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.  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.  The latter causes higher patient costs in addition to increased risk of management by health care providers not entirely skilled in a given case.  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.  The orbital fracture findings contradict Haron et al.’s 2013 study, which stated medical doctors were less likely to refer to OMFS.  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. 
Government-funded hospitals in Kuwait established broad guidelines on referrals.  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. , 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 cavity (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.  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.  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.  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.