Knowledge and Attitudes of Pediatric Dentists Regarding Temporomandibular Disorders

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Knowledge and Attitudes of Pediatric Dentists Regarding Temporomandibular Disorders

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Introduction: Temporomandibular disorders (TMD) are musculoskeletal and neuromuscular conditions involving the temporomandibular joint, masticatory muscles, and other related structures. There is a paucity of studies that have evaluated knowledge and attitudes of pediatric dentists regarding TMD.

Objective: To evaluate knowledge and attitudes of pediatric dentists toward diagnosing and treating TMD in pediatric patients.

Materials and Methods: Observational, analytical, cross-sectional study; 266 pediatric dentists responded to a 41-item questionnaire, of which 35 items related to knowledge (divided into four domains: Pathophysiological, Psychophysiological, Psychiatric Disorders, and Chronic Pain), and six items related to attitudes. The data were analyzed using descriptive statistics, and a chi-square test was applied for comparisons; (p < 0.05).

Results: The mean correct response rate across the four domains was 49.5%, with the pathophysiological domain exhibiting the lowest rate at 33%, the psychophysiological domain demonstrating a 50% response rate, the psychiatric disorders domain showing a 64.1% response rate, the chronic pain domain exhibiting a 50.4% response rate.

The rate was 83.1%, while 16.87% of respondents indicated a preference for referring patients with TMD. Furthermore, 31.2% of respondents indicated that they did not consider it necessary to provide preventive education on TMD. Statistically significant differences were found in four out of 13 items in the Pathophysiological domain and in two out of nine items in the Psychophysiological domain.

Conclusion: The pediatric dentists demonstrated limited knowledge of TMD, yet they expressed positive attitudes toward providing proper diagnosis and treatment. However, they did not recognize their role in preventive education on the subject.

Dentistry

Temporomandibular Disorders (TMD)

Temporomandibular Joint (TMJ)

knowledge

pediatric dentists

children

The American Academy of Pediatric Dentistry defines Temporomandibular Disorders (TMD) as a group of musculoskeletal and neuromuscular conditions that present with a range of clinical signs and symptoms affecting the Temporomandibular Joint, masticatory muscles, and other associated structures [1]. Children are also affected by TMD. The most common symptoms include myofascial pain, headaches, neck pain, difficulty chewing, and clicking noises when opening and closing the mouth [2].

Since 1993, numerous authors have reported a dearth of knowledge about TMD among professionals in various areas of dentistry, including general dentistry, orthodontics, and TMD specialists, with a more pronounced deficiency among general practitioners. In 2007, Tegelberg et al. [3] conducted an evaluation of the self-perceived knowledge, attitudes, and clinical experience in treating TMD among general dentists in Sweden. The authors concluded that while dentists demonstrated had a positive attitude toward caring for children and adolescents with TMD, many lacked established protocols for diagnosis and treatment decision-making.

In the year 2000, Lee et al. [4] conducted an investigation into the knowledge and belief held by general dentists in Korea regarding TMD findings revealed that the knowledge in the psychophysiological and psychiatric disorder domains but deficiencies in the pathophysiological domain. In 2010, Baharvand et al. [5] discovered that TMD specialists exhibited significantly greater knowledge than general dentists. Furthermore, the study indicated that attitudes toward TMD became less favorable with increasing age and years of practice.

In 2016, Espinosa et al. [6] conducted a cross-sectional observational study involving 161 dental educators in Puebla, Mexico. The results demonstrated notable inconsistencies in the participant’s knowledge of TMD’s, underscoring the low priority accorded to this field in dental education and the considerable variability in diagnostic and treatment expertise concerning pathophysiology. In the same year, Porto et al. [7] conducted a comparative analysis of the knowledge and beliefs about TMD held by experts using the same survey instrument employed twenty years earlier. Notwithstanding the introduction of new questions in the pathophysiological and chronic pain domains, there were no significant changes in knowledge. In 2020, Al-Huraishi et al. [8] assessed TMD knowledge among recent graduates and specialists. Their results indicated that recent graduates exhibited limited knowledge across all domains compared to specialists, underscoring a critical deficiency in dental education curricula.

In 2020, Mozhdeh et al. [9] conducted an evaluation of TMD knowledge among general dentists and specialists in Italy. The specialists demonstrated a higher level of knowledge items, with a score of over 75% on items, while the general dentists exhibited a lower level of knowledge, with a score of less than 41%. This indicates that general dentists may lack the necessary knowledge to effectively manage TMD.

In 2023, Tormes et al. [10] conducted an assessment of predoctoral dental students in northeastern which revealed an overemphasis on occlusal factors and a lack of confidence in managing TMD. In a final study published in 2023, Xiong et al. [11] evaluated the knowledge and attitudes of general dentists and postgraduate students. Both groups demonstrated inadequate knowledge to manage TMD, indicating a lack of training in this field.

There is a considerable variability in the knowledge and training that dentists receive about diagnosing and treating TMD [12]. To date, few studies have focused on evaluating the knowledge of pediatric dentists in this area [11]. Given that pediatric dentists are often the initial point of contact for patients, it is imperative to assess their comprehension of an expertise in diagnosing and treating TMD. The results of this evaluation may inform the development of educational strategies designed to enhance the knowledge base of the target population with respect to this topic. The objective of this study was to assess the knowledge of pediatric dentists regarding TMD knowledge and their attitudes toward diagnosing and treating pediatric patients with this condition.

2.1 Study Design

A cross-sectional, analytical, observational homodemic, and prolective study was conducted to evaluate the knowledge and attitudes of pediatric dentists associated with AMOP. A total of 266 pediatric dentists participated voluntarily and answered a 41-item questionnaire, 35 of which were related to knowledge, and 6 related to attitudes, with a response time of 10 minutes.

The instrument used to assess knowledge was the one proposed by Linda Le Resche in 1993 [13]. The instrument was reviewed by two pediatric dentists with over 20 years of experience in diagnosing TMD. The questionnaire items were classified into four domains: Pathophysiological, Psychophysiological, Psychiatric Disorders, and Chronic Pain.

The questionnaires were distributed during the AMOP’s October 2022 Magno Course via QR code published at various strategic points of the assembly and disseminated via email. The respondents were AMOP-affiliated pediatric dentists, including both graduates and students from various universities in Mexico. All participants completed the questionnaire on a voluntary basis and received no monetary compensation.

In 2022, the AMOP registered a total of 770 pediatric dentists, 266 participated, resulting in a response rate of 34.5% (Fig. 1). The inclusion criteria were all pediatric dentists who expressed a desire to participate voluntarily, while exclusion criteria were incomplete responses to the questionnaire. This study was approved by the Faculty of Stomatology Research Committee at BUAP (CIFE) in July 2022, with the approval number 2022179.

2.2 Questionnaire

The questionnaire was structured into three sections. The initial section of the questionnaire was designed to collect general information, including the respondents’ email addresses, gender, the university from which they graduated, the level of their education, and the year in which they graduated. The second section comprised questions pertaining to knowledge, while the third section consisted of questions regarding attitudes.

Responses were recorded on a Likert scale with three possible answers: disagree, agree, and prefer not to answer. A correct answer was defined as one that aligned with the consensus of 13 American TMD experts. In contrast, an incorrect answer was one that did not align with the consensus, or one that was selected by the pediatric dentist when they “prefer not to answer” option.

The “Attitude” component comprised six items, each of which required a dichotomous response (i.e., “yes” or “no”).

2.3 Statistical Analysis

All nominal variables were presented with frequencies and percentages. Dimensional variables were presented using measures of central tendency and measures of dispersion.

A chi-square statistical test was employed to analyze the comparison of TMD knowledge between AMOP pediatric dentists and experts, with a significance level less than 0.05.

A total of 266 of the 770 AMOP-affiliated pediatric dentists responded to the survey, representing a response rate of 34.5%. Of the respondents, 182 were women (68.4%) and 84 were men (31.6%). A total of 66 institutions were represented, comprising 25 public universities (37.8%) and 41 private universities (62.2%). Of the 25 public universities (37.8%) and 41 private (62.2%). Of the 25 public universities, 24 were represented by 198 respondents (74.4%), while 41 private universities accounted for 68 respondents (25.6%).

The respondents had obtained educational qualifications beyond the level of a bachelor’s degree, including specializations, master's degrees, and doctorates. Of the total number of participants, 220 were graduates (82.7%) and 46 were postgraduate students in pediatric dentistry (17.3%). The mean number of years since graduation exceeded nine with a median of six years (Table 1).

Table 1. Demographic Characteristics
Gender
Men	84 (31.6%)
Women	182 (68.4%)
University
Public	198 (74.4%)
Private	68 (25.6%)
Education Level
Master's (Graduates)	220 (82.7%)
Bachelor's (Students)	46 (17.3%)
Years Since Graduation
Less than 10	184 (69.2%)
11 to 20	46 (17.3%)
21 to 30	21 (7.9%)
31 to 40	13 (4.8%)
More than 41	2 (0.8%)

The results for the four domains of the applied instrument indicated an average correct response rate of 49.5%. The domain with the lowest percentage of correct answers was observed in the pathophysiological domain at 33.1%. In the psychophysiological domain, the correct response rate was 50%. The psychiatric disorders domain demonstrated an average of 64.1%, while the chronic pain domain exhibited an average of 50.4%. A comparison of the results between respondents and experts revealed statistically significant differences in four of the 13 items within the pathophysiological domain and two of the nine items within the Psychophysiological domain. No significant differences were observed in the Psychiatric and Chronic Pain domains (Tables 2–5).

Table 2

Comparison of Results According to Experts in the Pathophysiological Domain
Pathophysiological Domain	Experts	Pediatric Dentists	Chi-square p-value
Balancing interferences are commonly related to TMD.	Disagree 85.0%	Disagree 9.8%	0.01
Occlusal equilibration is a useful early treatment for TMD.	Disagree 85.0%	Disagree 3.8%	0.00
Orthodontic or orthodontic treatment can prevent the onset of TMD.	Disagree 77.0%	Disagree 10.5%	0.01
Arthroscopic surgery is almost completely effective in repositioning the disc in patients with internal derangements.	Disagree 100.0%	Disagree 30.1%	0.31
Orthodontic therapy is the best treatment to resolve TMD in a patient with skeletal malocclusion.	Disagree 92.0%	Disagree 60.2%	0.71
TMD caused by trauma is much more difficult to treat and has far worse prognosis than other types of TMD.	Disagree 83.0%	Disagree 36.5%	0.42
Transcranial films are the most accurate method for viewing the TM Joint.	Disagree 77.0%	Disagree 43.6%	0.52
The presence of arthritic changes on tomograms, along with crepitus in the joint indicates the need for treatment.	Disagree 77.0%	Disagree 10.9%	0.01
The position of the condyle in the fossa as seen in tomograms is a very accurate indication of internal derangement.	Disagree 92.0%	Disagree 32.0%	0.34
Mandibular repositions splints are more effective than maxillary splints.	Disagree 100.0%	Disagree 27.8%	0.27
Nocturnal bruxism is caused by occlusal interferences.	Disagree 85.0%	Disagree 65.4%	0.76
Ice packs and/or heat packs and passive muscle stretching are good early treatments for TMD.	Agree 100.0%	Agree 66.9%	0.78
All individuals with clicking TMJs require treatment.	Disagree 100.0%	Disagree 41.0%	0.48
Median percentage of right answers according to experts: 33.7%

Table 3

Comparison of Results According to Experts in the Psychophysiological Domain
Psychophysiological Domain	Experts	Pediatric Dentists	Chi-square p-value
The mechanisms of acute and chronic pain are the same.	Disagree 100.0%	Disagree 87.2%	0.92
Biofeedback can be useful for treating TMD.	Agree 100.0%	Agree 40.6%	0.48
Oral parafunctional habits are often significant in the development of TMD	Agree 85.0%	Agree 86.5%	0.92
Patients with TMD who clench/brux do so either during the day or at night, but not both.	Agree 85.0%	Agree 18.4%	0.11
Stress management is indicated for many TMD patients.	Agree 77.0%	Agree 95.1%	0.97
Stress is a major factor in the development of TMD	Agree 100.0%	Agree 92.9%	0.96
Tension and stress increase jaw muscle EMG levels in susceptible patients.	Agree 82.0%	Agree 3.00%	0.00
Progressive muscle relaxation is not an effective treatment for TMD.	Agree 92.0%	Agree 23.7%	0.20
Information on the daily pattern of TMD symptoms can be helpful for identifying contributing factors.	Disagree 92.0%	Disagree 2.6%	0.00
Median percentage of right answers according to experts: 50%

Table 4

Comparison of Results According to Experts in the Psychiatric Disorders Domain
Psychiatric Disorders Domain.	Experts	Pediatric Dentists	Chi-square p-value
Clinical depression is rare in chronic TMD patients.	Disagree 100.0%	Disagree 49.2%	0.59
Depressed mood is fair common in chronic TMD patients.	Agree 86.0%	Agree 64.7%	0.76
Anxiety disorders are more common in TMD patients than in the population at large.	Agree 79.0%	Agree 71.4%	0.81
Depression can be an important etiologic factor in chronic pain.	Agree 79.0%	Agree 71.1%	0.81
Median percentage of right answers according to experts: 64.1%

Table 5

Comparison of Results According to Experts in the Chronic Pain Domain
Chronic Pain Domain	Experts	Pediatric Dentists	Chi-square p-value
Chronic TMD patients should be advised to rest and limit their work and social activities when they are experiencing pain.	Disagree 85.0%	Disagree 42.9%	0.51
PRN narcotics (i.e., "as needed " for pain) are a treatment of choice when TMD pain is severe.	Disagree 93.0%	Disagree 19.2%	0.12
Antidepressants are never indicated in the management of TMD.	Disagree 88.0%	Disagree 43.2%	0.52
An extensive history of previous treatment failures in a TMD patient is usually an indication for surgery.	Disagree 100.0%	Disagree 35.0%	0.39
Chronic pain is a behavioral as well as a physical problem.	Agree 96.0%	Agree 66.5%	0.77
Although some TMD patients have psychological problems, these problems are usually unrelated to their pain.	Disagree 85.0%	Disagree 38.3%	0.45
Difficulty with sleep is a common finding in chronic pain.	Agree 96.0%	Agree 78.9%	0.87
Some patients use pain as an excuse to avoid unpleasant chores.	Agree 89.0%	Agree 54.5%	0.66
Behavior modification treatments are appropriate for patients with chronic TMD pain.	Agree 88.0%	Agree 75.2%	0.84
Median percentage of right answers according to experts: 50.4%

A survey of Pediatric Dentists’ attitudes regarding Temporomandibular Disorder (TMD).

The survey results indicated that pediatric dentists exhibited a favorable attitude toward diagnosing and treating TMD. Six attitude-related questions were posed, and the results were favorable (83.13%) in terms of providing information, care, diagnosis, and treatment. A minority of respondents; 16.87% preferred to refer patients with any signs or symptoms of TMD to another specialist (Table 6).

With regard to the question of whether pediatric dentists should assume the role of information and advice on TMD, 31.2% of respondents asserted that they did not consider this to be within their remit. However, 94.3% of respondents indicated that they would advise or provide recommendations to parents on the prevention of TMD.

Table 6

Attitudes of Pediatric Dentists
Items	Negative	Positive
Pediatric dentists should be the main provider of information and advice on TMD	31.20%	68.80%
Pediatric dentists should examine and diagnose TMD during routine wellness checkups	3.00%	97.00%
Would refer a patient with TMD to another specialist?	19.90%	80.10%
Would examine the TMJ of patients for signs and symptoms of TMD?	3.00%	97.00%
Would provide advice on TMD prevention to parents of patients?	5.70%	94.30%
As part of their standard practice, they conduct preventive consultations for TMD.	38.40%	61.60%

The study included a survey of 266 pediatric dentists affiliated with AMOP, who were surveyed regarding their knowledge and attitudes about TMD. The sample size is comparable to that used in other studies employing the same instrument in various countries.

In this study, the results for the four domains assessing pediatric dentists' knowledge of TMD demonstrated an average correct response rate of 49.5%. In a similar vein, Le Resche et al. in 1993 [13] reported comparable outcomes in their research of 386 general and specialist dentists. These findings suggest that there is a dearth of comprehension regarding the etiology, diagnosis and treatment of TMD, particularly within the pathophysiological and psychophysiological domains.

The domain with the lowest score in this study was the pathophysiological domain, with a mere 33.1% of responses correctly identified. Similarly, Lee et al. (2000) [4] and Al-Huraishi et al. (2020) [8] found that the pathophysiological domain exhibited the greatest deficiency among general dentists. A cross-sectional study conducted in Brazil by Tormes et al. (2023) [10] also identified deficiencies in the knowledge of dental practitioners regarding the relationship between occlusion and TMD. Xiong et al. (2023) [11] evaluated the participants’ knowledge and found a lack of training, understanding, and confidence regarding TMD management.

Inadequate training and erroneous assumption among pediatric dentists that they possess sufficient knowledge of TMD may be pivotal factors contributing to the low correct response rate in the pathophysiological domain. The level of competence in this area can vary considerably depending on the educational methods employed at the university level. Methods that incorporate more clinical practice tend to enhance knowledge acquisition compared to traditional methods [8].

In the item regarding the potential of orthopedic or orthodontic treatment to prevent the onset of TMD, only 10.5% of respondents indicated agreement with the expert panel. The relationship between orthodontic treatment and TMD remains a topic of contention in the scientific community. According to a systematic review by Fernández-González et al. (2015) [14] revealed an absence of evidence indicating a causal relationship between orthodontic treatment and TMD, as well as an inability to ascertain whether such treatment can improve or prevent them.

Furthermore, nearly 90% of respondents concurred that the presence of arthritic changes in tomographies, in conjunction with crepitus in the joint, signifies the necessity for treatment. This response is not aligned with the prevailing expert opinion or the existing literature on the subject. Crepitus is a common finding in patients with degenerative joint disease of the Temporomandibular Joint (TMJ), yet it is not a mandatory criterion for treatment [15].

A survey of pediatric dentists revealed that approximately 30% of respondents felt that the responsibility for providing preventive education did not fall within the scope of their professional duties. Some pediatric dentists may perceive their professional role as limited to traditional dental problems and not extend to complex conditions like TMD, which may require a transdisciplinary approach. Such a perception may result in a diminished interest in providing preventive education on the subject [16].

The integration of education on TMD and orofacial pain into undergraduate and postgraduate dental programs is generally inadequate, resulting in a lack of knowledge and skills in this area among graduating students [12].

The majority of pediatric dentists (55%) exhibited a favorable disposition toward addressing TMD in children and adolescents. However, they demonstrated limited awareness of their potential role in preventive education for parents and children. This may be attributable to deficiencies in their capacity to accurately diagnose and treat TMD as well as a dearth of confidence in the efficacy of preventive education and treatment modalities beyond therapies.

Since 2001, studies conducted by Tegelberg et al. (2016) [3] to Xiong et al. in 2023 [11] have underscored the critical necessity for specialized training in TMD and the formulation of protocols for referring patients or consulting with specialists. Indeed, only 19.9% of respondents in the present study indicated that they had referred patients for this type of consultation. It is plausible that a considerable number of pediatric dentists may not fully recognize the severity or complexity of TMD in pediatric patients, which could potentially result in an underestimation of the necessity for specialist referrals. TMD cases in children are frequently regarded as less severe or transient [17].

This present study was limited by the representativeness of the sample, as the respondents were exclusively AMOP-affiliated pediatric dentists. Nevertheless, the utilized instrument is the most commonly employed globally, facilitating the comparison of findings with those documented in existing literature.

Affiliated pediatric dentists with AMOP membership demonstrate a limited understanding of TMD. However, they exhibit a positive disposition towards providing accurate diagnoses and treatments, although they tend to overlook their responsibility in preventive education on this subject. This may indicate that pediatric dentistry specialists are unable to accurately diagnose or prove adequate treatment for children and adolescents with this type of condition. Consequently, this may result in the underdiagnosis of a significant condition that could have long-term implications for oral health and quality of life in adulthood. It would be prudent for undergraduate and postgraduate dental programs to conduct a review of the manner in which TMD knowledge is taught with the objective of ensuring that professionals are adequately prepared in this area.

Disclosure statement

No potential conflict of interest was reported by the author(s)

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The authors declare no competing interests.

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Knowledge and Attitudes of Pediatric Dentists Regarding Temporomandibular Disorders

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1. Introduction

2. Materials and Methods

2.1 Study Design

2.2 Questionnaire

2.3 Statistical Analysis

3. Results

4. Discussion

5. Conclusion

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References

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