1. Introduction
Good oral health contributes to overall health and wellbeing [
1,
2]. Poor oral health, on the other hand, is associated with oral pain, discomfort, and a reduced quality of life, which can affect an individual’s ability to eat, speak, and socialize [
2,
3]. In 2022, approximately 3.5 billion people worldwide were affected by oral diseases, and oral diseases are the most common chronic condition worldwide [
4]. Between 2020 and 2021, less than half (48%) of Australians over the age of 15 visited a dental professional, while 1 in 9 (11%) children aged 5–14 years had never visited a dental practice [
3]. Furthermore, nearly 67,000 hospitalisations in Australia between 2019 and 2020 were due to preventable dental conditions [
3].
Community pharmacists in Australia are readily accessible to the public and are well positioned to recognise, prevent, and manage common oral health conditions [
5]. With approximately 5800 community pharmacies equitably distributed throughout Australia and over 35,000 registered pharmacists [
6,
7], pharmacy professional services are mostly provided without charge or the need for an appointment; in outer regional and remote areas, pharmacists are often the first or only contact with a health professional [
8,
9]. The study by Taing et al. showed that more than 80% of Australian pharmacists were consulted for oral healthcare advice up to five times or more each week, with more than half being involved in identifying the signs and symptoms of oral health problems [
10]. Therefore, it is crucial that community pharmacy staff are capable of appropriately identifying common oral conditions or issues and know when referral to a dental practitioner may be necessary [
11].
Anecdotal reports from pharmacy academics in Queensland and New South Wales suggest that, on average, pharmacy students receive just two lectures during their entire program on topics related to oral health, and interprofessional education between pharmacy and dentistry students is slowly gaining momentum [
10,
12]. Australian practicing pharmacists are provided with continuing professional development in oral healthcare through seminars and magazine/journal articles [
10]. Previously, case vignettes have been used to evaluate Australian pharmacy staff’s knowledge and management of various common oral conditions, including dental pain, gingivitis, dry mouth, non-healing mouth ulcers, and oral hygiene [
5]. However, the findings by Taing et al. indicated that a significant proportion of pharmacists were not correctly identifying these conditions or providing the best practice care. These oral conditions are among the most commonly seen in community pharmacy, but do not include common mucosal diseases, such as cold sores, geographic tongue, hairy tongue, angular cheilitis, denture-associated erythematous stomatitis, and oral thrush [
13,
14]. These mucosal disorders commonly encountered in the Australian community are not associated with a significant morbidity and mortality, and can be managed in general practice [
14].
Currently, no studies have assessed whether Australian pharmacy students or pharmacists can appropriately identify common mucosal diseases and have the knowledge to manage these conditions effectively. Therefore, the aim of this study was to evaluate the ability of Australian pharmacists and final-year pharmacy students to recognise and manage common oral mucosal diseases using case vignettes. This study also reports on the frequency of oral mucosal disease presentations encountered by participants during their practice. The findings from this study will provide an indication of how prepared pharmacists and pharmacy students are in identifying common oral mucosal disorders in practice and will inform future training requirements for delivering improved oral healthcare within Australian communities.
2. Materials and Methods
2.1. Design of Survey Questionnaire and Case Vignettes
Clinical or case vignettes are frequently used to evaluate the quality of care and depth of knowledge of health professionals [
5,
15]. This study employed 6 case vignettes to assess the ability of Australian pharmacists and final-year pharmacy students to manage common oral mucosal presentations [
14], including cold sores (scenario A), geographic tongue (scenario B), hairy tongue (scenario C), angular cheilitis (scenario D), denture-associated erythematous stomatitis (scenario E), and oral thrush (scenario F). Final-year pharmacy students were selected because they are approaching the end of their undergraduate training and are likely to commence supervised pharmacy practice on a full-time basis, following which, a large proportion of them practice as community pharmacists [
16].
The survey questionnaire and accompanying six case vignettes comprised a series of multiple choice, Likert scale, and open-response questions (see
Supplementary Material A and B). For each vignette, a photographic representative of the condition and a brief description of the patient’s symptoms, medical history, and other relevant information were provided to improve the ecological validity. The cases were designed by an expert consensus within the multidisciplinary team, consisting of experts in oral medicine, dentistry, and pharmacy practice (authors MM, LT, and MWT), where the signs and symptoms representative of each condition and best practice recommendations were validated using evidence-based guidelines (see
Table 1: summarised case vignettes and best practice recommendations) [
11,
14,
17]. These guidelines were developed for non-dental practitioners and are relevant to patients of all ages and population groups [
14,
17]. The participants completed demographic questions at the beginning of the survey (
Supplementary Material A) and the questionnaire items within all 6 case vignettes (
Supplementary Material B). For each case vignette, participants were asked to rate their confidence in assessing and managing the condition, identify the presentation, provide treatment advice, list resources used to assist and advise, and on average how often they would see these types of oral mucosal presentations each week in their practice.
The case vignettes and demographic questionnaire items were piloted by practicing pharmacists (n = 4) and final-year pharmacy students (n = 5). Their feedback informed changes in phrasing and formatting to increase clarity. The final case vignettes, along with the demographic questionnaire items, were uploaded onto the online survey platform checkbox. The case vignettes were identical for the pharmacists and final-year pharmacy students, with slight differences in the demographic questionnaire items. (See
Supplementary Material A and B)
2.2. Participant Recruitment
The Australian practicing pharmacists (intern and registered), as well as the final-year pharmacy students, were recruited via convenience sampling between the months of May and August 2022. To recruit the final-year pharmacy students, an online advertisement containing the survey link/QR code was posted on final-year university learning management systems (LMS) websites and/or sent directly to student email accounts from final-year course convenors. To enhance the representation of final-year pharmacy students within Australia, four pharmacy schools from different states participated in the study: the University of Western Australia (UWA), the University of Sydney (USyd), the University of Queensland (UQ), and the University of South Australia (UniSA). The survey advertisement was distributed four times, at approximately 2–4 week intervals, by each university pharmacy program provider to encourage recruitment. The surveys were closed approximately 12 weeks after the first announcement. Final-year pharmacy students recruited at UQ were also provided with two extra reminders via a social media Facebook group (UQ Pharmacy Class of 2022), which comprised the majority of these final-year UQ pharmacy students. As an incentive to participate, the final-year UQ pharmacy students were provided with an AUD 5 coffee voucher for their participation. The students who completed the survey from other universities were included in a draw to win one of five AUD 50 eGift vouchers.
The pharmacists (intern and registered) were recruited nationally by posting the survey advertisement with the survey link/QR code six times via the Pharmaceutical Society of Australia’s Early Career Pharmacist social media Facebook page (ECP FBP). The ECP FBP has over 12,400 members, approximately one third of the total registered pharmacists in Australia, with the majority being pharmacists or interns within their first ten years of graduating. The ECP FBP is open to all pharmacists, with the goal of providing a space for the discussion of contemporary issues affecting pharmacists, and it is a frequently used platform for recruiting registered Australian pharmacists for research. Similar to recruiting pharmacy students, the survey advertisement containing the link/QR code was distributed four times at approximately 2–4 week intervals, and then an additional 2 rounds were conducted to improve response rates. Similar to the students, the pharmacists were also offered a chance to win one of ten AUD 50 eGift vouchers for completing the survey.
2.3. Data Analysis
After the survey closure, coding templates were created for each case vignette to categorise the participant responses for the open-ended questions. The responses were coded as categorical variables within Microsoft Excel for Microsoft 365 (Washington, DC, USA) and SPSS v26 (SPSS Inc., Chicago, IL, USA) to enable a descriptive analysis. For the open-ended questions, the responses were coded as binary entries (correct [1] or incorrect [0]) within the coding templates. Pharmacist interns were categorised as pharmacists for analysis purposes, as their training is closely aligned with pharmacists. Students who reported practicing in pharmacy (68 out of 76 student responses) were included in the analysis relating to the average weekly frequency consulted for each presentation. Data from incomplete participant responses were excluded from the analyses.
To determine whether differences existed between the pharmacy students’ and pharmacists’ responses, Pearson’s chi-squared test was used. Fisher’s exact test was applied when the expected responses per cell were fewer than 5 [
18]. Adjusted standardised residuals were used to identify cells with significantly larger/smaller counts than expected if the variables were independent in contingency tables larger than 2 × 2. The significance level was set at
p < 0.05. The study was approved by the University of Queensland’s Human Research Ethics Committee (approval no. HE002431, date of approval 14 April 2022).
4. Discussion
This is the first study to assess the ability of Australian pharmacists and final-year pharmacy students in managing six common oral mucosal conditions, including cold sore, geographic tongue, hairy tongue, angular cheilitis, denture-associated erythematous stomatitis, and oral thrush. The majority of the practicing pharmacists and students reported seeing all types of oral mucosal presentations, except for denture stomatitis, either less than once/week or more. Using case vignettes, most of the practicing pharmacists and students were able to appropriately identify the cold sore and oral thrush presentations (97% and 84%, respectively) and most recommended the appropriate anti-viral treatments for cold sores. However, 15% or less of the participants provided the best practice advice for the geographic tongue, hairy tongue, angular cheilitis, and denture-associated stomatitis presentations (14%, 15%, 8%, and 6%, respectively). This contrast in ability to manage cold sore and oral thrush presentations compared to other oral mucosal issues may partly be explained by the availability of over-the-counter cold sore and oral thrush pharmacy medications in Australian community pharmacies. These conditions are therefore inherently taught in the Australian pharmacy curriculum and supported by pharmacy practice resources [
20,
21,
22].
A concerning finding in this study was a clear demonstration of poor differentiation skills between geographic tongue, hairy tongue, and oral thrush. The majority of the participants confused geographic and hairy tongue as oral thrush (57% and 72%, respectively), which was also observed in how the participants managed these conditions—more than half inappropriately recommended topical oral antifungal treatments. Topical miconazole is widely available on the market for over-the-counter use, and although fungal resistance is currently relatively low, studies have shown
C. albicans resistant strains with a geographical susceptibility lower in the UK compared to Italy [
23]. Drawing parallels with antibiotic resistance, superficial mycoses are becoming more resistant to antifungal medications [
23,
24], which is consistent with the increased use of antimicrobial drugs and increased microbial resistance patterns [
23]. There is a possibility that the indiscriminate provision of antifungal agents in the community may contribute to antifungal resistance patterns; however, more research is required to better elucidate the associations between antifungal resistance and its usage in clinical/community settings [
24]. Collectively, the findings from this study indicate that, apart from cold sore presentations, there is a need to improve the training for both Australian pharmacists and undergraduate students in common oral mucosal presentations, particularly in how to differentiate between oral thrush and other similar presenting conditions such as hairy tongue.
This study found that the confidence levels varied widely among both the pharmacists and pharmacy students, ranging from 8 to 83% of pharmacists and 7 to 75% of student, respectively, reporting that they were confident in managing the presented oral mucosal conditions. However, the association between confidence and the ability to identify and provide the best practice recommendations in this study was mixed. Regardless of the case presented, confidence did not always translate into the appropriate identification and provision of the best practice recommendations. Interestingly, for geographic tongue, the pharmacists who reported higher confidence were significantly less likely to correctly identify and manage it appropriately. This highlights the limited usefulness of confidence as a predictor of the appropriate identification and management of common oral mucosal conditions in Australian pharmacy practice. These findings are consistent with a study by Taing et al., which showed that confidence among Australian pharmacists and assistants was not highly correlated with the appropriate management of related oral conditions, including tooth pain, gum problems, mouth ulcers, xerostomia, and oral health promotion [
5]. Together, these studies demonstrate a disconnect between self-confidence and the ability to appropriately manage common oral health presentations in pharmacy practice. As a result, there is a need for the development and integration of oral healthcare training courses and resources tailored to the pharmacy profession, which could be embedded within undergraduate and postgraduate programs and continuing professional development courses. To be effective, the development of these training resources must be multi-disciplinary and include organisational partnerships between pharmacy and dentistry professions, universities, consumers, and government healthcare networks. These partners possess the skill sets and capabilities to create practical and effective resources that promote implementation [
25]. Additionally, the effectiveness, feasibility, and patient acceptability/outcomes of these resources should be evaluated. The current lack of Australian pharmacy-specific resources to support oral healthcare [
25] may explain why only a small proportion of the pharmacists and students referred to resources to support their decision making in the study.
Internationally, the implementation of oral healthcare interventions within pharmacy settings have been successful in providing patient benefits to communities. In the UK, an intervention study by Sturrock et al. showed positive responses from pharmacy staff and patients. The pharmacist-led intervention involved providing oral health promotion advice for dental caries, fluoride toothpaste, dietary advice, and appropriate care for teeth and dentures. Over 70% of 1069 patients who received the intervention reported that their oral health knowledge had improved significantly, and 65% of the participants stated that the way they cared for their teeth would change. Within this study, 64% of the participants agreed that pharmacies were “definitely” the right place to receive teeth/oral healthcare advice, while only 3% disagreed [
26]. This study also demonstrated that pharmacy staff were able to connect with patients who had not visited dental practitioners for more than two years [
26].
A limitation of this study is that the participant responses from the case vignettes may not have been entirely reflective of the respondents’ responses in an actual working environment [
27]. Additionally, since the findings were self-reported, they may be subject to respondent recall and social desirability biases. In addition, while some conditions such as denture stomatitis were reported to be uncommonly presented, the participants may not have been aware or able to identify these conditions, and so these results may be partly reflective of the participants’ knowledge of the mucosal conditions rather than the true clinical presentations encountered. Moreover, the survey had low response rates (<1% for pharmacists and 14% for pharmacy students), not all Australian Universities were included in the student sample, and the characteristics of non-responders were not obtained. These low response rates may have been due to several reasons, including the length of the survey, the fact that pharmacists are an over-surveyed population, and the additional time pressures brought about by peak COVID infection rates during the survey period. Nonetheless, the sample of 65 pharmacists and 76 final-year pharmacy students would provide approximate population estimates with a 12% margin of error [
28]. However, volunteer bias may have been present, as the respondents were mainly younger, and the responses may represent participants who had a greater interest in oral healthcare; hence, our findings likely represent the views of younger/early career pharmacists and those about to enter the Australian pharmacy workforce who have an interest in oral healthcare. The response rates from this study are comparable to many recent Australian pharmacy-practice-based surveys, which report similar responses from approximately <1% to 20% [
29,
30,
31,
32,
33]. It is also worth noting that most participants practiced in community settings, which is reflective of the fact that minor ailments are mainly treated and triaged by community pharmacists. The strengths of the study included the collection of data from both final-year pharmacy students and practicing registered pharmacists, which provides valuable insight into the current provision of oral healthcare from students about to begin their internship training year and those already practicing in the industry. The case vignettes used in this study were also reflective of common oral mucosal conditions that may present in pharmacy settings, and the questionnaires were piloted for their content and face validity by a multidisciplinary team of dental and pharmacy academics, as well as practicing pharmacists and pharmacy students. Past studies have suggested that case vignette findings may be overestimated. For example, a recent simulated patient study showed that only 10% of pharmacy staff referred potentially cancerous oral lesions compared to a 50% referral rate reported in case vignettes [
34]. Future simulated patient studies would be valuable in validating the findings of this study.