DOI: https://doi.org/10.17921/2447-8938.

2022v24n1p35-41

Knowledge on Oral Cancer in a Group of Undergraduate Dentistry Students

Conhecimento Sobre Câncer Oral em um Grupo de Acadêmicos de Odontologia

Luan de Araújo Lopesa; Suzziane Silva Santosa; Taís de Araújo Limaa; Sheinaz Farias Hassama; Juliana Cassol
Spanembergbc; Jener Gonçalves de Fariasad; Juliana Andrade Cardosoa
a
Centro Universitário Unifas (Unime), Dentistry course. BA, Brasil.
b
Universitad de Barcelona, Facultad de Odontología, Departamento de Odontoestomatología. Spain.
c
Universidad Fernando Pessoa Canarias. Spain.
d
Universidade Estadual de Feira de Santana. BA, Brasil.  
*E-mail: juliandradec@gmail.com

Abstract
Oral cancer is a multifactorial disease with a high occurrence rate considered to be an important public health problem. The knowledge of
the Dentist is essential in the early diagnosis process, with preparation beginning since graduation to know the pathology, carry out accurate
examinations, and act correctly in the face of suspected oral cancer cases. This study aimed to evaluate the knowledge of undergraduate
students in Dentistry at a university regarding oral cancer and its risk factors. This was an observational, cross-sectional, qualitative and
descriptive study, with use of forms on students from the 4th to the 9th semester. After data collection, the results were submitted for statistical
analysis in the IBM SPSS2018 program. The total number of correct answers related to ten questions, nine with a single correct answer and one
with six possibly correct answers. The correlation between the number of correct answers and the progress of the semesters (from the 4th to
the 9th) was tested with Kendall’s tau b coefficient. The analysis for each question used was performed by Fisher’s exact test with Monte Carlo
approximation. There was no significant difference (p = 0.334; rt = -0.093) in the evolution of knowledge surrounding the questions applied.
In the analysis for each question, there was a significant difference in questions two and five (p = 0.000). The level of knowledge of dentistry
students was considered good, needing improvement. It is essential to implement continuous educational measures throughout the course.
Keywords: Mouth Neoplasms. Oral Health. Delivery of Health Care.

Resumo
O câncer bucal é uma doença multifatorial com alta incidência, é considerado um problema de saúde pública. O conhecimento do cirurgião-
dentista é fundamental no processo de diagnóstico precoce, está preparado desde a graduação para realização de exames precisos, conhecer
acerca da patologia e agir corretamente frente aos casos suspeitos de câncer bucal. Este estudo teve como objetivo avaliar o conhecimento dos
graduandos em Odontologia da UNIME Lauro de Freitas a respeito do câncer bucal e seus fatores de risco. Metodologia: Tratou-se de estudo
observacional, do tipo transversal, qualitativo e descritiva, aplicando formulários a alunos do 4º ao 9º semestre. Após a coleta, os dados foram
submetidos à análise estatística no programa IBM SPSS2018. O índice total de acertos relacionados a dez questões, sendo nove com uma única
resposta correta e uma com a possibilidade de seis respostas corretas. A correlação entre o número de acertos e o avançar dos semestres (do
4º ao 9º) foi testada com o coeficiente tau b de Kendall. E a análise para cada questão empregada foi realizada pelo teste exato de Fisher com
aproximação de Monte Carlo. Não foi observada diferença significante (p=0,334; rt=-0,093) na evolução do conhecimento sobre as questões
aplicadas. Na análise para cada questão houve diferença significativa nas questões dois e cinco (p=0,000). O nível de conhecimento dos
estudantes de Odontologia foi considerado bom, necessitando melhorar. É imprescindível a implementação de medidas educativas contínuas
ao longo do curso.
Palavras-chave: Neoplasias Bucais. Saúde Bucal. Atenção à Saúde

1 Introduction leading cause of death in Brazil in 2020. In 2018, 18,078,957

cases were estimated worldwide, of which 354,864 cases were
Cancer is synonymous with malignancy. It corresponds
to a type of aggressive pathology, which has high rates of in the oral cavity, thus being eighteenth in the world ranking,
incidence and mortality in the world population1. Such diseases with mortality in 2018 estimated at 177,384 deaths worldwide,
are characterized by the ability to invade the organism’s occupying the sixteenth position3. In Brazil in 2018, cancer
structures through the disorderly increase of the body’s cells, ranked second in morbidity4.
justified by the loss of control of cell division2. Considered a Malignant neoplasms can develop in any cell and tissue in
chronic condition distributed worldwide, cancer presents an the body. It is considered oral cancer, any type of malignancy
important public health problem, taking into account the high that affects the regions of the tongue, gums, hard palate, floor
prevalence of the disease and the impact it causes on the lives of mouth and buccal mucosa4. In countries that have a low
of individuals3. to medium Human Development Index (HDI), like some
Cancer represents the second leading cause of mortality countries in Latin America, men have an incidence rate of oral
in the world today, with the prospect of occupying the first cancer by standardized age of 8.7%3.

J Health Sci 2022;24(1):35-41 35

 Among the various types of malignant neoplasms in one researcher, thus eliminating issues related to the
the mouth, more than 90% are of the variant squamous standardization of questions and answers, with cordiality, in
cell carcinoma, considered the most common histological no way forcing the participation of students as to not make
type. The main risk factors for oral cancer are smoking and this moment unpleasant or leave participants feeling coerced.
alcoholism, increasing the chances for the disease to occur if After explanation of the objective, method, guarantee of data
there is a combination of both5. Alcoholism and smoking are confidentiality and the possibility of giving up at any stage of
considered public health problems, increasing the morbidity the research, students were invited to participate in the study,
and mortality of cancer cases6. In addition, excessive exposure being asked to sign the Informed Consent Form.
to sunlight without the necessary protection is a considerable
risk factor for oral cancer, and recent studies claim that 2.3 Inclusion and exclusion criteria
types sixteen and eighteen of human papillomavirus (HPV) The exclusion criteria for the study was students of age
infections are related to the causes of mouth cancer and less than eighteen years (in view of the impossibility of
mainly, oropharyngeal cancer7,8. signing the informed consent form). The form consisted of ten
In Brazil, oral cancer is the fifth most common in men objective questions in relation to the perception, knowledge,
and the ninth most common in women in the Northeastern etiology, symptoms, diagnosis and treatment of oral diseases,
region, affecting people over the age of forty and in most especially in oral cancer. Questions were raised that were
cases leukoderma individuals2. In 60% of oral cancer cases, seen as important and necessary to identify the knowledge of
the diagnosis is only reached in the advanced stages of the students in the sample, such as the signs and symptoms of
disease, which reduces the chances of survival and gives a oral cancer, which professional to look for when presenting
worse prognosis, increasing the costs and complexity of cancerous signs and how to conduct treatment after diagnosis.
treatment. Late diagnosis can be related to some factors The inclusion criteria were students aged eighteen and
such as poor professional training and/or lack of specialized over, who were duly enrolled from the fourth to the ninth
services9,10,11. semester of the dentistry course.
Taking into account the high mortality caused by this
disease, prevention and early diagnosis are fundamental to 2.4 Data collection and analysis
improve prognosis, allowing for a 90% chance of cure, taking After collection, the data was input in the Windows
into consideration that the Dentist is the most appropriate Excel Software and submitted for statistical analysis in the
health professional for such actions12. Thus, it is essential IBM SPSS 2018 program. The total index of correct answers
that undergraduate dentistry students have, throughout their related to ten questions, nine with a single correct answer
academic experience, a qualified training regarding oral and one with the possibility of up to six correct answers
cancer. Considering that the educational process contributes to was measured in each semester evaluated. The correlation
reducing morbidity and mortality statistics, this study aimed between the number of correct answers and the progress of
to identify the level of knowledge of undergraduate dentistry
the semesters (from fourth to ninth) was tested with Kendall’s
students at a university in relation to lesions with potential
tau b coefficient. Then, an analysis was performed for each
for malignancy, oral cancer, their risk factors and treatment
question, considering the proportions of responses for each
of this disease.
choice provided in the structured questionnaire. Fisher’s exact
2 Material and Methods test with Monte Carlo approximation was used. Graphs and
tables representing the values ​​found with their respective
2.1 Study design and study population percentages were constructed from the data collected.
This was an observational, cross-sectional, qualitative and
3 Results and Discussion
descriptive study. The Dentistry course at the university where
this study was conducted consists of nine academic semesters. 236 students regularly enrolled in the Dentistry course
Forms were applied to students from the fourth to the ninth participated in the study. Thirty-six students attending the ninth
semester of this institution. The sample was chosen at random semester and 200 between the fourth and eighth semesters
and consisted of 236 students of both sexes, regularly enrolled (forty per semester). Of the total respondents, 176 (74.58%)
in the course, with forty students from each semester from were female and sixty (25.42%) were male. Regarding the
the fourth to the eighth and thirty-six students from the ninth age group, the students were between eighteen and forty-
semester, as there were only this number of students enrolled eight years old, with the average age of the participants being
in that semester in the period the research was conducted. twenty-three years old, with a standard deviation of 3.96.
The total number of correct answers related to ten
2.2 Ethical approval and informed consent
questions, nine with a single appropriate answer and one with
The Research Ethics Committee approved this study the possibility of up to six correct answers was measured in
under protocol: 4.114.723. The form was applied by only each semester evaluated. The correlation between the number

J Health Sci 2022;24(1):35-41 36

 of correct answers and the progress of the semesters (from the rt = -0.093), that is, there was no difference in the evolution
fourth to the ninth) was tested with Kendall’s tau b coefficient. of knowledge about the questions used throughout the tested
There was no statistically significant difference (p = 0.334; semesters, with results shown in Table 1.

Table 1 - Distribution of the number and percentages of responses, per semester, on factors related to knowledge of oral cancer, 2020
Correct Answers per Semester
4TH 5TH 6TH 7TH 8TH 9TH Correct
Variable Semester Semester Semester Semester Semester Semester Answers
N (%)
N (%) N (%) N (%) N (%) N (%) Total (%)
What is the most common type 28 34 30 25 32 29 178
1
of oral cancer? (70%) (85%) (75%) (62.5%) (80%) (80.56%) (75.42%)
What is the most common
8 20 6 8 5 16 63
2 anatomical region affected by
(20%) (50%) (15%) (20%) (12.5%) (44.44%) (26.69%)
oral cancer?
What is the most common
26 29 29 ( 27 29 173
3 clinical presentation of oral 33 (82.5%)
(65%) (72.5%) 72.5%) (67.5) (80.56%) (73.31%)
cancer in early-stage patients?
What are the features of
12 11 15 15 92
4 the lymph node in regional 17 (42.5%) 22 (61.1%)
(30%) (27.5%) (37.5%) (37.5%) (38.98%)
metastasis?
Which type of pre-cancerous 30 34 31 17 20 18 150
5
lesion is the most frequent? (75%) (85%) (77.5%) (42.5%) (50%) (50%) (63.56%)
The highest prevalence of oral 34 36 31 27 34 21 183
6
cancer occurs in: (85%) (90%) (77.5%) (67.5%) (85%) (58.33%) (77.54%)
Which professional should be
28 31 33 33 30 32 187
8 sought in case of suspected
(70%) (77.5%) (82.5%) (82.5%) (75%) (88.89%) (79.24%)
oral cancer?
Assuming that a patient comes
to your practice with a lesion
that has been present for more 26 37 37 27 27 183
9 29 (72.5%)
than 15 days, abscesses and (65%) (92.5%) (92.5%) (67.5%) (75%) (77.54%)
darkened parts, what would be
the best course of action?
In the case of a lesion with
35
suspected malignancy or with 34 32 23 27 180
10 (87.5%) 29 (72.5%)
potential for malignancy, what (85%) (80%) 57.5%) (75%) (76.27%)
type of biopsy is indicated?
Source: Resource data.

An analysis was performed for each question employed, As for the second question, as shown in table 2, there
considering the proportions of responses for each choice was a difference between the semesters in the proportions
provided in the structured questionnaire. For this, Fisher’s of the answers when asked, “What is the most common
exact test with Monte Carlo approximation was used. anatomical region for the presentation of oral cancer?” (p
There was no difference between semesters in the = 0.000). It was observed that 20% of students in the fourth
proportions of responses to the first question “What is the semester answered the question correctly, 50% in the fifth
most frequent type of oral cancer?” (p = 0.069). In the fourth semester, 15% in the sixth semester, 20% in the seventh
semester, 70% of students answered the question correctly; semester, 12.5% in​​ the eighth semester and 44.4% in the
there was an adjustment to ninth semester.

Table 2 - Distribution of the number and percentage of responses per semester, surrounding the anatomical region with the highest
prevalence in oral cancer, 2020
Semester of Participant at Time of Interview
What is the most common
4th
5th 6th 7th 8th 9th
anatomical region for occurrence Total
semester semester semester semester semester semester
of oral cancer?
Number count Bucal Mucosa
8 10 8 10 5 4 45
% of semester of participant at time
20.0% 25.0% 20.0% 25.0% 12.5% 11.1% 19.1%
of interview
Number count TONGUE
8 20 6 8 5 16 63
% of semester of participantat time
20.0% 50.0% 5.0% 0.0% 12.5% 44.4% 26.7%
of interview

J Health Sci 2022;24(1):35-41 37

 Semester of Participant at Time of Interview
What is the most common
4
th
5th 6th 7th 8th 9th
anatomical region for occurrence Total
semester semester semester semester semester semester
of oral cancer?
Number count FLOOR OF MOUTH
21 7 24 21 28 15 116
% of semester of participant at time
52.5% 17.5% 60.0% 52.5% 70.0% 41.7% 49.2%
of interview
Number count OROPHARYNX
0 2 1 0 1 0 4
% of semester of participant attime
0.0% 5.0% 2.5% 0.0% 2.5% 0.0% 1.7%
of interview
Number count GINGIVA
1 1 0 0 1 1 4
% of semester of participant at time
2.5% 2.5% 0.0% 0.0% 2.5% 2.8% 1.7%
of interview
Number count NO ANSWER
2 0 1 1 0 0 4
% of semester of participant at time
5.0% 0.0% 2.5% 2.5% 0.0% 0.0% 1.7%
of interview
Number count TOTAL
40 40 40 40 40 36 236
% of semester of participant at time
100% 100% 100% 100% 100% 100% 100%
of interview
Source: Resource data.

There was no difference between semesters in the Figure 1 - Graph that presents the factors for oral cancer and the
proportions of responses to the third question “What is the number of students who opted for each one
most common clinical presentation of oral cancer in patients
at an early stage?” (p = 0.143). In the fourth semester, 65% of
students got it right, in the fifth semester 72.5%, in the sixth
semester 72.5%, in the seventh semester 67.5%, in the eighth
semester 82.5% and in the ninth semester 80.6%.
There was no difference between the semesters in the
proportions of the answers to the fourth question “What are
the characteristics of the lymph node in regional metastasis?”
(p = 0.116). The percentage of correct answers among
students in the fourth semester was 30%, in the fifth semester
it was 27.5%, in the sixth and seventh semester it was 37.5%, Source: Resource data.

in the eighth semester it was 42.5% and the ninth semester There was no difference between the semesters in the
was 61.1%. proportions of the answers to the eighth question “Which
There was a difference between the semesters in the professional should be sought in case of suspected oral
proportions of the answers to the fifth question “Which type cancer?” (p = 0.409). The correct answer was given by 70% of
of pre-malignant lesion is the most frequent?” (p = 0.000). In students in the fourth semester, 77.5% of students in the fifth
the fourth semester, 75% of students answered the question semester, 82.5% of students in the sixth semester, 82.5% of
correctly, while in the fifth semester 85%, 77.5% in the sixth, students in the seventh semester, 75% of students in the eighth
in the seventh semester it was 42.5%, in the eighth it was 50% semester and 88.9% of ninth semester students.
and the ninth semester was 50%. There was no difference between the semesters in the
There was no difference between the semesters in the proportions of the answers to the ninth question “Assuming
proportions of the answers to the sixth question “The highest that a patient arrives at your practice presenting a lesion that
prevalence of oral cancer occurs in ...” (p = 0.156). Of the has been present for more than fifteen days, abscesses and
students in the fourth semester 85% answered “males”, in darkened parts, what would be the best course of action?” (p =
the fifth semester 90% gave this answer, in the sixth semester 0.095). The percentage of students who gave the correct answer
77.5%, in the seventh semester 67.5%, in the eighth semester in each semester was 65% for the fourth semester, 92.5% for
85% and in the ninth semester 86,1%. the fifth semester, 92.5% for the sixth semester, 67.5% for the
There was no difference between the semesters regarding seventh semester, 72.75% for the eighth semester and 75% for
the proportions of the answers to the seventh question “Check the ninth semester.
the correct alternative(s) surrounding the risk factors of oral Dentistry students are the future workforce and they are
cancer” (p = 0.663). For this question, each interviewee had responsible for diagnosing oral cancer and disseminating
the possibility to give more than one answer, and there was patient education on the subject, although other professionals
more than one correct answer, as illustrated in Figure 1. can contribute13. It is essential to act in the community in

J Health Sci 2022;24(1):35-41 38

 order to achieve health promotion. Therefore, in order to temperature in the oral cavity, promoting harmful effects.
work efficiently in the prevention of a certain disease, it is Alcohol consumption, on the other hand, is closely related to
plausible to know how to identify its characteristics, and cellular hyperproliferation, increasing the fragility of inhaled
thus create effective measures that can favorably reach or ingested carcinogens and also in DNA repair, especially in
individuals, thereby reducing its occurrence. For this reason, the consumption of ethanol.
it is vitally important to carry out research that evaluates the Alcoholism and smoking have synergistic effects,
knowledge of dentistry students, verifying their preparation however, in previous studies it was found that alcohol
and qualification to execute their role with competence14. can be an independent factor for the cause of oral cancer,
According to the consulted literature, women have depending on the dose and consumption routine21. In a study
greater participation in questionnaires, possibly due to their carried out by SOARES et al.22, which aimed to describe the
willingness to contribute to research15,16, this statement epidemiological and clinical profile of people with oral cancer
corroborates the data of this study in which the majority of treated at reference hospitals in Brazil during from 2005 to
participants, 176 (74.58%), were female. However, there 2014, 62.52% were smokers and 48.77% alcoholics, a result
was a lack of interest from the students in collaborating with that also draws attention and shows the importance of dental
the study. Some justified it with feelings such as fear and professionals in raising awareness to their patients and general
insecurity, especially those finalizing their course. Others population.
showed disinterest in answering the questions, justifying Another factor related to pathogenesis of oral cancer is
that there was no need, remembering that all students infection by the Human Papilloma Virus (HPV), being placed
interviewed had already attended or were taking the Clinical as one of the alternatives to be marked by the students. In 1987,
Propaedeutics class, which covers contents of Stomatology Syrjänen24 first reported the possibility of HPV acting as an
and Oral Pathology. etiological factor in oral cancer. In this study, students showed
Dental students should not treat the subject of oral cancer that they did not know this information, since the statement
as isolated from their curriculum, but as a necessity for their presented one of the lowest rates of choice by students, with
daily practice17. Thus, this study is of fundamental importance, only seventy-three markings, corresponding to 7.4% of the
since the ability of Dental Surgeons to make an early diagnosis total. There are approximately 120 virus subtypes that can
of oral cancer is directly proportional to the knowledge and be associated with benign and malignant lesions, and in the
skills acquired during the period of their studies18. Therefore, oral cavity, HPV subtypes six and eleven can be associated
it is of utmost importance to evaluate student learning and to with benign lesions, while subtypes sixteen and eighteen with
be able to propose the carrying out of extension activities that potential malignancy and squamous cell carcinoma. HPV-16,
provide continuity of learning, improving the knowledge of mainly, has been considered as a factor in the development of
future professionals. a subset of squamous cell carcinoma, mainly at the base of
To favor the prevention of a disease, it is important to the tongue25.
know how to identify the population and the risk factors Recognizing excessive exposure to solar radiation as a
involved, then establishing measures that are beneficial and risk factor for development of lip cancer is a pre-requisite.
favorable to the individual, in order to reduce the probability Ultraviolet (UV) rays damage the cells of the epithelium as
of its occurrence19. In this sense, in the seventh question, well as the connective tissue, increasing the possibility of
students were asked the factors that cause oral cancer and triggering lip carcinoma26. For the prevention of this type of
no statistically significant difference was found for this cancer, there are measures that range from the population’s
questioning. Most students were able to answer at least one awareness and guidance on the disease, to encouraging the
of the main factors. use of hats and sunscreens. It is important to avoid exposure
The results showed that all students interviewed in the to sunlight during the period from ten in the morning to four
fifth semester were unanimous in responding to smoking and in the afternoon, and mainly, to have the routine use of lip
exposure to sunlight as predisposing factors to oral cancer, and sunscreen, more precisely fifteen to thirty minutes before
thirty-eight of the students from that period, also responded exposure to sunlight, performing its reapplication after
to alcoholism. In relation to the entire sample, 233 (23.5%) accentuated activities, in which the product may have been
signaled smoking, 222 (22.4%), alcoholism and 203 (20.5%) removed and its effect reduced or even cancelled27.
exposure to sunlight. Another aspect that is important to discuss is related
According to literature, smoking, drinking and solar to the students’ doubts and difficulty in responding to the
radiation are the main triggers for the development of oral characteristics of the lymph node in regional metastasis. In
cancer6. Scheidt et al.20 affirm that tobacco is a major factor for this regard, only ninety-two students in the sample (39.00%)
the development of oral cancer, with about 50 substances with answered correctly. This result corroborates the findings by
carcinogenic potential in its composition, such as nitrosamines Soares et al.28, who conducted a survey with dental students,
and aromatic hydrocarbons, in addition to the great increased in order to observe the level of knowledge on oral cancer

J Health Sci 2022;24(1):35-41 39

 and, when asked about the characteristics of lymph nodes a scientific article. J Sci Commun 2010;163:51-9. doi: https://
in regional metastasis, only 44.36% of students were able to doi.org/10.1016/j.Sc.2010.00372.
answer that metastatic lymph nodes are firm and painless. 2. Van der Geer J, Hanraads JAJ, Lupton RA. The art of writing
In both studies, less than half of the sample answered a scientific article. Heliyon 2018;19:e00205. doi: https://doi.
the question correctly, which shows not only the difficulty org/10.1016/j.heliyon.2018.e00205
of the suspected diagnosis of metastasis, but also the 3. INCA. Estimativa 2020 – Brasil. Rio de Janeiro: INCA; 2020.
difficulty in performing the examination of the lymphatic
4. Brasil. Ministério da Saúde. Sistema de informações sobre
chains, emphasizing the need to further explore the content Mortalidade. Brasília: MS; 2019.
in specific disciplines. This thinking also corroborates with
5. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal
the study by Awojobi et al.29 who, when investigating the
A. Global cancer statistics 2018: GLOBOCAN estimates of
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