Kosovar dentists’ knowledge on oral cancer

Introduction

Oral cancer is globally recognized as a significant health issue, traditionally affecting men more than women [1], although recent trends show increasing rates among women and younger people [2].
Annually, around 657,000 individuals worldwide are newly diagnosed with oral and pharyngeal cancer, leading to over 330,000 fatalities [3]. In Kosovo, the Kosovo Statistical Authority reported 51 cases of malignant tumors of the lip, mouth, and larynx (COO-C14) diagnosed at the University Clinical Centre of Kosovo in 2020 [4].
Oral cancer risk is primarily associated with tobacco use, alcohol intake, inadequate diet, human papillomavirus (HPV) infection, and a weakened immune system. Gaining insight into how these factors contribute to the onset of cancer is essential for enhancing both preventive approaches and treatment options [3].
Oral cancer most commonly occurs on the lip, in the oral cavity, back of the nose, throat, tongue, inner cheeks, and on the floor of the mouth [1, 3]. This disease usually manifests as a non-healing ulcer, while additio­nal signs can involve discomfort, swelling, bleeding, and difficulties with eating and swallowing [2].
Early detection of pre-malignant lesions in the mouth, such as erythroplakia and leukoplakia, is crucial for managing oral cancer mortality and morbidity [5]. However, cancer and pre-malignant lesions in the mouth can be seen and diagnosed by both dentists and physicians [1, 3]. Moreover, dentists more than physicians, are often able to detect oral cancer lesions during a re­gular appointments [6], due to their familiarity with oral structures [7]. Numerous studies [8-11] have indicated that dentists are primarily responsible for performing intra-oral and extra-oral examinations at each appointment, and are particularly attentive to patients’ high-risk habits.
In addition, the American Cancer Society [3] recommends regular oral checks during health examinations by a dentist or physical therapist. When oral cancer is dia­gnosed early, treatment is generally very effective [1, 3].

Objectives

Despite the existence of numerous global surveys on oral cancer, there is a notable lack of research focusing specifically on this issue in Kosovo. For this reason, the study intended to examine the level of oral cancer knowledge among Kosovo’s dentists, and to reveal any differences in their understanding.

Material and methods

The current prospective observational study (a type of cross-sectional study) was carried out at the University Clinical Dental Centre of Kosovo in Prishtina, Kosovo, between June and November 2021. The study included 137 resident dentists from the University Clinical Dental Centre of Kosovo, who were randomly selected from the Ministry of Health’s list of specialized dentists [12]. They were invited through e-mails, messenger profiles, and face-to-face interviews, and were asked to parti­cipate anonymously by completing the questionnaire. An informational letter and a consent form were included with the invitations. The study received ethical approval from the Kosovo’s Dental Chamber on May 25, 2021 (reference No: 12), and data confidentiality was ensured throughout the study by storing it on a password-protected laptop.
A questionnaire, previously used in other research, was adapted for this study. The original questionnaire, designed to evaluate dentists’ understanding and clinical practices concerning oral cancer, was sourced from established research [13-15]. Since an Albanian version was unavailable, the questionnaire was translated from English to Albanian by the authors of this study. For the questionnaire’s clarity and relevance, a pilot test study was performed to confirm the validity and reliability of the translated questionnaire among a small group of 15 dentists not included in the main study sample. Reliability was assessed through the pilot test, with internal consistency evaluated using Cronbach’s α, yielding satisfactory results (> 0.70), and indicating that the questionnaire’s items were measuring the intended constructs reliably. The final version of the questionnaire comprised twenty-eight items divided into four sections: 1) personal and professional information; 2) knowledge on oral cancer; 3) opinions about oral cancer, and 4) practices regarding oral cancer. The survey mainly contained multiple-choice questions in the first and second sections, which were the main focus of this study. In contrast, the third and fourth sections included Likert’s scale items used in other analyses, but not in the present study. A list of questions from the first and second sections of the survey is provided in Supplementary material.
Consistent with earlier research [14, 15], every correct response scored one point, and answers were subsequently ranked based on total score (knowledge on oral cancer clinical features: 0-4 – low, 5-8 – medium, 9-11 – high).
However, in this study, only data from the first and second sections were collected and analyzed.
Data were documented with MS Excel 2013 (Microsoft Corporation, Redmond, WA, USA), and analyzed using SPSS program version 25.0 (IBM Corp., Armonk, NY, USA). Demographic variables and questionnaire answers were summarized using counts and percentages, and visually displayed in tables. To compare categorical variables, such as gender, age, and graduation year, c2 test was employed. Statistical significance was assigned at p-values below 0.05.

Results

From the total sample of 147 participating dentists, 137 filled out and submitted the questionnaire, leading to a 93.19% response rate. The demographics and professional information of the dentists are summarized in Table 1, providing an overview of gender, age, years of experience, and education level.
The dentists were surveyed regarding their knowledge on oral cancer and diagnostic methods related to this malignancy. The responses for each item are detailed in Table 2. The correct answers of the dentists, categorized by knowledge score level and years since graduation, are shown in Table 3. Among the 137 dentists, 58.39% demonstrated moderately satisfactory knowledge of oral cancer diagnostics. Female dentists (31.38%) showed a higher percentage of mild knowledge compared with male dentists, although there were no significant gender differences (p > 0.05). Additionally, within 13 years of graduation, female dentists (32.84%) presented higher level of knowledge than male dentists, though it was not significantly different in proportions of low, medium, and high scores between graduation periods. Notably, dentists older than 30 years demonstrated a significantly better knowledge regarding oral cancer diagnostics (p < 0.05).

Discussion

Previous research emphasized the importance of dentists’ knowledge on oral cancer, especially recognizing at-risk individuals, conducting mouth examinations, documenting tissue changes, and offering treatments to potentially reduce oral cancer’s occurrence, severity, and death rates [16]. Our findings indicate that resident dentists in Kosovo have moderately satisfactory knowledge regarding diagnostic procedures for oral cancer, as evidenced by Tables 2 and 3. However, similar to other studies [7, 13-24], their knowledge differs widely. This variability underscores the need for consistent and comprehensive education on oral cancer. Despite some progress, the considerable range in knowledge levels among Kosovar’s dentists highlights the necessity for targeted educational initiatives to standardize and enhance diagnostic skills.
To address these knowledge gaps, we recommend the following specific training strategies: 1) integrating oral cancer education into dental curricula; 2) organizing workshops with case-based learning; and 3) implementing periodic assessments to track improvements in knowledge. Oral cancer frequently occurs on the tongue and the floor of the mouth, accounting for around 40% of cases within the oral cavity [25]. These specific areas in the mouth have a mucosa that lacks keratin, with lesser defense against harmful substances [26]. However, only 16.05% of Kosovo dentists correctly identified these common sites of oral cancer (Table 2). This result is notably worse comparing with findings from studies conducted in Qatar [15], Italy [17], Turkey [18], Kuwait [19], Yemen [20], and Iran [21]. This low percentage highlights a significant training gap that requires urgent attention. Targeted educational initiatives focusing on high-risk areas in the oral cavity are essential to enhance diagnostic accuracy and early detection.
In its early stages, squamous cell carcinoma commonly appears as leukoplakia, erythroplakia, or erythro­leukoplakia [25]. Our research found that 64.96% of the dentists accurately recognized these early lesions (Table 2), in line with findings from a study conducted in Turkey [18] (64.1%), and higher than that reported from Canada [14] (42.5%), Qatar [15] (53.7%), and Italy [17] (53.8%). In contrast, surveys conducted in Yemen [20] and Spain [22] reported much higher reco­gnition rates (87% and 95%, respectively). This indicates that, while the majority of dentists in Kosovo can identify early lesions of oral cancer, improvements are still needed. Education programs focusing on early detection and symptom recognition can enhance diagnostic capabilities and improve treatment outcomes.
It is concerning that only 25.54% of the dentists identified squamous cell carcinoma as the predominant form of oral cancer (Table 2), significantly lower rate than that reported from Qatar [15] (84.2%), Italy [17] (50.5%), Yemen [20] (82.8%), Iran [21] (81.2%), and Spain [22] (90.6%). This suggests the need for improved knowledge regarding oral cancer classification.
In the phases of oral cancer and pre-cancerous conditions, symptoms are often subtle and asymptomatic. The clinician must sustain a heightened level of vigilance, when well-known contributing factors, for instance, tobacco and alcohol use, are present [25]. Interestingly, only 20.43% of our dentists acknowledged that patients might be without symptoms in the initial stages of oral cancer (Table 2), similar to a 21.5% shown in Qatar [15]. In contrast, a study from Spain revealed a much higher value of 95.6% [22]. This underscores a critical educational gap that must be addressed through focused training on recognition of subtle and asymptomatic symptoms.
It has been demonstrated that most cancer cases are found in individuals aged 45 years and above [13]. Our study found that only 51.82% of the dentists recognized age as a causative factor to oral cancer development (Table 2), which is lower than reported in other studies [16, 22]. This indicates the necessity for increased stress on the relationship between age and oral cancer risk in educational programs. Patients often seek diagnosis and treatment at stages III or IV, delaying early detection of oral cancer [25].
Additionally, fewer than half of our dentists (48.17%) stated that oral cancer is frequently detected in its later stages (Table 2), consistent with recent surveys [13-15, 23, 24]. Improving early detection practices through strengthened screening protocols could significantly reduce late-stage diagnoses. On a positive note, 72.99% of our dentists correctly linked sun exposure to lip cancer (Table 2), in line with a finding of 63.3% in Qatar [15], but lower than 96.2% in Spain [22]. Although this reflects a good level of awareness, further education could help support local knowledge with international standards.
A total of 70.07% of the specialists correctly identified that oral cancer lesions typically manifest as small, painless, and red spots (Table 2), in line with studies conducted in Canada [14] (77%), Qatar [15] (66.7%), and Italy [17] (59.5%). While most dentists can identify typical oral cancer lesions, continued education is necessary to ensure that all dentists have this crucial diagnostic skill. In addition, only 53.28% knew that a firm, movable/ immovable lymph node can indicate oral cancer spreading (Table 2), which is lower than 75.7% and 86.2% showed in studies from Qatar [15] and Spain [22]. This moderate awareness suggests the need for additional training in recognizing signs of cancer metastases.
One advantage of our study was the high response rate (93.19%), achieved through various invitation methods. The study’s limitations include a relatively small sample size and the predominance of young practicing dentists, which may affect generalizability of the results. Increasing the sample size and diversity in future research can provide more detailed insights into the level of oral cancer knowledge among Kosovo’s dentists. Conclusions Despite its limitations, this research sheds light on the current state of oral cancer education among Kosovar’s dentists. Addressing knowledge gaps through ongoing education and targeted training will improve healthcare outcomes. We strongly advocate for the implementation of continuous oral cancer education through lectures, workshops, and courses, to ensure that dentists are well-equipped to diagnose and treat oral malignances effectively. Additionally, raising awareness of oral cancer diagnostic procedures could positively influence and improve healthcare in Kosovo.

Disclosures

1. Institutional review board statement: The study was approved by the Ethics Committee of the Dental Chamber of Kosovo (Reference No. 12 [25.05.2021]) in accordance with the Declaration of Helsinki.
2. Assistance with the article: We would like to thank all the resident dentists who participated in the study.
3. Financial support and sponsorship: None.
4. Conflicts of interest: The authors declare no potential conflicts of interest concerning the research, author­ship, and/or publication of this article.

References