Public Perception of the Scope of Practice of Oral

Public Perception of the Scope of Practice of

Oral & Maxillofacial Surgeons in Ontario

by

Oscar Dalmao

A thesis submitted in conformity with the requirements

for the degree of Master of Science in Oral and Maxillofacial Surgery

Discipline of Oral and Maxillofacial Surgery

Faculty of Dentistry

University of Toronto

© Copyright by Oscar Dalmao 2020

ii

Public Perception of the Scope of Practice of

Oral & Maxillofacial Surgeons in Ontario

Oscar Dalmao

Master of Science in Oral and Maxillofacial Surgery

Discipline of Oral and Maxillofacial Surgery

Faculty of Dentistry University of Toronto

2020

Abstract

Purpose: Investigate and compare the General Public’s, General Dentists’ and Primary Care Physicians’

level of knowledge of the scope of practice of Oral and Maxillofacial Surgeons (OMS). Materials and Methods: A mail-out survey of the General Public, General Dentists and Primary Care Physicians in

Ontario, Canada. Survey consisted of a screener along with 24 clinical scenarios. Responses

between groups were compared to identify any significant differences between subjects with P

value set at 0.05. Results: The majority of Dentists (100%) and Primary Care Physicians (95.5%) have heard of OMS, in

contrast only 73.7% of the General Public (p < 0.001). A general lack of awareness of OMS

scope of practice by all groups exists. Conclusion: A proportion of the General Public are unaware of OMS. More concerning, the General Public

and health professionals as a whole are unfamiliar with the full scope of practice of OMS.

iii

Acknowledgments

This work was supported by a Canadian Association of Oral and Maxillofacial Surgeons

Research Grant. I would like to thank my supervisor Dr. David Lam who provided me with the

mentorship and tremendous support throughout this master’s process. My sincerest gratitude also

goes to my committee members, Dr. Laura Dempster and Dr. Marco Caminiti for their guidance

and encouragement over the course of the project. Finally, thank you to my family and friends,

especially my girlfriend Dr. Lexi Corrigan for their love and support over the entire course of my

education!

iv

Table of Contents

Abstract……………………………………………………………………………………………ii

Acknowledgments………………………………………………………………………………..iii

Table of Contents…………………………………………………………………………………iv

List of Tables.…………………………………………………………………………………….vi

List of Figures……………………………………………………………………………………vii

List of Abbreviations……………………………………………………………………………viii

List of Appendices ……………………………………………………………………………….ix

Chapter 1. Introduction…………………………………………………………………………1

1.1. An Overview of Oral and Maxillofacial Surgery….....................................................1

1.2. Oral and Maxillofacial Practice vs Reality Gap...........................................................2

1.3. Perceptions of OMS Internationally……….................................................................2

1.4. Value of the Study........................................................................................................4

1.5. Purpose of the Study.....................................................................................................4

Chapter 2. Statement of Objectives and Hypothesis..................................................................6

2.1. Objectives....................................................................................................................6

2.2. Hypothesis....................................................................................................................6

Chapter 3. Public Perception of the Scope of Practice of

Oral & Maxillofacial Surgeons………………………………………………………………....7

3.1 Abstract………………………………………………………………………………..8

3.2 Introduction……………………………………………………………………………9

3.3 Materials and Methods………………………………………………………………10

3.4 Results………………………………………………………………………………..12

3.5 Discussion……………………………………………………………………………14

3.6 Conclusion…………………………………………………………………………...16

3.7 Acknowledgments…………………………………………………………………...16

3.8 References…………………………………………………………………………...17

3.9 Table/Figure Legends..………………………………………………………………21

Chapter 4. Discussion…………………………………………………………………………..48

6.1. Limitations …………………………………………..……………………………………..48

6.2. Implications, Future Directions………... ………………………………………………….49

References……………………………………………………………………………………….51

v

Appendices…………………………………………………………………………………….56

vi

List of Tables

Table 1 Clinical Scenario Questionnaire..……………………………...……………………….18

Table 2 Demographics.………………………………………………………………………….60

Table 3 OMS % selected per condition/scenario by all groups.………………………………...63

Table 4 OMS % selected per condition/scenario Family Physicians vs. General Dentists.…….64

Table 5 OMS % selected per condition/scenario General Public vs. General Dentists.………...65

Table 6 OMS % selected per condition/scenario Family Physicians vs. General Public……….66

vii

List of Figures

Figure 1. Awareness of Specialists……………………………………………………………23

Figure 2A. Fracture of the Upper Jaw……………………………………………………..……24

Figure 2B. Fracture of the Lower Jaw………………………………………………………..…25

Figure 2C. Fracture of the Nose……………………………………………………………...…26

Figure 2D. Fracture of the Eye……………………………………………………………….…27

Figure 2E. Fracture of the Cheek…………………………………………………………..……28

Figure 2F. Fracture of the Skull…………………………………………………………………29

Figure 2G. Cut on the face…………………………………………………………………….…30

Figure 3A. Cancer of the mouth, tongue or lip……………………………………………..……31

Figure 3B. Non-cancerous lesion of the mouth, tongue or lip……………………………...……32

Figure 3C. Non-cancerous tumor/cyst of the upper or lower Jaw…………………………….…33

Figure 3D. Removal of TMJ lesion………………………………………………………...……34

Figure 3E. Salivary Gland Removal………………………………………………………..……35

Figure 3F. Infection/swelling around the mouth/neck……………………….………………..…36

Figure 3G. Infection/swelling around the Eye………………………………….……………..…37

Figure 4A. Child with cleft lip…………………………………………………………….….….38

Figure 4B. Child with cleft palate……………………………………………………………..…39

Figure 4C. Soft tissue grafts for oral reconstruction…………………………………………..…40

Figure 4D. Hard tissue grafts for oral reconstruction……………………………………………41

Figure 5A. Removal of Wisdom teeth………………………………………………………...…42

Figure 5B. Placement of dental implants………………………………...………………………43

Figure 5C. Providing general/deep sedation……………………………………..………………44

Figure 6A. Corrective Jaw surgery………………………………………………..…………..…45

Figure 6B. Nose corrective surgery…………………………………………………..……….…46

Figure 6C. Facial appearance procedures…………………………………………………..……47

viii

List of Abbreviations

AAOMS American Association of Oral and Maxillofacial Surgeons

CAOMS Canadian Association of Oral and Maxillofacial Surgeons

CPSO College of Physicians and Surgeons of Ontario

DDS Doctor of Dental Surgery

ENT Otolaryngologist

GP General Public

GS General Surgeon

MD Doctor of Medicine

OMS Oral and Maxillofacial Surgeons

P Periodontist

PS Plastic Surgeon

RCDSO Royal College of Dental Surgeons of Ontario

UK United Kingdom

US United States of America

ix

List of Appendices

Appendix A. Additional Detailed Methodology……………………………………….………56

Appendix B. Additional Detailed Results………………………………………………..……..59

Appendix C. Initial Contact Letter……………………………………………………....……..67

Appendix D. Invitation to study participation…………………………………………………68

Appendix E. Information and Consent for Participation…………………………………..…69

Appendix F. Study Survey……………………………………………………...……………….71

1

1. Introduction

1. Oral and Maxillofacial Surgery

1.1. An Overview of Oral and Maxillofacial Surgery

Oral and Maxillofacial Surgery is a specialty of dentistry responsible for the diagnosis and

treatment of disorders, diseases, injuries, and defects involving the oral and maxillofacial

regions1, 2 In Canada, Oral and Maxillofacial Surgery can date its origins as far back as the early

20th century where W.G Beers limited his practice to exodontia and is often regarded as the first

Oral and Maxillofacial Surgeon (OMS) in Canada3. The profession continued to evolve and saw

rapid progression during the Second World War where Oral and Maxillofacial Surgery’s

importance as a specialty emerged4. Following this, in the mid-1950s the first three-year training

program in Oral and Maxillofacial Surgery was established at Toronto General Hospital5.

While the profession initially centered around the dentoalveolar complex, it has increasingly

been expanding its scope beyond that to complex facial surgeries6. Oral and Maxillofacial

Surgery training has become more specialized and skilled in a diverse range of treatments in the

maxillofacial anatomical region. This ranges from dentoalveolar procedures, to facial fractures,

craniofacial injuries, dental and skeletal deformities, salivary gland diseases, temporomandibular

disorders and oral and facial cancers with reconstruction by flaps and microvascular tissue

transfer7. The complex surgical procedures performed today follow extensive training that varies

worldwide8. In some countries, as it is in Canada, a dental degree only is required prior to further

Oral and Maxillofacial Surgery training. Once accepted into a Canadian Oral and Maxillofacial

Surgery training program, either a four-year single degree (DDS) or six-year dual degree (DDS/

MD) pathway are available. As in the United States these pathways are program-dependent and

not geographically-dependent. In contrast, in France and Spain, OMS applicants complete a

medical degree without any or little dental training. A combination of both medical and dental

training is required in other countries such as Australia and the United Kingdom (UK). In the

UK, OMS complete dental training prior to medical training in perhaps the lengthiest time to

graduate, taking approximately 18 years to qualify.

2

1.2. Oral and Maxillofacial Surgery Practice vs Reality Gap

The profession has continued to evolve; however, even with the extensive training in major

surgeries of the maxillofacial complex, until as recently as 1982 the Joint Commission on

Accreditation of Healthcare Organizations (a private sector US based non-profit organization

which accredits most US hospitals) still interfered with OMS practice in the hospital. OMS had

difficulty admitting or discharging their own patients or operating in a hospital setting unless

they were overseen by a medical colleague9. Due to Oral and Maxillofacial Surgery bridging the

fields of dentistry and medicine, confusion about the scope of practice has been present since its

inception10,11. Adding to the public’s confusion is the apparent overlap in the OMS scope of

practice with that of more routinely recognized medical specialties such as Plastic Surgery and

Otolaryngology12, 13. OMS require different credentials depending on where the degree is

obtained with countries such as Canada and the United states offering both four-year single

(DDS) and six-year dual (DDS/MD) degree programs, whereas most countries in Europe only

offer dual degree options8. This adds to lack of awareness not only by the public but the medical

community as well, with regards to the level of training that is required to obtain an Oral and

Maxillofacial Surgery degree. To add to that, the scope of Oral and Maxillofacial Surgery within

each individual country may vary by region, as is the case in Canada where cosmetic surgery

such as facelifts is practiced in Alberta but not in Ontario. In Ontario, which has the largest

number of practicing OMS in Canada, guidelines have been set through the Royal College of

Dental Surgeons of Ontario (RCDSO) to determine what procedures fall under the Oral and

Maxillofacial Surgery scope of practice in Ontario.

Even with the progressive steps made by the Oral and Maxillofacial Surgery profession in

education of the public in relation to its place in health care, there is a gap between the perceived

and actual scope of practice of OMS. Most studies completed internationally highlight the

ongoing limited perception by the public1, 7, 10, 12-16.

1.3. Perceptions of OMS Internationally

Geographic variations with respect to the awareness of OMS scope of practice exist.

Unfortunately, most studies suggest there is a lack of awareness of the Oral and Maxillofacial

Surgery specialty1, 10. An Australian survey found that most Family Physicians appropriately

referred cases to OMS when involving fractures of the maxilla, mandible or dentoalveolar

3

complex (75.5 to 92.2%). This drastically decreased with nasal fractures, frontal bone, zygomatic

fractures and lacerations to the face2.

In the UK, a questionnaire determined that out of its 200 General Public citizens, an astonishing

79% had not heard of Oral and Maxillofacial Surgery, compared to 17% that had not heard of

Plastic Surgery, or 46% of ENT. When asked what OMS do, 74% of the General Public

answered ‘Don’t Know’ with only 12% reporting that they work in the mouth. Both medical and

dental professionals showed better awareness of what the profession does; yet still lacked in

awareness of its scope in nasal and cleft lip and palate surgeries1. Ten years later, investigators

conducted a new study to compare their prior results. They found a slight improvement, yet

similar to before, only 34 of 100 people heard of OMS and none surveyed felt OMS could treat

patients unhappy with their facial appearance14.

In contrast, study participants in Florida showed greater recognition of OMS compared to those

in the UK6. Out of 300 General Public participants, 66% had heard of OMS. Similarly, a survey

conducted in India, that focused on the perceptions of medical workers and what OMS do

showed that all dental students and professionals had heard of Oral and Maxillofacial Surgery10

and that 41% of medical students, 76% of medical practitioners and 58% of paramedical workers

had heard of Oral and Maxillofacial Surgery10. However even with greater recognition, still less

than 15% of medical practitioners believed the OMS role included cleft lip and palate (14%),

cosmetic surgeries of the face (11%) and craniofacial anomalies (9%)10.

Even among undergraduate medical and dental students, which one would imagine would have

significant insight into Oral and Maxillofacial Surgery, exposure to a career in Oral and

Maxillofacial Surgery is limited17, 18. A review of the literature, found that a varied knowledge

base of Oral and Maxillofacial Surgery existed from limited in the UK and US to good in Brazil

among medical and dental students19 . Undergraduate medical students in the UK demonstrated a

lack of awareness of the OMS role in aesthetic facial surgeries and felt that certain conditions

such as face and neck infections, were better managed by specialties other than OMS17.

Interestingly in 1975, the American Society of the Oral and Maxillofacial Surgery profession

changed its name from ‘oral surgery’ to ‘oral and maxillofacial surgery20. The change was made

in an effort to more accurately describe the scope and to increase perception of the scope among

dental students. However, some suggest that the more recent name is unfamiliar to the General

4

Public and reported a reduced awareness of the scope of OMS among less-educated respondents

when compared to other specialties21.

1.4. Purpose of the Study

Public perceptions of OMS have only been studied in other geographic areas and have never

been investigated in Canada. Therefore, the purpose of this study was to examine this within

Ontario and see if perceptions held elsewhere also apply to the Canadian population.

The specific aims of the study were 1) to investigate the level of awareness of OMS in Ontario

by the General Public, General Dentists and Family Physicians and 2) to determine the level of

knowledge of the scope of practice of OMS throughout the Ontario population. We hypothesize

that there is a generalized lack of awareness of Oral and Maxillofacial Surgery and limited

knowledge of the scope of practice of OMS throughout the Ontario population, with the General

Public being the least informed and the General Dentists the most informed.

1.5. Value of the Study

It is imperative that the General Public have an awareness of OMS so that in time of need,

patients know where to seek treatment. With General Dentists and Family Physicians holding

key positions as gatekeepers for both appropriate dental and medical referrals, their

understanding is invaluable14. Having all parties adequately informed may allow for better access

to treatment and decrease wait times for patients. If all specialists who can perform a treatment

are recognized, more options will be available for patients and referring physicians to ensure the

population is able to receive care in the shortest possible time.

The results of this study have potential value to the specialty of Oral and Maxillofacial Surgery

and patients alike. Based on the results of this study, important information regarding the

public’s and health care professionals’ perception of OMS in Ontario will be gathered; this may

then be used to address areas where the OMS scope of practice perception is lacking so that

educational or promotional campaigns can be targeted. Beginning in 2014, American

Association of Oral and Maxillofacial Surgeons (AAOMS) created informational campaigns

costing approximately $4 million with goals to increase OMS awareness, inform and to convey

Oral and Maxillofacial Surgery's contributions to the general public22, 23. Using social media,

5

AAOMS made great strives to reach the public24. A website was developed with the patient in

mind using search engine optimization and providing informational videos on various common

procedures in Oral and Maxillofacial Surgery. AAOMS has received awards for this campaign

and effectively reached consumers. The Canadian Association of Oral and Maxillofacial

Surgeons (CAOMS) in contrast is lagging behind their American counterparts on this front. In

January 2019 the CAOMS executive committee along with the OMS resident representative met

and had discussions about creating a task force to determine the feasibility of undertaking a

national rebranding and educational campaign such as the one conducted by AAOMS. At that

time, only discussions were held and no definitive plans were put in place. Similarly, the Ontario

Society of Oral and Maxillofacial Surgeons is currently establishing a scope of practice steering

committee but has not finalized anything yet 25. Results from our study may elucidate areas in

which the specialty of Oral and Maxillofacial Surgery can focus on to enhance its importance as

a specialty in the public eye before these campaigns are put into effect. Identifying gaps in

awareness of scope will continue to help determine areas to focus on, to optimize the pathway to

care and prioritize complex treatments for patients. This may also help or alter government

funding where appropriate.

As well, further expansion of the Oral and Maxillofacial Surgery profession depends on ensuring

the referral pathways are consolidated to support this expansion. The majority of referral bases

continue to come from dentists, which may help explain the vast proportion of dentoalveolar

work. If a disconnect is identified in participant groups with respect to oral vs extraoral

procedures for OMS, steps can be made to highlight OMS expertise in procedures of the facial

complex, not just the dentoalveolar one. This may help increase referrals from both medical and

dental professionals and promote continued expansion of treatment beyond just the dental

complex, which is what OMS are truly trained for.

6

Chapter 2 Statement of Objectives and Hypothesis

2. Statement of Objectives and Hypothesis

2.1. Objectives

1) To determine the level of awareness of the specialty of Oral and Maxillofacial Surgery by

the General Public, General Dentists and Family Physicians in Ontario.

2) To investigate the level of knowledge of the scope of practice of Oral and Maxillofacial

Surgeons (OMS) throughout the Ontario population, including the General Public, General

Dentists and Family Physicians, and determine if there is a significant difference between

these groups.

2.2. Hypotheses

1) Health care professionals (General Dentists and Family Physicians) are more aware of the

Oral and Maxillofacial Surgery specialty than the General Public.

2) There is a generalized lack of knowledge of the scope of practice of OMS throughout the

Ontario population and the level will vary with the General Dentists being the most

informed and the General Public the least.

7

Chapter 3

3. Public and Professional Perceptions of the Scope of

Practice of Oral & Maxillofacial Surgeons Manuscript submitted to Journal of Oral and Maxillofacial Surgery

Oscar E. Dalmao DDS,a Laura J. Dempster BSc. D (DH), MSc, PhD,b Marco F. Caminiti DDS,

MEd, FRCD(C),c Nick Blanas DDS, FRCD(C)1,d David K. Lam MD, DDS, PhD, FRCD(C).e

a Chief Resident, Oral & Maxillofacial Surgery, Faculty of Dentistry, University of Toronto, 124

Edward Street, Toronto, Ontario, Canada M5G 1G6

b Associate Professor, Dental Public Health, Faculty of Dentistry, University of Toronto, 124

Edward Street, Toronto, Ontario, Canada M5G

c Program Director, Oral & Maxillofacial Surgery, University of Toronto, 124 Edward Street,

Toronto, Ontario, Canada M5G 1G6

d Assistant Professor, Oral & Maxillofacial Surgery, University of Toronto, 124 Edward Street,

Toronto, Ontario, Canada M5G 1G6

e Professor & Chairman, Departments of Surgery and Oral & Maxillofacial Surgery, Stony Brook

Medicine, Stony Brook, NY

Corresponding Author: Oscar Dalmao

Oral & Maxillofacial Surgery, University of Toronto, 124 Edward Street, Room 143, Toronto,

Ontario, Canada M5G 1G6

Telephone: 416-979-4922 Ext 4329

Fax: (416) 979-4936

Email: [email protected]

8

3.1 Abstract

Purpose:

To investigate and compare the General Public’s, General Dentists’ and Primary Care Physicians’

level of knowledge of the scope of practice of Oral and Maxillofacial Surgeons (OMS). We

hypothesized that there is a generalized lack of knowledge of the scope of practice of OMS, with the

General Public being the least informed and the General Dentists the most informed.

Materials and Methods:

A cross-sectional survey study was conducted, via a mail-out survey that was delivered to a

random sample of the General Public, General Dentists and Primary Care Physicians in Ontario,

Canada. A total of 1800 participants were selected. The survey consisted of a demographic

screener along with 24 clinical scenarios in which the participants could select all the specialists

they thought were capable of completing the treatment. Inferential statistics were computed

using a chi-square test to compare responses between the groups and identified any significant

differences between participants for each of the 24 scenarios with P value set at 0.05.

Results:

Total response rate of 50.1% (n=902) was achieved. The majority of health professionals (100%

Dentists, 95.5% Primary Care Physicians) have heard of OMS, in contrast to only 73.7% of the

General Public (p < 0.001). There was a general lack of awareness of OMS scope of practice by

all groups wherein OMS were selected less than 50% of the time in 10 (General Dentists), 14

(Primary Care Physicians) and 16 (General Public) of 24 clinical scenarios.

Conclusion:

Greater than 25% of the General Public are unaware of OMS. More concerning, the General

Public and health professionals as a whole are unfamiliar with the full scope of practice of

OMS. To enhance access to care by qualified specialists, educational programs highlighting key

aspects of OMS should be developed and distributed to all populations.

9

3.2 Introduction

Oral and Maxillofacial Surgery is a specialty of dentistry responsible for the diagnosis and

treatment of disorders, diseases, injuries, and defects involving the oral and maxillofacial

regions1,2. In Canada, Oral and Maxillofacial Surgery can date its origins as far back as the early

20th century3. The profession has continued to evolve; however due to it bridging the fields of

dentistry and medicine, confusion about Oral and Maxillofacial Surgeons (OMS) scope of practice

has been present since its inception4. Adding to the public’s confusion is the apparent overlap in

the OMS scope of practice with that of more routinely recognized medical specialties such as

Plastic Surgery and Otolaryngology5,6. Even with the progressive steps made by the Oral and

Maxillofacial Surgery profession in education of the public in relation to its place in health care,

most studies completed internationally highlight the ongoing lack of knowledge of the scope of

practice by the public1,4-9.

The level of knowledge of the scope of OMS has only been studied in other geographic areas

but not in Canada, therefore the aim of this study was to examine the level of knowledge within

Ontario, Canada. The purpose of the study was to investigate the level of awareness of Oral and

Maxillofacial Surgery as a profession and the level of knowledge of the scope of practice of OMS

among the General Public, General Dentists and Primary Care Physicians.

10

3.3 Materials and Methods

A mail-out survey was delivered to a random sample of the General Public, General Dentists and

Primary Care Physicians in Ontario. Primary Care Physicians and General Dentists are usually

the ones who will be consulted first for a head, neck or oral complaint and thus have the

responsibility of making the appropriate referral8,10. They act as potential gatekeepers to

OMS, which is why these two groups along with the General Public who may request their

own referral were surveyed. Ethics approval was obtained from the University of Toronto

Research Ethics Boards (34462). A total of 1800 participants were selected, with 600 per group.

Inclusion criteria:

1. General Public (GP): Adults over the age of 18 who are neither medical nor dental

professionals and living in Ontario.

2. General Dentist (DDS): Any general dentist with a valid provincial dental license

(RCDSO).

3. Primary Care Physician (MD): Any primary care physician with a valid provincial

medical license (CPSO).

Survey Questionnaire

The survey consisted of demographic questions including gender, age and whether participants

were physicians, dentists, or members of the public. Survey participants were asked if they had

heard of, or been treated by specific specialists (General surgeon, ENT (Otolaryngologist), OMS,

Plastic Surgeon, and Periodontist), along with 24 clinical scenarios in which the participants could

select all the above specialists, along with an “Other” option, they thought were capable of

completing the described treatment (Table 3.1). The 24 clinical scenarios where chosen to

encompass the full scope of Oral and Maxillofacial Surgery and similar to previous studies, were

grouped into five categories; Trauma, Pathology, Reconstructive Surgery, Oral Procedures and

Cosmetics5,8.

Data Collection

To maximize participant response rate, an initial contact letter was sent out to inform potential

participants of their selection to partake in our study. This was done to prime participants for the

11

upcoming survey. In addition, surveys were sent out in three separate waves along with follow up

reminder phone calls to all non-responders.

Data Analysis

Descriptive statistics reported demographic data. Inferential statistics via a chi-square test

compared responses between the General Public, Primary Care Physicians, and General Dentists

to identify any significant differences between subjects. Subsequent chi- square tests were

completed between individual groups when significant differences were identified between the 3

groups. To account for type 1 error, a Bonferroni correction was completed and the level of

significance was set at p < 0.0167.

12

3.4 Results

An overall response rate of 50.1% (n=902) was achieved: 259 (43.1%) General Public, 332

(55.3%) General Dentists, and 311 (51.8%) Primary Care Physicians. The average age of the entire

survey population was 49.4±13.5 years with no significant difference between groups. A

significant difference in gender composition (p< 0.01) was evident with the General Dentist

population (67.5%) having a higher male percentage compared to both for Primary Care

Physicians (57.9%) and the General Public (54.1%). Most health care professionals (95.5%

Primary Care Physicians, 100% General Dentists) were aware of OMS, in contrast to 73.7% of the

General Public (p<0.001, Figure 1). Primary Care Physicians and the General Public selected

General Surgeons as the specialty that had treated them the most with 25.4% and 30.9%,

respectively, while General Dentists selected OMS with 26.5%.

In the broad scope of practice encompassed by the 24 clinical scenarios, OMS were selected 42.3%

by the General Public, 42.8% by Primary Care Physicians, and 60.8% by General Dentists

(p<0.001).

Trauma Scenarios

The majority of participants selected OMS for treatment of maxillary (74.9-99.1%, Figure 2A) and

mandibular fractures (65.5-77.4%, Figure 2B). With regards to the remainder of maxillofacial

trauma scenarios, Plastic Surgeons were the dominant selection for treatment of facial lacerations

(81-94.5%, Figure 2G), as well as nasal (63.2-77.5%, Figure 2C), orbital (45.7-78.8%, Figure 2D),

and zygomatic fractures (48.8-78.5%, Figure 2E).

Pathology Scenarios

For clinical situations involving pathology of the head and neck, ENT was the dominant selection

for cancerous lesions (43.0-86.8%, Figure 3A). OMS were the primary selection for noncancerous

lesions (52.3-94.3%, Figure 3B), noncancerous cysts/tumors (60.5-97.0%, Figure 3C) and TMJ

pathology (69.5-98.2%, Figure 3D). Salivary gland pathology and infections/swellings around the

neck/mouth had mixed results with OMS selected the most by General Dentists (71.1%, Figure 3E

and 46.7%, Figure 3F, respectively) and the General Public (93.7%, Figure 3E and 45.2% Figure

3F, respectively), while the Primary Care Physicians selected ENT the most for both scenarios

13

(81.4%, Figure 3E and 75.2%, Figure 3F respectively). General Surgeons were selected the most

for infections/swellings around the eye by all survey participant groups (65.9-72.6%, Figure 3F).

Reconstructive Surgery Scenarios

All survey participant groups selected Plastic Surgeons the most for reconstructive surgery

scenarios involving cleft lip (64.5-89.1%, Figure 4A) or cleft palate (56.0-89.1%, Figure 4B).

Primary Care Physicians also selected Plastic Surgeons the most for reconstruction of oral

structures with soft or hard tissue (66.9%, Figure 4C and 62.4%, Figure 4D, respectively). General

Dentists selected Plastic Surgeons for soft tissue procedures (66.3%, Figure 4C) and OMS for hard

tissue procedures (59.0%, Figure 4D). The General Public selected OMS the most for both soft

and hard tissue procedures (48.2%, Figure 4C and 44.8%, Figure 4D, respectively).

Oral Procedure Scenarios

Oral procedures such as wisdom teeth extractions (76.4-99.4%, Figure 5A) and dental implants

(56.4-88.9%, Figure 5B) had a predominantly OMS selection. OMS were selected to provide

anaesthesia by both Primary Care Physicians (50.8%) and General Dentists (86.4%) but not

by the General Public who selected General Surgery the most (54.4%) (Figure 5C).

Cosmetic Scenarios

Jaw corrective surgery was the only cosmetic scenario, which had OMS as the primary selection

(58.3-97.0%) by all survey participant groups (Figure 6A). Nose corrective procedures (83.4-

90.7%, Figure 6B) and facial cosmetic procedures (92.7-98.8%, Figure 6C) had Plastic Surgery as

the highest selection by all survey participant groups

14

3.5 Discussion

The goal of health care is to provide optimal care for patients, including providing patients with

access to care by all surgical specialties capable of providing them care. This ensures that patients

can make the most educated decision. For this to occur, there must be a sound understanding of

the Oral and Maxillofacial Surgery specialty by medical and dental professionals, and the public

so that appropriate referrals are made, leading to effective and efficient treatment for the public1,5.

In our study, the level of awareness of Oral and Maxillofacial Surgery by the General Public

(73.7%) is on the higher end compared to similar international studies that range from 15-83%1,4-

9. Yet, this is significantly lower than health professionals in this study (100% of General Dentists

and 95.5% of Primary Care Physicians). Of greater clinical importance is the limited familiarity

with Oral and Maxillofacial Surgery's full scope of practice, even by General Dentists. This was

demonstrated by the fact that for the majority of the 24 clinical scenarios, OMS were selected less

than 50% of the time and were the highest selection in only 33%, 50% and 42% of the 24 clinical

scenarios by the Primary Care Physicians, General Dentists and General Public groups,

respectively. As anticipated, General Dentists had higher selection than both the Primary Care

Physicians and the General Public for OMS. Our findings suggest there is a lack of awareness of

the full scope of practice of OMS with a distinction occurring between scenarios limited to the oral

cavity versus those occurring outside of it.

Our study was able to highlight recognition of OMS in providing treatment for maxillary and

mandibular trauma, pathology (involving benign lesions and TMJ conditions), cosmetic treatment

via jaw corrective surgery, and oral procedures (such as wisdom teeth extractions and implants).

All of the conditions that had a high OMS selection were related to the dentoalveolar complex.

This is in keeping with previous studies conducted internationally both in the UK, Kuwait and

India.4,7,9

On the other hand, scenarios within the head and neck that fell outside the oral complex usually

had a diminished OMS selection, with one of the medical specialties ENT, Plastic Surgery or

General Surgery favoured. Similar to prior studies by Rocha and colleagues in Brazil, and Hunter

and colleagues in the USA, Plastic Surgeons were selected for treatment of facial lacerations over

OMS5,8. Rocha and colleagues, and Hunter and colleagues had OMS as the primary selection for

zygomatic fractures, however in our study orbital and zygomatic fractures had Plastic Surgery as

15

the most favoured selection 5,8. In keeping with prior studies, ENT was selected for malignant and

salivary gland pathologies, and Plastic Surgery was selected for cosmetic procedures 4,5,8,9.

Various reasons for this lack of awareness have been proposed in the past. Ameerally and

colleagues felt that the name, “OMFS” is confusing for the lay person1. Hunter and colleagues

reasoned that the lack of awareness stems from the fact that the foundation of Oral and

Maxillofacial Surgery is in dentistry and not medicine5. Since referrals in Canada are largely from

General Dentists, oral-related procedures such as wisdom tooth extractions, represent a significant

proportion of work for OMS. Perhaps, it therefore makes sense that the perception by the General

Public in Ontario, of the scope of OMS, is misconstrued to largely oral-related procedures. We

suspect that this also contributes to a diminished awareness of the scope of OMS in a hospital

setting or procedures beyond the mouth. There is also significant overlap among specialties of

Plastic Surgery, ENT and Oral and Maxillofacial Surgery. In addition, regional variations in the

scope of practice exist in Canada as they do in the rest of the world. In certain locations or certain

hospitals, one discipline may take the responsibility for a condition over another and this may

change in another location. This only adds to the confusion of the scope of OMS.

Regardless of why this diminished perception of the scope of practice is present, the aim must be

to have these perceptions changed. Informational campaigns such as the one conducted by

AAOMS which had the goals to increase the public perception of the OMS scope of practice,

inform prospective patients of OMS education and training, and convey the specialty’s

contributions to public health should be carried out in Canada13. Educational videos, consumer

website and public service announcements were all used to address the issues and resulted in very

positive feedback as evident by the 26 awards that were granted to AAOMS for this campaign13.

In addition, implementing teaching that illustrates what OMS can do into both dentists

and physicians’ curriculum during their training would be beneficial. This would allow the

establishment of knowledge at the grass roots level, when practitioners are most receptive to new

ideas. If physicians and dentists exit their training programs with this knowledge in place, all future

campaigns will only reinforce what they have already been taught, instead of being the initial

exposure to this information.

16

Study Strengths and Limitations

Mailed surveys, as all surveys must address the issue of inadequate response rate, however

strategies to enhance this were used resulting in an overall favorable response rate of 50.1%11,12.

The random selection of participants also ensured equal representation among the participant

groups. A mailed survey was also beneficial in our study as email directories where either too

costly or not expansive enough for our chosen subject groups.

The study was restricted to participants in Ontario; therefore the results cannot be generalized to

awareness of OMS across Canada. However, since Ontario is the largest province with the greatest

number of Oral and Maxillofacial Surgeons, one could expect that the awareness reported in

Ontario represents the greatest potential recognition and exposure that would be reported

nationally.

3.6 Conclusion

The results of this study suggest a low level of awareness among the General Public, General

Dentists and Primary Care Physicians in Ontario of OMS full scope of practice. Although

varying levels of awareness have been reported previously in international studies, the theme

remains that people don’t know what the full OMS scope entails. Greater progress needs to be

made in the education of Primary Care Physicians, General Dentists and the General Public, if

the specialty of Oral and Maxillofacial Surgery is to be practiced to its full potential and patients

are to benefit from access to care by highly qualified specialists5,10. Future steps should include

advocacy efforts at all levels including the OMS individual, institutional and association levels.

Focus needs to be placed on key areas such as trauma and pathology where patient care is crucial

and may be expedited if all those involved are aware of what OMS can perform. In addition

procedures that were selected the least based on survey results including facial lacerations,

salivary gland pathology, cleft lip and palate reconstruction and facial cosmetic procedures

should also be highlighted. Ongoing education and advocacy is imperative for increased

awareness of the scope of OMS and therefore improved patient care, access to care and

efficiency of care

3.7 Acknowledgements

This study was supported by a Canadian Association of Oral and Maxillofacial Surgeons

Research Grant.

17

3.8 References

1. Ameerally P, Fordyce AM., Martin, IC: So you think they know what we do? The public and

professional perception of oral and maxillofacial surgery. Br J Oral Maxillofac Surg 32:142,

1994

2. Lababidi E, Breik O, Subramaniam S: Perceptions of oral and maxillofacial surgery amongst

Australian medical general practitioners. Oral Maxillofac Surg Oral Med Oral Pathol 30:229–

232, 2018

3. Weinberg S. (2003, May 1) The End of an Era. Retrieved from

https://www.oralhealthgroup.com/features/the-end-of-an-era

4. Subhashraj K, Subramaniam B: Awareness of the specialty of oral and maxillofacial surgery

among health care professionals in Pondicherry, India. J Maxillofac Oral Surg 66:2330–4,

2008

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 54:1227, 1996

6. Farook SA, Rihal K, Abullakutty A, Coombes D: Lost tribe? Awareness of oral and

maxillofacial surgery (OMFS) among the general public. Br J Oral Maxillofac Surg 51:e4–e5,

2013

7. Ifeacho SN, Malhi GK, James G: Perception by the public and medical profession of oral and

maxillofacial surgery—Has it changed after 10 years? Br J Oral Maxillofac Surg 43:289, 2005

8. Rocha NS, Laureano Filho JR, Silva ED, Almeida RC. Perception of oral maxillofacial surgery

by healthcare professionals. Int J Oral Maxillofac Surg 37:41– 46, 2008

9. Haron, IM, Sabti MY, Andersson L, Sharma PN. Perception of oral and maxillofacial surgery

by medical and dental health care professionals in Kuwait. J Oral Maxillofac Surg Med Oral

Pathol 25:5–11, 2013

10. Vadepally AK, Sinha R, Uppada UK, Rama Krishna Reddy BV, Agarwal A: Oral and

maxillofacial surgery: Perception of its scope among the medical fraternity and general

public. J Cranio Max Dis 4:21-7, 2015

11. Brtnikova M, Crane LA, Allison MA, Hurley LP, Beaty BL, Kempe: A method for achieving

high response rates in national surveys of U.S. primary care physicians. PLoS ONE 13(8),

2018

12. Asch DA, Jedrziewski MK, Christakis NA: Response rate to Mail Surveys Published in

Medical Journals. J Clinic Epidemiol 50:1129-1136, 1997

18

Table 1. Clinical Scenario Questionnaire

Conditions/ Procedures

General Surgeon

Periodontist Plastic Surgeon

Oral and Maxillofacial Surgeon

Otolaryngologist (ENT)

Other (please specify)

Trauma:

1. Fracture of the upper jaw (broken upper jaw)

2. Fracture of the lower jaw (broken lower jaw)

3. Fracture of the nose (broken nose)

4. Fracture of the eye bones

5. Fracture of the cheek bones

6. Fracture of the skull

7. Cut on the face

Pathology:

8. Cancer of the mouth, tongue or lip

9. Non cancerous lesion of the mouth, tongue or lip

10. Non cancerous tumor/cyst of the upper or lower jaw

11. Removal of temporomandibular joint (TMJ) lesions (Jaw Joint lesions)

19

12. Salivary Gland removal

13. Infection/swelling around the mouth/neck

14. Infection/swelling around the eye


General Surgeon




Other (Please specify)

Reconstruction:

15. Child with cleft lip (improperly joined lip)

16. Child with cleft palate (improperly formed/joined roof of the mouth)

17. Soft tissue (skin, fat, muscle) grafts for oral reconstruction (taking soft tissue to rebuild the oral cavity)

18. Hard tissue (hip, tibia and skull bone) grafts, for oral reconstruction (taking bone tissue to rebuild the oral cavity)

Oral Procedures:

19. Removal of wisdom teeth (3rd molars)

20. Placement of Dental implants

20

21. Providing general anesthesia/deep sedation (putting patients to sleep during dental procedures)

Cosmetic

22. Jaw corrective surgery

23. Nose corrective surgery

24. Facial appearance procedures. (facelift, eyebrow lift, Botox, chemical peels etc..)

21

3.9 Table / Figure Legends:

Table 1. Clinical Scenario Questionnaire. Study participants were asked to review all the surgical

conditions/procedures listed in the table below and select which specialist(s) they thought were

competent (capable) of dealing with each condition.

Figure 1. Awareness of Specialists. The percentage that each of the survey participants were aware of

the following specialists: General Surgeon (GS), Oral and Maxillofacial Surgeon (OMS),

Otolaryngologist (ENT), Periodontist (P), and Plastic Surgeon (PS), is displayed. A total of 95.5% of

Primary Care Physicians, 100% of General Dentists, and 73.7% of General Public were aware of OMS

(*** p<0.001, Primary Care Physicians vs General Public; *** p<0.001, General Dentists vs General

Public).

Figure 2. Trauma Scenarios. Survey participants selected all the specialists they thought were

capable of treating each trauma scenario: (A) Fracture of the Upper Jaw (** p<0.01, Primary Care

Physicians vs General Public; ** p<0.01, General Dentists vs General Public), (B) Fracture of the Lower Jaw .

(** p<0.01, Primary Care Physicians vs General Public; *** p<0.001,General Dentists vs Primary Care Physicians;

*** p<0.001, General Dentists vs General Public), (C) Fracture of the Nose, (D) Fracture of the Eye Bones,

(E) Fracture of the Cheek Bones (** p<0.01, General Dentists vs Primary Care Physicians; ** p<0.01, General

Dentists vs General Public; ** p<0.01, General Public vs Primary Care Physicians), (F) Fracture of the Skull ( ***

p<0.001, General Public vs Primary Care Physicians), and (G) Cut on the Face (** p<0.01, Primary Care

Physicians vs General Public; ** p<0.01, General Dentists vs Primary Care Physicians; *** p<0.001, General

Dentists vs General Public). Primary Care Physicians, General Dentists and General Public selected OMS

the most for treating fractures of the upper and lower jaws.

Specialities are represented by the following colors; General Surgeon, Oral and Maxillofacial

Surgeon, Otolaryngologist, Periodontist, Plastic Surgeon.

Figure 3. Pathology Scenarios. Survey participants selected all the specialists they thought were

capable of treating each pathology scenario: (A) Cancer of mouth, tongue, or lip (*** p<0.001, General

Dentists vs Primary Care Physicians; ** p<0.01, General Public vs Primary Care Physicians), (B) Non-Cancerous

lesion of mouth, tongue, or lip ( *** p<0.001, General Dentists vs Primary Care Physicians; *** p<0.001, General

Dentists vs General Public), (C) Non-Cancerous tumor/cyst of the Upper or Lower Jaw (*** p<0.001, Primary

Care Physicians vs General Public; *** p<0.001, General Dentists vs Primary Care Physicians; *** p<0.001, General

Dentists vs General Public), (D) Removal of TMJ Lesions (*** p<0.001, Primary Care Physicians vs General Public;

** p<0.01, General Dentists vs Primary Care Physicians; *** p<0.001, General Dentists vs General Public), (E)

Salivary Gland Removal (*** p<0.001, General Dentists vs Primary Care Physicians; *** p<0.001, General Dentists

vs General Public; ** p<0.01, General Public vs Primary Care Physicians), (F) Infection/Swelling around

Mouth/Neck (** p<0.01, Primary Care Physicians vs General Public; *** p<0.001, General Dentists vs Primary Care

Physicians; *** p<0.001, General Dentists vs General Public), and (G) Infection/Swelling around Eye (***

p<0.001, General Dentists vs Primary Care Physicians; *** p<0.001, General Public vs Primary Care Physicians).

Primary Care Physicians, General Dentists and General Public selected OMS the most for treating

Non-Cancerous tumor/cyst of the Upper or Lower Jaw, and Removal of TMJ Lesions.



22

Figure 4. Reconstructive Surgery Scenarios. Survey participants selected all the specialists they

thought were capable of performing each reconstructive surgery scenario: (A) Child with Cleft Lip

(*** p<0.001, General Dentists vs Primary Care Physicians; *** p<0.001, General Public vs Primary Care Physicians),

(B) Child with Cleft Palate (*** p<0.001, General Dentists vs Primary Care Physicians; *** p<0.001, General Public

vs Primary Care Physicians), (C) Soft Tissue Grafts for Oral Reconstruction (*** p<0.001, General Dentists vs

Primary Care Physicians; ** p<0.01, General Public vs Primary Care Physicians), and (D) Hard Tissue Grafts for

Oral Reconstruction (** p<0.01, General Dentists vs Primary Care Physicians; ** p<0.01, General Dentists vs

General Public, ** p<0.01, General Public vs Primary Care Physicians). Primary Care Physicians did not select

OMS highly for any reconstruction surgery scenario.



Figure 5. Oral Procedure Scenarios. Survey participants selected all the specialists they thought

were capable of performing each oral procedure scenario: (A) Removal of Wisdom Teeth ( ** p<0.01,

General Dentists vs General Public), (B) Placement of Dental Implants ( ** p<0.01, General Dentists vs Primary

Care Physicians; *** p<0.001, General Dentists vs General Public), and (C) Providing General/Deep Sedation (*** p<0.001, Primary Care Physicians vs General Public; *** p<0.001, General Dentists vs Primary Care Physicians; ***

p<0.001, General Dentists vs General Public). Primary Care Physicians, General Dentists and General Public

selected OMS the most for removal of wisdom teeth and placement of dental implants.



Figure 6. Cosmetic Scenarios. Survey participants selected all the specialists they thought were

capable of performing each cosmetic scenario: (A) Jaw Corrective Surgery (*** p<0.001, Primary Care

Physicians vs General Public; * p<0.05, General Dentists vs Primary Care Physicians; *** p<0.001, General Dentists vs

General Public), (B) Nose Corrective Surgery (** p<0.01, General Public vs Primary Care Physicians; *** p<0.001,

General Public vs General Dentists), and (C) Facial Appearance Procedures (*** p<0.001, General Dentists vs

Primary Care Physicians). Primary Care Physicians, General Dentists and General Public selected OMS

the most for performing jaw corrective surgery.



23

Figure 1. Awareness of Specialists

24

Figure 2A. Fracture of the Upper Jaw

25

Figure 2B. Fracture of the Lower Jaw

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Medical physician General dentist General public

Sp

eci

alt

y S

ele

cte

d (

%)

Survey Participant

***

**

Primary Care

PhysiciansGeneral Dentists General Public

26

Figure 2C. Fracture of the Nose

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Medical physician General dentist General public

Sp

eci

alt

y S

ele

cte

d (

%)

Survey Participant

Primary Care

PhysiciansGeneral Dentists General Public

27

Figure 2D. Fracture of the Eye

28

Figure 2E. Fracture of the Cheek

29

Figure 2F. Fracture of the Skull

30

Figure 2G. Cut on the face

31

Figure 3A. Cancer of the mouth, tongue or lip

32

Figure 3B. Non-cancerous lesion of the mouth, tongue or lip

33

Figure 3C. Non-cancerous tumor/cyst of the upper or lower Jaw

34

Figure 3D. Removal of TMJ lesion

35

Figure 3E. Salivary Gland Removal

36

Figure 3F. Infection/swelling around the mouth/neck

37

Figure 3G. Infection/swelling around the Eye

38

Figure 4A. Child with cleft lip

39

Figure 4B. Child with cleft palate

40

Figure 4C. Soft tissue grafts for oral reconstruction

41

Figure 4D. Hard tissue grafts for oral reconstruction

42

Figure 5A. Removal of Wisdom teeth

43

Figure 5B. Placement of dental implants

44

Figure 5C. Providing general/deep sedation

45

Figure 6A. Corrective Jaw surgery

46

Figure 6B. Nose corrective surgery

47

Figure 6C. Facial appearance procedures

48

Chapter 6 Discussion

6.1 Limitations:

This study is not without limitations. This survey was performed only in Ontario, and therefore

the results may not be applicable throughout Canada. However, Ontario is the largest province

and has the greatest number of Oral and Maxillofacial Surgeons, so one would expect that they

would have the greatest recognition and exposure here. If anything, in provinces where fewer

OMS are present, the results would be expected to show even less awareness of OMS scope.

Another potential limitation in this study was our response rate of 50.1%. It was slightly below

the mean response rate of 54-61% for physicians and 68% for non-physicians obtained in

systematic review of postal questionnaires 26. However other sources have stated values as low

as 6% for health care professional and 48.4% for published academic studies, therefore our

50.1% response rate represents an acceptable result and not a true limitation 27,28. Our approach

was a modification of The Dillman Tailored Design Survey Method, with the use of an initial

invitation letter, a phased distribution and follow up phone calls all done to maximize the

response rate as multiple mail outs and follow-up reminders are known to reduce bias and

optimize response rate 29. Due to the cost of each wave of mail out surveys, no further strategies

such as monetary incentives could be applied. Our budget also did not allow for a larger sample

to be contacted, as it would not have been feasible and would have likely meant that less waves

of the survey would have been sent. Lastly regional variations in scope of practice exist in

Canada as they do in the rest of the world, making it difficult to accurately assess. Procedures

that are taught in training programs and fall within OMS scope of practice may not be practiced

in some parts of the country. This subsequently makes it hard to determine if there is a true lack

of awareness or if the awareness identified is in fact representative of what is practiced in that

region. With this in mind, only a few procedures listed in our Survey are not routinely performed

in Ontario, therefore the majority of procedures are a true representation of what an Ontario

OMS performs.

49

6.2 Implications and Future Directions: Our study is the first of its kind to be performed in Canada. It showed similar results to those

obtained internationally and has the potential to be applied to a variety of areas. There is a global

lack of awareness of the scope of practice of Oral and Maxillofacial Surgeons in Ontario.

General Dentists appear to be the most knowledgeable, with no difference demonstrated between

Family Physicians and the General Public, however all populations underestimated the true

scope of OMS. Our findings have important implications in the areas of public health and public

education. In terms of public health, everyone should be able to obtain the best possible and most

timely treatment. The goal of health care is to provide optimal care for patients, including

providing patients with all the treatment options and surgical specialties capable of providing

them care. This ensures that they can make the most educated decision. For this to occur, there

must be sound understanding of the Oral and Maxillofacial Surgery specialty by medical and

dental professionals, as well as the General Public so that appropriate referrals are made, leading

to effective and efficient treatment for all1, 12. If Oral and Maxillofacial Surgeons are not

recognized as potential treatment providers, patients may in fact be waiting weeks to months for

medical specialist referrals due to the nature of our saturated health care system. Undergraduate

medical students in the UK, who demonstrated a lack of awareness of OMS, also found a

significant delay to consult Oral and Maxillofacial Surgeons compared to other surgical

specialists17. If all specialties that can manage a specific issue are recognized, the public has a

greater amount of options, which likely means a reduced interval from time of referral to

consult/treatment. Previously, it was found that of the General Public that were aware of OMS, a

majority had heard of it from a friend’s or family member’s experience11. This demonstrates that

any awareness of OMS is gained through personal experience more than public knowledge or

social media currently. Family Physicians and General Dentists are, many times, the primary

point of contact for any head, neck or oral complaint by the public. These professionals act as

potential gatekeepers to OMS 30. They may determine the course of patients, thus having them

informed of all options allows them the opportunity to provide the best care. This is why our data

which showed a clear lack of awareness must be applied to the education of health care

professionals30. As such, greater progress needs to be made in the education of Family

Physicians, General Dentists and the General Public, especially in the areas that were grossly

50

underrepresented, if the specialty of Oral and Maxillofacial Surgery is to be practiced to its full

potential and patients are to receive all treatment options7, 12.

The scope of OMS has expanded more and more in recent years, which underscores the

importance of promoting the profession. While overlapping boundaries with plastic surgery and

ENT may cause confusion, some propose that this creates more of a healthy competition31.

O’Keefe suggests that policymakers encourage this growth to promote innovation that would

provide patients more choice and a better quality of care 32. Future studies should be directed

towards analyzing education patterns on OMS scope of practice and improving education

opportunities for health care providers and patients. In addition, conducting similar studies

throughout the rest of Canada would be beneficial to see if perceptions held in Ontario are held

in the rest of the country. Along with this, the specialty of Oral and Maxillofacial Surgery should

aim for the establishment of a national scope of practice that is consistent from province to

province. This would allow the identification of recurrent areas of weakness in the population’s

perception, without regional variations playing a role, so that education campaigns could be

optimized and conducted on a national level.

Future directions should follow our proactive neighbors with AAOMS prioritizing informational

campaigns. AAOMS targeted the public with branding that was easily understood and well

received using slogans such as “Oral and Maxillofacial Surgeons: The Experts in Face, Mouth

and Jaw Surgery”24. A patient-specific website and information videos on common Oral and

Maxillofacial Surgery procedures helped the profession keep up to date with social media and

allow people to use their tech devices to get answers in the comfort of their home. AAOMS had

much success as a result. Another campaign targeted dental students with the “Morning Huddle

Student Edition” providing daily electronic resources to dental students regarding the scope of

OMS. In Ontario, we can make similar steps to help people understand who to turn to: the

experts.

51

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2. Lababidi E, Breik O, Subramaniam S: Perceptions of oral and maxillofacial surgery

amongst Australian medical general practitioners. Oral Maxillofac Surg Oral Med Oral

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https://www.osoms.ca/

55

26. Asch DA, Jedrziewski MK, Christakis NA: Response rate to Mail Surveys Published in

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28. Baruch Y, Holtom B: Survey response sate levels and trends in organizational research.

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Medical Research Methodology 6(5), 2006

30. Cottrell DA, Reebye UN, Blyer SM, Hunter MJ, Mehta N: Referral patterns of general

dental practitioners for oral surgical procedures. J Oral Maxillofac Surg 65:686-690, 2007

31. McArdle PJ, Whitnall M: The referral practice of general medical practitioners to the

surgical specialties: implications for the future. Br J Oral Maxillofac Surg 34:394–399,

1996

32. O’Keefe JP: Is Competition Good for care? Editorial. J Can Dent Assoc: 72, 2006

56

Appendices

Appendix A. Additional Detailed Methodology

Study Design, Population and Questionnaire

A cross-sectional study via a mail-out survey to a random sample of general dentists, family

physicians and the general public in Ontario was performed. Ethics approval was obtained from

the University of Toronto (protocol #: 34462) Research Ethics Boards. The sample size (n)

calculation is based on the population size (N), proportion of population expected to choose 1 of

2 responses (P=0.5 to allow for maximum variance), the assumed sampling error (C=0.05), and

the Z-statistic of 1.96 (for a 95% confidence interval – CI). Ontario population of 13.6 million,

the sample size of 384 was calculated. n = [ (N)(P)(1-P) ] / [ (N-1)(C/Z)2 + (P)(1-P) ] n = 384.

General Dentist Ontario 8019, the sample size of 367 was calculated n = [ (N)(P)(1-P) ] / [ (N-

1)(C/Z)2 + (P)(1-P) ] n = 367. Medical Professionals 40890, the sample size of 381 was

calculated n = [ (N)(P)(1-P) ] / [ (N-1)(C/Z)2 + (P)(1-P) ] n = 381. The sample target was

increased to 600 in each group to ensure adequate number of responses for analysis of the data

with an expected response rate below 50%. Allocated funds only allowed an increase in all

groups to 600.

Study Population The survey population was a representative sample of the General Public,

General Dentists and Family Physicians in Ontario. The source of this sample frame was the

physician registry and general dentist registry via the CPSO and ODA websites from which a

random population was generated by selecting at random every 67th person from the CPSO and

every 13th person from the ODA websites to obtain a total of 600 participants from each of the

two populations. The General Public was similarly drawn by selecting a random sample of 600

from the Ontario telephone directory and cross matching each selection ensuring they were not

either a registered General Dentist or Family Physician.

Inclusion criteria: 1. General Population: Adults over the age of 18 who are neither medical nor

dental professionals and living in Ontario. 2. Family Physician: Any general medical family

57

physician with a valid CPSO number. 3. General Dentist: Any general dentist with a valid

RCDSO number.

Exclusion Criteria: Any subject under the age of 18. Oral and Maxillofacial Surgeons, medical

and dental professionals cannot be included into the General Public sample. In addition, no Oral

and Maxillofacial Surgeon can be included in either the General Dentist or medical professional

population.

Survey Tool: The survey tool (see Appendix F) was designed based on other patient-related

questionnaires in the literature12, 15. The survey tool was pilot tested amongst 15 participants in

each of the 3 population groups in order to evaluate the validity of the design, respondent burden,

time needed to complete the survey, and level of understanding of the survey. Revisions were

made after pilot testing. The survey consisted of a demographic screener along with 24 clinical

scenarios in which the participant could select all the specialists they thought were capable of

completing the treatment. For each of the 24 clinical scenarios, 5 specialties were given as

options (General surgeon, ENT, OMS, Plastic Surgeon and Periodontist) along with an “Other”

option. This protocol was adopted from previous survey studies5-8. It asks participants to identify

which health care professional performs specific treatments, as well as demographic questions,

and for health professionals, the level of training and type of specialty. The specific treatment

situations were selected to include the entire scope of practice that is taught during an oral and

maxillofacial training program and are in line with those used in the current literature related to

OMS scope.

Survey Implementation: The initial mail-out contact was a brief letter informing the selected

participants of their selection to potentially partake in the study. It informed them that they

would receive the full survey package with further details and full instructions within the

following 2 weeks. This initial contact letter was incorporated to try and maximize survey

response rate. The first full mail out package was sent out 2 weeks after the initial contact letter,

it consisted of the study invitation, research cover letter, information sheet for participants, the

questionnaire, as well as a pre-stamped and pre-addressed return envelope. Four weeks after the

initial mail out contact, only the non-responders were mailed a reminder invitation to participate

in the study, as well as a second questionnaire and a pre-stamped return envelope. Four weeks

58

after the reminder letters were sent, the first follow up phone calls were made to all non-

responders. Four weeks after the first follow up phone call, a final package of the questionnaire

and pre-stamped and pre-addressed envelopes were sent to the remaining non-responders again.

Four weeks after the final mail-out contact, the non-responders received a second phone call

follow up. This staggered survey distribution along with periodic phone call follow-ups was

implemented to maximize study response rate. Data collection began with the initial survey

distribution and ceased with the last follow up phone call over the course of a 22-week period.

Statistical Analysis: Questionnaire data from completed and returned questionnaires were input

into a Microsoft Excel (Microsoft Corp, Redmond, WA) file, and the database exported into the

Statistical Package for Social Sciences software 21.0 (Armonk, NY : IBM Corp.) Descriptive

statistics reported demographic data. Inferential statistics via a chi-square test compared

responses between the general population, physicians, and dentists to identify any significant

differences between subjects. Level of significance was set at p < 0.05. If significant differences

between the three groups were identified a second set of chi-square tests were done comparing

General Dentists vs Family Physicians, General Dentists vs General Public and Family

Physicians vs General Public. A Bonferroni correction was completed to account for type 1 error

making the level of significance p< 0.0167.

59

Appendix B. Additional Detailed Results

Patient Demographics

An overall response rate of 50.1% (n=902) was achieved, 311 Family Physicians, 332 General

Dentists and 259 from the General Public. Demographic data of the respondents was analyzed.

Demographic data (Table 1) shows a statistically significant difference in gender composition (p

= .007) and location (p < .001). General Dentists have higher proportion of males (67.5%)

compared to Family Physicians (57.9%) and the General Public (54.1%). Also, the General

Public participants are more likely to reside in large urban areas (94.2%) compared to Family

Physicians (66.9%) and General Dentists (66.5%). No significant difference was found for age (p

= .06) with the mean age of the entire survey population 49.41 +13.5, or for years of practice (p

= .37).

60

Table 1. Demographics

Demographic Total sample

(n = 902)

Family

Physicians

(n = 311)

General

Dentists

(n = 332)

General

Public

(n = 259)

Comparison between

groups

Gender, n (%) Χ²(4) = 14.2, p = .007

Female

357

(39.6%)

131

(42.1%)

107 (32.2%) 119 (45.9%)

Male

544

(60.4%)

180

(57.9%)

225 (67.5%) 140 (54.1%)

Age, mean ± SD

49.4 ±

13.50

50.6 ±

13.50

49.4 ±

11.90

47.9 ±

15.23

F(2.9) = 2.7, p = .06

Years of practice,

mean ± SD

21.5 ±

13.23

21.1 ±

14.27

21.9 ±

12.19

- F(1,639) = 0.8, p =

.37

Location, n (%) Χ²(6) = 75.4, p < .001

Rural 2 (0.2%) 1 (0.3%) 1 (0.3%) 0

Small urban 108(12.0%) 51 (16.4%) 54 (16.3%) 3 (1.2%)

Medium urban 119

(13.2%)

51 (16.4%) 56 (16.9%) 12 (4.6%)

Large urban 672(74.6%) 208

(66.9%)

220 (66.5%) 244(94.2%)

61

Clinical Scenario Selection:

Similarly, to previous studies, the 24 clinical scenarios were grouped into 5 categories; trauma,

pathology, reconstructive surgery, oral procedures and cosmetic surgery15. 13 of 24 scenarios

had a total OMS selection of less than 50% as seen in Table 3. When each population was

examined individually, the General Population had 16, Family Physicians, 14, and General

Dentists, 10 scenarios, where OMS were selected less than 50%. General Dentists had the

highest OMS selection in 20 of the 24 scenarios (Table 2). When the population groups were

compared to each other, General Dentists had statistically significant higher selection of OMS in

19 of 24 scenarios compared to Family Physicians (Table 3) and 16 of 24 when compared to the

General Public (Table 4). Meanwhile, Family Physicians had 8 of 24 and the General Public had

10 of 24 scenarios with a significant higher OMS selection when compared to each other (Table

5).

Trauma:

OMS selection in trauma scenarios 1. maxillary, 2. mandibular, 3. nasal, 4. orbital, 5. cheek and

6. skull fractures and 7. cuts on the face was (table 3, Fig 2): Bold indicates > 50% selection.

1. Total: (73.3%, 86.9%, 20.6%, 22.9%, 37.5%, 14.1%, 36.4%)

2. General Dentists (77.4%, 99.1%, 23.2%, 27.4%, 47.6%, 14.4%, 53.9%)

3. Family Physicians (75.2%, 83.9%, 20.3%, 19.6%, 28.3%, 7.2%, 35.4%)

4. General Public (65.6%, 74.9%, 17.8%, 20.9%, 35.7%, 21.4%, 15.1%)

Pathology:

OMS selection involving pathology of the head and neck, 1. cancerous lesions, 2. non-cancerous

lesions, 3. non-cancerous cyst/tumors, 4. TMJ pathology, 5. salivary gland treatments, 6.

infections of the neck and 7. infections of the eye was (Table 3, Fig 3): Bold indicates > 50%

selection.

1. Total: (42.8%, 71%, 79.1%, 84.1%, 51.7%, 66.6%, 18%)

2. General Dentists (58.7%, 94.3%, 97%, 98.2%, 71.1%, 93.7%, 25%)

3. Family Physicians (20.3%, 61.7%, 75.6%, 81.4%, 35%, 55.6%, 8%)

4. General Public (49.6%, 52.3%, 60.5%, 69.5%, 46.7%, 45.2%, 20.8%)

62

Reconstructive Surgery:

OMS selection in scenarios involving 1. Cleft lip, 2 Cleft palate, reconstruction of oral structures

with 3. hard or 4. soft tissue was (table 3, Fig 4): Bold indicates > 50% selection.

1. Total: (29.8%, 40.0%, 43.4%, 46.2%)

2. General Dentists (34%, 44.3%, 49.4%, 59%)

3. Family Physicians (21.5%, 31.2%, 33.1%, 33.8%)

4. General Public (34.4%, 45.2%, 48.2%, 44.8%)

Oral Procedures:

OMS selection in Oral procedures such as 1. wisdom teeth extractions, 2. dental implants and 3.

providing anesthesia was (Table 3, Fig 5): Bold indicates > 50% selection.

1. Total: (86.9%, 71.6%, 58.3%)

2. General Dentists (99.4%, 88.9%, 86.4%)

3. Family Physicians (82.3%, 65.9%, 50.8%)

4. General Public (76.4%, 56.4%, 31.3%)

Cosmetic Surgery:

OMS selection for cosmetic procedures 1. Nose corrective procedures, 2. Jaw corrective surgery

and 3. facial appearance procedures had an OMS selection of (Table 3, Fig 6): Bold indicates >

50% selection.

1. Total: (10.3%, 81.5% and 8.5%)

2. General Dentists (6.9%, 97%, 13%)

3. Family Physicians ( 8.4%, 84.2%, 4.2%)

4. General Public (17.7%, 58.3%, 7.7%

63

Table 3. OMS % selected per condition/scenario by all groups.

Bold indicates > 50% selection.

Condition /

Scenario

Total

sample

(n = 902)

Family

Physicians

(n = 311)

General

Dentists

(n = 332)

General Public

(n = 259)

Comparison between

three groups

1 73.3% 75.2% 77.4% 65.6% p = .004

2 86.9% 83.9% 99.1% 74.9% p < .001

3 20.6% 20.3% 23.2% 17.8% p = .27 (NS)

4 22.9% 19.6% 27.4% 20.9% p = .043

5 37.5% 28.3% 47.6% 35.7% p < .001

6 14.1% 7.2% 14.4% 21.4% p < .001

7 36.4% 35.4% 53.9% 15.1% p < .001

8 42.8% 20.3% 58.7% 49.6% p < .001

9 71.0% 61.7% 94.3% 52.3% p < .001

10 79.1% 75.6% 97.0% 60.5% p < .001

11 84.1% 81.4% 98.2% 69.5% p < .001

12 51.7% 35.0% 71.1% 46.7% p < .001

13 66.6% 55.6% 93.7% 45.2% p < .001

14 18.0% 8.0% 25.0% 20.8% p < .001

15 29.8% 21.5% 34.0% 34.4% p < .001

16 40.0% 31.2% 44.3% 45.2% p < .001

17 43.4% 33.1% 49.4% 48.2% p < .001

18 46.2% 33.8% 59.0% 44.8% p < .001

19 86.9% 82.3% 99.4% 76.4% p < .001

20 71.6% 65.9% 88.9% 56.4% p < .001

21 58.3% 50.8% 86.4% 31.3% p < .001

22 81.5% 84.2% 97.0% 58.3% p < .001

23 10.3% 8.4% 6.9% 17.0% p < .001

24 8.5% 4.2% 13.0% 7.7% p < .001

64

TOTAL 49.3% 42.8% 60.8% 42.3% p < .001

Table 4. OMS % selected per condition/scenario Family Physicians vs. General Dentists.


Condition / Scenario Family Physicians

(n = 311)

General Dentist

(n = 332)

Comparison of groups

1 75.2% 77.4% p = .5 (NS)

2 83.9% 99.1% p < .001

3 20.3% 23.2% p = .3 (NS)

4 19.6% 27.4% p = .02 (NS)

5 28.3% 47.6% p =.004

6 7.2% 14.4% p = .002

7 35.4% 53.9% p = .003

8 20.3% 58.7% p < .001

9 61.7% 94.3% p < .001

10 75.6% 97.0% p < .001

11 81.4% 98.2% p =.003

12 35.0% 71.1% P < .001

13 55.6% 93.7% p <.001

14 8.0% 25.0% p < .001

15 21.5% 34.0% p < .001

16 31.2% 44.3% p < .001

17 33.1% 49.4% p < .001

18 33.8% 59.0% p = .007

19 82.3% 99.4% p = .02 (NS)

20 65.9% 88.9% p = .004

21 50.8% 86.4% p < .001

22 84.2% 97.0% p = .003

23 8.4% 6.9% p = .5 (NS)

24 4.2% 13.0% p < .001

65

TOTAL 42.8% 60.8% p < .001

Table 5. OMS % selected per condition/scenario General Public vs. General Dentists.


Condition / Scenario General Public

(n = 259)

General Dentist

(n = 332)


1 65.6% 77.4% p = .002

2 74.9% 99.1% p < .001

3 17.8% 23.2% p = .1 (NS)

4 20.9% 27.4% p = .07 (NS)

5 35.7% 47.6% p =.003

6 21.4% 14.4% p = .03 (NS)

7 15.1% 53.9% p < .001

8 49.6% 58.7% p = .02 (NS)

9 52.3% 94.3% p < .001

10 60.5% 97.0% p < .001

11 69.5% 98.2% p < .001

12 46.7% 71.1% P < .001

13 45.2% 93.7% p <.001

14 20.8% 25.0% p < .24 (NS)

15 34.4% 34.0% p < .9 (NS)

16 45.2% 44.3% p < .8 (NS)

17 48.2% 49.4% p < .8 (NS)

18 44.8% 59.0% p =.002

19 76.4% 99.4% p = .007

20 56.4% 88.9% p < .001

21 31.3% 86.4% p < .001

22 58.3% 97.0% p < .001

23 17.0% 6.9% p = .001

24 7.7% 13.0% p = .04 (NS)

66

TOTAL 42.3% 60.8% p < .001

Table 6. OMS % selected per condition/scenario Family Physicians vs. General Public.


Condition / Scenario Family physicians

(n = 311)

General Public

(n = 259)


1 75.2% 65.6% p = .01

2 83.9% 74.9% p =.008

3 20.3% 17.8% p = .5 (NS)

4 19.6% 20.9% p = .7 (NS)

5 28.3% 35.7% p =.01

6 7.2% 21.4% p < .001

7 35.4% 15.1% p = .007

8 20.3% 49.6% p = .009

9 61.7% 52.3% p = .02 (NS)

10 75.6% 60.5% p < .001

11 81.4% 69.5% p < .001

12 35.0% 46.7% p = .005

13 55.6% 45.2% p =.01

14 8.0% 20.8% p < .001

15 21.5% 34.4% p < .001

16 31.2% 45.2% p < .001

17 33.1% 48.2% p < .001

18 33.8% 44.8% p = .01

19 82.3% 76.4% p = .08 (NS)

20 65.9% 56.4% p = .02 (NS)

21 50.8% 31.3% p < .001

22 84.2% 58.3% p < .001

23 8.4% 17.0% p = .002

24 4.2% 7.7% p = .07 (NS)

67

TOTAL 42.8% 42.3% p = .9 (NS)

Appendix C. Initial Contact Letter

Dear _________________,

My name is Oscar Dalmao and I am a graduate student at the University of Toronto. This invitation letter

is being sent to you as you have been randomly selected. I am inviting you to participate in a research

project studying the perception of Surgeons’ scope of practice. You can expect to receive a survey in the mail in 2 weeks time.

I would appreciate your help by completing the survey you will receive in 2 weeks. The survey will take

approximately 10 minutes to complete and the results will be made available once the study has

concluded. Further details about study participation will be explained in the mailed out survey package.

Thank you for your time. It is only with the help of generous people like you that our research can be

successful.

Sincerely,

Oscar Dalmao, MSc Candidate

University of Toronto.

Room 143, 124 Edward Street, Toronto, ON, M5G 1G6 Email: [email protected]

68

Appendix D. Invitation to study participation

Dear _________________,

My name is Oscar Dalmao and I am a graduate student at the University of Toronto. I am inviting you to participate in a research project studying the perception of Surgeons’ scope of practice.

I would appreciate your help by participating in this survey which will take approximately 10 minutes to complete. There are no right or wrong answers. Your participation is voluntary and you may withdraw from this study at any time, for any reason.

Your privacy is important to us, and this survey is completely confidential. Your responses will not be linked to your name. Although, I am encouraging you to complete this questionnaire, if you choose to not participate in this study, this will in no way affect the care you receive at the University of Toronto Faculty of Dentistry, or at a private dental clinic.

In regards to the survey itself, you can contact me at [email protected]. Kindly ensure your responses are received no later than ###################

Thank you for your time. It is only with the help of generous people like you that our research can be successful.

Sincerely,

Oscar Dalmao, MSc Candidate

University of Toronto.

Room 143, 124 Edward Street, Toronto, ON, M5G 1G6

Email: [email protected]

mailto:[email protected]

69

Appendix E - Information and Consent for Participation

How was I selected to be in this Sample? Who will see my answers? Will my answers be confidential?

You were selected at random to be part of this sample being drawn either from the Ontario Dental Association (ODA), the College of Physicians and Surgeons of Ontario (CPSO) or Ontario population registry. During this research project, names and addresses of participants will be stored electronically on a secure and encrypted network, on a password-protected computer. The surveys will be kept in a locked cabinet in the Discipline of Oral and Maxillofacial Surgery. All electronic data will be stored on a password-protected computer in the Discipline of Oral and Maxillofacial Surgery and the primary investigator will be the only individual with access to these data. Each questionnaire is numbered: the number represents your mailing address. The list that identifies your address is stored separately in a locked cabinet at a different location, and will also be destroyed upon completion of this study. As a result, there is little - if any - possibility of linking a returned survey to the individual who completed it. Contact information is only used for survey distribution and tracking responses. At the end of this study, all of the contact information and all of the surveys will be destroyed and shredded.

Your responses are completely confidential. Your name and any personal identifying information will not be stored with your answers, and it will also not be used in any reports or publications from this study. If chosen, (a) representative(s) of the Human Research Ethics Program (HREP) may access study related-data and/or consent materials as part of the review. All information accessed by the HREP will be upheld to the same level of confidentiality that has been stated by the research team.

What happens if I do not participate?

Participation is completely voluntary. It is your right to refuse to answer any questions or participate, and you can withdraw from the study at any time by not completing the survey and not returning it to us, or by contacting us and informing us about your wishes to withdraw from the study. There are no consequences to you if you decline to participate in this study.

Does my participation provide any benefits to myself?

There are no immediate benefits to you. However obtaining an understanding of the population's view of Oral and Maxillofacial Surgeons may encourage the profession to explore areas where the can provide greater service to the overall public.

Are there any risks or harms in participating?

There are no risks or harms in participating in this study.

70

How do you obtain my consent to participate?

Completing this questionnaire and returning it to the primary investigator implies your consent to participate in this study.

Who can I contact for more information?

Further questions about this study can be answered by myself (the principal investigator) at any time. Kindly email me at [email protected]

mailto:[email protected]

71

Appendix F - Study Survey

Thank you for taking the time to fill out this survey. Please answer all of the questions.

Once completed, please return only the questionnaire in the prepaid postage envelope included with this package. If you decline to participate in this study, please return the unfilled questionnaire using the pre-stamped envelope attached, so we do not contact you in the future. Thank you

1. Do you agree to participate in this study?

⎕ Yes

⎕ No

2. Current gender identity: (please check one answer)

⎕ Male

⎕ Female

⎕ Transgender

⎕ Do not identify as male, female or transgender

3. Date of birth

4. Are you a Medical physician or Dentist?

⎕ Yes

⎕ No

If so please indicate your specific field of practice and years of practice

⎕ Family physician

⎕ Medical specialist (please specify)

⎕ General dentist

⎕ Dental specialist (please specify)

Years of practice: ______

72

5. Have you ever heard of any of these specialists? (Please check all that apply)

Specialist YES NO

General Surgeon

Periodontist

Plastic Surgeon



6. Have you ever been treated by any of these specialists? (Please check all that apply)

Specialist YES NO

General Surgeon

Periodontist

Plastic Surgeon



7. Please review all the surgical conditions/procedures listed below and select which specialists you think are competent (capable) of dealing with each condition. (Please check ALL specialists who apply for EACH of the conditions/procedures listed)


General Surgeon




Other (please specify)

Trauma:

1. Fracture of the upper jaw (broken upper jaw)

73

2. Fracture of the lower jaw (broken lower jaw)

3. Fracture of the nose (broken nose)

4. Fracture of the eye bones

5. Fracture of the cheek bones

6. Fracture of the skull

7. Cut on the face

Pathology:

8. Cancer of the mouth, tongue or lip

9. Non cancerous lesion of the mouth, tongue or lip

10. Non cancerous tumor/cyst of the upper or lower jaw

11. Removal of temporomandibular joint (TMJ) lesions (Jaw Joint lesions)

12. Salivary Gland removal

13. Infection/swelling around the mouth/neck

14. Infection/swelling around the eye

74


General Surgeon




Other (Please specify)

Reconstruction:

15. Child with cleft lip (improperly joined lip)

16. Child with cleft palate (improperly formed/joined roof of the mouth)

17. Soft tissue (skin, fat, muscle) grafts for oral reconstruction (taking soft tissue to rebuild the oral cavity)

18. Hard tissue (hip, tibia and skull bone) grafts, for oral reconstruction (taking bone tissue to rebuild the oral cavity)

Oral Procedures:

19. Removal of wisdom teeth (3rd molars)

20. Placement of Dental implants

21. Providing general anesthesia/deep sedation (putting patients to sleep during dental procedures)

Cosmetic

22. Jaw corrective surgery

23. Nose corrective surgery

75

24. Facial appearance procedures. (facelift, eyebrow lift, Botox, chemical peels etc..)

Thank you for taking the time to participate in this survey!

Please place the filled questionnaire in the enclosed self-addressed and self-stamped envelope, seal it, and return it to us.

Documents

Public Perception of the Scope of Practice of Oral