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I. Introduction
Diverse anatomical components of the stomatognathic system enable the mouth to open, swallow, breathe, phonate, suck, and make diverse facial expressions1. One of these structures is the fully mobile temporomandibular joint (TMJ). The TMJ controls the jawʼs opening and shutting. Clinical issues involving the masticatory muscles, the TMJ, and related structures are caused by temporomandibular disorders (TMD). This results in significant socioeconomic costs because of frequently leaving work and needing medical care and surgical procedures2,3. TMDs have been identified as the common source of non-dental orofacial discomfort and are frequently treated by medical practitioners. In terms of diagnosis, prognosis, and therapy, it is the disease that modern society faces as the greatest challenge. To diagnose TMDs, a thorough history and physical examination are essential. TMJ dysfunction frequently manifests as pain and restricted ranges of motion. As additional diagnostic resources, radiographic examinations are used. A clinician must carefully include TMJ imaging in the patient’s therapy plan together with the clinical presentation, signs, and symptoms3,4.
A study conducted on dentists in Italy regarding their knowledge of the symptoms and treatment related to TMD showed that 41% of general practitioners had sufficient TMD knowledge, 12% were aware of TMD, and 47% had insufficient knowledge5.
A multidisciplinary approach involving general dentistry, oral medicine and radiography, orthodontics, oral surgery, physical therapy, and psychology may be necessary to fully address the patientʼs needs. The diagnoses and treatment are influenced by the dental professionals’ training, outlook, and experience6.
Dentistry plays a huge role in managing orofacial problems. Problems related to TMJ are among the most important in dentistry. Dentists must know about TMJ as part of their practice7. This study evaluates undergraduate and postgraduate students’ knowledge of basic anatomy, physiology, clinical examination, and pathology of TMJ because these students will be TMD-experienced dental practitioners in areas of dentistry that are specialized for the diagnosis and treatment of TMDs. This study aims to assess the knowledge, attitude, and practice of undergraduate and postgraduate dental students.
II. Materials and Methods
1. Study design, study population, and study setting
The present cross-sectional study was conducted with a cohort of 610 undergraduate (UG) and postgraduate (PG) dental students in a dental institute in the Western Maharashtra Region of India. The study was conducted from September 2023 to November 2023. The undergraduate students included the students from the Bachelor of Dental Surgery course during their first, second, third, and fourth years of study and the internship. Ethical clearance was obtained from the Ethics Committee at Dr. D. Y. Patil Dental College & Hospital (No. DYPDCH/DPU/EC/920/28/2023). A written informed consent was obtained from all the study participants after explaining to them the objectives of the study.
1) Sample size
The sample size was calculated using an online calculator available at raosoft.com. A minimum of 599 survey responses were needed with a margin of error of ±1% and a confidence level of 95%, a population size of 638 (total number of UG and PG students), and a response distribution of 50%.
3) Inclusion criteria
Those undergraduate and postgraduate students who gave consent to participate were included in the study.
4) Study questionnaire
A questionnaire consisting of 18 items related to the knowledge of basic anatomy, clinical examination, and pathology of the TMJ among dental UG and PG students was developed by the authors and subjected to a panel of five experts consisting of academicians from the field of oral medicine and radiology, oral surgery, and public health dentistry for review and content validation. Details of the content validity index (CVI) were the Scale-CVI/Ave (based on Item-CVI [Item-level CVI]): 0.90; Scale-CVI/Ave (based on proportion relevance): 0.91; Scale-CVI/UA (Scale-level CVI based on the universal agreement method): 0.86. Necessary modifications were made as per suggestions, and one item was removed from the questionnaire. A final questionnaire consisting of 17 items was subjected to assess internal consistency. The value of Cronbach’s alpha coefficient (internal consistency reliability) was 0.80, which was considered good. The questionnaire was then administered to another group of five dentists on two different occasions to check test-retest reliability. The kappa coefficient value obtained was 0.84, which shows strong agreement between the responses.
An email with a link to the survey questionnaire was sent to all the student participants. One week later, they were again reminded through an email to complete the survey. Responses to the survey were collected through an online survey administration app (Google forms). The responses obtained were modified according to correct and incorrect answers to every question. Correct answers were identified as “score 1,” and incorrect answers were identified as “score 0.” Based on the responses obtained, the knowledge of each participant was categorized into excellent (12-17 correct responses), good (7-11 correct responses), and below average (6 or fewer correct responses).
2. Statistical analysis
The questionnaire was mailed to all the UG and PG students of the dental institute (total of 638), out of which 610 students responded with a completed questionnaire (response rate of around 95%). The data were compiled using Microsoft Excel 16 software (Microsoft) and analyzed using IBM SPSS Statistics software (ver. 26; IBM Corp.). The level of significance was kept at 5%. Demographic details and the distribution of correct answers were presented using descriptive statistics. A comparison of correct answers (in %) among different student categories was performed using a one-way ANOVA test followed by a post hoc Tukey test for pairwise comparisons. A comparison of knowledge among different student categories was done using the chi-square test.
III. Results
The mean age of the study participants was 20.95±1.45 years. In given datasets, 292 were males (45.8%) and 346 were females (54.2%).(Table 1)
The distribution of correct answers (in %) varies from 8.0 to 82.6.(Table 2)
In a statistical analysis, all undergraduate, postgraduate, and internship students were analyzed with the help of a one-way ANOVA test. A significant difference with a P-value of 0.003 was determined among the results of different groups. Subsequent post hoc Tukey tests were performed to further explore the differences, revealing that the mean scores in the intern group were significantly different from those in the other groups (P≤0.05), marked with an asterisk (*) in Table 3.
For I Bachelor of Dental Surgery (BDS) mean value is 66.56. II BDS mean value is 71.25. III BDS mean value is 72.95. IV BDS mean value is 64.80. Interns’ BDS mean value is 78.87. Postgraduate students’ mean value is 65.14.(Table 3)
A pairwise comparison showed that the percentage of correct answers for interns significantly differed from that of IV BDS (P=0.050) and PG students (P=0.048).
A chi-square test was conducted to assess the distribution of knowledge levels (below average, good, excellent) among different groups (UG students, interns, PG students). A significant variation was seen among the groups with the P-value of <0.001. Specifically, in the interns group, the majority of participants demonstrated excellent knowledge (88.9%), whereas in the other groups, a more balanced distribution was observed. Knowledge levels were categorized as below average (0-6 correct answers), good (7-11 correct answers), and excellent (12 or more correct answers), with an asterisk (*) indicating statistical significance P-value.(Table 4)
A chi-square test was conducted to assess the associations between different groups (UG students, interns, PG students), and the results indicated significant differences in knowledge levels among the groups. Specifically, significant differences were observed between I BDS and II BDS (P-value of 0.001*), I BDS and III BDS (P-value of 0.002*), II BDS and IV BDS (P-value of less than 0.001*), I BDS and interns (P-value of 0.014*), II BDS and PG students (P-value of 0.001*), III BDS and IV BDS (P-value of 0.003*), and interns and PG students (P-value of 0.009*). The P-value was significant (≤0.05).(Table 5)
IV. Discussion
A comparable study was previously carried out with general dental practitioners (GDPs) and specialists in temporomandibular joint disorders (TMDs; i.e., prosthodontists, oral and maxillofacial surgeons, oral medicine specialists, and radiologists)8. It was shown that whereas GDPs had low/fair levels of understanding of TMDs, the majority of specialists had good levels of knowledge. Additionally, according to Al-Huraishi et al.8, GDPs had lower levels of etiology, diagnosis, and treatment understanding than did TMD specialists. Further proof that general practitioners, subject matter experts, and academic experts agreed that undergraduate dental education on TMDs and orofacial discomfort was inadequate comes from a survey that Celakil and Saruhanoğlu9 did in Iran. This strongly shows that the undergraduate curriculum needs to be enhanced to include information on TMD diagnosis and management that is both theoretical and practical8,9.
A few studies have examined relief from joint and muscle pain, but not from joint noise. Orthodontic therapies are thought to be able to remodel the TMJ by correcting malocclusion, which obviates the need for new functional requirements and maintains normal function. According to Singh et al.10, participants with symptoms like painless clicking and deviation could begin orthodontic therapy. The authors concluded that orthodontic therapy should come after pain and dysfunction have been addressed. According to Conti et al.11, the majority of study participants believed that individuals with TMDs should not begin orthodontic treatment. The management of TMDs appears to be most successful when occlusal interferences are found and removed, according to the literature12.
The available therapeutic options for TMDs are numerous, contradictory, and inconclusive. Occlusal interference correction was shown to have better outcomes. Other management modalities include like parafunctional habit therapy, physical therapy, medication management, heat application, surgical management, transcutaneous electrical nerve stimulation, prolotherapy, behavioral modification, trigger point therapy, and laser therapy, in that order13-16.
Because occlusal adjustment has the problem of being permanent, several systematic reviews and meta-analyses assert that there is no evidence to support its therapeutic use13. However, adjusting the occlusion is warranted if it is a contributing issue, such as the location of restorations causing TMD. The determination of possible clinical features of TMDs is key to the early diagnosis of TMJ dysfunction and adequate treatment17,18. The correct diagnosis and clinical examination of TMJ are necessary for dental students17. There are very few studies suggesting a direct relationship between knowledge about TMJ, TMD, and cognizance18. An adequate cognition is required among the students to investigate, diagnose, and treat TMDs at early stages18.
It is evident from the current study that most individuals have a good theoretical knowledge of basic anatomy, clinical examination, and pathology of the TMJ. These study results show that second-year students have the best knowledge of the TMJ. The reason for this could be a lack of awareness about the signs and symptoms of TMDs among the first-year students because the second-year students gave evidence of their knowledge of TMJ. The pairwise comparison showed that the percentage of correct answers for interns significantly differed from that of IV BDS and PG students. The reason for this could be the addition of awareness about signs and symptoms of TMDs among the interns due to their PG preparations. The authors recommend that more focus should be given on this topic with a more practically based approach of teaching through case-based and role-play learning will help students better understand the subject. Preclinical and clinical workshops should be conducted in the institute on TMJ to increase students’ knowledge.
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