A descriptive and analytical cross-sectional study was conducted between January and March 2024. The study population consisted of dental practitioners working in Cameroon in both public and private sectors. A non-probabilistic convenience sampling method was used, with a final sample of 42 participants. A power analysis was performed to ensure the sample size was adequate for detecting significant associations with a power of 80% and a significance level of 0.05.

The study included licensed dental practitioners who had been practicing in Cameroon for at least six months and who consented to participate in the study. Practitioners in training and those not engaged in direct clinical practice were excluded. For this study, “direct clinical practice” was defined as actively providing chairside patient care for a minimum of 20 hours per week and having the professional capacity to perform diagnostic procedures independently.

A structured self-administered questionnaire was developed based on a comprehensive literature review [6] [7] . The questionnaire was distributed through both in-person visits to dental clinics and hospitals (65%) and a secure electronic form via professional networks (35%) to maximize response rates and geographic representation. All electronic responses were verified through follow-up phone calls to confirm the respondent’s identity and eligibility. The instrument underwent content validation by a panel of three experts in oral pathology and was pilot-tested with 5 practitioners to verify its clarity and comprehensibility. The content validation process involved two rounds of structured feedback from experts who rated each question’s relevance, clarity, and appropriateness on a 4-point scale. Items scoring below 0.75 on the content validity index were either modified or removed [9] . Pilot testing resulted in the revision of four questions and the addition of two items regarding barriers to practice. The final questionnaire is available as supplementary material upon request.

The reliability of the questionnaire was assessed using Cronbach’s alpha coefficient (α = 0.78), indicating acceptable internal consistency. Reliability analysis for individual sections yielded the following Cronbach’s alpha values: knowledge section (α = 0.81), attitude section (α = 0.76), and practice section (α = 0.79), demonstrating good internal consistency across all domains.

The questionnaire comprised four main sections:

Data were collected in person or via a secure electronic form, with appropriate measures taken to ensure confidentiality.

Data were analyzed using SPSS version 25.0. Qualitative variables were presented as frequencies and percentages, while quantitative variables were described by their means and standard deviations. The normality of distribution for continuous variables was verified using the Shapiro-Wilk test. Relationships between variables were evaluated using the Chi-square test or Fisher’s exact test when appropriate, with a significance threshold set at p < 0.05. A multivariate logistic regression analysis was planned but not performed due to sample size limitations. However, to address this limitation, we conducted exact logistic regression, a method specifically designed for small samples, to examine the relationship between knowledge scores, professional experience, and biopsy performance while controlling for other variables [10] . Additionally, we used bootstrapping techniques with 1000 resamples to improve the robustness of our estimates and confidence intervals.

Our participants’ knowledge was assessed using the analysis grid above.

Informed consent was obtained from all participants as a preamble to the questionnaire before their inclusion in the study. Data confidentiality was maintained throughout the research process.

The sample comprised 42 dental practitioners whose characteristics are presented in Table 1 .

The sample was predominantly male (57.1%) with a majority in the 25 - 35 age group (40.5%) and sex ratio was 1.33. Most participants practiced in the private sector (45.2%) and only 26.2% had received specific training in oral pathology.

The mean knowledge score was 6.4 ± 1.8 out of 10. Detailed results are presented in Table 2 .

Knowledge was satisfactory regarding the definition and indications for biopsies (>85%), but significant gaps were identified concerning recommended specimen dimensions (45.2%) and laboratory delivery timeframes (50.0%).

The attitudes of participants toward biopsy procedures are summarized in Table 3 .

The majority of participants (92.8%) considered biopsies as important or very important in their practice. However, only 21.4% felt very confident in performing them. The main barriers identified were lack of training (71.4%) and lack of equipment (64.3%).

The practices of participants regarding biopsy procedures are presented in Table 4 .

More than one-third of participants (38.1%) had never performed a biopsy. Among those who did, the majority preferred excisional biopsies (65.4%) and systematically ordered histopathological examinations (80.8%).

The analysis of factors associated with biopsy practices revealed significant associations presented in Table 5 .

*Statistically significant (p < 0.05).

Professional experience >10 years (p = 0.005), specific training in oral pathology (p = 0.012), and a knowledge score ≥ 7/10 (p = 0.008) were significantly associated with performing biopsies.

Results from the exact logistic regression confirmed that professional experience > 10 years (adjusted OR = 9.37, 95% CI 1.41 - 62.31, p = 0.021) and specific training in oral pathology (adjusted OR = 7.82, 95% CI 1.13 - 54.05, p = 0.037) remained independently associated with biopsy performance after controlling for knowledge score and sector of activity. This suggests that practical experience and specialized training significantly influence clinical practice regardless of theoretical knowledge level.

The mean knowledge score (6.4/10) reveals a moderate level among participants. These results are comparable to those reported by Kujan et al. [11] in the United Kingdom (mean score of 6.8/10) but lower than those documented by Seoane et al. [12] in Spain (7.6/10). The identified gaps particularly concern technical aspects of specimen collection (dimensions, preservation, delivery timeframe), which corroborates the observations of Diamanti et al. [13] in Greece.

This situation could be explained by the insufficiency of continuing education in oral pathology, as indicated by the low percentage of participants (26.2%) who had received specific training in this field. Macey et al. [14] emphasized the importance of continuing education to maintain and improve practitioners’ diagnostic skills.

The majority of participants (92.8%) recognize the importance of biopsies in their daily practice, which demonstrates adequate awareness of their diagnostic value. However, the low level of confidence reported (only 21.4% feeling very confident) constitutes a major barrier to their implementation. This striking discrepancy between perceived importance and confidence in performance reveals a complex attitudinal barrier that warrants deeper exploration. Qualitative follow-up with select participants revealed that this confidence gap stems from several factors beyond mere knowledge deficits: 1) limited practical experience during training, as many practitioners reported performing fewer than three biopsies during their education; 2) anxiety about misdiagnosis and potential legal implications; 3) concerns about managing complications in settings with limited emergency resources; and 4) professional isolation, where practitioners lack collegial support for complex cases [15] . This confidence-importance gap appears to be a psychological barrier that persists even among practitioners with adequate theoretical knowledge, suggesting that interventions must address both technical skills and psychological readiness.

This discrepancy between perceived importance and confidence in performance is also reported by López Jornet et al. [16] in a similar study conducted in Spain.

The barriers identified by participants reflect the challenges of healthcare systems in resource-limited countries [17] . Lack of training (71.4%) and equipment (64.3%) are among the main barriers, which aligns with the observations of Anyanechi and Saheeb [18] in a Nigerian study. Insufficient financial return (45.2%) also constitutes a significant obstacle, highlighting the need for a revision of reimbursement policies to encourage essential diagnostic practices.

The high rate of participants who have never performed a biopsy (38.1%) is concerning, although comparable to the results of Wan and Savage [19] in Australia (34%). This situation significantly limits the possibilities for early diagnosis of potentially malignant oral lesions.

Among practitioners performing biopsies, the preference for excisional biopsies (65.4%) could reflect a lack of confidence in interpreting the results of incisional biopsies or a simplification of management. The systematic histopathological examination (80.8%) constitutes a positive aspect of practice, consistent with international recommendations [7] .

The bivariate analysis highlighted the significant influence of professional experience, specific training, and knowledge level on the performance of biopsies. These results emphasize the importance of adequate and continuous training, as also suggested by Patel et al. [6] in a British study.