Overall, the public is ill-informed about risk factors for and signs and symptoms of oral cancers. The misinformation about oral cancer and its early detection among the general public may in part be due to the lack of coverage about oral cancer in the popular press.⁶ A study also has demonstrated that there is a significant dearth of educational materials about oral cancer and that the available educational materials designed to teach adults about the risks and symptoms of oral cancer and the need for an oral cancer examination are inadequate.⁷

Furthermore, health care providers have been remiss in providing oral cancer examinations and detecting early oral cancers.⁸ Many dentists either do not include oral cancer examinations in their routine practice or do not inform their patients that they are performing oral cancer screenings. Not surprisingly, only 13 percent of U.S. adults aged 40 years or older reported having had an oral cancer examination.⁹ Clearly, there is an urgent need for health education and health promotion interventions aimed at health care providers and the public to increase knowledge about oral cancer.

In 1996, the Centers for Disease Control and Prevention, or CDC, convened a national conference—cosponsored by the National Institute of Dental Research of the National Institutes of Health and the ADA—to develop strategies for preventing and controlling oral cancer in the United States.¹⁰ One of the strategies proposed was to strengthen organizational approaches to reducing oral cancer by developing cooperative and collaborative arrangements involving commercial firms. The first such collaboration was formed in 2001 between the ADA and CDx Laboratories (Suffern, N.Y.), (formerly OralScan Laboratories, Suffern, N.Y.), which manufactures the OralCDx brush biopsy test. Together, they launched a national oral cancer public awareness campaign that emphasized the importance of early detection of oral cancer.

The campaign featured two advertisements (Figure 1) that appeared in 11 cities on billboards, bus shelters, commuter bulletins and taxi tops. Both advertisements displayed the ADA name, logo and Web site address and read: "It’s tiny now. Don’t let it grow up to be oral cancer. See your dentist. Testing is now painless." The seven-month program did not promote any specific products.

View larger version (57K): [in this window] [in a new window]   Figure 1. The ADA-sponsored oral cancer awareness campaign signs featured on billboards, taxi tops, bus shelters and other outdoor venues.

The purpose of this article is to report the results of a survey that was conducted among consumers to assess their knowledge about oral cancer, and another survey of dentists to determine the impact of the ADA campaign.

	METHODS AND MATERIALS

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The consumer survey and dental survey were conducted approximately four months after the oral cancer awareness campaign ended.

In the consumer survey, 1,270 adults chosen at random, nationwide, were interviewed by telephone. This survey consisted of questions about oral cancer facts (Table) and was not an attempt to determine if the ADA campaign had increased public awareness. Zogby International conducted the survey over a three-day period (Friday–Sunday), from its headquarters in Utica, N.Y. According to Zogby International, the survey had a margin of sampling error of ± 2.8 percent.

	RESULTS

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The results of the consumer survey are summarized in the table (page, 1264). The survey revealed that only 12 percent of responders correctly identified the fact that oral cancer claims more lives each year than melanoma or cervical cancer. Those answering the question correctly were predominantly young adults, aged 18 to 29 years, and East Coast residents.

Sixty-one percent of respondents did not know that dentists look for oral cancer as part of a routine dental examination. College graduates, women and those with annual incomes greater than $50,000 were most likely to know that dentists examine patients for oral cancer.

Eighty-seven percent of responders agreed that knowing their dentist performs a routine oral cancer examination at every visit and uses a painless test on identified spots would make them feel that they are getting the best possible care. Those who disagreed with this statement were mostly people with annual incomes less than $15,000.

In the survey of dentists, 1,129 of 2,500 responses were received, which resulted in an adjusted response rate of 45.2 percent. A total of 73.2 percent of dentists reported being aware of the campaign, while only 26.8 percent reported having no knowledge of it. Female dentists, younger dentists, dentists living in the Middle Atlantic region and general practitioners were more likely to have heard of the campaign.

Of those dentists who were aware of the campaign, ADA News and JADA were the sources of information cited by the majority (Figure 2, page 1265). Younger dentists were more likely to report having seen the oral cancer campaign in outdoor advertising, while older dentists were more likely to report having seen the campaign on ADA.org.

View larger version (28K): [in this window] [in a new window]   Figure 2. Percentage of dentists who reported having seen the oral cancer campaign promoted, by format.

A total of 18.5 percent of dentists who were aware of the campaign had more frequent discussions with their patients about oral cancer than previously, while only 8.4 percent of dentists who were not aware of the campaign had more discussions with their patients than previously. Awareness of the oral cancer campaign also increased the frequency of patients requesting lesion checks and dentists paying more attention to the presence of oral lesions.

The most common change in practice made by dentists as a result of the campaign was an increased likelihood of informing a patient that an oral cancer examination was being performed (Figure 3, page 1265). A total of 39.6 percent of dentists reported that they were more likely to inform a patient of an oral cancer examination than they were previously. A total of 8.6 percent of dentists reported that they had detected more lesions in the past six months.

View larger version (23K): [in this window] [in a new window]   Figure 3. Percentage of dentists who made changes in their practices in the six months before the survey.

A total of 63.4 percent of dentists reported that they evaluated small lesions more frequently because of the availability of the brush biopsy test. Furthermore, 33.7 percent of respondents who had used the brush biopsy test reported that they referred patients to an oral and maxillofacial surgeon more frequently than they had before use of the brush biopsy test (Figure 4, page 1266).

View larger version (24K): [in this window] [in a new window]   Figure 4. Change in dentists’ frequency of referring patients to oral and maxillofacial surgeons after an abnormal brush biopsy test result.

View larger version (26K): [in this window] [in a new window]   Figure 5. Motivators for testing small, benign-appearing lesions.

	DISCUSSION

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The results of the survey of dentists suggest that an oral cancer awareness initiative sponsored by the ADA can result in behavioral changes that may affect the early detection of oral cancer. Dentists said they appreciated the positive attention the effort attracted to the profession, and they believed that the campaign boosted public awareness. More importantly, the survey results indicate that more dentists will be likely to educate their patients about early detection of oral cancer, adjust their own practice routines to include more discussion about the disease with their patients and to look more closely for lesions, and may seek additional opportunities to learn more about early oral cancer detection. These changes can have a dramatic effect on reducing the mortality rate of this disease, since detection of oral cancer during a routine screening examination on asymptomatic patients has been demonstrated recently to be associated with an earlier stage at diagnosis, and this is more likely to occur in a dental office than a medical office.¹¹

Since the mid-1990s, direct-to-consumer, or DTC, campaigns about health issues and specific treatments have been implemented by the pharmaceutical industry, as well as other health-oriented organizations. These DTC campaigns have been shown to be an important source of information about treatment, options, benefits and risks to consumers in general, as well as to caregivers. In addition, DTC advertising also has facilitated discussions between health care providers and their patients, which can strengthen their relationships and prompt positive lifestyle changes.¹²

ADA’s oral cancer campaign, which may represent the dental profession’s first venture into DTC advertising and education since the fluoride education campaign, has proven that this educational effort could have similar positive effects. While it is difficult to conceive that any public health campaign planned for a national kick-off on the morning of Sept. 11, 2001, would have more than a minimal chance for success considering the events of that day, the positive behavioral changes dentists reported six months after the campaign was launched indicate that the determination to proceed was wise. Although a recent study concluded that not enough dentists include comprehensive oral cancer screenings in their oral examinations, and that they are not explaining to patients what they are doing when they provide these screenings,¹³ the preliminary results of our survey provide hope that this trend is reversing.

Overall, 23.6 percent of dentists reported having used the brush biopsy test to help detect cancer and, furthermore, about 60 percent of dentists reported that they evaluated small lesions more frequently because of the brush biopsy test. Since precancers and early-stage oral cancers can appear identical to harmless-looking lesions, in the past many precancerous and cancerous lesions were overlooked and the correct diagnosis was delayed.^14,15 As the brush biopsy test is indicated to test lesions that do not appear to be suspicious and would not have been referred for scalpel biopsy, identifying unsuspected cancers in their early stages can improve significantly the survival of patients with these types of lesions.

The findings of our survey demonstrate that general dentists are evaluating more small lesions using the brush biopsy test and referring more patients with oral lesions (those with abnormal brush biopsy test results) to oral surgeons. Before the advent of the brush biopsy test, many of these small lesions were watched repeatedly until they changed to more serious and advanced lesions. From our survey, it is clear that the availability of the brush biopsy test is having a positive impact on dentists who use it to evaluate small lesions, and such a change can only result in the detection of a greater number of early-stage cancers.

The consumer survey that followed the ADA campaign confirms the findings from previously published studies that showed that overall, the level of knowledge about risk factors for and signs and symptoms of oral cancers was low and the level of misinformation was high.^13,16 Although the public is uninformed about oral cancer, as evidenced by the fact that more than 60 percent of the surveyed consumers were unaware that dentists were responsible for examining the mouth for oral cancer, our survey did reveal that supplementary information about the disease would be welcomed by consumers, as would additional communication from dentists. Although the impact of the ADA campaign on consumer awareness of oral cancer facts cannot be adequately measured as no precampaign survey was administered, it is clear that extensive public education about oral cancer should be provided in dental offices and clinics, as well as in mass media of all types.

The ADA received several complaints from dentists who objected to the image of a young woman with a small lesion on her tongue being used to depict a woman with oral cancer.¹⁷ These dentists suggested the young female image was not a proper representation of a high-risk oral cancer patient and instead, suggested the use of an image of an elderly man. Yet, recently published data support the decision to feature a young woman. Studies have shown that there has been a nearly fivefold increase in the incidence of oral cancer in young oral cancer patients (those younger than 40 years of age), many of whom had no traditional risk factors.^18–20 Furthermore, the incidence of oral cancer in women has increased significantly in the past 40 years; according to the CDC, the male to female ratio in 1950 was 6:1 and the ratio was 2:1 in 2002. The image used by the ADA oral cancer campaign captured the attention of both the consumer and the dental profession, and it created dialogue about a disease that had been ignored for far too long.

The concept of a public-private partnership to improve the health of those who "suffer disproportionately" from oral disease, as outlined in the surgeon general’s Oral Health in America report,⁵ has been boosted significantly by the success of the campaign. The unrestricted use of a grant supplied by CDx Laboratories to the ADA shows how a private corporation–professional organization partnership can expand and build on existing resources. Such combined efforts are more productive than that put forth by each organization individually.

	CONCLUSION

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Results show that consumers are largely unaware of oral cancer, though they believe that when they receive early oral cancer detection examinations by their dentists, they are receiving the highest possible quality of care. As more than 80 percent of all dentists surveyed believed that the campaign helped raise the public’s awareness of oral cancer and the importance of early detection, additional resources are being devoted to expand on the ADA public awareness campaign for oral cancer. In June 2003, the ADA joined CDx Laboratories in launching another oral cancer educational campaign that emphasizes the increased trend in oral cancer in young patients and women and encourages oral cancer screenings for all new and recall patients, not just those at high risk.