Dental students’ awareness and attitudes toward HPV-related oral cancer: a cross sectional study at the University of Jordan

Cancers of the oral cavity, oropharynx and lips represent a growing problem worldwide with an estimated incidence of about 448,000 cases and 228,000 deaths in 2018 [1]. Although the majority of cancers arising from these three sub-sites are squamous cell carcinomas, they have different major etiologic factors (ultra-violet exposure for lip cancer, tobacco, alcohol, and areca-nut chewing for oral cavity cancer, and human papilloma virus [HPV] infection for oropharyngeal cancer) [2, 3]. Furthermore, cancers arising from different anatomic sub-sites exhibit different biologic behaviour, and different prognosis and management [4‐6].

The high mortality rate associated with oral cancer is related to late presentation of a large proportion of patients with advanced disease [7]. Thus, early diagnosis appears to be of prime importance for achieving a favourable outcome in the patients [8]. Although the oral cavity represents an easily accessible site for clinical examination, the lack of awareness in both the patients and health-care professionals precludes early detection of precancerous and early cancer lesions [9‐11]. A promising strategy to improve survival among patients with oral cancer is increasing awareness and knowledge among the patients and health-care professionals [12]. Dentists represent a significant sector which faces this problem, thus focusing on this group with educational material is of high value [12]. Identifying the gaps in dental professionals’ knowledge and increasing their confidence in discussing HPV as a sexually transmitted infection (STI) is important to detect early cases [13].

The potential role of high-risk HPV types, particularly HPV-16 as risk factors for the development of oral cancer has been elucidated for decades [14, 15]. Additionally, the burden of HPV-related oral cancer is increasing worldwide [16, 17]. Various studies from developed countries (e.g. North America, Europe, Japan and Australia) reported that 17–56% of all oral cancers are HPV-related [18]. However, limited data are available from the less developed regions including the Middle East and North Africa (MENA) [18]. HPV infection with malignant strains is likely to play a role in oral cancer in the MENA despite the scarcity of data on this subject including a few studies from Yemen, Sudan, Syria, and Iran [19‐23].

Several studies examined knowledge and awareness of patients, students, and dental professionals toward oral cancer in different parts of the world and reported variable results [10, 24‐26]. Nevertheless, few studies examined knowledge of health care professionals about HPV-related oral cancer and their attitude toward HPV screening and discussing personal topics with patients [27, 28].

Earlier studies from Jordan aimed to assess general knowledge of oral cancer of the dental students, recently graduated medical and dental professionals, and among the patients [10, 29, 30]. However, no previous reports have been found in Jordan that assessed knowledge of HPV-related oral cancer among dental students. Thus, the objectives of the current project were: (1) to assess the general knowledge of dental students at the University of Jordan (UJ) regarding different aspects of oral cancer (anatomic sites, clinical presentation and risk factors). (2) to evaluate the attitude of clinical students regarding screening of oral cancer. (3) to assess the knowledge of dental students at UJ regarding different aspects of HPV infection. (4) to assess the attitude of the clinical students regarding the discussion of personal topics with patients.

In the current study, the main objective was to assess knowledge and attitudes of dental students, interns and postgraduate maxillofacial surgery residents at UJ (the oldest and largest University in Jordan), towards HPV-related oral cancer. The UJ is one of two universities in the country that offers dentistry education. The current work was motivated by the accumulating evidence pointing to an increasing prevalence of high-risk HPV types as the underlying etiology for oral cancer worldwide [33‐39]. In addition, HPV is anticipated to be the most common risk factor for oral cancer in the next decade [40]. Sufficient knowledge on oral cancer among general practitioners and dentists is critical, since early diagnosis is a decisive factor in reducing the morbidity and mortality from the disease [12, 41].

The assessment of level of knowledge and attitudes of the future dentists is crucial to highlight the limitations of the current curriculum taught locally. Moreover, the results of the study are expected to be beneficial at the country level, and might have an added value at the regional level, since a relatively large percentage of the participants were non-Jordanians and likely to practice dentistry in the neighbouring countries. The emphasis on dental staff awareness and the importance of dentists’ roles in the early diagnosis of oral cancer is invaluable particularly in the developing countries [42, 43].

Oral microbiology is an integral part of the dentistry curriculum. Certain microbes including HPV mandate special focus in dentistry not only in relation to cancer [44]. HPV represents an important pathogen causing oral lesions that are frequently encountered by the dentists, hence deep knowledge is important for the diagnosis and ensuring the patients about the nature of HPV-related oral disease [44].

The main findings of the study can be summarized as follows: First, the results revealed good overall knowledge among the clinical group regarding different aspects of oral cancer compared to pre-clinical group. The commonest anatomic sites, clinical manifestations and risk factors were correctly identified by the majority of the participants in the clinical group. However, a relatively large percentage of the clinical group failed to identify lips, buccal mucosa and palate as potential sites for oral cancer development. Lack of knowledge regarding buccal mucosa is particularly worrisome since these cancers generally have poor prognosis [5]. In addition, more than one-third of the participants in the clinical group failed to identify the frequent early lesions of oral cancer including the hard painless masses and mixed red-white lesions “erytholeukoplastic lesions” which might lead to delay in diagnosis that is associated with less-favourable outcome [45]. For the risk factors of oral cancer, the clinical group showed better results compared to the previous studies that were conducted in Jordan both among dental students and recently graduated medical and dental professionals [29, 30]. This might be related to intervention measures including improved dental education in light of the previous results of studies conducted in Jordan and globally. In addition, the rate of correct identification of smoking, alcohol consumption and HPV as risk factors for the disease was higher than the rates observed in some of the MENA countries among dentists and dental students, but in line with results of studies conducted in the Netherlands, Spain and Saudi Arabia [31, 32, 46‐48].

Second, the participants in the clinical group showed varying attitudes toward oral cancer screening, with a stepwise increase in confidence to perform visual and manual palpation screening depending on the level of education. Improvements in the local educational curriculum are recommended including emphasizing the importance of conducting oral cancer screening as a routine practice.

Third, the participants in the clinical group showed better overall knowledge regarding HPV compared to participants in the pre-clinical group. Nevertheless, certain gaps were identified concerning basic knowledge of the virus. Despite the fact that oral cancer represents the most ominous outcome for HPV infection in the oral cavity, HPV comprises more than 200 types, with varying oncogenic potential [49]. Knowledge of these types and their associated clinical diseases is indispensable for dentists since HPV infections are common in the oral cavity and can manifest in different ways [44].

Fourth, participants in the clinical group were reluctant to discuss issues related to STI and history of sexual abuse with patients. This was particularly evident among female Jordanian participants. The role of communication with patients to reveal history of STIs and sexual abuse is important since HPV types that are associated with oral cancer are usually transmitted through oral sex [50‐52]. The aforementioned reluctance might be related to cultural and religious attitude towards discussing these issues in the MENA. However, similar difficulties in discussing these topics were also reported among American dentists and Spanish dental students [26, 32].

Finally, the majority of participants aspire for more training and devices that can aid in oral cancer screening which should be addressed. Possible options include continued education in the form of workshops, practical training sessions and awareness campaigns.

The current study had certain limitations as follows: One limitation inherent in a large number of surveys is the possibility that a fraction of participants responded in a way they believe to be suitable for the authors conducting the survey. During the distribution of the questionnaires to participants, it was attempted to minimize this limitation by declining to answer questions or responding to enquiries regarding the different questionnaire items. Sampling error is another potential limitation as the choice of participants to take part in the study might have been influenced by their previous knowledge on oral cancer and HPV which was evident by the low percentage of the pre-clinical participants who agreed to take part in the study. Non-response error should also be considered in spite of our attempt to formulate clear questions that were assessed and modified using the pilot testing. To reduce coverage error we tried to sample as much students as possible during the narrowest feasible period. Another potential limitation was the female predominance in the sample which might have influence on some results particularly those related to discussion of personal topics with patients. Since the study was conducted in a single institution (UJ), our results might not reflect the overall knowledge and attitudes of dental students in the country. Finally, the higher response rate among fourth year clinical students might be explained by the participation of three authors who are themselves at the same educational level, which might motivated some reluctant respondents to participate.

The majority of the participants in the clinical group at UJ showed better knowledge regarding oral cancer in various survey items compared to the pre-clinical group participants. Nevertheless, gaps in knowledge were observed particularly in aspects related to clinical presentation of the disease which might be an impediment to life-saving intervention measures. The overall knowledge of the participants in the clinical group regarding HPV was satisfactory, albeit with gaps in certain aspects (e.g. availability of vaccine). Participants in the clinical group showed reluctance to discuss topics like STIs and history of sexual abuse with the patients (particularly among female participants). This issue can be addressed through improved educational training programs. Knowledge about HPV-related oral cancer is crucial and is recommended to be taught as an integral part of the basic curriculum and clinical training of dental students. A follow-up comparative study is recommended among medical students.