Abstract
The prevalence of cutaneous malignancies in the head and neck region appears to be increasing. This is of great relevance to dentists as they may be the first medical professional to notice a suspicious lesion. However, education on this varies across institutions and countries, influencing future clinicians’ clinical competence to address these lesions. This project aimed to understand the importance of awareness and education about cutaneous malignancies, to explore the differences in teaching in dental schools in Birmingham, UK and Melbourne, Australia, and to investigate the outcomes of related teaching in these schools. The project used qualitative and quantitative research, including comparisons of curricula and a survey to assess students’ confidence and knowledge to manage suspicious lesions in practice. Analysis of the Birmingham and Melbourne dental school curricula showed differences in teaching hours and learning objectives. Results from the survey showed that Birmingham students felt more confident to identify cutaneous malignancies, and performed better in identifying referral timeframes than Melbourne students. However, both groups performed similarly in recognising these lesions. Dentists are well placed to identify cutaneous malignancies, but changes in curricula and teaching are needed to improve undergraduate education. This could then increase early recognition and improve patient outcomes.
Introduction
The prevalence of head and neck cancer appears to be increasing globally, and early recognition and diagnosis are extremely important for patient outcomes. The most common type of skin cancer is basal cell carcinoma (BCC) with at least 48,000 registered cases each year in England. Australia has one of the highest prevalences of skin cancer in the world due to high ultraviolet (UV) radiation, with incidence rates around two to three times higher than in the UK. Mortality rates, however, have been declining since 2011.
Dentists are often the medical professionals that patients see most regularly and therefore may be the first to notice a suspicious lesion. Patients may not notice suspicious skin lesions themselves or be able to give a history of growth rate. In a routine dental check-up, the clinician should assess tissues extraorally; assessing the skin of the head and neck could easily be incorporated into this check. General dental practitioners also describe and document suspicious oral lesions and decide if a referral is needed, for example, using the two-week referral pathway.
According to UK General Dental Council learning outcomes, the curricula in dental schools should prepare dental students to ‘Identify oral mucosal diseases and refer where appropriate’ and ‘Identify all stages of malignancy, the aetiology and development of tumours and the importance of early referral for investigation and biopsy’. Australian Dental Council professional competencies state that graduate dentists should be able to ‘manage diseases, pathology, and conditions associated with the dentition, orofacial complex, and associated structures’. These standards are deliberately vague and therefore somewhat open to interpretation surrounding cutaneous malignancy. This project will investigate whether teaching meets these standards, and compare the curricula in both dental schools.
Studies have shown that through validated educational programmes, dentists could be more confident to identify and manage skin cancer, and give preventative advice. Research into the knowledge and awareness of malignant melanoma in dental undergraduates in a Turkish University did not assess with clinical cases. Currently there is a gap in research on dental students’ knowledge of cutaneous malignancy which this project will investigate. It will compare teaching between dental schools internationally and how this affects the confidence and knowledge of undergraduate dental students to recognise and treat these lesions.
Methods
To compare differences in curricula between Birmingham and Melbourne dental schools, the curriculum of each school was investigated. Learning outcomes from module handbooks and lectures were used to analyse the content and structure of each curriculum, and informal interviews with relevant staff members were used to confirm accuracy. A cross-sectional survey was also conducted to assess the confidence of students to identify and manage suspicious lesions, and knowledge was assessed using 40 clinical photos provided by DermNet®. Students in their final two years of dental school (BDS4 and 5, DDS3 and 4) were invited to participate, as they would have completed all the teaching relevant to this study. Participation was voluntary, and informed consent was gained electronically. Ethics approval was also obtained before data collection began. Data were analysed using Microsoft Excel. Statistical analysis was done using IBM SPSS Statistics for Windows version 30.0.0 (IBM Corp) and statistical significance was calculated with the Mann-Whitney U test and chi squared test.
Results
Comparison of the curricula from Birmingham and Melbourne dental schools showed similarities. Both provided in-depth teaching on the pathology of neoplasia and oral neoplasia specifically, and both covered core aspects of cutaneous neoplasia (clinical presentation of BCC, cutaneous squamous cell carcinoma (cSCC) and melanoma; and level of referral urgency). Birmingham students were also taught a basic level of histology for these lesions.
In the Birmingham curriculum, objectives for the ‘Human disease’ module relating to cutaneous malignancies include:
Demonstration of knowledge and understanding of the pathology of the skin. In particular: recognition of the clinical features characteristic of benign and malignant neoplasms of the skin (for example, benign melanocytic naevi versus malignant melanoma), and understanding of the aetiology and pathogenesis of skin neoplasia Demonstration of clinical knowledge and understanding of dermatological disease and its oral manifestations: cutaneous neoplasia.
In comparison, the relevant learning objectives from modules from Melbourne Dental School: ‘Specialty preclinical dental practice’ and ‘Oral medicine, surgery and special needs’ do not mention cutaneous malignancies. Students should:
Recognise when referral is required given a patient scenario, and describe the key components of a referral. Describe the diagnosis and management of common disorders of the oral cavity and orofacial tissues. Understand the oral manifestation of a range of dermatological conditions; the presentation, diagnosis and treatment of oral mucosal malignancy and potentially malignant lesions.
Although module objectives did not mention cutaneous malignancies, the lecture ‘Oral dermatology and cutaneous pathology of the head and neck’ did outline BCCs, cSCCs, and melanomas.
Birmingham students received more teaching, as shown in Table 1 , with an additional small group teaching session, typically more interactive than a lecture. Both dental schools provided the opportunity to shadow an oral and maxillofacial surgeon in an external hospital, with possible exposure to cutaneous neoplasms depending on the clinics.
Table 1
Comparison of teaching on cutaneous malignancies between Birmingham and Melbourne dental schools.
| Birmingham | Melbourne | |
|---|---|---|
| Content |
Clinical presentation
Histology Referral |
Clinical presentation
Referral |
| Teaching hours | 3 hours | 1 hour |
| Teaching methods |
Lectures- 2 hours
Small group teaching– 1 hour |
Lecture |
| Clinical exposure |
Multidisciplinary team
Oncology clinic attendance |
Maxillofacial surgery shadowing |
| Exposure timing | BDS Y3 and 4 | DDS Y2 and 3 |
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