Table Of ContentCRANIO®
The Journal of Craniomandibular & Sleep Practice
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ycra20
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
Published online: 28 Jun 2020.
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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
aSchool 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 Temporomandibular
therapists (PTs) in terms of temporomandibular disorders (TMDs). disorders; dentists; physical
Methods: A 30-item structured online questionnaire was given to recruited PTs and dentists from therapists; disease
awareness; knowledge
January 2019 to December 2019. Welch’s t-test was used to compare the education, awareness,
assessment
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.
Introduction these disorders can be classified into simple or complex
and acute or chronic. Persistence and accompanying cog-
Clinical problems that involve the temporomandibular
nitive, behavioral, and psychosocial factors are linked with
joint, adjacent hard and soft tissues, and the muscles of
complex TMD. The chronicity of TMD worsens the prog-
mastication, or an assortment of these problems are
nosis of TMD, and interprofessional treatment is princi-
called temporomandibular disorders (TMD) [1].
pally vital. A combination of psychologists, speech
Discomfort in the masticatory muscles, diminished
pathologists, primary care physicians, physical therapists
movement of the mandible, pain in the temporoman-
(PTs), and dentists are usually involved in the treatment of
dibular joint (TMJ), accompanying noise upon use, and
TMD [8]. Behavioral therapy, physical therapy (PT), and
widespread pain in the surrounding muscles and fascia
occlusal appliances are proven to be effective treatment
of the jaw are some of the symptoms of TMD [2,3]. The
modalities in TMD. Active or passive techniques may be
work capability and socialization decrease in a person
used by PTs in correcting the range of motion, muscle
suffering from TMD, which is the most widespread
coordination, strength, and relaxation. Ultrasound, elec-
long-lasting orofacial pain disorder. More than 5% of
trotherapy, low-level laser therapy, or iontophoresis may
the population is considered to be suffering from TMD
also be used as specialized PT for TMD [9]. Despite the
[4], and 6–12% suffer from clinical indications of TMD
weak evidence, PT is a proven treatment option for TMD
[5]. Notwithstanding the 10% who suffer from TMD
[10]. Prevention of degenerative factors on the TMJ can
pain, only 3.6–7% will seek medical or dental help for
also be accomplished using occlusal splints. Determining
the treatment of this condition. These patients only seek
the correct occlusal device requires consultation from
help when the symptoms are too severe to handle [6].
a dentist [11]. The pain caused by TMD may also be
Classification of the different categories of TMD is
treated with the use of several classes of medications and
based on the Diagnostic Criteria for Temporomandibular
mainly based on expert opinion. Non-steroidal anti-
Disorders (DC/TMD) [7]. According to the DC/TMD,
CONTACT Junhel Dalanon [email protected] School of Dentistry, Southwestern University PHINMA.,Cebu City, Central Visayas 6000, Philippines
© 2020 Taylor & Francis Group, LLC
2 J. DALANON ET AL.
inflammatory drugs (NSAIDs), muscle relaxants, and tri- Materials and methods
cyclic antidepressants are just some of the drugs used for
Study design
the pharmacologic management of TMD [12–14].
In the Philippines, early diagnosis and treatment are This study used a cross-sectional comparative design
done by dentists. Although orofacial pain is not sanctioned by the Institutional Review Board of
a recognized dental specialty in the country, prostho- Southwestern University PHINMA.
dontists and orthodontists fabricate occlusal splints.
Additionally, oral and maxillofacial surgeons may per-
Recruitment
form surgery to correct the TMJ in rare instances [15].
Formal dental education in the Philippines started in Mixed methods were used to recruit participants for the
1903, and the Philippine Dental Association (PDA) study. A total of 620 health professionals were purpo-
occasionally includes TMD management in confer- sively sampled, of whom, 470 were PTs, and 150 were
ences. It is not until the first semester of the second dentists. Health professionals who are members of an
year of dental education that TMD is introduced. From Accredited Professional Organization (APO) in the
then on, TMJ and TMD are always discussed in most country and possess a professional license from the
courses, e.g., Anatomy, Oral Physiology and Occlusion, Professional Regulation Commission (PRC) were consid-
Prosthodontics, Orthodontics, Roentgenology, Oral ered in this study. The PDA and the PPTA are the APO
Surgery, and others [16]. It was only on July 13 2016, of the Filipino dentists and the PTs, respectively; being
when the first temporomandibular disorder and orofa- a member of these organizations was part of the inclusion
cial pain program was initiated by the Orofacial Pain criteria. From January 2019 to December 2019, invita-
Association of the Philippines (OPAP) at the University tions were sent by post, email, and personal conversa-
of the Philippines. Currently, the OPAP training pro- tions. Prior to the first part of the questionnaire,
gram is the only university-based program with a statement explaining the purpose and implications of
a curriculum framed by the International Association the study was given. It was also explicitly stated that
for the Study of Pain (IASP) [17]. participation of the survey was voluntary and that the
In contrast, the diagnosis and treatment of TMD in participant could choose to stop responding at any point
the Filipino Bachelor of Physical Therapy (BSPT) cur- in the process. Electronic signatures were used to verify
riculum has not been well developed. It was only in the the consent of the participants.
mid-1940s that PT began to be practiced in the
Philippines. There are currently only four schools
Questionnaire
that offer post-professional degrees in PT, but none
of them are related to the treatment of TMD. Of the A 30-item, structured online questionnaire was created
27,000 registered PTs in the country since 1969, there using Google Forms. The survey form contained 5 ques-
are only 4470 currently practicing their profession tions pertaining to demographics and education, 5 on
[18]. The concepts of the TMJ may be introduced as awareness of TMD, and 20 on knowledge of dentists and
early as the first semester of the first year of PT educa- PTs regarding TMD. The knowledge section questions
tion. TMD may be discussed in lectures or demonstra- of the online form were categorized into 5 queries on the
tions in courses like Anatomy, Applied Anatomy and epidemiology of TMD, 5 on the pathophysiology of
Kinesiology, and Internship [19]. The Philippine TMD, 5 on clinical features of TMD, and 5 on treatment
Physical Therapist Association (PPTA) is the accre- as well as diagnosis of TMD. These questions were based
dited professional organization of the PT in the on the TMD Fact Sheet of the International Association
Philippines and occasionally renders seminars, for the Study of Pain. Completing the survey was pro-
although the TMJ and TMD are rarely the topics of jected to last for about 10–20 minutes, on average.
interest [20].
The education, awareness, and knowledge of the
Data analysis
health professionals implicated in the treatment of
TMD are important in the success of dealing with the The association between the demographics and educa-
condition. Currently, and to the knowledge of the tion-related information was analyzed using Fisher’s
authors, there has been no record on the competence exact test at a 95% confidence interval. The data on
of Filipino dentists and PTs in dealing with TMD. TMD awareness were compared using unpaired t-tests
Therefore, the objective of this study was to compare with Welch correction. A similar statistical strategy was
the education, awareness, and knowledge of dentists and used on the figures concerning TMD knowledge per
PTs in the Philippines in terms of TMD. profession, training, and professional experience. TMD
CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 3
knowledge per component was analyzed using a Brown- considered as Level 6. This includes professional
Forsythe and Welch analysis of variance (ANOVA) test doctorates like the DDM or DMD and the DPT.
with Games-Howell multiple comparisons test. Data On the contrary, professional doctorates like the
were presented as mean ± SEM, unless otherwise speci- Ph.D. and Ed.D. are considered as Level 8 or doc-
fied. All descriptive and inferential statistics were done toral degrees [15].
using GraphPad Prism 8. 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
Results of 59.57% females and 40.43% males. Through Fisher’s
exact test, there was no association found between gen-
Demographics and education of the participants
der and profession (p > 0.999) (Figure 1b).
All 620 (100%) health professionals completed the The test for the relationship between professional
questionnaire. Of this number, 470 were PTs, and experience and profession yielded significance
150 were dentists. A correlation (p < 0.001) between (p < 0.001). About 70 dentists (46.67%) had more than
highest educational attainment and profession was 10 years of experience, and 80 (53.33%) had 1–10 years
found, where 60% of dentists were Doctor of of experience. On the other hand, only 20 of the PTs
Dental Medicine (DMD or DDM) degree holders (4.26%) had more than 10 years’ experience.
and 40% were Masters or Ph.D. degree holders. In A preponderance of 450 of these PTs (95.74%) only
contrast, 93.62% of the PTs were holders of the BSPT had 1–10 years of experience in their profession
or a Doctor of Physical Therapy (DPT) degree, while (Figure 1c).
only 6.38% had graduate degrees (Figure 1a). Due to Eighty of the dentists (53.33%) had no TMD training,
the Philippine Qualifications Framework (PQF), while 70 (46.67%) had formal or other training of some
which was derived from the ASEAN Qualifications sort in TMD management. On the contrary, 440 of the
Framework (AQF), all baccalaureate degrees are 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.
4 J. DALANON ET AL.
(6.38%) had training. The acquisition of TMD training Knowledge of TMD by profession, training, and
was found to have a connection with the profession professional experience
(p < 0.001) (Figure 1d).
According to the 20-item assessment of knowledge of
TMD, dentists had a significantly higher score than PTs,
Curricular and interprofessional management t(187.3) = 2.9, p = 0.03. With a possible highest score of
awareness concerning TMD 20, the dentists scored 11.8 ± 0.3, while the PTs scored
10.85 ± 0.1 (Figure 3a).
The TMD awareness of the dentists and PTs were com-
Moreover, the health professionals who had acquired
parable. The percentage of perceived awareness on
any type of training in TMD had higher scores in the
TMD was 89.3 ± 1.2, while it was slightly higher at
test for knowledge concerning TMD, t(110.4) = 3.1,
89.4 ± 0.7 for PTs. There was no statistical difference
p = 0.003. PTs or dentists who had TMD training scored
between the TMD awareness of each profession, t
12.2 ± 0.4, while those who did not have any training
(257) = 0.02, p = 0.983 (Figure 2a).
scored just 10.9 ± 0.1 (Figure 3b).
However, professionals who had undergone TMD
The health providers with more than 10 years of
training were found to have more awareness relating
experience in their respective fields scored 12.2 ± 0.5.
to TMD, t(261.6) = 7.6, p < 0.001. The percentage of
Meanwhile, those who had only 1–10 years of relative
perceived awareness of trained professionals was
working experience as PTs or as dentists garnered
96.0 ± 0.8, while it was a mere 88.1 ± 0.7 for the
a score of only 10.9 ± 0.1. The results showed that
untrained health providers (Figure 2b).
professionals with experience exceeding 10 years had
Interestingly, the length of time pertaining to profes-
higher scores than those with 10 years or less of experi-
sional experience also affects TMD awareness. The
ence, t(95.5) = 2.6, p =.010 (Figure 3c).
health professionals who had extensive experience in
Furthermore, the results of the study showed that
their respective fields had a greater awareness of TMD,
there was a statistically significant difference in the
t(207.3) = 6.6, p < 0.001. The perceived awareness per-
scores of the health professionals across the different
centage of dentists and PTs who had worked for
test components for TMD knowledge (F(3,
1–10 years was 88.3 ± 0.7, while, for those with more
2454) = 39.9, p < 0.001). At a possible perfect score of
than 10 years of professional experience, it was
5, the Games-Howell post hoc test showed that test
95.6 ± 0.9 (Figure 2c).
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.
CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 5
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 females over males [21]. The relative newness of PT as
significantly higher than those for epidemiology an occupation in the Philippines may also be the reason
(2.9 ± 0.04, p = 0.012), diagnosis and treatment there are more PTs with only 1–10 years of experience
(2.7 ± 0.05, p < 0.001), and pathophysiology [18]. There were more dentists than PTs who were
(2.4 ± 0.04, p < 0.001) (Figure 3d). 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
Discussion [15,22]. On the other hand, while similar basic science
courses are offered to PTs, they have no clinical intern-
Overall findings of the study
ships that are solely focused on TMD [19,20].
In the present study, 40% of the dentists had post- This study reported that both professionals are the
professional degrees, while only 6.38% of PTs had same in terms of their level of TMD awareness.
earned theirs. This is particularly critical, as specializing Recently, the Philippine educational system, through
or pursuing a graduate degree has shown to increase the the Commission on Higher Education (CHED),
capacity of health professionals in treating complex dis- adopted curriculums that promote a multidisciplinary
eases. The majority of the PTs (59.57%) and dentists and interprofessional practice. This could be the reason
(60%) in this study were females. Although there was no for the increased awareness of both PTs and dentists
significance found between gender and profession, it is [22]. It is also interesting and logical to note that profes-
not surprising to observe that Filipino families usually sionals who had undergone training in TMD had more
send their children to collegiate education in favor of awareness that it is present in their curriculum. These
6 J. DALANON ET AL.
health care providers were also aware that multidisci- Furthermore, the knowledge component that needed
plinary and interprofessional collaborations are impor- the most improvement was pathophysiology.
tant in attaining effective treatments for TMD. In Emphasizing this in future seminars and workshops
training programs like the OPAP workshop, the curri- sanctioned by the PPTA and PDA may help improve
culum is a derivative of the proposed course of the IASP the knowledge of these professionals in terms of TMD
[17]. This study also revealed that health professionals pathophysiology. It is also important to modify the
with more years of experience are more aware of TMD. DMD and BSPT curriculum to include an emphasis
Even if experiences may not be directly related to the on the epidemiology and diagnosis of TMD. While the
diagnosis and treatment of TMD, vicarious encounters clinical features of TMD were the strength of these
with patients may help the health professional hone health providers, this needs to be maintained. Chronic
good clinical judgment skills. An Italian study in 2001 pain is partly due to joint microenvironment and central
found that awareness is increased by increasing the nervous system modification. Therefore, understanding
experience of taking time to listen, evaluating the care the pathophysiology, diagnosis, and treatment may be
given, and reassuring patients with Alzheimer’s disease confounded [27].
[23]. Another study in China found that the lack of
confidence may result from the lack of experience in
Study limitations
dealing with primary varicose veins. The resulting
incompetence may contribute to the impending failure Despite having a response rate of 100%, the 480 PTs and
of a treatment given [24]. Gadotti et al. [6] reported the 150 dentists were purposively sampled from thousands
lack of confidence of American PTs in Florida and of dentists and PTs in the Philippines. In addition,
insinuated the addition of ample training. neurosurgeons, oral and maxillofacial surgeons, ear
In this study, Filipino dentists had more knowledge nose and throat doctors, and primary care physicians
of TMD, as evidenced by the results of the 20-item test. are just some health professionals who were not
The dentists scored 12 out of 20, while the PTs scored 10 included in the study. The questions that tested the
out of 20. The results showed that these professionals knowledge of TMD were limited to 20 questions only.
barely scored more than 50%. This may suggest the need Moreover, these questions were objectively structured
to improve, augment, and emphasize the education of and directly framed. Problem-based questions or case
these professionals in terms of TMD management. studies may be used to effectively test the participants.
Similar findings were recorded in these health providers Since Google Forms is capable of embedding pictures
in terms of TMD training, where those who had some and videos, this can be added to augment the testing
sort of training acquired higher scores than those who dynamics. Similarly, the order of the questions can also
did not. Moreover, dentists or PTs with more than be randomized to prevent the sharing of answers. In
10 years of experience scored more than those with relation to this, there is no restriction that can hinder
less experience. The degree of experience incurred by a participant from searching for the answers online.
a health provider may influence clinical decisions made The number of dentists was relatively low compared
[25]. Prodoehl et al. [26] found that TMD diagnosis and to the sample of PTs. These may have implications in
management are part of the curriculum in 98.8% of the the analysis and interpretation of the results. The overall
entry-level programs offering PT in the United States of sample size could also be improved to increase the
America. However, they also found that the number of power of the statistical tests. Some analyses in this
hours devoted solely to TMD education was lacking. study combined participants from both professions.
They further suggested that supplementary postgradu- Prospectively, separate analyses can be made to indivi-
ate opportunities are needed. A review of the Philippine dual cohorts to compare them at different factors. The
curriculum for PTs would reveal that TMD may be findings in this study should be interpreted with abso-
discussed in only three courses. The internship program lute caution.
also affords only a minor portion, or nothing at all, in
contact hours dealing with TMD [19]. In contrast, the
Conclusion
dental education curriculum in the Philippines was
designed to review TMD management and diagnosis Highest educational attainment, gender, professional
in almost all of the courses. Correspondingly, organiza- experience, and TMD training were found to be asso-
tions like OPAP have increased the interest and visibi- ciated with Filipino professions involved in treating
lity of specializing TMD management in dentistry by TMD. There were no differences found in the TMD
offering training programs [17]. awareness of PTs and dentists, but mindfulness was
CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 7
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