Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7

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Early detection of oral cancer: Dentists opinions and practices before and after educational interventions in Northern-Germany
Katrin Hertrampf a, *, Hans-Jrgen Wenz b, Michael Koller c, Sebastian Grund b, Jrg Wiltfang a
Clinic of Oral and Maxillofacial Surgery (Head: Prof. Dr. Dr. Jrg Wiltfang), University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 26, 24105 Kiel, Germany Clinic of Prosthodontic, Propaedeutics and Dental Materials (Head: Prof. Dr. Matthias Kern), University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 26, 24105 Kiel, Germany c Centre for Clinical Studies (Head: Prof. Dr. Michael Koller), University Hospital Regensburg, 93042 Regensburg, Germany
b a

a r t i c l e i n f o
Article history: Paper received 1 September 2012 Accepted 9 January 2013 Keywords: Oral cancer Continuing dental education Dentists Survey Opinion Practice

a b s t r a c t
Introduction: The question whether educational programmes improve dentists knowledge of oral cancer is still an unexplored subject. The aim of this study was to assess dentists opinions and practices concerning oral cancer using a standardised survey after educational intervention over one year. Material and methods: Following a baseline survey which was mailed to every dentist in SchleswigHolstein, Germany (n 2280), the results were analysed to produce a multifaceted educational programme. After educational intervention, the same survey was redistributed and the results before and after intervention were compared. Results: The results are based on 394 surveys. Following intervention, 62% of responders, compared to 49% at baseline, described their overall knowledge as current. The percentage of dentists routinely investigating older patients at the recall appointment increased from 28% at baseline to 37% if the responders had attended a continuing education course during the period of intervention. Similar improvements were observed at initial appointment for older patients, with results improving from 33% to 38% for responders who attended a further educational course. Conclusions: Our results showed that a 1-year educational intervention with a multifaceted approach was successful. They underline that continuing education programmes improve the competence of dentists performing examination of the oral cavity. Therefore, regular participation in continuing educational courses is recommended. 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

1. Introduction More than 13,000 cases of oral cancer are diagnosed newly in Germany each year. Although diagnostic and therapeutic procedures are continuously improved, incidence rates have not changed over decades, and still more than 5000 people die from this type of tumour every year. In Germany, this type of tumour now ranks 5th (3.9%) for men and 15th (1.6%) for women, and the 5-year survival rate is still only 46% for men and 60% for women. These survival rates are as low as those for colon or stomach cancer (Robert Koch Institut 2012).

* Corresponding author. Tel.: 49 431 597 2896; fax: 49 431 597 4084. E-mail address: hertrampf@mkg.uni-kiel.de (K. Hertrampf).

More than two-thirds of new cases are diagnosed at an advanced stage (Pritzkuleit et al. 2011), with a resulting poorer prognosis for patients (Mourouzis et al. 2009). Early detection and consequently, an earlier start of therapy would improve survival rates and quality of life (Becker et al. 2012; Sankaranarayanan et al. 2005). Detailed patient information on the risk factors and structured routine examination of the oral tissues should be an integral part of the annual dental check-up. This routine examination is simple, inexpensive and safe because of the easy access to the oral cavity (Clovis et al., 2002, Kujan et al., 2006, Lopez-Jornet et al., 2010). Dentists as health care providers should incorporate this examination in all initial and recall appointments in their daily practice, however diagnostic accuracy requires current knowledge and continuing educational training to allow differentiation between

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Please cite this article in press as: Hertrampf K, et al., Early detection of oral cancer: Dentists opinions and practices before and after educational interventions in Northern-Germany, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.01.019

K. Hertrampf et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7

benign and possible premalignant and malignant lesions (Greenwood and Lowry 2001). The aim of this study was to evaluate dentists opinions and practices with oral cancer assessment and the conduct of routine examinations of the oral cavity at initial and recall appointments after a comprehensive educational intervention in SchleswigHolstein, Germany. 2. Material and methods 2.1. The study population Dentists opinions and practices at baseline, i.e. before the educational intervention, were evaluated by means of a survey in November 2007 (Klosa et al. 2011). In April 2009, i.e. after the educational intervention, the mailing of the second questionnaire for the re-evaluation was published in the Dental Associations monthly journal. The survey with a business reply envelope was mailed to all dentists within Schleswig-Holstein, Germany (n 2280), by the
Table 1 Contextual focus of the different approaches within the oral cancer educational intervention programme. Brochure Information about: Clinical signs, symptoms Diagnostic procedures Risk factors Standardised routine examination of the oral cavity Clinical decision pathway Health history evaluation Additional diagnostic adjuvants Examples for different oral cancer lesions Differential diagnosis Epidemiological background Histopathology Literature references Oral presentation x x x x x x x x Poster DVD

states Dental Association in May 2009. The Dental Association agreed responsibility for the mailing because in Germany, dentists are obligatory members of the dental association responsible for their respective place of residence and the association knows the precise number of licensed dentists at any time. The mailing procedure included two reminders after three and six weeks and was identical to that used at baseline. For anonymity, the reminders were sent to all dentists, no matter whether the individual dentist had already returned the questionnaire or not. 2.2. The interventional educational programme Based on the results of the baseline evaluation from autumn 2007 (Klosa et al. 2011), the project team together with the Dental Association of Schleswig-Holstein developed a comprehensive educational programme composed of different elements. The educational programme focused on aspects of primary prevention, i.e. patient information about risk factors, and secondary prevention, i.e. dentist information about signs and symptoms and a standardised routine examination of the oral cavity. The programme followed established requirements for implementing medical guidelines utilising a multifaceted approach (Margolis and Cretin 1999; Gross et al. 2001; Klinkhammer-Schalke et al. 2008a,b). Table 1 describes the different approaches and their contextual focus. 2.3. The study design

x x x x x x x

x x

x x x

x x x

x x x

Fig. 1 shows a temporal overview on the entire study from baseline to re-evaluation and the different aspects of the educational programme within the 1-year intervention period. The educational programme started with the mailing of a brochure e supported by the Deutsche Krebshilfe (German Cancer Aid) e sent to each dentist by the states Dental Association. After analysis of the baseline results, the project team developed an oral presentation and offered this presentation to all dental counties within the state. In Germany, each state dental association is divided into several dental county associations, and these authorities decide the

Baseline
11/2007 to 01/2008

Educational intervention
05/2008 to 04/2009

Reevaluation
05/2009 to 07/2009

Survey with two reminders 08/2008 Mailing of brochure*

Oral presentation in the dental county associations**

Survey with two reminders

03/2009 Announcement of poster and DVD*** 04/2009 Dentists order of posters and DVDs

*by the Dental Association of Schleswig-Holstein **presenters were two members of the project team ***personal letter to each dentist from the project team together with the Dental Association
Fig. 1. Overview on the different approaches within the 1-year intervention period of the educational programme.

Please cite this article in press as: Hertrampf K, et al., Early detection of oral cancer: Dentists opinions and practices before and after educational interventions in Northern-Germany, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.01.019

K. Hertrampf et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7

educational programmes to be offered to their dentists, independent of the State Dental Association. These dental county associations represent the base of the dental community. In addition to the oral presentation, the project team created a poster and a DVD, which were announced in a personal letter to every dentist within the state in spring 2009. A facsimile coupon was attached to the personal letter, so interested dentists only had to place a tick for the elected material and return the facsimile to the project team. 2.4. The survey The questionnaires used in the re-evaluation and at baseline in Autumn 2007 were identical. The original was developed by Yellowitz et al. (Yellowitz and Goodman, 1995, Yellowitz et al., 1998) and translated into German following a standardised translation procedure (Hertrampf et al. 2009). This questionnaire consisted of 41 items about oral cancer divided into different parts: signs, symptoms and risk factors, health history, opinions about oral cancer, dental education and continuing dental education. The evaluation of dentists knowledge about risk factors and diagnostic items after intervention are published elsewhere (Hertrampf et al. 2011). The results of self-reported questions about dentists opinions (cognitive) and practices (behavioural) on oral cancer after a 1-year intervention are described in this publication. We evaluated opinions on the need of routine cancer examinations of the oral cavity at initial and recall appointments for patients 40 years and older. In addition, the dentists estimated the percentage of their patients in this age group whom they orally examined at initial and recall appointments; divisions were never, up to 1/3 of my patients, 1/3 to 2/3 of my patients, more than 2/3 of my patients and always. Furthermore, we evaluated the estimate of percentage of this examination for edentulous patients. We also analysed dentists opinions on their own level of education and qualication, their assessment about dentists in general with regard to oral cancer risk assessment and examination and the estimation about their patients knowledge of signs, symptoms and risk factors with a 5-point Likert scale with agreement or disagreement to different statements ranging from strongly agree, agree, disagree, strongly disagree to dont know. 2.5. Statistical analyses Descriptive statistics of demographic variables of the sample and responses to the questionnaire were reported by means of counts and percentages and graphically presented in one gure and several tables. All analyses were carried out with the SPSS for Windows (SPSS Inc., Chicago, Illinois, USA). The project was approved by the Ethics Committee of the University of Kiel, Germany (AZ: A 113/06). 3. Results 3.1. The study samples At re-evaluation assessment, 394 out of 2280 questionnaires were returned, which represents a response rate of 17%. The majority in both surveys were men, and the majority of responding dentists were in the age group 40e49 years and 50e59 years (Table 2). The samples of responders at baseline and reevaluation were comparable in age and sex distribution with regard to the demographic distribution of the whole dental community within the state. Table 2 gives an overview on the dentists demographic distribution and the professional aspects at baseline

and re-evaluation. The detailed results at baseline have been described elsewhere (Klosa et al. 2011). At re-evaluation, 33% of the responding dentists e compared to 18% at baseline e indicated that they had attended a continuing educational course on oral cancer within the past year. This time period corresponded with the 1-year intervention period. 3.2. Use of the educational intervention programme within the study region In the intervention period between spring 2008 and spring 2009, 14 out of the 16 dental county associations and every dental clinic within the state had made appointments for our oral presentation. One of the other two dental county associations did not have an open time slot during the intervention period; therefore, the oral presentation took place after the re-evaluation, whereas the other one had already independently arranged an oral presentation about this topic before the start of the intervention, so this association decided not to participate with our oral presentation. 426 (23%) out of 1850 dentists, members listed in the dental county associations as well as clinic employees, participated in our oral presentation. Almost the same percentage of dentists ordered either the poster or the DVD, and the majority ordered both. Overall, the number of ordered DVDs was slightly higher than that of posters. 33% of the responders declared that they had attended a continuing education course on oral cancer within the past 12 months compared to 18% at baseline (Table 2). 3.3. Dentists assessment of their own competence At re-evaluation, almost 62% of all dentists described their overall knowledge on oral cancer as current compared to less than 50% of responders at baseline. Their opinions on their own qualications or current education status also showed improved results at re-evaluation compared to baseline. Moreover, dentists, who had attended an educational programme within the intervention period, showed higher assessment rates of their own competence than the whole sample of responders and the sample of responders who had not attended an educational programme at re-evaluation (Table 3). Dentists still estimated their patients knowledge on signs and symptoms as remarkably low (15% at baseline vs. 16% at reevaluation) and their patients knowledge on risk factors as low (27% at baseline vs. 25% at re-evaluation) (Table 3). 3.4. Routine examination of the oral cavity At baseline, only 33% of the responding dentists had always routinely examined older patients (!40 years) at the initial appointment and only 28% at the recall appointment. These results showed the clearest improvements at re-evaluation, particularly for responders who had participated in the educational programme, increasing by 5.6% at initial appointments and 9.3% at recall appointments. The results for older patients for never and up to 1/3 were both decreased. Interestingly, the percentage of dentists who agreed that examinations of the oral tissues should be carried out every year was still markedly higher than the percentage of dentists stating that they had conducted this examination of the oral cavity; this fact was particularly true for dentists who had not taken part in the educational programme (Tables 4 and 5). At baseline, 56% of the responders indicated that they had examined all their edentulous patients. At re-evaluation, the result of 57% was nearly the same for the whole sample of responders. The sample of dentists who had not attended the educational

Please cite this article in press as: Hertrampf K, et al., Early detection of oral cancer: Dentists opinions and practices before and after educational interventions in Northern-Germany, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.01.019

K. Hertrampf et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7

Table 2 Dentists demographic distribution and professional aspects at baseline and re-evaluation (expressed as a percentage). Demographic Distribution Baseline 2007 n 306 Gender Male 62 Female 34 Age 20e29 4 30e39 22 40e49 40 50e59 27 60e69 5 Type of practice Solo practice 47 Joint practice 38 In employment 9 Others 4 Date of graduation Before 1970 1 1970e1979 16 1980e1989 30 1990e1999 31 2000e2009 15a Time elapsed since last continuing education course on oral cancer Within past 12 months 18 Past 2e5 years 38 >5 years 25 Have never taken any course 13 New graduate e have 2 yet to attend a course Do not know 1 Not know 3
a b c

Re-evaluation 2009 n 394

Re-evaluation with educationb n 131 70 28 10 15 38 24 13 48 31 16 5 5 19 28 25 23

Re-evaluation without educationc n 263 60 35 8 23 30 27 8 43 32 18 4 2 11 27 30 23

63 33 8 20 33 26 10 44 32 17 4 1 14 25 28 23 33 32 15 12 3 2 3

Baseline: 2000e2007. Participation in the survey and attendance of a continuing education course on oral cancer within the past twelve months. Participation in the survey without attendance of a continuing education course on oral cancer within the past twelve months.

Table 3 Dentists assessment of their own competence at baseline and re-evaluation. Baseline (whole sample) n 306 Re-evaluation (whole sample) n 394 Participation at re-evaluation and attendance of a continuing education course on oral cancer within the past twelve monthsa n 131 72.5 84.4 Participation at re-evaluation without attendance of a continuing education course on oral cancer within the past twelve monthsa n 263 57.0 71.1

My knowledge of oral cancer is current I am adequately trained to examine patients for oral cancer Most dentists are adequately trained to perform oral cancer exams Dentists are qualied to perform oral cancer exams My patients are sufciently knowledgeable about oral cancer signs and symptoms My patients are sufciently knowledgeable about oral cancer risks factors
a

49.1 63.7

62.2 74.9

37.2

44.2

51.9

40.3

71.3 14.7

76.9 13.5

81.7 16.0

74.5 12.2

26.8

25.9

24.5

26.6

These twelve months were in accordance with the intervention period.

programme showed a slight decrease with 35% compared to the whole sample at re-evaluation. 4. Discussion We developed and implemented an educational intervention strategy using different approaches to reach as many dentists as

possible; a further aim was to document the use of these differing approaches. In our study, we selected knowledge transfer via oral presentation and a personalised approach for ordering the educational material (poster, DVD). This personalised approach method has been recommended as part of a multifaceted approach for the implementation of medical guidelines in Germany (Greco and Eisenberg 1993; Margolis and Cretin 1999; Gross et al. 2001;

Please cite this article in press as: Hertrampf K, et al., Early detection of oral cancer: Dentists opinions and practices before and after educational interventions in Northern-Germany, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.01.019

K. Hertrampf et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7 Table 4 Dentists opinions and practices about the routine examination of the oral cavity with regard patients 40 years and older in %. Item Baseline whole sample (n 306) Re-evaluation whole sample (n 394) Participation at re-evaluation and attendance of a continuing education course on oral cancer within the past twelve monthsa (n 131) Opinion 97 Practice 37 Participation at re-evaluation without attendance of a continuing education course on oral cancer within the past twelve monthsa (n 263) Opinion 93 Practice 25

Opinion Oral cancer examinations for adults 40 years of age and older should be provided annually
a

Practice 28

Opinion 94

Practice 27

94

These twelve months were in accordance with the intervention period.

Table 5 Dentists percentage estimate of their patients for whom they provide an routine examination of the oral cavity at initial and recall appointments, divided in never, up to 1/3 of my patients, 1/3 to 2/3 of my patients, more than 2/3 of my patients and always, for the age group 40 and older years. Baseline (whole sample) n 306 Re-evaluation (whole sample) n 394 Participation at re-evaluation and attendance of a continuing education course on oral cancer within the past twelve monthsa n 131 3.1 5.3 12.3 16.1 25.2 38.0 9.9 6.1 7.7 18.4 20.6 37.4 Participation at re-evaluation without attendance of a continuing education course on oral cancer within the past twelve monthsa n 263 8.4 12.2 16.0 15.3 19.5 28.9 15.6 12.2 14.4 16.4 16.4 25.1 Improvements from baseline to re-evaluation with continuing education course

Initial appointment No response 5.9 Never 11.4 Up to 1/3 15.4 1/3 to 2/3 14.7 More than 2/3 20.3 Always 32.4 Recall appointment No response 12.4 Never 13.7 Up to 1/3 15.0 1/3 to 2/3 13.4 More than 2/3 17.3 Always 28.1
a

6.6 9.9 14.9 15.6 21.2 32.0 13.7 10.2 12.3 17.1 17.7 29.2

2.8 6.1 3.1 1.4 4.9 5.6 2.5 7.6 7.3 5.0 3.3 9.3

These twelve months were in accordance with the intervention period.

Klinkhammer-Schalke et al. 2008a,b). A similar combination of different approaches for a continuing medical educational setting had also been investigated and then recommended by Davis et al. (Davis et al. 1999). We chose a 1-year intervention period to implement the different approaches; this time period is in accordance with the recommendation by Silverman et al. (2010), who described intervention strategies for 6 months as insufcient (Silverman et al. 2010). Although this survey has been used in many international studies, to the authors knowledge, no results using a pre-postinterventional design have been described in the literature. Two other study groups from Spain and England published data after educational interventions, but each used a different survey. Therefore, a comparison with these data is only conditionally possible (Seoane et al., 2010, Silverman et al., 2010). Our results showed an improvement in opinions and practices after educational intervention, particularly for the sample of responding dentists who had attended the continuing educational programme within the past 12 months, which was in accordance with the intervention period. This result showed the increased integration of routine examinations of the oral cavity into daily practice in contrast to the result of responders who had not attended any courses. These changes in behaviour with focus on secondary prevention were also described by the two Spanish and English research groups (Seoane et al. 2010; Silverman et al. 2010). At baseline, fewer than 50% of the dentists described their overall knowledge as current, whereas at re-evaluation, the gure

rose to almost 62% and to 73% in case of responders who had attended the educational intervention. In contrast, at baseline, 71% of the responders agreed that dentists are qualied to conduct cancer examinations of the oral cavity, representing an obvious discrepancy to the described estimation of their own knowledge. At re-evaluation, this discrepancy clearly decreased in favour of the increased estimation of their knowledge. Furthermore, their assessment on adequate training also increased, approaching results of other international studies (Yellowitz et al., 1998, Horowitz et al., 2000b, Gajendra et al., 2006, Ariyawardana and Ekanayake, 2008, Applebaum et al., 2009). After the educational intervention, almost 75% of the whole sample of responders (n 394) and 84% (n 131) of the responders attending an educational intervention, described themselves as adequately trained to conduct oral cancer investigations, vs 64% at baseline (n 306). 94% of dentists agreed at both baseline and re-evaluation that this examination should be provided annually for the age group of 40 years and older. This number was only slightly higher for the group who had attended an educational course (97%) (Tables 3 and 4). These results were comparable with studies in the USA and Spain (Clovis et al. 2002; Gajendra et al. 2006; Applebaum et al. 2009; Alonge and Narendran 2003; Lopez-Jornet et al. 2010). With regard to the percentage of dentists who always provide a routine examination of the oral cavity at the initial appointment, a slight positive trend was observed from baseline to the group who had attended an educational course at re-evaluation (32.4% vs.

Please cite this article in press as: Hertrampf K, et al., Early detection of oral cancer: Dentists opinions and practices before and after educational interventions in Northern-Germany, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.01.019

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38%, 5.6), which further improved to 9.3 for recall appointments. Although the results for recall appointments slightly improved, they were still lower than those of comparable international studies (Horowitz et al. 2000a,b; Clovis et al. 2002; Alonge and Narendran 2004; Gajendra et al. 2006; Lehew and Kaste 2007; Colella et al. 2008). Although the results for this examination showed a positively increased trend for the responders who had attended the educational intervention, the described discrepancy between opinion and practice at baseline was also observed at re-evaluation (Klosa et al. 2011). The examination of edentulous patients showed higher results, increasing from 56% at baseline to 59% at re-evaluation for the whole sample of responders and to 63% for responders who had attended a continuing education course. This positive development in examinations of the oral cavity is important because older age is a risk factor for developing oral cancer, and most edentulous patients are elderly. Similar results, ranging between 72% and 88%, were also observed in other studies (Yellowitz et al. 1998; Clovis et al. 2002; Applebaum et al. 2009). Only the study by Horowitz et al. (2002) showed a remarkably low result of only 14% compared to other studies. Our study, in line with the above-mentioned international studies showed the same discrepancy between the opinions, the necessity of examinations of the oral cavity within daily practice for the early detection of oral cancer and the reality, how often is this examination carried out?. The main limitation of our study is the low response rate of 17% at re-evaluation, which is slightly higher than that at baseline. The questionnaire was sent to all dentists throughout the state in a completely anonymous manner. Therefore, we did not receive any information about the non-responders. Anonymous questionnaires are associated with a low response rate (Warnakulasuriya and Johnson 1999; Kolesaric et al. 2007). This method was chosen as it met the data protection policy requirements of the State Dental Association, which only allows anonymous mailing instead of the use of a pseudonym as preferred by the authors. Recent studies by Ariyawardana and Ekanayake (2008) and Applebaum et al. (2009) have observed a trend to lower response rates, for instance, 38% for dentists and 26% for physicians, although they used a personal mailing procedure with direct letters and personal reminders. This decrease, described as survey saturation, has also been observed by Baruch and Holtom (2008) (Ariyawardana and Ekanayake 2008; Baruch and Holtom 2008; Applebaum et al. 2009). Thus, our results were not representative for the entire dental community because they did not reect the opinions and practices of all dentists within the state. But the demographic distribution by gender and age of the responders reected the demographic distribution of all dentists within the state. However, our results could present an overestimation because the responders were more interested in the topic. A positive trend was observed for the number of dentists attending a continuing educational course within the last 12 months (18% at baseline vs. 33% at re-evaluation) and for the dentists who regularly carry out these routine examinations. Therefore, improvements occurred at a quantitative as well as at a qualitative level. These positive results emphasise the recommendation for further educational programmes (Klosa et al. 2011). On the basis of these results and the positive feedback from many colleagues attending the educational interventions, we designed a second poster about potential oral lesions which was offered to dentists. In addition, following the recommendation of the already nished national guideline Diagnosis and management of precursor lesions in oral squamous cell carcinoma in dental, oral

and maxillary treatment (S2k, No 007-092, Working Group of the Scientic Medical Associations, Germany (AWMF)), co-initiated by the authors and co-coordinated by one author (KH), we have developed a small booklet as a support for the rst suspected diagnosis that will be offered to all dentists within the state. Furthermore, the State Dental Association has decided to incorporate this topic into the Associations annual programme. 5. Conclusion The results of our study show that a 1-year educational intervention with a multifaceted approach is successful. Opinions and practices on the early detection of oral cancer have improved, particularly for the group of dentists who attended an educational course. Therefore, our results underline that continuing education programmes improve the competence of dentists performing examination of the oral cavity. In conclusion, regular participation in continuing educational courses is recommended. Role of the funding source The project was supported by the Deutsche Krebshilfe (German Cancer Aid, no: 107385). The Deutsche Krebshilfe (German Cancer Aid) was not involved in the study design, in the collection, analysis and interpretation of the data, as well as in the writing and submission of the manuscript. Conicts of interest None declared. Acknowledgements The authors thank the Deutsche Krebshilfe (German Cancer Aid) for supporting the study Improvement of early detection of oral cancer in the population of Schleswig-Holstein (no. 107385). The authors are grateful to Monika Schoell for the linguistic revision of this manuscript. References
Alonge OK, Narendran S: Opinions about oral cancer prevention and early detection among dentists practising along the TexaseMexico border. Oral Dis 9(1): 41e45, 2003 Alonge OK, Narendran S: Oral cancer knowledge and practices of dentists along the TexaseMexico border. J Cancer Educ 19(1): 6e11, 2004 Applebaum E, Ruhlen TN, Kronenberg FR, Hayes C, Peters ES: Oral cancer knowledge, attitudes and practices: a survey of dentists and primary care physicians in Massachusetts. J Am Dent Assoc 140(4): 461e467, 2009 Ariyawardana A, Ekanayake L: Screening for oral cancer/pre-cancer: knowledge and opinions of dentists employed in the public sector dental services of Sri Lanka. Asian Pac J Cancer Prev 9(4): 615e618, 2008 Baruch Y, Holtom BC: Survey response rate levels and trends in organizational research. Hum Relat 61(8): 1139e1160, 2008 Becker ST, Menzebach M, Kuchler T, Hertrampf K, Wenz H-J, Wiltfang J: Quality of life in oral cancer patientseeffects of mandible resection and socio-cultural aspects. J Craniomaxillofac Surg 40(1): 24e27, 2012 Clovis JB, Horowitz AM, Poel DH: Oral and pharyngeal cancer: practices and opinions of dentists in British Columbia and Nova Scotia. J Can Dent Assoc 68(7): 421e425, 2002 Colella G, Gaeta GM, Moscariello A, Angelillo IF: Oral cancer and dentists: knowledge, attitudes, and practices in Italy. Oral Oncol 44(4): 393e399, 2008 Davis D, OBrien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A: Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behaviour or health care outcomes? JAMA 282(9): 867e874, 1999 Gajendra S, Cruz GD, Kumar JV: Oral cancer prevention and early detection: knowledge, practices, and opinions of oral health care providers in New York State. J Cancer Educ 21(3): 157e162, 2006 Greco PJ, Eisenberg JM: Changing physicians practices. N Engl J Med 329(17): 1271e1273, 1993 Greenwood M, Lowry RJ: Primary care clinicians knowledge of oral cancer: a study of dentists and doctors in the North East of England. Braz Dent J 191(9): 510e512, 2001

Please cite this article in press as: Hertrampf K, et al., Early detection of oral cancer: Dentists opinions and practices before and after educational interventions in Northern-Germany, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.01.019

K. Hertrampf et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7 Gross PA, Greeneld S, Cretin S, Ferguson J, Grimshaw J, Grol R, et al: Optimal methods for guideline implementation: conclusions from Leeds Castle meeting. Med Care 39(8 Suppl. 2): II85eII92, 2001 Hertrampf K, Wenz H-J, Koller M, Grund S, Wiltfang J: Oral cancer knowledge of dentists in Northern Germany after educational intervention. Eur J Cancer Prev 20(5): 431e437, 2011 Hertrampf K, Wenz H-J, Koller M, Springer I, Jargot A, Wiltfang J: Assessing dentists knowledge about oral cancer: translation and linguistic validation of a standardized questionnaire from American English into German. Oral Oncol 45(10): 877e882, 2009 Horowitz AM, Canto MT, Child WL: Maryland adults perspectives on oral cancer prevention and early detection. J Am Dent Assoc 133(8): 1058e1063, 2002 Horowitz AM, Drury TF, Canto MT: Practices of Maryland dentists: oral cancer prevention and early detection e baseline data from 1995. Oral Dis 6(5): 282e288, 2000a Horowitz AM, Drury TF, Goodman HS, Yellowitz JA: Oral pharyngeal cancer prevention and early detection. Dentists opinions and practices. J Am Dent Assoc 131(4): 453e462, 2000b Klinkhammer-Schalke M, Koller M, Ehret C, Steinger B, Ernst B, Wyatt JC, et al: Implementing a system of quality-of-life diagnosis and therapy for breast cancer patients: results of an exploratory trial as a prerequisite for a subsequent RCT. Br J Cancer 99(3): 415e422, 2008a Klinkhammer-Schalke M, Koller M, Wyatt JC, Steinger B, Ehret C, Ernst B, et al: Quality of life diagnosis and therapy as complex intervention for improvement of health in breast cancer patients: delineating the conceptual, methodological, and logistic requirements (modelling). Langenbecks Arch Surg 393(1): 1e12, 2008b Klosa K, Wiltfang J, Wenz H-J, Koller M, Hertrampf K: Dentists opinions and practices about oral cancer prevention and early detection in Northern Germany. Eur J Cancer Prev 20(4): 313e319, 2011 Kolesaric N, Borner BI, Sader R, Meyer J, Zeilhofer HF: [Early detection and prevention of oral precancer. An enquiry among dentists in Switzerland]. Schweiz Monatsschr Zahnmed 117(9): 911e919, 2007 Kujan O, Duxbury AJ, Glenny AM, Thakker NS, Sloan P: Opinions and attitudes of the UKs GDPs and specialists in oral surgery, oral medicine and surgical dentistry on oral cancer screening. Oral Dis 12(2): 194e199, 2006

Lehew CW, Kaste LM: Oral cancer prevention and early detection knowledge and practices of Illinois dentists e a brief communication. J Public Health Dent 67(2): 89e93, 2007 Lopez-Jornet P, Camacho-Alonso F, Molina-Minano F: Knowledge and attitudes about oral cancer among dentists in Spain. J Eval Clin Pract 16(1): 129e133, 2010 Margolis C, Cretin S: Implementing clinical practice guidelines. Chicago: AHA Press, 1999 Mourouzis C, Boynton A, Grant J, Umar T, Wilson A, Macpheson D, et al: Cutaneous head and neck SCCs and risk of nodal metastasis e UK experience. J Craniomaxillofac Surg 37(8): 443e447, 2009 Pritzkuleit R, Holzmann M, Eisemann N, Gerdemann U, Katalinic A: Krebs in Schleswig-Holstein. In: Band 9 Inzidenz und Mortalitt im Jahr 2008. Lbeck: Schmidt-Rmhild, 2011 Robert Koch Institut, G. d. e. K. i. D. e. V: Krebs in Deutschland 2007/2008. Berlin: Robert Koch Institut, 2012 Sankaranarayanan R, Ramadas K, Thomas G, Muwonge R, Thara S, Mathew B, et al: Effect of screening on oral cancer mortality in Kerala, India: a clusterrandomised controlled trial. Lancet 365(9475): 1927e1933, 2005 Seoane J, Velo-Noya J, Warnakulasuriya S, Varela-Centelles P, Gonzalez-Mosquera A, Villa-Vigil MA, et al: Knowledge of oral cancer and preventive attitudes of Spanish dentists. Primary effects of a pilot educational intervention. Med Oral Patol Oral Cir Bucal 15(3): e422ee426, 2010 Silverman Jr S, Kerr AR, Epstein JB: Oral and pharyngeal cancer control and early detection. J Cancer Educ 25(3): 279e281, 2010 Warnakulasuriya KA, Johnson NW: Dentists and oral cancer prevention in the UK: opinions, attitudes and practices to screening for mucosal lesions and to counselling patients on tobacco and alcohol use: baseline data from 1991. Oral Dis 5(1): 10e14, 1999 Yellowitz J, Horowitz AM, Goodman HS, Canto MT, Farooq NS: Knowledge, opinions and practices of general dentists regarding oral cancer: a pilot survey. J Am Dent Assoc 129(5): 579e583, 1998 Yellowitz JA, Goodman HS: Assessing physicians and dentists oral cancer knowledge, opinions and practices. J Am Dent Assoc 126(1): 53e60, 1995

Please cite this article in press as: Hertrampf K, et al., Early detection of oral cancer: Dentists opinions and practices before and after educational interventions in Northern-Germany, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.01.019