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The objectives of the study was to determine the proportion of patients attending dental access centers that are at risk of developing oral cancer because of lifestyle habits. Data were collected pro- spectively about the smoking and smokeless tobacco habits of patients attending a dental access centre at Karachi Medical and Dental College and Abbasi Shaheed Hospital in Karachi. It was a cross-sec- tional questionnaire survey. Results showed that more than 50% of patients attending the dental access centre were smokers, with almost 30% of the patients in high or very high tobacco use groups. The majority of attendees were under 45 years of age. It was concluded that significant numbers of patients attending the dental access centre have lifestyle habits that make them vulnerable to oral cancer. Dental access centres could usefully provide opportunistic health messages to patients about risk factors in the development of oral cancer and could create smoking cessation programmes.

Key Words: Oral cancer, dental access centers, lifestyle habits, smokeless and smoking tobacco.


Betal leaves and related products). Other main cause of illness is smoking.2,3 Public health professionals in dentistry for example dentists and dental hygienists can actively support their patients in their attempts to stop smoking through proper advice.4,5 There are studies which have shown the role of dentists in primary and secondary preventions of tobacco dependence.6

In Pakistan, consumption of smokeless tobacco is traditional practice and is culturally acceptable habit.

In Karachi, the consumption of betal nut in males (21%) One of the ten most common cancers worldwide is more common than in females (12%).2

When one is the oral squamous cell carcinoma.1 The incidence of oral cancer in Indo-Pakistan subcontinent is 40% of the total cancers as compared to Europe where prevalence is 2-4%.2 The high incidence rate in Pakistan is mainly due to the consumption of smokeless tobacco (betal nut, compared the rate of oral cancer in Pakistan with other countries in Eastern Mediterranean region the disease is more prevalent in Pakistan and the comparison in the prevalence of oral cancer within Pakistan shows that it is not same everywhere but differ among communities.

A report from Pakistan has also revealed that people using betal leaves with tobacco are 9.9 times more likely to develop oral cancer. Successful treatment for oral cancer requires early diagnosis, but due to the limited access to the proper medical care for poor communities this disease is often not diagnosed in early phase and therefore diagnosis and treatment in late stage causes spread of this disease and decreases the survival rate. Among all the Urban Cancer Registries of South Asia the incidence of Oral Cancer in both the gender was found to be the highest in this region.7,8

Diagnosing oral cancer in an early stage is the most effective way to reduce morbidity and improve survival rate.7 On the basis of known statistics on oral cancer it is essential to develop Oral Cancer Primary and Secondary prevention strategies to reduce the in- cidence of oral cancer.1 Age, tobacco, alcohol and areca nut increases the oral cancer landscape.9,10

Oral Leukoplakia and Submucous Fibrosis are po- tentially malignant in the oral cavity and are implicated by areca nut chewing. These disabling conditions in Asian population can be controlled by recommending the public to quit areca use. The epidemiological data arising largely from India, Pakistan and South Africa have derived much of the evidence implicating areca nut.11 The rationale of the study was to determine the proportion of patients who are at risk factors of devel- oping oral cancer.


A self-administered questionnaire was used to assess the main aims of the current study. Question- naire was carefully prepared from relevant published reports in international journals. The questionnaire questions were related to participants' nationality, age and sex. Data were collected prospectively about the smoking and smokeless tobacco habits of patients attending a dental access centre at Karachi Medical and Dental College and Abbasi Shaheed Hospital in Kara- chi. Response formats were used in the questionnaire such as yes,' no.' A pilot study was carried out on 10 patients at Karachi medical and dental college in the waiting area to assess the response of participants to the questionnaire before conducting the study.

369 questionnaires were distributed to the patients attending the outpatient dental clinic in Karachi Medi- cal and Dental College and Abbasi Shaheed Hospital one of the largest government hospital in Karachi, Pakistan. Completion of questionnaire was taken as consent from the patients. However, questionnaires which were not completely filled they were 11. Therefore the data of those 11 was excluded and a total of 357 completed questionnaires were entered into Statistical Package for Social Sciences (SPSS) version 13 for data statistical analysis. Descriptive data analysis was carried out.

Patients were categorised into one of four groups ranging from low risk to very high risk, according to their smoking tobacco and smokeless tobacco history. The four groups were as follows:

Group A: History of no addiction to smokeless tobacco and smoking tobacco or consuming very few smoking tobacco (1-4cigarretes/day) and 1-2 smokeless tobacco.

Group B: Using smoking tobacco 5-20 cigarettes/ day but no use of smokeless tobacco.

Group C: Using smokeless tobacco 3-5 quid/day but no use of smoking tobacco.

Group D: Using smoking tobacco greater than 20 cigarettes / day and/or smokeless tobacco greater than 5 quid / day.


In the current study though it appeared that a significant proportion of patients attending the access centre had the risk factors for oral cancer, but few oral cancers would present clinically at the dental access centers as patients were mostly under 45 years old. As







Males Under 45 years###112###29.4

Females Under 45 years###89###23.4

Males 45-60 years###77###20.4

Females45-60 years###49###12.9

Males Over 60 years###24###6.3

Females Over 60 years###27###7.1

Smoking tobacco use


less than 20 cigarettes/ day###73###19.2

reater than 20 cigarettes/ day###39###10.2

Smokeless tobacco use

Non user of smokeless###134###35.2


less than 5 quid /day###73###19.2

reater than 5 quid/ day###39###10.2


Urdu Speaking###183###48.0






Marital status






Number of family


less than 5 in numbers###160###42

less than 10###210###55.1

A consequence the value of oral screening and provision of information about self examination for these individ- uals was limited. It would had greater importance to provide advice about risk factors, as it was likely that in due course, some of these younger patients with adverse lifestyle habits would develop oral cancer in later life.

Present study has also shown that significant numbers of patients attending dental access centers at Karachi Medical and Dental College and Abbassi Shaheed Hospital had lifestyle habits comprising of smoking tobacco which made them vulnerable to oral cancer. Primary prevention of oral cancer could be achieved very well in the dental access centers as these centers appeared well placed to play this role. There was the opportunity to provide opportunistic information about the hazards of smoking tobacco and smokeless tobacco use to the patients whose lifestyle habits had placed them at risk of developing oral cancer. Infor- mation leaflets provided to the patients had showed to be effective in improving and increasing knowledge, awareness and perception about risk of oral cancer.17,18,19

In addition smoking cessation programs could be imple- mented to prevent them from continuing the smoking habits. However, a fact should be taken into account that these patients had visited dentist when they had pain and therefore might not give importance to the information about the primary preventive measures.

In this study sample, about half of the participants were employed and had less than 5 family members. Almost half of the participants were unemployed and had low socio-economic status. One of the study had investigated the cost effectiveness of screening for oral cancer, concluded that opportunistic screening of high- risk groups in the private dental practice may be cost effective if targeted towards 40-60 year olds.20 Hence dental access centers could incorporate opportunistic oral mucosal screening into their practice.

As mentioned earlier, the primary preventive programs such as cessation of smoking and betal nut chewing should be aimed at those age groups who are under 45 years and who consume tobacco and areca nuts. Secondary prevention programs include promotion of regular self or professional examination. Prompt help seeking for potentially malignant oral symptoms should be aimed at those age groups who are over 45 years of age, who use tobacco and chew moderately to heavily areca nut.12

Previous studies had reported that there was a role of dentist in the recognition of oral cancer via oppor- tunistic oral mucosal screening.15 This was based on the fact that dentist had depth knowledge about oral mucosal lesions, but unfortunately those who were most at risk of developing oral cancer were the least likely to visit a dentist on regular basis.16

It would appear that tobacco usage is widely rec- ognized by patients as a risk factor for oral cancer. The dental practice provides a potential opportunity to provide oral health promotion services. Dental ac- cess centers were there in a government and private set up. Due to the high cost of the dental treatments in the private setups the patient's access was mostly towards the government setup. Majority of the people that were at risk of developing oral cancer because of lifestyle habits were from the poor community or low middle class because of less awareness about the risk factors. Private setups obviously attract a different type of client to a dental practice. The best way to initiate oral health promotion services is to implement primary prevention programs (e.g smoking cessation program) at government dental access centers.

There were lots of barrier in achieving preventive health services such as cost, time, awareness, lack of adequate incentives and lack of regular and routine enquiry into the smoking habits.

Smoking is an addictive activities with strong social links and is very difficult to discontinue. Nevertheless, advice support and encouragement from health care professionals can have a major impact for those who want to stop. Smoking cessation program is one of the few areas of health promotion where good evidence exists to show effectiveness.21

Information provided by patients was taken at face value; there were no secondary questions to check the veracity of the responses, and this may be a source of under-reporting.13,14 Furthermore, the results are based on two dental access centers of same organization and as such it is questionable as to whether the findings are generalizable to dental access centres throughout the rest of the Pakistan. Future research should therefore include multi-centre studies to address this limitation.


This study indicates that dental access centers are able to identify target groups as part of their routine triaging processes. It may be possible to use dental access centers as an effective way to selectively target risk group individuals by designing effective informa- tion programs. There should be an investment made by the commissioning bodies in the provision of such health care messages in dental access centers. Given the relatively poor survival rates of Oral cancer patients, cessation of tobacco use remains the key element in the fight against oral cancer.


The authors are greatly thankful to Dr. Nabeel Baig, and Dr. Nauman Shirazi (Demonstrators in the Department of Restorative Dentistry and Oral Biology respectively KMDC) for their contribution in distrib- uting the questionnaire.


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Publication:Pakistan Oral and Dental Journal
Article Type:Report
Geographic Code:9PAKI
Date:Mar 31, 2015

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