Knowledge, attitude, and perception of oral and maxillofacial surgery specialty amongst healthcare professionals, and the General Public from a Gulf Cooperation Council (GCC) Country

Background Oral and maxillofacial surgery specialty has grown rapidly in Kuwait in recent years. However, the general public and healthcare professionals remain unaware of its expanding scope of practice. The aim of the study is to assess public and professional (dental and medical) perception of the oral and maxillofacial surgical specialty in Kuwait. Methods This is a cross-sectional study evaluating responses of dental professionals, medical professionals, and general public in Kuwait toward the oral and maxillofacial surgical specialty using a previously validated survey instrument with 100 participants in each group. Participants were asked to choose the most appropriate specialist to treat certain procedures across 4 disciplines: reconstruction, trauma, pathology, and cosmetic. Statistical comparison was conducted between dentists and medical doctors using Fisher’s exact test with a p-value of < 0.05. Results Disparities were noted each group’s responses. Oral and maxillofacial surgery was preferred overall for most clinical scenarios in trauma (p < 0.001), pathology (p < 0.001), and reconstructive surgery (p < 0.001). Plastic surgery was preferred for cosmetic surgeries (p < 0.001). Conclusions This study indicates the need to increase awareness especially towards cosmetic surgery procedures, and conduct health campaigns regarding oral and maxillofacial surgery among healthcare professionals, especially medical doctors, and the general public.


Background
Oral and maxillofacial surgery (OMFS) is a relatively young surgical specialty that focuses on diagnosing and treating conditions in the head and neck region, acting as a bridge between dentistry and medicine [1,2]. OMFS evolved significantly in recent years, triggering major technological and clinical advances in the fields of traumatology, dentofacial deformities, head and neck oncology and reconstruction, and temporomandibular joint disorders [3,4]. Presently, OMFS offers a fairly broad spectrum of treatments, including distraction osteogenesis, implant surgery, tissue engineering, sleep apnea treatment, and esthetic facial surgery [3,5,6].
Despite being a well-recognized specialty of the facial skeleton by major hospitals internationally, disparities remain regarding proper recognition of OMFS's scope and familiarity with OMFS surgical procedures among students, healthcare professionals, and laypersons [2,4,5]. Previous work in Kuwait by Haron et al. assessed the perception of OMFS by medical and dental professionals and found disparity regarding healthcare professional consultations for various conditions in the head and neck region based on a survey instrument evaluating 26 procedures [7]. A similar study in Saudi Arabia by Alnofaie et al. showed also significant differences between dentists and medical doctors perceiving OMFS [8].
The practice of OMFS in Kuwait officially began in the 1960s, mostly by foreign specialists visiting or practicing on regular basis. During later years, the development of the Kuwait healthcare and educational system led to local doctors being trained abroad in several North-American, European, Asian, and North-African countries to prepare them for the nationally subsidized Kuwaiti healthcare sector [7]. Over time, a heterogeneous group of OMFS surgeons formed with diverse training and a spectrum of clinical practice. The medical system in Kuwait is based on providing comprehensive care by the state-funded hospitals and many health care primary centers. Five health regions, with over 70 primary healthcare centers are responsible for managing the whole population in the state of Kuwait [9]. Primary healthcare centers are well staffed with general practitioners and general dentists who licensed thorough the Ministry of Health to offer mainly primary healthcare needs and serve as the initiating pathway toward referring cases to specialized centers for secondary and tertiary care services. The services provided across this multilateral system covers the whole spectrum of all medical and surgical specialties, along with the full spectrum of dental specialties. The Kuwait Ministry of Health attempts evaluate the standard of care, accreditation protocols, and the referral guidelines across all centers on regular basis [9]. There is currently insufficient reports on topics evaluating the medical referral system in Kuwait, with few studies published focusing mostly on patient safety culture and medical errors in the State of Kuwait [10,11].
We shall investigate the current levels of knowledge, attitude, and perception towards the OMFS specialty in Kuwait among dental and medical professionals as well as the general public. This will help revisit our referral protocols, conduct needed awareness campaigns among the healthcare professionals to enhance their understanding of the scope of the specialty, and refine our medical and dental school's curriculum to increase the OMFS educational content.

Participants
This cross-sectional survey drew one hundred subjects (n = 100) from both registered dentists and medical doctors working in all Kuwaiti healthcare sectors, the governmental and the private sectors, as well as the general public (laypersons) between April 1st to May 30th 2020. Participants were at least 18 years old and all participants voluntarily gave written consent to complete the questionnaire and were assured that their responses would be anonymous.

Questionnaire
A previously validated and applied survey is used in the study with slight modifications by expanding the procedures list, and permission to use the questionnaire has been obtained from its authors [12,13]. The questionnaire is divided into sections on demographics and general head and neck clinical conditions, some specific to OMFS practice (see Additional files, Questionnaire OMFS.pdf ). Additional items are included in the survey to expand the spectrum and give a broader range of clinical scenarios. Each participant has 5 options consisting of 4 different specialists and an unspecified specialty. Participants are asked to indicate whom would be most appropriate or competent in treating each clinical condition, and only one option can be chosen for each condition. The questions are grouped and categorized by discipline (trauma, pathology, reconstruction, or cosmetic) and analyzed accordingly. Links leading to the online survey instrument was electronically to the medical and dental associations groups and to the public groups in Kuwait via e-mail, WhatsApp, Instagram, and Twitter pages. Ethical approval was obtained for this study from the Institutional Review Board (IRB) at Kuwait University Health Sciences Center.

Statistical analysis
Statistical analysis is performed using SPSS Version 23.0 (IBM SPSS Statistics for Macintosh, IBM Corp., Armonk, NY, USA). Questionnaire responses from dentists and medical doctors are compared. Categorical data is compared using a chi-square test (cell count ≥ 5) or Fisher's exact test (cell counts < 5). A p-value of < 0.05 is considered statistically significant given an 80% test power. Responses by laypeople are presented categorically and not included in the statistical comparison.

Healthcare professionals (dentists and physicians)
The participants who completed the questionnaire consisted of 100 dentists and 100 physicians (Table 1). Participants were male (58%) and female (42%), with the majority aged 26-45 years. Medical doctors were older than their dentist counterparts (p = 0.012) and had more clinical experience (p = 0.033) with dentists possessing an average of 7.9 years (SD ± 7.4 years) compared to doctors holding 10.1 years (SD ± 6.9 years). Regarding receiving care, 27% had been supported by ear-nose-throat (ENT) specialists and 23% were treated by OMFS specialists, while 41% reported no prior medical treatment. Medical doctors had more personal experience with plastic surgery (PS) and ENT specialists while dentists had more personal experience with OMFS (p < 0.001).
Responses to trauma-related questions relating are presented in Table 2. An OMFS was preferred by both groups to treat broken jaws, eye bone fractures, and teeth trauma. Both groups would refer to PS for facial lacerations, but a larger proportion of dentists would refer to OMFS (43% vs. 19%; p < 0.001) while a larger proportion of medical doctors would refer to general surgery (GS) (26% vs. 7%; p < 0.001). Nose fractures caused more doctors to refer to ENT (79% vs. 43%; p < 0.001) while significantly more dentists would include an OMFS referral (37% vs. 4%; p < 0.001). Table 3 presents responses relating to pathology, showing OMFS being preferred by both groups for oral lesion biopsies, cancers of the lip, mouth, or tongue, and mouth lumps. For facial skin lesion biopsies, dentists tended to refer to OMFS (53% vs. 19%; p < 0.001), while doctors preferred PS (51% vs. 29%; p < 0.001). A patient seeking removal of a neck lump would be unlikely to get an OMFS referral from a medical doctor (7% vs. 63%;  p < 0.001), who generally preferred ENT (53%; p < 0.001) or GS referrals (37%; p = 0.003). For salivary gland removal and sinus surgery, medical doctors preferred ENT (52% and 80%; p < 0.001) while dentists preferred OMFS for both procedures (90% and 51%; p < 0.001). PS or OMFS was preferred for reconstructive surgery scenarios (Table 4). Dentists preferred OMFS for children with cleft lips (p < 0.001), cleft palates (p < 0.001), and both conditions (p < 0.001), while medical doctors referred to PS most often for these procedures. Facial reconstruction following trauma saw dentists more likely to choose OMFS (69% vs. 48%; p = 0.003) and medical doctors preferring PS (52% vs. 30%; p = 0.002). Dentists referred to PS (46%) and OMFS (47%) in roughly equal numbers for facial reconstruction requiring free flaps but medical doctors were more likely to refer to PS (72%; p < 0.001) than OMFS (28%; p = 0.006). Similarly, dentists would refer to OMFS for facial bone grafts more than medical doctors (75% vs. 44%; p < 0.001). While both dentists and medical doctors would refer to OMFS for wisdom teeth removal, a large proportion of doctors would also refer to other specialties (34%; p < 0.001).

Laypeople
One hundred laypeople were surveyed as part of this study (see Table 6), comprising 55 males and an even distribution of age ranges. Survey respondents reported their personal experiences with various specialties, with 12% having received PS treatment, 27% receiving ENT, 24% using OMFS, 77% accepting GS, and 26% getting another form of treatment.
Overall, OMFS was preferred for issues relating to trauma, pathology, and reconstructive surgery, while PS was preferred for cosmetic surgeries (Fig. 2). Laypeople felt that ENT services were most appropriate for nose fractures and sinus surgeries. They choose PS as most appropriate for facial lacerations, moles/lumps on the face, cleft lips, facial reconstructions and all cosmetic surgeries except jaw deformities and discrepancies. GS was deemed most appropriate for facial skin lesion biopsies and neck lumps. Perception of when OMFS consultation was suitable is presented in Table 7.

Discussion
Knowledge and perception of the OMFS specialty plays a crucial role in its development. With its wide scope of practice overlapping other medical specialties, OMFS has caused a notable disparity in referring preferences among healthcare workers, students, and general public [8,12]. Jensen mentioned that almost all medical specialties have overlapping scope to some extent, causing possible confusion when choosing an appropriate specialty for case management [14]. This necessitates establishing clear clinical guidelines and interdepartmental referral schemes in any given healthcare system. Proper referral systems ultimately lead to better patient care delivery, smaller burdens on hospital services, and greater patient satisfaction [15,16]. Undoubtedly, OMFS surgeons will most likely continue to gather knowledge and clinical skills depending on case exposure to over time. General public perception of OMFS is just as important health care provider perception. In Kuwait's private sector, the public has open access to all specialty clinics. Although such unrestricted access has benefits (such as fast patient flow), they are countered by possibly inappropriate self-referrals [16]. The latter causes higher patient costs in addition to increased risk of management by health care providers not entirely skilled in a given case [16]. Our findings indicate that most medical and dental clinicians will refer to OMFS for jaw fractures, orbital fractures, and dental trauma instead of ENT, GS, or PS, which is consistent with Rocha et al. 's findings [13]. The orbital fracture findings contradict Haron et al. 's 2013  [7]. This may be attributed to many North American-and European-trained surgeons joining the Gulf Cooperation Council (GCC) countries workforce in recent years due to the wide implementation of the government sponsored training schemes abroad, as well as social media becoming a valid platform for patient education [7,17]. Ameerally et al. mentioned that names given to specialties can create referral bias. (14) Our results demonstrated it is more likely for healthcare professionals and laypeople to refer cases of jaw, orbital, and dental trauma to OMFS. Such speculation is popular among other authors, such as Parnes who suggested a name change to OMFS altered its perceived spectrum. (15) However, it is extremely difficult to suggest a name that fully describes any given specialty [8].
Government-funded hospitals in Kuwait established broad guidelines on referrals [7]. Nasal fractures, for example, are to be referred to ENT specialists, which may explain why our results indicated ENT is the preferred specialty for nasal fracture management. We found that a significant number of dentists would also refer nasal fractures to OMFS. Dentists have firsthand experience with OMFS during undergraduate studies, and rotations and externships in OMFS service may grant dentists a firm understanding on the specialty's broad scope, on the other hand, many medical doctors are unaware of OMFS training and practice [18,19].
Regarding facial lacerations, we found that dentists and medical doctors gave equal preference to PS. However, a statistically significant difference was noted between dentists (43%) and medical doctors (19%) referring facial lacerations to OMFS. Plastic surgeons are well known for managing cases requiring special esthetic attention, which has been reported by Alnofaie et al. [8], making it unusual that GS was the second most likely specialty referral by medical doctors for facial lacerations.
Our results indicate that while OMFS is the preferred service for any pathological case of the oral  (Table 3), medical doctors mainly referred facial pathology requiring biopsies to PS. Our consensus among health care professionals that plastic surgeons are the most competent at treating esthetic cases is consistent with previously published studies [7,8]. Facial lesion management is within the core of OMFS specialty with most practitioners being well trained in PS, ENT, and GS. To date, OMFS is the specialty with the greatest focus on the facial region. All surgeons are held to high standards for care delivery and esthetic outcomes. Dentists are more likely to refer any given case to OMFS save skin lumps, which tended to be referred to PS.
Sinus surgeries and salivary gland removals are within the scope of OMFS and ENT. While dentists preferred OMFS referrals, doctors preferred ENT for such case management. Haron et al. 's study found that medical doctors would refer salivary gland pathology to GS [7]. In our study, GS was the second least preferred choice of all healthcare professionals. Regarding reconstructive surgery, dentists consistently referred all cases to OMFS first. However, dentists in Kuwait tend to refer any complicated head or neck region case to OMFS first [7]. Medical doctors mainly sent cleft lip and palate patients to PS. Children with cleft lips and palates require a team of healthcare professionals including orthodontists, pediatric physicians and dentists. The tendency of professionals to refer cleft lip and palate cases to PS could be attributed to the fact that the operatory segment of the cleft team governmental hospital established is consisted of plastic surgeons. Management of temporomandibular joints were mainly referred to OMFS by our participants, which was consistent with other published results [8,12]. Wisdom teeth extraction and dental implants were mainly sent to OMFS. A significant number of dentists and medical doctors chose to send such cases to professionals marked as "others", such periodontists and general dentists trained to manage minor oral surgical procedures (Table 4). Undoubtedly, their competence in such surgical intervention will reduce the burden on busy OMFS specialists in Kuwait.
For cosmetic surgery, all plastic facial procedures (except for chin corrections) were most likely to be sent to PS. Healthcare professionals prefer PS for Botox injections and hair transplants. Numerous specialties offer similar procedures, including dermatology, but the predominant worldwide perception that PS is a specialty dedicated to esthetics, with similar results found in other studies [12,20].
Almost all facial operations should have acceptable esthetic results, rendering them cosmetic [21]. It is worrisome that healthcare professionals would refer most of such patients a specific surgical specialty, even OMFS. Specialty overlap requires consideration and referrals should be distributed equally with emphasis on any given surgeon's expertise and skills. OMFS will evolve hugely based on experience, thus a proper referral system that considers its overlap and the training of different departments can be counted as a good investment in healthcare. Rhinoplasties are controversial as far as which specialty should offer care with PS and ENT being the top choices.
Laypeople preferred OMFS for all traumatic cases involving the face, except for nasal fractures where ENT scored higher. The Arabic name for OMFS translates literally to "jaw and facial surgery". It seems reasonable that descriptive name and nomenclature play a key role in choosing departments. Generally, laypeople are more likely to view OMFS surgeons as performing procedures involving the head and neck region, with the only significant exception being esthetic procedures, for which they prefer PS. This public perception of PS is longstanding and affected by popular culture and social media. A major limitation in our study is that the sample size (n = 100) was small to draw a broader conclusion on a complex and diverse healthcare system in Kuwait. Given the dynamic nature of the healthcare system in Kuwait with constant influx of healthcare professionals from various global systems and training schemes, the results can show significant variations within short time frames, as seen in this study with regard to the previous views recorded in 2013.