|Year : 2021 | Volume
| Issue : 3 | Page : 251-257
Perspectives, attitudes, and practices of orthodontists, prosthodontists, and maxillofacial surgeons toward temporomandibular joint disorders: A cross-sectional survey
Talat Hasan Al-Gunaid1, Rawah Talal Eshky2
1 Department of Pediatric Dentistry and Orthodontics, Taibah University, Madinah, Saudi Arabia; Ibb University, Ibb, Yemen
2 Department of Pediatric Dentistry and Orthodontics, Taibah University, Madinah, Saudi Arabia
|Date of Submission||22-Nov-2020|
|Date of Decision||23-Dec-2020|
|Date of Acceptance||04-Feb-2021|
|Date of Web Publication||18-Jun-2021|
Dr. Talat Hasan Al-Gunaid
Department of Pediatric Dentistry and Orthodontics, Taibah University, Madinah, Saudi Arabia, and Ibb University, Ibb.
Source of Support: None, Conflict of Interest: None
Aim: To determine whether discrepancies exist between orthodontists, prosthodontists, and maxillofacial surgeons regarding their knowledge, attitudes, practices, and experiences around temporomandibular joint disorders (TMDs). Materials and Methods: A cross-sectional study was conducted, and a convenient sample was used. An invitation with a link to the questionnaire was sent to orthodontists, prosthodontists, and maxillofacial surgeons. A total of 126 individuals agreed to take part, of whom 57 were orthodontists, 37 were prosthodontists, and 32 were oral and maxillofacial surgeons. Participants were asked to answer questions about their knowledge of TMDs, the relationship between orthodontics and TMDs, and how TMD awareness and number of referrals can be increased. Descriptive statistics, such as frequencies and descriptive measures, were obtained. Comparisons between groups were performed by using the chi-square test. Results: There was general agreement across all groups that identification and removal of occlusal interferences is effective in the management of TMDs, with the highest level of agreement found among prosthodontists. In addition, there was overall agreement among the groups that the best treatment of TMD cases involves multidisciplinary teamwork. All groups suggested more than one approach to enhancing TMD awareness and increasing referral rate. Conclusion: There is a general consensus that identification and removal of occlusal interferences is effective in the management of TMDs. Multidisciplinary teamwork is broadly considered to be the optimal approach for the management of TMDs. There is a discrepancy between orthodontists, prosthodontists, and maxillofacial surgeons in terms of their knowledge and experience around the treatment of patients with TMDs.
Keywords: Awareness, Cross-sectional Survey, Maxillofacial Surgeons, Orthodontists, Prosthodontists, TMDs
|How to cite this article:|
Al-Gunaid TH, Eshky RT. Perspectives, attitudes, and practices of orthodontists, prosthodontists, and maxillofacial surgeons toward temporomandibular joint disorders: A cross-sectional survey. J Int Oral Health 2021;13:251-7
|How to cite this URL:|
Al-Gunaid TH, Eshky RT. Perspectives, attitudes, and practices of orthodontists, prosthodontists, and maxillofacial surgeons toward temporomandibular joint disorders: A cross-sectional survey. J Int Oral Health [serial online] 2021 [cited 2021 Oct 26];13:251-7. Available from: https://www.jioh.org/text.asp?2021/13/3/251/318455
| Introduction|| |
The relationship between temporomandibular joint disorders (TMDs) and malocclusion and orthodontic treatment has been of interest to researchers for many years.,,, In general, and through observations in our clinical practice, we can say that there are three or four specialists who are individually or collectively involved in the diagnosis and treatment of patients with TMD: orthodontists, prosthodontists, maxillofacial surgeons, and orofacial pain specialists. Sometimes, general dental practitioners and other dental specialists play a role in the treatment of patients with TMD too. Diagnosis of orofacial pain may be a daunting procedure for many general dental practitioners, and even specialists. Having adequate knowledge and TMD-related skills helps dental practitioners to identify any abnormalities in the temporomandibular joint (TMJ) during examination. They can then refer patients to the appropriate experts, thereby ending the medical reference process. Generally speaking, some believe that teaching students about TMDs should be an integral part of the dental curriculum; graduates should be taught the basics of its diagnosis and management, both theoretically and practically. In contrast, others place stress on providing dental specialists with practical skills and a sound theoretical background. The concept, scope, and type of clinical training can vary between dental institutes. This results in graduates with differing skillsets when entering clinical practice, ultimately leading to a wide range of treatment protocols in both the diagnosis and treatment planning for common TMD problems. Collaboration between health centers and specialists needs to be promoted when considering aspects such as treatment protocols and treatment modalities. Several studies have been conducted to assess the knowledge and beliefs of dental practitioners regarding TMDs. In one study, there were major discrepancies in the diagnosis and treatment of TMDs between general dental practitioners and specialists, indicating both a lack of knowledge and up-to-date information in this area.
Studies have indicated that the prevalence of TMDs among different populations is relatively high, and has been reported to range from 40% to 60%. Other studies have stated that the percentage lies between 40% and 87% for one or more sign or symptom, and about 33% of the population exhibits at least one TMD symptom.,, It has been reported that TMDs are multifactorial due to interactions between physical and psychological factors. Other elements, such as prosthodontic treatment, orthodontic treatment, and orthognathic surgery, are blamed for causing TMJ alterations and the deterioration of existing TMDs. To the best of our knowledge, there are no published studies comparing the expertise, attitudes, and practices of orthodontists, prosthodontists, and maxillofacial surgeons who are practically involved in the process of TMD treatment. Therefore, this study aimed at determining whether any discrepancies exist between orthodontists, prosthodontists, and maxillofacial surgeons regarding their knowledge, attitudes, practices, and experiences around patients with TMD.
| Materials and Methods|| |
A cross-sectional survey was used to carry out this study. The questionnaire used was formulated and divided into several sections: demographic data, knowledge of TMDs, perception of the relationship between orthodontics and TMDs, and how to increase TMD awareness and referrals. To assess the questionnaire, several procedures were carried out. First, three assessors (one professor from the department of prosthodontics, and two associate professors from the departments of orthodontics and maxillofacial surgery) were invited to carefully read the questionnaire. They were then asked to provide their feedback on the number of questions, the clarity of the questions, grammatical mistakes, structure and contents, and whether or not the allocated time was appropriate. At the second stage, 10 assessors from different departments were invited to examine the questionnaire’s reliability. The panel was requested to complete the questionnaire and one week later, they were invited back to fill it out again. Finally, the answers from the two rounds were compared to check the reliability of the questionnaire. The final version was adopted, and the Google Forms template was used.
A cross-sectional observational study was conducted between October 2019 and January 2020. A convenient sample was used and an invitation with a link to the questionnaire was sent to all orthodontists, prosthodontists, and maxillofacial surgeons (academics, members of specialty societies, and specialists in private practices). Throughout the process, the authors made every effort to reach as many specialists as possible in Saudi Arabia and worldwide. Thus, the second step was to publish the survey on social networks such as WhatsApp groups, Facebook groups, and/or by making contact through related societies. An explanation of the purpose of the study, the research procedures, and consent to participate were all included in the questionnaire.
Data were collected, coded, and analyzed by using the Statistical Package for the Social Sciences version 20 (IBM Corporation, Chicago, Illinois, USA). Descriptive statistics were performed in term of frequency count, and percentages were done to describe the sample. At first, the characteristics of the participants were determined according to the demographic variables (profession, qualification, qualification place, and experience). Inferential statistics were followed by using the Chi-Square test to compare variations between groups. Two-tailed significance using a P value of 0.05 was considered to control for alpha error.
| Results|| |
[Table 1] outlines the demographic data of the participants. A total of 126 individuals agreed to take part, of whom 57 were orthodontists, 37 were prosthodontists, and 32 were oral and maxillofacial surgeons. Approximately 39% of the participants held a master’s degree (38.9%), followed by those who had a PhD degree (32.5%). Around 45% had graduated from Asian universities, whereas another 42.1% had graduated from universities in the Middle East and Africa. Twenty-four percent had 11–15 years of experience, shortly followed by those who had 6–10 years of experience (22.2%).
Knowledge of TMDs
[Table 2] shows the knowledge and experience of TMDs among the participants. There was general agreement across all groups regarding the statement “identification and removal of occlusal interferences are effective in the management of TMDs.” The highest level of agreement was found among prosthodontists (100%), followed by maxillofacial surgeons (93.8%). However, a significant difference also existed between the groups for this point (P < 0.05). There was a high consensus that not all individuals with joint sounds require treatment, and no significant difference was found between the groups.
Perception of the relationship between orthodontics and orthognathic surgery with TMDs
[Table 3] displays questions about the relationship between orthodontics and orthognathic surgery for TMDs. All groups agreed on six out of seven of the statements. However, the groups failed to reach a consensus regarding the statement “orthodontic treatment is the best treatment for TMD patients with skeletal malocclusion.” The one exception was maxillofacial surgeons, who gave the same rating for both agree and disagree. No significant differences were noted between the groups.
TMD awareness and referral patterns
Questions on how to increase TMD awareness and referral rate are presented in [Table 4]. There was a high level of agreement among all groups that TMD cases should be treated following a multidisciplinary teamwork approach. However, the results were found to be statistically nonsignificant (P > 0.5). Significant differences were found between groups when it came to TMD awareness and referral rate. Orthodontists suggested a continuous learning process of undergraduate, postgraduate, and continued dental education to enhance the awareness of TMDs and increase referral rate (P < 0.001). In contrast, 54.1% of prosthodontists and 40.6% of maxillofacial surgeons hold the opinion that awareness can be achieved through good undergraduate education.
More than 51% of prosthodontists rely on postgraduate education to increase referral rate, whereas 59.4% of maxillofacial surgeons believe undergraduate education to be sufficient.
| Discussion|| |
The results of this study revealed that there is general agreement across all groups regarding the inadequacy of undergraduate education on TMDs, and that proper knowledge could be strengthened through a combination of undergraduate, postgraduate, and continued education. This is in line with the findings of Baharv et al.,which showed that general practitioners and specialists agreed that undergraduate training on TMDs is insufficient. Another survey by Patil et al. found that 83% of TMD experts reported that they do not update their knowledge on TMDs. Not only this, but also 18.7% of TMD experts mostly rely on continuing dental education programs.
All groups agreed with the statement “identification and removal of occlusal interferences are effective in the management of TMDs.” The highest level of agreement was found among prosthodontists (100%), followed by maxillofacial surgeons (93.8%). We may presume that all groups were aware of the importance of occlusal adjustments and equilibration, and its impacts on the stability of TMJ and the normal activity of masticatory muscles. On the other hand, Koh and Robinson conducted a systematic review to study the effectiveness of occlusal adjustment for the treatment and prevention of TMDs. They concluded that there is no evidence to prove that occlusal adjustment can treat or prevent TMDs. Moreover, many studies have been unable to reach a consensus in this particular area, therefore indicating a lack of agreement in the literature.,,
It has been reported that not all patients with TMJ sounds require treatment., This is in accordance with the findings of this study, as all groups displayed a high consensus toward this particular point. In contrast, this finding disagrees with that reported by Patil et al., which revealed that 75% of TMD experts believed that all individuals with joint sounds require treatment. With regard to the probability of orthodontic treatment preventing or leading to TMDs, the results of this study supported those of Coêlho and Caracas. However, all groups disagreed with the statement that orthodontic treatment is the best treatment for TMDs, except for surgeons, who gave the same rating for agree and disagree. This aligns with the findings reported by Espinosa et al., but it differs from those of Coêlho and Caracas. It was found that the number of specialists who stated that they had treated TMDs in the past was higher than those who had not, and this was true across all groups in this study. With that said, it is highly likely that all groups have been involved in some treatment of patients with TMD, which requires a good level of knowledge and training. The study also revealed two interesting points related to the relationship between orthodontic treatment and TMDs: First, the majority of participants in all groups agreed that orthodontic treatment may improve pre-existing TMDs, with prosthodontists giving the highest consensus (83.8%), followed by orthodontists (70.2%). This suggests that when considering orthodontic treatment for TMDs, prosthodontists are more optimistic about its benefits than orthodontists; second, maxillofacial surgeons gave a far lower rating (46.9%) compared with the other groups when responding to the statement “surgical orthodontics may improve pre-existing TMDs.” Fernández-González et al. conducted a systematic review and concluded that there is no evidence available regarding the effect of orthodontic treatment on TMDs, nor that treatment may increase or prevent it. They further suggested that more longitudinal studies need to be conducted to confirm any possible connection. This highlights that there is not enough scientific evidence to support or deny these assertions. Further, significant scientific evidence now points toward a tendency of nonassociation among orthodontic treatment, dental occlusion, and TMDs. The majority of the respondents were in agreement that orthodontic treatment can be initiated in patients with TMDs, which supports the results of Ashwin and Siri and Varga. Patil et al. reported that most of the TMD specialists and general dental practitioners in their study did not reach a consensus when it came to initiating orthodontic treatment in patients with TMDs. In contrast, Varga insisted that pain and dysfunction should be manipulated before orthodontic treatment. Olsson and Lindqvist and Egermark and Thilander evaluated the relationship between orthodontic treatment and TMDs, finding that TMD symptoms decreased after orthodontic treatment.
When asked which specialist is responsible for the treatment of TMDs, several participants advocated orthodontists, others suggested prosthodontists, and many specialists believed it to be the job of a multidisciplinary team. Previous studies have attempted to explore this topic; however, these studies focused on specific countries,, residents, or general dental practitioners., Interestingly, there was a high level of agreement across groups that the optimal treatment approach for TMD cases is multidisciplinary teamwork. This provides support for a recent study by Garrigós-Pedrón et al., who emphasized the importance of the multidisciplinary approach in improving the clinical outcomes of patients with TMD. The researchers concluded that the multimodal and multidisciplinary method is more effective than their independent use. They also suggested the coordinated and effective development of special units or clinics with multiple professionals in one location.
A significant difference was found between groups when they were asked “how can TMD awareness be increased?”. More than 90% of orthodontists stated that TMD awareness could be increased through a combination of undergraduate, postgraduate training courses, and continued education. Conversely, most of the prosthodontists and surgeons indicated that undergraduate education would be sufficient. This may be related to the fact that orthodontists are prone to receiving many cases for the treatment of occlusal problems associated with TMJ problems. As a result, they are exposed to the challenges of these disorders more frequently than prosthodontists and maxillofacial surgeons, leading them to place higher importance on excellent undergraduate, postgraduate, and continued education programs.
To improve the referral rate of patients with TMD, orthodontists believe that more than one form of education should be used. Prosthodontists, on the other hand, think that undergraduate training is the best option for increasing referral rate, whereas surgeons favor postgraduate training.
The results of this study show that orthodontists are generally more aware and have more knowledge than prosthodontists and maxillofacial surgeons. The reason behind this may be related to the fact that orthodontists receive and deal with more TMD cases than the other two specialists (as shown in [Table 2]: Questions 2 and 3) and therefore might have gained more experience.
In this study, it is important to note that some answers may have been affected by the varying characteristics of the respondents and other factors such as age, time in practice, and country of practice. Despite these limitations, the areas of agreement that were found could be valuable to consider during the management of TMDs.
| Conclusion|| |
There is a general consensus that identification and removal of occlusal interferences is effective in the management of TMDs. Not only this, multidisciplinary teamwork is broadly considered to be the optimal approach to take in the treatment of TMD cases. However, there is a discrepancy between orthodontists, prosthodontists, and maxillofacial surgeons in terms of their knowledge and experience around the treatment of patients with TMDs.
Financial support and sponsorship
Conflict of interest
The authors declare no conflict of interest.
THA conceived and designed the study, analyzed and interpreted data and writing the article. RTE participated in data collection and critically revised the draft. All authors have read and approved the final article for submission. The authors have no conflicts of interest to disclose.
Ethical policy and institutional review board statement
This study was ethically approved by the Ethical Committee of the College of Dentistry, Taibah University, Saudi Arabia (approval number: TUCDREC/20190918/THGunaid2).
Patient declaration of consent
Data availability statement
Data can be obtained on written correspondence to the corresponding author on valid request.
| References|| |
Espinosa IA, Pérez EM, Gonzalez YM, Corona A. Assessment of knowledge on temporomandibular disorders among mexican dental educators. Acta Odontol Latinoam 2016;29:206-13.
Coêlho TG, Caracas HC. Perception of the relationship between TMD and orthodontic treatment among orthodontists. Dental Press J Orthod 2015;20:45-51.
Fernández-González FJ, Cañigral A, López-Caballo JL, Brizuela A, Moreno-Hay I, Del Río-Highsmith J, et al
. Influence of orthodontic treatment on temporomandibular disorders. A systematic review. J Clin Exp Dent 2015;7:e320-7.
Leite RA, Rodrigues JF, Sakima MT, Sakima T. Relationship between temporomandibular disorders and orthodontic treatment: A literature review. Dental Press J Orthod 2013;18:150-7.
Klasser GD, Greene CS. The changing field of temporomandibular disorders: What dentists need to know. J Can Dent Assoc 2009;75:49-53.
Klasser GD, Greene CS. Predoctoral teaching of temporomandibular disorders: A survey of U.S. and Canadian dental schools. J Am Dent Assoc 2007;138:231-7.
Patil S, Iyengar AR. Assessment of knowledge, attitude and practices of dental practitioners regarding temporomandibular joint disorders in India. J Adv Clin Res Insights 2016;3:64-71.
Silva RM da, Santos VL dos, Silva TV de A, Lins CC dos SA. Prevalence of temporomandibular joint disorder in people with Parkinson’s disease in a public university hospital. Rev CEFAC 2019;21:1-10.
Bertoli FMP, Bruzamolin CD, Pizzatto E, Losso EM, Brancher JA, de Souza JF. Prevalence of diagnosed temporomandibular disorders: A cross-sectional study in Brazilian adolescents. PLoS One 2018;13:e0192254.
Okeson JP. Management of Temporomandibular Disorders and Occlusion, 3rd ed. St. Louis: Mosby, Inc.; 2003.
Rokaya D, Suttagul K, Joshi S, Bhattarai BP, Shah PK, Dixit S. An epidemiological study on the prevalence of temporomandibular disorder and associated history and problems in Nepalese subjects. J Dent Anesth Pain Med 2018;18:27-33.
Zwiri AM, Al-Omiri MK. Prevalence of temporomandibular joint disorder among north Saudi university students. Cranio 2016;34:176-81.
Nassif NJ, Hilsen KL. Screening for temporomandibular disorders: History and clinical examination. American Dental Association. J Prosthodont 1992;1:42-6.
Manfredini D, Landi N, Bandettini Di Poggio A, Dell’Osso L, Bosco M. A critical review on the importance of psychological factors in temporomandibular disorders. Minerva Stomatol 2003;52:321-6, 327-30.
Goldstein BH. Temporomandibular disorders: A review of current understanding. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:379-85.
Baharvand M, Sedaghat Monfared M, Hamian M, Jalali Moghaddam E, Sadat Hosseini F, Alavi KA. Temporomandibular disorders: Knowledge, attitude and practice among dentists in Tehran, Iran. J Dent Res Dent Clin Dent Prospects 2010;4:90-4.
Koh H, Robinson P. Occlusal adjustment for treating and preventing temporomandibular joint disorders. Cochrane Database Syst Rev2003;1:CD003812.
Porto F, Harrell R, Fulcher R, Gonzales T. Knowledge and beliefs regarding temporomandibular disorders among orthodontists. Am J Orthod Dentofacial Orthop 2019;156:475-84.
Manfredini D, Perinetti G, Guarda-Nardini L. Dental malocclusion is not related to temporomandibular joint clicking: A logistic regression analysis in a patient population. Angle Orthod 2014;84:310-5.
Haralur SB, Addas MK, Othman HI, Shah FK, El-Malki AI, Al-Qahtani MA. Prevalence of malocclusion, its association with occlusal interferences and temporomandibular disorders among the Saudi sub-population. Oral Health Dent Manag 2014;13:164-9.
Ashwin PS, Siri PB. Assessment of knowledge, attitude and practice on temporomandibular joint disorders among postgraduate dental students. Int J Dent Res 2018;3:59-62.
Varga ML. Orthodontic therapy and temporomandibular disorders. Med Sci 2010;34:75-85.
Olsson M, Lindqvist B. Mandibular function before and after orthodontic treatment. Eur J Orthod 1995;17:205-14.
Egermark I, Thilander B. Craniomandibular disorders with special reference to orthodontic treatment: An evaluation from childhood to adulthood. Am J Orthod Dentofacial Orthop 1992;101:28-34.
Al-Khotani A, Björnsson 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.
Garrigós-Pedrón M, Elizagaray-García I, Domínguez-Gordillo AA, Del-Castillo-Pardo-de-Vera JL, Gil-Martínez A. Temporomandibular disorders: Improving outcomes using a multidisciplinary approach. J Multidiscip Healthc 2019;12:733-47.
[Table 1], [Table 2], [Table 3], [Table 4]