ORIGINAL Anandani ARTICLE et al
Awareness of General Dental Practitioners About Oral Screening and Biopsy Procedures in Udaipur, India Chitra Anandania/Rashmi Metgudb/Gayathri Rameshc/Karanprakash Singhd Purpose: Oral cancer presents with high mortality rates, and the likelihood of survival is remarkably better when detected early. The present study aimed to assess the awareness of general dental practitioners (GDPs) about oral screening and biopsy procedures in Udaipur, India. Materials and Methods: In this cross-sectional study, 83 GDPs were surveyed using a self-administered structured questionnaire consisting of several mandatory and optional questions. The data were analysed and frequency distribution was performed. Results: Most of the GDPs adequately performed complete oral cavity examinations and were aware of suspicious oral lesions, most common sites and risk factors for oral pre-cancer/cancer, but did not inquire about patients’ tobacco/ alcohol consumption habits. Half of them referred lesions requiring biopsy to a specialist/higher centre rather than performing biopsies themselves, even after recognising the importance of biopsy as a diagnostic tool due to concerns of inadequate experience and instruments required. Varied results regarding selection of the appropriate site for biopsy and preservation of biopsied specimens were noted. Conclusion: Most of the GDPs were adequately aware of oral screening and biopsy procedures but felt reluctant to perform them, which suggests that dental education programmes are needed for GDPs in oral pre-cancer/cancer detection as well as screening and diagnostic procedures. Key words: biopsy, general dental practitioners, oral cancer, questionnaire, screening Oral Health Prev Dent 2015;13:523-530 doi: 10.3290/j.ohpd.a32993
O
ral cancer is a global health problem with increasing rates of incidence and rising mortality rates (Gillison, 2007). These increases are continuing largely due to aging and growth of the world a
Senior Lecturer, Department of Oral and Maxillofacial Pathology, College of Dental Sciences and Research Centre, Bopal, Manipur, Ahmedabad, Gujarat. Concept, study design, performed literature search, data acquisition and analysis, prepared, edited, reviewed and proofread manuscript.
b
Professor and Head, Department of Oral and Maxillofacial Pathology, Pacific Dental College and Hospital, PAHER University, Udaipur, India. Study design, definition of intellectual content, data analysis, manuscript editing, review and proofreading.
c
Associate Professor, Department of Oral and Maxillofacial Pathology, Rama Dental College Hospital and Research Centre, Rama University, Lakhanpur, Kanpur. Study design, literature search, data analysis, manuscript review.
d
Tutor, Department of Public Health Dentistry, Sidhpur Dental College and Hospital, Sidhpur, Gujarat, India. Study design, performed data analysis and statistical evaluation, manuscript review.
Correspondence: Dr. C. Anandani, Department of Oral and Maxillofacial Pathology, College of Dental Sciences and Research Centre, Bopal, Manipur, Ahmedabad, India. Tel: +91-940-8442627. Email: [email protected]
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Submitted for publication: 22.01.13; accepted for publication: 26.08.13
population alongside an increasing spread of cancer-causing behaviours (Jemal et al, 2011). Oral cancer is the eleventh most common cancer in the world, with an estimate of 267,000 detected cases and 128,000 deaths annually, twothirds of which occur in developing countries. The Indian subcontinent accounts for one-third of the global oral cancer burden. In India, the age-standardised incidence rate of oral cancer is reported to be 12.6 per 100,000 people (Khan, 2012). Morbidity and mortality of other types of cancers have decreased over the past few decades, but oral cancer has increased (Ali et al, 2012). One reason for the lowest survival rates of oral cancer, despite recent therapeutic advances, may be the late presentation due to delays in diagnosis (period elapsed since the first symptom or sign until the definitive diagnosis) (Seoane-Lestón et al, 2010). Although the oral cavity is accessible to visual examination by patients and healthcare workers, it is most unfortunate that many pre-neoplastic le-
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sions are overlooked before they become frankly invasive. The majority of cases are detected only when they have reached a regional or metastatic stage, with low 5-year survival rates (20%-50%) depending on tumour sites. These issues suggest that, despite known risk factors, anatomical accessibility, and periodic or occasional visits of patients and at-risk persons to dentists, an effective primary or secondary prevention is not yet in place (Shetty and Jones, 2006; Ariyawardana and Ekanayake, 2008; Seoane-Lestón et al, 2010). Dental professionals have an important role in both primary prevention of oral cancer by encouraging healthy lifestyles and secondary prevention by detecting oral cancer or its precursor lesions at early stages (Sánchez et al, 2003). Biopsy serves as an important aid in achieving this goal. The literature contains few studies on general dental practitioners’ (GDPs) attitude and awareness towards oral biopsy. Studies on prevention, detection and management of oral pre-cancer and cancer have been conducted in different countries, but only very few in India (Murgod et al, 2011; Parwani et al, 2011; Vijay-Kumar and Suresan, 2012). To the best of our knowledge, there is no information available on this from Udaipur District. However, such information would be vital prior to designing an appropriate educational programme for dental healthcare workers. Thus, the present study aimed to explore the awareness of general dental practitioners in Udaipur District about oral screening and biopsy procedures.
MATERIALS AND METHODS Study population A descriptive cross-sectional study was conducted in November 2012 among the dentists in Udaipur district, located in the southern Rajasthan, India. A list of 98 private practitioners with a Bachelor of Dental Surgery qualification was acquired from the local sources (local Indian Dental Association branch and telephone directory), out of which 83 practitioners present during the study period were included in the study. The remaining 15 dentists were unavailable at their clinics when approached for the first time due to various reasons, and later could not be visited due to inconvenience. The study protocol was reviewed by the Ethics Committee of Pacific Dental College and Hospital
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and was granted ethical clearance (Ref no. PDCH/12/000569).
Questionnaire A comprehensive, self-administered, structured questionnaire was developed on the importance of oral screening and biopsy procedures in routine dental practice and discussed among the faculty of the various departments of our dental college. The questionnaire was administered to a convenience sample of 20 dentists, who were interviewed to gain feedback on the overall acceptability of the questionnaire in terms of length and language clarity. Based on this feedback, the questionnaire did not require any correction. Cronbach’s alpha was found to be 0.68, which showed internal reliability of the questionnaire. The mean Content Validity Ratio (CVR) was calculated as 0.87 based on the opinions expressed by a panel of six academicians. Face validity was also assessed; 94% of the participants found the questions unambiguous and easy to answer. The data gathered during the pilot survey was not included in the main study. The questionnaire comprised 22 mandatory and optional questions consisting of several items addressing the sociodemographic data; awareness regarding screening procedures (items 1–5); importance, attitude and practice regarding oral lesions requiring biopsy, biopsy methods, diagnostic pathology referral, preservation of specimens (items 6–19); and knowledge upgrading (items 20–22). On the data collection days, the investigator personally visited private clinics to have the questionnaires filled out. The questionnaires were distributed to all dentists (n = 83), who were also requested to fill in the written informed consent form. They were given a full explanation of how to fill out the questionnaire and were asked to respond to each item according to the response format provided with the questionnaire. Descriptive statistics were performed using SPSS 15 (SPSS; Chicago, IL, USA) for Windows.
RESULTS Out of the 98 practitioners approached, 15 were unavailable during the study period; hence, the response rate was 84.6%. None of the questionnaires filled out by the remaining 83 practitioners had to be discarded due to vague or incomplete answers.
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Out of the 83 respondents, the majority (61 [73.4%]) were males. 37.3% respondents were in the age range of 31–40 years and 34.9% had 10– 14 years of experience. All of them (100%) perceived that they were adequately trained to perform a complete oral cavity examination, while 92.3% were aware of the lesions which raise the suspicion of malignancy. To examine their attitude about oral pre-cancer and cancer, participating dentists were asked about the most common sites and risk factors for oral cancer. 26.2% of the respondents paid attention to the buccal/labial mucosa when looking for potentially malignant sites. They were also aware of the major risk factors most likely associated with oral cancer, since 34.1% and 27.7% of them identified tobacco in smokeless or smoking forms, respectively, followed by immunosuppression (14.3%)
and alcohol habits (14.1%). Still, only less than half (42%) routinely recorded the tobacco or alcohol consumption habits of the patient (Table 1). Table 2 shows the percentage distribution of the most common lesions encountered during routine daily practice. The maximum response rate was for cystic lesions (23.4%); most of the GDPs encountered such lesions once per month (50.8%). A very few (1.6%) also encountered such lesions daily. All of them (100%) felt that they were adequately aware of the importance of biopsy procedures for oral lesions (item 8) and most of them (60.2%) knew all types of biopsy methods (item 14). In terms of which lesions require biopsy, 7.8% thought that it should be done for all cystic, premalignant, benign and malignant lesions, while 23% believed that a biopsy should be taken only for malignant lesions (Table 3).
Table 1 Percentage distribution of general dental practitioners’ response on the common sites and risk factors for oral lesions Which sites would you pay attention to when looking for potentially malignant lesions?
What would you consider as risk factors for oral cancer?
Site
Response
Risk factors
Response
Buccal/ labial mucosa
26.2%
Smokeless tobacco
34.1%
Overall tongue
19.7%
Smoking tobacco
27.7%
All sites
39.3%
Immunosuppression
14.3%
Floor of mouth
8.2%
Alcohol
14.1%
Palate
6.6%
Family history
6.1%
Others
3.7%
Table 2 Percentage distribution of general dental practitioners’ response on the most common lesions encountered and their frequency Which lesions do you come across?
How often?
Lesion
Response
Frequency
Response
Cystic
23.4%
Daily
1.6%
Benign
11.2%
Weekly
41.0%
Premalignant
8.5%
Monthly
50.8%
Malignant
1.3%
Yearly
6.6%
Cystic / premalignant
10.2%
Benign / premalignant
14.3%
Benign / premalignant / malignant
16.8%
Premalignant / malignant
7.6%
Cystic / benign / premalignant / malignant
6.7%
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Table 3 Percentage distribution of general dental practitioners’ awareness regarding biopsy procedures Which lesions require biopsy?
Which biopsy methods are you aware of?
Lesions
Response
Methods
Response
Benign
10.1%
Incisional
9.3%
Premalignant
14.7%
Excisional
10.2%
Malignant
23.0%
Fine needle aspiration
7.2%
Benign / premalignant / malignant
Incisional / excisional
6.2%
15.1% Incisional / excisional / brush biopsy
3.3%
Benign / premalignant
13.1%
Incisional / excisional / fine needle aspiration
2.4%
Premalignant / malignant
16.2%
Incisional / excisional / fine needle aspiration / punch biopsy
1.2%
All
7.8%
Incisional / excisional / fine needle aspiration / brush biopsy / punch biopsy
60.2%
Table 4 Percentage distribution of general dental practitioners’ practices regarding lesions requiring biopsy What do you do for lesions requiring biopsy?
Reason for not performing biopsy on your own
Options
Response
Reasons
Response
Call a specialist
50.8%
Patients do not agree
13.7%
Refer to a higher centre
31.3%
Lack of experience and skills
32.4%
Perform biopsy on your own
11.3%
Lack of instruments required for biopsy
33.3%
Call a specialist / refer to a higher centre
6.6%
Lack of nearby pathology laboratory services
20.6%
Table 5 Percentage distribution of general dental practitioners’ practices regarding biopsy procedures How do you select appropriate site for biopsy?
After biopsy, do you send tissue for analysis?
Method of biopsy used
Method
Response
Methods
Response
Frequency
Response
Visual examination
57.4%
Incisional
40.1%
Always
37.0%
Toluidine blue vital staining
Excisional
53.7%
26.3%
46.3%
Fine needle aspiration
1.9%
Only when suspecting premalignancy or malignancy
Incisional / excisional
1.1%
Brush biopsy
0.3%
Never in case of excisional biopsy
16.7%
No response
2.9%
Visual examination / toluidine blue vital staning
16.3%
Table 6 Percentage distribution of general dental practitioners’ attitude and practices regarding preservation of specimen How do you think the specimen should be preserved before sending for analysis?
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Method of preservation of specimen used in your clinic
Methods
Response
Methods
Response
Saline
23.00%
Saline
56.40%
Formalin
52.60%
Formalin
32.60%
Alcohol
17% Alcohol
11%
No idea
7.40%
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When asked how they would proceed after noticing a lesion that requires biopsy, about half (50.8%) of the participants preferred to call a specialist to perform the biopsy, and when asked about the reason for their reluctance, most of them said it was due to lack of the instruments and experience required for taking biopsies (Table 4). Out of those who performed biopsy on their own, more than half (57.4%) used visual examination alone to select the biopsy site. 53.7% preferred to perform excisional biopsy and 46.3% sent the tissue for analysis only when suspecting premalignancy or malignancy (Table 5). Regarding the preservation of biopsy specimens, although about half (52.6%) of the GDPs knew that it should be placed in 10% formalin, over half (56.4%) still used saline in their clinics for preservation (Table 6). All the practitioners felt the need to update their knowledge regarding oral lesions and biopsy procedures, with 97.3% actually doing so. The various sources included scientific journals (41%), internet (39.3%), conferences (6.6%) and others (13.1%) (i.e. seminars, workshops, continuing dental education programmes, group practice, etc).
DISCUSSION Oral cancer is a major health problem and its diagnosis at early stages is both an educational objective and the basis for cancer prevention (Higuchi et al, 2006). Many experts agree that the key is not necessarily identifying oral cancer but identifying tissue that is not normal and taking appropriate action (Vijay-Kumar and Suresan, 2012). Biopsy is of paramount importance as it is strongly related to diagnosis and early detection of oral cancer. The present study confirmed that all the dentists were adequately prepared to perform a complete oral cavity examination, along with palpating cervical lymph nodes. Further, 92.3% were aware of the lesions which raise the suspicion of malignancy. Dental practitioners were often aware of the likely sites of oral squamous cell carcinoma and 39.3% of the GDPs paid attention to the entire oral cavity while screening for potentially malignant lesions. However, in a study by Greenwood and Lowry (2001), GDPs showed a preference for examining areas relating to the tooth-bearing or potentially denture-bearing tissues, rather than for some of the more high risk sites, e.g. floor of the mouth. In rating the risk factors of oral premalignant and malignant lesions, the GDPs considered tobacco in
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smokeless and smoking forms to be the most important risk factor, which indicates that their knowledge is consistent with the current understanding of the aetiology of oral premalignant and malignant lesions. This was in accordance with the results of Jaber (2011), Colella et al (2008) and Kujan et al (2006), whereas in a study by Vijay-Kumar and Suresan (2012), the use of alcohol was identified as the major risk factor. In spite of this, only 42% of the GDPs enquired into the patient’s history in terms of the nature and frequency of the habits (tobacco/alcohol) to which they were exposed. Identifying patients’ tobacco and alcohol use, whether current or past, is pivotal for a practitioner to assess their risk of developing oral cancer (VijayKumar and Suresan, 2012). The study depicts the easy accessibility of GDPs to patients, as the former encounter an enormous range of cystic, premalignant, benign and malignant lesions of the oral cavity quite frequently (once a month). This accentuates their key role in the screening and early diagnosis of oral lesions; negligence on this part may prove unfavourable for patients. This was in contrast to the study by Murgod et al (2011) and Wan and Savage et al (2010), who observed that 68.6% and 63.6% GDPs, respectively, encountered such lesions only once a year, while Diamanti et al (2002) found that 33% of GDPs detected lesions on more than one occasion each year. It was reassuring to note that all the dentists were well aware of the importance of biopsy procedures for the diagnosis of oral lesions. However, their awareness regarding the lesions that require biopsy was discouraging, as very few (7.8%) knew its correct indications and a dejecting 23% believed that it should be performed solely for malignant lesions. This was in contrast to the study by Murgod et al (2011), who found that 22.3% GDPs knew the right indications for lesions requiring biopsy. Our results may be attributed to inadequate attention paid to oral pathology (due to unawareness, lack of training, etc.) and their low awareness of the risk of premalignant alterations in white lesions. In our study, 11.3% of the respondents claimed to perform oral biopsies on their own. This was in accordance to the other studies by Jaber (2011), Murgod et al (2011), Diamanti et al (2002), Seoane et al (2004), Leao et al (2005) and Jornet et al (2007) in which also 10%, 14.9%, 15%, 24.5%, 25%, 32.1% of practitioners, respectively, performed biopsies on their own. However, in northwestern Spain, after an intervention funded by the
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Regional Government, up to 50% of the GDPs undertook at least one biopsy per year to confirm or rule out oral cancer (Seoane et al, 2006). In the current study, the practitioners surveyed either preferred to call a specialist (50.8%) or refer the patient to a higher centre (31.3%). Studies by Coulthard et al (2000), Diamanti et al (2002), Leao et al (2005), Wan and Savage et al (2010) and Murgod et al (2011) showed that 84%, 55%, 83.7%, 76.2% and 64.6% of GDPs surveyed, respectively, refer the biopsy cases to a specialist. It is cause for concern that GDPs do not wish to undertake invasive procedures. The reasons quoted by various authors for this reluctance are unfamiliarity with biopsy techniques, lack of confidence in personal diagnostic skills, fear of misdiagnosis of malignancy or serious pathology, misconception of it being a specialist procedure, fear of medico-legal complications, risk of litigation or concern that if the lesion is malignant, they may not be emotionally equipped to inform the patient that he/she has cancer (Diamanti et al, 2002; Wan and Savage, 2010; Murgod et al, 2011). Further, the negligence of GDPs in performing biopsies was acknowledged. Even though 50.8% of them encountered lesions monthly that required biopsy, 83.8% performed/referred biopsies only twice a year, which may ultimately lead to medicolegal complications. At present, in the United Kingdom, there is an increasing number of lawsuits against dental professionals, since the latter are responsible for identifying oral lesions and informing the patients accordingly. Neglect can be assumed in those cases where this is not done, or when the patient is not referred to another centre for study (Jornet et al, 2007). Failure to biopsy may lead to persistence of a misdiagnosed malignant lesion or other serious pathology, resulting in the progression of the lesion to an advanced stage before treatment is initiated (Wan and Savage, 2010). Most of the respondents (57.4%) used visual examination for the selection of an appropriate site for biopsy because this technique is inexpensive, simple, acceptable and has high sensitivity and specificity. Alternatively, staining of live tissues with toluidine blue has been identified as a useful aid in selection of biopsy sites in cases of premalignant lesions. Toluidine blue is a metachromatic stain taken up more readily by nuclear material and hence to a greater extent by malignant/premalignant than normal tissue. The use of toluidine blue facilitates selecting the appropriate site for biopsy (Parwani et al, 2011). However, despite reports by
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numerous investigators encouraging the use of toluidine blue, few respondents (26.3%) actually did so. This low percentage may reflect issues such as reliability, cost, lack of robust evidence and high number of false positive results from toluidine blue application (Kujan et al, 2006). This also reflects the negligence of GDPs and the inadequate training during their undergraduate curriculum regarding the importance of toluidine blue. In our study, the main reasons for the reluctance in performing biopsies were lack of instrumentation (33.3%) and lack of experience (32.4%) in performing the procedure. This agreed with the results by Diamanti et al (2002), Murgod et al (2011) and Wan and Savage et al (2010), which found that 25%, 22.3% and 58.1% of GDPs, respectively, did not feel competent to undertake biopsies, mainly due to lack of experience and practical skills. A GDP’s lack of experience in performing biopsies could be attributed to insufficient importance placed on the practical teaching of biopsy techniques during their undergraduate training. Wan and Savage et al (2010) found that over 50% of practitioners reported only being taught theoretical knowledge of biopsy procedures and diagnostic histopathology during undergraduate training, without having received any practical experience in these two areas. This lack of training in biopsy procedures was also shown in the study by Diamanti et al (2002), in which 39% of GDPs surveyed reported never being taught biopsy techniques. Therefore, GDPs who had been taught how to biopsy or had actually performed a biopsy during their undergraduate studies were more likely to undertake biopsy procedures in general practice (Diamanti et al, 2002; Seoane et al, 2004; Wan and Savage, 2010; Murgod et al, 2011). Further, about 60.2% of the practitioners were aware of all different biopsy methods. Of the 11.3% of GDPs who performed biopsies on their own, 53.7% used the excisional biopsy technique in their clinic while only 0.3% performed brush biopsies. Performing simple excisional biopsies in general practice provides the advantage of a reduced waiting time for the procedure and the results, as well as less travelling for the patient (Wan and Savage, 2010). However, excisional biopsies by GDPs done without oncological consideration of lesions suspected to be malignant could allow microscopic tumour remnants to remain in situ and cause destruction of the margins of the lesion, thus making re-excision and possibly neck treatment mandatory. On the other hand, incisional biopsies of lesions
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suspected of malignancy represent a more realistic approach for GDPs, but incisional biopsies at times may lead to underdiagnosis due to sampling errors (Seoane-Lestón et al, 2010). Hence, when considering the type of biopsy required for a particular case, the GDPs should be better informed about biopsy techniques, their indications as well as contraindications. The study also revealed that 46.3% of dentists sent the specimens for examination and histological analysis only given suspected premalignancy or malignancy and then not always. This transforms the procedure from an investigational to a final treatment protocol and misses the opportunity to obtain additional supportive information from the procedure. Moreover, those GDPs who perform excisional biopsy for clinically obvious lesions do not consider it necessary to send the tissue for histopathological analysis, even though routine histopathology of all soft tissues removed from a patient is indicated in order to obtain a definitive diagnosis of any presenting pathology, and to preclude any differential diagnosis. Pertaining to the preservation of the biopsy tissue specimen, 52.6% practitioners correctly knew that the tissue should be preserved in formalin, while 7.9% were completely unaware of preservation methods. Further, upon inquiring about the method of preservation used in their clinic, more than half of them (56.4%) unfortunately used saline as a fixative, which defeats the purpose, as saline has a negative impact on the tissues, a fact that is often ignored by the practiotioners. Moreover, it was again shocking to see that only 52.6% of GDPs used the correct concentration of formalin, i.e. 10%. The rest reported using concentrations of 40%, 30%, 20% and even 2%. Preservation of the tissue is an important facet in biopsy that is often disregarded by clinicians. If the tissue is not preserved properly, it produces artefacts which prevent the pathologist from giving an appropriate diagnosis, thus possibly inducing the clinician to take another biopsy, which further increases the trauma to the patient. Also, if the GDPs are willing to perform a biopsy and are short of formalin in their clinics, they should plan the procedure accordingly and request the pathological laboratory or higher centre to deliver formalin (Murgod et al, 2011). Finally, all the GDPs felt the need to update their knowledge on oral screening and biopsy procedures. 97.3% of them actually did so through various
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sources, such as journals, internet, conferences and discussion with their peers, which demonstrates their interest in the well-being of their patients. The limitation of the present questionnaire survey is that the reported responses may not match actual clinical practice. The tendency of practitioners to provide socially acceptable answers would usually bias against variability in reported practices, resulting in underestimations. This precludes extrapolation of the findings to the global population of dental professionals. Given the level of inconsistencies between the dentists’ oral cancer awareness and practice behaviours, it is apparent that further study is needed to understand the barriers they experience to implement this knowledge.
CONCLUSION Most of the general dental practitioners had knowledge of oral cancer screening and biopsy procedures, but many felt reluctant to perform them due to inadequate experience and skills. Relevant continuing dental education programmes/training on the management of suspicious oral lesions are recommended.
ACKNOWLEDGEMENTS We would like to thank all the faculty members in the Department of Oral and Maxillofacial Pathology for their general support.
REFERENCES 1. Ali FM, Prasant M, Patil A, Ahere V, Tahasildar S, Patil K, et al. Oral Biopsy in General Dental Practice: A Review. Int J Med Public Health 2012;2:3–6. 2. Ariyawardana A, Ekanayake L. Screening for Oral Cancer/ Pre-cancer: Knowledge and Opinions of Dentists Employed in the Public Sector Dental Services of Sri Lanka. Asian Pac J Cancer Prev 2008;9:615–618. 3. Colella G, Gaeta GM, Moscariello A, Angelillo IF. Oral cancer and dentists: Knowledge, attitudes, and practices in Italy. Oral Oncol 2008;44:393–399. 4. Coulthard P, Koron R, Kazakou I, Macfarlane TV. Patterns and appropriateness of referral from general dental practice to specialist oral and maxillofacial surgical services. Br J Oral Maxillofac Surg 2000;38:320–325. 5. Diamanti NN, Duxbury A, Ariyaratnam S, Macfarlane T. Attitudes to biopsy procedures in general dental practice. Br Dent J 2002;192:588–592. 6. Gillison M. Current topics in the epidemiology of oral cavity and oropharyngeal cancers. Head Neck 2007;29:779–792.
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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;191:510–512. Higuchi K, Cragg C, Diem E, Molnar J, O’Donohue M. Integrating clinical guidelines into nursing education. Int J Nurs Educ Scholarship 2006;3;[Epub] doi: 10.2202/1548923X.1223. Jaber MA. Dental practitioner’s knowledge, opinions and methods of management of oral premalignancy and malignancy. Saudi Dent J 2011;23:29–36. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin 2011;61:69– 90. Jornet PL, Nicolás AV, Beneyto YM, Soria MF. Attitude towards oral biopsy among general dentists in Murcia. Med Oral Patol Oral Cir Bucal 2007;12:116–121. Khan ZU. An overview of oral cancer in Indian subcontinent and recommendations to decrease its incidence. Cancer 2012;3:WMC003626. Kujan O, Duxbury AJ, Glenny AM, Thakker NS, Sloan P. Opinions and attitudes of the UK’s GDPs and specialists in oral surgery, oral medicine and surgical dentistry on oral cancer screening. Oral Dis 2006;12:194–199. Leao JC, Goes P, Sobrinho CB, Porter S. Knowledge and clinical expertise regarding oral cancer among Brazilian dentists. Int J Oral Maxillofac Surg 2005;34:436–439. Murgod V, Angadi PV, Hallikerimath S, Kale AD, Hebbal M. Attitudes of general dental practitioners towards biopsy procedures. J Clin Exp Dent 2011;3:418–423.
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16. Parwani RN, Wanjari SP, Chitnis P, S M, Singraju S. Biopsy: an abused tool!(?): a survey of biopsy skills among dental practitioners. J Indian Dent Assoc 2011;5:1053–1056. 17. Sánchez M, Martínez C, Nieto A, Castellsagué X, Quintana M, Bosch F. Oral and oropharyngeal cancer in Spain: influence of dietary patterns. Eur J Cancer Prev 2003;12:49– 56. 18. Seoane-Lestón J, Velo-Noya J, Warnakulasuriya S, VarelaCentelles P, Gonzalez-Mosquera A, Villa-Vigil M-A, et al. Knowledge of oral cancer and preventive attitudes of Spanish dentists. Primary effects of a pilot educational intervention. Med Oral Patol Oral Cir Bucal 2010;15:422– 426. 19. Seoane J, Valera-Centelles P, Ramírez J, Cameselle-Teijeiro J, Romero M. Artifacts in oral incisional biopsies in general dental practice: a pathology audit. Oral Dis 2004;10:113–117. 20. Seoane J, Warnakulasuriya S, Varela-Centelles P, Esparza G, Dios PD. Oral cancer: experiences and diagnostic abilities elicited by dentists in North-western Spain. Oral Dis 2006;12:487–492. 21. Shetty K, Jones D. Knowledge, opinions, and practices of dentists and dental hygienists in Texas regarding oral cancer. Internet J Epidemiol 2006;3[Epub] doi: 10.5580/e75 22. Vijay-Kumar K, Suresan V. Knowledge, attitude and screening practices of general dentists concerning oral cancer in Bangalore city. Indian J Cancer 2012;49:33–38. 23. Wan A, Savage N. Biopsy and diagnostic histopathology in dental practice in Brisbane: usage patterns and perception of usefulness. Aust Dent J 2010;55:162–169.
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Awareness of General Dental Practitioners About Oral Screening and Biopsy Procedures in Udaipur, India Chitra Anandania/Rashmi Metgudb/Gayathri Rameshc/Karanprakash Singhd Purpose: Oral cancer presents with high mortality rates, and the likelihood of survival is remarkably better when detected early. The present study aimed to assess the awareness of general dental practitioners (GDPs) about oral screening and biopsy procedures in Udaipur, India. Materials and Methods: In this cross-sectional study, 83 GDPs were surveyed using a self-administered structured questionnaire consisting of several mandatory and optional questions. The data were analysed and frequency distribution was performed. Results: Most of the GDPs adequately performed complete oral cavity examinations and were aware of suspicious oral lesions, most common sites and risk factors for oral pre-cancer/cancer, but did not inquire about patients’ tobacco/ alcohol consumption habits. Half of them referred lesions requiring biopsy to a specialist/higher centre rather than performing biopsies themselves, even after recognising the importance of biopsy as a diagnostic tool due to concerns of inadequate experience and instruments required. Varied results regarding selection of the appropriate site for biopsy and preservation of biopsied specimens were noted. Conclusion: Most of the GDPs were adequately aware of oral screening and biopsy procedures but felt reluctant to perform them, which suggests that dental education programmes are needed for GDPs in oral pre-cancer/cancer detection as well as screening and diagnostic procedures. Key words: biopsy, general dental practitioners, oral cancer, questionnaire, screening Oral Health Prev Dent 2015;13:523-530 doi: 10.3290/j.ohpd.a32993
O
ral cancer is a global health problem with increasing rates of incidence and rising mortality rates (Gillison, 2007). These increases are continuing largely due to aging and growth of the world a
Senior Lecturer, Department of Oral and Maxillofacial Pathology, College of Dental Sciences and Research Centre, Bopal, Manipur, Ahmedabad, Gujarat. Concept, study design, performed literature search, data acquisition and analysis, prepared, edited, reviewed and proofread manuscript.
b
Professor and Head, Department of Oral and Maxillofacial Pathology, Pacific Dental College and Hospital, PAHER University, Udaipur, India. Study design, definition of intellectual content, data analysis, manuscript editing, review and proofreading.
c
Associate Professor, Department of Oral and Maxillofacial Pathology, Rama Dental College Hospital and Research Centre, Rama University, Lakhanpur, Kanpur. Study design, literature search, data analysis, manuscript review.
d
Tutor, Department of Public Health Dentistry, Sidhpur Dental College and Hospital, Sidhpur, Gujarat, India. Study design, performed data analysis and statistical evaluation, manuscript review.
Correspondence: Dr. C. Anandani, Department of Oral and Maxillofacial Pathology, College of Dental Sciences and Research Centre, Bopal, Manipur, Ahmedabad, India. Tel: +91-940-8442627. Email: [email protected]
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Submitted for publication: 22.01.13; accepted for publication: 26.08.13
population alongside an increasing spread of cancer-causing behaviours (Jemal et al, 2011). Oral cancer is the eleventh most common cancer in the world, with an estimate of 267,000 detected cases and 128,000 deaths annually, twothirds of which occur in developing countries. The Indian subcontinent accounts for one-third of the global oral cancer burden. In India, the age-standardised incidence rate of oral cancer is reported to be 12.6 per 100,000 people (Khan, 2012). Morbidity and mortality of other types of cancers have decreased over the past few decades, but oral cancer has increased (Ali et al, 2012). One reason for the lowest survival rates of oral cancer, despite recent therapeutic advances, may be the late presentation due to delays in diagnosis (period elapsed since the first symptom or sign until the definitive diagnosis) (Seoane-Lestón et al, 2010). Although the oral cavity is accessible to visual examination by patients and healthcare workers, it is most unfortunate that many pre-neoplastic le-
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sions are overlooked before they become frankly invasive. The majority of cases are detected only when they have reached a regional or metastatic stage, with low 5-year survival rates (20%-50%) depending on tumour sites. These issues suggest that, despite known risk factors, anatomical accessibility, and periodic or occasional visits of patients and at-risk persons to dentists, an effective primary or secondary prevention is not yet in place (Shetty and Jones, 2006; Ariyawardana and Ekanayake, 2008; Seoane-Lestón et al, 2010). Dental professionals have an important role in both primary prevention of oral cancer by encouraging healthy lifestyles and secondary prevention by detecting oral cancer or its precursor lesions at early stages (Sánchez et al, 2003). Biopsy serves as an important aid in achieving this goal. The literature contains few studies on general dental practitioners’ (GDPs) attitude and awareness towards oral biopsy. Studies on prevention, detection and management of oral pre-cancer and cancer have been conducted in different countries, but only very few in India (Murgod et al, 2011; Parwani et al, 2011; Vijay-Kumar and Suresan, 2012). To the best of our knowledge, there is no information available on this from Udaipur District. However, such information would be vital prior to designing an appropriate educational programme for dental healthcare workers. Thus, the present study aimed to explore the awareness of general dental practitioners in Udaipur District about oral screening and biopsy procedures.
MATERIALS AND METHODS Study population A descriptive cross-sectional study was conducted in November 2012 among the dentists in Udaipur district, located in the southern Rajasthan, India. A list of 98 private practitioners with a Bachelor of Dental Surgery qualification was acquired from the local sources (local Indian Dental Association branch and telephone directory), out of which 83 practitioners present during the study period were included in the study. The remaining 15 dentists were unavailable at their clinics when approached for the first time due to various reasons, and later could not be visited due to inconvenience. The study protocol was reviewed by the Ethics Committee of Pacific Dental College and Hospital
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and was granted ethical clearance (Ref no. PDCH/12/000569).
Questionnaire A comprehensive, self-administered, structured questionnaire was developed on the importance of oral screening and biopsy procedures in routine dental practice and discussed among the faculty of the various departments of our dental college. The questionnaire was administered to a convenience sample of 20 dentists, who were interviewed to gain feedback on the overall acceptability of the questionnaire in terms of length and language clarity. Based on this feedback, the questionnaire did not require any correction. Cronbach’s alpha was found to be 0.68, which showed internal reliability of the questionnaire. The mean Content Validity Ratio (CVR) was calculated as 0.87 based on the opinions expressed by a panel of six academicians. Face validity was also assessed; 94% of the participants found the questions unambiguous and easy to answer. The data gathered during the pilot survey was not included in the main study. The questionnaire comprised 22 mandatory and optional questions consisting of several items addressing the sociodemographic data; awareness regarding screening procedures (items 1–5); importance, attitude and practice regarding oral lesions requiring biopsy, biopsy methods, diagnostic pathology referral, preservation of specimens (items 6–19); and knowledge upgrading (items 20–22). On the data collection days, the investigator personally visited private clinics to have the questionnaires filled out. The questionnaires were distributed to all dentists (n = 83), who were also requested to fill in the written informed consent form. They were given a full explanation of how to fill out the questionnaire and were asked to respond to each item according to the response format provided with the questionnaire. Descriptive statistics were performed using SPSS 15 (SPSS; Chicago, IL, USA) for Windows.
RESULTS Out of the 98 practitioners approached, 15 were unavailable during the study period; hence, the response rate was 84.6%. None of the questionnaires filled out by the remaining 83 practitioners had to be discarded due to vague or incomplete answers.
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Out of the 83 respondents, the majority (61 [73.4%]) were males. 37.3% respondents were in the age range of 31–40 years and 34.9% had 10– 14 years of experience. All of them (100%) perceived that they were adequately trained to perform a complete oral cavity examination, while 92.3% were aware of the lesions which raise the suspicion of malignancy. To examine their attitude about oral pre-cancer and cancer, participating dentists were asked about the most common sites and risk factors for oral cancer. 26.2% of the respondents paid attention to the buccal/labial mucosa when looking for potentially malignant sites. They were also aware of the major risk factors most likely associated with oral cancer, since 34.1% and 27.7% of them identified tobacco in smokeless or smoking forms, respectively, followed by immunosuppression (14.3%)
and alcohol habits (14.1%). Still, only less than half (42%) routinely recorded the tobacco or alcohol consumption habits of the patient (Table 1). Table 2 shows the percentage distribution of the most common lesions encountered during routine daily practice. The maximum response rate was for cystic lesions (23.4%); most of the GDPs encountered such lesions once per month (50.8%). A very few (1.6%) also encountered such lesions daily. All of them (100%) felt that they were adequately aware of the importance of biopsy procedures for oral lesions (item 8) and most of them (60.2%) knew all types of biopsy methods (item 14). In terms of which lesions require biopsy, 7.8% thought that it should be done for all cystic, premalignant, benign and malignant lesions, while 23% believed that a biopsy should be taken only for malignant lesions (Table 3).
Table 1 Percentage distribution of general dental practitioners’ response on the common sites and risk factors for oral lesions Which sites would you pay attention to when looking for potentially malignant lesions?
What would you consider as risk factors for oral cancer?
Site
Response
Risk factors
Response
Buccal/ labial mucosa
26.2%
Smokeless tobacco
34.1%
Overall tongue
19.7%
Smoking tobacco
27.7%
All sites
39.3%
Immunosuppression
14.3%
Floor of mouth
8.2%
Alcohol
14.1%
Palate
6.6%
Family history
6.1%
Others
3.7%
Table 2 Percentage distribution of general dental practitioners’ response on the most common lesions encountered and their frequency Which lesions do you come across?
How often?
Lesion
Response
Frequency
Response
Cystic
23.4%
Daily
1.6%
Benign
11.2%
Weekly
41.0%
Premalignant
8.5%
Monthly
50.8%
Malignant
1.3%
Yearly
6.6%
Cystic / premalignant
10.2%
Benign / premalignant
14.3%
Benign / premalignant / malignant
16.8%
Premalignant / malignant
7.6%
Cystic / benign / premalignant / malignant
6.7%
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Table 3 Percentage distribution of general dental practitioners’ awareness regarding biopsy procedures Which lesions require biopsy?
Which biopsy methods are you aware of?
Lesions
Response
Methods
Response
Benign
10.1%
Incisional
9.3%
Premalignant
14.7%
Excisional
10.2%
Malignant
23.0%
Fine needle aspiration
7.2%
Benign / premalignant / malignant
Incisional / excisional
6.2%
15.1% Incisional / excisional / brush biopsy
3.3%
Benign / premalignant
13.1%
Incisional / excisional / fine needle aspiration
2.4%
Premalignant / malignant
16.2%
Incisional / excisional / fine needle aspiration / punch biopsy
1.2%
All
7.8%
Incisional / excisional / fine needle aspiration / brush biopsy / punch biopsy
60.2%
Table 4 Percentage distribution of general dental practitioners’ practices regarding lesions requiring biopsy What do you do for lesions requiring biopsy?
Reason for not performing biopsy on your own
Options
Response
Reasons
Response
Call a specialist
50.8%
Patients do not agree
13.7%
Refer to a higher centre
31.3%
Lack of experience and skills
32.4%
Perform biopsy on your own
11.3%
Lack of instruments required for biopsy
33.3%
Call a specialist / refer to a higher centre
6.6%
Lack of nearby pathology laboratory services
20.6%
Table 5 Percentage distribution of general dental practitioners’ practices regarding biopsy procedures How do you select appropriate site for biopsy?
After biopsy, do you send tissue for analysis?
Method of biopsy used
Method
Response
Methods
Response
Frequency
Response
Visual examination
57.4%
Incisional
40.1%
Always
37.0%
Toluidine blue vital staining
Excisional
53.7%
26.3%
46.3%
Fine needle aspiration
1.9%
Only when suspecting premalignancy or malignancy
Incisional / excisional
1.1%
Brush biopsy
0.3%
Never in case of excisional biopsy
16.7%
No response
2.9%
Visual examination / toluidine blue vital staning
16.3%
Table 6 Percentage distribution of general dental practitioners’ attitude and practices regarding preservation of specimen How do you think the specimen should be preserved before sending for analysis?
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Method of preservation of specimen used in your clinic
Methods
Response
Methods
Response
Saline
23.00%
Saline
56.40%
Formalin
52.60%
Formalin
32.60%
Alcohol
17% Alcohol
11%
No idea
7.40%
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When asked how they would proceed after noticing a lesion that requires biopsy, about half (50.8%) of the participants preferred to call a specialist to perform the biopsy, and when asked about the reason for their reluctance, most of them said it was due to lack of the instruments and experience required for taking biopsies (Table 4). Out of those who performed biopsy on their own, more than half (57.4%) used visual examination alone to select the biopsy site. 53.7% preferred to perform excisional biopsy and 46.3% sent the tissue for analysis only when suspecting premalignancy or malignancy (Table 5). Regarding the preservation of biopsy specimens, although about half (52.6%) of the GDPs knew that it should be placed in 10% formalin, over half (56.4%) still used saline in their clinics for preservation (Table 6). All the practitioners felt the need to update their knowledge regarding oral lesions and biopsy procedures, with 97.3% actually doing so. The various sources included scientific journals (41%), internet (39.3%), conferences (6.6%) and others (13.1%) (i.e. seminars, workshops, continuing dental education programmes, group practice, etc).
DISCUSSION Oral cancer is a major health problem and its diagnosis at early stages is both an educational objective and the basis for cancer prevention (Higuchi et al, 2006). Many experts agree that the key is not necessarily identifying oral cancer but identifying tissue that is not normal and taking appropriate action (Vijay-Kumar and Suresan, 2012). Biopsy is of paramount importance as it is strongly related to diagnosis and early detection of oral cancer. The present study confirmed that all the dentists were adequately prepared to perform a complete oral cavity examination, along with palpating cervical lymph nodes. Further, 92.3% were aware of the lesions which raise the suspicion of malignancy. Dental practitioners were often aware of the likely sites of oral squamous cell carcinoma and 39.3% of the GDPs paid attention to the entire oral cavity while screening for potentially malignant lesions. However, in a study by Greenwood and Lowry (2001), GDPs showed a preference for examining areas relating to the tooth-bearing or potentially denture-bearing tissues, rather than for some of the more high risk sites, e.g. floor of the mouth. In rating the risk factors of oral premalignant and malignant lesions, the GDPs considered tobacco in
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smokeless and smoking forms to be the most important risk factor, which indicates that their knowledge is consistent with the current understanding of the aetiology of oral premalignant and malignant lesions. This was in accordance with the results of Jaber (2011), Colella et al (2008) and Kujan et al (2006), whereas in a study by Vijay-Kumar and Suresan (2012), the use of alcohol was identified as the major risk factor. In spite of this, only 42% of the GDPs enquired into the patient’s history in terms of the nature and frequency of the habits (tobacco/alcohol) to which they were exposed. Identifying patients’ tobacco and alcohol use, whether current or past, is pivotal for a practitioner to assess their risk of developing oral cancer (VijayKumar and Suresan, 2012). The study depicts the easy accessibility of GDPs to patients, as the former encounter an enormous range of cystic, premalignant, benign and malignant lesions of the oral cavity quite frequently (once a month). This accentuates their key role in the screening and early diagnosis of oral lesions; negligence on this part may prove unfavourable for patients. This was in contrast to the study by Murgod et al (2011) and Wan and Savage et al (2010), who observed that 68.6% and 63.6% GDPs, respectively, encountered such lesions only once a year, while Diamanti et al (2002) found that 33% of GDPs detected lesions on more than one occasion each year. It was reassuring to note that all the dentists were well aware of the importance of biopsy procedures for the diagnosis of oral lesions. However, their awareness regarding the lesions that require biopsy was discouraging, as very few (7.8%) knew its correct indications and a dejecting 23% believed that it should be performed solely for malignant lesions. This was in contrast to the study by Murgod et al (2011), who found that 22.3% GDPs knew the right indications for lesions requiring biopsy. Our results may be attributed to inadequate attention paid to oral pathology (due to unawareness, lack of training, etc.) and their low awareness of the risk of premalignant alterations in white lesions. In our study, 11.3% of the respondents claimed to perform oral biopsies on their own. This was in accordance to the other studies by Jaber (2011), Murgod et al (2011), Diamanti et al (2002), Seoane et al (2004), Leao et al (2005) and Jornet et al (2007) in which also 10%, 14.9%, 15%, 24.5%, 25%, 32.1% of practitioners, respectively, performed biopsies on their own. However, in northwestern Spain, after an intervention funded by the
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Regional Government, up to 50% of the GDPs undertook at least one biopsy per year to confirm or rule out oral cancer (Seoane et al, 2006). In the current study, the practitioners surveyed either preferred to call a specialist (50.8%) or refer the patient to a higher centre (31.3%). Studies by Coulthard et al (2000), Diamanti et al (2002), Leao et al (2005), Wan and Savage et al (2010) and Murgod et al (2011) showed that 84%, 55%, 83.7%, 76.2% and 64.6% of GDPs surveyed, respectively, refer the biopsy cases to a specialist. It is cause for concern that GDPs do not wish to undertake invasive procedures. The reasons quoted by various authors for this reluctance are unfamiliarity with biopsy techniques, lack of confidence in personal diagnostic skills, fear of misdiagnosis of malignancy or serious pathology, misconception of it being a specialist procedure, fear of medico-legal complications, risk of litigation or concern that if the lesion is malignant, they may not be emotionally equipped to inform the patient that he/she has cancer (Diamanti et al, 2002; Wan and Savage, 2010; Murgod et al, 2011). Further, the negligence of GDPs in performing biopsies was acknowledged. Even though 50.8% of them encountered lesions monthly that required biopsy, 83.8% performed/referred biopsies only twice a year, which may ultimately lead to medicolegal complications. At present, in the United Kingdom, there is an increasing number of lawsuits against dental professionals, since the latter are responsible for identifying oral lesions and informing the patients accordingly. Neglect can be assumed in those cases where this is not done, or when the patient is not referred to another centre for study (Jornet et al, 2007). Failure to biopsy may lead to persistence of a misdiagnosed malignant lesion or other serious pathology, resulting in the progression of the lesion to an advanced stage before treatment is initiated (Wan and Savage, 2010). Most of the respondents (57.4%) used visual examination for the selection of an appropriate site for biopsy because this technique is inexpensive, simple, acceptable and has high sensitivity and specificity. Alternatively, staining of live tissues with toluidine blue has been identified as a useful aid in selection of biopsy sites in cases of premalignant lesions. Toluidine blue is a metachromatic stain taken up more readily by nuclear material and hence to a greater extent by malignant/premalignant than normal tissue. The use of toluidine blue facilitates selecting the appropriate site for biopsy (Parwani et al, 2011). However, despite reports by
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numerous investigators encouraging the use of toluidine blue, few respondents (26.3%) actually did so. This low percentage may reflect issues such as reliability, cost, lack of robust evidence and high number of false positive results from toluidine blue application (Kujan et al, 2006). This also reflects the negligence of GDPs and the inadequate training during their undergraduate curriculum regarding the importance of toluidine blue. In our study, the main reasons for the reluctance in performing biopsies were lack of instrumentation (33.3%) and lack of experience (32.4%) in performing the procedure. This agreed with the results by Diamanti et al (2002), Murgod et al (2011) and Wan and Savage et al (2010), which found that 25%, 22.3% and 58.1% of GDPs, respectively, did not feel competent to undertake biopsies, mainly due to lack of experience and practical skills. A GDP’s lack of experience in performing biopsies could be attributed to insufficient importance placed on the practical teaching of biopsy techniques during their undergraduate training. Wan and Savage et al (2010) found that over 50% of practitioners reported only being taught theoretical knowledge of biopsy procedures and diagnostic histopathology during undergraduate training, without having received any practical experience in these two areas. This lack of training in biopsy procedures was also shown in the study by Diamanti et al (2002), in which 39% of GDPs surveyed reported never being taught biopsy techniques. Therefore, GDPs who had been taught how to biopsy or had actually performed a biopsy during their undergraduate studies were more likely to undertake biopsy procedures in general practice (Diamanti et al, 2002; Seoane et al, 2004; Wan and Savage, 2010; Murgod et al, 2011). Further, about 60.2% of the practitioners were aware of all different biopsy methods. Of the 11.3% of GDPs who performed biopsies on their own, 53.7% used the excisional biopsy technique in their clinic while only 0.3% performed brush biopsies. Performing simple excisional biopsies in general practice provides the advantage of a reduced waiting time for the procedure and the results, as well as less travelling for the patient (Wan and Savage, 2010). However, excisional biopsies by GDPs done without oncological consideration of lesions suspected to be malignant could allow microscopic tumour remnants to remain in situ and cause destruction of the margins of the lesion, thus making re-excision and possibly neck treatment mandatory. On the other hand, incisional biopsies of lesions
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suspected of malignancy represent a more realistic approach for GDPs, but incisional biopsies at times may lead to underdiagnosis due to sampling errors (Seoane-Lestón et al, 2010). Hence, when considering the type of biopsy required for a particular case, the GDPs should be better informed about biopsy techniques, their indications as well as contraindications. The study also revealed that 46.3% of dentists sent the specimens for examination and histological analysis only given suspected premalignancy or malignancy and then not always. This transforms the procedure from an investigational to a final treatment protocol and misses the opportunity to obtain additional supportive information from the procedure. Moreover, those GDPs who perform excisional biopsy for clinically obvious lesions do not consider it necessary to send the tissue for histopathological analysis, even though routine histopathology of all soft tissues removed from a patient is indicated in order to obtain a definitive diagnosis of any presenting pathology, and to preclude any differential diagnosis. Pertaining to the preservation of the biopsy tissue specimen, 52.6% practitioners correctly knew that the tissue should be preserved in formalin, while 7.9% were completely unaware of preservation methods. Further, upon inquiring about the method of preservation used in their clinic, more than half of them (56.4%) unfortunately used saline as a fixative, which defeats the purpose, as saline has a negative impact on the tissues, a fact that is often ignored by the practiotioners. Moreover, it was again shocking to see that only 52.6% of GDPs used the correct concentration of formalin, i.e. 10%. The rest reported using concentrations of 40%, 30%, 20% and even 2%. Preservation of the tissue is an important facet in biopsy that is often disregarded by clinicians. If the tissue is not preserved properly, it produces artefacts which prevent the pathologist from giving an appropriate diagnosis, thus possibly inducing the clinician to take another biopsy, which further increases the trauma to the patient. Also, if the GDPs are willing to perform a biopsy and are short of formalin in their clinics, they should plan the procedure accordingly and request the pathological laboratory or higher centre to deliver formalin (Murgod et al, 2011). Finally, all the GDPs felt the need to update their knowledge on oral screening and biopsy procedures. 97.3% of them actually did so through various
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sources, such as journals, internet, conferences and discussion with their peers, which demonstrates their interest in the well-being of their patients. The limitation of the present questionnaire survey is that the reported responses may not match actual clinical practice. The tendency of practitioners to provide socially acceptable answers would usually bias against variability in reported practices, resulting in underestimations. This precludes extrapolation of the findings to the global population of dental professionals. Given the level of inconsistencies between the dentists’ oral cancer awareness and practice behaviours, it is apparent that further study is needed to understand the barriers they experience to implement this knowledge.
CONCLUSION Most of the general dental practitioners had knowledge of oral cancer screening and biopsy procedures, but many felt reluctant to perform them due to inadequate experience and skills. Relevant continuing dental education programmes/training on the management of suspicious oral lesions are recommended.
ACKNOWLEDGEMENTS We would like to thank all the faculty members in the Department of Oral and Maxillofacial Pathology for their general support.
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