J Canc Educ
DOI 10.1007/s13187-015-0823-2
Factors Influencing Early Detection of Oral Cancer by Primary
Health-Care Professionals
Y. Hassona 1 & C. Scully 2 & A. Shahin 1 & W. Maayta 1 & F. Sawair 1
# American Association for Cancer Education 2015
Abstract The purposes of this study are to determine early
detection practices performed by primary healthcare profes-
sionals, to compare medical and dental sub-groups, and to
identify factors that influence the ability of medical and dental
practitioners to recognize precancerous changes and clinical
signs of oral cancer. A 28-item survey instrument was used to
interview a total of 330 Jordanian primary health-care profes-
sionals (165 dental and 165 medical). An oral cancer knowl-
edge scale (0 to 31) was generated from correct responses on
oral cancer general knowledge. An early detection practice
scale (0 to 24) was generated from the reported usage and
frequency of procedures in oral cancer examination. Also, a
diagnostic ability scale (0 to 100) was generated from correct
selections of suspicious oral lesions. Only 17.8 % of the par-
ticipants reported that they routinely performed oral cancer
screening in practices. Their oral cancer knowledge scores
ranged from 3 to 31 with a mean of 15.6. The early detection
practice scores ranged from 2 to 21 with a mean of 11.6. A
significant positive correlation was found between knowledge
scores and early detection practice scores (r=0.22; p<0.001).
The diagnostic ability scores ranged from 11.5 to 96 with a
mean of 43.6. The diagnostic ability score was significantly
correlated with knowledge scores (r=0.39; p<0.001), but not
with early detection practice scores (r=0.01; p=0.92). Few
significant differences were found between medical and dental
primary care professionals. Continuous education courses on
Electronic supplementary material The online version of this article
(doi:10.1007/s13187-015-0823-2) contains supplementary material,
which is available to authorized users.
* Y. Hassona
yazan@ju.edu.jo
1
Department of Oral and Maxillofacial Surgery, Oral Medicine, and
Periodontology, Faculty of Dentistry, The University of Jordan, PO
Box 11942, Amman, Jordan
2
University College London, London, UK
early diagnosis of oral cancer and oral mucosal lesions are
needed for primary health-care professionals.
Keywords Oral cancer . Early diagnosis . Diagnostic ability .
Knowledge . Practice
Introduction
Oral cancer is a significant world health problem. It is the sixth
most common cause of cancer-related deaths [1]. The known
etiology of oral cancer is primarily linked to tobacco use,
alcohol consumption, betel use, and combinations of these
habits. Human papillomavirus (HPV) infection is implicated
mainly in oropharyngeal cancer, and ultraviolet light is the
main factor in lip cancer. Many other factors are possibly
implicated in mouth, lip, and oropharyngeal cancers, includ-
ing immunosuppression, familial and genetic factors, diet, and
socioeconomic status [2]. Some cancers are preceded by oral
potentially malignant disorders (OPMD) such as
erythroplakia, leukoplakia, or actinic cheilitis.
The oral cavity is easily accessible and can be examined
with little discomfort. It is unfortunate however, that most oral
cancers, even in developed countries, are detected at late
stages [2]. The evidence suggests that earlier diagnosis of oral
cancer leads to less complex treatment and improved progno-
sis and quality of life [3]. Usually, patients with oral cancer are
first seen by primary health-care professionals (HCPs), mainly
medical and dental. Emphasis therefore has been placed on
opportunistic screening of the oral mucosa by HCPs as a pro-
active preventative measure which may lead to reduced mor-
bidity and mortality from oral cancer [4].
Several studies have been conducted in different parts of
the world to assess the knowledge, opinions, and practices of
HCPs regarding oral cancer and in the main, revealed an in-
adequate level of knowledge about oral cancer including lack
of knowledge about risk factors and proper examination tech-
niques [4–17]. Most of these studies have used self-reported

surveys that paid little attention to details of specific proce-
dures that health-care workers perform as part of their practice
related to oral cancer detection [15]. Many medical students
and doctors appear unaware of some risk factors (e.g., alcohol)
as a risk factor for oral cancer or that erythroplakia and
erythroleukoplakia are early signs of oral cancer [16]. One
study found that GDPs were able to list a mean of 2.75 chang-
es associated with oral cancer, compared to that of GMPs (a
mean of 1.75 changes identified); while most clinicians sur-
veyed identified mouth ulceration (70 % GMPs, 80 % GDPs),
few reported speckled leukoplakia or erythroleukoplakia [17].
In addition, none of these studies have directly examined the
ability of primary HCPs to recognize precancerous changes or
clinical signs suggestive of early cancer.
The purposes of the present study therefore were to deter-
mine the declared thoroughness of examination and early de-
tection practices performed by primary HCPs, to compare the
performances of dental and medical primary care practi-
tioners, and to identify factors that influence their ability to
recognize precancerous changes and clinical signs of oral
cancer.
Materials and Methods
The University of Jordan, Amman, Faculty of Dentistry Re-
search and Ethics Committee (FDREC) reviewed and ap-
proved the study which was conducted in full accordance with
the World Medical Association Declaration of Helsinki.
A total of 380 primary HCPs practicing in Amman (190
dental practitioners and 190 medical practitioners) were ran-
domly selected by choosing the first, middle, and last names
from each page in the registries of the Jordanian Medical
Association and the Jordanian Dental Association to partici-
pate in the study. Sample size was calculated using nQuery
Advisor Software with oversampling to account for possible
withdrawals. Participants’ offices were contacted by phone to
arrange for appointments. From this 380, 50 practitioners (25
dentists and 25 medical practitioners) did not participate be-
cause they were either not interested or were busy at the sur-
vey time. The final sample thus consisted of 330 primary
HCPs (165 medical practitioners and 165 dental practitioners)
of mixed genders and various ages and time from qualification
(see BResults^). We assessed the representativeness of the
sample by comparing the characteristics of those who were
selected with the national health workforce profiles [18].
Two coauthors (AS and WM together) simultaneously
interviewed all participants to avoid any bias that could result
from variations in conducting the interview. Both coauthors
were trained to perform a professional interview. The purpose
of the study was explained, and participants were reassured
that no personal identifying information would be disclosed.
The interview was conducted using English for medical
J Canc Educ
terminology, and Arabic translation of medical terms was
available upon request. The interview questionnaire elicited
information about demographics, knowledge of oral cancer,
early detection practices, and attendance of continuing profes-
sional development courses on oral cancer. The knowledge
section included questions about risk factors and epidemiolo-
gy of oral cancer, oral lesions/conditions that might transform
to cancer, clinical signs and symptoms of oral cancer, and
techniques that might help in early detection of oral cancer.
Responses to knowledge questions were assessed as cor-
rect or incorrect, and Bknowledge scores^ were calculated for
each respondent. Score 31 indicated that the participant an-
swered all the factual questions about oral cancer correctly,
and score zero indicated that the participant failed to answer
any question correctly or answered BI do not know^ for all
questions. To assess the components of early detection prac-
tices performed by participants, a series of questions probed
specific examination procedures and the frequency of perfor-
mance. For each procedure, points were assigned as follows:
always=3, sometimes=2, only upon complaint/rarely = 1, and
never=0. BEarly detection practices scores^ were calculated
for each respondent by summing the scores across each pro-
cedure. Questions used to generate the Bknowledge scores^
and Bearly detection practices scores^ are available as supple-
mentary material.
In addition, the interviewers showed participants a collec-
tion of clinical images that represented a wide spectrum of oral
mucosal diseases including benign, potentially malignant
(precancerous), and malignant conditions. A total of 52 clin-
ical images were shown, and participants were asked to
choose images that they would consider Bsuspicious for
malignancy^. Clinical images used were from the authors’
own collection, which could not have been previously viewed
by participants, and were validated for adequacy and clarity
by an independent group of specialists in oral medicine. Of the
52 clinical images, 26 represented OPMDs or early cancer and
judged by the specialists group to be Bsuspicious for
malignancy^ according to the clinical appearance. The rest of
the clinical images represented common benign oral conditions.
The clinical images are available as supplementary material.
The ability of participants to recognize Bsuspicious
lesions^ was measured in terms of sensitivity according to
the following formula: ability to recognize a suspicious lesion
= (X/26)×100 % where X represents the number of images
correctly identified by the participant as Bsuspicious for
malignancy^ and 26 represents the actual number of clinical
images that are truly suspicious for malignancy [19].
Statistical analysis was performed using SPSS for Win-
dows release 16.0 (SPSS Inc., Chicago, IL, USA). Descriptive
statistics were generated. Student’s t test and Pearson’s Corre-
lations test (r) were used to examine differences and correla-
tions between groups. Results were considered significant if
p values were less than 0.05.
J Canc Educ

Results When asked about the possible clinical presentations of

Of the 330 respondents, 233 (70.6 %) were males and 97
(29.4 %) were females. Half of the participants (n=165) were
general medical practitioners, and the other half (n=165) were
practicing dentists. The years of clinical practice of partici-
pants ranged from one to fifty two (median 12.5 years±11.2).
Almost half of the participants (49.4 %) reported that they
had seen at least one patient with oral cancer or OPMD—either
during their practice or training. Almost all participants (96.7 %)
were able to identify tobacco as a main risk factor for oral cancer.
Nearly half of the participants correctly identified alcohol
(57.3 %), chewing habits (53.9 %), and human papillomavirus
(43.3 %) as risk factors. The presence of OPMDs and a previous
history of upper aerodigetive tract malignancy were identified as
risk factors for oral cancer by 64.8 and 73.6 % of the partici-
pants, respectively. Fewer participants were able to identify poor
diet (26.7 %), prolonged immunosuppression (30.3 %), sun ex-
posure (24.2 %), and older age (37.3 %) as factors contributing
to the development of oral cancer.
Regarding knowledge about the types of oral lesions/
conditions that might transform to cancer, 93.3 % of the par-
ticipants knew at least one OPMD. Leukoplakia was the best
known OPMDs by the participants (66.4 %). Erythroplakia,
chronic hyperplastic candidiosis, lichen planus/lichenoid le-
sions, actinic cheilitis, and submucous fibrosis were known
as being OPMDs by 44.2, 39.7, 33.2, 17.9, and 15.5 % of the
participants, respectively.
oral cancer, participants were more knowledgeable of the later
signs/symptoms of oral cancer such as enlarged lymph nodes
(71.8 %), ulcerated lump (67.6 %), limited tongue mobility/
dysphagia (67.3 %), and pain (65.2 %). Fewer participants
however knew early presentations of oral cancer such as white
patch (46.4 %), red patch (42.4 %), and delayed healing of
extraction sites (43 %).
The majority of participants knew that scalpel biopsy is still
the main diagnostic aid in oral cancer and OPMDs. Fewer
participants however were aware of the existence of other
diagnostic techniques such as exfoliative cytology (51.5 %),
brush biopsy (35.8 %), fluorescent lights (27 %), and toluidine
blue (20.9 %). Only 13 % of the participants had received
specific training on diagnostic techniques relevant to oral can-
cer and OPMDs during their study.
Knowledge scores were calculated for each participant and
ranged from 3 to 31. The mean knowledge score was 15.6±
5.4. Knowledge scores of participants who encountered a pa-
tient with oral cancer or OPMDs during their practice/training
or reported recent attendance of continuous professional de-
velopment courses about oral cancer were significantly higher
compared to other participants (p<0.05). In addition, recently
graduate practitioners (<10 years) had significantly higher
knowledge scores (p<0.05). No significant association was
found between knowledge scores and gender, age, or specialty
(medical vs. dental) of participants (Table 1).
Regarding early detection practices, only 17.8 % of the

Table 1 Factors associated with early detection practices of oral cancer, knowledge about oral cancer, and diagnostic ability of early cancer and oral
potentially malignant disorders

Interviewee variable No (%). Early detection practice p value Knowledge scoreb P value Diagnostic p value
scorea mean (± SD) mean (± SD) abilityc mean (± SD)

Gender M 233 (70.6) 11.5 (4.6) 0.50 15.4 (5.4) 0.19 41.1 (17.8) 0.45
F 97 (29.4) 11.2 (4.3) 16.3 (5.3) 42.8 (20.2)
Age (years) ≤30 117 (35.5) 11.5 (4.5) 0.82 15.8 (5.0) 0.16 44.1 (17.5) 0.62
31–40 113 (34.2) 11.3 (4.5) 14.9 (5.2) 42.3 (18.8)
>40 100 (30.3) 11.1 (4.6) 16.3 (6.0) 44.7 (20.4)
Specialty GDP 165 (50) 11.2 (4.5) 0.15 15.6 (5.6) 0.79 43.7 (19.3) 0.99
GMP 165 (50) 11.9 (4.5) 15.8 (5.2) 43.7 (19.6)
Experience (years of practice) <10 183 (55.5) 12.0 (4.5) 0.045 15.8 (4.8) 0.037 43.4 (18.4) 0.76
11–20 76 (23) 10.5 (4.5) 14.4 (5.6) 45.0 (18.4)
>20 71 (21.5) 11.5 (4.4) 13.6 (6.3) 42.9 (20.7)
Encountered a patient with Yes 163 (49.4) 12.2 (4.7) 0.016 17.2 (5.4) <0.001 49.8 (20.2) 0.026
oral cancer/OPMDs No 167 (50.6) 11.0 (4.3) 14.2 (5.0) 42.0 (17.5)
Attendance of continuous Yes 52 (15.8) 13.5 (3.8) 0.001 17.2 (4.9) 0.026 43.1 (19.9) 0.82
professional development No 278 (84.2) 11.2 (4.6) 15.4 (5.0) 43.8 (18.7)
course on oral cancer/OPMDs

SD standard deviation, OPMDs oral potentially malignant disorders, GDP general dental practitioner, GMP general medical practitioner
a
Early detection practice score ranges from 0-24
b
Knowledge score ranges from 0-31
c
Diagnostic ability out of 100 %. p value of Student’s t test

participants reported that they routinely performed oral cancer
screening. Nearly half of the participants (53 %) reported that
they inspect mucosal surfaces of the oral cavity every time
they encounter a new patient. Fewer participants however
claimed that they always palpate oral mucosal surfaces
(14.2 %), examine floor of the mouth/ventrolateral surfaces
of the tongue and the retromolar trigone (21.5 %), inspect the
oropharynx (33.6 %), and palpate cervical lymph nodes
(32.7 %).
While 62.1 % of the participants reported that they always
ask patients about smoking habits, only 25.8 % reported such
practice regarding alcohol consumption. Less than half of the
participants (46.1 %) routinely provided patients with
smoking cessation and alcohol moderation advice.
When asked about their action when they encounter a pa-
tient with a suspicious oral lesion, most participants (87.6 %)
would refer the patient to the appropriate specialty, 10.6 %
would do biopsy, 0.9 % would wait and see, and 0.9 % would
attempt to treat the patient. Most participants (81.2 %) agreed
that they would value further training in the diagnosis and
assessment of oral cancer and OPMDs.
Early detection practice scores were calculated for each
participant and ranged from 2 to 21. The mean early detection
practice score was 11.55±4.5. Early detection practice scores
of participants who had encountered a patient with oral cancer
or OPMDs during their practice/training or who reported re-
cent attendance for continuous professional development
courses about oral cancer were significantly higher compared
to other participants (p<0.05). In addition, participants with a
relatively recent graduation (<10 years) had significantly
higher scores compared to older graduates (p<0.05). No sig-
nificant association was found between early detection prac-
tice scores and gender, age, or specialty (medical vs. dental) of
participants (Table 1). A significant positive correlation was
found between knowledge scores and early detection practice
scores (r=0.22; p<0.001) (Fig. 1).
Validated clinical images were shown to participants to
examine their ability to recognize suspicious oral lesions. Par-
ticipants were asked to choose images that they would con-
sider suspicious (i.e., represent cancer or OPMDs) from a
collection of 52 clinical images. The participants’ ability to
recognize suspicious lesions ranged from 11.5 to 96.15 %,
with a mean of 43.6±18.9 %. Participants who reported en-
countering patients with oral cancer or OPMDs during their
practice/training were significantly more capable of recogniz-
ing suspicious oral lesions compared to other participants
(p<0.05). No significant association was found between abil-
ity to recognize suspicious lesions and gender, age, attendance
of continuous education courses, and specialty of participants
(medical vs. dental) (Table 1). The ability of participants to
recognize suspicious oral lesions significantly correlated with
their knowledge scores (r=0.39; p<0.001). However, there
was no significant correlation between ability to recognize
J Canc Educ
Fig. 1 Scatter plot showing correlation between knowledge about oral
cancer and potentially malignant disorders and early detection practices
reported by participants. A significant positive correlation was found
between knowledge score and early detection practices score (r=0.22,
p<0.001)
suspicious oral lesions and early detection practices (r=0.01;
p=0.92) (Fig. 2).
Discussion
The poor prognosis of much oral cancer has been largely at-
tributed to delays in diagnosis and treatment [2]. Previous re-
search has indicated that opportunistic screening of oral muco-
sal surfaces by primary HCPs may lead to earlier diagnosis and
greatly increases the probability of cure and the rate of survival
with minimum deformity and impairment [20]. Many oral can-
cers are preceded by noticeable mucosal changes (OPMD);
this combined with the fact that the oral cavity is easily acces-
sible for examination makes the early diagnosis of oral cancer a
reasonably achievable target. However, most oral cancers,
even in developed countries, are still detected at late stages
[21]. In the present study, we wanted to examine factors that
influenced diagnosis of precancerous changes and early detec-
tion of oral cancer in a sample of primary HCPs in Jordan.
The findings of the present study revealed that most partic-
ipants were able to identify tobacco as a major risk factor for
oral cancer. Studies from both developed and developing
countries have shown similar results, indicating that tobacco
is a well-known risk factor for oral cancer among HCPs
[4–16]. Similar to other studies, the association between alco-
hol consumption and oral cancer was less known, indicating
that there is a need to educate health-care professionals about
the adverse effect of alcohol consumption on oral tissues [8,
15, 16]. In fact, only a minority of participants routinely asks
their patients about alcohol consumption, and less than half of
the participants routinely provide patients with smoking and
J Canc Educ
Fig. 2 Scatter plot showing correlations between ability to recognize
suspicious oral lesions and knowledge about oral cancer and potentially
malignant disorders and early detection practices reported by participants.
A significant positive correlation was found between diagnostic ability
alcohol cessation advice. Contrary to general beliefs, alcohol
is consumed by some Arab populations. HCPs should there-
fore be encouraged to inquire about risk habits such as
smoking and alcohol consumption and provide patients with
professional counseling regarding smoking and alcohol ces-
sation. This is particularly important in conservative commu-
nities, like Arab countries, where patients may understandably
be reluctant to disclose their habits, in particular alcohol con-
sumption because of cultural and religious reasons. High-risk
HPV infection, particularly with HPV-16 and HPV-18, is con-
sidered an independent risk factor for a subset of oropharyn-
geal cancers [22]. More than half of the participants in the
present study were unaware of this fact; a figure similar to that
reported findings in other studies [4, 6, 8]. In addition, the
majority of participants were unaware of the association be-
tween poor diet, prolonged sun exposure, immunosuppres-
sion, and older age with the development of oral cancer. These
findings suggest that there is a defect in the knowledge of
HCPs regarding risk factors of oral cancer, a factor that might
limit their ability to identify at risk patients and take appropri-
ate actions. Although a majority of the participants (64.8 %)
knew that oral cancer might develop from a precursor lesion,
only few knew the types, presentations, and diagnostic mo-
dalities of these lesions. For example, more than half of the
participants had no idea that erythroplakia is a OPMD, despite
this lesion having the highest risk of malignant transformation
[2]. It appears to be necessary to emphasize the teaching of
potentially malignant soft tissue lesions through the under-
graduate curriculum and to provide updating opportunities
for HCPs to ensure that their knowledge about oral cancer
and OPMDs. In fact, the results of our study showed that
attendance of continuous professional development courses
is associated with better knowledge about oral cancer and
and knowledge score (r=0.39, p<0.001) (a). No significant positive
correlation was found between diagnostic ability and early detection
practices score (r=0.01, p=0.92) (b)
OPMDs. Alami et al., 2013 also examined oral cancer knowl-
edge among recently graduated medical and dental profes-
sionals from Jordan and found that the knowledge of recently
graduate dentists is significantly better compared to recently
graduated medical practitioners [6]. In contrast to their find-
ings, we did not find a significant difference regarding the
overall knowledge about oral cancer between medical and
dental practitioners; probably because our study included
practitioners with variable ages and years of practice. It seems
that recently graduated practitioners have better factual knowl-
edge because they still retain information they were taught
during their undergraduate study. This knowledge however
is gradually lost over time through memory decay. The results
of our study support this notion because it shows that relative-
ly, recently graduated (<10 years) participants had significant-
ly better knowledge compared to practitioners with less recent
graduation. These findings also support the importance of
continuous professional development courses in maintaining
practitioners’ knowledge current and updated.
The present study examined the thoroughness of oral ex-
amination performed by primary HCPs by using a series of
questions that probed specific examination procedures and the
frequency of performance. In contrast to studies from UK and
USA, our study revealed that only a minority of participants
routinely perform oral cancer screening during their practice
[4, 5, 7, 9]. In addition, common sites of oral cancer develop-
ment such as floor of mouth, ventrolateral surfaces of the
tongue, retromolar trigone, and the oropharynx were often
overlooked during oral examination. Systematic soft tissue
screening is an area of professional practice which could be
improved with further training. In fact, several good manuals
and protocols are available for this purpose [23, 24]. We have
suggested a BRULE^ for cancer diagnosis—an acronym based

on red or white lesion, ulcer, lump, and exceeding 3 weeks
duration [25]. Oral cancer educational materials should be
made available for primary HCPs to improve their diagnostic
abilities for the early signs of oral cancer and other mucosal
diseases. The results of our study support this notion by dem-
onstrating a significant positive correlation between attendance
of continuous professional development courses on oral cancer
and the thoroughness of examination performed by primary
HCPs.
Importantly, the present study is the first to examine the
ability of primary HCPs to detect suspicious oral lesions using
a collection of clinical images. This method might be a prom-
ising tool for the assessment of early detection practices and
diagnostic abilities of HCPs because it overcomes the discrep-
ancy between what HCPs report to do and what they actually
do. However, further validation of the clinical images by in-
ternational experts in the field is warranted. Nevertheless, our
results showed that the participants have inadequate diagnos-
tic abilities with regard to oral cancer and OPMDs (mean=
43.6 %). The ability to recognize suspicious lesions was
strongly correlated with encountering a patient with oral can-
cer or OPMDs during practice or training. This finding sup-
ports the use of case-based approach and multimedia such as
clinical videos and images in continuous education courses
because these methods might be more effective in improving
practical skills such as oral cancer detection and screening.
Further studies however are needed to test this suggestion.
In contrast to other studies, the present study found no
significant differences between medical and dental practi-
tioners regarding their knowledge, early detection practices,
and diagnostic abilities [6, 11, 14]. This is surprising because
dental practitioners are expected to spend a good portion of
their undergraduate study in learning oral soft tissues pathol-
ogy including oral cancer and OPMDs; therefore, it is not
unreasonable to assume that dental practitioners would have
better scores. Dental students’ knowledge about oral cancer is
mainly introduced in oral medicine and oral pathology courses
in the 4th and 5th years of study. The current teaching of oral
pathology and oral medicine in Jordan has been largely theo-
retical with a very limited practical component. Similarly,
medical students are briefly introduced to the topic of oral
cancer in the general surgery lectures in the 5th and 6th years
of their study, with little clinical exposure. Improvement of
undergraduate curriculum in this regard is needed to increase
the clinical exposure of medical and dental students to patients
with oral mucosal diseases including OPMDs and oral cancer.
We have recently introduced the case-based approach in
teaching oral medicine for dental students. The effect of this
change on students’ knowledge and diagnostic abilities needs
to be studied.
Findings of the present study strongly indicate a need for
continuing education about oral cancer. Unfortunately, there is
no current continuous medical or dental education system in
J Canc Educ
Jordan. Health-care authorities such as Ministry of Health,
Jordan Medical Council, and health faculties in Jordanian uni-
versities should place collaborative efforts to establish contin-
uous medical/dental education system tailored to the educa-
tional needs of Jordanian health-care workers.
The present study possesses several limitations. Although
the characteristics of the participants were comparable to the
national workforce profile, the results may not fully reflect the
knowledge and practices of all medical and dental practi-
tioners. Further large scale studies are therefore needed. In
addition, clinical images used in the present study were vali-
dated by a small group of oral medicine specialists from a
limited geographic distribution and did not contain data with
regard to the history or duration of the lesions. Validation of
the clinical images by experts from different geographic dis-
tributions would be desirable. In addition, factors related to
lesions themselves such as color, size, and surface character-
istics might influence the selection process; this is under cur-
rent investigations by authors of the study.
Conclusion
The present study demonstrated an inadequate level of knowl-
edge about oral cancer and OPMDs among primary HCPs,
including knowledge about risk factors, presentations, and
diagnostic techniques. In addition, primary HCPs showed in-
adequate early detection practices and limited diagnostic abil-
ities. Although oral cancer is relatively uncommon in Jordan,
inadequate knowledge and practices of PHCs might have se-
rious consequences on affected individuals. Interventions to
improve primary HCPs knowledge and practices related to
early diagnosis of oral cancer, through improvement of under-
graduate curriculum and provision of continuous professional
development courses, are needed. The latter is mandatory in
some countries, such as UK and USA.
Conflict of Interest The authors declare that they have no conflict of
interest.
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