Awareness and intended behavioral responses to oral potentially malignant disorders: an image-based assessment among dental clinic attendees in Jordan

Abstract

Background

Oral potentially malignant disorders (OPMDs) are a group of oral diseases that have the potential for malignant transformation. A significant proportion of oral squamous cell carcinomas arise from OPMDs. Thus, their early detection contributes to the prevention of oral cancer. An investigation of the public’s awareness and intended behavioral responses to OPMDs helps identify health-seeking patterns, underscoring risk factors that are associated with poor awareness of OPMDs management.

Objectives

This study aims to investigate overall awareness of OPMDs among the public, and to understand the public’s behaviors as a response to different clinical subtypes of OPMDs.

Methods

A total of 528 patients attending a two-center dental institution in northern Jordan agreed to participate in this study. A researcher-administered questionnaire was employed to capture the responses of the participants to selected clinical images of OPMDs. Fifteen clinical image-based scenarios of OPMDs representing three lesion types—white, red, and erosive—in five oral locations—buccal, tongue, floor of the mouth, palate, and lips—were employed.

Results

Age and sex influenced overall OPMDs awareness (p < 0.001 and p = 0.006, respectively). Three behavioral phenotypes were identified among the study participants as follows: active/high awareness, moderately active/self-managing, and passive/low awareness. Lesion characteristics, including color and location, significantly influenced the response behaviors of participants.

Conclusion

The findings of this study reveal moderate public awareness of OPMDs, with variations according to age group and sex. Distinct behavioral patterns were identified, influenced by the clinical characteristics of OPMDs. The findings of this study indicate a previously unrecognized and latent awareness level of OPMDs clinical variants that necessitates educational interventions to increase OPMDs awareness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-026-07976-6.

Introduction

Oral potentially malignant disorders (OPMDs), a term that has been adopted by the World Health Organization (WHO), “are a group of disorders of varying etiologies, usually tobacco-related, characterized by a variable risk of malignant transformation to oral squamous cell carcinoma” [1]. OPMDs have various clinical presentations, including white, red, mixed, and erosive lesions [2]. Early detection and management of OPMDs is key in reducing the burden of oral cancer. Oral squamous cell carcinoma (OSCC) is the most common cancer of the head and neck and annually accounts for more than 300,000 new cases worldwide [3]. A significant proportion of OSCC lesions present in a potentially malignant form before undergoing malignant transformation [4]. Therefore, increasing awareness among the public is key in oral cancer prevention.

The risk of malignant transformation in OPMDs is dependent on several factors. Non-modifiable factors such as age, sex, and sociodemographic variables contribute to the risk of malignancy in patients with OPMDs [5]. Modifiable factors, on the other hand, are related to environmental and lifestyle determinants such as smoking, diet, lifestyle, and systemic health. Nonetheless, inherent characteristics of OPMDs are the primary contributors to therisk of malignant transformation. Red lesions, or erythroplakia (EP), harbor the highest degree of malignant potential if left untreated [6, 7]. On the other hand, white lesions, or leukoplakia (LP), are the most common OPMDs, particularly among smokers. Similarly, nonhomogeneous forms of LP, called erythroleukoplakia (EL), are associated with a significant risk of malignancy [6]. These differences in malignant behavior among OPMDs are generally correlated with histopathological characteristics, primarily oral epithelial dysplasia and anatomical location in the oral cavity [8]. Therefore, the clinical determinants of OPMDs, including color and location in the oral cavity, influence the pathological behavior of these conditions. Patient awareness of the appearance of such lesions significantly affects overall disease progression.

Oral health–related behaviors are shaped by a range of public and demographic factors. Previous research has shown that gender-based disparities influence attitudes toward oral health care, including participation in screening and willingness to discuss oral cancer with dental professionals [9]. Another population-based study demonstrated that adolescent behavior is significantly associated with both the type and severity of oral disease [10]. Collectively, these findings illustrate how demographic variables contribute to variations in oral health behaviors and ultimately influence public oral health outcomes.

In parallel, the integration of information technology into daily life has reshaped how the public perceives and responds to oral health concerns. For example, digital literacy has facilitated the adoption of new practices, such as online searches for home remedies to manage oral conditions [11]. Given these evolving behavioral patterns, it is essential to explore responses to OPMDs, identify gaps in awareness, and understand the perceptual biases that may hinder early detection or early management. Such insights are critical for designing targeted educational strategies and improving preventive efforts against oral cancer.

In Jordan, several studies have investigated the knowledge of oral cancer among dental students, dental practitioners, and dental patients [12–14]. However, to our knowledge, no studies have assessed the public’s awareness of OPMDs. The scope of this study extends beyond assessing prior knowledge to examine overall public awareness of OPMDs, as well as variations in health-related behavioral orientation and decision-making in response to OPMDs. Additionally, this study aimed to identify the clinical characteristics of OPMDs and the demographic factors that influence OPMDs-related health behaviors.

Methods

Study design

This was a quantitative, cross-sectional, clinical image survey-based study designed to assess the public’s awareness of and health-related behaviors toward OPMDs. To achieve these aims, awareness of OPMDs was assessed indirectly through participants’ intended health decisions in response to standardized, image-based clinical scenarios. The participants selected a management approach for each lesion, and awareness was inferred on the basis of the appropriateness of the selected response. An overall awareness score was calculated by summing appropriate responses across all the scenarios. This was followed by unsupervised clustering to identify distinct behavioral phenotypes among participants. Participant-related factors and the clinical characteristics of OPMDs were then examined for their associations with awareness levels and behavioral patterns.

Participants

Between March 2024 and July 2025, attendees of the two dental teaching centers of the Jordan University of Science and Technology were approached and invited to take the survey. Following an explanation of the study aims, the data being collected and the methods used to collect it, the participants who agreed to take the survey signed an informed consent form (supplementary file: S1. File). The questionnaire was then administered in the presence of a trained research assistant, whose role was assisting the participants in completing the questionnaire. As explicitly stated in the consent form, participation was voluntary, and participants were informed that they could quit at any time. As the study is exploratory and hypothesis-generating in nature, no prior sample size calculation was performed.

Questionnaire

Clinical images of OPMDs were selected by a certified oral and maxillofacial pathologist (RS) from validated resources, such as published clinical guidelines, case reports, and oral medicine textbooks, to clearly represent the OPMDs lesions of concern. For each scenario, the image had a clear arrow pointing to the lesion and a matching narrative description. The images were then validated by an oral medicine specialist. The clinical images, the narratives, and their sources are listed in supplementary file 2 (S2. File).

The questionnaire was developed and administered via Google Forms^®. It consisted of three sections. Section one was dedicated to collecting demographic information, including age, gender, educational background, job status, and income.

Section two presents fifteen image-based clinical scenarios representing three OPMDs lesion appearances—white, red, and erosive—in five oral locations: buccal mucosa, tongue border, floor of the mouth, palate, and lips. Each scenario evaluated the participant’s anticipated response to a lesion characterized by a specific appearance and anatomical location within the oral cavity. Four response options were given to each scenario: seek professional consultation, use home remedies, use home pharmacies/over-the-counter medications, or wait and see. For example, for a white OPMDs lesion on the buccal mucosa, the scenario was as follows: ‘If I noticed a painless white patch on the inner cheek, with no obvious reason, lasting four weeks or more: the action I would take’. Describing the lesions as painless was intended to assess participant recognition independent of pain-related cues, as pain is a common driver of dental care–seeking behavior, particularly in low socioeconomic populations [15].

Section three recorded smoking and alcohol consumption habits. At the end of the questionnaire, the participants were asked whether they were interested in learning about oral cancer self-inspection. For interested participants, a poster explaining the basic steps of self-inspection was shown with a brief demonstration of how to perform it. A copy of the questionnaire and the self-inspection poster can be found in supplementary file 3 (S3. File) and 4 (S4. File), respectively.

Awareness and behavioral analysis

To assess OPMDs awareness among participants, an overall awareness score for each participant was summed on the basis of an individual score (0 or 1) for each clinical scenario. Based on the role of OPMDs screening in facilitating early-stage oral cancer diagnosis [16], the response option ‘seeking professional consultation’ was operationally defined as the reference standard in the clinical scenarios, as it reflects recognition of lesion features that warrant professional evaluation and potential malignant risk. Thus, the response ‘seeking professional consultation’ was scored as 1, and any other response was scored as 0. This method reflects the accuracy of lesion recognition independent of the behavioral tendencies.

Next, participant-related and lesion-related variables were examined against the overall awareness score to test their associations. This was achieved by comparing variables, including age, sex, SES, smoking status, and alcohol intake, according to the overall awareness scores to evaluate demographic differences in lesion awareness separately from behavioral outcomes.

For behavioral analysis, participant responses were numerically coded to reflect behavioral tendencies and subjected to hierarchical clustering. Based on the structure of the survey responses, three broad behavioral patterns were hypothesized a priori (health-seeking, passive, and self-managing). Hierarchical cluster analysis was subsequently performed in an exploratory manner, with the number of clusters determined by dendrogram inspection. The cluster membership of each participant was determined based on proximity to cluster centroids.

Similarly, to determine whether participant characteristics were associated with specific behavioral phenotypes, demographic variables, including age, sex, SES, smoking status, and alcohol intake, were compared among the clusters. Additionally, OPMDs lesion characteristics (color/location) were examined for their influence on behavioral patterns. For this purpose, all lesion scenarios were recoded into behavioral categories (active, self-managing, passive) on the basis of the conceptual meaning of each response option. “Professional consultation” was coded as an active response, reflecting appropriate health-seeking behavior. “Home remedies” and “over-the-counter pharmacy use” were coded as self-managing responses, indicating autonomous management without professional input. “Wait and see” was coded as a passive response, reflecting delayed or absent action. The responses were then pooled across participants to generate a contingency table of lesion color/location versus behavioral response separately. Because multiple responses were obtained from each participant, the observations were not strictly independent; therefore, this analysis was intended as an exploratory, lesion-centered behavioral assessment rather than a participant-level inference.

Ethical approval

This study was approved by the institutional review board of the Jordan University of Science and Technology (number 44/165/2023, date: 06.12.2023). The study was conducted in accordance with the ethical principles of the Declaration of Helsinki (World Medical Association). Written consent was obtained from all participants. The responses were kept anonymous and stored on encrypted cloud storage specifically designed for this purpose.

Statistical analysis

Statistical analyses were conducted via BlueSky Statistics software (version 10.3.4; BlueSky Statistics LLC, Chicago, IL, USA). Associations between demographic variables and OPMDs-related variables and overall awareness scores were assessed via the Kruskal–Wallis test, Wilcoxon rank-sum test, and Friedman rank-sum test, as appropriate. Correlations between age and overall awareness scores were evaluated via Spearman’s correlation. Associations between demographic variables and OPMDs lesion-related characteristics with behavioral cluster membership were examined via the chi-square test. Statistical significance was set at p < 0.05.

Results

Participant characteristics

Table 1 summarizes the general participant characteristics. A total of 528 participants with a median age of 42 years participated in the study. The '18-−30' age group was the most prevalent age group (29.2%), followed by the '41-−50' age group (26.3%). Details of the participant characteristics are presented in supplementary file 5 (S5. File).

Table 1.

General participant characteristics

Age		No. (%)
	Median	42
	age range	18–65
	18–30	154 (29.2%)
	31–40	97 (18.4%)
	41–50	139 (26.3%)
	51–60	102 (19.3%)
	> 60	36 (6.8%)
Gender	female	295 (55.9%)
	male	233 (44.1%)
Education	no formal education	83 (15.7%)
	secondary	219 (41.5%)
	diploma	62 (11.7%)
	BA degree	144 (27.3%)
	Post grad	20 (3.8%)
Job status	employed/receives pension	212 (40.2%)
	unemployed	316 (59.8%)
Income (JDs)	no steady income	34 (6.4%)
	< 500	291 (55.1%)
	500–1000	173 (32.8%)
	1000–2000	26 (4.9%)
	> 2000	4 (0.8%)
smoking	yes	202 (38.3%)
	no	326 (61.7%)
Alcohol intake	yes	10 (1.9%)
	no	518 (98.1%)

JDs Jordanian dinars

Overall awareness and participant characteristics

To investigate how participant characteristics influence awareness of OPMDs, participant-related variables were tested for associations and correlations with the overall awareness score. Spearman’s rank correlation analysis revealed a significant positive correlation between participant age and the overall OPMDs awareness score (ρ = 0.21, p < 0.0001), although the strength of the association was weak. Figure 1 illustrates the relationship between age and the OPMDs awareness score.

Fig. 1.

Scatterplot of the correlation between age and the overall OPMDs awareness score. A significant positive correlation was found between age and awareness score (Spearman correlation, ρ = 0.21, p < 0.001)

Consistently, awareness scores differed significantly across age groups (p < 0.001), with participants aged >60 years demonstrating the highest median awareness score, whereas those aged 18–30 years presented the lowest median awareness score. Notably, the 18–30-year age group represented the largest proportion of the study population, highlighting a latent risk related to low OPMDs awareness within this demographic. The median awareness scores across participant demographic variables are summarized in Table 2. Detailed analyses of associations between demographic variables and overall OPMDs awareness are provided in Supplementary File 6 (S6 File).

Table 2.

Median OPMDs awareness scores of participant demographic groups

		Median awareness score	P value
Age group	18–30	9	< 0.001*
	31–40	11
	41–50	12
	51–60	13
	> 60	14
Gender	female	10	0.006**
	male	12
Socioeconomic status	High	12	0.574
	Middle	11
	Low	11
smoking	yes	12	0.0236**
	no	10
Alcohol intake	yes	12.5	0.6226
	no	11

*Statistically significant, Kruskal‒Wallis test

**Statistically significant, Wilcoxon-rank sum test

Overall awareness and lesion characteristics

To investigate whether OPMDs variants, including color and oral location, influence their perceived awareness among participants, the Friedman test was employed. Lesion characteristics significantly influenced awareness of OPMDs among participants (p < 0.001). Erosive lesions elicited the highest urgency to seek professional consultation, followed by red lesions, whereas white lesions triggered the lowest urgency. Similarly, lesions on the floor of the mouth presented the greatest alertness to OPMDs-like changes, whereas lesions on the lips presented the lowest alertness. Table 3 shows the mean rank of health urgency level among the lesion groups. Details of the associations between OPMDs lesion characteristics and overall awareness are presented in supplementary file 7 (S7. File).

Table 3.

Alertness mean ranks of OPMDs lesion appearance and anatomical location

		Mean rank	P value
Lesion color	Red	1.95	< 0.001*
	Erosive	2.15
	White	1.90
Lesion location	Buccal	3.04	< 0.001*
	Floor of the mouth	3.40
	Lips	2.48
	Palate	3.13
	Tongue border	2.96

*Statistically significant, Friedman rank sum test

Behavioral clustering and participant characteristics

Clustering identified three behavioral phenotypes: active (high awareness), self-managing (moderate awareness), and passive (low awareness). Patient demographic variables, including age, sex, and socioeconomic background, were examined for associations with the OPMDs-related behavioral phenotype. Table 4 lists the characteristics of the participants in the three behavioral groups. Age group was significantly associated with OPMDs-related behaviors (p=0.0152). Figure 2 illustrates how behavior clusters varied among different age groups. Other participant characteristics, including sex, socioeconomic level, and smoking/alcohol consumption, were not significantly different among the behavioral groups. Details of the participants' behavioral clustering are listed in supplementary file 8 (S8. File). The demographic-cluster associations are listed in supplementary file 9 (S9. File).

Table 4.

General participant characteristics of the OPMDs behavioral clusters

		Behavioral cluster			P value
		Active (high awareness)	self-managing (moderate awareness)	Passive (low awareness)
Age group	18–30	96	20	38	0.0152*
	31–40	65	9	23
	41–50	85	31	23
	51–60	74	14	14
	> 60	28	6	2
Gender	female	186	49	60	0.2925
	male	162	31	40
Socioeconomic status**	High	104	17	33	0.1772
	Middle	118	23	31
	Low	126	40	36
smoking	yes	143	23	36	0.1075
	no	205	57	64
Alcohol intake	yes	5	3	2	0.3164
	no	343	77	98

*Statistically significant, chi-square test

**Socioeconomic status was based on the sum of education level, income, and job status scores, followed by score-driven percentile cutoffs

Fig. 2.

OPMDS behavioral cluster membership across age groups

Behavioral clustering and OPMDs clinical characteristics

To investigate whether the clinical characteristics of OPMDs influence behavioral phenotypes, lesion color and anatomical location were examined for their associations with the three behavioral clusters. Both lesion color and lesion location were significantly associated with behavioral cluster membership (p < 0.0001). These findings indicate that participants’ responses to OPMDs scenarios vary according to lesion clinical characteristics, including color and location within the oral cavity. Table 5 summarizes differences in lesion-related variables across behavioral groups, while detailed lesion–cluster association analyses are presented in Supplementary File 10 (S10 File).

Table 5.

OPMDs lesion characteristics across the participant behavioral groups

		Behavioral cluster			P value
		Active (high awareness)	self-managing (moderate awareness)	Passive (low awareness)
Lesion color	Red	1791	487	362	< 0.0001*
	Erosive	1916	439	285
	White	1773	488	379
Lesion location	Buccal	1122	264	198	< 0.0001*
	Floor of the mouth	1232	200	152
	Lip	892	450	242
	Palate	1145	240	199
	Tongue border	1089	260	235

*Statistically significant, chi-square test

Discussion

This study examined the awareness and intended behavioral responses of OPMDs among attendees of two dental teaching centers in northern Jordan via standardized clinical images of OPMDs to simulate real-world detection and health decision-making scenarios.

Three distinct behavioral profiles emerged—active, self-managing, and passive—capturing the spectrum of decision-making patterns in the population. Overall, the participants demonstrated a moderate level of OPMDs awareness, with demographic variables such as age and gender exerting a significant influence on their responses. Importantly, lesion characteristics themselves—specifically color and anatomical location—substantially shaped behavioral tendencies, suggesting that certain presentations of OPMDs are more likely to trigger action or, conversely, inaction. These findings provide the first empirical insight from Jordan into the multidimensional determinants of public behavior toward oral premalignant conditions. They underscore how OPMDs lesion characteristics, patient awareness gaps, and the oral healthcare landscape converge to influence help-seeking decisions—ultimately shaping early detection and prevention outcomes.

One of the key findings of this study is the pronounced gender variation in overall awareness of OPMDs. Male participants demonstrated significantly higher awareness scores, highlighting potential differences in health-related behaviors between genders. However, this observation may reflect a deeper and more concerning reality: in Jordan, women continue to face socially reinforced barriers that restrict their access to health education and professional care [17]. Although national reports often describe women as more proactive in seeking healthcare [9, 18], our findings reflect a contradictory behavioral pattern: female participants showed greater tendencies toward hesitant behaviors than males did, including self-management and passive "wait and see" behaviors. This discrepancy suggests that structural and cultural constraints may override women’s willingness to seek appropriate care.

This pattern aligns with earlier findings showing a higher prevalence of OPMDs among female patients, despite traditional risk factors, such as cigarette smoking, being more prevalent in men [19]. Importantly, however, recent trends indicate a rise in alternative forms of tobacco use among women, including nargileh and vape [20], at a time where smoking rates in the country are among the highest in the region [21]. These combined observations point to an unsettling disparity: women may be simultaneously at increased risk of OPMDs while also facing barriers that limit their awareness, early detection, and access to care. These gender-based inequities underscore the urgent need for targeted public health interventions and a more equitable healthcare infrastructure for women. Knowledge and awareness of oral health issues among women are positively associated with children's oral health outcomes [22].

This study demonstrated that the clinical characteristics of OPMDs were significantly associated with a variation in behavioral responses among participants. Erosive lesions prompted the highest alertness level, whereas white lesions were associated with the lowest health urgency. This reflects a suboptimal awareness level of OPMDs. White OPMDs, or leukoplakia, is the most common form of OPMDs and has a high prevalence among smokers [23]. Erosive lesions, nonetheless, reportedly exhibit a high malignant transformation rate among other OPMDs lesions, and unhealing ulcerative lesions are considered a hallmark of oral cancer [24, 25]. This latent behavior may indicate that active health decision-making takes place at advanced stages of OPMDs, imposing a greater risk of malignancy. These observations underscore the importance of oral health education in promoting informed health decisions that ultimately improve oral cancer prevention.

SES is a critical determinant of health outcomes and access to care. Jordan’s economy continues to face substantial challenges that influence household income and financial stability [26]. In the present study, most participants had a low socioeconomic background, reflected by low or unsteady income, limited education, and unemployment. Interestingly, SES did not demonstrate a significant association with participants’ behavioral clusters. Nevertheless, individuals in the low SES group exhibited lower awareness of OPMDs than those in the high SES group did. Notably, latent behaviors, including self-managing and passive responses, were most common among participants in the low socioeconomic group. These findings align with previous studies showing that a lower socioeconomic position imposes structural and cognitive barriers to health literacy, preventive behaviors, and timely access to healthcare services [27]. Furthermore, the reliance on online searches for home remedies has increased in recent years due to the widespread integration of digital technologies. While accessible, such sources may disseminate oral health misinformation, potentially contributing to delayed detection and misinformed self-management behaviors [11, 28].

Age was also a key factor shaping participants’ behavioral responses. Older individuals showed greater awareness of OPMDs-like changes and were more inclined to seek professional evaluation promptly, whereas younger participants tended to adopt a “wait and see” approach. This observation aligns with previous studies reporting that younger adults generally exhibit lower oral health awareness and are more prone to delaying health-seeking behaviors [29, 30]. This pattern may be explained by several factors. Younger adults often underestimate their personal susceptibility to oral disease and are therefore less likely to interpret early mucosal changes as a cause for concern, leading to delayed help seeking [12]. They also tend to engage less with preventive dental care and rely more heavily on self-monitoring or online information rather than professional evaluation, which further contributes to postponing consultation [28]. These factors may explain why younger participants in this study were more likely to wait and see rather than visit a professional immediately.

This study highlights a potentially underrecognized OPMDs-related oral cancer risk in Jordan. According to GLOBOCAN estimates, 97 and 104 new cases of oral cancer were reported in Jordan in 2020 and 2022, respectively [27]. Although this represents only a modest increase, it underscores a latent and possibly growing risk that may be driven by changes in population behaviors and shifting exposure patterns. Jordan ranks among the countries with the highest prevalence of cigarette smoking globally, and the increasing popularity of nargileh and electronic vaping products, particularly among younger age groups, further exacerbates this risk landscape.

In alignment with these trends, the present study revealed that participants aged 18–30 years presented the lowest awareness of OPMDs. This finding suggests an emerging concern: younger individuals may disproportionately adopt risk behaviors while simultaneously lacking adequate awareness of early signs of oral cancer. This interpretation is consistent with prior evidence from Jordan showing that nargileh smoking is associated with a younger age at oral cancer diagnosis [31]. Collectively, these observations indicate that younger adults may represent an evolving high-risk group that has not been traditionally recognized. Moreover, the absence of research addressing the long-term impact of novel smoking habits on OPMDs and oral cancer incidence points to a potentially more sinister and largely undetected public health threat, where OPMDs remain unnoticed and progress to malignancy.

The use of herbal plants for their therapeutic properties has long been established among various ethnic groups [32–34]. In settings where access to professional healthcare is restricted, this practice has evolved into the use of alternative home remedies, particularly in under-resourced communities. For example, the COVID-19 pandemic was associated with a marked increase in the use of home remedies for the management of oral health issues [11, 35]. Several studies have explored factors associated with the widespread use of remedial treatments; however, their implications or health outcomes remain insufficiently investigated. This issue is particularly relevant in the context of the pervasive use of information technologies and social media, which facilitates the rapid dissemination of health misinformation.

The findings of this study confirm a tendency among the public to resort to home-based treatments when managing unfamiliar oral health conditions such as OPMDs. This behavior may reflect several underlying health-related factors. First, health-related anxiety may deter individuals from seeking professional consultation due to fear of dental procedures or concern about receiving a serious diagnosis [36, 37]. Second, barriers to accessing professional oral health care, whether due to socioeconomic constraints or the limited availability of oral medicine specialists, may further reinforce self-managing behaviors. Finally, reliance on misleading or unverified online health information may contribute to inappropriate self-care practices. This interpretation is supported by the present findings, which demonstrated that self-managing behaviors were most prevalent among participants from the lowest socioeconomic group. Notably, the study also revealed that lip lesions prompted the highest levels of self-managing behavior, underscoring the limited public awareness of OPMDs presentations at this anatomical site.

While this study offers significant insight into the health-related behaviors associated with OPMDs, it has several limitations. Questionnaire-based studies can capture latent behavioral constructs; however, they do not provide causal inferences on the captured behaviors. In addition, collecting responses in a dental care facility enhances the possibility of social desirability bias, where participants choose answers on the basis of what they think is expected and acceptable, which restricts the generalizability of the evidence [38]. Therefore, a community-based sample would reflect a broad real public perception of OPMDs. Paradoxically, this bias suggests that true behavioral tendencies in the general population may be even less optimal than those observed.

Another potential caveat relates to the predefined response options used in the clinical scenarios. While 'seeking professional consultation' was used as a reference standard, it may be interpreted as behavioral preference rather than a proxy of awareness that is mediated by lesion recognition. Future studies could address this limitation by employing refined scenario designs that disentangle cognitive recognition of lesion risk from behavioral tendencies. Additionally, the cross-sectional design of the study can reveal associations but cannot prove causality. While the participants of the study represent a convenience sample, the population is clinically relevant, as it represents individuals most likely to encounter OPMDs during routine dental visits. Finally, while standardized clinical images consistently capture the behavioral responses of OPMDs among participants, specific lesion characteristics, including the painless nature of lesions, may lead to variable interpretations that compromise true behavioral reflection. Variations in lesion size among the OPMDs subtypes presented in the survey were not controlled for as a confounding factor and may have influenced participants’ responses.

This study not only reveals OPMDs-related behavioral phenotypes and levels of public awareness but also highlights important knowledge gaps that warrant further investigation. Systemic health is a key determinant of the development and progression of premalignant conditions. Immunosuppression, for example, is a well-established risk factor for several head and neck malignancies, including oral cancer [39]. The cumulative effects of tobacco exposure, systemic predisposition, and limited disease awareness may therefore synergistically increase the risk of oral cancer development.

Moreover, older adults represent a particularly vulnerable demographic with respect to health decision-making, which is often complicated by comorbidities and functional limitations [40, 41]. In addition, chronic illnesses are often complicated by health anxieties that potentially impact health decision-making [37]. Although this study included participants aged over 60 years, they constituted a relatively small proportion of the sample, limiting the ability to adequately capture behavioral patterns and awareness levels within this high-risk group. Consequently, the behaviors and perceptions of the geriatric population, which often faces multiple healthcare and social burdens, may be underrepresented.

Future research should therefore prioritize the investigation of OPMDs awareness and behavioral responses among medically vulnerable and elderly populations. Addressing these gaps requires targeted public health strategies that extend beyond conventional healthcare settings, including community-based and social-level educational interventions tailored to reach older adults and other high-risk groups, to improve early detection and prevention of oral cancer. Additionally, while this study highlights potential barriers that delay early detection, these barriers should be investigated to understand how they influence health seeking and decision-making.

In conclusion, this study underscores the moderate public awareness of OPMDs and three distinct behavioral phenotypes in response to OPMDs. Demographic variables influenced overall awareness, where lower SES and younger age groups demonstrated suboptimal response behaviors to OPMDs. Additionally, the clinical characteristics of OPMDs shape the public's health decisions. Compared with white lesions, red and ulcerative lesions elicited more active health-seeking behaviors, suggesting that visual salience and perceived severity influence health decisions. This underpins the latent behaviors associated with premalignant oral conditions that hinder early detection. Collectively, these observations call for substantial interventions that aim to increase awareness of OPMDs among the public, particularly in high-risk groups.

Abbreviations

OPMDs

oral potentially malignant disorders

WHO

World Health Organization

OSCC

oral squamous cell carcinoma

EP

erythroplakia

LP

leukoplakia

EL

erythroleukoplakia

JD

Jordanian dinars

Authors’ contributions

Conceptualization: IRMethodology: IR, RSFormal analysis: IRInvestigation: SA, YAWriting – original draft: IR, SA, YAWriting – review & editing: SA, YA, RSSupervision: IR.

Funding

This research did not receive any specific funding.

Data availability

All relevant data are within the manuscript and its Supporting Information files.

Declaration

Ethics approval and consent to participate

The study was submitted to and approved by the institutional review board of the Jordan University of Science and Technology. The final approval was granted by Prof. Shaher Samrah, chairman of the institutional review board (number 44/165/2023, date: 06.12.2023). The study was conducted in accordance with the ethical principles of the Declaration of Helsinki (World Medical Association). Written informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.