Knowledge and attitudes of pediatric dentists regarding temporomandibular disorders

1. Introduction

The American Academy of Pediatric Dentistry defines temporomandibular disorders (TMD) as a group of musculoskeletal and neuromuscular conditions characterized by a range of clinical signs and symptoms affecting the temporomandibular joint (TMJ), masticatory muscles and associated structures [1]. Although TMD is often associated with adults, it can also affect pediatric patients, with the common symptoms comprising myofascial pain, headaches, neck pain, difficulty chewing and clicking sounds during mouth opening and closing [2].

The prevalence of TMD has increased significantly in recent years, not only among adults but also in pediatric patients. According to the American Academy of Orofacial Pain, TMD-related signs and symptoms are less commonly reported as chronic complaints in pediatric patients. However, when present, they can significantly affect the muscles of mastication, the TMJ and associated structures.

Since 1993, multiple studies have reported a lack of knowledge regarding TMD among dental professionals across various specialties, including general dentistry, orthodontics and TMD specialists, and this knowledge gap is particularly pronounced among general practitioners. Tegelberg et al. [3] evaluated self-perceived knowledge, attitudes, and clinical experience in managing TMD among general dentists in Sweden, and their findings indicated that while dentists exhibited a positive attitude toward treating children and adolescents with TMD, many lacked established diagnostic protocols and standardized decision-making processes for treatment.

Taqi et al. [4] investigated the knowledge and beliefs of general dentists in Korea regarding TMD. Their findings revealed deficiencies in the pathophysiological aspects. Similarly, Prabhakar et al. [5] reported in 2024 that TMD general dentists possessed significantly greater knowledge than specialists. Furthermore, their study suggested that attitudes toward TMD became less favorable with increasing age and years of clinical practice.

Espinosa et al. [6] conducted a cross-sectional observational study involving 161 dental educators in Puebla, Mexico, and reported significant inconsistencies in participants’ knowledge of TMD, highlighting the low priority given to this field in dental education and the substantial variability in diagnostic and treatment expertise, particularly regarding pathophysiology. Similarly, Cintra et al. [7] conducted a comparative analysis of TMD knowledge and beliefs among specialists in TMD and Orofacial Pain using the same survey instrument employed two decades earlier, and despite the inclusion of new questions addressing pathophysiology and chronic pain, no significant improvements in knowledge were observed. Moreover, Al-Huraishi et al. [8] assessed TMD knowledge among recent dental graduates and specialists and found that recent graduates had limited knowledge across all assessed domains compared to specialists, underscoring a major deficiency in dental education curricula. Mozhdeh et al. [9] evaluated TMD knowledge among general dentists and specialists in Italy and their findings demonstrated that only half of participants had proper knowledge (41% acceptable and 12% good) regarding TMD.

In 2023, Tormes et al. [10] evaluated predoctoral dental students in northeastern regions and observed an overemphasis on occlusal factors and a lack of confidence in managing TMD. Similarly, Xiong et al. [11] assessed the knowledge and attitudes of general dentists and postgraduate students, finding that both groups demonstrated inadequate knowledge on TMD management. These findings highlight persistent deficiencies in TMD-related education and training among dental professionals.

Despite the increasing recognition of TMD in clinical practice, considerable variability remains in the knowledge and training that dentists receive regarding its diagnosis and treatment [10]. While several studies have explored TMD awareness among general dentists and specialists, limited research has focused on pediatric dentists [11]. Given that pediatric dentists often serve as the first point of contact for children, assessing their understanding of TMD is essential for ensuring early diagnosis and appropriate management. A comprehensive evaluation of their knowledge and attitudes may provide valuable insights for developing targeted educational strategies to improve competency in this field. Therefore, this study aimed to assess the knowledge of pediatric dentists regarding TMD and their attitudes toward diagnosing and treating pediatric patients with this condition.

Further emphasizing the significance of this issue, Minervini et al. [12] conducted a systematic review in 2023 to summarise evidence on TMD prevalence in pediatric populations. Their findings indicated that TMD is more prevalent in females than in males, with reported prevalence rates ranging from 20% to 60% among children. Given the high prevalence of TMD and its potential impact on oral function and overall well-being, early identification and intervention are crucial in preventing disease progression.

As primary care providers for pediatric patients, pediatric dentists are in a unique position to recognize early signs of TMD, provide timely interventions and educate caregivers about preventive strategies. Strengthening their knowledge and clinical expertise in this area is, therefore, essential to reducing the risk of untreated TMD evolving into more complex conditions that may compromise quality of life.

2. Materials and methods

3. Results

Of the 770 AMOP-affiliated pediatric dentists, 266 participants responded to the survey, yielding a response rate of 34.5%. Among the respondents, 182 were women (68.4%) and 84 were men (31.6%). The participants represented 66 institutions, including 25 public universities (37.8%) and 41 private universities (62.2%). Of the 25 public universities, 24 were represented by 198 respondents (74.4%), while 41 private universities accounted for 68 respondents (25.6%).

All respondents had obtained educational qualifications beyond a bachelor’s degree, including specialization, master’s or doctoral degrees. Among them, 220 participants (82.7%) were practicing pediatric dentists, while 46 (17.3%) were pediatric dentistry students. The mean number of years since graduation was greater than nine, with a median of six years (Table 1).

The overall correct response rate across the four assessed domains was 49.5%. The pathophysiological domain had the lowest accuracy, with a correct response rate of 33.7% (Table 2). A notable misconception was observed regarding occlusal interferences, a concept evaluated in the pathophysiological domain. While occlusal interferences have traditionally been considered a risk factor for TMD development, this belief is not supported by current evidence. However, when assessing this concept, the majority of surveyed pediatric dentists incorrectly associated occlusal interferences with TMD, with only 9.8% providing a correct response.

Similarly, only 3.8% of respondents disagreed with the statement that occlusal balance is a useful treatment for TMD, suggesting that more than 96% of pediatric dentists may be implementing ineffective treatments.

Additionally, when asked whether orthopedic or orthodontic treatments could prevent the onset of TMD, nearly 90% of respondents incorrectly believed this to be true. However, findings from specialists in TMD and Orofacial Pain, as well as existing literature, indicate that these treatments do not prevent TMD development.

Furthermore, nearly 90% of respondents agreed that the presence of arthritic changes on tomographic imaging, along with joint crepitus, necessitates treatment. However, this perspective contradicts the consensus among TMD and Orofacial Pain specialists and the evidence available in the literature.

In the psychophysiological domain, the overall correct response rate was 50% (Table 3). One of the assessed items examined whether tension and stress increase electromyographic activity in the mandibular muscles of susceptible patients. While most TMD and Orofacial Pain specialists agree with this statement, only 3% of surveyed pediatric dentists provided responses aligning with the specialists’ consensus.

The psychiatric disorders domain demonstrated an average correct response rate of 64.1% (Table 4), while the chronic pain domain exhibited an average of 50.4% (Table 5). In these two domains, no significant differences were observed between TMD and Orofacial Pain specialists and pediatric dentists in terms of knowledge accuracy.

Attitudes of Pediatric Dentists Toward TMD.

The survey results indicated that pediatric dentists exhibited a favorable attitude toward diagnosing and managing TMD. Among the six attitude-related questions, 83.1% of respondents expressed a willingness to provide information, care, diagnosis, and treatment for pediatric patients with TMD. However, 16.9% of the respondents showed a median negative attitude regarding the items considered in this category (Table 6).

When asked whether pediatric dentists should assume the role of providing information and guidance on TMD, 31.2% of respondents stated that they did not consider this to be part of their professional responsibilities. Nevertheless, 94.3% of respondents reported that they would provide advice or recommendations to parents regarding TMD prevention.

4. Discussion

This study assessed the knowledge and attitudes of 266 pediatric AMOP dentists regarding TMD. The sample size is comparable to that of previous studies conducted in different countries using the same assessment instrument, thereby allowing for meaningful comparisons.

The results demonstrated that pediatric dentists exhibited limited knowledge of TMD, with an overall correct response rate of 49.5% across the four assessed domains. This finding aligns with the results reported by Le Resche et al. [13] who evaluated 386 general and specialist dentists and observed similar deficiencies in TMD-related knowledge. The persistence of these gaps over time suggests that the etiology, diagnosis, and treatment of TMD remain poorly understood, particularly within the pathophysiological and psychophysiological domains.

Among the four domains, the pathophysiological domain had the lowest correct response rate (33.1%), indicating a widespread misunderstanding of the biological mechanisms underlying TMD. This result is consistent with previous findings by Taqi et al. [4] and Al-Huraishi et al. [8] (2020), who also identified the pathophysiological domain as the area with the most pronounced knowledge deficiencies among general dentists. Similarly, Tormes et al. [10] (2023) reported significant gaps in practitioners’ understanding of the relationship between occlusion and TMD, further highlighting the persistent misconceptions in this area. Additionally, Xiong et al. [11] (2023) found that many dentists lacked adequate training, understanding, and confidence in TMD management, reinforcing the need for improved educational strategies.

A key factor contributing to the low correct response rate in the pathophysiological domain may be the misconception among pediatric dentists that their knowledge of TMD is sufficient despite clear evidence to the contrary. The variability in knowledge may also be linked to differences in educational methodologies at the university level. Studies have shown that curricula incorporating extensive clinical training are more effective in enhancing knowledge acquisition than traditional lecture-based approaches [8].

Misconceptions regarding the role of orthodontic and orthopedic treatments in TMD prevention were also evident in this study. When asked whether these treatments could prevent the onset of TMD, nearly 90% of respondents incorrectly believed that they could, while only 10.5% provided responses aligning with expert consensus. The association between orthodontic treatment and TMD remains a controversial topic in the scientific community. However, a systematic review by Fernández-González et al. [15] (2015) found no evidence supporting a causal relationship between orthodontic treatment and TMD. Furthermore, the review was unable to determine whether such treatments could prevent or improve TMD, emphasizing the need for caution when making clinical recommendations in this area.

Another widely held misconception among respondents was the belief that arthritic changes observed on tomographic imaging, in conjunction with joint crepitus, necessitate treatment. Nearly 90% of participants considered these findings to be definitive indicators for intervention, a perspective that contradicts both expert consensus and existing literature. While crepitus is commonly associated with degenerative joint disease of the TMJ, it does not necessarily indicate the need for treatment [16].

The survey assessing pediatric dentists’ attitudes toward TMD revealed that while most respondents were willing to diagnose and treat TMD, a significant proportion (30%) did not consider preventive education on TMD to be within their professional responsibilities. This suggests that many pediatric dentists may view their role as limited to managing traditional dental issues rather than extending to more complex conditions such as TMD, which often require a multidisciplinary approach. Such perceptions may reduce motivation to provide early education and preventive guidance, which is essential for minimizing the progression and long-term impact of TMD [17].

The findings of this study underscore the need to enhance TMD-related education in pediatric dentistry training programs. Addressing misconceptions regarding etiology, diagnosis, and management strategies may help improve clinical decision-making and ultimately enhance patient outcomes.

Most pediatric dentists (55%) exhibited a favorable disposition toward addressing TMD in children and adolescents. However, they demonstrated limited awareness of their role in preventive education for parents and children, which may be attributed to deficiencies in their ability to accurately diagnose and treat TMD, as well as a lack of confidence in the effectiveness of preventive education and non-therapeutic management strategies.

Since 2001, multiple studies, including those by Tegelberg et al. [3] (2016), Xiong et al. [11] (2023), and Liu et al. [17] (2024) have emphasized the need for specialized training in TMD and the development of standardized referral protocols. The findings of the present study further highlight this issue, as only 19.9% of respondents reported having referred patients for specialist consultation. This suggests that a considerable proportion of pediatric dentists may not fully recognize the severity or complexity of TMD in pediatric patients, potentially leading to an underestimation of the need for specialist referrals. Given that TMD cases in children are often perceived as mild or self-limiting [18], many pediatric dentists may opt for observation rather than referral.

More recently, in 2023, Razdan et al. [19] conducted a questionnaire-based study to assess knowledge and awareness of TMD among Indian dentists. Similar to the present study, their findings reflected that the knowledge of physiological anatomy along with the management of symptomatic TMD is insufficient.

5. Limitations

The study had several limitations worth highlighting. First, since the respondents were exclusively AMOP-affiliated pediatric dentists, the data cannot be generalized to other populations. Nevertheless, the utilized instrument is the most employed globally, facilitating the comparison of findings with those documented in existing literature. Another limitation is that a substantial proportion of respondents were postgraduate students and recently graduated pediatric dentists. Specifically, 40% of participants had less than five years of professional experience, which may have influenced their responses.

6. Conclusions

The findings of this study indicate that pediatric dentists affiliated with AMOP have a limited understanding of TMD compared to specialists in TMD and Orofacial Pain. Despite their positive disposition toward diagnosing and treating TMD, pediatric dentists often overlook their role in preventive education. This suggests that many pediatric dentistry specialists may lack the necessary knowledge and clinical proficiency to accurately diagnose and provide effective treatment for pediatric patients with TMD.

The underdiagnosis of TMD in children and adolescents may have significant implications, as untreated conditions could lead to chronic dysfunction affecting oral health and quality of life in adulthood. Given these findings, undergraduate and postgraduate dental programs should critically evaluate and refine their curricula to ensure that future professionals receive comprehensive training in TMD diagnosis, management, and prevention.

While the existing literature provides extensive knowledge on TMD, this study highlights the need for a stronger integration of theoretical knowledge with clinical practice. Thus, developing curricular improvements that enhance both conceptual understanding and hands-on experience could help bridge this knowledge gap. In addition, future research could focus on assessing the impact of such educational interventions on pediatric dentists’ competency in TMD management and tracking knowledge progression over time.

Availability of data and materials

Data and materials are available for consultation.

Author contributions

IAEDS—contributed to the conception and design; analysis; and interpretation of data and drafting of the manuscript. GNRDCQ and GMQ—in the conception and design interpretation of data. OPLS and AMMH—participated in the conception and design; interpretation of data and drafting of the manuscript. GCM—contributed to the material preparation; data collection and analysis being performed. The final manuscript has been reviewed and approved by the authors. All authors contributed to the study conception and design.

Ethics approval and consent to participate

The study was approved by the Faculty of Stomatology Research Committee at Benemérita Universidad Autónoma de Puebla (BUAP) in July 2022 (approval no.: 2022179). The study adhered to the Mexican health research regulations and complied with the ethical principles outlined in the Declaration of Helsinki (2025) [14].

All subjects provided informed consent to participate in the present study.

Acknowledgment

Not applicable.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Conflict of interest

The authors declare no conflict of interest.