Introduction
During the last two decades, several types of research conducted have variably emphasized the fact that there exists a two-way relationship between systemic conditions and oral disorders. In addition, an improved understanding of oral diseases demonstrates clearly that many oral disorders have multiple environmental, behavioral, and systemic risk factors for disease initiation and progression.1 Same is the case with tobacco lesions, wherein screening oral cavities is of utmost importance for earlier diagnosis of tobacco-induced cancers.2 Cancers due to tobacco use are preventable, and thus, it is important to pay attention to the increasing rates of tobacco usage for early intervention.3 The National Tobacco Control Program (2007-2008) has been launched in India, and constructive measures for tobacco control have already been put in place.4 Oral cavities serve as a natural mirror in identifying the initiation and progression of most of the tobacco-induced premalignant and malignant lesions.5 Thus, it is the sole duty of dental practitioners to assess the presence of any detrimental habit or any alteration in the otherwise healthy oral cavity that may be responsible for further progression into premalignant or malignant lesions. It is equally crucial to provide necessary treatment options either through self-intervention or referral at an early stage following this detection. As an attempt to understand the barriers faced by the dental community and to assess the practices followed by dental doctors towards tobacco cessation activities in their dental setting, the following survey was designed. This research intends to assess the approach of a routine dental practitioner (trained or otherwise) toward tobacco cessation activities in dental settings.
Materials and Methods
A cross-sectional research study was designed with the fabrication of a Google form questionnaire to gather information on the approach toward tobacco cessation in a dental setting by dental practitioners. The questionnaire included a series of questions firstly pertaining to the demographics of the population like the degree of respondents, their practice location, total experience or years of practice, etc. This was followed by basic questions related to tobacco screening, treatment modalities followed, routine practices, capacity building/ training needs, patient sensitization, etc. Identifying information like name, basic degree information, gender, practice location, and total years of experience was considered for future reference but was kept optional. This questionnaire was circulated through diverse WhatsApp groups and through posts on social media sites like Facebook to achieve responses across the country. A total of 114 responses were received through Google forms. The following responses were subjected to data cleaning and subsequent analysis using Microsoft Excel. Attempts to consider all responses from practicing dental doctors across the country were made in the survey. Multiple entries or more than one entry from the same person were excluded from the study. Also, the study attempted to not consider responses from students still studying for their dental bachelor's degree. No approval from the ethical committee was taken for this survey since this study did not involve any direct interaction with patients or any clinical intervention. Only the responses received through Google Forms were analyzed.
Demographics of population
Out of 114 data responses received, 105 entries were considered for analysis following data cleaning (Table 1). Out of these 105 entries, about 73.33 % (n=77) entries were achieved from BDS (Bachelors of Dental Surgery) doctors while 26.66% (n= 28) entries were achieved from MDS (Masters of Dental Surgery) doctors. Most of the respondents practiced in areas like Mumbai, Navi-Mumbai, Vasai-Virar, Thane, and the outskirts of the Thane area (n=72) (Figure 1). The majority of the respondents (84.76%) reported having a practice in a private setting while 12.38% practiced in semi-private or government settings like at a college, hospital, trust, organized chains, etc. About 12 of the respondents (n=12) reported having practiced dentistry for more than 10 years while the majority of respondents had a practice of about 1 to 5 years.
Table 1
Demographics of the population
Figure 1
Practicing location of the respondents
(Source: - Microsoft excel graph-original findings from the survey)
Figure 2
Barriers to quitting tobacco-related habits
(Source: - Microsoft excel graph-original findings from the survey)
Table 2
Assessment survey questions - I
Table 3
Assessment survey questions - II
Table 4
Assessment survey questions - III
Table 5
2 X 2 table -Workshop on tobacco vrs workshop in near future
Table 6
2 X 2 table - Workshop on tobacco vrs IEC
Results
The survey questionnaire focused on different aspects of tobacco cessation activities like screening, patient sensitization, commonly followed approaches, and training needs assessment. As per the responses received, only around 40% of respondents reported having “always” (5 out of 5 patients) screened for tobacco-related habits while around 3.8% of respondents “never” (0 out of 5 cases) screened for tobacco-related habits in their dental practice. 62.85% reported having never conducted a dental cancer screening camp (Table 2). Nearly 49% of the survey respondents lacked basic tobacco-related IEC material like banners, posters, demonstration videos, or help books required for patient sensitization even when the majority of dentists believed lack of motivation and deep-rooted cultural habits to be a common barrier for patients to quit tobacco (Figure 2). While treating tobacco-related lesions in a dental setting a multidisciplinary approach was followed which included a combination of more than one intervention like counseling, usage of quit tobacco services, intervention through biopsy, or referral to the nearby hospital depending on a case-by-case basis. Around 60% of respondents reported, that they “Always” (5 out of 5 cases) provided tobacco cessation advice in their clinics. Counseling was carried out for many patients with the time of counseling being 10 to 15 mins for most cases. Oral biopsy was not commonly approached in a dental setting. About 39.04% never carried out a biopsy in a dental setting while 36.19% rarely carried out an oral biopsy. This may be significantly related to the fact that 85.71% of respondent dentists accepted that they require extra support while performing a biopsy in a clinical setting. (For example: - A need for a MDS doctor or an Oral Surgeon consult, special tools, etc.) Nearly 64% of respondents reported that they had never attended any tobacco cessation workshops while 85% of respondents were willing to attend tobacco cessation workshops in near future.
On plotting a 2 by 2 table, taking into consideration the variable as those who attended any kind of workshop on tobacco cessation against those who would be willing to attend workshops in the coming future, it was observed that out of 37 respondents who had already attended tobacco cessation workshops, 31 (83.78%) were willing to attend more workshop related to tobacco cessation in coming future, while 6 of them were satisfied with the workshop earlier attended. (Table 5) Similarly, out of 37 respondents who had attended the workshop, only 21 respondents (56.76%) accepted having tobacco-related IEC materials in their clinic. (Table 6)
Discussion
Screening is the first step towards the realization of any unhealthy oral health conditions. While screening for tobacco-related habits holds high significance, not many dental doctors seem to consider this seriously. This highly suggests a need for a standardized format of reporting/diagnosing while screening patients in a dental setting so that no important finding is missed. This standardization in the dental OPD format can be thought over and developed by competent authorities like the dental associations or the dental councils and can be circulated amongst the dental community making it a mandate to obey. This will not only assure uniformity in the dental screening process all across the country but also assure the completeness of the screening process. With a standardized format, that includes screening questions on tobacco-related habits and lesions, other than dental health, there is a possibility for better and early diagnosis of tobacco-related illness.
Another sector of concern is the lack of community intervention efforts undertaken by the practicing dentist to include those beyond the reach of dental care. This is evident from the figures that around 62.85% of respondents in the survey never participated in dental cancer screening camps. Attempts should be made to enhance participation of the dental doctors in various community intervention activities for improving the reach of dental healthcare as a means to reduce dental health inequities.
In the coming decade, there has been a shift in the practices followed from initial referral to a multidisciplinary approach in a dental setting. It is good to see that most dentists are providing counseling and treatment per se. However, not much emphasis is being given to patient sensitization. Most patients involved in a tobacco habit are unaware of the consequences of tobacco intake. Thus, it is of importance that a dental setting possesses adequate IEC/BCC materials like posters, banners, help books, demonstration videos, etc. depicting the ill effects of tobacco and tobacco products consumption required for patient sensitization.
Motivation is a key factor for a patient to quit a tobacco habit. Maneuvering dedicated trained counselors for tobacco counseling might help provide better counseling and increase quit tobacco attempts. Barriers are faced by dentists while executing tobacco cessation activities in their dental settings. Most dentists have accepted the fact that they need support from a MDS doctor or oral consult while performing biopsies. Adequate education for upgrading the existing knowledge and skill set of a dentist is a must. There exists a need for rigorous coaching of the dentist so that they are more comfortable and efficient in their approach. Surgical procedures like biopsies are being avoided due to a lack of required tools and skillsets in general practice. A biopsy can be performed in the clinical setting if provided with adequate training and hence biopsy workshops should be held to encourage good biopsies. The majority of respondents in this survey were untrained which highlights the need for capacity building and catering to the training needs of dental doctors for tobacco cessation activities that can be carried out in a dental setting. This might help build competencies and better the chances of dental care delivery.
The survey's findings are supported by other previously published publications as well. For instance, an article on tobacco cessation by Murthy et al named “Tobacco cessation services in India: Recent developments and the need for expansion”; emphasizes the need for tobacco cessation training and its incorporation into the curriculum as a way forward in India. A survey study on tobacco cessation activities by Chandrashekar et al named “Addressing tobacco control in dental practice: A survey of dentist’s knowledge, attitudes, and behaviors in India, mentions similar findings about dentists needing formal training. A study by Parker et al on Attitudes, practices, and barriers in tobacco cessation counseling among dentists of Ahmedabad city suggests a requirement of formal training for tobacco cessation counseling. A similar study by Oswal K, et al. named Knowledge, Attitude and Practice of Tobacco Cessation Counselling among Dental Professionals in Maharashtra- An Opportunity for Health Promotion also highlights similar insights on this topic.
Limitations
This survey recorded very less responses as compared to the number of practicing dentists all over India. The reach of the survey was restricted to shares on WhatsApp groups. Thus, this study effectively portrays a snapshot of the population while more data on a larger scale is required to depict an accurate representation of the population. Secondly, the study was totally dependent on the responses that were received from the respondent taking into consideration that the respondent would have answered with honest replies. A disclaimer was included at the beginning of the survey encouraging the respondent to provide honest replies that would help authenticate the data.
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