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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 100-105

Knowledge, awareness, and practices in relation to potentially malignant disorders of the oral cavity in a rural area of Western Maharashtra, India


1 Department of Oral Pathology and Microbiology, Dr. Hedgewar Smruti Rugna Seva Mandal's Dental College, Hingoli, Maharashtra, India
2 Department of Oral Pathology and Microbiology, PIMS, Rural Dental College, Loni, Maharashtra, India
3 Department of Oral Pathology and Microbiology, Vasantdada Patil Dental College, Sangali, Maharashtra, India

Date of Submission06-Dec-2019
Date of Acceptance07-Jan-2020
Date of Web Publication3-Feb-2020

Correspondence Address:
Dr. Kshipra Chandrakant Deshpande
Department of Oral Pathology and Microbiology, Dr. Hedgewar Smruti Rugna Seva Mandal's Dental College and Hospital, Basamba Phata, Akola Road, Hingoli - 431 513, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmd.ijmd_58_19

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  Abstract 


Background: It has been well established by researchers that virtually all oral cancers are preceded by visible clinical changes in the oral mucosa mostly in the form of white or red patch. The prevention and early detection of such potentially malignant disorders (PMDs) have the potential of not only decreasing the incidence but also in improving the survival of those who develop oral cancer. The lack of knowledge and awareness of public about the signs, symptoms, and risk factors is responsible for the diagnostic delay in identifying the PMDs. This study aimed to evaluate the knowledge, awareness, and practices in relation to the early detection of PMDs.
Materials and Methods: It was a cross-sectional, community-based survey where 600 participants were enrolled in the study. A semi-structured preset, pretested questionnaire was used to elicit information about tobacco-associated oral habits, their knowledge and awareness toward PMDs, and to elicit information regarding practices in relation to these deleterious oral effects. The results obtained were statistically analyzed using the SPSS (version 11) software and Chi-square test.
Results: This study showed that there is a lack of knowledge and awareness about the early signs and common symptoms of PMDs. The level of knowledge and awareness was directly proportional to the education level, whereas it was inversely proportional to the prevalence of risk habit.
Conclusion: Lack of knowledge and awareness of early signs of oral cancer and oral PMDs was observed in studied population. As their general awareness about oral cancer and oral PMDs was good, a redirection of focus is warranted toward implementing intensive oral health education programs for the recognition of risk habits, warning signs of PMDs, and early detection of oral cancer.

Keywords: Awareness; knowledge; oral cancer; potentially malignant disorders; tobacco


How to cite this article:
Deshpande KC, Parakh S, Jadhav K. Knowledge, awareness, and practices in relation to potentially malignant disorders of the oral cavity in a rural area of Western Maharashtra, India. Indian J Multidiscip Dent 2019;9:100-5

How to cite this URL:
Deshpande KC, Parakh S, Jadhav K. Knowledge, awareness, and practices in relation to potentially malignant disorders of the oral cavity in a rural area of Western Maharashtra, India. Indian J Multidiscip Dent [serial online] 2019 [cited 2020 Sep 18];9:100-5. Available from: http://www.ijmdent.com/text.asp?2019/9/2/100/277456




  Introduction Top


Squamous cell carcinoma accounts for 95% of oral cancers and is associated with avoidable etiological risk factors. Tobacco (in smoking and smokeless forms) and alcohol use are the main risk factors of oral cancers.[1] Be it in the form of Gutka, quid, snuff or misri, and so on, tobacco when kept in mouth leaches out carcinogens, which act on the mucosa causing precancerous lesions, which lead to cancer. Compared with most sites, the oral cavity is readily accessible to examination. Thus, oral cancer should be amenable to early detection and treatment at the premalignant or early malignant phase.[2]

A wide array of conditions have been implicated in the development of oral cancer, including leukoplakia, erythroplakia, erythroleukoplakia, palatal lesion of reverse cigarette smoking, oral lichen planus, and oral submucous fibrosis.[3] It has been well established by researchers that virtually all oral cancers are preceded by visible clinical changes in the oral mucosa usually in the form of white or red patch (two-step process of cancer development). The prevention and early detection of such potentially malignant disorders (PMDs) have the potential of not only decreasing the incidence but also in improving the survival of those who develop oral cancer. Lack of public awareness about the signs, symptoms, and risk factors, along with the absence of knowledge are believed to be responsible for the diagnostic delay in identifying the PMDs.[4]

The purpose of this study was to evaluate the knowledge, awareness, and practices in relation to PMDs of the oral cavity in a rural area of Western Maharashtra, India.


  Materials and Methods Top


The present study was a cross-sectional, community based, and it was conducted in the rural population of Loni (Maharashtra) with the objectives to evaluate the knowledge, awareness, and practices of oral PMDs and risk factors for developing these disorders and to educate them about the hazards of tobacco and motivate them to quit the habit. This study was conducted among a sample size of 600 individuals above 16 years of age with a simple random sampling method. The instruments for collecting the data required for the study were a semistructured preset, pretested questionnaire. The questionnaire was pretested on a convenience sample of 30 participants. The questionnaire was then modified based upon responses, and the survey format was finalized. The questionnaire was organized into two sections:

  • Section A elicits information on demographic attributes of respondents (name, age, gender, education level, profession, address, and socioeconomic status)
  • Section B consists of questions related to tobacco-associated oral habits, mode of consumption, duration, frequency, and time of initiation of habit
  • The questions related to elicit their knowledge and awareness toward PMDs of the oral cavity and oral cancer
  • The questions related to elicit the practices in relation to these deleterious oral effects of different forms of tobacco and associated oral habits
  • The questions related to the knowledge and awareness about health hazard warnings on the tobacco and tobacco-associated commercial products.


The questionnaire elicited a “yes” or “no” response. The response “no” was given a score of “0,” whereas the response “yes” was given a score of “1,” with the exception of few questions which were open type and few questions had options. The calculation of these questions was done on a proportional/percentage basis. This questionnaire was converted in a local dialect of Marathi for the survey purpose.

Inclusion criteria

Voluntarily participating individuals aged 16 years and above were included in the study.

Exclusion criteria

Individuals aged below 16 years and individuals voluntarily not participating were excluded from the study.

Informed consent of each voluntarily participating individual was obtained. The Institutional Ethical Committee Clearance from the Pravara Institute of Medical Sciences (Deemed University), Loni, Maharashtra, India, was obtained for the survey study.

Statistical analysis

The results obtained were tabulated and subjected to the statistical analysis using the SPSS (version 11) software (IBM Software Private Limited, Bangalore, India). This analysis was on proportional percentage basis, study variables being tobacco chewing forms, age of tobacco initiation, duration of tobacco chewing, daily frequency, knowledge and awareness regarding the signs of oral premalignant and malignant disorders, knowledge and awareness regarding health hazards of tobacco in relation to oral premalignancies and malignancies. The Chi-square test was employed to evaluate the statistical significance of the results.


  Results and Observations Top


The results were discussed under the following headings.

Demographics

A total of 600 respondents participated in this study. The sample comprised 567 (94.5%) males and 33 (5.5%) females. More than half of them were aged between 20 and 40 years old (54.17%), with a mean age of 40 years in males and 38 years in females. Most of them had at least primary level of education (265; 44.16%).

Prevalence of risk habits

[Table 1] depicts that out of 600 individuals, 428 were perusing the tobacco habit in one or another form. Nearly 50% of individuals had more than one habit, and it was highest in the younger age group. There was a significant association between the educational status and habit of the individuals [Table 2]. The more number of individuals with a primary level of education was involved in deleterious tobacco habits than the individuals with higher levels of education.
Table 1: Prevalence of risk habits among males and females

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Table 2: Education level and habit

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Overall response for knowledge and awareness

The results showed the high levels of knowledge about oral precancerous and cancerous disorders in both males and females among the studied population [Graph 1]. For the open-ended question, there was varied response, with maximum persons 333 (55.5%) were saying that tobacco and related habits will lead to “oral cancer” followed by 9.5% saying oral ulcers, and 1%–2% giving answers such as lung and liver cancers, other oral problems such as teeth staining and tooth loss.



One question from the set questionnaire was provided with four options, and all these options were the signs of PMDs affecting the oral cavity. We found that the maximum response 115 (19.17%) was for option “A,” i.e., white or red patch in the mouth, followed by 111 (18.5%) for option “C,” i.e., burning sensation of the mouth. From the collected data, we observed that the individuals giving option “B” (inability to open the mouth widely), 83 (13.67%) had areca nut/gutka-chewing habit. Only 14 (2.33%) persons had knowledge about all signs of PMDs affecting the oral cavity. This was the very significant finding from the present study; as individuals were less knowledgeable about the signs of PMDs, though the overall response rate was above 60% for the questions which were related to the knowledge about PMDs.

The overall knowledge [Graph 1] and awareness [Graph 2] of studied population about oral cancer and precancer was good. The level of knowledge and awareness was directly proportional to the level of education [Table 3] and [Table 4], and these findings showed that as the education level increases, the level of knowledge and awareness also increases.
Table 3: Education level and overall knowledge about oral cancer and potentially malignant disorders

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Table 4: Education level and overall awareness about oral cancer and potentially malignant disorders

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This study also showed that there was a highly significant difference of knowledge and awareness in various occupational groups.

The levels of knowledge and awareness about the practices of risk habits

The level of education was directly proportional to the risk habits in both males and females; it was found statistically highly significant [Table 5] and [Graph 3]. Although the individuals with higher levels of education had good knowledge and awareness, they were engaged in one or the other deleterious oral habits, and this is more dangerous regarding the general health matter of the community. There was a highly significant difference observed regarding overall risk habit practices when compared with the different occupational groups in the studied rural population.
Table 5: Education level and overall risk habit practices in studied population

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In the present study, majority of the habitants (199; 46.49%) were found to have initiated their habit before the age of 16 years, and 147 (34.34%) of the chewers were chewing tobacco as many as 4–5 times a day. Out of habituates, 241 (59.06%) had tried to quit the habit many times, 82 (20.09%) tried at least once, but 105 (24.53%) had never attempted to quit the habit. Most of them (282; 65.88%) gave the reason of “dependency” for not able to quit the habit.


  Discussion Top


Oral cancers are one of the leading cancers in India today, with an age standardized incidence rate of 12.6/100,000 population. It is one of the leading cancers in Indian males accounting for approximately 30% of the cancer burden.[5] Patients with early lesions have better chances for cure and less treatment-associated morbidity, yet despite the easy accessibility of the mouth, most patients present with advanced tumors when treatment is more difficult, more expensive, and less successful compared with earlier interventions. The most logical approach for decreasing morbidity and mortality associated with oral cancer is to increase the detection of suspicious oral premalignant lesions and oral malignancies at an early stage. If premalignant or potentially malignant lesions are identified early enough, malignant changes may be prevented altogether or at least the chances of success of the treatment at an early stage are more.[6]

A major factor in poor outcome for oral cancers is late presentation, due in part to lack of knowledge and awareness about oral cancers and precancers in the community; therefore, the present study was planned with the objectives to evaluate the knowledge, awareness, and practices of oral PMDs and of risk factors for developing these disorders and to educate them about the hazards of tobacco and motivate them to quit the habit. Literature review suggests a lack of adequate knowledge and awareness among dentists, dental hygienists, physicians, nurses, medical and dental graduates, and the public[7] in the studies conducted in European countries. In India, Keluskar and Kale,[8] Garg and Karjodkar,[6] and Shaila et al.[9] have conducted the cross-sectional studies to elicit the knowledge and awareness regarding oral cancer and precancer.

In the present study, the prevalence of smoking and smokeless tobacco was highest in the age group of 20–39 years. A similar range of findings were also reported by previous studies.[1],[6],[8],[10] Nearly 50% of individuals were perusing more than one habit, and it was highest in the younger age group, as the young generation is getting easily addicted to the newly marketed commercial smokeless tobacco products such as gutka, pan masala, and mawa. In the present study, majority of the habitants (46.49%) were found to have initiated their habit before the age of 16 years, and 34.34% of the chewers were chewing tobacco as many as 4–5 times a day. The exposure of the habit of tobacco use in adolescent was influenced by various factors such as peer pressure, friends, elders, boys trying to follow hero images, feel great and powerful when using tobacco, and for fun.[11] Habit initiation in early adolescence may contribute toward strengthening the addiction, which eventually could hamper quitting efforts.

In the present study, there was highly significant difference between the proportions of various habits in males as compared to females (P < 0.05). There was a significant association between educational status and habit of the individuals (value of χ2 = 5.43, df = 2, significant [P < 0.05]) [Table 2]. These results are in accordance with the findings of the cross-sectional studies conducted by Elango et al.[7] and Mishra et al.[12] in the rural areas of Kerala and Maharashtra, respectively.

The overall knowledge of the studied population about the oral cancer and PMDs and their risk factors was found to be high, and these findings concurred with that reported by Elango et al.[7] In previous studies,[2],[10],[13] it was observed that the respondents correctly identified tobacco, but only few identified alcohol as a risk factor. In the present study, 343 (57.18%) individuals had knowledge that alcohol as a risk factor for oral cancer. Only 241 (40.17%) of individuals had the habit of alcohol, and out of these, 58.31% were well aware that alcohol is one of the causative factors for oral cancer. These results are in accordance with the studies of Amarasinghe et al.[14] and Gajendra et al.[15]

The response rate was above 60% for all the questions related to the knowledge about PMDs. A similar range of response rate was found in the studies by Elango et al.,[7] Shaila et al.,[9] and Raute et al.[16]

In previous studies,[7],[16],[17] it was observed that the respondents identified the oral cancer as a consequence of tobacco use. In the present study, more than half of the population correctly identified oral cancer as the major consequence of tobacco use. As in this era of globalization, people are getting maximum exposures to recently developing trends, but the basic problem for motivation from the dreadful habits remains the same, and the nongovernmental organizations, government policies as well as professional workers need to work in this regard.

One question was optional, and all the options provided were one or the other signs of PMDs affecting the oral cavity and individuals with tobacco habits can make out these oral mucosal changes, and most of the times, the nature of these signs might be heard by the nonhabituates also. However, in the present study, merely 14 (2.33%) persons had knowledge about all the signs of oral PMDs. The maximum response 115 (19.17%) was for the option of “white or red patch in the mouth since long time.” Although the overall response rate for knowledge was good in the studied population regarding PMDs, they were not knowledgeable about the correct signs of PMDs.

The present study revealed that people are still not well aware about the early signs and symptoms of oral cancer and precancer. Up till now, no work has been carried out to exactly elicit the knowledge and awareness about these frequently encountered oral premalignant disorders. From the findings of the present study, it can be inference that the education strategies are the prime requisite to improve the knowledge about the common signs of oral PMDs through visual aids such as charts, pamphlets, and short documentaries. There were, however, certain misconceptions about oral cancer and precancer in this studied rural population. Nearly 63.5% believed that oral cancer and precancer is a contagious disease. About 29.12% believed that oral cancer is not a curable disease; these results are in accordance with those of Elango et al.[18] studied in Thiruvankulam, a semi-urban area of Ernakulam district in Kerala.

When the overall knowledge about oral cancer and oral PMDs was crosstabulated with variables such as education, occupation, gender, and risk habits, the results were highly significant, which is comparable with earlier studies.[7],[14],[15] The level of knowledge is directly proportional to the level of education. This finding is supported by previous studies by Ariyawardana and Vithanaarachchi[13] and Elango et al.,[7] which have documented that knowledge is directly proportional to the education level of respondents. The individuals with the primary level of education had less knowledge as compared to the high school and college levels of education. The strategies related about the knowledge of oral cancer and PMDs should be incorporated at the primary education levels, so that the persons who are not able to take higher levels of education will at least get information about the preventive strategies at earlier levels.

In comparison to the previously reported studies,[3],[8] the present study reports high awareness of oral cancer, precancer, and its risk factors, with a response rate more than 60%. From the present study, it was found that as the education level increases, the level of awareness also increases.

It was observed in the present study that the knowledge and awareness was directly proportional to the level of education and inversely proportional to the prevalence of risk factors. This is consistent with the studies conducted previously by Mishra et al.[12] in rural Maharashtra and Elango et al.[7] in the rural area of Kerala. A question was asked to assess the awareness of treatment options and outcomes related to oral PMDs, 86% mentioned that early detection would give a better treatment outcome. These findings are in accordance with the findings by Ariyawardana and Vithanaarachchi[13] survey done at the Dental Hospital in Sri Lanka.

In spite of having the high levels of knowledge and awareness, there is a significant lack of motivation; as the individuals were engaged in one or the other deleterious tobacco-related oral habits and maximum it was found in between the age group of 20 and 40 years. Out of habituates, 59.06% had tried to quit the habit many times, 20.09% tried at least once, but 24.53% had never attempted to quit the habit. Most of them (65.88%) gave the reason of “dependency” for not able to quit the habit. Particular steps such as psychosomatic interventions and psychological counseling should be carried out to understand and eliminate the psychological root of the problem.

As the present study was the baseline cross-sectional survey to elicit the knowledge and awareness regarding the oral malignant, PMDs and the risk habits related to these disorders. As any type of screening or self-mouth examination techniques were not included in the present study. Therefore, further studies required by implementing these strategies to motivate those who are practicing the various venomous oral habits despite having high knowledge and awareness about the signs of oral cancer and precancer.


  Conclusion Top


Oral cancer screening programs have the potential to raise awareness and educate the public about the disease. The present study was a grass-root level questionnaire-based survey to elicit the knowledge and awareness about oral cancer, oral PMDs, and related risk factors. Overall, a lack of in-depth knowledge and awareness of early signs of oral cancer and PMDs was observed in this population. As their general awareness about oral cancer and PMDs was good, a redirection of focus was warranted toward implementing intensive oral health education programs for the recognition of risk habits, warning signs of PMDs, and early detection of oral cancer.



The imperative findings from this study was that despite having overall good levels of knowledge and awareness about oral cancer and oral PMDs, people were drawn in one or the other high-risk habits and there was significant lack of motivation in people to give up the habits. These findings can be stepping stone for tobacco cessation centers which can target the rural population and help them to quit the habit and actually reduce the incidence of oral cancer.

Acknowledgment

The authors would like to thank the Indian Council of Medical Research for providing funds to carry out the survey work and PIMS Deemed University, Loni, Maharashtra, India, for their support as a source of material.

The research work attributed at the Rural Dental College, Pravara Institute of Medical Sciences (Deemed University), Loni (MS).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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George A, Sreenivasan BS, Sunil S, Varghese SS, Thomas J, Devi G, et al. Potentially malignant disorders of oral cavity. Oral Maxillofac Pathol J 2011;1:95-100.  Back to cited text no. 4
    
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Keluskar V, Kale A. Epidemiological study for evaluation of oral precancerous lesions conditions and oral cancer among Belgaum population with tobacco habits. Biosci Biotech Res Commun 2010;1:50-4.  Back to cited text no. 8
    
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Shaila M, Shetty P, Decruz AM, Pai P. The self-reported knowledge, attitude and the practices regarding the early detection of oral cancer and precancerous lesions among the practising dentists of Dakshina Kannada-A pilot study. J Clin Diagn Res 2013;7:1491-4.  Back to cited text no. 9
    
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Ariyawardana A, Vithanaarachchi N. Awareness of oral cancer and precancer among patients attending a hospital in Sri Lanka. Asian Pac J Cancer Prev 2005;6:58-61.  Back to cited text no. 13
    
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Amarasinghe HK, Usgodaarachchi US, Johnson NW, Lalloo R, Warnakulasuriya S. Public awareness of oral cancer, of oral potentially malignant disorders and of their risk factors in some rural populations in Sri Lanka. Community Dent Oral Epidemiol 2010;38:540-8.  Back to cited text no. 14
    
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Raute LJ, Sansone G, Pednekar MS, Fong GT, Gupta PC, Quah AC, et al. Knowledge of health effects and intentions to quit among smokeless tobacco users in India: Findings from the International Tobacco Control Policy Evaluation (ITC) India Pilot Survey. Asian Pac J Cancer Prev 2011;12:1233-8.  Back to cited text no. 16
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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