Surface defect detection with machine learning has become an important tool in industries and a large field of study for researchers or workers in recent years. It is necessary to have a simplified source of information that helps us to better focus on one type of surface. In this systematic review, we present a classification for surface defect detection based on convolutional neural networks (CNNs) focused on surface types. Findings: Out of 253 records identified, 59 primary studies were eligible. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we analyzed the structures of each study and the concepts related to defects and their types on surfaces. The presented review is mainly focused on finding a classification for the types of surfaces most used in industry . We delve into the specifics of each surface category, offering illustrative examples of their applications within both industrial and laboratory settings. Furthermore, we propose a new taxonomy of machine learning based on the obtained results and collected information. We summarized the studies and extracted the main characteristics such as type of surface, problem types, timeline, type of network, techniques, and datasets. Among the most relevant results of our analysis, we found that the metallic surface is the most used, as it is the one found in 62.71% of the studies, and the most prevalent problem type is classification, accounting for 49.15% of the total. Furthermore, we observe that transfer learning was employed in 83.05% of the studies, while data augmentation was utilized in 59.32%. Our findings also provide insights into the cameras most frequently employed, along with the strategies adopted to address illumination challenges present in certain articles and the approach to creating datasets for real-world applications. The main results presented in this review allow for a quick and efficient search of information for researchers and professionals interested in improving the results of their defect detection projects. Finally, we analyzed the trends that could open new fields of study for future research in the area of surface defect detection. Defect detection is an important part of industrial processes. Currently, many manual inspections are carried out with experts in the process but have a high cost due to the staff’s working hours. In recent years, there has been a significant increase in the use of machine learning to carry out these processes, reaching a significant impact on industries to improve the quality of their products. Within the inspection process in an industry, the detection of defects has a very important role because it approves or rejects parts produced in factories or delivered by suppliers. It also helps to reduce material wastage because it can include the rework and repair of parts , even thIn this article, a CNN literature review is carried out, considering various aspects such as types of surfaces, different types of CNNs, datasets, cameras, and network architectures. It was possible to go from 253 studies to 59 specific studies and perform a systematic review. In this review, defect detection articles (DDAs) use labeled data, so all articles are of the supervised learning type, because the majority of the conducted studies using CNNs use supervised learning; therefore, we exclude other types such as unsupervised learning, self-supervised, semisupervised, and reinforcement.The study of surface defect detection has significant relevance in industries because it improves the quality of products and reduces production costs, but as of the date in which this systematic review is carried out, there are still no studies comparing types of surfaces, problem types, or origins of the datasets. This systematic review becomes a significant help for researchers and students who need to focus directly on a type of surface, speeding up the search time and providing a general guide.To conduct this review, we first conducted a preliminary study to define a group of which we consider to be the most relevant research questions (RQs), which we will answer throughout this article.RQ1: Which are the most used types of surfaces in defect detection?RQ2: What are the main problem types for surface defect detection?RQ3: Which is the type of network architecture most used for each type of surface defect detection?RQ4: What techniques were used to improve performance in studies regarding surface defect detection?RQ5: Which is the most used type of dataset?RQ6: How did the number of studies evolve over the years?A comparison between techniques is made by the type of material, which will guide researchers when searching specifically for a specific material or to perceive the main trends in the industry;The studies were classified by type of learning, to easily understand what is being used in each study reviewed;The proposal of a taxonomy for machine learning and surface defect detection.Besides the intrinsic value of the answers to the main research questions of this article, several other contributions are highlighted:In This systematic review was based on three stages represented in First, planning the review; the need to develop this systematic review was determined, and then we defined the research questions and created a review protocol. Second, conducting the review; with the review protocol implemented, the next step was to conduct the review stage. We started to identify the research questions because these serve as a guide to carrying out this review, and these questions were answered while this systematic literature review (SLR) was developed. Then, we defined search strategies where we found the first research studies to be reviewed, followed by a primary selection of studies that are relevant to our research questions. After that, we proceeded with the study quality assessment, obtaining better filtering. Once the studies were chosen, the next step was data extraction, where the information obtained from the primary studies was recorded; in this case, the work was made easier by using forms to answer the research questions posed at the beginning. Then, the results of the primary studies were collected and summarized (data synthesis). Finally, the results were reported; reporting the review results.The search was carried out using synonyms and alternative terms referring to the same topic, with a combination of the boolean expressions “AND” and “OR”. In addition, these searches were filtered to find studies between the years 2011 and 2021. We decided to start our search in 2011 until nowadays due to the big boom in deep learning using CNNs that started in 2012 when AlexNet won the 2012 ImageNet Challenge for image classification. AlexNet proved to be a landmark deep learning model with GPU acceleration, triggering the deep learning revolution. Although this network was not the first to use the GPU, the big stage where it succeeded gave it media attention, setting a milestone and sparking the deep learning revolution. These facts gave us a guideline, so we decided to keep a one-year margin (2011) to include possible studies before the rise of AlexNet.A general key was created as a basis and 559 primary research studies were found in Scopus. Then, the search parameters were improved, and after several attempts, Key1 was created and used to search for studies in electronic digital databases. After performing an analysis of backward and forward citation search, we found relevant articles that guided us to structure the search for studies; surveys especially helped us because they cited articles with relevant topics to our search topic. With this information, Key1 was improved again to focus mainly on surfaces, quality control, defect detection, and machine learning, in a combination that allowed us to find the articles studied in the following stages. Key1 can be used in several electronic journals because the journals share a general format, which facilitates the search process. The four electronic databases used to search for primary studies were Scopus, IEEE Xplore, ACM Digital Library, and Web of Science. Key1 is expressed as follows: ) AND (defect OR deformity OR fracture OR deficiency OR crack) AND  OR (detection OR detecting OR identification OR sensing OR classification)) AND ).The search process begins with the 4 electronic databases and Key1, so searches are performed to find candidate studies, which are then filtered according to the exclusion and inclusion criteria shown in the next section.The criteria results considered to assess the results in this study include both inclusion and exclusion criteria, which are presented below.Empirical studies using CNNs for surface defect detection;Empirical studies using supervised learning for surface defect detection;Empirical studies combining CNNs and other commonly used machine learning techniques;Review studies, conference papers, and articles;Studies between 2011 and 2021;Studies in English;Final published versions.Inclusion criteria:Studies without empirical analysis or results of the use of CNNs;Studies using CNN techniques in a context other than surface defect detection;Studies using CNNs with datasets not based on images;Studies with only abstracts;Articles in press.Exclusion criteria:This study selection is based on PRISMA , and theA quality assessment was performed to select only the most relevant studies for this review in the field of surface defect detection with CNNs. Thus, we developed a questionnaire of nine questions based on the guidelines in ,12, to aThe list of these 62 selected papers up to this point in the process, the scores of each researcher independently, and the final scores for each primary study can be found in Finally, after several meetings and debates on the exclusion and inclusion of the studies, only DDA12, DDA14, and DDA27 , or in interesting surfaces such as titanium-coated metal , microscEach study presents its categories of defects according to the experiments and the characteristics of the material used. Although some are similar, these defects are categorized according to the criteria of the researchers, for example, contusions , protrusAs for the techniques used, transfer learning was used in most of the experiments, to take advantage of the knowledge generated previously, marking a trend in the use of this technique for this type of surface. For data augmentation, the use is limited to half of the studies, due to several reasons. On the one hand, there are public datasets with large numbers of images; therefore, it is not necessary to apply the technique. On the other hand, the created datasets use this technique because the metal industry is limited by the rules of factories, which causes difficulties in capturing images for the datasets and makes necessary the use of the data augmentation technique to save time and improve the datasets. Finally, factories invest large amounts of money which, in most cases, allows them to purchase high-end equipment and create specific modules for image capture within the production environment. These modules contain fixed lighting to solve the problem of glare and mostly use industrial cameras due to image quality.Building surfaces cover several locations such as bridges, pavement, roads, houses, or dams. The most common defects are cracks, but there are others such as intact, spall, or efflorescence . In thisCreating a dataset becomes a challenge in this type of surface because of the difficulty of access to the site. To achieve a great variety of images, the authors take advantage of different time periods , different shooting distances, light and shadow illuminations, etc. Consequently, the authors use unmanned aerial vehicles for buildings with difficult access such as in ,61,63,65As shown in Defect detection in the ceramics industry is aimed at reducing manufacturing time and increasing production efficiency by avoiding the release of defective products to the market. As it is an industry with few studies, most of them use networks already created and compare them. Min et al.  proposedDefects like breaks, cracks, pinholes, dirt, pits, and spots, shown in , are repThe wood industry is a good place to conduct studies because wood has the characteristic of creating randomly textured surfaces, which is an advantage when using data augmentation techniques. In a study conducted by Jung et al. , the autAs in most studies, in , a custoThese two research papers demonstrate that a surface with few studies should use transfer learning and data augmentation techniques to improve results. Furthermore, in both cases, the authors were found to create their datasets with industrial cameras to improve image quality. These details are shown in These surfaces stand out for their unique qualities, and most use customized nets to achieve their objectives. Zou et al.  proposedAs detailed in This section presents the results gathered from the analysis of the primary studies for surface defect detection. We present the answers to the research questions in each subsection, including an analysis and discussion of each one, considering the information obtained throughout the systematic review and the results of We made a more detailed review of the results gathered in In the first instance, there is a significant difference between the surfaces used, as presented in P1: image classification;P2: object detection;P3: semantic segmentation;Instance segmentation.According to problem types, we categorized four types:To find the most used problem types, In this systematic review, we account for the problem types that have the greatest impact on each study. However, there are also studies where more than one type is used, as in the case of ,76, wherFor image classification challenges, exploring alternatives like graphs is valuable. In , a freshThe ongoing challenge in semantic and instance segmentation is the computational cost, which motivates researchers to concentrate on finding solutions. A starting point could be the analysis of performance under hardware limitations presented in  or the sGiven the plethora of variations within network architectures, our focus lies in categorizing them into two main types: CNNs and custom CNNs. A CNN entails a traditional convolutional neural network devoid of alterations. Typically, comparative studies involving datasets or techniques devised by researchers are employed to enhance outcomes. Conversely, a custom CNN pertains to a personalized convolutional neural network that undergoes structural alterations or modifications. In certain instances, authors enhance these networks by crafting novel modules or amalgamating components from various network architectures to engender a novel network configuration.The difference between the studies that created their own CNNs and those that used state-of-the-art networks to carry out the experiments is shown in DA: data augmentation;TL: transfer learning.According to the types of techniques, we categorized two types:The number of studies using transfer learning, data augmentation, or a combination of both to improve the performance of the models is summarized in To find out which is the most used technique, we are guided by The origin and availability of datasets are important parameters when starting experiments with defect detection. According to In this systematic review, the studied datasets primarily employ cameras for image capture. There are instances where existing datasets alone are used and others where a combination of precreated datasets and camera images are employed for defect detection experiments. The search key begins with studies from the year 2011, and the first two studies appear in the year 2017, while in the previous years, no studies were found, according to our filtering in In industry, metal surfaces are the most used, being in 62.71% of primary studies, even though this type of surface is difficult to study because the light is reflected and it is not easy to obtain superior-quality datasets at the beginning;According to problem types, image classification is the most used type of learning individually or in combination, because there is a lot of information and its computational cost is less high than the other problem types. It is followed by object detection and finally by semantic segmentation together with instance segmentation, which have the highest computational cost and take the longest time to compute;Using techniques to improve performance is common in this type of study, due to the difficulty of creating datasets with large numbers of images. A total of 93.22% of the studies use at least one technique to improve performance; it can be transfer learning or data augmentation. Individually, transfer learning is the most popular among researchers;The number of studies conducted on surface defect detection with CNNs is increasing every year because it provides better results in the industry, helps reduce costs, and increases the speed of production when implemented in a factory. These technological solutions not only offer these benefits but also have the potential to bring about significant changes in the industrial sector. By harnessing these advancements, businesses can gain a substantial competitive edge over their counterparts;To create datasets, industrial cameras are the most used and showed better results due to their ability to capture better-quality images than conventional cameras or web cameras. However, in conditions of difficult access to study sites, the authors used various types of cameras;The traditional networks have already been tested with several experiments and studies. However, to obtain more and more accurate results, current studies are focused on modifying these networks or creating complementary methods to improve defect detection. We note that this trend is growing, especially on surfaces with the largest number of studies.The review at hand encompassed a meticulous examination of numerous works within the chosen literature. Over the course of this systematic review, a predominant concern that emerged was the insufficiency of information in specific studies. Among the most notable aspects, information pertaining to lighting, quantity of images, and image dimensions stood out. Gathering this information proved to be a challenge; nevertheless, it served as a valuable learning tool that could drive the execution of further systematic reviews of this nature in the future. The obtained results and the collected information allowed us to arrive at a set of insights that translate into several lessons learned. Therefore, the main learned lessons are the following:In this paper, we present a systematic literature review for surface defect detection using CNNs with supervised learning. First, we carried out an analysis of the main databases, defining 59 primary studies between 2010 and 2021. Secondly, we summarized the studies and extracted the main characteristics such as type of surface, problem type, timeline, type of network, techniques, and datasets. Finally, we compared and analyzed the information gathered.The use of CNNs for surface defect detection is increasing every year. Even though the metal industry is the one that invests the most in these studies, other industries are beginning to investigate due to the satisfactory results that have been shown, and so in the future, they will continue to be excellent fields of study for future research and applications in the industry. In addition, computers are becoming more powerful and accessible, allowing researchers to perform more complex processing tasks, taking less time to obtain results. Therefore, although Classification is the most used problem type, in the coming years, projects could be carried out that combine the four types  to obtain more precise results that improve the quality of the products.We observed that in about half of the studies, there is no information provided regarding the cameras, lighting, or image size used. Specifically, we encounter challenges when searching for information that explains how they address lighting challenges in both controlled environments and those with natural light. This becomes critically important because in real industry settings, products are often manufactured in warehouses or spaces with natural lighting to save costs. Therefore, this aspect is vital for improving image quality, especially when cameras lack autofocus. All of this information becomes crucial when using a study as a reference in developing a practical application aimed at defect detection. However, we are faced with the difficulty of finding studies that offer the necessary guidance for creating effective applications in the industry.Researchers must diligently screen articles containing extensive information on image capture. Often, in this domain, data from one source can be reused in another, making data reuse feasible. In this scenario, it is noteworthy that only 15.25% of the studies did not reveal information about the use of cameras for their datasets. Therefore, existing modules created for image capture can be used as a guide;Some studies withhold relevant information within their datasets, especially the quantity of generated images. This omission restricts essential data access for researchers or professionals in need of using such information for real-world applications or comparing new network architectures. Therefore, utilizing existing datasets as a guide for constructing our dataset proves to be a prudent approach;Researchers about to conduct flaw detection studies must first focus on the type of surface they are going to study. If there is no information regarding the surface sought, similar surfaces must be used because defects are repeated on most surfaces;Researchers who possess limited experience in this field should initiate their endeavors by conducting experiments on metal surfaces, leveraging the wealth of existing data. Subsequently, they can transition to their specific area of interest or the surface type they are studying.The following guidelines were made for future researchers and professionals interested in this field of study:


To evaluate the impact of an educational intervention on the knowledge of nursing professionals regarding standard precautions.This is an almost experimental study conducted with 100 nursing professionals. Data collection was performed using a sociodemographic characterization instrument and the Standard Precautions Knowledge Questionnaire. The educational intervention was based on five moments, where the approach to questions with less than 70% accuracy was intensified.There was a significant difference between the scores of healthcare professionals before (16.20 ± 1.51) and after (16.90 ± 1.31) the educational intervention . Regarding knowledge about hand hygiene after glove use, an increase in knowledge from 83% to 93% was obtained.A positive effect on the professionals’ knowledge was recorded, demonstrating advances regarding the strengthening of already acquired knowledge and the understanding of new knowledge. An effective strategy for reducing HAIs and improving the quality of care is the proper use of standard precautions (SPs) -3. In addition, the Center for Disease Control and Prevention (CDC) has added other prevention measures such as respiratory hygiene or cough etiquette, safe injection practices, and the use of protective masks for inserting catheters or injections involving lumbar punctures. However, there is a lack of knowledge among professionals regarding the correct use of SPs.SPs provide safety and protection against biological risks. They involve the correct use of gloves, gowns, eye protection, hand hygiene, proper disposal of sharp objects, and cough etiquette.Several factors are directly related to the deficit in knowledge and adherence to SPs among professionals, such as management support for safer work practices, low perception of prevention efficacy due to inadequate knowledge of the importance of SP use, unavailability and inaccessibility of personal protective equipment (PPE), lack of safety performance feedback, among others. Another important aspect to highlight is that the low knowledge of SPs may also be related to the fact that most nurses do not receive training at the beginning of their work activities in healthcare institutions,7. With the onset of the COVID-19 pandemic and the growing global spread of the virus, significant changes have been observed in the production and distribution capacity of PPEs, resulting in incompatibility in the availability of some materials and compromising compliance with use. This atypical scenario required regulatory health agencies to issue new recommendations, such as surgical masks should be snugly secured on the face, eye protection should be used for all patient care encounters, and suspected or confirmed COVID-19 cases should use a respirator such as an N95 or PFF2 with eye protection, even when there is no exposure to aerosols, as recommended by the CDC -10.Thus, training has a significant and effective influence on the attitude and knowledge of professionals in performing their work activities safely, increasing awareness of safety protocols-6. In this context, the high demand for care for COVID-19 patients, the overload of care, and the deficit in knowledge are factors that contributed to the high turnover of nursing professionals during the COVID-19 epicenter -10.Although the use of PPE is not a recent recommendation, the transmission and spread mechanisms of COVID-19 required the development of new technical-scientific knowledge aimed at promoting safety in healthcare services .However, the proper use of PPEs does not eliminate the risks of exposure, but they are reduced with correct use, thereby reducing the propensity for work-related accidents. Failure to use PPEs exposes both the professional and the patient to infectious diseases. The importance of permanent education that promotes biosafety from the beginning of professional education is highlighted as a strategy to reduce the impacts of lack of knowledge when professionals are exercising their functions since work-related accidents may be related to a lack of knowledge.Offering training to professionals seeks to expand knowledge and promote correct practices regarding the use of SPs, thus minimizing the dissemination of pathogensTo evaluate the impact of an educational intervention on the knowledge of nursing professionals regarding standard precautions.The study was conducted in accordance with national and international ethical guidelines and approved by the Research Ethics Committee of the Federal University of Mato Grosso do Sul (UFMS), whose opinion is attached to this submission. Informed consent was obtained in writing from all individuals involved in the study..Quasi-experimental research, with a before-and-after design of a single group guided by the CONSORT tool. The essential characteristic of this investigation is that the researchers control and manipulate the conditions they are interested in, meaning they cause a change in the value of an independent variable and observe the effect of that change on another dependent variableThe study was conducted in the city of Três Lagoas, in the east of Mato Grosso do Sul, Brazil, in a hospital that currently serves as a reference for 10 municipalities in the state. The hospital has 166 existing beds, 90% of which are dedicated to public and free care through the Brazilian Unified Health System (SUS). The estimated population of the municipality is 123,281 inhabitants.The nursing team at the institution had a total of 358 active nursing professionals, of whom 149 were eligible to participate. Professionals who were in positions that did not have direct contact with the patient during data collection were excluded.. To measure knowledge, the Standard Precautions Knowledge Questionnaire (QCPP) was used, created by Chinese researchers and adapted to the Portuguese language in Brazil -16, with satisfactory validity indexes. Stability was calculated using the intraclass correlation coefficient (ICC), with a value of 0.91, and agreement was tested using the Kappa coefficient, with a “perfect” substantial classification for all items on the instrument.Initially, a sociodemographic characterization instrument was applied for variables such as gender, professional category, sector, age range, work time range at the hospital, and hours worked per week.The self-administered questionnaire has 20 questions, where each correct answer is scored 1 point, and each “I don’t know” or incorrect answer is scored 0 points. The possible score ranges from 0 to 20 points, and the higher the score, the greater the professional’s knowledge related to Standard Precautions. The use of the knowledge questionnaire can help in planning intervention actions aimed at patient and professional safety, with the aim of improving the use of Standard Precautions that conducted an educational intervention with healthcare professionals on standard precautions (SPs), consisting of 5 moments.The methodological approach used in this study was based on a previous studyAn initial approach was made with the nursing professionals who worked directly in the care, clarifying the research and obtaining authorization for participation through the Informed Consent Form (ICF). After acceptance, the instruments were answered by professionals during the shift through the Google Forms questionnaire link, using technological devices such as cell phones and tablets, with an average of 20 minutes for completion of all questionnaires.Data collection for the first step occurred from February to March 2022; the educational intervention in April; and the second questionnaire application in May and June 2022. It is pertinent to highlight that, during this period, the pandemic status conferred by the World Health Organization (WHO) was still in effect, but without social isolation, mandatory use of masks, with a reduction in the number of deaths and severe cases, and an increase in vaccination rates.After acceptance of the professionals, the instruments were used , and both instruments are self-reported by nursing professionals. Then, the answers to the instruments were analyzed in order to guide the construction of the educational intervention, with a focus on knowledge/practice.The ICF and electronic forms were sent through the Google/Gmail platform, called Google Forms, and the study subjects were provided with the survey link, which contained the ICF page. for SPs for the care of all patients, and an educational video validated by expert professionals was used to report the importance of using SPs.The presentation was built following the guidelines and recommendations proposed by the CDCIn the third moment, the educational intervention was carried out, with an average duration of 30 minutes, in 4 periods, covering all shifts of the hospital professionals. It was based on the analysis of the results obtained in the knowledge questionnaire on SPs, through studies where the researcher asked the questions, exposing through the use of a Data Show, and the professionals answered afterwards..For each question with a correct answer of less than 70%, the true answer based on the theoretical reference of the last 5 years of Brazilian and international literature was presented. A culture of educational and constant learning promotes the development of resilience, facilitating learning and improving professional readinessIt took place in April 2022, lasting three days, covering all shifts of the institution. The construction of the material was consulted through virtual databases, using the PowerPoint tool for better organization of information and exposure to collaborators, bringing, first, concepts related to HAI related to patient safety and types of SPs.-24. In order to strengthen knowledge and the importance of using SPs among nursing professionals, an educational video was used to compose the intervention material, a video built with the strategic objective of stimulating the adherence to SPs by nursing workers.Further in-depth analysis was carried out on questions with a cutoff value of <70% in the first phase of data collection, for the construction of the intervention proposal, as recommended by the literature. Before conducting the educational intervention with the professionals, a presentation and discussion meeting was held with the nursing and medical coordination of the Hospital Infection Control Commission (CCIH) and the continuing education department of the institution to obtain their agreement, considering the hospital’s existing norms and routines on the topic.This same video was constructed through a descriptive study conducted with 197 nursing workers in Cuiabá, Mato Grosso, in 02 hospitals. For the construction of the video, data were collected through the Questionnaire for Knowledge and Compliance with Standard Precaution Scale (Portuguese version), to identify knowledge and factors that interfere with adherence to SPs. Afterwards, a methodological study was carried out and the video was structured based on the results obtained in the first phase of the research, following Nola Pender’s revised health promotion model. The video was validated using the Delphi technique and reviewed by 13 specialists. Therefore, the video was considered valid by the experts and could be used to expand and strengthen knowledge among nursing professionals, encouraging adherence to standard precautionsAfter the completion of the educational intervention, the standard precaution knowledge questionnaires were re-administered to analyze the impact on the knowledge of PPE among nursing professionals after the educational intervention. At this stage, the COVID isolation unit was already inactive due to the decrease in severe cases, which may be related to the vaccination coverage and isolation measures that were followed.Finally, a comparative analysis of the 1st and 4th moments was conducted in relation to knowledge before and after the educational intervention.The scores obtained before and after the intervention were represented by mean and standard deviation. The Wilcoxon test was performed to evaluate possible significant differences. In addition, the score of each questionnaire was evaluated according to the sociodemographic characteristics of the sample. The Mann-Whitney and Kruskal-Wallis tests were performed to evaluate possible differences. Spearman’s correlation analysis was performed with the scores before and after the questionnaires with sociodemographic characteristics. The number of correct answers per question was evaluated according to the nominal variable “correct” and “incorrect”. To evaluate possible differences in the proportion of each questionnaire item, the Q-Cohrane test was performed. The Statistical Package for the Social Science (SPSS) software version 20.0 was used. The level of significance was set at 0.05.Categorical variables were represented according to absolute and relative frequencies. To evaluate the difference between the responses before and after the intervention, the McNemar-Bowker test was performed. The statistical power of the sample was calculated using G Power software, considering a total of 99 individuals, an error rate  of 0.05, a bicaudal distribution area, and an effect size of 0.40. After the calculation, a 97.2% analysis power was obtained.Of the 100 nursing professionals who made up the final sample of the study, the majority were female (85.9%), and nursing technicians were the majority category of participants. The sociodemographic characterization data can be observed in The Below is -27 in the literature showing knowledge gaps among professionals regarding standard precautions, reinforcing the need for constant training for the entire team. Our findings are supported by another study conducted in São Paulo, Brazil, which diagnosed an improvement in the positive data of professionals’ knowledge after intervention.We observed an increase in the average score of knowledge after an educational intervention aimed at improving the knowledge of nursing professionals about standard precautions. We also observed a decrease in the standard deviation, which suggests less dispersed scores among healthcare professionals before (16.20 ± 1.51) and after (16.90 ± 1.31) the intervention. However, this result contrasts with several studies-29.Although the context of standard precautions is broad, there is a significant improvement in the knowledge indicators concerning the purpose of standard precautions, moments for hand hygiene, indications for the use of gloves, shoe covers, and caps, and the PPE involved in the collection of biological material. After the educational intervention, the number of correct answers regarding the purpose of standard precautions doubled, and this increase was statistically significant. Although it may indicate a favorable scenario for knowledge change, this data is still concerning as it may minimize the importance of these measures due to improper or suboptimal use. The use of standard precautions, in addition to protecting professionals against occupational risks, also protects patients against possible infectious agents transported on the hands of professionals or equipment used.Regarding hand washing after using gloves, there was also a statistically significant increase in professionals’ knowledge. This result is particularly interesting considering the need to always improve good hand hygiene practices, as incorrect practices can favor the chain of cross-infection and compromise patients, families, and professionals, especially in the context of a health crisis like the current COVID-19.Since glove use prevents contamination, hand washing is indispensable regardless of suspicion or confirmation of infection between the care of different patients, and the understanding that glove use does not replace hand hygiene after care. According to the WHO, which has incorporated the “five moments for hand hygiene” approach for workers, hand hygiene is performed before and after touching a patient, before performing aseptic procedures, after exposure to body fluids, and after touching the patient’s environment, being one of the most important measures for infection prevention.The COVID-19 pandemic has made the need for correct hand washing even more critical in the prevention of viral infections. Therefore, for future pandemics, the need to strengthen these measures, including sanitary measures, will be of utmost importance in their containment and spread.Furthermore, regarding other types of precautions and when to use each PPE, we noted positive results regarding the protection of professionals in contact with patients with hepatitis C and syphilis. Before the intervention, 59.6% of professionals agreed that only standard precautions need to be adopted in these situations, and after the intervention, 65.7% of professionals demonstrated knowledge on this issue. This finding is supported by another intervention study conducted in Iran, which also showed a positive effect on professionals’ perception of the risk and severity of infection susceptibility to possible irreversible injuries resulting from contagion with these pathogens-30.On the other hand, regarding the adoption of droplet precautions and not aerosol precautions for assisting patients with active tuberculosis or chickenpox, 92 professionals continued to agree with the statement and 9.1% claimed they did not know which type of precaution to use when in contact with intestinal and skin infections, after an educational intervention. After the intervention, 5.1% of these professionals still had a lack of knowledge on the subject. We know the importance and necessity of knowing which personal protective equipment (PPE) to use and in which situations it is recommended, as this contributes to safe care for both the professional and the patient, reducing the occurrence of adverse events. On the other hand, there are reports in the literature about performing venous punctures without gloves. Factors such as haste and talc were mentioned as reasons for not adhering to this PPE. Nevertheless, it is important to emphasize that individualized care for different patients is necessary to minimize the risk of infection and dissemination of microorganisms.However, after the educational intervention, we noticed a decrease in the percentage of professionals who considered it necessary to use gloves for blood collection, venous punctures, and whenever there is a possibility of hand contact with patient secretions, as well as an increase in patient exposure. This is concerning because the improper and indiscriminate use of gloves can be associated with the transmission of pathogenic agents.We observed that even with an increase in correct answers regarding the statement that needles should not be bent, twisted or actively capped, this practice still occurs among nursing professionals. Disposal containers should be placed close to the manipulation area, and there were professionals who continued to consider this statement false, suggesting that the practice of needle recapping is still present in their work activities, regardless of diagnosis, and the critical scenario experienced during the COVID-19 pandemic seems to have amplified erroneous practices related to precautions, especially due to the lack of adequate knowledge. Although we recognize that knowledge alone is not sufficient to sustain a behavioral change, it remains a fundamental element for sustained behavioral change. Thus, nursing professionals can only carry out their activities with greater safety after acquiring the necessary knowledge.Precautions should be applied in the care of all patients.Some misconceptions demonstrate the lack of necessary knowledge and, consequently, increase the likelihood of occupational risks, leading to a higher risk of certain diseases for professionals. Therefore, knowledge about precautions includes safe and essential practices in the control of healthcare-associated infections, such as good hand hygiene, performed frequently, using not only water but also soap, as well as proper disposal of sharps and cleaning of surfaces and floors in case of blood spills. It is important to highlight that hospital control and organization need to be constant, especially after the pandemic, where considerable behavioral and care technique changes were observed, making it necessary to monitor the changes caused by COVID-19 closely, requiring greater coordination by management in ensuring the necessary resources and qualified workforce.The importance of training involving biosafety practices is emphasized not only in the workplace, but also as a strategy to minimize the impacts resulting from a lack of knowledge about precautions since the professional’s preparationThe main limitations of this study are that it was conducted in a single hospital, which limits its generalizability. The fact that it relied solely on self-reporting and not on direct observation should also be considered. Lastly, it is worth noting that the focus on the knowledge aspect does not necessarily reflect the daily practical adherence to standard precautions by the healthcare professional during patient care.The study demonstrates advancements for nursing science regarding the strengthening of existing knowledge and the understanding of new knowledge related to safe practices in healthcare settings. It allows for contributions to evidence-based practice, enabling a situational diagnosis of nursing professionals’ knowledge regarding the use of standard precautions after a pandemic outbreak, identifying knowledge deficits, and providing support for the development of targeted educational interventions. These interventions can serve as a foundation for the development of strategies after a public health crisis, such as the COVID-19 pandemic.The educational intervention proved to be effective, as an increase in the score of the Standard Precautions Knowledge Questionnaire and a decrease in the range for most questions were observed before and after the educational intervention. However, significant misunderstandings were still reported after the educational intervention, which suggests uncertainties among professionals in some of the topics covered. This could be related to the individual’s cognitive absorption capacity in understanding changes in a short period since the educational action was only appreciated by each participant once before the post-questionnaire reapplication for knowledge impact evaluation. This reflects the need for periodic and multimodal educational interventions. Therefore, the development of educational interventions with a defined methodological approach and the use of validated educational materials and tools led to knowledge improvement among the healthcare professionals.


Burning mouth syndrome (BMS) is characterized by a persistent intraoral burning sensation, often experienced by postmenopausal women. The etiology of BMS remains partially understood, and consequently, treatments remain suboptimal. Extraoral manifestations of BMS, such as extraoral dryness, are less studied. However, it has been suggested that the identification of the frequency and patterns of extraoral dryness and potential underlying mechanisms are essential to optimize treatment strategies and reduce the burden of disease. Therefore, we conducted this systematic review to provide existing evidence about extraoral dryness in BMS. The guidelines for the conduction and reporting of systematic reviews were followed. An electronic search was conducted in four major databases—PubMed, Web of Science, COCHRANE Library, and EBSCOhost—and the grey literature was assessed through Google Scholar. From each included article, information on extraoral dryness in BMS was extracted, and odds ratios were calculated for extraoral dryness among BMS patients compared with non-BMS controls. The findings demonstrated higher odds of the prevalence of extraoral dryness in BMS, which was found to a high degree in the lips, eyes, skin, and genitalia. The pattern of spread and locations of extraoral dryness propose a potential central mechanism. Based on our findings, we encourage the standardization of the assessment, recording, and reporting of the extraoral characteristics of BMS, including extraoral dryness, which can lead to better management strategies and enhance the quality of life of the affected patients. Oral health is an important public health issue . AccordiThe absence of obvious causative pathosis and the convoluted diagnostic criteria of BMS have left it problematic to diagnose clinically, and it is often a diagnosis of exclusion by the process of elimination ,9. The sExtraoral dryness has also been reported as a co-existing condition in BMS patients in older  and neweA systematic review was chosen as the method for conducting this review because this comprehensive and standard method is known to be reliable for summarizing existing evidence thoroughly and transparently, whereby the available evidence is identified, analyzed, and reported ,29. The It has been recommended to create a systematic review protocol and register it before the actual review phase ,29. To pThe PICO  process was used to develop the clinical review question and the search strategy . The intWe utilized a well-designed search strategy to minimize the risk of missing important studies and ensure a comprehensive and unbiased synthesis of available evidence. The literature search in Google Scholar, PubMed, Web of Science, COCHRANE Library, and EBSCOhost started on 18 October 2022 and was finalized on 14 November 2022. The searches through the databases were conducted in the same chronological order as listed. The advanced search was utilized if the function was available, i.e., for the case of PubMed with PubMed Advanced Search Builder and MeSH  terms, Web of Science with Advanced Search Query Builder in their Core Collection, COCHRANE Library with Advanced Search and MeSH, and EBSCOhost with their default Advanced Search option. EBSCOhost provides the option to search through specific databases that are included in the EBSCOhost database, namely, Academic Search Ultimate, CINAHL, eBook Collection, eBook Open Access Collection, Education Source, and MEDLINE, which were included in the EBSCOhost search.The search strategies in the selected databases were different in their techniques for how to narrow down and focus the search results regarding the utilization of Boolean operators and truncations. Boolean operators are used as conjunctions to combine or exclude keywords, with AND, OR, and NOT as the main Boolean operators in most databases. Truncations are used to shorten a word by including a “*” and will include any endings or spelling of that word, such as for the truncated word “comorbid*” which returns the results for the words comorbid, comorbidity, and comorbidities. Different combinations of these techniques were utilized. A supplementary manual search was also performed during January 2023 to include additional relevant studies.The number of studies to be identified in a systematic review is not standardized, and the number of studies depends on the research area and research question. However, it is recommended to identify and synthesize all available evidence of the research interest that meets the inclusion criteria regardless of the number . TherefoThe main target patient consists of women of pre- and postmenopausal age with BMS. Only studies with clearly defined characteristics of BMS were included. Given the lack of complete standardization in the diagnostic criteria for BMS, we decided to include various diagnostic criteria that have been utilized. The occurrence of other morbidities in the patient group was taken into consideration. The inclusion of comorbidity studies was deemed important as they may include extraoral dryness. The male population was included only when it was mentioned, and separate data were presented. The age means of the population groups were taken into consideration, and studies with an age mean of above 50 years old were included. Studies with an age mean of under 50 years old were excluded. Studies conducted with children, teens, and young adults were also excluded. The population groups included in this systematic review were, therefore, late “middle-aged adults” or “aged” including both females and males.Only human clinical studies were included, and animal studies and in vitro studies  related to BMS were excluded. Only quantitative studies published in English were included. Studies published in other languages were excluded, although no specific regions of the world were considered a limitation. Due to limited research in this area with only a few empirical studies, all available data were included.Only full-text published studies were searched and included. Abstract-only texts, such as conference abstracts, proceedings, editorials, preprints, or manuscripts, and other non-full text research journal studies were excluded. Books and documents were also excluded. Epidemiological studies within disease research for burning mouth syndrome were included. This included observational studies such as cohort studies, case–control studies, panel studies, surveys and questionnaires, and experimental studies such as randomized controlled trials.There was no limitation to the type of included reviews, and topical, systematic, narrative, scoping reviews and meta-analyses were also included in addition to the original research articles. Comparative studies with a BMS population and a control group were included. No limitation was introduced related to the type of the control group .Studies with BMS as the main topic were screened for relevancy for extraoral dryness. The primary outcome of this review was extraoral dryness in patients with BMS. Studies with data of little relevance were excluded. For example, study data not about the primary target topic of BMS were excluded, as well as data not referring to the prevalence or incidence of extraoral dryness within the study population. Studies with discrete quantitative data regarding the prevalence or incidence of extraoral dryness or the dichotomous outcomes of extraoral dryness within the BMS population were included. The search terms were tailored to the specific review question and included medical subject headings, free-text terms, and Boolean operators to refine the search. The search terms for the literature search were defined specifically to search for the population and outcome. Therefore, the search terms included BMS and different descriptors of outcomes to reflect the main outcome of this review focus, i.e., extraoral dryness. Both full terms and abbreviations were used, for example, for BMS. Many descriptions of the outcome were searched for to accommodate various forms of records in the literature, such as “Dry skin”, “Dryness”, “Xerosis”, “Dermatitis”, “Skin disease”, “comorbidity”, “association”, and “prevalence”. The two search terms “Xerosis” and “Dermatitis” were also included.Some databases require one to differentiate between the words in the search term so that the included words do not mix or blend. For example, the division of words provides the foundation of which words are searched for in a search term. This was carried out by using parentheses to divide the words in a search term. For example, the inclusion of the population and outcome of this review was formulated as (Burning mouth syndrome patients) AND (dryness). The dividers were used for search terms in all selected databases other than Google Scholar. This is because the Google Scholar database does not recognize parentheses as dividers.The search terms included many syntax techniques, such as Boolean operators and truncations. The search terms accommodated the differences between the selected databases and, as such, had different utilizations of Boolean operators and truncations. For example, the most common Boolean operator to include for finding synonyms or similar concepts is the usage of “OR”. The Boolean operator “OR” is usable in all selected databases, but one search term in Google Scholar also included an alternative symbol to represent “OR” by using “|”. The Boolean operator “OR”, as well as “AND”, was widely used in the literature search for all of the selected databases.It was highly relevant to find the words “comorbidity” and “patient” in many of their different endings, hence the usage of truncation in the search terms. The truncation of the words was represented as “comorbid*” and “patient*” in all selected databases other than Google Scholar. The exception of Google Scholar was made because the database does not recognize truncations, which was not a problem due to their automatic stemming of any complete word. Quotation marks were used to search for the exact relevant phrases. This function was used for all the selected databases. Various tools are available to help organize and manage systematic reviews. One of the assisting tools for conducting systematic reviews is Rayyan, which was used in its web-based version for this systematic review. The literature search results were easily transferrable to Rayyan, where independent reviewers could collaborate on screening and article selection, the discussion of conflicts, and resolving in addition to adding full texts and comments.The screening of titles and abstracts was conducted independently (“blind on” function in Rayyan) by both authors. The screening of articles started on 18 November 2022 and finished on 3 December 2022. Rayyan automatically screens for duplicates and recommends the removal of duplicates. Duplicate studies were therefore removed, and the titles and abstracts were screened against the set of eligibility criteria (inclusion/exclusion). Articles that met the criteria were then included or excluded. Any disagreements between the reviewers for inclusion or exclusion were thereafter resolved through discussions. As a backup to Rayyan, the Excel program was used. The entire process, including all articles, files, discussion notes, etc., was stored in a Microsoft Teams folder dedicated to this systematic review.The extraction of data from the included articles started on 4 December 2022 and finished on 13 February 2023. Full texts of all of the included studies were read for the data collection, and the extracted information was organized in a systematic format in Microsoft Excel. Following the registered review protocol and agreement between the authors, the main data points to extract were general information about the papers , the patient population (demographic information), study methodology, and the study outcomes.The data points for the study methodology were the design of the studies, the type of burning mouth syndrome reported, and the study participants. This includes whether the study used a control group, and additional information regarding the control group was also extracted, such as whether they were sex- and age-matched with the burning mouth syndrome patients. Additional relevant data were extracted based on the study design. For example, the length of follow-up and their details were collected if the study design was a cohort study. We also examined the description of the study participants, which included the number of participants and population groups, the sex of the participants, the mean and median age of the participants, and the diagnostic criteria for BMS.The data points for the study outcomes were the extraoral outcomes in the BMS patients and the outcomes for the control group if they were included in the study. All study outcomes regarding extraoral dryness were collected together with the information on how the outcome was assessed and measured. The definition of extraoral dryness in the studies was carefully considered, with the importance of an exact description such as “dry” or “dryness”. An exception was considered for skin problems where they were ambiguously described as rosacea, eczema, dry skin, and psoriasis. Other common prevalent comorbidities reported in the included studies were also noted.It is important to assess the quality of the included studies by assessing the risk of bias to ensure the integrity and validity of systematic reviews . Bias haFor the Quality Assessment of Case–Control Studies, the number of yes answers from 0 to 5 is considered poor, the number of yes answers from 6 to 9 is considered fair, and the number of yes answers from 10 to 12 is considered good. For the Quality Assessment Tool for Case Series Studies, the number of yes answers from 0 to 4 is considered poor, the number of yes answers from 5 to 7 is considered fair, and the number of yes answers with 8 or 9 is considered good. Any disagreement regarding the quality ratings was discussed between the authors, and agreement was reached. Studies with poor quality were excluded from further analysis. A good score rating indicates a low risk of bias and, therefore, valid study results; a fair score rating indicates not having sufficient bias to invalidate the study results, and a poor score rating indicates a significant risk of bias; therefore, the study should be excluded.A meta-analysis is to combine data from several studies for advanced statistical analyses . A prereWhen a meta-analysis is not feasible, several methods are available such as narrative synthesis, vote counting, thematic synthesis, and framework synthesis . The choThe execution of the protocol for this systematic review was successful. The standard steps of conducting a systematic review yielded presentable data. In the following, the PRISMA flow diagram for the literature search, a description of the included studies, a quality assessment of the included studies, and summarized data on characteristics and data values for the within- and between-group comparisons regarding the narrative synthesis are presented. A summary table of the extraoral dryness values presenting the calculated odds ratios and 95% confidence intervals, as well as an extraoral dryness prevalence diagram of the reported extraoral dryness values, are also demonstrated.The literature search yielded 284 studies from the electronic databases Google Scholar, PubMed, Web of Science, Cochrane Library, and EBSCOhost. A supplementary manual search yielded an additional 179 studies from the electronic databases Google Scholar and PubMed. The combination of the literature search and the supplementary manual search yielded a total of 463 studies. Following the elimination of duplicates, a total of 409 studies were obtained for screening and potential inclusion in the systematic review. The screening of titles and abstracts for eligibility based on the inclusion and exclusion criteria resulted in the exclusion of 267 studies and the inclusion of 142 studies for the retrieval of the full texts. Seven studies were not retrievable , but 135 full-text studies were collected and assessed based on the inclusion and exclusion criteria for eligibility. This step resulted in the exclusion of 126 studies. The basis for the exclusion was the language used being one other than English, irrelevant constructs such as the design and context, irrelevant data or outcomes, and an irrelevant target population. Following this step, nine studies remained eligible and were included in the next step of the data extraction and narrative synthesis. The PRISMA flow diagram is presented in Nine studies were included in this systematic review. The study IDs are presented as Study 1 by Grushka (1987) , Study 2Two types of study designs were identified in the included studies, whereby eight were case–control studies and one was a case series. Seven studies included a control group and presented data from both cases and controls. Five studies were carried out in European countries, three in North American countries, and one in a South American country.The total number of participants  varied between the studies and presented a range from 31 to 226 participants . The population consisted mostly of women. The sex between the participant groups of BMS patients and control groups was mostly equal because of the diagnostic criteria for the controls being sex-matched.The age of the participants between the participant groups was fairly consistent, as the diagnostic criteria of the controls were age-matched. The weighted mean age was calculated and ranged from 57.23 to 67.75 years . One study reported a median age of 60 rather than the mean. The background and lifestyles of the patients were not reported in any of the studies.The diagnostic criteria for burning mouth syndrome varied between the included studies. The most common symptom reported was xerostomia, which was reported in six studies. All included studies reported a variety of extraoral dryness in the participants. Other more common symptoms reported in at least three studies were gastrointestinal problems, dysgeusia, and insomnia. The other associated symptoms were less often reported and included dizziness, carcinophobia, and common mental illnesses.For details, please refer to the summary tables of the results presented in Conducting a quality assessment  with theThe quality assessment tool by the NHLBI  was utilQ1: Was the research question or objective in this paper clearly stated and appropriate? Q2: Was the study population clearly specified and defined? Q3: Did the authors include a sample size justification? Q4: Were the controls selected or recruited from the same or similar population that gave rise to the cases (including the same timeframe)? Q5: Were the definitions, inclusion and exclusion criteria, algorithms, or processes used to identify or select cases and controls valid, reliable, and implemented consistently across all study participants? Q6: Were the cases clearly defined and differentiated from the controls? Q7: If less than 100 percent of eligible cases and/or controls were selected for the study, were the cases and/or controls randomly selected from those eligible? Q8: Was there use of concurrent controls? Q9: Were the investigators able to confirm that the exposure/risk occurred prior to the development of the condition or event that defined a participant as a case? Q10: Were the measures of exposure/risk clearly defined, valid, reliable, and implemented consistently (including the same time period) across all study participants? Q11: Were the assessors of exposure/risk blinded to the case or control status of participants? Q12: Were key potential confounding variables measured and adjusted statistically in the analyses? If matching was used, did the investigators account for matching during the study analysis?The quality assessment tool by the NHLBI  was utilQ1: Was the study question or objective clearly stated? Q2: Was the study population clearly and fully described, including a case definition? Q3: Were the cases consecutive? Q4: Were the subjects comparable? Q5: Was the intervention clearly described? Q6: Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants? Q7: Was the length of follow-up adequate? Q8: Were the statistical methods well described? Q9: Were the results well described?The findings of this systematic review are presented in summary tables. The extraoral dryness extracted from the included articles was identified as dry eyes, skin problems, genital dryness, and dry lips. The odds ratio and 95% confidence intervals are reported in The reported extraoral dryness was summed according to the body region , and odds ratio and 95% confidence intervals were calculated if applicable. The most prevalent extraoral dryness in the BMS patients was located on the lips (54.8%), followed by the following order: in the eyes (38.5%), on the skin (32.1%), and in the genital area (17.8%). The objective of this systematic review was to identify and evaluate extraoral dryness in BMS. We hypothesized that dryness is not limited to intraoral dryness and can be found in other regions of the body. Our results confirmed this hypothesis, and the outcome showed the presence and distribution of extraoral dryness in BMS patients in the eyes, skin, lips, and genital area. In the following, the systematic review findings are discussed in detail.A noticeable finding came from the comparison between the oldest 1987)  and the   and theThe lack of a standardized clinical diagnosis could have implications for the reliability and validity of the results of the individual-included studies, as the differences between the diagnoses could potentially introduce bias as well as inconsistent study results. Improvements in standardizing clinical diagnosis would improve the accuracy of the conclusions and increase confidence in the results . In addiThe age group of BMS patients observed in the included studies (~57 to ~68 years) aligned with the typical age noted in BMS diagnostic criteria. We also identified that the majority of BMS patients were women. The age and sex characteristics of BMS hint at two main points: (1) age and body changes that could include the susceptibility to dry skin by the nature of decreased water content and overall drier skin  and (2) Collectively, the included studies reported the presence of extraoral dryness. The bodily locations of dryness included the eyes, lips, genital regions, and skin. However, the extent of extraoral dryness was less investigated or reported in the included studies. This might be due to the lack of a standard methodology for data collection from BMS outside the mouth or focusing on intraoral characteristics. Some of the included studies had reported these characteristics with various terminologies such as “associated symptoms for BMS patients” or “comparisons of general health between BMS patients and control groups”. Therefore, these categories were not accessible to explore further, and the outcomes were merely utilized to present the existence of associated symptoms rather than detailed characteristics. Except for one study (Study 8 ), none oOut of nine studies, dry eyes were reported in five studies, dry lips were reported in two studies, genital dryness was reported in two studies, and skin problems were reported in three studies. These findings point to the fact that a standard reporting scheme in BMS is lacking in including both the intraoral and extraoral characteristics of dryness. Considering the evidence found through this systematic review, it is proposed that dryness must be added to the armamentarium of BMS clinical data collection. Even though self-reporting is an acceptable form of data collection, similar to what was collected in Study 4 , the preDue to the lack of reported values for extraoral dryness in the included studies, the analysis was mainly limited to the description and presentation of the extracted characteristics. The outcome variables of the included studies were not sufficient to permit conducting a meta-analysis; therefore, we could only utilize analysis of the odds ratios for the occurrence of extraoral dryness in BMS patients and the control groups. Odds ratios are commonly used in epidemiology to address the strength of association between two variables ,61. The Extraoral dryness not only complicates the features of the disease and the management of BMS but can dramatically impact the quality of life in the affected patients. This was, in fact, the focus of one of the studies in this systematic review (Study 7 ) which eStudy 8  and StudRelated to regions where the extraoral dryness in BMS occurred, we identified dry eyes with the lowest odds, skin problems with odds that were in the middle of the spectrum, and genital dryness with the highest odds. Dry lips, however, did not have a comparator and, therefore, were not included in the analysis. Collectively, our findings show that BMS patients have higher odds of extraoral dryness and that the dryness occurs in different regions of the body, with the highest odds for the genital area. Although the occurrence odds of genital dryness are the highest, it is interesting to note that it has the lowest percent prevalence among BMS patients. This suggests that while genital dryness may occur more frequently compared to the other regions, it is not as commonly reported by a significant portion of BMS patients or this feature might not be commonly assessed by clinicians or professionals during clinical evaluation. Instead, symptoms such as dryness of the lips, eyes, or skin appear to be more prevalent. These findings emphasize the need for a comprehensive approach to address extraoral symptoms in BMS patients. Addressing dryness in the identified regions is crucial to offer help for subsiding and improving the overall quality of life for BMS patients. This finding is important in the clinical management of BMS patients, who are mainly treated for intraoral disturbances. We, therefore, draw attention to the extraoral symptoms, namely, extraoral dryness, that can be disturbing to patients.Potential mechanisms underlying extraoral dryness in BMS have not been investigated. Various hypotheses have emerged ,63 relatThe other associated symptoms that were reported by the included studies were not uniform. The most common associated symptom was xerostomia. Xerostomia ,68, or tOther examples of the most commonly reported symptoms are gastrointestinal problems, dysgeusia, and insomnia. Only one study reported the type of gastrointestinal problem as gastroesophageal reflux disease in Study 4 . Lamy etCandida species and BMS [Candidiasis was reported in Study 9 , which i and BMS .Taken together, the presence of various symptoms in BMS implies that the mechanisms underlying BMS might influence a broader spectrum than the intraoral cavity. Indeed, brain imaging studies have demonstrated structural and functional changes in BMS compared with healthy individuals . We specRegardless of the mechanism, the clinical value of extraoral symptoms is to urge healthcare professionals to develop more comprehensive diagnostic criteria and treatment approaches tailored to the specific needs of BMS patients. This will consequently help patients’ care, lowering the burden and enhancing quality of life.We conducted a systematic review to provide a comprehensive and unbiased synthesis of existing evidence on extraoral dryness in BMS. Systematic reviews have been reported to be valuable resources for evidence synthesis and, accordingly, for evidence-based decision-making and policy formulation . We, theSeveral limitations, however, are present. The inclusion of EBSCOhost resulted in several duplicate studies in the literature search phase. EBSCOhost has multiple databases, including MEDLINE, which is a large subset of PubMed. Language bias might have limited the included articles since only English-language studies were considered. Considering the high level of evidence that is often provided by randomized clinical trials, we only included case–control and case series studies, which might be susceptible to bias, which can impact result accuracy. These study designs are generally considered lower-quality evidence compared to randomized control trials and cohort studies, according to the evidence pyramid ,89. The Another limitation is related to extraoral dryness when it comes to the skin. Differences between the studies reporting skin problems with limited information about location and characteristics led to the consideration of dry skin as an overall patient complaint rather than a specific condition.Using narrative synthesis in a systematic review has drawbacks, including the increased risk of bias, limited data comparability, and a potential lack of transparency ,92. HereExtraoral dryness in BMS patients has been largely neglected. The findings from this systematic review indicated that extraoral dryness occurs in BMS patients with higher odds than non-BMS controls. The pattern of occurrence of extraoral dryness in different body regions indicated a potential systemic origin of dryness that expands beyond the intraoral cavity in BMS. The most prevalent sites were—from most to least—dry lips, dry eyes, dry skin, and dry genital areas. There is a clear need to include standardized methods to evaluate and document extraoral clinical manifestations of BMS, such as extraoral dryness. These manifestations can also be added to diagnosis criteria or accompanying symptoms to help clinicians better understand and manage BMS. This would, in turn, facilitate and enhance the quality of patient care. Currently, no definitive guideline exists for handling extraoral dryness in BMS. More research is also needed to understand the pathomechanisms underlying extraoral dryness in BMS, including exacerbating risk factors. This can be performed with the aid of preclinical and clinical studies. Campaigns for patient awareness and education about BMS and its accompanying symptoms seem useful for empowering patients and increasing their health literacy to report their symptoms to clinicians and seek advice for preventing or treating extraoral problems in BMS.


Timely delivery of high-quality cancer care to all patients is barely achieved in South Africa and many other low- and middle-income countries, mainly due to poor care coordination and access to care services. After health care visits, many patients leave facilities confused about their diagnosis, prognosis, options for treatment, and the next steps in their care continuum. They often find the health care system disempowering and inaccessible, thereby making access to health care services inequitable, with the resultant outcome of increased cancer mortality rates.The aim of this study is to propose a model for cancer care coordination interventions that can be used to guide and achieve coordinated access to lung cancer care in the selected public health care facilities in KwaZulu-Natal.This study will be conducted through a grounded theory design and an activity-based costing approach that will include health care providers, patients, and their caregivers. The study participants will be purposively selected, and a nonprobability sample will be selected based on characteristics, experiences of the health care providers, and the objectives of the study. With the study’s objectives in mind, communities in Durban and Pietermaritzburg were selected as study sites, for the study along with the 3 public health facilities that provide cancer diagnosis, treatment, and care in the province. The study involves a range of data collection techniques, namely, in-depth interviews, evidence synthesis reviews, and focus group discussions. A thematic and cost-benefit analysis will be used.This study receives support from the Multinational Lung Cancer Control Program. The study obtained ethics approval and gatekeeper permission from the University’s Ethics Committee and the KwaZulu-Natal Provincial Department of Health, as it is being conducted in health facilities in KwaZulu-Natal province. As of January 2023, we had enrolled 50 participants, both health care providers and patients. Dissemination activities will involve community and stakeholder dissemination meetings, publications in peer-reviewed journals, and presentations at regional and international conferences.This study will provide comprehensive data to inform and empower patients, professionals, policy architects, and related decision makers to manage and improve cancer care coordination. This unique intervention or model will address the multifactorial problem of cancer health disparities. If successful, this study will affect the design and implementation of coordination programs to promote optimal cancer care for underserved patients.DERR1-10.2196/34341 Cancer is increasingly becoming one of the leading public health problems globally -4. The WMedical care is error-prone even when it is delivered by a single provider; the opportunities for serious issues or difficulties escalate when multiple providers are involved -21. InheDespite the potential benefits of patient access to coordinated cancer care services -37, mostTo be comprehensive, cancer care must be coordinated between primary care providers and oncology specialists; however, achieving this has proven to be considerably challenging -21. UndeThis study aims to propose a model for cancer care coordination interventions that can be used to guide and achieve coordinated access to lung cancer care in the selected public health care facilities in KwaZulu-Natal. This will be carried out in 4 phases. The specific objectives are as follows:Phase 1: Assess the factors that affect access or delivery of coordinated lung cancer careTo identify health system barriers and key pillars affecting access to a coordinated lung cancer care continuum.To conduct a needs assessment to lung cancer care necessary for achieving coordinated care.Phase 2: Identify a model relative to cancer care coordination interventionsTo understand the scope of cancer care coordination interventions and services employed in low-and middle-income countries, in order to synthesize the existing evidence and identify the key model and its elements used to manage and improve cancer care coordination in these settings.To systematically analyze the available evidence on the identified model’s characteristics, outcomes, and effectiveness across the cancer care continuum in low-and middle-income countries.Phase 3: Identify key elements of the proposed modelTo explore what the primary functions of proposed model will be.To identify the roles and skill sets needed for proposing the key personnel required to implement the proposed model.To explore how the proposed model can be better integrated into the clinical care program.Phase 4: Costing of the proposed intervention modelTo conduct a costing exercise in order to determine the feasibility of developing and implementing the proposed model.The study will use a mixture of the grounded theory (GT) approach and an activity-based costing (ABC) approach. The central principle of GT is that the researcher’s theories about a topic are constructed based on their data . It is aDescribed as “the most comprehensive qualitative research methodology available” , this apThe ABC approach has 2 major elements: cost measures and performance measures. It is a methodology that measures the cost and performance of activities, resources, and cost objects . ResourcThe study will be conducted in the province of KwaZulu-Natal. This province has the second-largest economy in the country . The stuA geographical scoping and mapping of study clusters were done in each of the representative communities. In total, 40 out of 879 clusters were selected using probability proportional to population size sampling. Maps were used to identify the selected clusters along with their boundaries. This technical mapping exercise gave details of the location of the communities, population numbers, broad socioeconomic baseline characteristics of the communities, and resources available in the area, for example, clinics and hospitals, as well as other community social commons.We selected both clinics and hospitals to ensure that the sampled data have implications for the full spectrum of cancer care providers. Furthermore, all public hospitals with oncology units in KwaZulu-Natal  located in 2 cities will be recruited to participate in the study. These 3 participating health facilities were chosen on the basis that they are the only public hospitals offering oncology services in the province. Greys Hospital is located in Pietermaritzburg, whereas Inkosi Albert Luthuli Central Hospital and Addington Hospital are located in Durban.Research staff will be concerned about participants’ risks and also their risk of exposure during the collection of data. The study will be conducted in 4 phases.Phase 1 will be through in-depth interviews (IDIs), determining the barriers and pillars affecting coordinated lung cancer care. Accomplishments and ongoing barriers to engagement in medical care identiﬁed in phase 1 will be prioritized and translated into service plans that will deﬁne the speciﬁc action steps in the proposed model. Throughout this phase, participants’ demographic and clinical information will be collected.Phase 2 will focus on identifying an intervention aimed at assisting patients in overcoming barriers to coordinated lung cancer care in KwaZulu-Natal. Based on phase 1 results, the models will be reviewed and modified to meet the needs identified in phase 1. The following will be key areas of focus for the strategy during the scale-up process. This phase will be conducted in two steps: (1) a scoping review to identify relevant models from the literature and all their components for coordinated care and (2) a systematic review of the identified or proposed care coordination model’s effectiveness. The aim of this phase is to provide descriptions of a wide variety of care coordination interventions and thereafter propose an intervention or model. The search strategy will include PubMed, Scopus, Google Scholar, and Web science databases using keywords such as “cancer care coordination,” “coordination of care,” or “coordinated care.”Phase 3 will be through focus group discussion (FGD). The approach will facilitate awareness, understanding, and commitment to the optimal proposed cancer care coordination model among stakeholders and facilities involved. The goal is to identify key elements of the proposed model and obtain stakeholder support for coordinated referrals and linkage pathways for patients with cancer. This is anticipated to inform the development and implementation of a coordination model to improve lung cancer care.Lastly, in phase 4, a costing exercise will be conducted in order to determine the feasibility of the development and implementation of the proposed model; this may be useful in the move to certify and establish the intervention. This phase will be achieved through ABC.For this study, an IDI and FGD guide will be used to address the study objectives. These were developed for this study; however, the FGD guide will be informed by the IDIs’ and phase 2 responses. Both the IDIs and FGDs will be facilitated by the lead investigator, who is experienced in qualitative research. Lastly, the costing exercise will be informed by findings from the IDIs, FGDs, and reviews. The study population will encompass patients, health care providers drawn from the participating health care facilities, including surgeons, radio-oncologists, medical oncologists, general practitioners, chemotherapy nurse practitioners, and social workers, all with a coordination activity for patients with cancer, and also the caregivers with whom they interact as part of their care activity. Caregivers will be proxies for patients who are unable or not in a condition to answer the questions and participate in the study. A proxy is a person authorized to act on behalf of someone else .There are no exclusion criteria based on socioeconomic status, race, or sex, but patients with no lung cancer will be excluded. Phase 1: patients with lung cancer , caregivers, and health professionals in lung cancer careInclusion criteriaPatients diagnosed with lung cancer and are within the selected facilitiesCaregivers of patients who meet the inclusion criteria and are unable but willing to participate in the studyHealth professionals involved in the care and coordination of patients with cancerExclusion criteriaPatients diagnosed with other diseases other than lung cancerPatients receiving care for lung cancer, but outside the selected facilitiesCaregivers of patients with lung cancer who do not meet the inclusion criteriaProfessionals who are not involved in the care of patients with cancerPhase 2: systematic and scoping reviewInclusion criteriaStudies presenting evidence published in low- and middle-income countries (LMICs)Studies presenting evidence on cancer care coordinationStudies presenting evidence on coordination interventions or modelsStudies reported in EnglishExclusion criteriaStudies presenting evidence not published in LMICsStudies not presenting evidence on cancer care coordinationStudies presenting evidence on coordination interventions or modelsStudies reported in EnglishPhase 3: identified stakeholders to be involved in the designing of the proposed model for coordinationInclusion criteriaIdentified stakeholders to be involved in the designing of the proposed model for coordinationHealth professionals involved in the care activity of patients with cancerExclusion criteriaStakeholders with no coordination activity for patients with lung cancerHealth professionals with no role in the care activity of patients with cancerPhase 4: informed by phases 1, 2, and 3Eligible patients will be identified during their visits or hospitalization in the participating facilities and will be informed about the study in a personal interview and with the help of written consent documents. A modified version of snowballing will be used to identify caregivers of patients not eligible to participate due to health conditions. Patients will be asked to invite their primary caregivers to participate in the study. Health care providers involved in cancer care  will be approached directly by the research team to participate in a focus group or interview. Eligible potential participants will be invited by email or telephone to participate in the study. The invitation letter will include a general introduction to the research topic and the study’s aim and rationale. They will also be presented with information about their involvement, such as the anticipated length of the interview and where it would be conducted. General information about measures taken to guarantee confidentiality and informed consent will also be given.Purposive sampling will be used to identify the participants relevant to address the research objectives -55,60. PThe sample for FGDs will be purposive and will include individuals with characteristics of the overall population. Purposive sampling is often used when a researcher wants information-rich participants , in the For the IDIs, sampling saturation will be achieved when the same stories, themes, or codes and issues are emerging from the interviewees, and then a sufficient sample size will have been reached (saturation). We will take note of the importance of availability , willingness, and the ability to communicate experiences and opinions in an articulate, expressive, and reflective manner. It is anticipated that data saturation will be reached at 25 interviews for each category  of participants. For FGDs, and with support from the literature, the sample size will be between 7 and 12 participants to be effective .Bias can arise from the approach or instrument adopted for collecting or measuring data in a study . InformaCredibility is defined as the confidence that can be placed in the truth value of the research findings, which is essential in establishing whether or not the research findings represent plausible information drawn from the participants’ original data and is a correct interpretation of the participants’ original views . In thisThe study results will be based on the data generated through the thick description  of the phenomenon in order to enhance the transferability of the findings. The thick description will also include the context in which the study was carried out. Transferability, a concept that is comparable to generalizability in quantitative research, refers to the degree to which the results of qualitative research can be transferred to other settings with comparable contexts . ConfirmData analysis will follow a GT approach, a constant comparative analysis ,73. In GResults will be discussed until consensus between analysts is achieved. The construction process of these thematic categories and codes is both inductive and deductive because the development of themes and subthemes rests on both literature and emerging categories of empirical analysis ,74,77,78FGDs usually yield both qualitative and observational data where analyses can be demanding. For the discussion, thematic analysis, as the most common forms of analysis in qualitative research, will be used to analyze the data collected. It puts emphasis on, pinpoints, examines, and records patterns (or “themes”) within the data . AlthougThe study obtained ethics approval and gatekeeper permission from the University’s Ethics Committee (Ref: BREC/00002153/2020) and the KwaZulu-Natal Provincial Department of Health (NHRD Ref: KZ_202010_030), as the study is to be conducted in health facilities in KwaZulu-Natal province. Written permission has been further sought from the concerned authorities and authorities from the different study sites to gain access to the facilities.This study is anticipated to involve minimal risks. This means that the probability of harm or discomfort anticipated as a result of participation in the study is not greater than those ordinarily encountered in the daily lives of the participants. Adequate care will be taken to ensure the competence of the fieldworker for the study through continued educational sessions.Participation in this research project will contribute to the improvement of collective medical, palliative, and public health knowledge that will enable the design of interventions to strengthen care coordination for patients with lung cancer while strengthening the cancer care program. The study will also provide strategic and scientific information on the implications of lung cancer during the access, diagnosis, referral, and treatment processes.Informed consent is sought in writing from every potential participant prior to participating in the study. Both the English and isiZulu versions of the participant information sheet will be appended to the protocol. The informed consent forms comprise 2 sections: the participant information sheet and the informed consent. These are shared with each potential participant a day or 2 before data collection to allow them time to read and process the documents. Measures are taken to ensure that the respect, dignity, and freedom of each participant are honored in the study. To guarantee the anonymity of each participant, the names of respondents, their addresses, or other identifying information will not be included in the transcripts, but a unique identification number will be used. Further, participants will be assured of the confidentiality of all their information. Their rights to refuse to participate and to opt out of the study at any time will be emphasized.This study receives support from the Multinational Lung Cancer Control Program, which is funded by Bristol-Myers Squibb Foundation. The support is granted for the lifespan of the study, from June 2020 to March 2023. The study obtained ethics approval and gatekeeper permission from the University’s Ethics and KwaZulu-Natal Provincial Department of Health, as the study is being conducted in health facilities in KwaZulu-Natal province. As of January 2023, we enrolled 50 participants, both health care providers and patients. We started with data analysis of interviews with patients and their caregivers, saturation was reached at 21 interviews. We have concluded data collection and analysis of interviews with health care providers, and finalizing manuscript write-up. Once all the data are analyzed, the results will be consolidated into a coherent report for dissemination. In addition, manuscripts for all phases will be prepared for publication. A scoping review article emanating from results from phase 2 was published and is currently working on the next step which is a systematic review, assessing the effectiveness of the identified coordination model.Cancer is a complex condition that often requires multiple interventions provided by a variety of health professionals within the health care continuum -21. The There is a need to continuously review multilevel barriers  that threaten cancer care coordination across different settings and levels of clinical care to identify potential solutions for improving care. This study carries the promise of generating pertinent information for both policy makers and health care professionals. Decision makers will be provided with important information, concerning the proposed model designed with a costing exercise to determine the implementation viability. Once all the study phases are complete, the results will be consolidated into a coherent report for dissemination to key stakeholders and will also be presented in conferences and seminars. A technical report or policy brief is also anticipated from this study. A meeting of the relevant stakeholders will be organized, where the results will be presented and discussed. The thesis will be one of the outputs of this study, and this will be available in the University of KwaZulu-Natal library. The findings of the study will also be published in Department of Higher Education and Training accredited peer-reviewed journals.The results of this study may be biased toward those patients who proactively seek or positively respond to diagnostic and treatment referrals by the health care professionals at the lower levels of care. Since the participating hospitals and the community-level study sites are located within the 2 major cities in KwaZulu-Natal, the profiles of patients may not be fully reflective of the geographical spread of the province. In addition, the global pandemic has presented a variety of challenges, including physical, emotional, financial, and much more, the effects of which are only beginning to be felt . In our This study will provide comprehensive data to inform and empower patients, professionals, policy architects, and related decision makers to manage and improve cancer care coordination. This unique intervention will be designed to address the multifactorial problem of cancer health disparities. If successful, this study will help inform the design and implementation of coordination programs in LMICs to promote optimal cancer care for underserved patients.