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Perception of oral maxillofacial surgery by health-care professionals
Int. J. Oral Maxillofac. Surg. 2008; 37: 41–46 doi:10.1016/j.ijom.2007.07.001, available online at http://www.sciencedirect.com
Perception of oral maxillofacial surgery by health-care professionals
N. S. Rocha1, J. R. Laureano Filho2, E. D. O. Silva2, R. C. A. Almeida2 1 Department of Oral Maxillofacial Surgery, Getulio Vargas Hospital, Recife, Brazil; 2 Department of Oral Maxillofacial Surgery, University of Pernambuco, Recife, Brazil
N. S. Rocha, J. R. Laureano Filho, E. D. O. Silva, R. C. A. Almeida: Perception of oral maxillofacial surgery by health-care professionals. Int. J. Oral Maxillofac. Surg. 2008; 37: 41–46. # 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Oral and Maxillofacial Surgery (OMFS), a dentistry specialty recognized by the Federal Dentistry Board in the mid-1960s, is responsible for the diagnosis, and clinical and surgical treatment of traumatic, congenital, developmental and iatrogenic lesions in the maxillofacial complex. Even today, difficulties are experienced owing to the lack of knowledge of the general public and health professionals concerning the scope of OMFS. To investigate recognition of the scope of OMFS, 400 questionnaires were sent to dentistry students, medical students, dentists and doctors, in 4 equal groups. The questionnaire covered 26 clinical situations in four different specialties (OMFS, Plastic Surgery, Ear Nose and Throat Surgery, Head and Neck Surgery) and an option with no specialty specified. Each interviewee had to correlate the clinical situation with the respective specialist. For facial trauma, dento-facial deformities, mandibular reconstruction and temporomandibular joint surgery, most respondents would consult the OMF surgeon for treatment (mean, 90%). In cases of oral biopsy and treatment of benign mandibular tumours the mean referral rate to OMFS was low (48%). On the basis of the questionnaire responses, a good level of knowledge of the scope of OMFS was found. In order to ensure the correct referral of all patients, the specialty needs to broaden its horizons.
Despite the perception that the public is unfamiliar with what an oral and maxillofacial (OMF) surgeon does, there is currently no supporting evidence to confirm this. Although a survey by HUNTER et al.5 showed that 72% of the public had heard of the specialty, an earlier study conducted by AMEERALLY et al.1 in England revealed that 79% of the general public had never heard of Oral and Maxillofacial Surgery (OMFS). A similar study 10 years later by IFEACHO et al.6 showed an increased awareness of the work undertaken by the specialty. This lack of understanding is even more important when it comes to health professionals. Patients regularly present to their 0901-5027/01041 + 06 $30.00/0
dentists or emergency departments with abnormalities that require the expertise of specialists in OMFS. Our medical and dental colleagues need to have the necessary knowledge to make informed decisions about their patients’ management. The aim of this study was to discover the current levels of awareness of the OMFS specialty in Recife, Brazil, among dentists, doctors, and dental and medical students. Methods
A questionnaire was designed that listed 26 clinical situations and four different specialists, with an option ‘others’ that
Key words: oral maxillofacial surgery; recognition. Accepted for publication 2 July 2007 Available online 18 September 2007
applies to a professional of an unspecified specialty. Respondents were asked to indicate who they would expect to treat them if they had one of a number of specified conditions (Table 1). Demographic data relating to age and gender was also collected. The 400 interviewees where divided into four groups: 100 dentists, 100 physicians, 100 dental students and 100 medical students. Medical and dental students were in the clinical years of their course at the University of Pernambuco and Federal University of Pernambuco. Doctors were interviewed at eight emergency hospitals in the city of Recife. Dentists
# 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
42
Rocha et al.
Table 1. Questionnaire requiring correlation of clinical situation with specialist Specialist
Clinical situation
OMF surgeon Plastic surgeon Head and neck surgeon Otolaryngologist
Mandibular fracture Maxillary fracture Nose fracture Zygomatic fracture Dento-alveolar trauma Cancer of the mouth Removal of salivary gland Biopsy of oral lesion Maxillary cyst Benign mandible tumour Lump in the neck Lump in the mouth Dental implant Child with cleft lip Child with cleft palate Child with cleft lip and palate Removal of wisdom tooth Rhinoplasty Problems with facial appearance Mandibular excess Mandibular deficiency Maxillary deficiency Maxillary excess Mandibular reconstruction Bone graft in the mandible TMJ surgery
answered the questions in the same universities and at Centers of Dental Specialties. The questionnaire was intended to determine the percentage of respondents in each group that made the correct referral of the patients presenting different clinical situations. The questions and the groups were based on those in previous studies to enable comparisons to be made1,5,12.
years, respectively, while that of the dental and medical students was 22.3 and 22.7 years, respectively (Table 2). The sex distribution showed that women were the predominant gender among dental professionals (59%) and dental students (66%), but doctors and medical students presented a lower percentage (41%, 48%) (Table 3). For convenience, the 26 clinical situations were divided into four different categories: trauma, pathology, reconstruction and cosmetic. The results for the four groups of respondents are shown in Tables 4–7. Most respondents (57– 100%) in all four groups would consult an OMFS for fracture of the mandible, maxilla and zygoma. In cases of nasal
Results
Demographic data of the respondents were analysed. The age range was similar in all four groups. The average age of the dental and medical professionals was 35 and 33.2 Table 2. Number and age of respondents Group
Number
Age range (years)
Dental students Dentists Medical students Doctors
100 100 100 100
19–33 22–66 20–29 23–56
Table 3. Evaluation of the respondents according to gender
Gender
Dentist n
Female Male Total
Doctor (%)
n
(%)
Dental student
Medical student
n
n
(%)
Total (%)
n
59 41
59 41
41 59
41 59
66 36
66 36
48 52
48 52
214 186
100
100
100
100
100
100
100
100
400
(%) 53.5 46.5 100
fracture, the referral patterns were more equally distributed, with OMFS ranging from 36 to 76%, plastic surgeon 6–30%, otolaryngologist 8–30% and head and neck surgeon 2–17%. In situations involving pathology (i.e. oral biopsy, benign mandible tumour), there was a significant difference in responses between dental and medical groups (P < .0001). Surprisingly, for oral biopsy, only 26% of medical practitioners (Table 7) and 23% of medical students (Table 6) would consult an OMF surgeon for the procedure, whereas 54% of dental students (Table 4) and 66% of dental practitioners (Table 5) would favour an OMF surgeon. For the treatment of benign mandibular tumour, 69% of dental students (Table 4) and 77% of dentists (Table 5) would most likely consult an OMF surgeon, whereas 58% of medical students (Table 6) and 66% of doctors (Table 7) would rather consult a head and neck surgeon. For a lump in the mouth, most respondents (50–90%) would consult an OMF surgeon for treatment. For maxillary cyst, 64% of doctors (Table 7) and 50% of medical students (Table 6), and 86% of dental practitioners (Table 5) and 75% of dental students (Table 4) would most likely consult an OMF surgeon. For oral carcinoma and removal of salivary gland, most respondents (47– 82%) chose the head and neck surgeon for treatment. A similar response was observed for lump in the neck. For the questions involving reconstructive surgery, there were some differences in terms of what specialty would treat a cleft palate and cleft lip and palate between the medical and dental groups (P < .0003). Dental students (72%) and practitioners (75%) would consult an OMF surgeon for a cleft palate (Tables 4 and 5), whereas medical students (36%) and medical practitioners (62%) (Tables 6 and 7) would rather go to a plastic surgeon. A similar response was found for cleft lip and palate. Conversely, for a cleft lip, most respondents (35–81%) would consult a plastic surgeon for treatment. In cases of mandible reconstruction and mandible graft, an OMF surgeon would be consulted for treatment by most of the respondents (55–96%). For dental-based procedures like removal of wisdom teeth and dental implants, interviewees recognized that an OMF surgeon should be responsible for treatment (60–94%). A high percentage of the respondents chose an OMF surgeon for temporomandibular joint (TMJ) problems that need surgery (80–98%).
43
Perception of oral maxillofacial surgery Table 4. Responses of dental students (N = 100) Plastic surgeon
Otolaryngologist
OMF surgeon
Head and neck surgeon
– – 6 – –
– – 8 – –
100 99 76 91 91
– 1 10 9 2
– – – – 7
Pathology Cancer of the mouth Removal of salivary gland Biopsy of oral lesion Maxillary cyst Benign mandibular tumour Lump in the neck Lump in the mouth
– – – – – 3 2
– 1 – 2 – 1 –
29 40 54 75 69 10 90
47 55 15 14 22 81 6
24 4 31 9 9 5 2
Reconstructive surgery Dental implants Cleft lip Cleft palate Cleft lip and palate Mandibular reconstruction Mandibular graft Removal of wisdom tooth TMJ surgery
– 35 11 16 3 4 – –
– 3 5 7 – – – –
65 50 72 64 96 92 91 96
2 6 6 9 1 2 1 4
33 6 6 4 – 2 8 –
Cosmetic surgery Rhinoplasty Problems with facial appearance Mandibular excess Mandibular deficiency Maxillary excess Maxillary deficiency
97 91 5 2 6 4
1 – – – – –
1 7 91 95 91 91
1 – 4 3 3 5
– 2 – – – –
Trauma Mandibular fracture Maxillary fracture Nasal fracture Zygomatic complex fracture Dento-alveolar fracture
Other
Table 5. Responses of dental practitioners (N = 100) Plastic surgeon
Otolaryngologist
OMF surgeon
– – 17 1 –
– – 30 – –
98 98 48 93 93
2 2 4 4 1
– – 1 2 6
Pathology Cancer of the mouth Removal of salivary gland Biopsy of oral lesion Maxillary cyst Benign mandible tumour Lump in the neck Lump in the mouth
– – – – – – 5
– 1 1 1 – 2 –
33 44 66 86 77 11 87
56 51 13 8 19 80 6
11 4 20 5 4 7 2
Reconstructive surgery Dental implants Cleft lip Cleft palate Cleft lip and palate Mandibular reconstruction Mandibular graft Removal of wisdom tooth TMJ surgery
– 50 17 29 7 1 – –
– – 1 1 – – – –
60 43 75 62 89 95 93 98
1 3 2 3 2 1 1 1
39 4 5 5 2 3 6 1
Cosmetic surgery Rhinoplasty Problems with facial appearance Mandibular excess Mandibular deficiency Maxillary excess Maxillary deficiency
98 95 6 5 5 5
2 – – – – –
– 3 91 83 89 82
– – – 1 1 2
– 2 3 11 5 11
Trauma Mandibular fracture Maxillary fracture Nasal fracture Zygomatic complex fracture Dento-alveolar fracture
Head and neck surgeon
Other
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Rocha et al.
Table 6. Responses of medical students (N = 100) Plastic surgeon
Otolaryngologist
OMF surgeon
Head and neck surgeon
Trauma Mandibular fracture Maxillary fracture Nasal fracture Zygomatic complex fracture Dento-alveolar fracture
Other
1 1 30 8 –
– 1 15 2 1
93 92 36 57 94
5 6 17 32 1
1 – 2 1 4
Pathology Cancer of the mouth Removal of salivary gland Biopsy of oral lesion Maxillary cyst Benign mandibular tumour Lump in the neck Lump in the mouth
1 – 4 2 1 2 22
14 19 9 12 2 6 3
17 22 23 50 32 3 50
52 58 44 33 58 74 19
16 1 20 3 7 15 6
Reconstructive surgery Dental implants Cleft lip Cleft palate Cleft lip and palate Mandibular reconstruction Mandibular graft Removal of wisdom tooth TMJ surgery
2 61 36 35 31 26 – 1
– 5 11 9 1 – – 2
89 18 34 36 55 58 87 80
– 13 15 16 12 16 4 16
9 3 4 4 1 – 9 1
Cosmetic surgery Rhinoplasty Problems with facial appearance Mandibular excess Mandibular deficiency Maxillary excess Maxillary deficiency
95 96 35 28 34 26
1 1 1 1 2 1
2 2 50 56 53 57
2 1 9 13 10 14
– – 5 2 1 2
Otolaryngologist
OMF surgeon
Head and neck surgeon
Table 7. Responses of medical practitioners (N = 100) Plastic surgeon
Other
Trauma Mandibular fracture Maxillary fracture Nasal fracture Zygomatic complex fracture Dento-alveolar fracture
2 2 24 8 –
2 1 26 4 –
94 94 45 81 98
2 3 5 7 –
– – – – 2
Pathology Cancer of the mouth Removal of salivary gland Biopsy oral lesion Maxillary cyst Benign mandibular tumour Lump in the neck Lump in the mouth
– – – – – – 15
3 2 3 15 – – –
10 13 27 64 34 – 78
82 85 67 21 66 91 5
5 – 3 – – 9 2
Reconstructive surgery Dental implants Cleft lip Cleft palate Cleft lip and palate Mandibular reconstruction Mandibular graft Removal of wisdom tooth TMJ surgery
– 81 62 64 16 20 – 1
– 4 7 13 – – – –
94 5 16 8 81 80 89 93
– 8 15 15 3 – 3 6
6 2 – – – – 8 –
97 100 21 19 17 20
3 – – – – –
– – 76 78 80 77
– – 1 1 – 3
– – 2 2 3 –
Cosmetic surgery Rhinoplasty Problems with facial appearance Mandibular excess Mandibular deficiency Maxillary excess Maxillary deficiency
Perception of oral maxillofacial surgery With regard to cosmetic procedures, problems with facial appearance and rhinoplasty led to a definite predilection for a plastic surgeon among all respondents (91–100%). In all cases of dentofacial deformities involving maxilla and mandible, a majority of all groups surveyed would most likely consult an OMF surgeon for treatment (50–95%). Discussion
The scope of different dental and medical specialties still produces some confusion, especially among the general public. The majority of health-care professionals recognize OMFS, but some students and professionals are not aware of the wide surgical field of the specialty7,10. The adult and paediatric OMFS services in the state of Pernambuco are centralized in the capital, Recife, and serve a population of 5.5 million. Peripheral hospitals provide OMFS services through outpatient clinics and day-care facilities. The four principal emergency hospitals provide all aspects of OMFS and take referrals from all GPs and dentists in the area. Otolaryngology and plastic surgery are similarly organized. AMEERALLY et al.1 stated that if patients are to receive the optimal treatment for oral and facial problems, dental and medical practitioners need to have a better understanding of what our specialty has to offer. OMFS has a long and complicated Latin name, and health coordinators have to be informed of the importance of this specialty in the management of complex and diverse problems within a welldefined anatomical area. These authors suggested changing to a much simpler name such as ‘Oral and Facial Surgery’, and also advocated a better system of education for both the public and professionals, including medical and dental students. HUNTER et al.5 demonstrated that, not surprisingly, most professionals, dental and medical students have heard of OMFS, but only a few realize the full scope of the specialty. They attribute this to a lack of publicity in the media, along with the fact that OMFS is grounded in dentistry rather than medicine. There is also a tremendous overlap between the specialties otolaryngology, plastic surgery and OMFS with no definite procedure specific to each specialty. PARNES13 stated that in 1993 the governing bodies of the American Association of Oral and Maxillofacial Surgery formed a task force to discuss a possible name change for the specialty. Any change from
the current name was rejected at that time. One of the concerns over changing the name was that another specialty of dentistry or medicine might adopt the abandoned. IFEACHO et al.6, 10 years later, compared their results with those of AMEERALLY et al.1, and noticed that recognition of OMFS among the general public and health professionals had increased (21– 34%), but that the specialty had improved only marginally. Their results suggest that there was a clear division in awareness between conditions relating to the mouth and those outside the mouth in the head and neck region, despite the latter being well within the scope of OMFS. The need for publicity is underscored by the authors, particularly on account of the unusual name, which lay people do not understand or easily remember. LASKIN et al.8 evaluated knowledge of 12 different specialties to determine whether such unfamiliarity is true only for OMFS or whether it occurs with other specialties. The result of this study showed that name recognition was not a problem only for OMFS. Although this does not mean that no effort should be made to inform the public about what OMF surgeons do, it does indicate that no name alone can ever be completely descriptive11,15,16. In general, the present survey demonstrated that most situations involving facial trauma, such as mandible, zygoma, maxilla and dento-alveolar fracture, would most likely be referred to an OMF surgeon. Nasal fracture presented an equal distribution between OMFS, plastic surgery and otolaryngology. This is justified primarily by the fact that the nasal area is an anatomical site where all three specialties are responsible for treatment and for trauma situations with no specific procedures for each specialty14. Similar results were found in previous studies1,5,6,9,12. With respect to pathologic conditions, medical students and practitioners believed that head and neck surgeons were more qualified in the treatment of benign mandible tumour and oral biopsy, whereas dental students and practitioners would rather consult an OMF surgeon. In the treatment of maxillary cyst and lump in the mouth most respondents agreed that they would rather consult an OMF surgeon. This suggests that most medical students and professionals recognize OMFS, but they are not clear about what clinical expertise the specialty offers. Oral carcinoma and lump in the neck were referred to a head and neck surgeon by
45
most of the respondents (47–82%). In Brazil, the professional responsible for the surgical management of oral cancer is the head and neck surgeon. The answers to the questions on TMJ surgery, mandible reconstruction and mandible graft showed that a higher percentage of the interviewees would consult an OMF surgeon for treatment. The same occurred with dental implants and removal of wisdom teeth. These results differed from those of the study by HUN5 TER et al. The treatment of cleft lip and palate deformities demonstrated a difference between dental students and professionals, who preferred OMFS for the management of cleft palate and cleft lip and palate, and medical students and professionals, who recommended the plastic surgeon in the same situation. It is clear nowadays that these patients need a number of different specialties, and surgeons with formal training and experience in all phases of care, regardless of the specialty to which they belong. Management of dentofacial deformities may be correlated by lay people with some of the aesthetic procedures performed by a plastic surgeon. The results here showed high recognition of OMFS by all four groups in the surgical correction of such deformities. This survey was performed only in the Recife area, and therefore the results may not be applicable elsewhere. Regional variations exist, and surgeons are responsible for educating their own community and referral circles about the scope of their practice, which will depend on training, experience and areas of interest. It is clear that greater progress needs to be made in the education of medical and dental students, as well as the general public, if the specialty of OMFS is to be practiced to its full potential2–5. References 1. Ameerally P, Fordyce AM, Martin IC. So you think they know what we do? The public and professional perception of Oral Maxillofacial Surgery. Br J Oral Maxillofac Surg 1994: 32: 142–145. 2. Brennan DS, Spencer AJ, Singh KA, Teusner DN, Goss AN. Practice activity trends among Oral Maxillofacial surgeons in Australia. BMC Health Services Res 2004: 4: 37. 3. Dodson TB, Guralnick WC, Donoff RB, Kaban LB. Massachusetts General Hospital/Harvard Medical School MD Oral Maxillofacial Surgery Program: A 30-year review. J Oral Maxillofac Surg 2004: 62: 62–65.
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4. Ferreira RA. Me´dico ou Dentista? De quem e´ o bisturi? Rev Assoc Paul Cirurg Dent 1997: 51: 9–19. 5. Hunter MJ, Rubeiz T, Rose L. Recognition of the scope of Oral and Maxillofacial Surgery by the public and health care professionals. J Oral Maxillofac Surg 1996: 54: 1227–1232. 6. Ifeacho SN, Malhi GK, James G. Perception by the public and medical profession of Oral Maxillofacial Surgery—has it changed after 10 years. Br J Oral Maxillofac Surg 2005: 43: 289–293. 7. Laskin DM. Considering the patient as well as the problem. J Oral Maxillofac Surg 1996: 54: 1049. 8. Laskin DM, Ellis Jr JA, Best AM. Public recognition of specialty designations. J Oral Maxillofac Surg 2002: 60: 1182–1185. 9. Le BT, Holmgren EP, Holmes JD, Ueeck BA, Dierks EJ. Referral patterns for the treatment of facial trauma in teaching hospitals in the United States.
10.
11.
12.
13.
14.
J Oral Maxillofac Surg 2003: 61: 557– 560. Lesny RJ. A Survey of resident selection procedures in Oral Maxillofacial Surgery. J Oral Maxillofac Surg 2000: 58: 666– 667. McArdle PJ, Whitnall M. The referral practice of general medical practitioners to the surgical specialties: implications for the future. Br J Oral Maxillofac Surg 1996: 34: 394–399. Moreira RWF, Nogueira EC, Passeri LA, Ambrosano GMB. Nı´vel de conhecimento do pu´blico e profissionais de sau´de sobre a cirurgia bucomaxilofacial. Rev Fac Odont Passo Fundo 2000: 5: 47– 51. Parnes EI. Recognition of the scope of oral and maxillofacial surgery by the public and health care professionals— Discussion. J Oral Maxillofac Surg 1996: 54: 1233. Sherick DG, Buchman SR, Patel PP. Pediatric facial fractures: Analysis of dif-
ferences in subspeciality care. Plast Reconstr Surg 1998: 102: 28. 15. Spina AM, Smith TA, Marciani RD, Marshall EO. A Survey of resident selection procedures in Oral Maxillofacial Surgery. J Oral Maxillofac Surg 2000: 58: 660–666. 16. Szuster FSP, Nastri AL, Goss AN, Spencer AJ. Survey of Australian and New Zealand Oral Maxillofacial Surgery trainees and recent specialists—education and experience. Int J Oral Maxillofac Surg 2000: 29: 305–308. Address: Nelson Studart Rocha Getulio Vargas Hospital Department of Oral Maxillofacial Surgery Desembargador Martins Pereira Street 257/102 Grac¸as 52050-220 Recife PE Brazil E-mail: [email protected]
Perception of oral maxillofacial surgery by health-care professionals
N. S. Rocha1, J. R. Laureano Filho2, E. D. O. Silva2, R. C. A. Almeida2 1 Department of Oral Maxillofacial Surgery, Getulio Vargas Hospital, Recife, Brazil; 2 Department of Oral Maxillofacial Surgery, University of Pernambuco, Recife, Brazil
N. S. Rocha, J. R. Laureano Filho, E. D. O. Silva, R. C. A. Almeida: Perception of oral maxillofacial surgery by health-care professionals. Int. J. Oral Maxillofac. Surg. 2008; 37: 41–46. # 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Oral and Maxillofacial Surgery (OMFS), a dentistry specialty recognized by the Federal Dentistry Board in the mid-1960s, is responsible for the diagnosis, and clinical and surgical treatment of traumatic, congenital, developmental and iatrogenic lesions in the maxillofacial complex. Even today, difficulties are experienced owing to the lack of knowledge of the general public and health professionals concerning the scope of OMFS. To investigate recognition of the scope of OMFS, 400 questionnaires were sent to dentistry students, medical students, dentists and doctors, in 4 equal groups. The questionnaire covered 26 clinical situations in four different specialties (OMFS, Plastic Surgery, Ear Nose and Throat Surgery, Head and Neck Surgery) and an option with no specialty specified. Each interviewee had to correlate the clinical situation with the respective specialist. For facial trauma, dento-facial deformities, mandibular reconstruction and temporomandibular joint surgery, most respondents would consult the OMF surgeon for treatment (mean, 90%). In cases of oral biopsy and treatment of benign mandibular tumours the mean referral rate to OMFS was low (48%). On the basis of the questionnaire responses, a good level of knowledge of the scope of OMFS was found. In order to ensure the correct referral of all patients, the specialty needs to broaden its horizons.
Despite the perception that the public is unfamiliar with what an oral and maxillofacial (OMF) surgeon does, there is currently no supporting evidence to confirm this. Although a survey by HUNTER et al.5 showed that 72% of the public had heard of the specialty, an earlier study conducted by AMEERALLY et al.1 in England revealed that 79% of the general public had never heard of Oral and Maxillofacial Surgery (OMFS). A similar study 10 years later by IFEACHO et al.6 showed an increased awareness of the work undertaken by the specialty. This lack of understanding is even more important when it comes to health professionals. Patients regularly present to their 0901-5027/01041 + 06 $30.00/0
dentists or emergency departments with abnormalities that require the expertise of specialists in OMFS. Our medical and dental colleagues need to have the necessary knowledge to make informed decisions about their patients’ management. The aim of this study was to discover the current levels of awareness of the OMFS specialty in Recife, Brazil, among dentists, doctors, and dental and medical students. Methods
A questionnaire was designed that listed 26 clinical situations and four different specialists, with an option ‘others’ that
Key words: oral maxillofacial surgery; recognition. Accepted for publication 2 July 2007 Available online 18 September 2007
applies to a professional of an unspecified specialty. Respondents were asked to indicate who they would expect to treat them if they had one of a number of specified conditions (Table 1). Demographic data relating to age and gender was also collected. The 400 interviewees where divided into four groups: 100 dentists, 100 physicians, 100 dental students and 100 medical students. Medical and dental students were in the clinical years of their course at the University of Pernambuco and Federal University of Pernambuco. Doctors were interviewed at eight emergency hospitals in the city of Recife. Dentists
# 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
42
Rocha et al.
Table 1. Questionnaire requiring correlation of clinical situation with specialist Specialist
Clinical situation
OMF surgeon Plastic surgeon Head and neck surgeon Otolaryngologist
Mandibular fracture Maxillary fracture Nose fracture Zygomatic fracture Dento-alveolar trauma Cancer of the mouth Removal of salivary gland Biopsy of oral lesion Maxillary cyst Benign mandible tumour Lump in the neck Lump in the mouth Dental implant Child with cleft lip Child with cleft palate Child with cleft lip and palate Removal of wisdom tooth Rhinoplasty Problems with facial appearance Mandibular excess Mandibular deficiency Maxillary deficiency Maxillary excess Mandibular reconstruction Bone graft in the mandible TMJ surgery
answered the questions in the same universities and at Centers of Dental Specialties. The questionnaire was intended to determine the percentage of respondents in each group that made the correct referral of the patients presenting different clinical situations. The questions and the groups were based on those in previous studies to enable comparisons to be made1,5,12.
years, respectively, while that of the dental and medical students was 22.3 and 22.7 years, respectively (Table 2). The sex distribution showed that women were the predominant gender among dental professionals (59%) and dental students (66%), but doctors and medical students presented a lower percentage (41%, 48%) (Table 3). For convenience, the 26 clinical situations were divided into four different categories: trauma, pathology, reconstruction and cosmetic. The results for the four groups of respondents are shown in Tables 4–7. Most respondents (57– 100%) in all four groups would consult an OMFS for fracture of the mandible, maxilla and zygoma. In cases of nasal
Results
Demographic data of the respondents were analysed. The age range was similar in all four groups. The average age of the dental and medical professionals was 35 and 33.2 Table 2. Number and age of respondents Group
Number
Age range (years)
Dental students Dentists Medical students Doctors
100 100 100 100
19–33 22–66 20–29 23–56
Table 3. Evaluation of the respondents according to gender
Gender
Dentist n
Female Male Total
Doctor (%)
n
(%)
Dental student
Medical student
n
n
(%)
Total (%)
n
59 41
59 41
41 59
41 59
66 36
66 36
48 52
48 52
214 186
100
100
100
100
100
100
100
100
400
(%) 53.5 46.5 100
fracture, the referral patterns were more equally distributed, with OMFS ranging from 36 to 76%, plastic surgeon 6–30%, otolaryngologist 8–30% and head and neck surgeon 2–17%. In situations involving pathology (i.e. oral biopsy, benign mandible tumour), there was a significant difference in responses between dental and medical groups (P < .0001). Surprisingly, for oral biopsy, only 26% of medical practitioners (Table 7) and 23% of medical students (Table 6) would consult an OMF surgeon for the procedure, whereas 54% of dental students (Table 4) and 66% of dental practitioners (Table 5) would favour an OMF surgeon. For the treatment of benign mandibular tumour, 69% of dental students (Table 4) and 77% of dentists (Table 5) would most likely consult an OMF surgeon, whereas 58% of medical students (Table 6) and 66% of doctors (Table 7) would rather consult a head and neck surgeon. For a lump in the mouth, most respondents (50–90%) would consult an OMF surgeon for treatment. For maxillary cyst, 64% of doctors (Table 7) and 50% of medical students (Table 6), and 86% of dental practitioners (Table 5) and 75% of dental students (Table 4) would most likely consult an OMF surgeon. For oral carcinoma and removal of salivary gland, most respondents (47– 82%) chose the head and neck surgeon for treatment. A similar response was observed for lump in the neck. For the questions involving reconstructive surgery, there were some differences in terms of what specialty would treat a cleft palate and cleft lip and palate between the medical and dental groups (P < .0003). Dental students (72%) and practitioners (75%) would consult an OMF surgeon for a cleft palate (Tables 4 and 5), whereas medical students (36%) and medical practitioners (62%) (Tables 6 and 7) would rather go to a plastic surgeon. A similar response was found for cleft lip and palate. Conversely, for a cleft lip, most respondents (35–81%) would consult a plastic surgeon for treatment. In cases of mandible reconstruction and mandible graft, an OMF surgeon would be consulted for treatment by most of the respondents (55–96%). For dental-based procedures like removal of wisdom teeth and dental implants, interviewees recognized that an OMF surgeon should be responsible for treatment (60–94%). A high percentage of the respondents chose an OMF surgeon for temporomandibular joint (TMJ) problems that need surgery (80–98%).
43
Perception of oral maxillofacial surgery Table 4. Responses of dental students (N = 100) Plastic surgeon
Otolaryngologist
OMF surgeon
Head and neck surgeon
– – 6 – –
– – 8 – –
100 99 76 91 91
– 1 10 9 2
– – – – 7
Pathology Cancer of the mouth Removal of salivary gland Biopsy of oral lesion Maxillary cyst Benign mandibular tumour Lump in the neck Lump in the mouth
– – – – – 3 2
– 1 – 2 – 1 –
29 40 54 75 69 10 90
47 55 15 14 22 81 6
24 4 31 9 9 5 2
Reconstructive surgery Dental implants Cleft lip Cleft palate Cleft lip and palate Mandibular reconstruction Mandibular graft Removal of wisdom tooth TMJ surgery
– 35 11 16 3 4 – –
– 3 5 7 – – – –
65 50 72 64 96 92 91 96
2 6 6 9 1 2 1 4
33 6 6 4 – 2 8 –
Cosmetic surgery Rhinoplasty Problems with facial appearance Mandibular excess Mandibular deficiency Maxillary excess Maxillary deficiency
97 91 5 2 6 4
1 – – – – –
1 7 91 95 91 91
1 – 4 3 3 5
– 2 – – – –
Trauma Mandibular fracture Maxillary fracture Nasal fracture Zygomatic complex fracture Dento-alveolar fracture
Other
Table 5. Responses of dental practitioners (N = 100) Plastic surgeon
Otolaryngologist
OMF surgeon
– – 17 1 –
– – 30 – –
98 98 48 93 93
2 2 4 4 1
– – 1 2 6
Pathology Cancer of the mouth Removal of salivary gland Biopsy of oral lesion Maxillary cyst Benign mandible tumour Lump in the neck Lump in the mouth
– – – – – – 5
– 1 1 1 – 2 –
33 44 66 86 77 11 87
56 51 13 8 19 80 6
11 4 20 5 4 7 2
Reconstructive surgery Dental implants Cleft lip Cleft palate Cleft lip and palate Mandibular reconstruction Mandibular graft Removal of wisdom tooth TMJ surgery
– 50 17 29 7 1 – –
– – 1 1 – – – –
60 43 75 62 89 95 93 98
1 3 2 3 2 1 1 1
39 4 5 5 2 3 6 1
Cosmetic surgery Rhinoplasty Problems with facial appearance Mandibular excess Mandibular deficiency Maxillary excess Maxillary deficiency
98 95 6 5 5 5
2 – – – – –
– 3 91 83 89 82
– – – 1 1 2
– 2 3 11 5 11
Trauma Mandibular fracture Maxillary fracture Nasal fracture Zygomatic complex fracture Dento-alveolar fracture
Head and neck surgeon
Other
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Table 6. Responses of medical students (N = 100) Plastic surgeon
Otolaryngologist
OMF surgeon
Head and neck surgeon
Trauma Mandibular fracture Maxillary fracture Nasal fracture Zygomatic complex fracture Dento-alveolar fracture
Other
1 1 30 8 –
– 1 15 2 1
93 92 36 57 94
5 6 17 32 1
1 – 2 1 4
Pathology Cancer of the mouth Removal of salivary gland Biopsy of oral lesion Maxillary cyst Benign mandibular tumour Lump in the neck Lump in the mouth
1 – 4 2 1 2 22
14 19 9 12 2 6 3
17 22 23 50 32 3 50
52 58 44 33 58 74 19
16 1 20 3 7 15 6
Reconstructive surgery Dental implants Cleft lip Cleft palate Cleft lip and palate Mandibular reconstruction Mandibular graft Removal of wisdom tooth TMJ surgery
2 61 36 35 31 26 – 1
– 5 11 9 1 – – 2
89 18 34 36 55 58 87 80
– 13 15 16 12 16 4 16
9 3 4 4 1 – 9 1
Cosmetic surgery Rhinoplasty Problems with facial appearance Mandibular excess Mandibular deficiency Maxillary excess Maxillary deficiency
95 96 35 28 34 26
1 1 1 1 2 1
2 2 50 56 53 57
2 1 9 13 10 14
– – 5 2 1 2
Otolaryngologist
OMF surgeon
Head and neck surgeon
Table 7. Responses of medical practitioners (N = 100) Plastic surgeon
Other
Trauma Mandibular fracture Maxillary fracture Nasal fracture Zygomatic complex fracture Dento-alveolar fracture
2 2 24 8 –
2 1 26 4 –
94 94 45 81 98
2 3 5 7 –
– – – – 2
Pathology Cancer of the mouth Removal of salivary gland Biopsy oral lesion Maxillary cyst Benign mandibular tumour Lump in the neck Lump in the mouth
– – – – – – 15
3 2 3 15 – – –
10 13 27 64 34 – 78
82 85 67 21 66 91 5
5 – 3 – – 9 2
Reconstructive surgery Dental implants Cleft lip Cleft palate Cleft lip and palate Mandibular reconstruction Mandibular graft Removal of wisdom tooth TMJ surgery
– 81 62 64 16 20 – 1
– 4 7 13 – – – –
94 5 16 8 81 80 89 93
– 8 15 15 3 – 3 6
6 2 – – – – 8 –
97 100 21 19 17 20
3 – – – – –
– – 76 78 80 77
– – 1 1 – 3
– – 2 2 3 –
Cosmetic surgery Rhinoplasty Problems with facial appearance Mandibular excess Mandibular deficiency Maxillary excess Maxillary deficiency
Perception of oral maxillofacial surgery With regard to cosmetic procedures, problems with facial appearance and rhinoplasty led to a definite predilection for a plastic surgeon among all respondents (91–100%). In all cases of dentofacial deformities involving maxilla and mandible, a majority of all groups surveyed would most likely consult an OMF surgeon for treatment (50–95%). Discussion
The scope of different dental and medical specialties still produces some confusion, especially among the general public. The majority of health-care professionals recognize OMFS, but some students and professionals are not aware of the wide surgical field of the specialty7,10. The adult and paediatric OMFS services in the state of Pernambuco are centralized in the capital, Recife, and serve a population of 5.5 million. Peripheral hospitals provide OMFS services through outpatient clinics and day-care facilities. The four principal emergency hospitals provide all aspects of OMFS and take referrals from all GPs and dentists in the area. Otolaryngology and plastic surgery are similarly organized. AMEERALLY et al.1 stated that if patients are to receive the optimal treatment for oral and facial problems, dental and medical practitioners need to have a better understanding of what our specialty has to offer. OMFS has a long and complicated Latin name, and health coordinators have to be informed of the importance of this specialty in the management of complex and diverse problems within a welldefined anatomical area. These authors suggested changing to a much simpler name such as ‘Oral and Facial Surgery’, and also advocated a better system of education for both the public and professionals, including medical and dental students. HUNTER et al.5 demonstrated that, not surprisingly, most professionals, dental and medical students have heard of OMFS, but only a few realize the full scope of the specialty. They attribute this to a lack of publicity in the media, along with the fact that OMFS is grounded in dentistry rather than medicine. There is also a tremendous overlap between the specialties otolaryngology, plastic surgery and OMFS with no definite procedure specific to each specialty. PARNES13 stated that in 1993 the governing bodies of the American Association of Oral and Maxillofacial Surgery formed a task force to discuss a possible name change for the specialty. Any change from
the current name was rejected at that time. One of the concerns over changing the name was that another specialty of dentistry or medicine might adopt the abandoned. IFEACHO et al.6, 10 years later, compared their results with those of AMEERALLY et al.1, and noticed that recognition of OMFS among the general public and health professionals had increased (21– 34%), but that the specialty had improved only marginally. Their results suggest that there was a clear division in awareness between conditions relating to the mouth and those outside the mouth in the head and neck region, despite the latter being well within the scope of OMFS. The need for publicity is underscored by the authors, particularly on account of the unusual name, which lay people do not understand or easily remember. LASKIN et al.8 evaluated knowledge of 12 different specialties to determine whether such unfamiliarity is true only for OMFS or whether it occurs with other specialties. The result of this study showed that name recognition was not a problem only for OMFS. Although this does not mean that no effort should be made to inform the public about what OMF surgeons do, it does indicate that no name alone can ever be completely descriptive11,15,16. In general, the present survey demonstrated that most situations involving facial trauma, such as mandible, zygoma, maxilla and dento-alveolar fracture, would most likely be referred to an OMF surgeon. Nasal fracture presented an equal distribution between OMFS, plastic surgery and otolaryngology. This is justified primarily by the fact that the nasal area is an anatomical site where all three specialties are responsible for treatment and for trauma situations with no specific procedures for each specialty14. Similar results were found in previous studies1,5,6,9,12. With respect to pathologic conditions, medical students and practitioners believed that head and neck surgeons were more qualified in the treatment of benign mandible tumour and oral biopsy, whereas dental students and practitioners would rather consult an OMF surgeon. In the treatment of maxillary cyst and lump in the mouth most respondents agreed that they would rather consult an OMF surgeon. This suggests that most medical students and professionals recognize OMFS, but they are not clear about what clinical expertise the specialty offers. Oral carcinoma and lump in the neck were referred to a head and neck surgeon by
45
most of the respondents (47–82%). In Brazil, the professional responsible for the surgical management of oral cancer is the head and neck surgeon. The answers to the questions on TMJ surgery, mandible reconstruction and mandible graft showed that a higher percentage of the interviewees would consult an OMF surgeon for treatment. The same occurred with dental implants and removal of wisdom teeth. These results differed from those of the study by HUN5 TER et al. The treatment of cleft lip and palate deformities demonstrated a difference between dental students and professionals, who preferred OMFS for the management of cleft palate and cleft lip and palate, and medical students and professionals, who recommended the plastic surgeon in the same situation. It is clear nowadays that these patients need a number of different specialties, and surgeons with formal training and experience in all phases of care, regardless of the specialty to which they belong. Management of dentofacial deformities may be correlated by lay people with some of the aesthetic procedures performed by a plastic surgeon. The results here showed high recognition of OMFS by all four groups in the surgical correction of such deformities. This survey was performed only in the Recife area, and therefore the results may not be applicable elsewhere. Regional variations exist, and surgeons are responsible for educating their own community and referral circles about the scope of their practice, which will depend on training, experience and areas of interest. It is clear that greater progress needs to be made in the education of medical and dental students, as well as the general public, if the specialty of OMFS is to be practiced to its full potential2–5. References 1. Ameerally P, Fordyce AM, Martin IC. So you think they know what we do? The public and professional perception of Oral Maxillofacial Surgery. Br J Oral Maxillofac Surg 1994: 32: 142–145. 2. Brennan DS, Spencer AJ, Singh KA, Teusner DN, Goss AN. Practice activity trends among Oral Maxillofacial surgeons in Australia. BMC Health Services Res 2004: 4: 37. 3. Dodson TB, Guralnick WC, Donoff RB, Kaban LB. Massachusetts General Hospital/Harvard Medical School MD Oral Maxillofacial Surgery Program: A 30-year review. J Oral Maxillofac Surg 2004: 62: 62–65.
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4. Ferreira RA. Me´dico ou Dentista? De quem e´ o bisturi? Rev Assoc Paul Cirurg Dent 1997: 51: 9–19. 5. Hunter MJ, Rubeiz T, Rose L. Recognition of the scope of Oral and Maxillofacial Surgery by the public and health care professionals. J Oral Maxillofac Surg 1996: 54: 1227–1232. 6. Ifeacho SN, Malhi GK, James G. Perception by the public and medical profession of Oral Maxillofacial Surgery—has it changed after 10 years. Br J Oral Maxillofac Surg 2005: 43: 289–293. 7. Laskin DM. Considering the patient as well as the problem. J Oral Maxillofac Surg 1996: 54: 1049. 8. Laskin DM, Ellis Jr JA, Best AM. Public recognition of specialty designations. J Oral Maxillofac Surg 2002: 60: 1182–1185. 9. Le BT, Holmgren EP, Holmes JD, Ueeck BA, Dierks EJ. Referral patterns for the treatment of facial trauma in teaching hospitals in the United States.
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J Oral Maxillofac Surg 2003: 61: 557– 560. Lesny RJ. A Survey of resident selection procedures in Oral Maxillofacial Surgery. J Oral Maxillofac Surg 2000: 58: 666– 667. McArdle PJ, Whitnall M. The referral practice of general medical practitioners to the surgical specialties: implications for the future. Br J Oral Maxillofac Surg 1996: 34: 394–399. Moreira RWF, Nogueira EC, Passeri LA, Ambrosano GMB. Nı´vel de conhecimento do pu´blico e profissionais de sau´de sobre a cirurgia bucomaxilofacial. Rev Fac Odont Passo Fundo 2000: 5: 47– 51. Parnes EI. Recognition of the scope of oral and maxillofacial surgery by the public and health care professionals— Discussion. J Oral Maxillofac Surg 1996: 54: 1233. Sherick DG, Buchman SR, Patel PP. Pediatric facial fractures: Analysis of dif-
ferences in subspeciality care. Plast Reconstr Surg 1998: 102: 28. 15. Spina AM, Smith TA, Marciani RD, Marshall EO. A Survey of resident selection procedures in Oral Maxillofacial Surgery. J Oral Maxillofac Surg 2000: 58: 660–666. 16. Szuster FSP, Nastri AL, Goss AN, Spencer AJ. Survey of Australian and New Zealand Oral Maxillofacial Surgery trainees and recent specialists—education and experience. Int J Oral Maxillofac Surg 2000: 29: 305–308. Address: Nelson Studart Rocha Getulio Vargas Hospital Department of Oral Maxillofacial Surgery Desembargador Martins Pereira Street 257/102 Grac¸as 52050-220 Recife PE Brazil E-mail: [email protected]