The present study was a cross-sectional questionnaire survey which was conducted among 200 randomly selected clinicians of Dakshina Kannada, Karnataka, India. The study was conducted between April 2012-June 2012. Self-administered questionnaires were personally handed out to the practising dentists. In addition, a letter assured the dentists anonymity and confidentiality of all the responses. The completed questionnaires were collected back immediately. The informed consents of the participants were obtained.

The questionnaire [Table/Fig-1] consisted of eighteen questions which had to be answered by each respondent, which had the options, ‘yes’ or ‘no’. The questionnaire assessed the management practice regarding oral cancer by asking whether the dentists performed an exfoliative cytology along with a visual examination, and their current knowledge on the recent advances in this field. Finally, the respondents were asked about their training in this direction, and whether they needed additional training/information/oral pathologists as consultants in their clinics.

The data was entered in MS Excel for Windows and it was statistically analysed by using SPSS, version 17.0. Descriptive statistics were carried out in the present study and they were presented as number and percentage.

[Table/Fig-1] shows the responses of the subjects (number and percentage). The response rate was 100%. Exfoliative cytology was performed only by 2% of the practitioners and only 55.5% were trained for the same.

Also, 94.5% felt that the procedure was unsuitable for their clinical practice. Although 85% of the general practitioners attended education programs in this direction and 72% welcomed additional training. About 88% of the dentists referred the suspicious lesions to other centres, whereas 29.5 % performed biopsies. All the practitioners preferred a follow up strategy for the innocuous looking lesions, but only 52 % knew that such lesions too could be transformed to cancer. Only 13% counseled the patients who had lesions. Although 43.5% of them were aware of the recent advances in the field of cytology, 98.5% felt that it was not suitable for their clinical usage, due to economic reasons. About 86% felt that there was the need for an oral pathologist as a consultant in their clinics.

This investigation reports the overall knowledge, attitudes, and the practice regarding the early detection of oral cancer among the dentists of Dakshina Kannada and the data provides a comprehensive picture of the current status of the knowledge and practice among these dentists.

The results greatly concern us, as many of the dentists themselves showed significant gaps in their knowledge with respect to the diagnostic procedures, with only 2 percent performing an exfoliative cytology in their clinical practice and most of them thinking that it was unsuitable in a clinical set up. Not surprisingly, those who performed an exfoliative cytology in their clinics were all oral pathologists. Another element which needs to be discussed is that only 55.5% of the dentists claimed to be trained in this procedure. Horowitz et al., in his survey, reported that only 10% of all the dentists had ever done an oral cytology smear, that only 42% were taught about how to do a smear and that 96.9% of the dental offices lacked the necessary materials for performing an exfoliative cytology [14]. Despite innumerable studies and articles regarding the usage of brush biopsies, only 16% were aware of such a technique. This clearly points out at the existing gap between the research studies and their actual implementation in the clinical practice. There is strong available evidence to suggest that the visual inspection of the oral mucosa is effective in reducing the mortality from oral cancer, in individuals who are exposed to risk factors. Although biopsy is the gold standard for the diagnosis of oral cancer, adjunctive techniques like the toluidine blue staining, brush biopsies, chemiluminescence and tissue autofluorescence have been suggested, to increase our ability to differentiate between the benign abnormalities and the dysplastic/malignant changes, as well as to identify the areas of dysplasia/early OSCC that are not visible to the naked eye [19]. Among the dentists who practised along the Texas-Mexico border, [17] 90% agreed that oral cancer examinations should be conducted annually for the patients who are 40 years of age and older. A positive acquaintance on the oral cancer knowledge was associated with the performance of an oral cancer examination, as was implied by Alonge and Narendran [17]. Another shocking revelation was that only 13% counseled their patients with lesions regarding the stoppage of the habits which led to oral cancer. The role of the health care professionals as the communicators of public health messages, needs to be stressed and dentists must be familiar with the risk factors, clinical signs and the symptoms of oral cancer, if they are to be effective in identifying, referring and counseling the high-risk patients. It was noticed that many dentists did not feel comfortable with the idea of counseling patients on the matters such as smoking or alcohol cessation [11].

The dentists who attended an educational course in the preceding year on oral cancer were more likely to have a higher level of knowledge on oral cancer. In the medical literature, similar findings have been found in previous studies which were done among the dentists who were practising in the United States. [9,10,14]. So, supplementary educational efforts are necessary, simply because a specific risk and benefit communication is a skill that can be taught.

A similar study assessed the oral cancer knowledge, attitude and the screening practices among 240 dental practitioners in Bangalore city [11], where 68% claimed to be adequately trained in conducting oral cancer examinations. Two hundred and thirty-seven (98%) dentists strongly agreed that the patients should be referred to specialists if they suspected oral cancer in any lesion; whereas 88% among our respondents referred their patients. 31% of the dentists educated their patients on the adverse effects of these habits and assisted them in cessation programmes, in contrast to 13%, as was noted in our study. They believe that there were missed opportunities in the dental office. First, with the dentists’ focus being limited to the oral cavity, it is reasonable to believe that they might be able to easily obtain a focused medical and behavioral history, which included the key risk factors for oral cancer. Second, multiple opportunities exist during a patient’s visit to a dental office for tobacco-use intervention services, as it has been established that the dental patients traditionally are receptive to preventive health messages [11].

Although 43.5% of the dentists were aware of the recent advances in the field of cytology, many felt that it was not suitable for their clinical usage, due to economic reasons. This is an important indication for researchers to develop techniques which are simple and economic, which can prove to be feasible in an Indian clinical setup. Although exfoliative cytology does have its limitations, it still suits the above mentioned needs. The procedure requires the necessary armamentarium, a microscope and above all, a qualified oral pathologist to interpret the smears. Researches on the techniques which are simpler, non invasive, economically feasible and less time consuming and those which require minimal armamentarium at site of the collection, may be fruitful and more readily accepted and implemented by the clinicians. An oral pathology consultant can contribute considerably to the control of oral cancer by detecting the dysplasia at the earliest; thereby, availing treatment to the patient at an early stage. This step can be a benchmark in increasing the 5 year survival rate of oral cancer, which to the dismay of the health care professionals, has remained unaltered for the past 50 years. Also, the dentists who are in group practice are generally involved in different specialties and, therefore, they may be able to share their collective knowledge and clinical experiences about oral cancer.

The results of this study must be interpreted in the context of the potential methodological limitations. First, since this was an observational study, it provides only circumstantial evidence for the causal nature of the relationships which we have observed. Second, as is typical of any survey which uses the self-reported data to measure, for example, the adherence to the preventive precautions, there exists the possibility that the reported behaviours may not match the actual clinical practice. The tendency of the respondents to provide socially acceptable answers would usually present a bias against the variability in the reported practices, possibly resulting in an underestimation of the non-adherence. However, the anonymous nature of the questionnaire has minimised this type of information error. Finally, in our survey, we chose a quasi-convenience cohort, although it was randomly selected, of the dentists who attended continuing education courses and academic institutions, and the results may not be generalised to all the dentists nationwide, because those who were sampled may have been more knowledgeable.

In summary, in view of the findings of this study, improving the level of the knowledge and the usage of exfoliative cytology by a population of dentists becomes a very important public health and preventive strategy, along with patient counseling for the reduction of the burden of the disease. Because such an improvement can be gradually achieved, an increased awareness on the role of the oral pathologists as consultants in the clinical practice, needs to be emphasised. This is a pilot study which was conducted on a convenient group of dentists; hence, a further survey on a larger scale, is necessary to assess and implement any measures. An increased awareness on the importance of the role of health care professionals as the communicators of public health messages, should be emphasised, so that appropriate and systematic educational strategies can be implemented quickly. A strategic alliance of the stake holders is proposed: individuals, communities, organizations, corporations and governments to deliver action through the conduction of nationwide surveys, policy development and interventions at individual, community and national levels [20].

This pilot survey identified an existing gap in the knowledge and practices among physicians and dentists and it emphasises the need to increase the numbers of oral cancer detection workshops among the professional groups.