnant women (Basha et al., 2018), Invitro study on surface modi ications of cement retained implant crowns under fatigue loads (Ajay et al., 2017) was done in our institute and that I prefer to do a cross sectional study on awareness of oral cancer among undergraduate Dental students. Dental professionals should have suf icient awareness and knowledge of carcinoma and its associated risk factors and appropriate clinical skills to properly perform a scienti ic carcinoma examination. In previous studies, there's a scarcity of carcinoma awareness amongst doctors and dentists, particularly among medical and dental students. Only 39.0% of dental surgeons and 9.0% of physicians knew the way to identify the foremost common sites during which carcinoma develops. Interestingly, only a couple of them prepared to perform the biopsy procedure (da Silva et al., 2016). Among the university students, 71% and 61.5% of scholars reported that ulcer or oral bleeding and swelling are signs and symptoms of carcinoma (Dubai et al., 2012). While, among postgraduate students 96% of scholars were aware that habits were the most risk factor for many of the carcinoma whereas 50% of students were conscious of carcinoma and 67% of them were con ident about the correct treatment protocol (Ramaswamy et al., 2014). Studies performed on medical and dental students, dentists, dental hygienists, physicians, and nurse practitioners have shown their lack of carcinoma awareness and inability to perform standardised preventive measures and diagnostic procedures (Burzynski et al., 2002). Dentists are professionally liable for determining whether patients are in danger of developing carcinoma, also as for providing a comprehensive carcinoma examination for his or her patients. Therefore assessing Dentist knowledge, opinions and practices toward carcinoma is vital. In previous literature, there's no better knowledge and practices about oral cancer among undergraduate Dental students. Therefore, the aim of this study is to examine the dental student's awareness, knowledge of prevention and early detection of oral cancer.

MATERIALS AND METHODS
Self-administered structured questionnaires comprising 17 questions covering socio demographic information, knowledge, attitude and perception were framed. The questionnaire comprised a few open-ended questions and mix of multiple choice. The questionnaire was distributed through Google forms and the study population included 100 undergraduate dental students. The participants were selected randomly by using a simple random sampling method. Students took 5min to complete the survey. In this study, the pros include economical, easy to create, gather larger data, quick interpretation and wide reach whereas Cons includes response, survey fatigue, homogeneous population. This study obtained approval from the Scienti ic review board, Saveetha Dental college and hospitals in Chennai. The measures taken to minimise the sampling bias is based on internal and external validity, minimise error in questions and avoid leading questions. The internal validity is based on awareness, knowledge and preventive measures of oral cancer whereas the external validity is based on awareness, results and outcomes of the study. In this study, the output variables are demographic information, social media, Oral cancer, etiological factors, signs and symptoms, early detection and prevention of oral cancer. Each output variable was collected as ordinal data and the collected data were represented as a bar graph. The Statistical Package for the Social Sciences (SPSS) was used to enter and analyse the data.

RESULTS AND DISCUSSION
Out of total 17 questionnaires that were distributed, the response rate of the study was 100%. There were 48% male and 52% females who participated in this study (Figure 1). There were 25% of students in 1st year, 23% of students in 2nd year, 18% of students in 3rd year, 15% of students in 4th year and 19% of students in an internship ( Figure 2). Among the participants, 76% of students were aware of Oral cancer (Figure 3). The labial/ buccal mucosa was the structure which is most ordinarily examined during diagnosis of oral cancer, this answer was supported by 41% of students ( Figure 4). The oral cancer was diagnosed more frequently at the age group of 45-59 years, which was supported by 45% of students ( Figure 5). 48% of students responded smoking tobacco and alcohol consumption would be the etiological factor for oral cancer (Figure 6). 42% of students reported that labial/ buccal mucosa was the foremost common site for oral cancer (Figure 7). 53% of students reported that oral cancer is asymptomatic in early stage; 9% of students responded that Oral cancer shows any mild symptoms in early stage and 38% of students reported in a moderate way whether it is an symptomatic or asymptomatic in early stage (Figure 8). 31% of students responded that white or red patches within the mouth could be the sign of oral cancer (Figure 9). Oral cancer is usually diagnosed in advanced stage, which was supported by 83% of students, whereas 17% of students reported that Oral cancer isn't mostly diagnosed in advanced stage ( Figure 10). 80% of students declared that erythroplakia and leukoplakia are the foremost common lesions associated with Oral cancer. While, 20% of students weren't accepted ( Figure 11). 46% of students suggested that early detection of oral cancer improves survival; 9% of students reported that early detection of cancer isn't possible to increase the survival rates and 45% of students reported in a moderate way that early detection may or may not be possible to extend survivability (Figure 12). 18% of students reported that the Clinical exam would be the early detection of oral cancer; 12% of students reported to Biopsy; 33% of students reported to Regular dental checkup and 37% of students reported to Patient education ( Figure 13). 26% of students reported that Good oral hygiene would prevent oral cancer; 16% of students reported Quitting Tobacco; 29% of students reported Regular checkup to dental clinics; 2% of students reported Quitting alcohol consumption and 27% of students reported that maintaining good oral hygiene, quitting tobacco and alcohol consumption, regular checkups to clinics would prevent oral cancer (Figure 14). 2% of students referred their patient to Plastic surgery specialist while suspecting them with oral malignancy; 7% of students referred to an Oral and maxillofacial surgeon; 19% of students referred to an Oral medicine specialist and 59% of students referred to an Oncology specialist ( Figure 15). 59% of students reported that they have suf icient knowledge concerning prevention and management of oral cancer whereas 41% of students are lacking in knowledge ( Figure 16). 31% of students preferred information packages for gaining knowledge regarding detection and prevention of oral cancer; 36% of students preferred Continuous education lectures; 16% of students preferred Seminars; 15% of students preferred Webinars and a couple of students preferred Participation in Organised research ( Figure 17). Dentists need to possess a radical knowledge of risk factors, clinical signs and symptoms. Early diagnosis and rapid access for treatment of cancer is a crucial factor for improving outcomes for oral cancer. In this present study, females were more than male participants. Similarly, there is a large female participation (Soares et al., 2014). Tobacco use is the main risk factor of oral cancer. Joanne.et.al., 90% of dental professionals considered tobacco as the main risk factor for Oral cancer (Clovis et al., 2002). Similarly, smoking and alcohol consumption were correctly mentioned by 92.4% and 84.21% of the students whereas in our study 44% of students considered smoking tobacco is the main risk factor for Oral cancer. Gabriela.et.al., 56% of dental practitioners identi ied older age as a possible risk factor for development of oral cancer (Decuseara et al., 2011) whereas in our study, 45% of students considered 45-57 years have the high risk factor for developing oral cancer. Warnakulasuriya.et.al.,84% of the dental practitioners examine oral mucosa for diagnosing Oral cancer (Warnakulasuriya and Johnson, 2008) whereas in our study, 41% of dental students diagnose Labial/ buccal mucosa for examining oral cancer. Zayed.et.al.,46.6% of students believed that the most oral cancer could not be diag- nosed in early stage whereas in our study, 83% of students believed that oral cancer is usually diagnosed in advanced stage (Alfadhel et al., 2019). Similar to our indings, Joseph.et.al., 75% of dentists considered Oral cancer diagnosed in an advanced stage. In a similar study, 90.7% of dentists believed that early detection of oral cancer improves survival whereas in our study 46% of students declared that early detection of oral cancer increases survival rates (Joseph et al., 2012). Human papillomavirus vaccination showed promising results in oral cancer prevention (Chainani-Wu et al., 2011;Daley et al., 2014). Oral cancer screening programs found to be a cost-effective measure in raising the awareness and reducing mortality (Petti and Scully, 2007). Thus, the dental students should be prepared to play a part in public health awareness regarding the explanation of the potential burden of sexually transmitted viruses as HPV, in its act in oral cancer and in luence of vaccination. Most of the students preferred Oral medicine specialists when they suspect a patient with oral malignancy (Arnout, 2016) whereas in our study most of the students preferred Oncology specialists. Similar to our indings, Ahmed and Naidoo reported that most of the participants referred their patient to an oral medicine specialist, while remaining of the participants was attributed to oral and maxillofacial surgeon, general surgeon and dentists. This inding could indicate the presence of confusion among general dentists of the referral system of these diseases (Ahmed and Naidoo, 2019). Joanne.et.al., 46% of the dental practitioners considered that their knowledge regarding Oral cancer was insuf icient (Clovis et al., 2002). While in our study, 41% of dental students considered their knowledge regarding Oral cancer was insuf icient. Zayed.et.al.,34.7% students had suf icient knowledge concerning the prevention and detection of Oral cancer (Alfadhel et al., 2019) whereas in our study 59% of students had suf icient knowledge regarding the preventive measures as well as detection of Oral cancer. Awan.et.al.,61.1% of students preferred seminars to gain information regarding prevention and detection of oral cancer (Awan et al., 2014) whereas in our study, most of the students preferred continuous education lectures for gaining current and adequate knowledge about oral cancer. We acknowledge that our study has some limitations, such as being based on self-applied questionnaires, using students' own perceptions and the limited number of populations. In further studies, awareness on oral cancer among dental and medical professionals. The Knowledge of oral cancer among dentists as well as medical professionals is utmost important.
In Figure 18, Chi-square test was analysed and pvalue was 0.000, and it was found to be statistically signi icant. 46% of students were aware that smoking and alcohol consumption are the etiological factor of oral cancer whereas 54% of students were unaware of the etiological factors of oral cancer. In Figure 19, Chi-square test was analysed and p-value was 0.253, and it was found to be not statistically signi icant. In Figure 20, Chi-square test was analysed and p-value was 0.000, and it was found to be statistically signi icant. 42% of students believed that labial or buccal mucosa was the most commonest site for oral cancer. Majority of the interns chose labial or buccal mucosa as the commonest site of oral cancer than other years of students. In Figure 21, Chi-square test was analysed and p-value was 0.010, and it was found to be statistically significant. 38.38% of students were aware of symptoms of oral cancer. In Which interns were more aware of signs and symptoms of oral cancer. In Figure 22, Chisquare test was analysed and p-value was 0.000, and it was found to be statistically signi icant. 58.59% of students have enough knowledge regarding prevention and management of oral cancer. However, the higher prevalence of knowledge was seen in interns than other years of students.

CONCLUSION
This study demonstrates that most of the dental students are aware and had a fair knowledge about the various aspects of oral cancer. This study revealed quite a satisfactory level of awareness concerning oral cancer among the undergraduate dental students and also entailed the necessity to enhance dental students' knowledge about early detection of oral cancer through upgraded theoretical and practical knowledge.