doi: 10.56294/shp202215

ORIGINAL

Oral cancer education intervention for high-risk patients aged 35-59 years, clinic 16

Intervención educativa sobre cáncer bucal en pacientes de alto riesgo entre 35-59 años, consultorio 16

Yoneisy Abraham-Millán¹ *, Rosa María Montano-Silva¹ *, Yanelilian Padín-Gámez² *, Eridania Pantoja-García² *, Iraida Céspedes-Proenza¹ *, Bárbara Zenaida Pérez-Pérez¹ *

¹Facultad de Ciencias Médicas Isla de la Juventud. Isla de la Juventud, Cuba.

²Clínica Estomatológica Docente Dr. José Lázaro Fonseca López del Castillo. Isla de la Juventud, Cuba.

Cite as: Abraham-Millán Y, Montano-Silva RM, Padín-Gámez Y, Pantoja-García E, Céspedes-Proenza I, Pérez-Pérez BZ. Oral cancer education intervention for high-risk patients aged 35-59 years, clinic 16. South Health and Policy. 2022; 1:15. https://doi.org/10.56294/shp202215

Submitted: 25-02-2022                   Revised: 12-05-2022                   Accepted: 12-10-2022                 Published: 13-10-2022

Editor: Dr. Telmo Raúl Aveiro-Róbalo

Corresponding author: Yoneisy Abraham-Millán *

ABSTRACT

Educational intervention is the intentional process that should encompass the design, planning, execution, monitoring and evaluation of a system of actions aimed at implementing in practice a differentiated care that favours the acquisition of knowledge. The aim of this research was to develop an educational intervention in patients between 35 and 59 years of age at high risk for oral cancer. An explanatory intervention study was carried out with an experimental design, with pre-test, post-test and control group in clinic 16 belonging to the Pueblo Nuevo Popular Council, in the period April-September, 2022. Systematic selection of sample elements was used to determine the units of analysis, forming two groups of 47 patients at high risk for oral cancer. The variables level of risk for predicting oral cancer, sex, risk factors associated with oral cancer, level of knowledge about oral cancer, experimental groups and teaching methods were taken into account. The predominant sex was male in both experimental groups. Among the main risk factors were stress, smoking, and ingestion of hot, spicy and highly seasoned foods, which were reduced by 23 % in the experimental group and 23 % in the experimental group and 6 % in the medium group. Satisfactory results were obtained in terms of the modification of knowledge and the level of risk, with an increase in knowledge to reduce the risk of oral cancer after the educational intervention in the experimental group. The differences observed before and after the intervention through the application of the educational Web media demonstrated the effectiveness and impact of the intervention, showing the importance of maintaining the innovative capacity to transmit promotion and prevention messages in a pleasant and didactic way.

Keywords: Oral Cancer; Educational Intervention; Risk Factors; Knowledge; Prevention.

RESUMEN

La intervención educativa es el proceso intencional que debe abarcar el diseño, planificación, ejecución, seguimiento y evaluación de un sistema de acciones dirigidas a instrumentar en la práctica una atención diferenciada que propicie la adquisición de conocimientos. La presente investigación tuvo como objetivo desarrollar una intervención educativa en pacientes entre 35 y 59 años con alto riesgo para padecer cáncer bucal. Se realizó un estudio de intervención explicativo, con diseño experimental, con pre-pruebas, post-pruebas y grupo de control en el consultorio 16 perteneciente al Consejo Popular Pueblo Nuevo, en el período abril-septiembre, 2022. Se utilizó la selección sistemática de elementos muestrales para determinar las unidades de análisis, quedando conformados dos grupos de 47 pacientes con alto riesgo para padecer cáncer bucal. Se tuvieron en cuenta las variables nivel de riesgo para predecir cáncer bucal, sexo, factores de riesgo asociados a cáncer bucal, nivel de conocimiento sobre cáncer bucal, grupos del experimento y medios de enseñanza. El sexo que predominó fue el masculino en los dos grupos del experimento. Entre los principales factores de riesgo se encontraron el estrés, tabaquismo, e ingestión de alimentos calientes, picantes y muy condimentados que se lograron reducir en el grupo experimental el primero y el último un 23 %; y el del medio un 6 %. Se obtuvieron resultados satisfactorios en cuanto a la modificación de los conocimientos y el nivel de riesgo, lográndose elevar el conocimiento para disminuir el riesgo a padecer cáncer bucal después de la intervención educativa en el grupo experimental. Las diferencias observadas antes y después de la intervención mediante la aplicación de la Web media educativa demostraron la efectividad e impacto de la misma, evidenciando la importancia de mantener la capacidad innovadora para trasmitir mensajes de promoción y prevención de forma amena y didáctica.

Palabras clave: Intervención Educativa; Cáncer Bucal; Factores de Riesgo; Conocimiento; Prevención.

INTRODUCTION

The prevention of oral cancer is a challenge that must be taken up by health professionals responsible for educating and treating patients at risk of developing this disease. The practice of dentistry, more than a way of life, is a profound sense of purpose, in which one should not limit oneself to trying to cure diseases but rather to preventing them by applying the potential of dentistry as a health science.⁽¹⁾ This research addresses the study of oral cancer, highlighting the importance of educating the population about the main risk factors, the importance of prevention, early diagnosis, and the measures to be taken to address this disease.⁽¹⁾

A premalignant lesion is morphologically altered tissue in which oral cancer can develop more easily than in equivalent tissue that appears normal. The origin of premalignant states and lesions is believed to involve multiple factors dependent on the host, the environment, and chemical, physical, or biological carcinogenic agents.⁽²⁾

There are a number of clinical conditions of the oral mucosa, many of which are insignificant in the early stages but can in some cases undergo malignant transformation. These include actinic cheilitis, traumatic ulcer, lichen planus, inverted smoker’s palate, erythroplasia, and leukoplakia.

Leukoplakia, a term coined by Hungarian dermatologist Ernö Swimmer in 1877, refers to white lesions with a predisposition to malignancy. From that moment on, the scientific literature was flooded with publications on this pathology. Santana Garay, for his part, defined it in 1966 as an “alteration of keratinization or epithelial maturation that goes through three evolutionary stages”.⁽³⁾

As each researcher used the term according to their own criteria, in 1978 the World Health Organization (WHO) Collaborative Reference Center for Precancerous Oral Lesions, with the aim of standardizing criteria, defined it as: “a white patch or plaque that cannot be characterized clinically or histopathologically as any other disease”.⁽⁴⁾ Since then, efforts have been made to reach agreement on the concept, classification, and other aspects of the condition.

During the First Conference on Oral Leukoplakia, better known as the Malmö Seminar, held in Sweden in 1983, the pathology was defined as “a white patch or plaque that cannot be characterized clinically or pathologically as any other disease and is not associated with any physical or chemical agent except tobacco use”.⁽⁵⁾ Another definition accepted by the scientific community was that of the International Symposium in Uppsala, Sweden, in 1994, where it was conceptualized as a “predominantly white lesion that cannot be characterized as any other well-defined lesion”.⁽⁵⁾

More recently, at the workshop coordinated by the Collaborative Centre for Oral Cancer and Precancer, London 2005, the use of the term “potentially malignant disorders” was recommended, suggesting that the boundary between lesion and premalignant state should be removed, and the following concept of leukoplakia is offered: “a whitish patch or plaque of uncertain risk that cannot be characterized, clinically or histopathologically, as another disease”.⁽²⁾

It is understood that this is a definition by exclusion, but it is the most universally accepted. In Budapest, during the XIV International Cancer Congress, a meeting of experts suggested that the following be added to the above definition: “and that it is not associated with any other physical or chemical cause, except tobacco use”.⁽⁴⁾ In conclusion, there are two types of leukoplakia: true leukoplakia, caused by tobacco use, and idiopathic leukoplakia, where no definite etiological cause is found.

White lesions caused by local factors such as irritation, trauma, bites, or other specific causes are not considered leukoplakia; in this case, the white lesion is caused by a bite on the cheek mucosa. Leukoplakia is considered the most common premalignant lesion, a condition that can be found at virtually all ages, but is more common in older adults and the elderly.⁽⁶⁾

In Cuba, the most commonly used nomenclature is that of Santana Garay, which classifies them as diffuse keratosis, focal keratosis, and leukoplakia. Hyperkeratosis is an essential histopathological feature that gives it its white appearance, but it is epithelial dysplasia that is used to establish its degree of premalignancy and its future transformation to oral cancer. The severity of dysplasia is most commonly associated with a higher risk of malignancy.⁽⁵⁾

In India, the custom of chewing a mixture of betel nut appears to influence the appearance of leukoplakia and oral cancer.⁽⁷⁾ This is probably due to the fact that the agents causing these lesions act cumulatively and/or require prolonged exposure times.

Inverted smoker’s palate is a peculiar form of keratosis that mainly affects the palate and is caused by smoking various types of cigarettes with the lit end inside the mouth.⁽⁸⁾ The cause of inverted smoker’s palate is very easy to determine, as it is a direct consequence of the heat produced by the combustion of tobacco inside the mouth. One of the objectives of this habit is to slow down the consumption of tobacco, which increases the harmful action of heat and volatile products on the mucosa of the palate and, secondarily, on other sites such as the back of the tongue. In Cuba, smoking with the cigarette upside down is not common, but it is common in countries such as India, Panama, and Colombia.⁽⁷⁾

Risk control, therefore, occupies an important place in primary health care and is included in numerous recommendations on the applications of stomatological medical care.⁽⁹⁾ If these premalignant lesions are not stopped in their development, they become carcinomas.⁽¹⁰⁾ This highlights the need for health prevention, where the educational work of the stomatologist is of vital importance.

According to the WHO in 1978, premalignant states are a generalized condition or disease that does not necessarily alter the appearance of the mucosa but may be associated with a significant increase in the risk of cancer. A premalignant lesion is a morphologically altered tissue in which oral cancer can appear more easily than in equivalent tissue of normal appearance.⁽¹¹⁾

Knowledge of oral pathology and systematic examination of the stomatognathic system will allow for a better understanding of the patient’s general condition and, more importantly, will facilitate early diagnosis and successful treatment of serious lesions. Oral cancer is the most visible of all types of cancer due to its anatomical location, and within this group, it is the most disfiguring from an aesthetic and functional point of view, causing difficulties in swallowing, seeing, smelling, and hearing, as well as a high degree of deformity, which sometimes leads to the affected person being marginalized and rejected by society.⁽¹²⁾

The WHO defines the word cancer as referring to a group of more than 100 different diseases with more than 1 000 histopathological varieties. A common characteristic of these diseases is the abnormal and uncontrolled proliferation of cells that invade nearby and distant tissues and organs and, if not treated in time, cause the death of the individual.⁽¹⁾

Hippocrates (469 to 370 BC), who first described it, used the terms carcinos and carcinomas. It is a common term used to refer to all malignant tumors, derived from the Latin word “cancrum” (crab). Other authors have defined it as an “ “ tumor process that occurs in all human and animal populations, appearing in tissues composed of cells with the potential to divide.⁽¹³⁾

Cancer is one of the greatest problems facing humanity, not only for public health, but for other sciences in general. It affects more than 200 diseases that can affect any anatomical region of the human body. It threatens survival, is socially stigmatized, can lead to mutilation, does not follow a specific pattern, requires invasive treatment, particularly chemotherapy and radiotherapy, disrupts daily life, and also causes changes in the patient’s lifestyle and self-image.⁽¹⁴⁾

Neoplasia refers to the uncontrolled proliferation of somatic cells resulting from an irreversible change in those cells. Neoplasms can be benign, if they are localized and do not invade adjacent tissues or spread to the rest of the body, or malignant, if they invade and destroy tissues and are capable of spreading.⁽¹²⁾

Oral cancer is an aggressive malignant neoplasm; it is considered a global health problem, capable of producing anatomical and physiological sequelae in those who suffer from it. It is more aggressive and lethal than other tumors, has multiple etiological factors, and a high metastatic potential that has a cumulative effect over time, compromising the patient’s appearance and function, and eventually leading to death.⁽²⁾

According to the National Comprehensive Stomatological Care Program, it is defined as follows:⁽¹¹⁾

· Risk: the probability of the occurrence of an event that may be harm or disease that you experience as something that will happen. Some authors also define it as the set of abnormal conditions that could produce a harmful effect on the individual, generating diseases of varying magnitudes in accordance with the explosion of the causal agents.

· Risk factor: an attribute or characteristic that gives an individual a variable degree of susceptibility to contracting a disease or health disorder. It is individual susceptibility in probabilistic terms.

Lifestyle modification is an essential element in cancer prevention. It is estimated that 30 % of cancers are preventable through smoking control.⁽¹⁵⁾ There are a group of risk factors and diseases that are associated with oral carcinoma, such as tobacco, alcohol, stress, syphilis, premalignant lesions and other precancerous conditions, lichen planus, atrophic mucosa, trauma, oral sepsis, submucosal fibrosis, and others. tobacco, alcohol, stress, syphilis, premalignant lesions and other precancerous conditions, lichen planus, atrophic mucosa, trauma, oral sepsis, oral submucosal fibrosis, florid oral papillomatosis, exposure to high levels of ionizing radiation, and Human Immunodeficiency Syndrome (AIDS).⁽¹⁶⁾

Smoking is one of the most common habits in the world population. For both men and women, this risk factor develops malignant and premalignant neoplastic lesions in the oral cavity.⁽¹⁷⁾ Some 3 500 substances have been found in tobacco smoke, more than 20 of which are carcinogenic. These include polycyclic aromatic hydrocarbons, nitrosamines, aromatic amines, and ethylene oxide, which act on oral tissues, causing intracellular biochemical changes. Added to these chemical agents is the heat of combustion, which is a physical factor that causes cell damage, hence the importance of the method (cigarettes, tobacco, or pipes) and frequency of smoking. In some Asian countries, smoking is combined with the habit of chewing betel nut, which increases the risk of oral cancer.⁽¹⁸⁾

A positive correlation has been demonstrated between excessive alcohol consumption and oral cancer, which is why heavy drinkers are 10 times more likely to develop this disease. Alcohol causes local dehydration of the mucous membranes, but after being metabolized, it is transformed into salivary acetaldehyde, which increases the activation of nitrosamines present in tobacco smoke, causing a powerful synergistic effect between the two factors.⁽¹⁹⁾

It is worth noting that heat can cause burns to the soft tissues of the oral complex, therefore, the consumption of hot beverages such as coffee, tea, chocolate, and milk causes chronic irritation of the oral mucosa and the organs that make up the digestive system. It has been noted that almost all smokers drink hot coffee, which can aggravate the development of oral lesions.⁽²⁰⁾

Another risk factor that has been reported is the consumption of hot, spicy, or highly seasoned foods. These foods are significantly irritating to the mucosa that makes up the organs of the digestive system, especially the epithelial tissue that lines the oral cavity. In this group, hot foods have a marked relationship with oral cancer, as these “ “ irritate the oral tissues from the first contact, regardless of the way they are chewed and the amount of food ingested.⁽¹¹⁾

Chronic trauma is a very important physical risk factor in the origin and development of cancer in the oral cavity. Repeated traumatic irritation occurs when a hard object crushes or lacerates the soft tissues that make up the organs in the mouth, causing cell damage that requires continuous repair and, in the long term, induces abnormal and uncontrolled cell multiplication.⁽²¹⁾

Traumatic irritants can include poorly fitting or poorly made dentures, dentures that have been repaired, overused or biomechanically altered, teeth or root remnants with sharp edges, and defective fillings. Other traumatic irritants include the introduction of objects into the mouth, incorrect chewing, and certain oral habits such as lip, cheek, or tongue biting.⁽²²⁾

There is abundant evidence that ultraviolet radiation from the sun induces an increase in the incidence of skin cancer, which is why regular exposure to the sun is of great importance in the formation of squamous cell carcinoma or epidermoid carcinoma on the lips. Sunlight is one of the fundamental causes of cancer in the last 15 years.⁽²²⁾

The degree of risk depends on the type of ultraviolet rays, the intensity of exposure, and the amount of light-absorbing melanin in the skin. This reaffirms the high risk for people with fair skin and the importance of high-risk occupations such as farmers, ranchers, fishermen, and construction workers.⁽²³⁾

Our country has a National Oral Cancer Early Detection Program (PDCB) that is unique in the world and has reduced mortality from this cause by 15 % in the last 30 years, based on 100 % oral examinations of patients.⁽²⁴⁾ The PDCB in Cuba is part of the National Comprehensive Dental Care Program (PNAEI), which in turn is part of the Cancer Control Program.

In 1985, the Cuban Ministry of Public Health (MINSAP) officially established the PDCB, which aims to reduce the morbidity and mortality of oral cancer. It was thus established that, following the oral cavity examination methodology, all patients attending primary care stomatology consultations or population screening for oral complex disorders should be examined.⁽²⁵⁾

Training in self-examination of the oral complex is provided so that individuals can examine their own mouths and detect lesions at an early stage. In addition, it is considered essential that routine examinations be carried out by both stomatologists and general practitioners (GPs), as it is the duty of all healthcare professionals to detect oral cancer at an early stage, which requires adequate and concise training.⁽²⁾

The National Oral Cancer Prevention Program in Cuba provides guidance on the prevention of this disease to all people who come to our health services and institutions. It establishes that promotion should be carried out through health education and its various means of dissemination, educational talks in workplaces, schools, waiting rooms of stomatological institutions, as well as in urban and rural communities.⁽²⁶⁾

Oral cancer prevention and promotion activities have been carried out regularly on the Isle of Youth. The PDCB examination is performed on the entire population that attends consultations and in the field, in addition to active screening of all persons over 15 years of age. Currently, the examination has been incorporated for all patients aged 3 months and older, due to the presence of premalignant and malignant lesions in age groups under 15 years. As can be seen, the variability in approach to premalignant lesions in older adults requires attention and follow-up to maximize their quality of life.

From a biological point of view, each person has different characteristics throughout their life, and in old age, health risks become apparent as part of their frailty, where a psychological and neurological decline in abilities is detected. If preventive measures are not established in advance, health risks increase. At this stage, age is a variable that represents a risk factor, both due to the manifestation of human immunology and its social significance.

In Latin America, Cuba is one of the countries where population aging is a demographic problem due to its demographic structure. As the oldest country in the region, this factor is the main demographic problem, but it also poses a problem for the health institutions’ actions.  It should be noted that the development of certain diseases depends on this sociodemographic factor, caused by changes in cellular metabolic processes with an increase in degenerative and oxidative processes.

Under these circumstances, it is expected that by 2025, the population over 60 will reach more than 25 % of the total population,⁽²⁷⁾ according to the 2017 MINSAP Statistical Yearbook, and Cuba will continue to be one of the oldest countries in the region.⁽²⁸⁾ The current life expectancy at birth in Cuba is 75 years, which means that community services are primarily focused on health promotion through senior citizen circles, senior citizen homes, and recreation and guidance groups.⁽²⁹⁾

In the first half of 1997, the National Program for the Care of Older Adults was implemented, which has been adjusted annually. Since 2002, actions aimed at older adults have become an important part of the National Comprehensive Dental Care Program.⁽²⁵⁾ Oral lesions are more prevalent in the elderly population and are related to physiological degenerative changes caused by aging and increased tooth loss, which translates into a greater need for dental prostheses to maintain masticatory and aesthetic functions.⁽³⁰⁾

Early detection can also be carried out through screening and health measures that, through diagnostic procedures performed on the supposedly healthy population, allow individuals with the disease or at risk of developing it to be identified. This will enable timely action to be taken and reduce current cancer mortality rates, especially if these actions are taken at an early age and not in patients over 60, given that the aim is to prevent, rather than cure and rehabilitate.⁽²⁾

If cancer is detected early, treatment will be indicated with the intention of curing the disease. If the population is educated to detect the early signs and symptoms of the disease, then medical care will be more effective.⁽³¹⁾ As a preventive method, health education can play a much more effective role through the work of general dentists, who, together with dental assistants, form part of the health team led by the family doctor. The Health Team has all the conditions necessary to carry out creative educational work, coming into direct contact with individuals, families, and the community to promote self-responsibility and joint collaboration in reducing this disease in the population.⁽³²⁾

The objective of Health Education is not only to present facts to fill an information gap, but to present them in such a way that people change their attitudes and thus influence their quality of life. A fundamental principle of the Health Promotion approach is to involve the entire population. To this end, it is essential that there be effective community participation in defining problems, making decisions, and implementing measures to modify and improve the determinants of health.⁽³³⁾

It is essential that dentists keep up to date with the use of the media and techniques to be employed. Above all, they must bear in mind that talks, interviews, demonstrations, and group dynamics, which have been used systematically, must be enriched with participatory affective techniques, through which integration, reflection, and motivation can be promoted in the individual. The interrelation of these components also gives rise to two other processes that are essential to communication: the link between the educator and the learner, and motivation, which occurs internally in the learner and enables behavior modification through learning. It follows that the acquisition of knowledge does not necessarily imply immediate and automatic behavioral changes.⁽³³⁾

In order to achieve the desired results, both the educator and the learners must be motivated and thus contribute to shaping attitudes based on individual, family, or community motivations:⁽³³⁾

· Attitude is an acquired and lasting mental predisposition of the individual to behave in a certain way that can be positive or negative towards objects, people, or situations.

· Motivations: these are the driving forces behind human behavior, indirectly influencing people through a consciously adapted goal or determination, and determining their interests.

Certain requirements must be taken into account to achieve motivation, where we must understand their points of view and not try to impose our own; listen to the subjects, give them the opportunity to speak, to understand how they think, we must know everything, in order to motivate them and communicate with them; understand their needs and their scale of values.⁽³³⁾ This situation emphasizes that dentists must play a leading role in the education, prevention, and early diagnosis of pre-neoplastic conditions or cancer in individuals dependent on their health care.

This essential task does not allow for superficiality or theoretical trials that imply limitations. An adequate level of prevention must also include sufficient training, whose work dynamics allow for the discovery of any clinical pre-neoplastic condition and the identification of signs of possible premonitory alterations of a preclinical malignancy.⁽³⁴⁾ In primary care, health promotion and prevention activities are mainly aimed at guiding oral self-examination and modifying the risk factors associated with the appearance of premalignant lesions and oral cancer, especially in patients at high risk of developing these diseases.⁽³⁵⁾

As a malignant disease, cancer has a high mortality rate, with four million people dying from it worldwide each year. If this trend continues, it will be considered the leading cause of death in this century.⁽¹³⁾ Oral cancer is a public health problem. Ninety percent of cases are squamous cell carcinoma. The incidence of this cancer worldwide in 2012 was 4 new cases per 100 000 inhabitants: 5,5 new cases per 100 000 men and 2,5 per 100 000 women. The mortality rate is 2,7 per 100 000 for men and 1,2 per 100 000 for women.⁽³⁶⁾

In Latin America, it is the second leading cause of death, and the economic burden it imposes will increase significantly in the coming years. Due in large part to aging and population growth, the incidence of the disease and mortality in Central and South America will continue to rise sharply between 2012 and 2035. The number of cases is expected to increase by 91 % during this period, while deaths will increase by 106 %.⁽³⁶⁾

Among all types of cancer, oral cancer is the sixth leading cause of death worldwide, and in Cuba it is becoming increasingly prevalent and deadly. In 2013, the crude rate of lip, oral cavity, and pharynx cancer in both sexes was 6,5 per 100 000 inhabitants, ranking fifth among the top ten locations.⁽³⁷⁾ In that same year, 723 Cubans died from this type of cancer. It is a disease to be taken seriously in the country, since four to seven out of every 100 cancers are oral cavity cancers.⁽³⁸⁾

According to the Statistical Yearbook of Public Health in Cuba, the incidence of lip, oral cavity, and pharynx cancer by sex in 2014 reported 1 189 cases in males and none in females.⁽³⁹⁾ Between 2000 and 2015, the mortality rate increased from 146,8 to 215,0 per 100 000 inhabitants, with 24 131 deaths from this cause in the latter year, representing 24,2 % of all deaths in the country.⁽⁴⁰⁾

Among all types of cancer, oral cancer is the sixth leading cause of death worldwide, and in Cuba it is becoming increasingly prevalent and deadly. In 2015, the Pan American Health Organization (PAHO) promoted the slogan “Cancer prevention and control is within our reach,” which sought to reduce deaths through cost-effective interventions focused mainly on actions that promote healthy lifestyles, which are protective and basic factors in combating these diseases.⁽⁴¹⁾

In the Special Municipality of Isla de la Juventud, according to records from the Héroes del Baire General Teaching Hospital, in 2016, 128 patients belonging to the Oral Cancer Detection Program (PDCB) underwent maxillofacial surgery, while in 2017, 135 patients underwent surgery, an increase of 7 patients compared to the previous year. In 2017, mortality in Cuba from malignant tumors of the lip, oral cavity, and pharynx in males reported a total of 672 deaths, while in females, 157 deaths were reported. The most affected age groups were those between 40 and 59 years old with 225 cases and those between 60 and 79 years old with 345 deaths. In females, the same age groups predominated, but with 25 and 77 deaths, respectively.⁽²⁸⁾

With regard to oral cancer figures in the Special Municipality of Isla de la Juventud in 2017, eight new patients with this disease were registered and two died. In 2018, there were 8 patients and 5 deaths, 4 of whom belonged to the Juan Manuel Páez Inchausti University Teaching Polyclinic, making it the year with the highest number of deaths from this health problem.

In 2019, mortality from malignant tumors of the lip, oral cavity, and pharynx was reported to be 893 deaths, or 8,0 %. Among males, 722 deaths were reported, or 12,9 %, and among females, 171 deaths were reported, or 3,0 %. The most affected age group was 60-79 years old, with a total of 365 patients out of 722, for a rate per 100 000 men of 40,2 out of a total of 12,9; Among females, the predominant age group was also 60-79, with 91 deaths out of a total of 171, for a rate of 9,0 per 100 000 women out of a total of 3 042.

It is estimated that there are currently around 14 000 000 people with cancer. The economic and health consequences make it a major health problem; moreover, with the increase in smoking and the aging population, it is thought that, if control measures are not taken, there will be an increase in its incidence and mortality.⁽²³⁾

Worldwide, there are around 600 000 incident cases and 300 000 deaths each year. On March 25, 2020, the WHO reported that 4 cases per 100 000 inhabitants are diagnosed, with 20 cases per 100 000 inhabitants unreported.⁽⁴³⁾ The highest incidence rates of oral cancer for that year were reported in Pakistan, Brazil, India, and France, in some cases associated with the ingestion of concoctions.⁽³⁷⁾

In recent years, it has been estimated that approximately 40 000 new cases of oral cancer are diagnosed annually in the United States alone. in 2021, 54 010 patients were diagnosed, 15 210 female and 38 800 male, resulting in 10 850 deaths, 7 620 in male patients and 3 230 in female patients. Cuba is no exception to this reality due to its high cancer incidence and mortality rates. The epidemiological outlook represents the greatest obstacle to achieving a life expectancy of over 70 or 80 years or quality of life.

In 2021, it was reported that 57 male patients aged 30-44 suffered from cancer of the lip, oral cavity, and pharynx, for a rate of 5,1 per 100 000 men; in the 45-59 age group, there were 551 patients for a rate of 41,2 per 100 000 men and no females. That year, there were a total of 899 deaths, with a rate of 8,0 per 100 000 inhabitants. Among males, there were 689 deaths, with a rate of 12,4 per 100 000 males, and among females, there were 210 deaths, with a rate of 3,7 per 100 000 females. The most affected age groups in both sexes were patients aged 60-79, with 354 deaths for a rate of 39,9 % in the case of males and 108 for a rate of 10,9 % in the case of females.

The established model of primary health care, through its three levels of care: primary, secondary, and tertiary, represented by the polyclinic, the hospital, and the institute, coordinated with each other and with mass organizations, provides free medical care. It is characterized by working to achieve the health status of the population through comprehensive actions of promotion, education, prevention, diagnosis, cure, and rehabilitation of the individual, family, and community.

Furthermore, the Guidelines for the Economic and Social Policy of the Party and the Revolution refer to the need to strengthen health actions in promotion and prevention to improve the lifestyle of communities with intersectoral participation, and to continue improving education and health, as well as updating university training and research programs. All of this is to work in line with the real needs of the country’s economic and social development.

Taking into account the arguments presented above, the author poses the following scientific problem: How can we help prevent the onset of oral cancer in patients aged 35-59 with high risk in clinic 16, belonging to the Pueblo Nuevo People’s Council, in the period April-September 2022?

The results of this research provided a study on the promotion and prevention of oral cancer in high-risk patients and an educational website.

General Objectives

To develop an educational intervention on oral cancer in patients aged 35-59 years with high risk from clinic 16, belonging to the Pueblo Nuevo People’s Council, in the period April-September 2022. 

Specifics

· Identify patients aged 35-59 who are at high risk of oral cancer. 

· Characterize the study sample according to sex.

· Identify the main risk factors associated with the onset of oral cancer before and after the educational intervention.

· Determine the individual risk of developing oral cancer before and after the educational intervention.

· Determine the level of knowledge about oral cancer before and after the educational intervention.

· To evaluate the impact of the educational intervention on promotion and prevention activities carried out in patients at high risk of oral cancer.

METHOD

An explanatory study with an experimental design was conducted with pre- and post-tests and a control group of patients aged 35-59 years with a high risk of oral cancer from clinic 16 belonging to the Pueblo Nuevo People’s Council in the town of Nueva Gerona, Isla de la Juventud Special Municipality, during the period from April to September 2022.

Universe and sample

The study universe consisted of 1 210 patients, the population of 370 patients aged 35-59 years from clinic 16, belonging to the Pueblo Nuevo People’s Council, while the sample consisted of 94 patients at high risk of oral cancer. From this, an experimental group and a control group were formed, each consisting of the same number of patients. The selection of patients to form each group of the experiment was carried out using the systematic sampling technique, allowing for random selection from an interval (K). Thus, from the total number of patients in the sample (N→ 370), the number of patients who formed the groups was (n→ 94), and the interval was (K→ 4). Thus, K=N/n, where (N) is the total number of patients, (n) is the sample for each group in the experiment, and (K) is a systematic selection interval. We began at random using a die; the number that came up was the initial selection, which was made using a list prepared for this purpose in Excel.

The sample was divided into two groups, one control and one experimental. To achieve initial equivalence in this experimental design, the groups were randomly assigned to the experiment. A fair coin was used to randomize the groups, and the side of the coin that corresponded to each group in the experiment was designated.

Inclusion criteria

· Patients between 35 and 59 years of age with a high risk of oral cancer.

· Patients who agree to participate in the research.

· Patients with full mental capacity.

The following methods were used during the research process.

Theoretical methods

Used for the conceptual interpretation of the empirical data found, to explain the facts, essential relationships, and fundamental qualities of the phenomenon under study; within these methods, the following were used:

· Analytical-synthetic: this allowed the study of the elements of the scientific problem in their relative independence from one another and also revealed the relationships between them, as well as the dialectical interaction that was established between them.

· Inductive-deductive: this allowed generalizations to be established on the basis of the study of singular phenomena, which made it possible to arrive at certain generalizations that constituted starting points for inferring and confirming theoretical formulations.

· Historical-logical analysis: this allowed us to study the trajectory of events that have marked important aspects in the promotion of health and prevention of oral cancer in the community context, and to reveal the internal logic of the development of these phenomena, as well as the relationship between the promotion and prevention of this disease and the means of teaching; and its progressive march towards a deeper, more complete, and more developed point.

· System approach: provided general guidance for studying the overall reality, health promotion and prevention in the community context and the forms of interaction between them.

Empirical methods 

· Observation: of the activities and social environment of the study population, from which theoretical generalizations were made to facilitate practice, enrich knowledge, and analyze elements related to oral cancer promotion and prevention.

· Documentary analysis: an analysis was carried out of documents such as family medical history, oral cancer screening programs, and other documents that are required reading in relation to oral cancer.

· Survey: questionnaires were administered to patients selected for the experiment to identify the risk of oral cancer and the main risk factors associated with it, in order to then assess the level of knowledge about oral cancer in the study sample before and after the educational intervention.

· Experimental: this allowed us to verify the relationships between the elements of the scientific problem and determine more precisely the cause-effect relationship between them.

· Mathematical-statistical methods: these allowed the sample to be studied to be determined, as well as the processing of the information collected through the information collection sources or measurement instruments, facilitating the generalizations and interpretations that were made from the data (expressed in relative and absolute frequencies, as well as percentages).

Selection of variables

Variables: risk of predicting oral cancer, sex, risk factors associated with the onset of oral cancer, level of knowledge about oral cancer, teaching methods, and experimental groups.

Dependent variables: risk of oral cancer, risk factors associated with the onset of oral cancer, level of knowledge about oral cancer. 

Independent variables: teaching methods (educational web media).

Extraneous variables: gender, experimental groups.

Table 1. Operationalization of variables
Variable	Type	Measurement scale	Description
Level of risk for predicting oral cancer	Qualitative Ordinal Dichotomous	High Low	According to interview form used to predict risk scale. For oral cavity cancer: the risk is HIGH if it is greater than or equal to 10 points. For lip cancer: The risk is HIGH if greater than or equal to 15 points.
Sex	Nominal dichotomous qualitative	Male Female	According to biological gender
Risk factors associated with the onset of oral cancer	Nominal polytomous qualitative	Smoking Alcoholism Wearing ill-fitting dentures Sun exposure Chewing on nails Stress Ingestion of hot, acidic, and spicy foods.	According to interview form to identify risk factors for oral cancer and oral cancer awareness survey.
Level of knowledge about oral cancer	Qualitative Ordinal Polythetic	Good Fair Poor	According to a survey on the level of knowledge about oral cancer.
Medium Teaching	Qualitative Non-metric Nominal Dichotomous	Yes	Patients who were given web media and educational talks.
		No	Patients who did not receive web media or educational talks.
Experimental groups	Qualitative Non-metric Dichotomous Nominal	Experimental group	Patients between 35 and 59 years of age with a high risk of oral cancer who were given web media and educational talks.
		Control group	Patients aged 35-59 years with a high risk of oral cancer who did not receive web media or educational talks.

Techniques and procedures

An exhaustive review of the literature on the research topic in Cuba and worldwide was conducted, which allowed for the use of a questionnaire (table 2) and a survey on the level of knowledge about premalignant lesions and oral cancer (table 3) that collected all the questions of interest for obtaining information during the research process.

The sources of information used during the research were:

· Family medical history of stomatology (table 1). 

· Interview form used to predict risk scale (table 3).

· Survey on the level of knowledge about oral cancer for people over 15 years of age (table 4).

With prior informed consent (table 2) from patients, a form was administered to determine their risk of oral cancer, which allowed the study sample to be formed by patients who identified themselves as being at high risk of oral cancer. A survey on oral cancer awareness was administered to the patients in the study sample before and after the educational intervention, as was the interview form administered to the patients in the experimental sample to identify their risk of oral cancer.

All patients in the sample were given a survey (table 3) to measure risk scale, identifying patients at low and high risk of oral cancer before and after the educational intervention.

Table 2. Dates
Factor	Score	Oral cavity	Lip
Smoking	10
Alcoholism	7
Thermal irritants	4
Traumatic irritants	4
Oral history	5
Sun exposure	15
Self-care	-
Regular dental check-ups	-
Antioxidant diet	-

For oral cancer: the risk is HIGH if it is greater than or equal to 10 points.

For lip cancer: the risk is HIGH if it is greater than or equal to 15 points.

Instructions for using the oral cancer risk scale

Scale data

Risk factors: these are factors with a harmful effect, whose values are added to the cumulative total when they are present. They are risk factors found in clinical practice and confirmed by epidemiological studies.

Toxic habits: For these, addiction will be taken into account according to the following criteria:

· It exceeds the normal level of consumption in a given environment, such that the abuse is not temporary but stable.

· Organic, psychological, or social damage has been proven as a result of the habit.

· When there is a level of addiction to the toxic substance that determines that the subject recognizes the harmful effect from personal experience but is unable to stop consumption.

Smoking: considered if the individual is an active smoker, in any form, at least once a day, and also former smokers who have quit for less than five years. Alcoholism: considered as such for individuals who consume more than 200 ml of strong alcoholic beverages or their equivalent (1 bottle of wine or 5 cans of beer) on a weekly basis.

Thermal irritants: these include hot foods and drinks consumed at least once a day.

Traumatic irritants: these include all oral trauma caused by ill-fitting dentures (more than 5 years in use), lack of rehabilitation in areas with chewing activity, sharp teeth, defective restorations, and traumatic habits.

Sun exposure: only added when the patient has white skin or is mixed race with fair skin. Considered positive when exposed for more than 30 minutes between 10:00 a.m. and 3:00 p.m.-4:00 p.m. depending on the time of year (winter-summer), with a frequency greater than or equal to 3 times a week.

Oral pathological history: presence of any premalignant condition or lesion, with clinical and histopathological diagnosis if possible. This includes leukoplakia, erythroplakia, lichen planus, candidiasis, angular stomatitis, actinic cheilitis, herpes simplex lesions, papillomas, glossitis, nevi, or other lesions in this group.   

Protective factors: these are factors whose values are subtracted from the cumulative total when present. They are elements that prevent damage to the patient’s health and act as preventive or prophylactic agents, even if other risk factors are present.

Self-care: 4 points are deducted if the patient brushes their teeth at least twice a day and has mastered at least three steps of oral self-examination. If the patient only brushes their teeth once a day or never, and has no knowledge of oral self-examination, 0 points are awarded.

Visits to the dentist: 4 points are deducted if the patient visits the dentist at least once a year and has done so for the last 5 years. If the patient only visits sporadically or in emergencies, 0 points are added. 

Antioxidant diet: considered normal when the patient consumes fruits and vegetables in their natural state at least three times a week, in which case 4 points are deducted. If consumption is occasional, 0 points are added.

A survey on oral cancer awareness was conducted (table 4), containing questions addressing aspects related to this disease. The survey was designed by Dr. Sheyla Arlettys Matos Arias and validated by Antonio Suárez Rodríguez, a graduate in psychology and higher education. It was administered to the high-risk patients who made up the sample, before and after the educational intervention. The survey consists of 10 questions, which are rated as Good, Fair, or Poor as follows:

· The correct answer to question 1 is (4 times). One point was awarded.

· The correct answer to question 2 is (after breakfast, lunch, dinner, and before bedtime). One point was awarded for each correct answer.

· The correct answer to question 3 is (Yes). One point was awarded.

· The correct answer to question 4 is (twice a year). One point was awarded.

· The correct answer to question 5 is (1, 4, 5, 6, 8, and 9). One point was awarded for every two correct answers.

· The correct answer to question 6 is (Yes). One point was awarded.

· The correct answer to question 7 is (Yes). 1 point was awarded.

· The correct answer to question 8 is (c, b, f, e, g, a, d, h). 0,5 point was awarded for each correct answer.

· The correct answer to question 9 is (1, 5, 6, 7, 8, 11, 12, 14, 15, and 16). 0,5 point was awarded for each correct answer.

· The correct answer to question 10 is (1, 3, 4, 6, 7, 8, and 11). 0,5 points were awarded for each correct answer.

The total evaluation of the oral health knowledge survey is based on 24 points distributed as follows:

· Good (17 to 24 correct answers)

· Fair (9 to 16 correct answers)

· Poor (less than 9 correct answers)

Participants were instructed on how to perform oral self-exams using educational web media (table 5) as a teaching tool through educational talks at each meeting, which were held once a week for a month. The control group completed the surveys at home during the initial stage. The surveys were then administered to both groups in the experiment after the educational intervention.

An educational website designed by Dr. Marisnelys Nile Despaigne was used, with a program that has excellent features, including a gallery of images, videos, and information about this condition. Each of the pages was linked to a central page (also called the home page, cover page, index, or homepage, Tecnobyte 2019), on which the directory or folder tree structure was directly based.

The computer product was designed to create interactivity with the user and could be accessed on a computer. This website facilitated the acquisition of knowledge, as patients learned through the use of images, animations, and videos, which motivated and aided in learning.

Techniques for processing and analyzing results

The data collected was organized in a database for subsequent statistical analysis. Percentages were used as summary measures for the selected variables. The results were expressed in tables and graphs for better understanding. A computer with Windows 10 operating system and Microsoft Word and Excel programs, both from Microsoft Office 2019, were used for both procedures to prepare the text, tables, and statistical graphs.  The data were processed by calculating the absolute and relative frequencies, the latter to achieve a better interpretation of the results; percentages were also used. The results were analyzed and discussed, comparing them with other studies in order to achieve the proposed objectives, draw conclusions, and make the relevant recommendations. 

Ethical considerations

The research was conducted with the informed consent of the patients who participated in the educational intervention. The data obtained in the study were used confidentially, demonstrating respect for the principle of autonomy of the international code of bioethics for intervention in human beings. They were not used for personal purposes, nor were details of this research published that could compromise the integrity of researchers, patients, or entities. The information obtained was used by the author for research purposes. The results were presented collectively and not individually.

RESULTS AND DISCUSSION

Table 3. Distribution according to risk for predicting oral cancer in patients aged 35-59 belonging to clinic 16, Nueva Gerona. Dr. José Lázaro Fonseca López del Castillo Dental Clinic. Special Municipality of Isla de la Juventud, 2022
Risk for predicting oral cancer	Patients aged 35-59
	No	%
High	94	25,4
Low	276	74,6
Total	370	10

Table 3 shows the distribution of patients aged 35-59 years belonging to clinic 16 according to risk for oral cancer. As can be seen, 94 were at high risk, representing 25,4 % of the total population in this age group at clinic 16, while 276 patients were at low risk, representing 74,6 %.

Similar studies conducted by Dr. Yanelilian Padín Gámez and Dr. Katherine Grandal García show consistent results; however, in the same year, a study conducted by Dr. Marisnelys Nile Despaigne obtained different results.

Advanced age is an important marker in the origin of all tumors that affect men, since with the passage of time there is a deterioration of tissues and a cumulative effect of the carcinogens that have been present in the individual’s life. Added to this is the temporality or temporary effect of risk factors, which is directly proportional to increasing age. Cancer is more common in people over 35 years of age, although cases have been reported in young people where heredity is believed to have played a role in the disease.⁽²⁷⁾

The author considers that the results shown are related to the high presence of risk factors associated with the onset of oral cancer in the population over 15 years of age. Identifying the risk of developing this disease was of vital importance for the development of the research, since determining the characteristics that may make individuals susceptible to cancer in any of the anatomical locations of the stomatognathic system guided the preventive work to be carried out and served as a guide for the preparation of the teaching materials to be used during the educational work. 

The eminent Cuban scientist Dr. Julio César Santana Garay pointed out the need for oral cancer prevention in the first instance and, to achieve this, the creation of a Center for Research and Detection of Oral Neoplasms, highlighting the vital importance of systematizing a meticulous clinical oral examination. The Risk Scale for predicting oral cancer can measure each individual’s probability of developing oral carcinomas and, at the same time, serves as a guide for educational and preventive work with patients. The progress and considerable scientific development that stomatology has experienced in this century is the result of numerous factors that have systematically sought to apply basic sciences to the development of clinical practice, transforming clinical technicality into a science of knowledge, preservation, and recovery of the health of the stomatognathic system.

Several clearly differentiated disciplines participate in health promotion, such as health sciences, psychology, education, and communication, which will be the core on which both the theoretical and practical aspects of the program are based. Collective learning methods are very attractive for channeling this proposal, as they allow people with the same needs, interests, and level of competence to be grouped together, making them useful when developing common learning objectives. The author believes that the greatest effort should be directed at reducing the incidence of malignant oral conditions, taking into account the risk of oral cancer, by increasing promotional activities in the community, which has a favorable influence on the knowledge, attitudes, and behaviors of individuals and communities. Joint action between individuals, families, and health personnel is essential to ensure that patients themselves have access to and the opportunity to transform the health information provided into knowledge, attitudes, and appropriate practices that enable them to care for and protect their health, as well as to develop healthy lifestyles now that will accompany them throughout their lives.

Table 4. Distribution by sex of patients aged 35-59 with a high risk of oral cancer, belonging to clinic 16, Nueva Gerona. Dr. José Lázaro Fonseca López del Castillo Dental Clinic. Special Municipality of Isla de la Juventud, 2022
Sex	Experimental groups				Total
	Experimental group		Control group
	No	%	No	%	No	%
Female	11	23	17	36	28	30
Male	36	77	30	64	66	70
Total	47	50	47	50	94	100

Table 4 shows the distribution of the experimental and control groups according to gender, where a predominance of males is observed in both the experimental and control groups, with a total of 66 males (70 %), demonstrating the internal validity of the experiment.

Some authors have pointed out that sex influences the genesis of oral cancer, but current trends consider that there is no biological predisposition between the sexes and that only behavior can influence one sex to be more vulnerable than the other. Biological sex generally defines gender differences and risk factors such as toxic habits, which are more common in males, and therefore there is a traditional belief that oral cancer is more common in men than in women.⁽²⁶⁾ Similarly, females have a longer life expectancy, as they have a greater perception of risk with regard to health care and practice a more hygienic lifestyle in their daily lives.

The data found do not coincide with those presented by Dr. Juan Carlos Quintana Díaz⁽¹³⁾ in the province of Artemisa in his research on risk factors for premalignant and malignant oral lesions, where females predominated at 54,5 %. These findings are similar to those obtained by Ruth Ramón Jiménez⁽²⁵⁾ in Santiago de Cuba in 2015, where males predominated with 58 %.

It also differs from the research on oral lesions in older adults and risk factors at the “Dr. Tomás Romay” polyclinic in Havana, Cuba, carried out by Drs. Marín, Reyes, and Mesa, where 62,8 % were women.

In the author’s opinion, high life expectancy and low birth rates in Cuba are factors that contribute to the aging of the population, which is a characteristic that must be taken into account when carrying out promotion and prevention activities to prevent the development of this disease, which is so harmful to human beings. With increasing age, the risk of developing oral cancer increases significantly as a result of greater exposure to carcinogens. These results reaffirm that increasing age is a tangible risk factor and one of the main determinants of the onset of oral cancer, hence the need to take action in younger age groups.

General dentists are the first line of defense in oral cancer prevention and health education, so their level of knowledge and perception of the population’s risk of developing oral cancer is of great importance for prevention in primary health care.

The combination of primary and secondary prevention is a widely recommended method for improving the epidemiological situation of chronic noncommunicable diseases such as oral cancer. This alliance has the advantage of including educational, preventive, and therapeutic actions for prophylactic purposes.⁽³⁶⁾

Table 5. Distribution according to risk factors before and after the educational intervention of patients aged 35-59 years with a high risk of oral cancer, belonging to clinic 16, Nueva Gerona. Dr. José Lázaro Fonseca López del Castillo Dental Clinic. Special Municipality of Isla de la Juventud, 2022
Risk factors associated with the onset of oral cancer	Before intervention				After intervention
	Experimental group		Control group		Experimental group		Control group
	No	%	No	%	No	%	No	%
Smoking	37	79	42	89	34	72	41	87
Alcoholism	6	13	5	11	5	11	4	9
Ingestion of hot, acidic, and spicy foods	39	83	32	68	28	60	27	57
Wearer of ill-fitting dentures	9	19	11	23	8	17	11	23
Constant exposure to the sun	4	9	5	11	2	4	3	6
Stress	29	62	30	64	17	36	18	38
Queilophagia	2	4	3	6	-	-	1	5

Table 5 shows the distribution of the sample according to the main risk factors present before and after the educational intervention.

Research in oncology and oral pathology has shown that the formation of oral cancer is a chronic and complex process in which several elements act together and possibly no single agent is capable of causing a malignant neoplasm, confirming that it is a multifactorial disease.⁽⁴⁰⁾

Risk factors include smoking, which is a chronic disease caused by the habit of smoking; nicotine is one of its main active components and is responsible for addiction. In addition to nicotine, tobacco contains substances such as N-nitrosamine, N-nitrosonornicotine, and 4(Methylnitrosamine)-1-(3-pyridyl)-1-Butanone, which are also believed to be responsible for premalignant and malignant processes in the oral cavity.

Nicotine affects peripheral circulation, causing significant gingival vasoconstriction, which reduces the supply of repair elements from the blood to the gingival tissue and, consequently, weakens the healing capacity of this tissue. The immune system may also be suppressed due to a reduction in chemotaxis and phagocytosis by leukocytes. In addition, nicotine causes damage to the extracellular matrix of gingival fibroblasts. A concentration of less than 0,0075 % causes cell death, 0,075 % causes vacuolization of fibroblasts, and 0,05 % inhibits the production of fibronectin and type II collagen, causing a breakdown of the gingival extracellular matrix and, consequently, increasing the severity of periodontal disease. Based on the above, we can assume that a similar effect can occur in any other part of the oral mucosa and not only in the periodontium.

Smoking, in addition to being a risk factor associated with the development of oral cancer, causes other oral health problems such as halitosis, staining of the teeth and tongue, decreased sense of smell and taste, increased plaque and tartar buildup on the teeth, increased bone loss in the jaw, gum disease and tooth loss, increased risk of leukoplakia and slow healing after periodontal treatment, tooth extraction or other surgery.⁽²⁹⁾

In the present study, the intake of hot, spicy, and acidic foods predominated. Diet is a risk factor that plays a role in the prevention and progression of cancer due to the constant supply of antioxidants provided by food. In the mouth, it is suggested that low intake of foods rich in vitamins and minerals (vitamins A, C, E, B complex, and minerals such as iron and selenium) favors the occurrence of oral cancer. Fresh fruits and vegetables are excellent protectors, as they have an antioxidant effect that prevents mutations by free radicals and protects the epithelium.⁽³⁵⁾

These results coincide with the study conducted by Dr. Mirna Mendoza Fernández and Dr. Ana Margarita Ordaz González,⁽³⁸⁾ in the municipality of Guamá in the province of Pinar del Rio in 2013, where it was found that before the educational intervention was implemented, there was a predominance of very hot and spicy food intake, followed by the inappropriate use of ill-fitting dentures. It also coincides with research on oral lesions in older adults and risk factors at the “Dr. Tomás Romay” polyclinic in Havana, Cuba, by r. Marín, Reyes, and Mesa, where the consumption of hot or very spicy foods reached the highest percentage, 85,5 %.

This does not coincide with the study conducted by Dr. Yuberny Salazar Martínez on the Isle of Youth in the period 2017-2019, where the predominant risk factor was smoking; nor are there any similarities with the study conducted on the Isle of Youth by Dr. Sheyla Arletys Matos Arias, where stress was the predominant factor. Although they do not completely coincide, it should be noted that in the present study, the second predominant risk factor was smoking and the third was stress.

As can be seen, there are a considerable number of risk factors in the sample under study, which indicated the importance of educational intervention on oral cancer. It is extremely difficult to modify risk factors that, as habits, are ingrained in each patient and form a conditioning part of their lifestyle. Many, despite having the knowledge provided after the educational intervention, continue to practice the same behaviors, which is indicative of the patients’ low perception of risk. The behavior of individuals will depend, in the first instance, on each patient’s perception of risk.

After the educational intervention was implemented, a considerable reduction in all risk factors was observed in the experimental group over a short period of time. In most cases, it is difficult to change the lifestyle of patients in the community, who, despite having the knowledge, continue without modifying their behavior. The author considers that these results are caused by a lack of risk perception and low awareness among patients of the dangers to which they are exposed in terms of health.

Despite the short time the intervention was applied, each risk factor was reduced. This is of great importance when considering that several risk factors can coexist in the same patient, which increases the risk of developing the disease. Therefore, if several factors are eliminated in a patient, the risk of developing cancer would be reduced to a qualitatively lower level for those patients.

The patient’s attitude toward their health is a decisive factor in the onset of oral cancer, because if they do not master oral self-examination and do not visit the dentist regularly, barriers are created that hinder the early detection of any oral lesions. As the carcinogenic process is slow and progressive, each individual has the possibility of detecting changes in their mouth early on, and if they visit their dentist every six months, it is almost impossible for a premalignant or malignant lesion to go undiagnosed.⁽¹⁸⁾

Based on the above, the author considers that the most important task of dentists should be aimed at modifying harmful lifestyles directly in the population at high risk of oral cancer, through educational interventions that take into account the existence of numerous risk factors that are harmful to the population. Furthermore, the author agrees with the criterion endorsed by research that risk factors must be controlled in order to prevent oral cancer. In this regard, health promotion plays a very important role in counteracting the nonspecific phase of the disease, i.e., preventing the possible incidence of risk factors that favor the onset of these pathologies.

Table 6. Distribution according to risk level for predicting oral cancer before and after the educational intervention in patients aged 35-59 years with a high risk of oral cancer, belonging to clinic 16, Nueva Gerona. Dr. José Lázaro Fonseca López del Castillo Dental Clinic. Special Municipality of Isla de la Juventud, 2022
Risk level for predicting oral cancer	Before the procedure								After the intervention
	Experimental group				Control group				Experimental group				Control group
	Lip		Oral cavity		Lip		Oral cavity		Lip		Oral cavity		Lip		Oral cavity
	No	%	No	%	No	%	No	%	No	%	No	%	No	%	No	%
High	12	26	35	74	17	36	30	64	6	13	18	42	11	24	22	47
Low	-	-	-	-	-	-	-	-	6	13	17	32	5	11	8	17

Table 6 shows the distribution of the experimental groups according to risk level for predicting oral cancer before and after the educational intervention, where it can be seen that both groups presented a high risk of developing oral cancer, with the most affected anatomical location being the oral cavity.

The author considers it important to highlight the significant influence of risk factors associated with the onset of oral cancer, which are strongly related to the onset and subsequent development of this disease. The greater the number of risk factors to which a person is exposed, the greater the risk of developing oral cancer; as the potency of each factor increases, the sensitivity and specificity of the multifactorial risk index increases.

Cancer is a multifactorial disease caused by alterations in genes through a wide range of mechanisms that also involve non-genetic factors. Some factors mentioned above, such as radiation, infections, diet, chronic irritation, excessive sun exposure, and, as the most important risk factors, smoking and alcohol consumption, are relevant in carcinogenesis. Many of the symptoms of oral cancer can be the result of other non-cancerous medical conditions, so it is important to receive regular medical and dental care, especially if the person drinks alcohol regularly or currently uses tobacco products or has done so in the past.

The author believes that patients who are at high risk are due to the accumulation of numerous risk factors, so it is useful to identify them in order to carry out health promotion activities, including educating and promoting oral health. Identifying the risk factors present allows them to be controlled with specific actions, refer patients to the second level of care for early treatment, eliminate possible lesions, rehabilitate disabled patients, and repeat the evaluation after 6 months in a timely manner.  

The estimated number of deaths from lip and oral cavity cancer by continent in 2018 shows a significant increase. Asia accounts for 129 939 deaths from these diseases, Europe 24 063, Africa 9 314, Latin America and the Caribbean 7 874, North America 5 198, and Oceania 996.⁽²⁵⁾

In Cuba (2019), the mortality rate for lip, oral cavity, and pharyngeal cancer in males was 12,1, showing a notable difference compared to females, which was 2,6. These figures are worrying, considering that we have a national coverage program, which is a pipe dream for most countries.⁽²⁰⁾

In the present intervention in high-risk patients carried out in the Special Municipality of Isla de la Juventud, the number of patients at high risk of oral cancer decreased considerably, which is why the author considers that educational intervention has a high impact and infinite usefulness in terms of economics and health.

The presence of a cluster of risk factors associated with the onset of oral cancer is the cause of a high risk of developing these diseases. It is very useful to identify these factors in order to carry out effective health promotion work, as well as to organize primary preventive measures and highlight the risk factors that require specific protection both in the patient and in their family or community environment.

The ability to identify patients at high risk of oral cancer and detect the disease at an early stage is currently a challenge for stomatologists, as it allows us to measure each individual’s chances of developing cancer of the lip and oral cavity. This knowledge provides stomatologists with a guide for educational and preventive work with patients, always based on the premise that health is the most precious asset a human being has because it allows them to enjoy a good quality of life.

If the probabilities of developing oral cancer are known, individuals can contribute to improving lifestyles within our society, because each patient will be aware of the risk factors that affect them and will also be able to perceive the risks in their family and community, which can transform them from individuals into community or social health promoters.

Table 7. Distribution according to level of knowledge before and after the educational intervention of patients over 15 years of age with a high risk of oral cancer, belonging to clinic 16, Nueva Gerona. Dr. José Lázaro Fonseca López del Castillo Dental Clinic. Special Municipality of Isla de la Juventud, 2022
Level of knowledge about oral cancer	Before the intervention				Total		After the intervention				Total
	Experimental group		Control group				Experimental group		Control group
	No	%	No	%	No	%	No	%	No	%	No	%
Good	-	-	-	-	-	-	24	51	16	34	40	43
Average	29	62	30	64	59	63	17	36	21	45	38	40
Bad	18	38	17	36	35	37	6	13	10	21	16	17
Total	47	100	47	100	94	100	47	100	47	100	94	100

Table 7 shows the distribution of the experimental groups according to their level of knowledge about oral cancer before and after the educational intervention, where it can be seen that regular knowledge predominated in both experimental groups, with 62 % for the experimental group and 64 % for the control group.

Before the intervention, no patient in the sample had a good level of knowledge, which demonstrated the lack of knowledge about the signs, symptoms, risk factors associated with the onset of oral cancer, and how to perform oral self-examination.

These results demonstrate that hard work must continue in patient education, with an emphasis on modifying and raising the level of knowledge of the population through health promotion activities, targeting mainly the most affected age groups and taking into account that most of the risk factors associated with the onset of this disease depend on the attitudes, knowledge, and behavior of each individual.

The results of this research were compared with a study in Argentina, where interviews were conducted through systematic sampling using the telephone directory. The results showed that between 41 % and 45 % were aware of the questions in the questionnaire, and only 32 % remembered having had a proper oral examination. In Peru, a questionnaire administered to 150 dentistry students concluded that this population has little knowledge, with only 38 % having a favorable opinion.

This coincides with a study conducted by Moctezuma G, Díaz de León R, Rodríguez FJ62, Mexico 2015, where the level of knowledge was average. This study found references linking low levels of education with the possibility of developing premalignant lesions and oral cancer.

The initial results were also compared with other studies, finding that the results do not coincide with the work carried out by Dr. Mirna Mendoza Fernández and Dr. Ana Margarita Ordaz González,⁽³⁹⁾ in the municipality of Guamá in the province of Pinar del Rio, and the intervention carried out by Dr. García Heredia in Havana, reporting that more than 70 % of the patients surveyed were rated as (poor), which demonstrates the lack of knowledge about oral cancer prevention, signs and symptoms, and self-examination.

In the Special Municipality of Isla de la Juventud, various studies were conducted to determine the level of knowledge about oral cancer among the population. The results of this research coincide with those of Dr. Sheyla Matos Arias, which reflected the predominance of regular evaluation in both the experimental and control groups, with a total of 44,7 %, followed by poor representation with 34,3 %. The results of this research differ from those of the educational intervention on oral health in people over 15 years of age with high- r risk in clinic 27, belonging to polyclinic 2, carried out by Dr. Katherine Grandal, where there was a predominance of poor knowledge about oral cancer in both the experimental and control groups, represented by 48,9 % and 41,5 % in those groups, respectively.

After the intervention was implemented, notable improvements were found in the experimental group, which included 47 patients. Of these, 24 were rated as “good,” responding satisfactorily to the knowledge survey, with only 6 respondents remaining in the “poor” category.

Changes were also observed in the control group, although only educational talks were given without any visual impact. Many of the patients acquired the knowledge but did not apply it in their daily practice, leaving 10 patients still classified as “poor.” This is because the cognitive component is only one link in the behavior change process. It is necessary for individuals to develop an adequate perception of risk, which is an incentive to continue developing educational efforts in the community.

Community education is the ideal method for raising awareness and risk perception about oral cancer. Primary prevention should first motivate people, especially young people and adults, through attractive proposals that achieve massive and active participation by patients, urging them not to start unhealthy habits. Second, it should encourage those who already practice unhealthy habits to quit and, as a last resort, to modify or reduce these habits. 

With regard to the use of new information and communication technologies in the promotion and prevention of premalignant lesions and oral cancer, it is necessary to bear in mind the appropriate selection and updating of information, to ensure the training of professionals and to provide accurate guidance through the learning environment to facilitate patient interaction with the medium, as well as the availability of the necessary resources for its implementation.

CONCLUSIONS

The risk of oral cancer was low in the population aged 35-59, although the sample of high-risk patients is representative.

Males prevailed in both groups of the experiment.

The main risk factors associated with the onset of oral cancer in the study sample were: eating hot, spicy, or highly seasoned foods, smoking, and stress prior to the educational intervention, which were positively modified after the intervention in the experimental group.

The level of knowledge about oral cancer in the study sample that prevailed before the intervention was average in both groups of the experiment, but it increased significantly after the intervention in the experimental group.

The use of web media in the educational intervention had significant results in the research.

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FINANCING

None.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.

AUTHOR CONTRIBUTION

Conceptualization: Yoneisy Abraham-Millán, Rosa María Montano-Silva, Yanelilian Padín-Gámez, Eridania Pantoja-García, Iraida Céspedes-Proenza, and Bárbara Zenaida Pérez-Pérez.

Data curation: Yoneisy Abraham-Millán, Rosa María Montano-Silva, Yanelilian Padín-Gámez, Eridania Pantoja-García, Iraida Céspedes-Proenza, and Bárbara Zenaida Pérez-Pérez.

Formal analysis: Yoneisy Abraham-Millán, Rosa María Montano-Silva, Yanelilian Padín-Gámez, Eridania Pantoja-García, Iraida Céspedes-Proenza, and Bárbara Zenaida Pérez-Pérez.

Research: Yoneisy Abraham-Millán, Rosa María Montano-Silva, Yanelilian Padín-Gámez, Eridania Pantoja-García, Iraida Céspedes-Proenza, and Bárbara Zenaida Pérez-Pérez.

Methodology: Yoneisy Abraham-Millán, Rosa María Montano-Silva, Yanelilian Padín-Gámez, Eridania Pantoja-García, Iraida Céspedes-Proenza, and Bárbara Zenaida Pérez-Pérez.

Project administration: Yoneisy Abraham-Millán, Rosa María Montano-Silva, Yanelilian Padín-Gámez, Eridania Pantoja-García, Iraida Céspedes-Proenza, and Bárbara Zenaida Pérez-Pérez.

Resources: Yoneisy Abraham-Millán, Rosa María Montano-Silva, Yanelilian Padín-Gámez, Eridania Pantoja-García, Iraida Céspedes-Proenza, and Bárbara Zenaida Pérez-Pérez.

Software: Yoneisy Abraham-Millán, Rosa María Montano-Silva, Yanelilian Padín-Gámez, Eridania Pantoja-García, Iraida Céspedes-Proenza, and Bárbara Zenaida Pérez-Pérez.

Supervision: Yoneisy Abraham-Millán, Rosa María Montano-Silva, Yanelilian Padín-Gámez, Eridania Pantoja-García, Iraida Céspedes-Proenza, and Bárbara Zenaida Pérez-Pérez.

Validation: Yoneisy Abraham-Millán, Rosa María Montano-Silva, Yanelilian Padín-Gámez, Eridania Pantoja-García, Iraida Céspedes-Proenza, and Bárbara Zenaida Pérez-Pérez.

Visualization: Yoneisy Abraham-Millán, Rosa María Montano-Silva, Yanelilian Padín-Gámez, Eridania Pantoja-García, Iraida Céspedes-Proenza, and Bárbara Zenaida Pérez-Pérez.

Writing – original draft: Yoneisy Abraham-Millán, Rosa María Montano-Silva, Yanelilian Padín-Gámez, Eridania Pantoja-García, Iraida Céspedes-Proenza, and Bárbara Zenaida Pérez-Pérez.

Writing – review and editing: Yoneisy Abraham-Millán, Rosa María Montano-Silva, Yanelilian Padín-Gámez, Eridania Pantoja-García, Iraida Céspedes-Proenza, and Bárbara Zenaida Pérez-Pérez.