Knowledge and attitude regarding obstructive sleep apnoea among medical and dental practitioners working in North-Eastern Peninsular Malaysia: A comparative cross-sectional study

1 Introduction

Sleep-related breathing disorders and habitual snoring are prevalent in Asia, particularly among the Malaysian population, and they constitute a significant cause of morbidity [1, 2]. Among these disorders, Obstructive Sleep Apnoea (OSA) stands out as the most common [1, 2] sleep disorder. Obstructive Sleep Apnoea (OSA) is a sleep disorder characterized by recurring instances of abnormal breathing, resulting from partial or complete blockage of the airways during sleep [3]. Common risk factors associated with OSA include obesity, advanced age, and certain orofacial deformities [4, 5]. It can be diagnosed with clinical features such as snoring, fatigue, daytime sleepiness, and mood disturbances [6]. The development of Obstructive Sleep Apnoea (OSA) can be attributed to the obstruction of the posterior airway, specifically at the levels of the nasopharynx and oropharynx, caused by an enlarged soft palate [6]. This blockage leads to conditions such as hypoxia, palpitations, high blood pressure, and subsequent disruptions in the quality of sleep [7], as well as an increased risk of experiencing cardiac dysrhythmias[8]. As a sequence, it may contribute to the onset of cardiovascular diseases, diabetes, and depression, potentially impacting job performance negatively [9]. The prevalence of OSA is expected to increase alongside rising obesity rates, and recent results indicate a strong relationship between OSA and metabolic syndrome [10]. Sleep-related breathing disorders and habitual snoring are prevalent in Asia, particularly among the Malaysian population, and are recognized as leading causes of morbidity [1, 2]. In Malaysia, a cross-sectional survey revealed a widespread prevalence of sleep problems, including regular snoring, sleep-disordered breathing, and severe daytime sleepiness, with clinical OSA suspicions in 7% of respondents [1]. Adequate knowledge and skills among medical and dental professionals are crucial for performing early diagnosis and treatment of OSA, thereby reducing morbidity. However, the literature suggests that knowledge regarding the diagnosis and treatment of OSA is insufficient among medical practitioners in developing countries such as Malaysia [11]. Although primary care physicians in Kuala Lumpur exhibit awareness of OSA, they lack confidence in managing the disease [11]. Medical doctors play a pivotal role in diagnosing and treating patients with obstructive sleep apnoea (OSA). However, there is evidence of inadequate knowledge, skills, and training in OSA management among medical professionals residing in Ecuador and Italy [12, 13]. In contrast, Dentists play a crucial role in the early diagnosis, and treatment of mild to moderate cases of OSA by providing oral appliances as well as referring them for further investigations [14]. A patient experiencing obstructive sleep apnoea (OSA) might present various dental symptoms when seeking dental care including a high arch, an elongated or enlarged uvula, constriction on the lateral peritonsillar area, hypertrophy of the tonsils, a narrow hard palate, issues with jaw relationships, and variations in relative tongue size. Additionally, the patient may exhibit bruxism, which can be associated with temporomandibular problems, potentially linked to disrupted sleep and symptoms of orofacial pain, known as temporomandibular disorders (TMD) [14]. The dentists’ inability to recognize, treat, and appropriately refer patients with Obstructive Sleep Apnoea (OSA) may result in inadequate care which may later lead to complications among the patients [15]. Previous studies revealed a lack of knowledge, positive attitude, and training among American [3] and Saudi Arabian dental practitioners [16] suggesting the need for greater training and practical expertise in sleep medicine. Highlighting the significance of inquiring about sleep patterns during medical and dental visits holds considerable importance, as routine inquiries regarding sleep patterns are often overlooked [17, 18]. Given that medical and dental practitioners often feel inadequately equipped to clinically recognize and address Obstructive Sleep Apnoea (OSA), despite acknowledging their shortcomings, it is imperative to introduce amendments in the curriculum of both medical and dental schools. This should include complementary training focused on OSA to enhance active and collaborative patient management [2, 19–22]. However, there is a lack of statistics on the prevalence of OSA and OSA screening in Malaysia, particularly in the North-Eastern peninsular region, such as the state of Kelantan. In Malaysia, high-quality treatments for OSA such as CPAP are considered expensive and are only available in certain tertiary hospitals. Therefore, the incidence of OSA places a heavy financial strain on a rising economy due to poor work performance and treatment costs [11] Our study results will assist medical and dental practitioners and academicians in recognizing the severity of the situation. Upon grasping the necessity for enhancing their knowledge and skills, they can proceed to update themselves through training, reading articles in journals, engaging in discussions with specialists, and participating in continuing medical education courses and workshops. Earlier research has noted variations in the levels of knowledge between Malaysian dental and medical undergraduate students [23]. However, there has been no study conducted to investigate the distinctions in knowledge and attitudes regarding obstructive sleep apnoea among medical and dental practitioners in North-Eastern Peninsular Malaysia. Considering the pivotal roles of medical and dental practitioners in the identification of OSA, it is vital to evaluate the disparity in awareness of OSA among these professionals in Malaysia. Insights derived from this study will assist authorities in implementing revisions to medical and dental curricula, aiming to improve proficiency in managing OSA patients both individually and with collaboration. In consideration of the current scenario, our study aimed to compare knowledge and attitudes regarding OSA between Medical and Dental Practitioners in North-Eastern Peninsular Malaysia.

2 Materials and methods

3 Results

The mean age of the participants was 34.6 years (standard deviation = 6.28). This demographic included 65.6% of medical/dental officers, and residents, with 31.7% comprised of medical and dental specialists, alongside 2.9% of junior doctors from both medical and dental domains. The current study shows that 97.1 % of all the respondents had no previous exposure to any OSA training in the latest clinical practice guidelines (CPG) regarding OSA and medical education (CME) related to OSA, tabulated in Table 1. Knowledge scores ranged from 0 to 18 in the OSAKA questionnaire. The correct responses of the Medical and Dental Practitioners regarding individual questions in the OSA knowledge questionnaire are presented in Table 2. In the knowledge section, both Medical and dental practitioners have inadequate knowledge of most of the questions. It has been observed that only 38.5% of Medical and 11.5% of dental practitioners could answer correctly the question “Uvulopalatopharyngoplasty is curative for most patients with OSA”. In addition, 26.9% of Medical and 28.8% of Dental practitioners answered correctly when asked if CPAP (Continuous Positive Airway Pressure) may cause nasal congestion. Additionally, it is revealed from Table 2, that a minimum number of Medical (11.5%) and dental practitioners (17.3%) respectively responded correctly when asked whether laser-assisted uvuloplasty is an appropriate treatment for severe OSA or not. When asked whether less than five apnea or hypopneas per hour is normal for an adult or not, a small number of medical (36.5%) and dental practitioners (19.2%) could provide correct responses. However, 92.3% of medical practitioners and 96.1% of dental practitioners answered correctly whether asking about “Most patients with OSA snore is true or not” and only this question was answered correctly by the majority of the respondents. Additionally, 84.6% of medical and 73% of dental practitioners responded correctly while asking whether “Overnight sleep is a gold standard diagnosis for OSA” is true or not. When asked about “Loss of upper airway muscle tone contributes to OSA”, 94.2% of medical practitioners answered correctly. However, only 59.2% of the dental respondents could answer correctly which revealed dentists have lower knowledge on this question than medical practitioners for this question. Among them, 94.2% and 78.8% of medical practitioners and their dental counterparts respectively could recognize the most common cause of OSA in children and that is the presence of large tonsils. When asking about Craniofacial and Oropharyngeal examinations is useful in the assessment of patients with OSA (84.6%) and (78.8%) medical and dental practitioners could answer correctly.

Table 3 exhibits the information regarding the attitude profile of participants. In short, these results depict that medical practitioners are more confident in treating and managing patients with OSA and their management under CPAP therapy as compared to their dental counterparts.

Table 4 shows the result of the Mann-Whitney U test, which exhibits significant differences in knowledge level between medical and dental practitioners (z-statistics = –4.39, U = 827.00 with p <  0.05, and effect size, r = 0.61). Medical practitioners showed a significantly higher median (11) knowledge score than Dental practitioners (9) proving that medical practitioners had significantly greater knowledge of OSA compared to dental practitioners.

Table 4 also revealed significant differences in attitude levels between medical and dental practitioners (Z-Statistics = –3.42, U = 725.00 with p <  0.05, and effect size, r = 0.47) from the Mann-Whitney U test. Medical practitioners showed significantly higher confidence levels in treating OSA compared to dental practitioners as the median score for medical practitioners in regard to attitude was significantly higher (12) than for dental practitioners (9). Surprisingly one respondent attended a workshop from his interest regarding Obstructive sleep apnea.

Table 5 shows no significant differences in total knowledge score by gender (p-value >  0.05), ethnicity (p-value >  0.05), total service years (p-value >  0.05), and attending training on OSA (p-value >  0.05). However, only differences were found regarding knowledge score by professional status. (p-value <  0.05) No significant differences have been observed (Table 6) in total attitude score by ethnicity (p-value >  0.05), Total service years(p-value >  0.05), attending training on OSA (p-value >  0.05) and professional status (p-value >  0.05) except gender (p-value <  0.05). Males had a higher median attitude score (6) than females (4).

This study strives to assess the knowledge and attitude of OSA among medical and dental practitioners working in North-Eastern Peninsular Malaysia, and to the author’s knowledge, this is the first study in Asia comparing knowledge and attitude between Medical and Dental Practitioners that could be considered as the strength of our study. The current study reported significant differences between dental and medical practitioners regarding the knowledge and attitude of OSA management. Medical practitioners in this study recorded a higher knowledge and attitude score as compared to their dental counterparts but it was still considered inadequate. Due to inadequate knowledge and training among medical and dental professionals, OSA is often reported as a common underdiagnosed disease [12, 26].

The average knowledge score in the current study is the same as a study conducted previously in Malaysia assessing primary care physician’s knowledge of OSA [4]. The survey among primary care physicians in the Middle-East and North Africa regions exhibits similar findings [5]. Another study conducted in Lithuania reported the mean knowledge score of Lithuanian dentists regarding OSA was 10.2 which supports our study findings [20]. Surprisingly, Italian anesthetists also revealed comparable results [13]. All of these findings are comparable to our study outcome. From these findings, it can be said that both medical and dental practitioners have limited knowledge and attitude regarding OSA and now this matter has become a serious public health concern. It is of utmost importance to enhance the knowledge of the practitioners on OSA and incorporate elements of OSA management in their educational programs. Policymakers should tackle this issue by introducing mandatory training for both medical and dental practitioners to acquire skills regarding proper diagnosis, referral, and treatment of OSA patients. It should be an obligatory rule for them to attend workshops and training regarding OSA.

Narrowing down the scope, this study found out that there was only one question, that was answered correctly by over 90% (92.3% by medical doctors and 96.1% by dental doctors) of the respondents namely, ‘Most of the patients with OSA snore.’ This indicates that most of the practitioners working in Kelantan state from both professional fields, were aware that snoring is the common presentation of OSA while most of the respondents considered laser-assisted uvuloplasty as an appropriate treatment for severe OSA which was incorrect. Only a mere 36.5% of the total respondents answered the item correctly. The variation in the knowledge might be due to exposure to OSA as well as experience in the field. Taking into consideration, this could be since 31.7% of the participating population were specialists and lecturers, who have had continuous education and training. However, less than half (47.1%) of the respondents agree that they are confident in identifying patients at-risk for OSA. It is also found that, respondents encompass 24% and 15.3% feel confident in managing patients with OSA and managing patients on CPAP therapy. However, less than half (47.1%) of the respondents agree that they are confident in identifying patients at-risk for OSA. The findings were almost similar to the study conducted in Latin America [27] and Nigeria [28]. From this study, we noticed that medical practitioners have relatively higher knowledge and positive attitude which is opposite to the study conducted in USA where the authors revealed that dental practitioners have an equivalent understanding of OSA as compared to medical practitioners [29]. After the literature review, this current study shed light on the importance of improving dental curriculum and training to enable dentists to prepare for identifying and managing OSA, and it will be a crucial step for policymakers[30]. Inadequate dissemination of information and lack of exposure to sleep medicine training have been identified as one of the causes of the variation in results [30]. Another study showed dentists exhibited limited OSA-related knowledge and a negative attitude toward OSA in Jeddah, Saudi Arabia [16]. Apart from medical doctors, practicing dentists more frequently encounter patients with potentially developing OSA [31]. More focus should be placed on improving the ability of both physicians and dentists to identify patients at risk of OSA. Educating and assisting dentists in this position would help people live better lives while lowering the rising healthcare expenses associated with untreated OSA [30]. According to a survey conducted by the National Sleep Foundation, United States, 70% of respondents claimed that their doctor had never enquired about their sleep habits or patterns and 89% of them agreed that their physicians should discuss sleep patterns and problems with their patients [32] which implies that sleep medicine is continuously underrepresented in the current medical curriculum. Our study findings showed only one respondent received training in OSA which is alarming for the diagnosis and patients. Without proper diagnosis and referral, there is a chance of mistreatment of the patients and tends to life-threatening conditions. A study done in 2013 confirmed a clear need for improving medical and dental curricula, however, the scenario has not yet been changed [2]. Hence, policymakers should take our study result into consideration and improvise medical and dental curriculums by emphasizing sleep education ensuring accessibility to sleep medicine for general people [33]. Understanding the pathophysiology and the signs and symptoms of the disease will help in early diagnosis and lower the risk of complications, and the only effective way of treating the illness is by first effectively and competently recognizing and diagnosing it [34]. Because oral appliance therapy (OAT) is a recognised treatment for OSA, and dentists have critical roles in constructing and providing, it is essential to validate the treatment by sleep doctors. As dentists have an important role in screening, diagnosing, and treating patients with OSA [29], educating and assisting dentists in this position would help people live better lives with improved sleep patterns while lowering the rising healthcare expenses associated with untreated OSA [35]. Collaborative relationships between physicians and dentists should be improved in order to perform successful OSA management [36]. For the knowledge score significant difference by professional status(junior doctor, Medical /Dental Officer, Medical/dental specialist) has been observed which is similar to the study conducted in Italy [13] but no significant differences found by gender, age, and years in practice which is unlikely to the study performed in Italian anesthetists [13]. For the attitude score, male shows more positive attitude than female which is in contrary with the study performed among Italian anesthetists [13].

To reduce the morbidity and minimize the cost of CPAP both medical doctors and dentists should receive proper training regarding initial diagnosis and treatment of OSA. If policy makers can train medical doctors and dentists for OSA diagnosis and treatment and allocate them in the government sector, referral to other specialists without examination according to previous study [18] will be limited. In this way work burden will be properly distributed. On the other hand, if they apply other treatment for example educate people in weight reduction, making oral devices or apply other necessary treatment in order to improve sleep quality of the patients, cost for setting CPAP procedure could be mitigated and it will be a great benefit for healthcare system. Furthermore, Malaysian health sector can properly utilize their health resources (manpower and logistics) to reduce severe health problems due to sleep disorder and produce a healthy nation who may help in economic growth of the country as well.

5 Conclusions

A difference was noticed in the knowledge and attitude scores of OSA from both medical and dental professionals. Medical practitioners exhibit a greater depth of knowledge and a positive attitude toward OSA in comparison with their dental counterparts.