Knowledge Attitude and Practice Regarding Cryosurgery among Dental Students

Keywords

Cryosurgery; Knowledge; Tumours; Liquid Nitrogen.

Introduction

Cryosurgery is a controlled and targeted destruction of diseased tissue by the application of low temperatures. The beneficial effects of cold as a therapeutic agent are known for an extended time, with ancient population conscious of the reinvigorating effects of cold water either taken orally or used for baths. The use of cold, mainly locally, still remains in our daily common activities. It is a simple, cost effective, efficacious, and esthetically acceptable modality for the treatment of various dermatoses. It is a very safe, inexpensive, reproducible, repeatable, and simple office procedure. It requires a short preparation time, is a suture less procedure with minimal risk of infection and no anesthesia is usually required. It may be performed at any age, including in old patients with pacemakers, in whom electrocautery is contraindicated, patients on anticoagulants, patients allergic to esthetic agents, [1]. patients with transmissible conditions such as human immunodeficiency virus and hepatitis, during pregnancy, and over most of the body sites. It provides high healing rates even in difficult areas, with excellent cosmetic results if performed appropriately. In view of all these advantages, it is regarded as a treatment of choice by many dermatologists for various benign and malignant dermatoses [2, 3]. On spraying the cryogen, there is a rapid transfer of heat from the tissue to the cryogen, with ice formation in the extracellular compartment. The extracellular solutes are concentrated, setting up an osmotic gradient, with the movement of fluid extracellularly and concentration of solutes within the cell leading to cell damage. The ice crystals also damage the cell membrane mechanically [4]. Moreover, intracellular ice formation occurs, damaging organelles such as mitochondria and endoplasmic reticulum. There are severe vasoconstriction and endothelial damage because of cold temperature resulting in platelet aggregation and microthrombi formation, producing ischemic necrosis of the tissue. There is inflammation in response to cell death causing further destruction [5-7].

Cryosurgery is often used to treat conditions that involve irritation of an isolated nerve. In general, such conditions include benign nerve growths (neuromas) and pinched nerves (nerve entrapments), vascular lesions, benign tumors, acne, pigmented lesions, viral infections, inflammatory dermatoses, and infectious dermatoses. Premalignant and malignant tumors are also being treated by cryosurgery [8, 9]. Complications include local pain more in the periungual area, temple, plantar areas, eyelids, lips, mucous membranes, tingling and numbness, especially on the fingers, edema, especially on the eyelids, lips, labia, and prepuce, more in infants and the elderly, cryoblister formation, and syncope (vasovagal reaction) in anxious patients along with occasional headache (migraine type) after the treatment of the head and neck area [10]. Common protracted complication includes hypopigmentation, especially in dark-skinned individuals, atrophic scar, and local hypoesthesia due to nerve damage, especially in areas, where the nerves lie superficially, such as the sides of fingers, angle of jaw, post-auricular area, sides of tongue and ulnar fossa of elbow, milia formation, and cicatricial alopecia [10, 11]. Absolute contraindications include blood dyscrasias of unknown origin, cold intolerance, Raynaud’s disease, cold urticaria, cryoglobulinemia, lesions in areas of compromised circulation, sclerosing basal cell carcinoma (BCC), or recurrent BCC or squamous cell carcinoma located in high-risk areas such as the temple or nasolabial folds [10-12]. Previously our team had conducted numerous clinical trials and invitro studies [13-27] over the past 5 years now we are focussing on surveys the idea of this survey stemmed from the current interest in our community. So the aim of our survey was to access the knowledge, attitude and awareness of cryosurgery among dental students.

Materials and Methods

An online survey was done with the structured questionnaire based on knowledge, attitude, practice survey among the dental students regarding cryosurgery.

Ethical approval

Ethical permission and approval for the project was obtained from the Institutional Review Board of Saveetha Institute of Medical and Technical Sciences, Chennai, India on Date 25/04/2020.

Sampling and data collection

This cross sectional survey was conducted among 100 dental undergraduate students who were in 3rd year, 4th year and interns. A structured questionnaire consisting of 21 questions was shared online and 100 responses were obtained. Data entry was made in the Excel sheet, SPSS software was used to analyze the data. The advantages of online surveys is that it was economical, easy to create, wide reach and disadvantage is repeated and incomplete answers.

Statistical analysis

The descriptive statistics were used to determine the responses given by the participants. Statistical analysis, Chi square test was used to assess the association between the year of study and the responses. And the results are depicted in the form of a bar chart.

Results and Discussion

In the present study [fig 1] there are a total of 100 participants there are 35 males and 65 females [fig 2]. 81% of the participants are aware of the cryosurgery. [fig4] 75% of the subjects selected liquid nitrogen as the common cryogen used in cryosurgery whereas 25% selected argon and carbon dioxide.[fig 5] 68% of the study participants said -19.6 degrees centigrade is the operating temperature of liquid based cryoprobe. [fig 6] 51% of the participants said -127 degrees as the boiling point of the cryogen. [fig 7] 63% of the participants aren't aware that the spray freezing is the most destructive type of cryosurgery only 37% of the participants selected probe freezing is the most destructive type in cryosurgery. [fig 8] 51% of the subjects said that the 540 psi is the pressure of spray in the spray freezing technique. [fig 9] only 26% of the participants selected correct answer for the indications of the cryosurgery. [fig 10] majority of the participants said they are not aware of the acute complications of cryosurgery. [fig 11] 38% of the students said that they are not aware of the protracted complications of cryosurgery. [fig 12] Only 25 % of the participants said raynauds disease is the absolute contraindication in cryosurgery 75% of the participants selected the wrong option for the contraindications.[fig 13] 42% of the participants said they do not know the relative contraindications of the cryosurgery.[ fig14] 77% of the participants said they will prefer cryosurgery to destroy abnormal tissue and 23% of the study population disagreed with it. [fig 15] 69% of the study participants agreed with the fact that cryosurgery can be used to treat malignant and premalignant lesion and 31% disagreed with the fact.. [fig 16] 38% of the total study participants said the cryosurgery tip should be placed 1 to 1.5 cm distance from the target leision. [fig 17] 47% of the study participants selected destruction of benign lesions require a temperature of about -100 to -150 degrees centigrade. [fig 18] 46% of the students said they do not know the effective temperature at which malignant tissues get destroyed [ fig 19] 39% of the participants said the operating temperature of the whole body cryotherapy is between -110 to -140 degrees centigrade. [fig 20] majority of the students said skin overlying nerves and the corners of the eye are the areas where cryosurgery is not recommended. [fig21] 86% of the participants are willing to attend a workshop on cryosurgery.

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Health professionals play a pivotal role in providing knowledge regarding oral health and its significance among the general public. Dental students should possess a high level of the awareness of both medicinal and practical knowledge. Cryosurgery is more often used in modern rehabilitation for the treatment of various diseases [6]. About 95.3% cure rate was achieved in the treatment of facial BCC by Mallon and Dawber and Noah and Scheinfeld successfully treated verruca vulgaris [28] depicting the various application of cryogens which dentists and other medical professionals must be aware. Cryosurgery competes well on morbidity and cosmetic outcome and is the quickest, easiest, cheapest, and most readily available of the treatment options [29]. This technique can be used, even by those inexperienced in cryosurgery, to achieve predictable success rates. A study was conducted by Asrani et al., [30] evaluating the efficacy of cryosurgery in the management of oral mucosal lesions concluded, cryosurgery is overall a better modality for the treatment of oral lesions as it is more reasonable with adequate success. The procedure is relatively more stable and has shown to have a faster recovery. Another study conducted by Murugadoss et al. [31] concluded cryosurgery with its ability to produce very low temperatures causes effective tissue destruction. It has been utilized for oral cavity lesions of the infants, elderly patients, and also immunocompromised patients. With a wide variety of cryogens that have come in the market and by combining these cryogens, better treatment protocols and freezing times have been established, producing excellent results. With cryosurgery becoming one of the most chosen treatment modalities for various oral lesions, it is necessary for the dentists to have complete knowledge of them.

Conclusion

The present study concluded that most of the subjects had limited knowledge regarding cryosurgery, yet there were significant knowledge gaps in some of the important aspects like indications contraindications types of techniques in cryosurgery. These findings clearly indicate the importance of improving subjects knowledge regarding cryosurgery via health education and training programs through webinars for dentists.