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This study aimed to investigate the possible factors affecting dentists’ behavior relating to performing oral cancer examinations as part of routine clinical examination. A total of 95 direct clinical observation sessions—utilizing an instrument consisting of 19 evidence-based observational criteria for oral cancer examinations—were observed by four calibrated dentists. Thirty-two final- year students, 32 interns, and 31 faculty members of Jazan Dental School were examined between April 9 and May 4, 2017. A descriptive analysis was conducted to investigate the frequencies/percentages of the performed observing criteria by all exam- iners. ANOVA and Tukey tests were carried out to investigate the difference between the examiner groups. A total number of 32 patients participated in the study, whereby each patient was examined by three different examiners from each group, as well as by the attending observer/s. Fewer than 50% of the examiners performed the clinical steps necessary for an oral cancer examination—for example, taking into account past medical history, as well as extra and intra-oral examinations. More than 90% of the examiners examined hard tissue, whereas fewer than 30% of them educated their patients about possible risk factors. A significant difference between examiner groups was found in favor of faculty members. A gap between knowledge and actual practice of oral cancer examinations was evident: majority of participants failed to perform the necessary steps for an oral cancer examination. Previous experience and confidence in performing oral cancer examination are possible explanations for the dentist’s behavior toward oral cancer examination. . . . . . . Keywords Early detection Oral cancer Behavior Clinical practice Determinants Oral cancer screening Patient education Introduction carcinoma—is among the most frequently occurring cancers in terms of incidence rates. Most reported cases came from the Global incidences of oral cancer are still rising, with South Jazan region of Saudi Arabia [2, 3]. Several possible factors Asian countries having the highest incidence rates . In could put people at a significantly higher risk of contracting Saudi Arabia, oral cancer—mainly squamous cell oral cancer: using tobacco, in particular the smokeless form of it, and heavy alcohol usage [4–7]. Evidence on systematic disease association with oral cancer is not yet conclusive, ex- * Mohammed Jafer cept for diabetes, autoimmune diseases, and a few separate firstname.lastname@example.org syndromes [8–10] .Evidence showed a weak association be- tween dermatological conditions and oral cancer; neverthe- Department of Preventive Dental Science, College of Dentistry, less, it commonly manifests itself among patients with derma- Jazan University, Jazan, Saudi Arabia tological diseases . Furthermore, the risk of oral cancer Department of Health Promotion, Maastricht University/CAPHRI, increases tremendously when a first-degree relative has a his- P.O. Box 616, 6200 MD Maastricht, The Netherlands tory of oral cancer [18, 19]. Department of Maxillofacial Surgery and Diagnostic Sciences, Most oral cancer cases are detected at a late stage when the College of Dentistry, Jazan University, Jazan, Saudi Arabia tumor has already metastasized to another location in the body Department of Oral Medicine, Infection, and Immunity, Harvard . Several studies endorse the fact that the early detection of School of Dental Medicine, Harvard University, Cambridge, USA oral cancer leads to a better prognosis for the disease and Dental Division, Ministry of Health, Jazan, Saudi Arabia better survival rates, and this can be achieved through routine dental clinical examinations [21–24]. An insufficient Jazan University, Jazan, Saudi Arabia 1 3 J Canc Educ (2022) 37:932–941 933 examination contributes to a delay in the detection of oral later those who accepted received an explanation of the study cancer, which hampers the prognosis of the disease and great- and related aspects in the same aforementioned process for ly affects the 5-year survival rate of oral cancer patients . interns. Four faculty members (dentists) from JDS were the Factors that might influence dentists’ behavior in terms of observers in the dental examination sessions, three of whom practicing routine oral cancer examinations are not fully un- are also authors of this study, with one acting as the main derstood . Possible determinants of the dentists’ behavior observer. The rule for the observer was to observe the exam- can be abstracted individually from a previously published iner’s practice and to subsequently mark the performed action work—for example, dentists’ knowledge , awareness in regard to the checklist items. , perceptions , experience , limited clinical exam- To ensure the study was conducted as a form of routine ination time , and focusing on previously examined con- dental examination at JDS clinics, it was decided that all the ditions . Moreover, some dentists reported that they did study’s clinical examinations would be conducted on new not perform oral cancer examinations because they were wor- dental patients from the waiting list of JDS clinics. To com- ried about their patients’ reactions toward oral cancer exami- pare between the three different groups of clinicians, dental nations . Therefore, the present study investigates possible students, interns, and faculty members, it was decided that explanations for dentists’ behavior by directly observing rou- each patient would be examined by a dental student, intern, tine clinical dental examination sessions. and a faculty member, as well as an observer. Therefore, to reach the target number of 32 new patients who are willing to participate and be examined by three clinicians and available Methods observer/s, around 93 patients were contacted and invited over the phone by the principal investigator from the JDS clinics’ The present study was performed according to the ethical patient relation office. This process was repeated later to invite standards of the institutional research committee, as well as nine more new patients to replace the five patients who did not the 1964 Helsinki Declaration. It received ethical approval show up to their appointment and four patients who refused to from Jazan University (registry no. [CDREC-06]), dated 21 be examined by all three examiners. December 2016. All participants have consented prior to their An instrument for the observation of oral cancer screening participation, including with regard to the publication of the practice in form of checklist was developed and was based on findings. The reporting of this present study followed the the current available evidence relating to the recommended STROBE guidelines for reporting cross-sectional studies . practice of oral cancer screening. The observation instrument The present study utilized a descriptive cross-sectional included the most appropriate clinical steps to be taken during study design, in which direct clinical observation was carried comprehensive clinical examinations of dental patients [35, 36], as well as the risk factors of oral cancer [37–39]. At first, out among final-year dental students, interns, and faculty members between April 9, 2017, and May 4, 2017. The main the instrument consisted of 32 items in the form of a checklist, targets of this study were the dental interns who are the first with two labeled boxes for the options “done” and “not done.” line of treatment in JDS clinics and who oversee the comple- However, 15 items (11 to 25) were condensed to 6 items (11 to tion of the primary dental charts of all new patients. The total 16) after reaching a consensus from four oral cancer consul- number of interns was 40 at the time of planning this study. A tants, who evaluated the proposed observational instrument, to personal invitation was sent to all the interns and an explana- be able to fully reflect on the examiners’ performance of the tion of the study process was delivered to them in the form of targeted screening steps. Both checklists are available at two discussion sessions by the principal investigator (PI). To <https://osf.io/4v9gr/>. Therefore, the utilized observational minimize effects on the behavior of clinicians under observa- instrument in the present study finally consisted of a 19-item tion in dental examination sessions, the study and its process checklist, with the first 17 items relating to the essential steps were explained to the participants without mentioning that the of routine oral cancer screening, and the last two items were study would focus on the dental examinations and, in partic- for when further diagnostic/evaluation step(s) were re- ular, oral cancer screening performance and the required re- quired. Items 1–10 related to reporting the patient’sgen- lated steps as a follow-up. We aimed to reduce the Hawthorne eral health, family history of cancer, habits, and diet. effect  (i.e., when the observer influences the examiners’ Items 11–16 related to the performance by the examiner behavior) by notifying the observers to remain unreactive of different steps for the head, neck, and oral examination. while observing the sessions and to remain passive. All 32 Item 17 was for obtaining a plain radiograph, and items interns who accepted the invitation to participate were in- 18 and 19 were for conditions when the further evaluation formed later of their scheduled appointment to examine a pa- was necessary to diagnose potential positive oral cancer tient in a designated clinic that was booked for the study. cases. Each item was given a weight of one, two, or three, Afterwards, final-year dental students and Arabic-speaking based on the degree of significance and relevance as sup- ported by current evidence [4–19, faculty members were invited to participate in the study, and 39–53], with one 1 3 934 J Canc Educ (2022) 37:932–941 standing for items of the least significance and three for designated weight and supportive evidence.) The sum of items of the most significance. (Please see Table 1 for the performed item weights from the checklist was used as more detailed information on each of the items with the the main outcome of the study. Table 1 Justification table for the selected items in the instrument No. Observing criteria Weight Justification Reference 1 Systemic diseases 1 Evidence on systematic disease association with oral [8–10] cancer is not yet conclusive, except for diabetes, autoimmune diseases and a few syndromes 2 Infectious Diseases (HPV, HIV, HBC, etc.) 1 Their association with oral cancer is a foregone [11–16] conclusion. It is given a weighting score of one, as these infectious diseases are less prevalent in the Jazan region 3 Dermatologic conditions 1 Evidence showed weak association with oral cancer  but is a common manifestation among patients with dermatological diseases 4 Medication (immunosuppressive, 1 Evidence on its association with oral cancer is scarce  anti-inflammatory antihypertensive, and steroids delivered in inhaler/ topical/oral form) 5 Previous family cancer history (type and 1 The risk of oral cancer is increased tremendously [18, 19] associated treatment) when a first-degree relative has a history of oral cancer 6 Tobacco smoking (frequency and duration) 3 Smoking Tobacco, Smokeless Tobacco, and drinking [24–27] 7 Smokeless tobacco (habit type, frequency, 3 Alcohol are well-known major risk factors for and duration) oral cancer. However, Alcohol was given two as it 8 Alcohol (frequency and duration) 3 is illegal in Saudi Arabia and is not common in the region 9 Diet (antioxidant, minerals, etc.) 2 Although a substantial body of evidence demonstrated [6, 28–31] its role in preventing oral cancer e.g. vitamin A (retinol), E (α-tocopherol); and carotenoids (β-carotene), diet is a loose term and cannot be retrieved very well while reporting patient history 10 Oral hygiene (heavy bacterial load, acetaldehyde 1 Few studies reported an increased risk of oral cancer [33–36] production) with poor oral health. However, these studies carry many confounding factors that affect its strength 11 Palpate for enlarged lymph nodes of the neck 3 Almost all oral squamous cell carcinomas are preceded [37–39, 42] 12 Examining upper and lower lip mucosa and 3 by visible mucosal changes, such as white, red, or buccal mucosa mixed patches, lymph nodes tenderness, palpation 13 Examining the lateral and ventral of the tongue 3 of abnormal mucosal findings on the lip; cheek; (white and red patches) and tongue lumps lateral, dorsal and ventral surfaces of the tongue; (feeling the tongue lumps) palate; floor of the mouth and teeth and their 14 Examining the palate 3 supporting structures are essential steps in oral cancer screening. These steps facilitate early 15 Examining the floor of the mouth 3 detection of the disease and improve the 16 Examining dentitions and supportive structure 3 treatment and survival rate. Unfortunately, these structures are skipped during head and neck examinations by most of dental practitioners 17 Obtaining plain radiographs 1 Obtaining a radiograph is given a weighting of one [43, 44] as it is not recommended by the previous studies in the context of epithelial tumors. However, it may be useful in demonstrating the extent of cortical bone invasion in large tumors [40, 41] *18 Additional diagnostic tests relevant to the 3 A biopsy is a must for any abnormality with features evaluation (biopsy, other devices for diagnosis) of potential malignancy or when it does and consulting specialist/s not respond to two-week treatment protocols. *19 Advice/s on oral cancer risk factors 3 Referring a suspicious case to a specialist for further evaluation and confirmation is a must, as well. As these two items are not done routinely, they are used as extra items in case the initial screening reveals (a) suspicious lesion(s) *If needed 1 3 J Canc Educ (2022) 37:932–941 935 Prior to the initiation of the present study, a thorough discus- dental students, interns, and faculty members). The total num- sion session including observers and the PI was conducted to ber of participating patients was 32, with ages ranging be- acquaint all with the observational instrument and the logistics tween19and 70 yearsold andwith62.5% males (see of the study. Afterwards, two hands-on clinical training ses- Table 2). sions were provided with two volunteers, who acted as the Table 3 shows the frequency of the observed items by the patient and the examiner to facilitate the training sessions. main observer; 70% of examiners investigated the systemic This was also to provide the observers with experience in han- diseases of their patients, while fewer than 30% of examiners dling the checklist while also carefully observing the examiner investigated their patients’ tobacco use and their oral hygiene performing the clinical examination as well as patients’ re- practices. Moreover, 90% of the examiners checked their pa- sponses. A feedback discussion session for observers, which tients’ dentations, while fewer than 50% of them examined included the PI, was conducted after the two training sessions their patients for enlarged lymph nodes of the neck, lip, check, to reflect on the experience, as well as to discuss and reach a tongue, palate, and floor of the mouth. Furthermore, among consensus regarding the appropriate approach for handling the the participating patients, three had suspected lesions that re- observational sessions and checklist. Then, for the internal va- quired further investigation, and 14 required advice regarding lidity testing of the observational instrument, eight dental ex- oral cancer risk factors, according to the main observer. amination sessions—which included eight volunteer patients However, among participating examiners, only three female and eight volunteer dentists—were overseen by all observers, final-year dental students out of nine examiners had requested whereby interrater reliability was investigated using an inter- specialist consultations, as well as only 11 examiners out of 42 class correlation coefficient test that showed significant consis- providing advice to the patients who needed it (see Table 3). tency (p < .000). Prior to the present study’s dental examination There were statistically significant correlations between the sessions, each participating patient was first examined by the main observer and other observers, with the strongest correla- observer/s who then observed the clinicians’ dental examina- tion (r = .807) between the main observer and the second ob- tion sessions. All 95 dental examination sessions were observed server (see Table 4). Moreover, no statistically significant dif- by the main observer and mentored by the PI. In addition, 18 of ferences were found between the main observer and other these sessions were observed by all the observers, while others observers (second observer p = .571 and fourth observer were overseen by two or three observers (see Table 4). p = .062), except for the third observer (p = .018); see Descriptive analyses were run to investigate the participants’ Table 4. Furthermore, there were no statistically significant demographics, as well as the frequency of the individual perfor- differences between all 95 examiners based on their sex. mance items in the observational checklist by the main observer. Furthermore, paired t tests and correlation tests were run to in- vestigate any relationships between the main observer’sfindings Table 2 Demographics of Participants and other observers’ findings. Later, using total score by the main *n Frequency % M SD observer and mean total score by all observers, independent t tests were run to investigate any differences between examiners’ Examiner 95 gendersaswellaspatients’ gender. Similarly, ANOVA tests Sex were run to investigate any differences between examiners’ oc- Male 48 50.5 cupations (final-year dental students, interns, and faculty Student 16 33.3 members) with Tukey’s HDS comparison between each occupa- Intern 16 33.3 tion category. Additionally, Pearson’s correlations were run to Faculty member 16 33.3 investigate any correlation between patient age and total score by Female 47 49.5 the main observer and mean total score by all observers. A qual- Student 16 34 itative approach was utilized to perform post-exam investigations Intern 16 34 in the form of two focus group discussions (FGDs) with the Faculty member 15 31.9 participants of the current observation study. The FGDs aimed Patients ** 32 to explore the possible factors explaining the observed findings. Age 38.6 14.4 The 95 participants in the cross-sectional study were invited to (Range: 19–70) participate in the follow-up discussions by direct contact. Sex Male 20 62.5 Female 12 37.5 Results *Number of participating examiners, as observed by the main observer The total number of participating examiners was 95, with an **Number of participating patients; however, 95 was the total number of clinical dental examinations, as observed by the main observer almost equal distribution of gender and occupation (final-year 1 3 936 J Canc Educ (2022) 37:932–941 Table 3 Descriptive findings **W 43 No. ***Observing items Frequency of performed item Total in % Total Student Intern Faculty M/ F/ M/ F/ M/ F/ 16 16 16 16 16 15 1 1 Systemic diseases 68 8 12 12 12 11 13 71.6 1 2 Infectious diseases (HPV, HIV, HBC, etc.) 8 0 1 0 2 5 0 8.4 1 3 Dermatologic conditions 2 0 0 0 0 1 1 2.1 1 4 Medication (immunosuppressive, anti-inflammatory 34 46 56 67 35.8 antihypertensive, and steroids delivered in inhaler/ topical/oral form) 3 5 Previous family cancer history (type and associated treatment) 5 1 2 0 0 1 1 5.3 3 6 Tobacco smoking (frequency and duration) 18 2 4 1 3 5 3 18.9 3 7 Smokeless tobacco (habit type, frequency, and duration) 26 4 8 1 3 8 2 27.4 2 8 Alcohol (frequency and duration) 2 0 0 0 0 2 0 2.1 2 9 Diet (antioxidant, minerals, etc.) 7 0 1 0 1 4 1 7.4 1 10 Oral hygiene (heavy bacterial load, acetaldehyde production) 18 5 1 0 2 6 4 18.9 3 11 Palpate for enlarged lymph nodes of the neck 32 78 04 76 33.7 3 12 Examining lips and cheek 46 10 8 5 5 9 9 48.4 3 13 Examining the sides and underside of the tongue 41 88 56 410 43.2 (white and red patches) and tongue lumps (Feeling the tongue lumps) 3 14 Examining the palate 14 12 21 44 14.7 3 15 Examining the floor of the mouth 22 23 41 66 23.2 3 16 Examining dentitions and supportive structure 86 15 13 14 14 16 14 90.5 1 17 Obtaining radiographs 20 3 3 5 5 2 2 21.1 3 *18 Additional diagnostic tests relevant to the evaluation 3/9 0 30 00 0 33.3 (biopsy, other devices for diagnosis) and consulting specialist/s if needed 3 *19 Advice on oral cancer risk factors if needed 11/42 0 6 0 1 3 1 26.2 *If needed **Items weight ***As completed by the main observer Table 4 Paired t tests and correlation tests between observers (N =95*) 2nd observer 3rd observer 4th observer Main observer n =29 n =38 n =18 1 M =34.9, SD = 21 1 M =34.2, SD =20.3 1 M = 33.5, SD = 22 3 M = 36.3, SD = 20.4 2 M =28, SD =15 4 M = 25.2, SD = 13 M = − 1.4, SD = 12.9 M = 6.3, SD = 15.5 M = 8.3, SD = 17.6 95% CI for difference [− 6.28–3.53] 95% CI for difference [1.14–11.36] 95% CI for difference [− 0.48–17.07] t (28) = − 0.574 t (37) = 2.48 t (17) = 1.994 p =.571 p =.018 p =.062 d =0.034 d =0.175 d =0.156 r =.807 r =.648 r = .584 p = .000 p =.000 p =.011 *Number of clinical dental examination sessions, as observed by the main observer 1 3 J Canc Educ (2022) 37:932–941 937 Table 5 Independent t tests and ANOVA tests for examiners (N =95*) * Sex ° Sex * Occupation ° Occupation Total score ♂M = 29.8, SD = 20.3 ♂M = 28.2, SD = 17.2 F =4.944 F =4.081 ♀M = 30, SD = 14.8 ♀M = 29.8, SD = 14 p = .009 p =.020 2 2 η =0.097 η =0.081 p p 95% CI for difference [− 7.47–7.03] 95% CI for difference [− 8.02–4.74] t (86) = − 0.061 t (93) = − 0.510 p =.952 p =.611 d =0.005 d =0.051 *Number of participated examiners as observed by the main observer °Using mean total scores by all observers However, there was a statistically significant difference based Majority of participants thought it is not important to ask on the examiners’ occupation (see Table 5). The statistically patients about items 3 and 9 (dermatologic conditions and significant difference was found between faculty members diet) as they assumed it has no clear relationship with their and interns, using both the total score by the main observer patients’ oral health. Participants linked the cultural and reli- and the total mean score by all observers (p = .007 and gious unacceptability of alcohol use to the observed low score p = .031, respectively) (see Table 6). On the other hand, there in item 8 (alcohol). For items 6, 7, and 19 (tobacco smoking, were no statistically significant differences found between ex- smokeless tobacco, and advice on oral cancer risk factors), aminers based on the patients’ age or sex (see Table 7). female students and interns had higher scores than their coun- A total number of 23 participants have accepted to partic- terpart. The participants mentioned that female students/ ipate in the two follow-up FGDs. The two FGDs revealed a interns are more vigilant to the oral changes associated with number of factors that are possibly associated with the ob- tobacco as they are used to examine mainly female patients served items’ scores. The majority of the 23 participants stated who are usually non-smokers. Moreover, female participants that the presence of questions related to items 1, 4, 12, and 16 mentioned that the tobacco advice they had given to the pa- in the JDS clinical charts made them used to do it. tients was based on their personal beliefs, as they did not Dependence on previous dental examination is a factor that receive formal training on tobacco counseling. In relation to was elicited by the majority of the participants to be generally item 17 (obtaining radiograph), participants denoted the rea- related to the low-score items in the checklist. Another factor son for obtaining radiograph is related to the chief complaint that reached agreement by all participants is the lack of con- only. Dental interns revealed that two factors could be related fidence to identify oral precancerous/cancerous lesion, to pro- to their general low score in comparison to students and fac- vide tailored risk factor education or to provide tobacco ulty members. The first one was because they rely on the other counseling as they lacked formal training on these skills. dentists whom the patient will be referred to do the next oral Table 6 ANOVA comparisons of Group Mean difference Tukey’sHSD 95% confidence interval examiners (N =95*) comparisons (p values) Student Intern Intern Main observer − 8.48 − 18.63–1.65 All observers − 8.88 − 17.88–0.11 Faculty member Main observer 4.82 − 5.40–15.04 All observers 0.91 − 8.15–9.98 Faculty member Main observer 13.31 3.08–23.53 All observers 9.80 0.73–18.87 p value <.05 1 3 938 J Canc Educ (2022) 37:932–941 Table 7 Independent t tests and Person correlation tests for examiners based on patients (P) (N =95*) * P sex ° P sex * P age ° P age Total score ♂M =31.5, SD =17.7 ♂M = 30.1, SD = 14.3 r = .076, p =.461 r =.062, p = .551 ♀M =27.3, SD =17.5 ♀M = 27.2, SD = 17.5 95% CI for difference [− 3.28–11.59] 95% CI for difference [− 3.66–9.45] t (93) = 1.110 t (93) = 0.877 p = .270 p =.383 d = 0.119 d =0.091 *The number of participating patients was 32; however, 95 was the total number of clinical dental examinations, as observed by the main observer °Using mean total scores by all observers care/treatment. While the second factor was because they can- The knowledge of oral cancer among dentists has been investigated thoroughly in previous studies and postulated to not perform full oral screening on each patient as they have a busy clinical schedule with large number of patients. be related to dentists’ practice of oral cancer examinations [27–29, 55]. However, knowledge (or lack thereof) alone is not enough to explain, for example, why dentists are not performing oral cancer examinations in their routine practice. Discussion According to behavior-change theories, such as the Reasoned Action Approach, the Social Cognitive Theory and the I- The present study investigated possible explanations for den- Change Model, knowledge only has a distal influence on the tists’ behavior by means of direct observations of routine den- individual’s behavior and its effect is often limited when try- tal clinical examination sessions. The interns in this study ing to explain complex behaviors; such as in our case: den- were recruited from the same group that were evaluated in tists’ practice of oral cancer examinations [56–58]. This is in two recent studies that included students, interns, and faculty line with the findings of this study, as most participants failed members for their knowledge, attitude, self-efficacy, and opin- to perform oral cancer examinations even though they had ions regarding oral cancer practice [32, 54], in which oral adequate knowledge of oral cancer [54, 59, 60]. This obser- cancer knowledge of dental interns was found to be adequate vation has highlighted the important role of dentists having . In addition, favorable perceptions among dentists toward actual control over their practice of oral cancer examination. oral cancer practices were found regardless of the reaction of Dentists have actual control over their practice of oral can- patients . However, the experience and the confidence to cer examinations when they demonstrate their ability to per- perform oral cancer examinations and educate patients on risk form the following essential sub-behaviors: extra- and intra- factors was found to be limited to dentists specialized in fields oral screening skills, obtaining radiographs, taking a biopsy, related to oral cancer . The factors relating to time con- writing referral reports, specialist consultations, communicat- straints and previously examined conditions were controlled ing with or counseling patients (e.g., smokeless tobacco for in this study, as no time restriction was placed on dental users), specifying an oral cancer provisional treatment plan examination sessions and all were carried on new patients. (treatment modalities, outcome), and referring suspicious The overall findings of the study indicated that the examiners cases to specialized centers (Table 1). Additionally, the lack performed the clinical steps with which they had more expe- of these basic sub-behaviors can adversely affect dentists’ rience and higher confidence, in terms of performing and un- practice of oral cancer examination, either directly or indirect- derstanding the potential treatment modalities and outcomes. ly via self-efficacy. As described in the Social Cognitive The majority of them examined the dentations of their patients Theory by Albert Bandura, an individual’s confidence in his and asked for patients’ systemic diseases, which could be capability to produce the desired effect through his actions necessary for their usual practice. However, fewer than half constitutes a core belief that operates via its impacts on various of the examiners performed other extra- and intra-oral exam- processes—both cognitive and affective . Among the four ination steps and less than one-third of them investigated their main sources that enhance self-efficacy, the individual’sex- patients’ potential risk factors for oral cancer. This is also perience (mastery and vicarious/modeling) is recognized as supported by the statistically significant difference favoring creating and strengthening a stronger sense of self-efficacy. the faculty members’ group, as they have a higher level of This suggests that a dentist’s efficacy can be influenced by his experience and are confident in performing oral cancer own experience in practicing oral cancer examinations. In examinations. addition, observing other dentists succeeding at practicing oral 1 3 J Canc Educ (2022) 37:932–941 939 cancer examinations is able to reinforce the observing den- Compliance with Ethical Standards tist’s belief in his own capability to master comparable actions Ethics Approval and Consent to Participate All procedures performed required to succeed. Hence, dentists’ practice of oral cancer in the present study were in accordance with the ethical standards of the examinations could be greatly influenced by their previous institutional research committee and with the 1964 Helsinki declaration. experience and confidence in their ability to perform oral can- Prior to conducting the present study, ethical approval was acquired from cer examinations [56, 57]. Jazan University (registry no. [CDREC-06]), dated 21 December 2016. All participants were informed of recording the FGDs and have provided Direct clinical observation methods strengthen this written consent prior to their participation including the publication of the study by capturing the clinical steps that dentists may or findings. may not have performed, which leads to a better under- standing of the behavior’s potential causes. Due to the Consent for Publication All participants have consented to the publica- cross-sectional nature of this study, the findings need to tion of the study findings. be tested through experimental study design, in order to Conflict of Interest The authors declare that they have no conflict of measure the effect of experience, skills, and self-efficacy interest. on dentists’ behavior. Furthermore, having a main observ- er present, who observed all dental clinical examination Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adap- sessions, added to the reliability of the comparison be- tation, distribution and reproduction in any medium or format, as long as tween different examiners. Similarly, having four observers you give appropriate credit to the original author(s) and the source, pro- to compare findings with added to the internal validity of vide a link to the Creative Commons licence, and indicate if changes were this study. Moreover, the observational instrument that made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a was developed for the study had not been tested in previ- credit line to the material. If material is not included in the article's ous independent work. However, the findings of this study Creative Commons licence and your intended use is not permitted by indicated that the developed instrument had the capacity to statutory regulation or exceeds the permitted use, you will need to obtain investigate oral cancer examinations as part of routine permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. dental clinical examinations. All observers had strong sta- tistical correlations, with no statistical difference being found between the three of them. To conclude, the present study has shed light on the References gap that existed between knowledge and actual practice of oral cancer examinations by dentists. The practice of oral 1. Warnakulasuriya S (2009) Global epidemiology of oral and oro- cancer examinations is a complex behavior that is influ- pharyngeal cancer. Oral Oncol 45(4–5):309–316. https://doi.org/ enced by multiple factors: oral cancer knowledge, percep- 10.1016/j.OralOncol.2008.06.002 tions, experience, self-efficacy, actual control, and other 2. Saudi Cancer Registry. Saudi Arabia cancer incidence report 2012 [document on the Internet]. Riyadh, Saudi Arabia: Saudi Cancer external factors such as the afforded clinic time per pa- Registry; 2015 [cited 2018 Apr 1]. 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Journal of Cancer Education – Springer Journals
Published: Aug 1, 2022
Keywords: Early detection; Oral cancer; Behavior; Clinical practice; Determinants; Oral cancer screening; Patient education
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