Comparative analysis of education, awareness, and knowledge of dentists and physical therapists in the treatment of temporomandibular disorders

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CRANIO® The Journal of Craniomandibular & Sleep Practice

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Comparative analysis of education, awareness, and knowledge of dentists and physical therapists in the treatment of temporomandibular disorders Junhel Dalanon,, Raul B. Ugalde,, Leonedes D. Catibod,, John Michael L Macaso,, Kazuo Okura, & Yoshizo Matsuka, To cite this article: Junhel Dalanon,, Raul B. Ugalde,, Leonedes D. Catibod,, John Michael L Macaso,, Kazuo Okura, & Yoshizo Matsuka, (2020): Comparative analysis of education, awareness, and knowledge of dentists and physical therapists in the treatment of temporomandibular disorders, CRANIO®, DOI: 10.1080/08869634.2020.1786332 To link to this article: https://doi.org/10.1080/08869634.2020.1786332

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CRANIO : THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE https://doi.org/10.1080/08869634.2020.1786332

EDUCATION

Comparative analysis of education, awareness, and knowledge of dentists and physical therapists in the treatment of temporomandibular disorders Junhel Dalanon, DMD, MAT, EdD a,b, Raul B. Ugalde, PTRP, DPTc,d, Leonedes D. Catibod, PTRP, MScSPc, John Michael L Macaso, PTRP, MScSPc, Kazuo Okura, DDS, PhDb and Yoshizo Matsuka, DDS, PhD b a

School of Dentistry, Southwestern University PHINMA, Cebu, Philippines; bDepartment of Stomatognathic Function and Occlusal Reconstruction, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan; cCollege of Rehabilitative Sciences, Southwestern University PHINMA, Cebu, Philippines; dDepartment of Physical Therapy, Loma Linda University School of Allied Health Professions, Loma Linda, CA, USA ABSTRACT

KEYWORDS

Objective: To compare the education, awareness, and knowledge of Filipino dentists and physical therapists (PTs) in terms of temporomandibular disorders (TMDs). Methods: A 30-item structured online questionnaire was given to recruited PTs and dentists from January 2019 to December 2019. Welch’s t-test was used to compare the education, awareness, and knowledge of health professionals. Brown-Forsythe and Welch ANOVA with Games-Howell post hoc were used to compare test scores across the knowledge components. Results: Of the 620 professionals, 46.67% dentists and 6.38% PTs had training in TMD. Professionals with more years of experience and who had previous TMD training were more aware of TMD management. Both dentists and PTs showed the lowest knowledge in TMD pathophysiology. Discussion: This study showed high awareness but low education and knowledge of Filipino dentists and PTs in TMD management. Improving the educational curriculum and refining the training given by accredited professional organizations is suggested.

Temporomandibular disorders; dentists; physical therapists; disease awareness; knowledge assessment

Introduction Clinical problems that involve the temporomandibular joint, adjacent hard and soft tissues, and the muscles of mastication, or an assortment of these problems are called temporomandibular disorders (TMD) [1]. Discomfort in the masticatory muscles, diminished movement of the mandible, pain in the temporoman­ dibular joint (TMJ), accompanying noise upon use, and widespread pain in the surrounding muscles and fascia of the jaw are some of the symptoms of TMD [2,3]. The work capability and socialization decrease in a person suffering from TMD, which is the most widespread long-lasting orofacial pain disorder. More than 5% of the population is considered to be suffering from TMD [4], and 6–12% suffer from clinical indications of TMD [5]. Notwithstanding the 10% who suffer from TMD pain, only 3.6–7% will seek medical or dental help for the treatment of this condition. These patients only seek help when the symptoms are too severe to handle [6]. Classification of the different categories of TMD is based on the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) [7]. According to the DC/TMD,

CONTACT Junhel Dalanon © 2020 Taylor & Francis Group, LLC

[email protected]

these disorders can be classified into simple or complex and acute or chronic. Persistence and accompanying cog­ nitive, behavioral, and psychosocial factors are linked with complex TMD. The chronicity of TMD worsens the prog­ nosis of TMD, and interprofessional treatment is princi­ pally vital. A combination of psychologists, speech pathologists, primary care physicians, physical therapists (PTs), and dentists are usually involved in the treatment of TMD [8]. Behavioral therapy, physical therapy (PT), and occlusal appliances are proven to be effective treatment modalities in TMD. Active or passive techniques may be used by PTs in correcting the range of motion, muscle coordination, strength, and relaxation. Ultrasound, elec­ trotherapy, low-level laser therapy, or iontophoresis may also be used as specialized PT for TMD [9]. Despite the weak evidence, PT is a proven treatment option for TMD [10]. Prevention of degenerative factors on the TMJ can also be accomplished using occlusal splints. Determining the correct occlusal device requires consultation from a dentist [11]. The pain caused by TMD may also be treated with the use of several classes of medications and mainly based on expert opinion. Non-steroidal anti-

School of Dentistry, Southwestern University PHINMA.,Cebu City, Central Visayas 6000, Philippines

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inflammatory drugs (NSAIDs), muscle relaxants, and tri­ cyclic antidepressants are just some of the drugs used for the pharmacologic management of TMD [12–14]. In the Philippines, early diagnosis and treatment are done by dentists. Although orofacial pain is not a recognized dental specialty in the country, prostho­ dontists and orthodontists fabricate occlusal splints. Additionally, oral and maxillofacial surgeons may per­ form surgery to correct the TMJ in rare instances [15]. Formal dental education in the Philippines started in 1903, and the Philippine Dental Association (PDA) occasionally includes TMD management in confer­ ences. It is not until the first semester of the second year of dental education that TMD is introduced. From then on, TMJ and TMD are always discussed in most courses, e.g., Anatomy, Oral Physiology and Occlusion, Prosthodontics, Orthodontics, Roentgenology, Oral Surgery, and others [16]. It was only on July 13 2016, when the first temporomandibular disorder and orofa­ cial pain program was initiated by the Orofacial Pain Association of the Philippines (OPAP) at the University of the Philippines. Currently, the OPAP training pro­ gram is the only university-based program with a curriculum framed by the International Association for the Study of Pain (IASP) [17]. In contrast, the diagnosis and treatment of TMD in the Filipino Bachelor of Physical Therapy (BSPT) cur­ riculum has not been well developed. It was only in the mid-1940s that PT began to be practiced in the Philippines. There are currently only four schools that offer post-professional degrees in PT, but none of them are related to the treatment of TMD. Of the 27,000 registered PTs in the country since 1969, there are only 4470 currently practicing their profession [18]. The concepts of the TMJ may be introduced as early as the first semester of the first year of PT educa­ tion. TMD may be discussed in lectures or demonstra­ tions in courses like Anatomy, Applied Anatomy and Kinesiology, and Internship [19]. The Philippine Physical Therapist Association (PPTA) is the accre­ dited professional organization of the PT in the Philippines and occasionally renders seminars, although the TMJ and TMD are rarely the topics of interest [20]. The education, awareness, and knowledge of the health professionals implicated in the treatment of TMD are important in the success of dealing with the condition. Currently, and to the knowledge of the authors, there has been no record on the competence of Filipino dentists and PTs in dealing with TMD. Therefore, the objective of this study was to compare the education, awareness, and knowledge of dentists and PTs in the Philippines in terms of TMD.

Materials and methods Study design This study used a cross-sectional comparative design sanctioned by the Institutional Review Board of Southwestern University PHINMA. Recruitment Mixed methods were used to recruit participants for the study. A total of 620 health professionals were purpo­ sively sampled, of whom, 470 were PTs, and 150 were dentists. Health professionals who are members of an Accredited Professional Organization (APO) in the country and possess a professional license from the Professional Regulation Commission (PRC) were consid­ ered in this study. The PDA and the PPTA are the APO of the Filipino dentists and the PTs, respectively; being a member of these organizations was part of the inclusion criteria. From January 2019 to December 2019, invita­ tions were sent by post, email, and personal conversa­ tions. Prior to the first part of the questionnaire, a statement explaining the purpose and implications of the study was given. It was also explicitly stated that participation of the survey was voluntary and that the participant could choose to stop responding at any point in the process. Electronic signatures were used to verify the consent of the participants. Questionnaire A 30-item, structured online questionnaire was created using Google Forms. The survey form contained 5 ques­ tions pertaining to demographics and education, 5 on awareness of TMD, and 20 on knowledge of dentists and PTs regarding TMD. The knowledge section questions of the online form were categorized into 5 queries on the epidemiology of TMD, 5 on the pathophysiology of TMD, 5 on clinical features of TMD, and 5 on treatment as well as diagnosis of TMD. These questions were based on the TMD Fact Sheet of the International Association for the Study of Pain. Completing the survey was pro­ jected to last for about 10–20 minutes, on average. Data analysis The association between the demographics and educa­ tion-related information was analyzed using Fisher’s exact test at a 95% confidence interval. The data on TMD awareness were compared using unpaired t-tests with Welch correction. A similar statistical strategy was used on the figures concerning TMD knowledge per profession, training, and professional experience. TMD

CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE

knowledge per component was analyzed using a BrownForsythe and Welch analysis of variance (ANOVA) test with Games-Howell multiple comparisons test. Data were presented as mean ± SEM, unless otherwise speci­ fied. All descriptive and inferential statistics were done using GraphPad Prism 8.

Results Demographics and education of the participants All 620 (100%) health professionals completed the questionnaire. Of this number, 470 were PTs, and 150 were dentists. A correlation (p < 0.001) between highest educational attainment and profession was found, where 60% of dentists were Doctor of Dental Medicine (DMD or DDM) degree holders and 40% were Masters or Ph.D. degree holders. In contrast, 93.62% of the PTs were holders of the BSPT or a Doctor of Physical Therapy (DPT) degree, while only 6.38% had graduate degrees (Figure 1a). Due to the Philippine Qualifications Framework (PQF), which was derived from the ASEAN Qualifications Framework (AQF), all baccalaureate degrees are

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considered as Level 6. This includes professional doctorates like the DDM or DMD and the DPT. On the contrary, professional doctorates like the Ph.D. and Ed.D. are considered as Level 8 or doc­ toral degrees [15]. In terms of gender, the majority of the participants were females. The dentists were comprised of 60% females and 40% males, while the PTs were composed of 59.57% females and 40.43% males. Through Fisher’s exact test, there was no association found between gen­ der and profession (p > 0.999) (Figure 1b). The test for the relationship between professional experience and profession yielded significance (p < 0.001). About 70 dentists (46.67%) had more than 10 years of experience, and 80 (53.33%) had 1–10 years of experience. On the other hand, only 20 of the PTs (4.26%) had more than 10 years’ experience. A preponderance of 450 of these PTs (95.74%) only had 1–10 years of experience in their profession (Figure 1c). Eighty of the dentists (53.33%) had no TMD training, while 70 (46.67%) had formal or other training of some sort in TMD management. On the contrary, 440 of the PTs (93.62%) had no training in TMD, and only 30

Figure 1. Association of profession with (A) highest educational attainment, (B) gender, (C) years of professional experience, and (D) TMD training in dentists and PTs. D = dentists; PT = physical therapists; B = bachelor’s degree (e.g. DMD, BSPT, DPT); G = graduate degree; F = female; M = male; NT = no training; T = with training; TMD = temporomandibular disorder. Note: ***< 0.001 calculated using Fisher’s exact test.

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(6.38%) had training. The acquisition of TMD training was found to have a connection with the profession (p < 0.001) (Figure 1d). Curricular and interprofessional management awareness concerning TMD The TMD awareness of the dentists and PTs were com­ parable. The percentage of perceived awareness on TMD was 89.3 ± 1.2, while it was slightly higher at 89.4 ± 0.7 for PTs. There was no statistical difference between the TMD awareness of each profession, t (257) = 0.02, p = 0.983 (Figure 2a). However, professionals who had undergone TMD training were found to have more awareness relating to TMD, t(261.6) = 7.6, p < 0.001. The percentage of perceived awareness of trained professionals was 96.0 ± 0.8, while it was a mere 88.1 ± 0.7 for the untrained health providers (Figure 2b). Interestingly, the length of time pertaining to profes­ sional experience also affects TMD awareness. The health professionals who had extensive experience in their respective fields had a greater awareness of TMD, t(207.3) = 6.6, p < 0.001. The perceived awareness per­ centage of dentists and PTs who had worked for 1–10 years was 88.3 ± 0.7, while, for those with more than 10 years of professional experience, it was 95.6 ± 0.9 (Figure 2c).

Knowledge of TMD by profession, training, and professional experience According to the 20-item assessment of knowledge of TMD, dentists had a significantly higher score than PTs, t(187.3) = 2.9, p = 0.03. With a possible highest score of 20, the dentists scored 11.8 ± 0.3, while the PTs scored 10.85 ± 0.1 (Figure 3a). Moreover, the health professionals who had acquired any type of training in TMD had higher scores in the test for knowledge concerning TMD, t(110.4) = 3.1, p = 0.003. PTs or dentists who had TMD training scored 12.2 ± 0.4, while those who did not have any training scored just 10.9 ± 0.1 (Figure 3b). The health providers with more than 10 years of experience in their respective fields scored 12.2 ± 0.5. Meanwhile, those who had only 1–10 years of relative working experience as PTs or as dentists garnered a score of only 10.9 ± 0.1. The results showed that professionals with experience exceeding 10 years had higher scores than those with 10 years or less of experi­ ence, t(95.5) = 2.6, p =.010 (Figure 3c). Furthermore, the results of the study showed that there was a statistically significant difference in the scores of the health professionals across the different test components for TMD knowledge (F(3, 2454) = 39.9, p < 0.001). At a possible perfect score of 5, the Games-Howell post hoc test showed that test

Figure 2. Comparison of perceived TMD awareness by (A) profession, (B) TMD training, and (C) years of professional experience. D = dentists; PT = physical therapists; NT = no training; T = with training; TMD = temporomandibular disorder. Note: ***< 0.001 calculated using unpaired t-tests with Welch’s correction.

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Figure 3. Comparison of TMD knowledge by (A) profession, (B) TMD training, (C) years of professional experience, and (D) TMD knowledge component. D = dentists; PT = physical therapists; NT = no training; T = with training; TMD = temporomandibular disorder; E = epidemiology; P = pathophysiology; C = clinical features; D = diagnosis and treatment. Note: (A-C) ***< 0.001 calculated using Fisher’s exact test. (D) Calculated using Brown-Forsythe and Welch ANOVA test with Games-Howell’s multiple comparisons test.

scores relating to clinical features (3.1 ± 0.05) were significantly higher than those for epidemiology (2.9 ± 0.04, p = 0.012), diagnosis and treatment (2.7 ± 0.05, p < 0.001), and pathophysiology (2.4 ± 0.04, p < 0.001) (Figure 3d).

Discussion Overall findings of the study In the present study, 40% of the dentists had postprofessional degrees, while only 6.38% of PTs had earned theirs. This is particularly critical, as specializing or pursuing a graduate degree has shown to increase the capacity of health professionals in treating complex dis­ eases. The majority of the PTs (59.57%) and dentists (60%) in this study were females. Although there was no significance found between gender and profession, it is not surprising to observe that Filipino families usually send their children to collegiate education in favor of

females over males [21]. The relative newness of PT as an occupation in the Philippines may also be the reason there are more PTs with only 1–10 years of experience [18]. There were more dentists than PTs who were trained in TMD management. Dental education, semi­ nars from PDA, and the OPAP program are just some of the sources of information or workshops available [15,22]. On the other hand, while similar basic science courses are offered to PTs, they have no clinical intern­ ships that are solely focused on TMD [19,20]. This study reported that both professionals are the same in terms of their level of TMD awareness. Recently, the Philippine educational system, through the Commission on Higher Education (CHED), adopted curriculums that promote a multidisciplinary and interprofessional practice. This could be the reason for the increased awareness of both PTs and dentists [22]. It is also interesting and logical to note that profes­ sionals who had undergone training in TMD had more awareness that it is present in their curriculum. These

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health care providers were also aware that multidisci­ plinary and interprofessional collaborations are impor­ tant in attaining effective treatments for TMD. In training programs like the OPAP workshop, the curri­ culum is a derivative of the proposed course of the IASP [17]. This study also revealed that health professionals with more years of experience are more aware of TMD. Even if experiences may not be directly related to the diagnosis and treatment of TMD, vicarious encounters with patients may help the health professional hone good clinical judgment skills. An Italian study in 2001 found that awareness is increased by increasing the experience of taking time to listen, evaluating the care given, and reassuring patients with Alzheimer’s disease [23]. Another study in China found that the lack of confidence may result from the lack of experience in dealing with primary varicose veins. The resulting incompetence may contribute to the impending failure of a treatment given [24]. Gadotti et al. [6] reported the lack of confidence of American PTs in Florida and insinuated the addition of ample training. In this study, Filipino dentists had more knowledge of TMD, as evidenced by the results of the 20-item test. The dentists scored 12 out of 20, while the PTs scored 10 out of 20. The results showed that these professionals barely scored more than 50%. This may suggest the need to improve, augment, and emphasize the education of these professionals in terms of TMD management. Similar findings were recorded in these health providers in terms of TMD training, where those who had some sort of training acquired higher scores than those who did not. Moreover, dentists or PTs with more than 10 years of experience scored more than those with less experience. The degree of experience incurred by a health provider may influence clinical decisions made [25]. Prodoehl et al. [26] found that TMD diagnosis and management are part of the curriculum in 98.8% of the entry-level programs offering PT in the United States of America. However, they also found that the number of hours devoted solely to TMD education was lacking. They further suggested that supplementary postgradu­ ate opportunities are needed. A review of the Philippine curriculum for PTs would reveal that TMD may be discussed in only three courses. The internship program also affords only a minor portion, or nothing at all, in contact hours dealing with TMD [19]. In contrast, the dental education curriculum in the Philippines was designed to review TMD management and diagnosis in almost all of the courses. Correspondingly, organiza­ tions like OPAP have increased the interest and visibi­ lity of specializing TMD management in dentistry by offering training programs [17].

Furthermore, the knowledge component that needed the most improvement was pathophysiology. Emphasizing this in future seminars and workshops sanctioned by the PPTA and PDA may help improve the knowledge of these professionals in terms of TMD pathophysiology. It is also important to modify the DMD and BSPT curriculum to include an emphasis on the epidemiology and diagnosis of TMD. While the clinical features of TMD were the strength of these health providers, this needs to be maintained. Chronic pain is partly due to joint microenvironment and central nervous system modification. Therefore, understanding the pathophysiology, diagnosis, and treatment may be confounded [27]. Study limitations Despite having a response rate of 100%, the 480 PTs and 150 dentists were purposively sampled from thousands of dentists and PTs in the Philippines. In addition, neurosurgeons, oral and maxillofacial surgeons, ear nose and throat doctors, and primary care physicians are just some health professionals who were not included in the study. The questions that tested the knowledge of TMD were limited to 20 questions only. Moreover, these questions were objectively structured and directly framed. Problem-based questions or case studies may be used to effectively test the participants. Since Google Forms is capable of embedding pictures and videos, this can be added to augment the testing dynamics. Similarly, the order of the questions can also be randomized to prevent the sharing of answers. In relation to this, there is no restriction that can hinder a participant from searching for the answers online. The number of dentists was relatively low compared to the sample of PTs. These may have implications in the analysis and interpretation of the results. The overall sample size could also be improved to increase the power of the statistical tests. Some analyses in this study combined participants from both professions. Prospectively, separate analyses can be made to indivi­ dual cohorts to compare them at different factors. The findings in this study should be interpreted with abso­ lute caution.

Conclusion Highest educational attainment, gender, professional experience, and TMD training were found to be asso­ ciated with Filipino professions involved in treating TMD. There were no differences found in the TMD awareness of PTs and dentists, but mindfulness was

CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE

higher in both groups of professionals who had some training in TMD management and those who had more than 10 years of professional experience. Knowledge regarding TMD was low in both professions, with den­ tists being slightly more knowledgeable than PTs. Knowledge in TMD was also higher in professionals with more years of professional practice and TMD training. Even though both dentists and PTs need to improve their knowledge of diagnosis and treatment, epidemiology, and clinical features of TMD, these pro­ fessionals need to progress most on pathophysiology. These outcomes may be important to academics, edu­ cators, and health professionals for enhancing TMD education, awareness, and knowledge.

[6]

[7]

[8]

Disclosure of interest The authors report no conflicts of interest.

Funding

[9]

[10]

This study was not funded by any grant or other sources of funding. [11]

ORCID Junhel Dalanon, DMD, MAT, EdD http://orcid.org/00000002-0279-126X Yoshizo Matsuka, DDS, PhD http://orcid.org/0000-00031069-2605

[12]

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