Oral Oncology (2004) 40 638–644

http://intl.elsevierhealth.com/journals/oron/

Dental hygienists and oral cancer prevention:knowledge, attitudes and behaviors in Italy

Gaetano Nicotera, Francesca Gnisci, Aida Bianco, Italo F. Angelillo*

Chair of Hygiene, Medical School, University of Catanzaro “Magna Græcia”,Via Tommaso Campanella, Catanzaro 88100, Italy

Received 17 December 2003; accepted 15 January 2004

Summary This study explored knowledge of risk factors and diagnostic proceduresfor oral cancer, attitudes and behavior among dental hygienists in Italy. A randomsample of 500 dental hygienists received by mail a questionnaire focusing ondemographics and practice characteristics, knowledge, attitudes and behaviorsregarding oral cancer assessment practices. Almost all dental hygienists correctlyindicated tobacco usage and having a prior oral cancer lesion as risk factors.Although 88.8% knew that the tongue is one of the two most common sites of oralcancer, only 13.5% identified the floor of the mouth. Less than half (42.8%)recognized that an early oral lesion usually is a small, painless and red area and only4.2% knew the examination procedures of the tongue. Results of the multiplelogistic regression showed that those dental hygienists who worked a higher numberof hours and treated a lower number of patients in a week were more likely toindicate tobacco and alcohol use as risk factors for oral cancer. Higher number ofyears in practice, scientific journals and associations as sources of information aboutoral cancer, and knowledge that ventral lateral border of tongue is the mostcommon site for oral cancer, significantly predicted compliance with oral cancerexamination. Dental hygienists’ sex, age, and years in practice were associated witha positive attitude towards oral cancer prevention. Further educational interven-tions in order to early detect and prevent oral cancer are strongly needed.

�c 2004 Elsevier Ltd. All rights reserved.

KEYWORDS

Attitudes;Behavior;Dental hygienists;Italy;Knowledge;Oral cancer;Prevention

Introduction

Cancer of the oral cavity and pharynx worldwideaccounts for over 350.000–400.000 new cases per

* Corresponding author. Tel.: +39-961-777669; fax: +39-961-777345.

E-mail address: angelillo@unicz.it (I. F. Angelillo).

1368-8375/$ - see front matter �c 2004 Elsevier Ltd. All rights reserdoi:10.1016/j.oraloncology.2004.01.003

year and according to the National Cancer Insti-tute’s Surveillance, Epidemiology, and Ends Resultsprogram, 30% of oral cancers originate in the ton-gue, 17% in the lip, and 14% in the floor of themouth.1 In Italy, the most recent epidemiologicaldata have estimated that oral cancer representapproximately 4% of all cancers in the men and 1%in the female.2 The oral cancer diagnosis continues

ved.

Dental hygienists and oral cancer prevention 639639

to rely on patient presentation and physicalexamination with biopsy confirmation and, there-fore, this may result in delay in diagnosisaccounting for the fact that the majority of thesecancers are diagnosed at a late stage.3

In order to detect these cancers at an early andcurable stage dental care workers need to identifypatients at increased risk as a result of unhealthylifestyle and target advice and counselling to themin addition to systematic examination of the oralcavity. Recently, the American Cancer Societyidentified cancers of the oral cavity as a potentiallypreventable cause of major morbidity and mortal-ity and a comprehensive oral cancer examination isrecommended every 3 years for those 20–39 yearsof age and annually for individuals 40 years of ageand over.4

Previous studies have evaluated whether or notdentists have the skills necessary to assist patientsin cancer prevention,5–8 but little knowledge isavailable about dental hygienists. Information onthis topic is strongly needed to assess if they areprepared for determining whether patients are atrisk of developing oral cancer, as well as for pro-viding a comprehensive oral cancer examination.Therefore, the purpose of the present study was toexplore knowledge of risk factors and diagnosticprocedures for oral cancer, attitudes and behavioramong dental hygienists in Italy.

Materials and methods

From April to July 2003, a random sample of 500dental hygienists from the Italian Dental HygienistsAssociation was surveyed. A letter was mailed to alldental hygienists in the sample emphasizing theimportance of the study, a questionnaire and a pre-paid, pre-adressed envelope to facilitate the re-turn of the completed questionnaire. Numberidentified returned envelopes, known only by theresearch team, in order to identify which dentalhygienists had not returned their questionnairesand required follow-up. Six weeks after the initialmailing, a follow-up letter with a second ques-tionnaire was mailed to the non-respondents. Afterthe second mailing, the identification key was de-stroyed, thus maintaining complete confidentialityof all respondents. In an attempt to maximize theresponse rate, telephone calls were made to alldental hygienists before mailing the questionnaireand before the follow-up mailing. Only 28 dentalhygienists could be not contacted by telephonebecause a number was not available. Informedconsent was obtained and confidentially of re-sponse was assured.

The questionnaire consisted of questions focus-ing on dental hygienists’ demographics and prac-tice characteristics; their knowledge about oralcancer risk factors and about diagnostic proceduresof oral cancer; attitudes toward oral cancerexamination; their behaviors with respect to theoral cancer examination and regarding other healthassessment practices.

The questionnaire was pre-tested and modifica-tions were made to improve the validity of re-sponses.

Statistical analysis

Multiple logistic regression analysis was per-formed. Four models were developed includingthose variables that were considered to be poten-tially associated with the following outcomes ofinterest: knowledge about tobacco and alcohol asrisk factors for oral cancer (Model 1); performingan oral cancer examination (Model 2); asking aboutpatients’ past and current tobacco and alcoholusage (Model 3); belief that oral cancer examina-tion and anti-smoking campaign are effective fororal cancer prevention (Model 4). For purposes ofanalysis, outcome variables originally consisting ofmultiple categories were collapsed into two levels.In Model 1, dental hygienists were classified asthose who knew that tobacco and alcohol were riskfactors for oral cancer and all others; in Model 2,they were grouped according to whether theyperformed an oral cancer examination versus allothers; in Model 3, according to whether askingabout patients’ past and current tobacco andalcohol usage and all others; in Model 4, those whohad a positive attitude towards oral cancer pre-vention versus all others. The explanatory variablesincluded in the models were the following: age(continuous, in years), sex (male¼ 0, female¼ 1),number of years in practice (continuous), numberof hours worked per week (continuous), number ofpatients treated in a week (continuous), and sci-entific journals and dental associations as sourcesof information on the prevention of oral cancer(no¼ 0, yes¼ 1). In Model 2, the variables knowl-edge of the examination procedures of the tonguefor oral cancer detection (no¼ 0, yes¼ 1) andknowledge that ventral lateral border of tongue isthe most common site for oral cancer (no¼ 0,yes¼ 1) were also included. In Models 3 and 4, thevariable knowledge that tobacco and alcohol usewere risk factors for oral cancer (no¼ 0, yes¼ 1)was also included. In Model 4, the variables per-forming an oral cancer examination (no¼ 0,yes¼ 1) and asking about patient’s past and current

640 G. Nicotera et al.

tobacco and alcohol use (no¼ 0, yes¼ 1) were alsoincluded. The significance level for including vari-ables in the models was at p ¼ 0:2, and p ¼ 0:4 fordropping variables from the models. Odds ratios(ORs) and 95% confidence intervals (CIs) were cal-culated. The data were analyzed using the Statasoftware program.9

Results

Of the original sample of 500 dental hygienists,28 were ineligible because of retirement or be-cause they were not in clinical practice. For theremaining 472 dental hygienists, 215 question-naires were returned for a response rate of 45.6%.

Demographic and practice characteristics of theresponding dental hygienists are presented in Table1. The majority were females, the mean age was 36years (range 22–65), the mean duration of work

Table 1 Selected characteristics of the study pop-ulation

Characteristic Na % Mean ± SD

SexMale 37 17.2Female 178 82.8

Age group, years 36 ± 7.56 30 50 23.231–35 60 2836–40 53 24.6>40 52 24.2

Years in practice 9.2 ± 6.76 1 18 8.62–5 55 26.46–9 44 21.210–13 44 21.2>13 47 22.6

Number of hours worked per week6 15 40 19.416–20 30 14.621–25 14 7.826–30 37 1731–35 22 10.7>35 63 30.5

Number of patients treated in a week<10 34 15.810–20 52 24.221–30 65 30.231–40 46 21.4>40 18 8.4

a The number that do not add to 215 are due to missingdata for that variable.

activity was 9.2 years, and more than 40% providedcare for more than 30 h in a week.

Respondents’ knowledge about oral cancer ispresented in Table 2. With regard to knowledge oforal cancer risks, almost all correctly indicatedtobacco usage (99.5%) and having a prior oralcancer lesion (95.8%) as risk factors, whereas only49.3% and 34.9% identified older age and alcoholusage respectively. The responses about knowledgeof oral cancer diagnostic procedures showed thatonly 53.1% of dental hygienists knew that squa-mous-cell carcinoma is the most common form oforal cancer. Although 88.8% knew that the tongueis one of the two most common sites of oral cancer,only 13.5% identified the floor of the mouth. A vastmajority of the sample knew that leukoplakia(86.5%) and less than half that erythroplakia(48.4%) are the two conditions most likely to beassociated with oral cancer. Finally, 42.8% ofdental hygienists recognized that an early oral le-sion usually is small, painless and red area and only4.2% knew the examination procedures of thetongue. The results of the multiple logisticregression showed that those dental hygienists whoworked a higher number of hours and treated alower number of patients in a week were morelikely to indicate tobacco and alcohol use as riskfactors for oral cancer (Model 1 in Table 3).

With respect to screening procedures by per-forming an oral examination, 80.7% of the respon-dents provide this examination on their patientsand 74.5% of them provide oral examination to allpatients 40 years of age and older. Results of theregression analysis on the responses of dentalhygienists who conducted an oral cancer exami-nation indicated that, among all variables, numberof years in practice, sources of information, andknowledge that ventral lateral border of tongue isthe most common site for oral cancer significantlypredicted compliance with oral cancer examina-tion. Indeed, the odds of performing oral cancerexamination was significantly higher for thoserespondents practicing for a long period of time(OR¼ 1.09, 95% CI¼ 1.00–1.19, p ¼ 0:041), fordental hygienists who correctly indicated the ven-tral lateral border of tongue as the most commonsite for oral cancer (OR¼ 3.04, 95% CI¼ 1.35–6.83,p ¼ 0:007), and those who learned about oral can-cer from scientific journals and dental associationshad an adjust OR of 2.77 (95% CI¼ 1.24–6.22,p ¼ 0:013) compared with those who did not usethese sources of information (Model 2 in Table 3).Regarding health assessment practices, only 51.2%of respondents reported that they asked about thepersonal patients’ experience and about the pa-tients’ family of oral cancer. Moreover, almost all

Table 2 Respondents’ knowledge providing correct responses about oral cancer

Correctly indicated

N %

Risk factorsUse of tobacco 214 99.5Prior oral cancer lesion 206 95.8Older age 106 49.3Use of alcohol 75 34.9

Diagnostic proceduresSquamous-cell carcinoma is most common form oral cancer 114 53.1Tongue is one of the two most common sites for oral cancer 191 88.8Floor of mouth is one of the two most common sites for oral cancer 29 13.5Leukoplakia is one of the two most likely type of precancerous lesion 186 86.5Erythroplakia is one of the two most likely type of precancerous lesion 104 48.4Early oral lesion usually is small, painless, red area 92 42.8Ventral lateral border is tongue area most likely site for oral cancer 146 67.9When palpated, lymph node is hard, painless, mobile or fixed 137 63.7Patients sticks out tongue; posterior dorsum of tongue is examined;pull tongue out checked; examine under side

9 4.2

Dental hygienists and oral cancer prevention 641641

(94%) reported asking about patients’ tobaccoproducts use and 67.4% of alcohol use. Theregression analysis showed that dental hygienistswere more likely to ask about patients’ past andcurrent use of tobacco and alcohol if they wereolder (OR¼ 1.06, 95% CI¼ 1.02–1.11, p ¼ 0:008)and if they knew that tobacco and alcohol use wererisk factors of oral cancer (OR¼ 2.55, 95%CI¼ 1.36–4.78, p ¼ 0:004) (Model 3 in Table 3).

The dental hygienists’ attitudes towards oralcancer prevention indicated that 80.9% agreed thatan oral cancer examination should be providedannually to all patients 40 years of age and older. Apositive attitude towards prevention was reportedby 72.1% who agreed that most oral cancers can beprevented and by 97.2% who agreed that oral car-cinomas found early can be cured. However,respectively, 44.7% and 20.9% were uncertain oragree that oral cancers have an unfavorable prog-nosis. Results of the multiple regression modelindicated that dental hygienists’ sex, age, andyears in practice were associated with a positiveattitude towards oral cancer prevention. Indeed,the number of dental hygienists who believed thatoral cancer examination and anti-smoking cam-paign are effective for oral cancer prevention wassignificantly higher among females (OR¼ 4.69, 95%CI¼ 2.06–10.64, p < 0:001), older (OR¼ 1.1, 95%CI¼ 1.03–1.17, p ¼ 0:007), and in those with alower number of years in practice (OR¼ 0.93, 95%CI¼ 0.87–0.99, p ¼ 0:036) (Model 4 in Table 3).

Questions concerning sources of informationindicated that the respondents learned about pre-

vention of oral cancer mainly from scientific jour-nals (71.2%) and continuing education courses(66.6%); however, they also relied from associa-tions (17.3%). Nonetheless, almost all (96.7%) feltthey needed additional information.

Discussion

This is the first national survey that describedthe knowledge, attitudes and demographic factorsrelated to dental hygienists cancer-preventivebehaviors in Italy, and emphasizes the importanceof performing these surveys in order to plan edu-cational interventions and to develop and imple-ment related policies. However, since the studyhad a response rate of 45.6%, it may be arguedwhether the sample was representative of thepopulation of dental hygienists in Italy. No signifi-cant differences in demographics and practicecharacteristics between participants and non-participants were found in the study. Furthermore,if there is potential bias due to non-response, itmay be in the direction that lack of knowledgeamong dental hygienists is underestimated andinterest in future oral cancer continuing educationis overestimated, but we believe that our resultsare representative of the population of dentalhygienists in our country.

In the past decade a large body of literature hasbeen published investigating some of these issuesamong health care professionals and in particularknowledge and practices of oral cancer among

Table 3 Logistic regression models results

Variable OR SEa 95% CI p-Value

Model 1: Knowledge of tobacco and alcohol as risk factors for oral cancer. Log-likelihood¼)126.33,chi-square¼ 10.56 (4 df), p ¼ 0:032

Number of patients treatedin a week

0.96 0.16 0.93–0.99 0.028

Number of hours worked perweek

1.04 0.2 1.00–1.08 0.046

Sources of information 0.56 1.81 0.29–1.05 0.072Sex 1.91 0.83 0.81–4.49 0.137

Model 2: Performing oral cancer examination. Log-likelihood¼)82.81, chi-square¼ 24.89 (8 df), p ¼ 0:0016

Knowledge of tongue as mostcommon site for oral cancer

3.04 1.25 1.35–6.83 0.007

Sources of information 2.77 1.14 1.24–6.22 0.013Years in practice 1.09 0.05 1.00–1.19 0.041Knowledge of the examinationprocedures of the tongue

0.21 0.19 0.34–1.24 0.084

Sex 0.33 0.22 0.94–1.18 0.089Number of patients treatedin a week

1.04 0.02 0.99–1.09 0.114

Age 0.94 0.03 0.88–1.02 0.121Number of hours worked perweek

0.97 0.03 0.92–1.02 0.2

Model 3: Asking about patients’ past and current tobacco and alcohol usage. Log-likelihood¼)131.91,chi-square¼ 18.61 (4 df), p ¼ 0:0009

Knowledge of tobacco andalcohol as risk factors for oralcancer

2.55 0.82 1.36–4.78 0.004

Age 1.06 0.02 1.02–1.11 0.008Sources of information 1.49 0.48 0.79–2.81 0.218Sex 0.67 0.27 0.3–1.46 0.312

Model 4: Belief that oral cancer examination and anti-smoking campaign are effective fororal cancer prevention. Log-likelihood¼)115.66, chi-square¼ 19.97 (5 df), p ¼ 0:0013

Sex 4.69 1.96 2.06–10.64 <0.001Age 1.1 0.04 1.03–1.17 0.007Years in practice 0.93 0.03 0.87–0.99 0.036Performing oral cancer exami-nation

1.96 0.82 0.86–4.46 0.109

Asking about patients’ past andcurrent tobacco and alcoholuse

0.71 0.24 0.37–1.37 0.303

a Standard error.

642 G. Nicotera et al.

primary care physicians,7;10–12 knowledge andopinions in nurse practitioners,13;14 and oral cancerprevention and detection among dentists.5–8;15

Comparisons with the most recent findings of thesestudies must be interpreted cautiously becauseseveral variables may influence the outcomesof interest, such as oral cancer prevalence inthe population, the health care delivery system,the attitudes and the behaviors of the patient, thetarget population surveyed, and the survey’smethodology.

The results of this study revealed a limited levelof knowledge, despite a vast majority indicated

that the use of tobacco and having a prior oralcancer lesion were risk factors, less than halfidentified older age and use of alcohol. Moreover,although a large majority (88.8%) knew that tongueis one of the two most common sites for oral can-cer, only 13.5% knew the floor of the mouth assecond most common site. A higher degree ofknowledge was reported in US dental hygienists,since respectively 99.7% and 74.3% know that useof tobacco and alcohol are oral cancer risk factorsand that almost two-thirds correctly identifiedolder age as a risk factor.16 Regarding the knowl-edge of oral cancer diagnostic procedures only 4.2%

Dental hygienists and oral cancer prevention 643643

of our sample correctly identified the examinationprocedures of the tongue for oral cancer detectioncompared with the approximately 91% of theMaryland dental hygienists. With respect toinquiring into risk habits, half of respondents(54.4%) routinely asked about patients’ past andcurrent tobacco and alcohol usage. With respect toconducting oral cancer examinations, more thantwo-thirds of dental hygienists responded that theyprovided this examination to patients 40 years ofage and older and this value is lower, although notdirectly comparable since the studies were con-ducted on dentists, to those reported in the UKwith 84% that provided routine oral mucosa exam-ination irrespective of the patient’s complaint5 andin the United States with 91.3% that performed theexamination at the initial appointment for patients40 years of age or older,6 respectively. Moreover,we found that performing oral cancer examinationwas significantly higher if dental hygienist had re-ceived information on the prevention of oral can-cer from scientific journal and associations.Furthermore, a survey previously conducted bysome of us among Italian primary care physicians’revealed that they were unknowledgeable aboutrisk factors for oral cancer. In Italy patients aremore frequently to have access to medical carethan dental care and primary care physicians act as“gate-keepers” for access to secondary servicesand they should play a crucial role in the imple-mentation of oral cancer preventive programs.Their degree of knowledge on risk factors is inagreement with that reported in the present study,since smoking was well known to be a potentialcause of oral cancer (87.6%) but knowledge ofalcohol and prior oral cancer lesion were indicatedby 64% and 31.5% of the respondents.12 It should benoted that a vast majority knew that leukoplakiaand only about a third that erythroplakia were thetwo conditions most likely to be associated withoral cancer and 68.8% and 37.1%, respectively,were aware that the tongue and the floor of themouth were the two most common sites of oralcancer. Oral cancer detection can and should in-volve not only dentists but also other oral healthcare professionals, such as dental hygienists, andphysicians and this collaborative effort is impor-tant in reducing morbidity and mortality related tooral cancer by providing health education to theirpatients on tobacco and alcohol cessation and byproviding a screening for oral cancer. The lack ofknowledge and the failure to routinely ask aboutthe personal patients’ experience and the patients’family of oral cancer and with respect to the oralcancer examination is of concern and do not allowItalian dental hygienists to play an effective role in

the prevention of oral cancer, since practices ofhealth care professionals are influenced by theirknowledge and opinions and this may result in de-lay of diagnosis indicating that it is vital to ensurethat dental hygienists receive additional trainingboth in dental hygiene schools and continuingeducation courses. Moreover, it is well known thatoral cancer detection techniques can be completedwithin a few minutes, the procedure is simple, itdoes not require any additional medical equipmentand it can incorporate inspection for usual lesionsand suspicious changes for effective primary pre-vention. Adherence to guidelines is critical forcorrectly identified such lesions.

The vast majority of the Italian dental hygienistshad a positive attitude towards the effectiveness oforal cancer examination diagnosis and anti-smokingcampaign in preventing oral cancer. Moreover,older dental hygienists were significantly moremotivated compared to younger, and this may beinterpreted as an increase of attention to oralcancer in more experienced subjects. These re-sults, however, do not seem congruent with a highdegree of self confidence, since dental hygienistsseems that they do not feel comfortable in per-forming that examination with one-quarter (25.5%)of those surveyed that did not provide oral exam-ination to all patients 40 years of age and older.This contradiction also is evident in the responsesof approximately half who declared that they donot ask about patients’ past and current use oftobacco and alcohol.

In conclusion, our data, considering the extremeimportance of reducing oral cancer morbidity andmortality rates, strongly emphasize the need thatdental hygienists must acquire the skills necessaryto assists patients in cancer prevention anddetection.

Acknowledgements

We extend our sincere thanks to the dentalhygienists for their willing participation in thestudy.

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