Assessment of the feasibility of opportunistic screening for oral potentially malignant disorders and oral cancer at dental colleges in India : a public health initiative from Bengaluru.

Abstract

Introduction

Oral cancer (OC) is a cancer that is preventable by controlling the risk factors and treating the precancerous stages. However, it remains a global problem, principally due to tobacco and alcohol use. In India, the problem is compounded by the cultural acceptance of the risk factors (smokeless tobacco and areca nut) and limited availability and accessibility of cancer diagnostic services. The result is both high incidence and mortality from OC. 60-80% of OC cases are diagnosed at advanced stages, when treatment is less effective. Thus, continued exposure to risk factors and lack of both - primary prevention and screening/early detection have made OC-related mortality the leading cause of cancer death among Indian men and a major contributor to additional poverty as a result of out-of-pocket treatment costs. With both aging of, and increase in, the population, the OC burden is projected to increase. High-income countries can provide opportunistic screening as part of periodic health examination for high- risk groups. Such actions contribute to improvement in survival rates. Though opportunistic screening for high-risk groups at dental-health facilities has been recommended for India, making it available at public-health facilities is a challenge because healthcare budgets are small and stretched. The 315 dental colleges (DCs) distributed across India are the major dental service providers and earlier studies have recommended their use for OC control. However, there is a lack of empirical evidence for judicious use of these limited resources. Such evidence would support decision-making in India on implementation of opportunistic screening. Thus, this study was undertaken to assess the ability of DCs to provide an opportunistic screening programme for groups at high risk of OC; this involved assessment of the demographic and socioeconomic characteristics, habit status, awareness of oral potentially malignant disorders (OPMDs) and OC, and screening behaviour of the dental attendees, as well as the prevalence among them of OPMDs and risk factors, and, finally, the facilities available at DCs to establish opportunistic screening. Although OC is a country-wide problem, I am cognizant of the unique socio-cultural, socio-economic, and geopolitical diversities across the different regions within the country and initially committed to undertake this as a region-based study.

Methods

This was a cross-sectional study conducted in the Oral Medicine and Radiology department of 13 DCs and three of their outreach clinics in Bengaluru, India. Data were obtained from three sources. Firstly, 414 dental attendees aged ≥30 years were recruited consecutively according

to their outpatient registration numbers. Then, through a face-to-face interview, data on demographic and socioeconomic particulars, high-risk habit status, awareness of OPMDs and their risk factors, signs, and symptoms, as well as the attitudes of the patients, were documented using a structured questionnaire. Following this, an oral examination by visual inspection was undertaken to screen for OPMD/OC. The results were documented in the same questionnaire. Standard primary preventive measures were provided and those with lesions were referred for biopsies or oncology treatment. Secondly, using a structured questionnaire. the department head or faculty in charge was interviewed face-to-face to obtain data on the facilities available for screening of OPMDs and cessation methods for tobacco and areca nut. Thirdly, additional data were obtained from reception and observations during the process of undertaking this study. Then, a descriptive analysis of the collected data was undertaken in SPSS Version 26.

Results

Interviews and screening were accepted by 98.8% of the eligible dental attendees. The sociodemographic characteristics of the participants were generally comparable to those of the relevant population in the Bengaluru Census 2011 data. 58% had a low socioeconomic status and rural attendees was over-represented compared with their population proportion. 69.1% of the participants had a high-risk habit. Overall, 12.6% (95% CI: 9.3-15.7) were screen positive. Of these, 51.9% accepted a biopsy but this could not be completed for all within the time available. Four of the six biopsies showed dysplastic changes. The screening centres were accessible to 85% of the participants; the majority (76.6%) had spent less than INR 100.0 (US$1.31) for their transportation to visit the DC or outreach clinic. In DCs, the oral healthcare providers at outpatients included dental interns, postgraduates, and dental specialists and comprehensive oral examinations were routinely practised; 53.3% (N = 8) of DCs routinely conducted biopsies and 60.0% had organised tobacco-cessation clinics for habit cessation. Dental consultations were offered free of charge in six of the 13 dental colleges and the outreach clinics; in the others, there was a one-time payment of INR 10 to 50 (US$ 0.13 to US$ 0.66). Biopsies were free or, if charged for, the fee was between INR 150 to 250 (US$ 1.98 to US$ 2.33). Though participants' awareness of OPMDs and their signs and symptoms were low, majority (72%-smoking and 82.0%-smokeless tobacco) were knowledgeable about tobacco as a risk factor. However, AN as a risk factor was known to only 26.0%. The majority (84.8%) showed a positive attitude towards screening.

Conclusion

The DCs’ infrastructure and services, the characteristics of the dental attendees, and a remarkably high prevalence of OPMDs and OC suggest that opportunistic screening for OPMDs and OC among high-risk groups can be achieved at DCs. This easy, safe, simple model of screening also provided an opportunity for socioeconomically and geographically disadvantaged people to be screened and to obtain treatment for OPMDs, and referrals for OC; they will otherwise present with a delay or not at all. High acceptance of screening among these participants – for whom it was convenient to visit DCs and who were representative of the general population – has positive implications for the translation of this research into a broader opportunistic screening programme that needs to be underpinned by relevant state-wide and, ultimately, national policies.

Recommendations

With the uniformity in the availability of the facilities in DCs across the country, scaling up such opportunistic screening services would ensure that they reach larger sections of society. However, further research in this dental setting, where opportunistic screening has been found feasible, needs to be undertaken to assess the efficacy of screening. The epidemiological data on the prevalence and patterns of the risk-factors necessitates that evidence-based, culturally specific, and gender-sensitive primary preventive strategies that include hogesoppu, kaddipudi, AN, and lime be developed and widely publicised. It is important to establish strategies to educate the population and especially those at risk about OPMDs and their signs and symptoms to enable early recognition.