Barriers to improved orofacial pain practice in Saudi Arabia

Background: Orofacial pain (OFP), an emerging field in dentistry, is associated with evaluation diagnosis, and treatment of non-odontogenic disorders affecting the mouth, jaws and face. The aim of this study was to investigate the barriers encountered by Saudi dentists engaged in OFP practice. Methods: A cross-sectional survey study was performed using a validated closed-end questionnaire that was distributed to the general dental practitioners (GDPs) and dental specialists in four major provinces in Saudi Arabia: Riyadh, Makkah, Asir, and Eastern Province. Inclusion criteria were registration with the Saudi Commission for Health Specialties and a minimum of 2 years’ experience. The collected data were analysed using descriptive parameters. Results: Three-hundred-and-forty questionnaires were completed by 168 males and 172 females. Around two-third of the participants were GDPs (60.9%), and the remainder were dental specialists. There was an obvious consensus by the participants that "Low payment/reimbursement" and “Lack of OFP knowledge” were among the most common barriers (85% and 83.5%, respectively; both P-value < 0.01). In contrast, "Legal risks" was the least frequently reported factor (38.8%; P-value < 0.01). The most commonly reported barrier by GPDs was “Shortage of patients/lack of demand;” this was significantly different from the experience of dental specialists (87% vs. 72.2%; P- value < 0.01). In terms of the country of graduation or years of experience, there were no significant differences Conclusion: The current study demonstrates the existence of many significant barriers other than OFP knowledge, such as reimbursement, facility, and demand that could present obstacles and challenges to the management of OFP by dentists.

The current study thus explored potential barriers to provision of OFP care by dentists and the opinion of practicing dentists regarding OFP.

Methods
A human research ethical approval was obtained through King Saud University -Faculty of Dentistry (KSU-FD), Riyadh, Saudi Arabia. A cross-sectional survey was performed using a two-part English language questionnaire that included 14 closeended questions. The first section focused on socio-demographic and descriptive parameters, including age, sex, specialty, experience, type of practice, and country of graduation. The second section assessed potential barriers to management of patients with OFP and relevant recommendations. There was a cover letter attached to the questionnaire including information regarding the background and objective of the study. The survey was conducted from February to August 2018.
Prior to the study, the questionnaire was validated by 10 dental practitioners to assess its feasibility and validity and to determine the time needed to conduct the survey. Their comments were thoroughly considered in the final modification of the questionnaire. The study was then distributed to 600 participants [300 GDPs and 300 dental specialists] in the four major provinces in Saudi Arabia: Riyadh, Makkah, Asir, and Eastern Province. Participants were selected randomly as representative of the Saudi dental community, and included governmental hospitals, large private dental practices (> 10 dentists), and dental schools. Inclusion criteria were registration with the Saudi Commission for Health Specialties and a minimum of 2 years' experience. Prior to data collection, written informed consent was obtained.
There was no financial incentive for participants to complete the questionnaire. The study was performed with anonymized data. S t a t i s t i c a l a n a l y s i s Statistical analysis was performed using SPSS software (IMP SPSS statistics, Version 22, Armonk, NY, 2013). Age, sex, specialty, experience, type of practice, and country of graduation responses were expressed as frequency. Proportional t-tests and chi-square tests were used to analyse intergroup differences. Statistical significance for all analyses was set at P-value < 0.05.

Participants' demographics
Three-hundred-and-forty dental specialists and GDPs returned the completed survey from Riyadh, Makkah, Asir, and Eastern province in Saudi Arabia. The response rate was 56.6%. The questionnaires were completed by 168 males (49.4%) and 172 females (50.6%). Around two-thirds of the participants were GDPs (60.9%), while the remainder were dental specialists (39.1%). Most had a Saudi educational background (253/340), and around 52% of participants were < 30 years old. Overall, 71.1% (247/340) had < 10 years' occupational experience. Participants were either employed in the governmental sector (37.3%), at academic institutes (28.2%), in private practice (20.8%), or in a combination of these. Participants' demographics are shown in Fig. 1.

Perceived barriers
Participants perceived "Low payment /reimbursement" and "Lack of orofacial pain knowledge" as the most common barriers to practicing OFP care (85% and 83.5%, respectively; both P-value < 0.01). In contrast, "Legal risks " was the least reported issue (38.8%; P-value < 0.01). Almost equal proportions of participants considered OFP practice as being (49.4%) or not being (43.5%) "Time consuming" (P-value = 0.10). Detailed responses are listed in Table 1. The barrier most frequently reported by GDPs was "Shortage of patients/lack of demand;" this was significantly different to the barriers experienced by dental specialists (87% vs. 72.2%; P-value < 0.01). On the other hand, the greatest barriers experienced by dental specialists were "Lack of orofacial pain knowledge" (86.5%) and "Low payment/reimbursement" (86.5%). However, no other differences were significant between GDPs and specialists. Both groups noted "Legal risks" (41.5% and 34.6%, respectively) as the least important barrier (Fig. 2).
Graduates from Saudi programs mostly reported "Shortage of patients/lack of demand" (87%) as a barrier, whereas the statement "Low payment/reimbursement" was most common among graduates from non-Saudi programs. Both graduate groups reported "Legal risks" (44.8% and 36.8% respectively) as the least common barrier. Differences between the two graduate groups were not statistically significant (Fig. 3).
GDPs and dental specialists reported the same barrier factors, regardless of years of experience. Although the differences were not significant, "Shortage of patients/lack of demand" and "Lack of facility" were barriers that decreased with years of experience. On the other hand, the "Time consuming" response increased with years of experience (Fig. 4). There were no other significant differences within each groups related to sex, country of graduation, or years of experience.

Perceived recommendations
Agreements to the two proposed recommendations were highly significant (P-value < 0.01). Overall, 74.7% of participants agreed that dentists should manage patients with OFP, while 25.3% were not sure about or disagreed with this concept. Most GDPs and dental specialists (95.9%) in the study recommended adding a course on OFP care to dental education curricula ( Table 2).  (12) and found that although OFP education had improved, it was still lacking in some respects. Ziegeler et al. found that 83% of German senior dental students reported that OFP was only included in a lecture on another topic (13). Thirty percent of senior German dental students did not feel confident at all in diagnosing OFP, while 48% were somewhat confident. Klasser and Greene recommended including OFP study in pre-doctoral dental education (14). The International Association for the Study of Pain (IASP) has recently suggested an interprofessional pain curriculum outline, which included multiple topics on OFP (15). Although the present study confirmed that lack of knowledge of OFP was a major factor, we found no differences between graduates of Saudi and of non-Saudi programs. However, Al Khotani et al. found dental professional knowledge in Saudi Arabia was significantly less than that of their Swedish counterparts (11), suggesting gaps in in the Saudi dental educational system.
OFP practice is undoubtedly time-consuming in both diagnosis and management; however, this was the only potential barrier showing conflict among our participant groups, with almost equal proportions agreeing (49.4%) and disagreeing (43.5%) that this is a barrier. This may be because OFP could be overlooked as a health problem that requires prioritising by the physician. In addition, years of experience might also have contributed to this conflict. We noted that participants with more years of experience tended to agree more that this was an issue. It is possible that practitioners with more years of experience have encountered more OFP patients, so that they are more aware of how time-consuming OFP practice could be. We also found that 85% of our study sample considered that "low payment /reimbursement" is a significant barrier; this may because OFP care is time-consuming and does not have as high a cost-effort ratio as other dental procedures.
Most of our participants underestimated OFP prevalence: 81.2% of participants reported that shortage of patients/lack of demand was one of the major barriers, although the specialists agreed less with this statement than did GDPs. This imaging modalities, access to controlled medications, and a multidisciplinary team approach. The accessibility of facilities may require an OFP practice in a hospital setting or tertiary pain centre. This may explain the high agreement on this factor, as most participants were GDPs and most likely work in primary dental clinics, whereas dental specialists agreed less with this statement.
The present study had several limitations. Participants were limited to dentists; however, OFP patients may express other opinions about barriers to good care.
Hence future studies should investigate patients' perceptions during the process of seeking oral care. Additionally, the percentage of senior dentists was low in this study. The years of experience was a key factor that may independently influence the barriers perceived, since senior dentists will have encountered more patients with OFP. However, the distribution by age and years of experience was consistent with the distribution of dentists in the country and the potential subjects were selected randomly in this study. Moreover, there have been few previous studies on this topic, so that the newly constructed questionnaire could not be validated; this needs to be addressed in future. In addition, study participants were limited to four main provinces in Saudi Arabia. Although Riyadh, Makkah, Asir, and Eastern Province are the largest and most diverse in this country, it will be valuable to survey other provinces and investigate if differences across regions exist, to provide a more inclusive database of dentists for future improvements of national health care. Finally, the recruited participants were not randomly selected from different dental sectors within each province. However, the study sample was equally distributed over academic institutes, governmental sectors, and private practices, to compensate in part for bias.

Conclusion
OFP practice is a complex field that is further complicated by multiple barriers.
Although OFP education is critical, the current study emphasises that knowledge levels among dentists was not the only barrier that requires addressing: other factors, such as reimbursement, facility, and demand were also considered barriers.
There is a misconception about the prevalence of OFP among dental professionals.
OFP courses should be included in dental school curricula to train future dentists.
Well-designed educational programs should be planned to target dental specialists and GDPs in Saudi Arabia to insure delivery of appropriate patient care at the highest international standards. In addition, there is a critical need to address issues, such as available facilities, to encourage OFP care practise.

Ethics approval and consent to participate
The study was approved by the Ethical Review Committee of King Saud University, Faculty of Dentistry (KSU-FD), Riyadh, Saudi Arabia and written informed consent was taken from each participant prior to data collection

Consent for publication
Not Applicable

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests

Funding
None.

Author contributions
EH designed, analysed the data and interpreted the results, and was a major contributor to the writing of the manuscript. EH read and approved the final manuscript.  Figure 1 Demographic characteristics of study participants are presented in numbers.

Figure 2
Respondents were divided into general dental practitioner and specialists. This graph shows Figure 3 Respondents were divided into two groups according to the country of graduation. This graph  Demographic characteristics of study participants are presented in numbers.

Figure 2
Respondents were divided into general dental practitioner and specialists. This graph shows the p Respondents were divided into two groups according to the country of graduation. This graph show Respondents were divided into three groups according to years of occupational experience. This g