|Year : 2019 | Volume
| Issue : 10 | Page : 1365-1371
Dentists' knowledge of chronic orofacial pain
EM Hadlaq1, H Khan2, AB Mubayrik1, NS Almuflehi3, H Mawardi4
1 Department of Oral Medicine and Diagnostic Sciences, King Saud University, College of Dentistry, Riyadh, Saudi Arabia
2 Ministry of Health, Riyadh, Saudi Arabia
3 Department of Periodontics and Community Dentistry, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
4 Department of Oral Diagnostic Sciences, King Abdulaziz University, Faculty of Dentistry, Jeddah, Saudi Arabia
|Date of Acceptance||27-May-2019|
|Date of Web Publication||14-Oct-2019|
Dr. E M Hadlaq
Department of Oral Medicine and Diagnostic Sciences, King Saud University, College of Dentistry, P.O. Box 60169, Riyadh 11545
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: Orofacial pain (OFP) is a unique group of dental conditions with focus on chronic nonodontogenic pain affecting mouth, jaws, and face. The aim of this study is to investigate the knowledge of dentists in Saudi Arabia toward OFP assessment. Materials and Methods: An English language questionnaire containing 20 close-ended questions was used to capture data. The questionnaire included diagnostic criteria and clinical symptoms and signs of various OFP conditions. It was distributed to general dental practitioners (GDP) and dental specialists in four major provinces in Saudi Arabia. Results: A total of 318 questionnaires were completed by 163 males and 155 females. Most participants were GDPs (193/318) and the remaining were specialists from different dental specialties. A majority of participants were not able to diagnose neuropathic OFP or neurovascular/vascular OFP conditions (33% and 28.6%, respectively). On the other hand, only 40.3% were confident enough to diagnose different types of temporomandibular disorders. The results also showed that graduates from non-Saudi programs had significantly higher self and knowledge assessment score (59.8% and 43.4%, respectively) compared with graduates from Saudi programs (39.9% and 22.6%, respectively). The dental specialists had higher self-assessment scores compared with GDPs (48% vs. 43.7%). Overall, there was a weak positive correlation between self-assessment and knowledge assessment (20.2%). Conclusion: This study demonstrates a higher OFP knowledge and confidence for dental specialists compared with GDPs. However, this difference does not necessarily translate into more competencies in clinical practice. Therefore, the implementation of OFP courses in dental schools' curricula may benefit future dentists and improve patients' care.
Keywords: Assessment, knowledge, orofacial pain, survey, temporomandibular disorders
|How to cite this article:|
Hadlaq E M, Khan H, Mubayrik A B, Almuflehi N S, Mawardi H. Dentists' knowledge of chronic orofacial pain. Niger J Clin Pract 2019;22:1365-71
| Introduction|| |
Orofacial pain (OFP) is a unique group of dental conditions with focus on prevention, evaluation, diagnosis, treatment, and rehabilitation of nonodontogenic disorders affecting the head and neck area. The American Academy of Orofacial Pain defines OFP as a group of disorders of different entities including temporomandibular joint disorders (TMJDs), masticatory musculoskeletal pain, cervical musculoskeletal pain, neurovascular pain, neuropathic pain, sleep disorders related to OFP, orofacial dystonias, headaches, intraoral, intracranial, extracranial, and systemic disorders which may cause OFP. The reported prevalence of various OFP symptoms ranges between 21% and 42%.,, Of all, symptomatic temporomandibular disorders (TMDs) have been reported in 7%–10% of the population, and the prevalence of persistent idiopathic facial pain ranges between 0.03%–2.1% and 0.03%–0.3% for trigeminal neuralgia.,,,,,,,, Other OFP conditions tend to be less frequent, yet observed in general population in several occasions.
As the annual reported new cases of OFP disorders internationally continue to increase, the role of dental practitioners is expected to expand in parallel and include management of such cases. To fulfill this task, the dental practitioner knowledge and understanding of OFP should be at an optimum level to provide standard of care to patients in need. In addition, pain in general is a subjective finding which requires comprehensive assessment with detailed patient history and clinical examination as mandatory practitioners' skills to serve the purpose of helping OFP patients. Reviewing the current literature, several studies reported less than average knowledge on OFP disorders among dental students., In addition, studies looking at dentists and dental specialists' knowledge reported similar results as well.,, To reach the highest level of patient care competencies, OFP should be included in dental schools' curricula as an integral component of the educational process across all schools. However, there is limited information on the level and depth of integrated OFP core courses provided to dental students today.,
The aim of this study is to investigate knowledge of dentists in Saudi Arabia toward OFP assessment.
| Materials and Methods|| |
A human research ethical approval was obtained through King Saud University – Faculty of Dentistry, Riyadh, Saudi Arabia. An English language questionnaire containing two sections with a total of 20 close-ended questions was developed. The first section of the questionnaire focused on sociodemographic and descriptive parameters including age, gender, dental specialty, dental experience, type of practice, and country of graduation. The second section asked questions on dentists' knowledge and perception toward OFP assessment in the form of 14 statements including diagnostic criteria and clinical signs and symptoms of various OFP conditions which fall under four domains of (1) temporomandibular joint and muscle disorders, (2) neurovascular pain, (3) neuropathic pain, and (4) psychogenic pain. The questionnaire was formulated based on previously conducted studies with modification, which was reviewed by five OFP specialists.,,, Prior to initiating the study, the questionnaire was validated by 10 private dental practitioners. Afterward, the study questionnaire was distributed to general dental practitioners (GDP) and dental specialists in four major provinces in Saudi Arabia: Riyadh, Makkah, Asir, and Eastern Province. Recruited participants were selected randomly to represent the Saudi dental community including governmental hospitals, large private dental practices (>10 dentists), and dental schools. To ensure participants' confidentiality, the study design was anonymous with no data linked to participants. In addition, there was no financial incentive for participants to complete the questionnaire.
Statistical analysis was performed using SPSS software (IBM SPSS Statistics, Version 22; Armonk, NY, USA; 2013). Descriptive analysis for age, gender, dental specialty, experience, type of practice, and country of graduation was expressed as frequencies. To analyze participants' knowledge, responses were scored as 1 for sufficient knowledge or 0 for insufficient knowledge. For the purpose of statistical analysis, the option of “I don't know” was considered as insufficient knowledge. Pearson's correlation analysis and T-test were used to analyze intergroup correlations and differences. Statistical significance for all analysis was set at P < 0.05.
| Results|| |
This study was conducted from January 2017 to January 2018. A total of 318 questionnaires were completed by 163 males (51.2%) and 155 females (48.8%). More than half of the participants (52.2%) were below the age of 30 years. Most of participants were GDPs (193/318), and the remaining were specialists from different dental specialties. Overall, 72.9% (232/318) had completed predoctoral or postdoctoral programs in Saudi Arabia, and 71.1% (228/318) had an occupational experience for less than 10 years. Study participants were currently working at academic institutes (27%), governmental sectors (37.7%), private practices (22.3%), or a combination of more than one. Details of participants' demographics can be found in [Figure 1].
Self and knowledge assessment
A majority of participants (79.6%) reported the ability to differentiate between odontogenic and nonodontogenic pain. However, only 40.3% were confident to diagnose different types of TMDs. On the other hand, a majority of participants were not able to diagnose neuropathic OFP or neurovascular/vascular OFP conditions (62% and 63.2%, respectively) [Table 1]. To assess participants' knowledge, all GDPs and specialists were asked 10 questions on common TMD and OFP disorders. Participants demonstrated low knowledge level in most of the questions with more than 70% incorrect answers. Out of 10 questions, only 2 questions were answered correctly by more than 60% of participants. In addition, study participants disagreed with expert's responses on multiple questions. Detailed responses are listed in [Table 2].
To analyze demographic, self-assessment, and knowledge characteristics, independent t-test within groups was applied. Self-assessment in males was significantly higher than females (48.8% vs. 41.8%; P = 0.049). However, no significant difference was reported between males (35.3%) and females (37.2%) in their knowledge assessment. In addition, graduates from non-Saudi programs had significantly higher self and knowledge assessment scores (59.8% and 43.4%, respectively) compared with graduates from Saudi programs (39.9% and 22.6%, respectively). On the other hand, dental specialists had higher self-assessment scores compared with GDPs (48% vs. 43.7%), which was statistically insignificant. In addition, GDP scored 33.3% in overall knowledge assessment (P = 0.001) compared with specialists (48.9%). In terms of type of practice, age, or experience, no statistical significant differences were reported within groups for self or knowledge assessments [Table 3].
|Table 3: Analysis of self-assessment and knowledge assessment in subgroups|
Click here to view
To evaluate the relationship between self and knowledge assessment, Pearson's correlation analysis was conducted. Overall, there was a weak positive correlation between self-assessment and knowledge assessment (20.2%) mainly for specialists compared with GDPs (26.1% vs. 12.7%). Accounting for the country of graduation, graduates from non-Saudi schools had significant correlation between self and knowledge assessment (20.1%) compared with Saudi graduates (11.9%) although both had below average scores. No significant correlation between self-assessment and knowledge assessment was noted within all other demographic parameters [Table 4].
|Table 4: Correlation coefficient between self-assessment and knowledge assessment|
Click here to view
| Discussion|| |
Acute and chronic OFP disorders affect 7%–10% of adults and can reach up to 50% in elderly population with variable severities. In Saudi Arabia, the reported prevalence of TMJDs ranges between 21% and 34% with no available data as of today for other OFP disorders. Patients typically present with a wide range of symptoms including but not limited to swelling and limitation in TMJ movements, pain of various qualities and intensities, and various types of headaches. Management approaches include patient education, behavioral modification, physical exercises, occlusal splint, and pharmacological treatments. More severe and advanced cases may require irreversible surgical intervention such as arterial decompression for trigeminal neuralgia. Considering pain as the most frequent complain reported by patients, GDPs and dental specialists are expected to have the level of knowledge and clinical skills needed to identify the cause followed by best practice management approach to address patient's chief complaint and relief symptoms. This study aimed to test the level of OFP knowledge and confidence among GDPs and dental specialists in Saudi Arabia.
Patients with persistent OFP disorder may seek medical help and visit multiple clinicians prior to referral to a healthcare provider with more advanced expertise in OFP. Hence, a good understanding of pain types and other associated symptoms is critical for dental professionals as they are at the forefront of patients in need for treatment. The current data demonstrated overall competencies of dentists in Saudi Arabia to differentiate between odontogenic and nonodontogenic pain. However, their abilities to identify the designated disorder category followed by treatment are still questionable. In addition, basic OFP disorders' knowledge such as trigeminal neuralgia and psychogenic pain was also below expectations for most participants. It is universally accepted in dental communities that patients with neuropathic or neurovascular pain are mostly challenging, not easy to manage, and impose a burden on healthcare services. As such, lack of knowledge and risk of medical errors may explain dentists' hesitation to manage similar cases. Therefore, patients with OFP disorders typically go through multiple referrals and delayed treatment, which impact the overall cost of national healthcare, patient recovery, and rehabilitation.
No gender or age differences which could potentially influence the results were noted. In contrary, comparing dental specialists from different specialties with GDPs, the former demonstrated more confidence in OFP knowledge. However, this finding did not translate into true and/or better clinical competencies. Similar results were reported by Al-Khotani et al. when comparing the knowledge of dental professionals in Saudi Arabia to their Swedish counterparts which was significantly less. This finding was related to gaps in knowledge in the Saudi dental educational system. Other studies reported different results in terms of knowledge levels between GDPs and dental specialists.,, This finding raises concerns on overall healthcare service delivery and patient's safety as accurate diagnoses may not be reached for most of these cases. This is despite the importance of early detection of OFP disorders to control patient symptoms and attempt to prevent the risk of the associated psychosocial and behavioral changes that follow chronic pain syndromes.
To better understand the reasons behind deficiencies in management of OFP disorders, several studies investigated the knowledge and attitude of dental students and compared them with dentists with more clinical experience using research methods adopted from nursing communities surveys and reported gaps in knowledge., In addition, deficiencies in OFP knowledge and clinical competencies among GDPs and dental hygienists were also reported emphasizing on the importance of well-structured courses within the dental school curricula. To close these gaps, these studies emphasized on the importance of customizing undergraduate programs and continuing education courses on OFP with focus on proper evaluation and management approaches for patients in need. In a study by Watt-Watson et al., health sciences undergraduate students received a 1-week intensive course on pain with pre- and posttest of their knowledge. A significant improvement in pain knowledge was reported among students, which supported the implementation of such short courses in the dental curricula. A cross-sectional survey at Case Western Reserve University – School of Dental Medicine reported improvement in fourth-year dental student knowledge following implementation of OFP and TMD course in the Fall semester of the third-year curriculum. Recent surveys of orthodontic practices revealed significant discrepancies between respondents and current literature on TMJDs. All these reported data have shed some light on shortcomings of the present dental curriculum.
To date, minimal literature is available on OFP knowledge of dentists in Saudi Arabia. Looking at the current data, several reasons may explain the discrepancy between self and knowledge assessment. A majority of study participants are graduates from Saudi local programs. Dentists from non-Saudi programs demonstrated higher self and knowledge assessment and these could reflect the difference in curricula contents compared to elsewhere. Until recently, topics on OFP (definition, mechanisms, categories, and management) were not included in the predoctoral curriculums across Saudi Arabia. As a result, dental students' exposure to this particular discipline of dentistry has been limited to random and unfocused resources from other disciplines such as prosthodontics and orthodontics, which may have created this gap in dental knowledge. Implementation of OFP courses in the dental school curricula following the International Association for the Study of Pain recommendation may aid in graduating students advancing knowledge to adapt to the continuously evolving world of pain. To prevent this gap in knowledge, Malmo University incorporated OFP courses in the dental school curriculum and demonstrated improved dental students' knowledge to support this approach. In addition to dental schools' curricula, the short working experience of participants could also be considered as a factor with impact on OFP best practice as a majority had less than 10 years of practice experience. Compared to other professions, dentistry is a unique career in a sense as graduates from dental programs learn the main basics and skill sets needed to practice as a competent dentist during dental years. However, due to time limitations and number of cases treated, graduating dentists may not gain the highest level of experience and exposure to various dental cases with potential challenge on dental providers. Following completion of dental school, and as they start their dental career, the levels of graduates' hand skill gradually improve over time.
Following completion of an undergraduate program, available resources for dentists' development in OFP become considerably limited to continuous education courses or courses as part of graduate programs of other disciplines. Other options include enrollment in advanced programs offered in OFP, which comes with downside of additional cost and time. OFP continuous education courses have demonstrated significant benefit in improving practitioner's skills and clinical judgment as reported in the literature. A study by Lindfors et al. reported increase in proper history taking from patients and better clinical routine for management of OFP patients using jaw exercises and pharmacological approach by general practitioners after receiving an educational course including examination templates and case discussions. Therefore, the need for continuous education courses offered at more convenient times and lower costs is key to reach out to a large number of dental practitioners and improve standard of care.
One of the challenges in the field of OFP is the disparity in available classification systems. As of today, four main classification systems are being used in the daily practice which are the International Association for the Study of Pain, International Classification of Headache Disorders, the American Academy of Orofacial Pain, and the Research Diagnostic Criteria for Temporomandibular Disorders (RDCTD). Of all, RDCTD is the one with focus on biopsychosocial components where the other three focus on biomedical aspects. The lack of a single, robust classification system may complicate delivery of knowledge and focused education to dental students and dentists. In addition, it does not provide a unified language for dental practitioner communication which may impact patient care and research.
This study has several limitations. First, study participants were limited to four main provinces in Saudi Arabia. Even with these provinces of Riyadh, Makkah, Asir, and Eastern Province considered as the largest and most divers in the country, it will be valuable to survey other provinces and combine their knowledge data with this study to check for any differences. This will provide a more inclusive database of dentists for future governmental plans to improve national health care. Second, recruited participants were not randomly selected from different dental sectors within each province. However, the study sample was equally distributed over academic institutes, governmental sectors, and private practices to partially compensate for any bias. Third, this study was of a cross-sectional design. Longitudinal study approach will help in assessing individual career development and knowledge progression through the years which would be optimal and informative for governmental use.
| Conclusion|| |
The diversity of OFP conditions continues to be a challenge for dental practitioners. Knowledge and clinical judgment are two key pillars in managing patients at any particular time. This study analyzed advanced OFP knowledge and confidence in dental specialists and GDPs. The superior self-assessment and knowledge base noted in the dental specialist group did not necessarily translate into better competencies in clinical practice. As such, higher weight of OFP courses should be included in dental schools curricula to train future dentists. In addition, well-designed educational programs should be planned to target dental specialists and GDPs with better hands-on experience in Saudi Arabia to ensure delivery of patient care at highest international standards. In addition, there is a critical need for higher number of OFP specialists to serve the population of Saudi Arabia.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lipton JA, Ship JA, Larach-Robinson D. Estimated prevalence and distribution of reported orofacial pain in the United States. J Am Dent Assoc 1993;124:115-21.
Chung JW, Kim JH, Kim HD, Kho HS, Kim YK, Chung SC. Chronic orofacial pain among Korean elders: Prevalence, and impact using the graded chronic pain scale. Pain 2004;112:164-70.
Oberoi SS, Hiremath SS, Yashoda R, Marya C, Rekhi A. Prevalence of various orofacial pain symptoms and their overall impact on quality of life in a tertiary care hospital in India. J Maxillofac Oral Surg 2014;13:533-8.
Ostensjo V, Moen K, Storesund T, Rosen A. Prevalence of painful temporomandibular disorders and correlation to lifestyle factors among adolescents in Norway. Pain Res Manag 2017;2017:2164825.
Salonen L, Hellden L, Carlsson GE. Prevalence of signs and symptoms of dysfunction in the masticatory system: An epidemiologic study in an adult Swedish population. J Craniomandib Disord 1990;4:241-50.
Schiffman EL, Fricton JR, Haley DP, Shapiro BL. The prevalence and treatment needs of subjects with temporomandibular disorders. J Am Dent Assoc 1990;120:295-303.
Sanders AE, Slade GD. Gender modifies effect of perceived stress on orofacial pain symptoms: National Survey of Adult Oral Health. J Orofac Pain 2011;25:317-26.
Ram S, Teruel A, Kumar SK, Clark G. Clinical characteristics and diagnosis of atypical odontalgia: Implications for dentists. J Am Dent Assoc 2009;140:223-8.
Mueller D, Obermann M, Yoon MS, Poitz F, Hansen N, Slomke MA, et al
. Prevalence of trigeminal neuralgia and persistent idiopathic facial pain: A population-based study. Cephalalgia 2011;31:1542-8.
El-Tallawy HN, Farghaly WM, Rageh TA, Shehata GA, Abdel Hakeem MN, Badry R, et al
. Prevalence of trigeminal neuralgia in Al-Quseir city (Red sea Governorate), Egypt. Clin Neurol Neurosurg 2013;115:1792-4.
Nixdorf DR, Moana-Filho EJ, Law AS, McGuire LA, Hodges JS, John MT. Frequency of persistent tooth pain after root canal therapy: A systematic review and meta-analysis. J Endod 2010;36:224-30.
Polycarpou N, Ng YL, Canavan D, Moles DR, Gulabivala K. Prevalence of persistent pain after endodontic treatment and factors affecting its occurrence in cases with complete radiographic healing. Int Endod J 2005;38:169-78.
Borromeo GL, Trinca J. Understanding of basic concepts of orofacial pain among dental students and a cohort of general dentists. Pain Med 2012;13:631-9.
Alonso AA, Heima M, Lang LA, Teich ST. Dental students' perceived level of competence in orofacial pain. J Dent Educ 2014;78:1379-87.
Rezaei F, Sharifi R, Shahrezaee HR, Mozaffari HR. Knowledge about chronic orofacial pain among general dentists of kermanshah, Iran. Open Dent J 2017;11:221-9.
Al-Khotani A, Naimi-Akbar A, Bjornsson O, Christidis N, Alstergren P. Professional knowledge among Swedish and Saudi healthcare practitioners regarding oro-facial pain in children and adolescents. J Oral Rehabil 2016;43:1-9.
Al-Khotani A, Bjornsson O, Naimi-Akbar A, Christidis N, Alstergren P. Study on self-assessment regarding knowledge of temporomandibular disorders in children/adolescents by Swedish and Saudi Arabian dentists. Acta Odontol Scand 2015;73:522-9.
Klasser GD, Gremillion HA. Past, present, and future of predoctoral dental education in orofacial pain and TMDs: A Call for interprofessionall education. J Dent Educ 2013;77:395-400.
Steenks MH. The gap between dental education and clinical treatment in temporomandibular disorders and orofacial pain. J Oral Rehabil 2007;34:475-7.
Sharav Y, Benoliel R. Orofacial Pain and Headache. Edinburgh, New York: Mosby; 2008.
Okeson JP, Bell WE. Bell's Orofacial Pains: The Clinical Management of Orofacial Pain. 6th
ed. Chicago: Quintessence Pub. Co.; 2005.
Feteih RM. Signs and symptoms of temporomandibular disorders and oral parafunctions in urban Saudi Arabian adolescents: A research report. Head Face Med 2006;2:25.
Leresche L, Truelove EL, Dworkin SF. Temporomandibular disorders – A survey of dentists knowledge and beliefs. J Am Dent Assoc 1993;124:90-4, 97-106.
Aggarwal VR, Joughin A, Zakrzewska JM, Crawford FJ, Tickle M. Dentists' and specialists' knowledge of chronic orofacial pain: Results from a continuing professional development survey. Prim Dent Care 2011;18:41-4.
Glaros AG, Glass EG, McLaughlin L. Knowledge and beliefs of dentists regarding temporomandibular disorders and chronic pain. J Orofac Pain 1994;8:216-22.
Watt-Watson J, Hunter J, Pennefather P, Librach L, Raman-Wilms L, Schreiber M, et al
. An integrated undergraduate pain curriculum, based on IASP curricula, for six health science faculties. Pain 2004;110:140-8.
McCaffery M, Ferrell BR. Nurses' knowledge of pain assessment and management: How much progress have we made? J Pain Symptom Manag 1997;14:175-88.
Gnauck M, Magnusson T, Ekberg E. Knowledge and competence in temporomandibular disorders among Swedish general dental practitioners and dental hygienists. Acta Odontol Scand 2017;75:429-36.
Just JK, Perry HT, Greene CS. Treating TM disorders: A survey on diagnosis, etiology and management. J Am Dent Assoc 1991;122:55-60.
Vallon D, Nilner M. Undergraduates' and graduates' perception of achieved competencies in temporomandibular disorders and orofacial pain in a problem-based dental curriculum in Sweden. Eur J Dent Educ 2009;13:240-7.
Lindfors E, Tegelberg A, Magnusson T, Ernberg M. Treatment of temporomandibular disorders – Knowledge, attitudes and clinical experience among general practising dentists in Sweden. Acta Odontol Scand 2016;74:460-5.
Renton T, Durham J, Aggarwal VR. The classification and differential diagnosis of orofacial pain. Expert Rev Neurother 2012;12:569-76.
[Table 1], [Table 2], [Table 3], [Table 4]