Orofacial pain and jaw function in children and adolescents : epidemiology, biopsychosocial implications and caregivers' approach

Relying on practitioner knowledge of the diagnosis and treatment of orofacial pain (OFP) and temporomandibular disorders (TMD) in children and adolescents tends to be insufficient for effective dental practice. To improve overall performance, it is crucial to discuss topics related to practitioner competency, including professional knowledge and its associated perspectives. In light of the prevalence of OFP/TMD, insufficient knowledge in this area might result in under-treatment of children with these conditions.

This thesis consists of four studies. Studies I and II aimed to examine professional knowledge among Swedish and Saudi Arabian practitioners regarding several aspects of OFP/TMD in children and adolescents. Further, the studies investigated whether there is a need to improve education and practices in this field, especially in Saudi Arabia. Studies III & IV investigated the prevalence of OFP/TMD in the general population of Jeddah in Saudi Arabia by determining the number of children and adolescents with diagnoses of TMD in 2014. Further, III & IV aimed to examine which biopsychosocial perspectives possibly affect the incidence of TMD.

In studies I and II, we sent a questionnaire comprised of four domains on OFP/TMD knowledge to 383 dental and medical practitioners (general practicing and specialists) in Sweden and Saudi Arabia. The questionnaire used an 11-point modified Likert scale (0-10) as the response format and all responses were compared to those of the reference group, Swedish specialists in OFP/TMD. We added 10 questions to the questionnaire that allowed the participants to assess their own knowledge. Studies III & IV included 456 children and adolescents (aged 10–18 years), selected from schools (boys and girls separately) in the five major regions of the city of Jeddah, Saudi Arabia. Both schools and school-classes were randomly selected. The children’s examinations followed the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD [Axis I & II]). However, for Axis II of the RDC/TMD, we replaced the Symptom Checklist-90-Revised (SCL-90-R) with the Youth Self Report (YSR). All children and adolescents underwent screening for TMD.

The main findings from Studies I and II indicate limitations in almost all domains of professional knowledge among the dental and medical practitioners in both countries with regard to OFP/TMD. Agreement between the Swedish general practitioners and the reference group, however, was higher than between the Saudi Arabian practitioners and the reference group. Highest agreement occurred between Swedish specialists in oral and maxillofacial surgery and the reference group. On the other hand, there were significant associations in self-assessment of professional knowledge among almost all Swedish groups in all domains except for Chronic pain and Pain behavior. In the Saudi Arabian group, however, there was only a significant association in the Diagnosis and classification domain. The main finding from Studies III & IV was a prevalence of diagnosed TMD in children and adolescents among the Saudi Arabian general population of 27.2%. The studies also found indications of a significant association between a TMD diagnosis and self-reported OFP and/or headache that occurs once a week or more. The same studies reported that aggressive behaviors, depression, anxiety, stomachache, sleeplessness, feeling tired and dizzy, and eye problems are significantly associated with a painful TMD diagnosis compared to children and adolescents with a non-painful TMD diagnosis.

Taking all these studies together, the thesis concludes that there are gaps in professional knowledge of OFP/TMD among both medical and dental practitioners in Sweden and Saudi Arabia. Nevertheless, both professional knowledge and selfassessment ability seem to be higher among Swedish practitioners than Saudi Arabian. This difference suggests improving and modernizing educational methods in undergraduate and postgraduate studies in Saudi Arabia. It also suggests improving the OFP/TMD curriculum in Sweden, especially regarding Chronic pain and pain behavior. Moreover, the results from the present thesis found indications of a high prevalence of TMD among children and adolescents in Saudi Arabia. The prevalence in Saudi Arabia is also high when compared to counterpart studies in Brazil, Germany, and China using the same methodology. No certain conclusions can be drawn from a single study in one country, despite the high prevalence of TMD found, so future studies in other countries are warranted. Similar to many studies, the current results showed a significant association between painful TMD conditions and biopsychosocial factors when compared to pain-free TMD conditions. These findings indicate a need to improve OFP/TMD education in Saudi Arabia and suggest the need for an accredited OFP/TMD specialty in Saudi Arabia.

List of scientific papers

I. Al-Khotani A, Naimi-Akbar A, Björnsson O, Christidis N, Alstergren P. Professional knowledge among Swedish and Saudi healthcare practitioners regarding oro‐facial pain in children and adolescents. Journal of Oral Rehabilitation. 2016 Jan;43(1):1-9
https://doi.org/10.1111/joor.12330

II. Al-Khotani A, Björnsson O, Naimi-Akbar A, Christidis N, Alstergren P. Study on self‐assessment regarding knowledge of temporomandibular disorders in children/adolescents by Swedish and Saudi Arabian dentists. Acta Odontologica Scandinavica. 2015;73(7):522-9
https://doi.org/10.3109/00016357.2014.997794

III. Al-Khotani A, Naimi-Akbar A, Albadawi E, Ernberg M, Hedenberg-Magnusson B, Christidis N. Prevalence of diagnosed TMD among children and adolescents : a cross‐sectional epidemiological study in the general population. [Accepted]
https://doi.org/10.1186/s10194-016-0642-9

IV. Al-Khotani A, Naimi-Akbar A, Gjelset M, Albadawi E, Bello L, Hedenberg-Magnusson B, Christidis N. The associations between psychosocial aspects and TMD‐pain related aspects in children and adolescents. The Journal of Headache and Pain. 2016, 17:30.
https://doi.org/10.1186/s10194-016-0622-0