Keywords
malignant transformation - alcohol use - tobacco use - level of knowledge
Introduction
In 2018, a systematic review reported 354,864 new oral cavity and lip cancer cases
globally.[1] Another study in Asia found that oral cancer incidence varies from 0.12 to 4.12
per 1,000, with an average of 8.5 per 100,000 individuals.[2] Furthermore, Global Cancer Observatory (Globocan) 2021 reported that Indonesia had
5,780 new cases (1.5%) and 3,087 deaths (1.3%) related to oral cancer.[3]
In oral carcinogenesis, oral carcinoma is often preceded by a group of lesions called
oral potentially malignant disorder (OPMD).[4] OPMD is an umbrella term encompassing various oral lesions or conditions with a
higher risk of transforming into malignancies.[5] The most common OPMDs are leukoplakia, erythroplakia, actinic cheilitis, oral submucous
fibrosis (OSF), and oral lichen planus erosive type.[6] A meta-analysis reported that the global prevalence of OPMD is 4.47%, with a higher
incidence in men.[3] The etiopathogenesis of OPMD is a complex multifactorial process involving various
genetic and environmental factors.[1]
[7] However, many studies confirmed that tobacco smoking and frequent alcohol consumption
are the main risk factors for most OPMD development.[7] Other etiological factors such as ultraviolet (UV) exposure and betel nut chewing
are the primary factors in actinic cheilitis and OSF, respectively.[1]
The diagnosis of OPMD is made based on clinical and histopathological examination.[1]
[8] An assessment of risk factors is also needed to support a diagnosis.[8] Early detection of OPMD lesions and oral cancer improves survival and reduces morbidity,
damage, treatment time, and cost.[1] Mouth self-examination (MSE) is a useful tool for detecting suspicious lesions in
the oral cavity and may aid in the early detection of oral cancer and OPMD.[9] A previous study reported that the delays in OPMD diagnosis are due to the lack
of public awareness and knowledge about the signs, symptoms, and risk factors of OPMD
lesions.[10]
According to a cross-sectional research conducted in Uganda, young males riding motorcycles
smoke cigarettes and drink alcohol frequently.[11] The study by Ozoh et al[12] also found a strong correlation between current smoking and alcohol usage, as well
as a high rate of alcohol consumption among Nigerians. The motorcycle community is
considered to be at high risk for OPMD since smoking and drinking alcohol are risk
factors for developing the disease. The study's objective is to determine the level
of knowledge of the motorcycle community about OPMD. Thus, this study can serve as
the basis for further in-depth programs to prevent the onset of OPMD.
Materials and Methods
Study Design and Participants
This descriptive study's population is made up of the 68 consenting participants from
the “SunmoriYuk” motorbike club in Surabaya City, East Java Region, Indonesia. The
Slovin formula (e: 0.05) is used to apply simple random sampling, with a minimum of 59 samples needed
due to the population size of 68 participants. The details of the sample size calculation
are shown in [Fig. 1]. This formula can be used to estimate the ideal sample size when the population
is limited, and the researchers lack sufficient details on the behavioral distribution
of the population.[13] The informed consent procedure was used to obtain respondents' permission to participate
in the study. The study took place online from July 2021 until September 2021.
Fig. 1 Slovin's formula.
Questionnaire Format
The study was performed through 15 statement questionnaires that had passed statistical
tests for reliability and validity using the Windows-based IBM SPSS version 25 (IBM
Corporation, United States) applications. According to the results of the validity
and reliability tests, 13 out of the 15 items in the questionnaire are valid, and
all 15 questions are reliable. The questionnaire consists of several segments, including
sociodemographic data. The second segment contains information on risk factors, clinical
symptoms, and OPMD generally.
A Google Form questionnaire was used to collect the data, and the link was shared
on social media. Before completing the questionnaire section, respondents must select
the option to provide consent if they are willing to participate. The Guttman scale
was used to modify respondents' responses from 0 to 1, which was added to provide
a total result. Based on the total number of respondents' scores, the motor community
“SunmoriYuk's” knowledge level was divided into three categories: low (number of scores
0–4), medium (number of scores 5–9), and high (number of scores 10–15). Questionnaires
1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15 have a value of 1 for “yes” responses
and 0 for “no” responses. Questionnaire no. 3 scores 1 for “no” and 0 for “yes” responses.
Results
The sociodemographic distribution of the respondents is provided in [Table 1]. The questionnaire was given to 68 community members, and 60 of them responded.
Results were analyzed and had an 88% response rate, which met the required minimum.
The age range of 20 to 21 years old had the highest responses, with 50 respondents
(83.00%). The age groups of 18 to 19, 22 to 23, and 24 to 25 were represented by 6
respondents (10.00%), 3 respondents (5.00%), and 1 respondent (1.70%), respectively.
All of the respondents have graduated from senior high school. The study's respondents
also come from a variety of backgrounds. There were 52 respondents (86.7%) with no
cancer knowledge background. There were 53 (83.30%) respondents who had a history
of smoking, with 20 (33.30%) of them having smoked for 3 to 5 years and 14 (23.30%)
of them smoking 1 to 20 sticks daily. Of the 60 respondents, 46 (76.70%) drank alcohol,
with 19 (31.70%) doing so more than once monthly.
Table 1
Sociodemographic distribution of the respondents
|
Frequency
|
Percentage
|
|
Gender
|
Male
|
60
|
100
|
|
Female
|
0
|
0
|
|
Age
|
18–19
|
6
|
10.00
|
|
20–21
|
50
|
83.00
|
|
22–23
|
3
|
5.00
|
|
24–25
|
1
|
1.70
|
|
Education
|
Elementary school
|
0
|
0
|
|
Junior high school
|
0
|
0
|
|
Senior high school
|
60
|
100
|
|
Others
|
0
|
0
|
|
Family history with cancer
|
Yes
|
8
|
13.30
|
|
No
|
52
|
86.70
|
|
Smoking background
|
Yes
|
53
|
88.30
|
|
No
|
7
|
11.70
|
|
Smoking duration
|
Never/passive
|
10
|
16.70
|
|
< 1 y
|
1
|
1.70
|
|
1–3 y
|
13
|
21.70
|
|
3–5 y
|
20
|
33.30
|
|
> 5 y
|
16
|
26.70
|
|
Total cigarette consumption
|
Never/passive
|
10
|
16.70
|
|
< 1 stick/week
|
1
|
1.70
|
|
< 1 stick/day
|
3
|
5.00
|
|
1–5 sticks/day
|
12
|
20.00
|
|
6–10 sticks/day
|
13
|
21.70
|
|
11–20 sticks/day
|
14
|
23.30
|
|
> 20 sticks/day
|
7
|
11.70
|
|
Consuming alcohol background
|
Yes
|
46
|
76.70
|
|
No
|
14
|
23.30
|
|
Consuming alcohol duration
|
Never/passive
|
17
|
28.30
|
|
< 1 y
|
5
|
8.30
|
|
1–3 y
|
15
|
25.00
|
|
3–5 y
|
17
|
28.30
|
|
> 5 y
|
6
|
10.00
|
|
Alcohol consumption
|
Never/passive
|
17
|
28.30
|
|
< 1 time/month
|
19
|
31.70
|
|
2–4 times/month
|
18
|
30.00
|
|
2–3 times/week
|
4
|
6.70
|
|
> 4 times/week
|
2
|
3.30
|
[Table 2] provides the information of the knowledge level of the respondents about OPMD. It
is shown that the majority of respondents—26 (43.30%) respondents—had a moderate knowledge
about OPMD. The respondents were followed by others with a high level of knowledge—21
(35.00%) respondents—and others with a low level of knowledge—13 (21.70%) respondents—about
OPMD.
Table 2
Level of knowledge of members of the community about OPMD
|
Frequency
|
Percentage
|
|
Low (0–4)
|
13
|
21.70
|
|
Moderate (5–9)
|
26
|
43.30
|
|
High (10–15)
|
21
|
35.00
|
|
Total
|
60
|
100
|
Abbreviation: OPMD, oral potentially malignant disorder.
The questionnaire was divided into three domains: the knowledge of general information
about OPMD, the risk factors of OPMD, and the clinical features of OPMD. The distribution
of respondents' answers is provided in [Table 3].
Table 3
Respondents statement answers (n = 60)
|
Statements
|
Right
answer
|
False
answer
|
|
OPMD in general
|
Soft tissue disorders oral potentially malignant disorders (OPMD) are different from
precancerous lesions of the oral cavity
|
33 (55.00%)
|
27 (45.00%)
|
|
You heard about a mouth self-examination and/or performed at some[a]
|
11 (18.30%)
|
49 (81.70%)
|
|
Cancer of the oral cavity cannot develop from OPMD soft tissue abnormalities
|
41 (68.30%)
|
19 (31.70%)
|
|
Oral cancer can be prevented and treatment is improved with early diagnosis of OPMD
soft tissue disorders
|
41 (68.30%)
|
19 (31.70%)
|
|
Risk factor of OPMD
|
Smoking tobacco has the ability to contribute to OPMD's soft tissue abnormalities
|
47 (78.30%)
|
13 (21.70%)
|
|
Alcohol-containing beverages may result in OPMD soft tissue abnormalities[a]
|
28 (46.70%)
|
32 (53.30%)
|
|
Consuming betel nut can result in soft tissue abnormalities, according to OPMD[a]
|
25 (41.70%)
|
35 (58.30%)
|
|
UV radiation may result in OPMD's soft tissue abnormalities[a]
|
24 (40.00%)
|
36 (60.00%)
|
|
OPMD soft tissue problems can be exacerbated by a deficiency of fruits and vegetables
|
38 (63.30%)
|
22 (36.70%)
|
|
Elderly persons are more sensitive to OPMD soft tissue disorders
|
42 (70.00%)
|
18 (30.00%)
|
|
In OPMD, the human papillomavirus (HPV) may result in soft tissue abnormalities[a]
|
24 (40.00%)
|
36 (60.00%)
|
|
Clinical features of OPMD
|
OPMD could manifest as lesions or ulcers that are difficult to heal (permanent)
|
43 (71.70%)
|
17 (28.30%)
|
|
OPMD may develop red patches to appear in the oral cavity
|
42 (70.00%)
|
18 (30.00%)
|
|
OPMD may develop white patches to appear in the oral cavity[a]
|
25 (41.70%)
|
35 (58.30%)
|
|
OPMD may manifest as edema in the mouth[a]
|
20 (33.30%)
|
40 (66.70%)
|
Abbreviations: OPMD, oral potentially malignant disorder; UV, ultraviolet.
a Statement that indicates a knowledge gap.
Discussion
The first statement of the first domain is oral cancer can be prevented and treatment
is improved with early diagnosis of OPMD soft tissue disorders. This statement was
correctly answered by 41 responders (68.30%). The diagnostic process begins with an
oral clinical examination, including a visual and digital examination of the oral
cavity.[1] Statement, namely, OPMD soft tissue abnormalities do not have the potential to develop
into oral cavity cancer, received a total of 41 responses (68.30%) in its favor. This
claim is false since OPMDs are a specific type of epithelial lesion or condition that
manifests before invasive oral cancer and has a higher chance of developing into a
malignancy.[8]
[14] Some respondents to the study acknowledged that OPMD had the potential to develop
into oral cancer. The results also showed that the majority of the community, 49 respondents
(81.70%), incorrectly responded to the statement, “You have heard of and/or performed
in a self-examination of the oral cavity.” According to the study's findings by Wetzel
and Wollenberg,[9] the majority of community members are still unaware of the benefits of MSE, which
can help in the early detection of disorders like oral cancer and other damaging conditions
by detecting potentially malignant lesions in the oral cavity. Shrestha and Maharjan[15] described the MSE brief method, including visual inspection and palpation, which
is a simple, affordable, and harmless method for detecting oral precancerous lesions
that do not require to be examined by a dentist. The absence of proper research and
informal education regarding MSE in Indonesia may be responsible for the respondents'
lack of knowledge. MSE can contribute to prevention by preventing high-risk community
behaviors like drinking alcohol and smoking.[16]
In the second domain, 47 respondents (78.30%) correctly answered, “Smoking tobacco
can contribute to OPMD's soft tissue abnormalities.” This statement is true because
cigarettes containing nitrosamines will promote the hyperplastic transformation of
oral mucosal cells and its smoke exposure induces the risk of developing oral cancer
due to increased macrophages, lymphocytes, and matrix metalloproteinase-9 expression
in tongue epithelial cells.[17] In this domain, respondents also incorrectly answered a few questions. Thirty-two
(53.30%) respondents did not know that alcohol-containing beverages may result in
OPMD soft tissue abnormalities. According to Warnakulasuriya,[16] excessive alcohol consumption is a common risk factor for OPMD. Different results
were displayed in the journal by Firincioglulari et al,[18] 64.0% of participants knew drinking alcohol increased the risk of oral cancer, but
their attitudes remained the same. Thirty-five (58.30%) respondents chose the incorrect
answer to the statement that consuming betel nuts can result in soft tissue abnormalities.
According to the study by Warnakulasuriya and Chen,[19] according to all Taiwanese investigations, the risk of developing leukoplakia or
submucous fibrosis increases with an exposure level of chewing time and quantity of
areca nut. A survey in Jakarta revealed that 13 out of 1,000 respondents identified
as betel nut users.[20] A total of 36 (60%) respondents chose the wrong answer to the statement that UV
radiation may result in OPMD's soft tissue abnormalities. According to Pires et al,[21] actinic cheilitis was more common in male patients (68%) because of the higher frequency
of occupational exposure to UV radiation and the lower likelihood of sunscreen use
among males, one of the risk factors for the development of OPMD. The findings indicated
that there is still a need for improvement in the community's understanding of UV
light as a risk factor for OPMD. Lastly, 36 (60.00%) respondents incorrectly answered
that the human papillomavirus (HPV) might result in soft tissue abnormalities. HPV
infection has grown in oropharyngeal head and neck cancers over time, increasing from
40.50% before 2000 to 72.20% in 2005 to 2009; these data suggest that HPV infection
is a significant indication of oral cancer risk.[22] Research from Formosa et al[23] showed as many as 121 (77%) respondents did not agree that HPV is a risk factor
for cancer. The results showed that many community members need more understanding
of the risk factors of OPMD. Good knowledge of risk factors for OPMD can be used to
avoid delays in diagnosing OPMD.[10]
Knowledge of the clinical manifestations of OPMD can be used in detecting suspicious
lesions in the oral cavity and can assist in the early detection of oral cancer and
OPMD.[9] OPMD may develop white patches to appear in the oral cavity.[7] A total of 43 respondents (71.70%) were correct in their statement; OPMD could manifest
as lesions or ulcers that are difficult to heal (permanent). This result is aligned
with a previous study by Warnakulasuriya,[16] where a biopsy is required if a lesion develops for more than 2 weeks without healing,
which is a sign of malignancy. A chronic lesion is one of the clinical signs of OPMD,
as shown by another study.[8] The majority of the respondent is already aware that persistent lesions are one
of OPMD's clinical symptoms, according to the findings of a study. Additionally, 40
respondents (66.700%) responded incorrectly to the statement, “OPMD may manifest as
enlargement of the oral cavity.” Focal induration may be a sign of dysplasia or even
cancer.[24] The respondent may not be aware of swelling as a clinical sign of OPMD since they
have never personally experienced the disease.
Limitation
Given that this study was conducted in a single community (single-center), the results
cannot be generalized to other communities (multicenter). The language used in the
questionnaire and the data collecting method, a self-administered questionnaire, had
to have an impact on the study's findings in the form of gaps in each domain because
respondents can have difficulty understanding OPMD and MSE. Smokeless tobacco use
and tobacco chewing were excluded as etiological factors for OPMD because they are
still infrequent in Indonesia. However, the community in this study tends to be homogeneous
based on the gender, age, and educational background of each respondent. The same
sociodemographic distribution of respondents may help to reduce variations in the
study's findings about the knowledge level of the motor community “SunmoriYuk.”
Conclusion
According to the results of this study, the majority of the SunmoriYuk motorcycling
community's members have moderate knowledge of OPMD.
