Abstract
This study evaluates dentists’ knowledge of oral and dental procedures before and after radiotherapy for head and neck cancer patients in Gulf Cooperation Council (GCC) countries. A web-based cross-sectional survey was distributed via social media to dentists in six GCC countries, assessing knowledge of pre- and post-radiotherapy oral care. Data were analysed using descriptive statistics, Chi-square tests, and logistic regression. Among 1,223 participants, the highest representation was from Saudi Arabia (n = 387). Overall, 40.1% had poor knowledge, 51.3% moderate, and 8.7% good. Dentists with less than five years of experience demonstrated better knowledge (p < 0.0033). Saudi dentists and those in government clinics had higher knowledge than private practitioners and dentists in other GCC countries. General practitioners outperformed specialists (p < 0.0033). Knowledge of post-radiotherapy care was better than pre-radiotherapy, with significant gaps in management awareness. The findings highlight substantial knowledge deficiencies, particularly in pre-radiotherapy care. Surprisingly, less experienced dentists performed better, likely due to recent education. Despite relatively higher knowledge among Saudi dentists and government employees, overall knowledge remains suboptimal. These findings underscore the need for targeted education and training programs to enhance dentists’ understanding of radiotherapy-related oral care.
Several risk factors contribute to the development of HNCs in the GCC countries, with tobacco use being one of the most significant. Both cigarette smoking and traditional forms of tobacco consumption, such as shisha, are prevalent in the region and strongly associated with these cancers. A study estimated that tobacco smoking accounted for 16.3% of cancer cases in GCC countries in 2018, with notably higher rates among males (22.8%) compared to females (2.8%). Furthermore, the use of smokeless tobacco products, such as shammah, which is particularly popular in Yemen and southern Saudi Arabia-has been associated with an increased risk of oral cancers. Shammah is typically composed of powdered tobacco mixed with lime, ash, pepper, and aromatic oils, and is placed in the buccal vestibule for prolonged contact with the oral mucosa, allowing for nicotine absorption before the residual material is expelled. Research has shown a significant relationship between shammah use and the development of oral squamous cell carcinoma in the Gizan region of Saudi Arabia.
Treatments for head and neck cancer (HNC), such as supportive care, chemotherapy, surgery, and radiotherapy, can have a significant impact on oral health. Common complications include xerostomia (90%), mucositis (60%), candidiasis (40%), post-radiotherapy caries (50%), and osteoradionecrosis (15%), highlighting the importance of managing dental and oral tissues during HNC care. Radiation therapy is preferred for preserving organ function and is the primary treatment for tumours in the oropharynx, nasopharynx, hypopharynx, and larynx. In contrast, oral cavity cancers achieve the best cure rates through surgery, often combined with adjuvant or post-operative radiotherapy, with or without chemotherapy. Radiotherapy to the head and neck region can cause adverse effects such as oral mucositis, hyposalivation, loss of taste, dental caries, osteoradionecrosis, and trismus, significantly impacting patients’ quality of life. Oncology patients are traditionally treated in specialized cancer centers, but most lack dental departments, and dentists are rarely included in the oncology multidisciplinary team unless the treatment specifically involves the head and neck region.
Dental assessment and management of head and neck cancer (HNC) patients before and after cancer treatment are essential components of a comprehensive care approach. Few studies have assessed dentists’ knowledge regarding dental and oral procedures before or after radiotherapy for head and neck cancer patients, revealing variable levels of understanding among dental practitioners and students. This study aims to assess the level of knowledge among dentists regarding dental and oral procedures both before and after radiotherapy in head and neck cancer patients across a sample of Gulf Cooperation Council (GCC) countries.
Materials and methods
Study design and ethical approval
This study was conducted as a cross-sectional survey utilizing an open, web-based questionnaire, adhering to the guidelines specified in the Checklist for Reporting Results of Internet E-Surveys21. Ethical approval was granted by the Ethical Review Board (REC-HSD-113-2022) at Prince Sattam bin Abdulaziz University in Al Kharj, Saudi Arabia, ensuring that all procedures were in line with the highest standards of research ethics. The use of an online platform enabled broad participation, allowing for a diverse and representative sample to contribute valuable insights into the subject matter. All methods were caried out in accordance with relevant guidelines and regulations.
Setting and sample
The sample size was calculated using the Open-Source Epidemiologic Statistics for Public Health software, OpenEpi. We used 50% as the hypothesized percentage frequency of the outcome factor in the population, which is recommended for unknown frequencies, 5% as the absolute precision, and 20,000 as the estimated population size. The minimum sample size for this survey was 377. To ensure we obtained a representative sample from each country, we calculated the minimum sample size for each country using 10% as the absolute precision, which gave a minimum sample size of 96 for each country.
Questionnaire
Data for this study were collected through a web-based questionnaire, adapted from previous similar studies22,23,24. The questionnaire was aligned with guidelines from the Multinational Association of Supportive Care in Cancer (MASCC) and the International Society of Oral Oncology (ISOO) for managing oral complications in head and neck cancer patients. Prior to circulation, it was reviewed by six experts—three oral and maxillofacial surgeons and three oral pathologists—each with over five years of professional experience. Their feedback was used to refine the content, and items deemed irrelevant or unclear were revised or removed to ensure comprehensive coverage of both pre- and post-radiotherapy oral care procedures.
To further ensure relevance and clarity, a pilot test was conducted with 20 dentists from various GCC countries, including general practitioners and specialists with varying levels of experience. Participants assessed the questionnaire’s clarity, relevance, and feasibility. Based on their feedback, revisions were made, including rephrasing several questions for clarity and removing two redundant items to reduce respondent fatigue. These modifications were intended to enhance the questionnaire’s reliability and improve response rates in the main study.
The finalized questionnaire was then distributed via a Google Forms link, shared with potential participants through a range of social media platforms. To maximize geographic and demographic reach across the target GCC countries, the survey was exclusively disseminated via widely used social media platforms, including Facebook, Instagram, Twitter, and WhatsApp. This approach aimed to engage a broad and diverse group of respondents. Participation in the survey was entirely voluntary, with the purpose and significance of the study clearly outlined to encourage sharing and involvement. The confidentiality of participants was emphasized, and informed consent was obtained from all respondents before they began completing the questionnaire.
The survey was designed to ensure full participation, with all questions marked as mandatory. Respondents could not submit the survey unless all items were completed. To enhance the response rate, six reminder notifications were sent via social media platforms. The questionnaire was divided into three sections: the first section gathered sociodemographic information, including gender, country of practice, qualification (general dental practitioner or dental specialist), clinical experience (years), and work sector (governmental, private, or both). The second section focused on assessing dentists’ knowledge of dental and oral procedures prior to radiotherapy for head and neck cancer patients, while the third section addressed their knowledge of post-radiotherapy dental and oral procedures.
Data analysis
Demographics of participants were presented as frequencies and corresponding percentages, and plotted across demographics and participating countries.
The responses of dentists to various knowledge questions were presented as percentages of “correct” answers by country. The quality of knowledge was assessed using Bloom’s cut-off points25. Good knowledge was defined as correctly answering 80–100% of the listed questions, moderate knowledge as 60–79%, and poor knowledge as having fewer than 60% correct answers.
The Chi-square test was used to examine associations between the quality of dentists’ knowledge and demographics, including gender, work sector, qualification, clinical experience, and country of practice. The Bonferroni correction was applied to account for multiple comparisons, setting the significance level at p < 0.0033 (0.05/15).
A multivariate binary logistic regression model was created with good knowledge of dental and oral procedures for head and neck cancer patients undergoing radiotherapy as the outcome variable. Predictor variables included gender, work sector, specialty, clinical experience, and country of practice. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. A p-value of < 0.05 was considered statistically significant. Data analysis was performed using IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA).
Bias
Bias was minimized in this study through several measures. To address selection bias, the survey was disseminated widely via multiple social media platforms to ensure broad participation across GCC countries. Response bias was mitigated by assuring participants of anonymity and emphasizing the importance of honest responses. The questionnaire was carefully adapted from validated studies and reviewed by experts to reduce measurement bias. Additionally, it was pilot-tested and refined to enhance clarity and relevance. Sampling bias was addressed by targeting diverse demographics, including dentists from various specialties, work sectors, and levels of experience.
