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

Abstract

BACKGROUND:

Obstructive Sleep Apnea (OSA) is a temporary airflow obstruction during periods of sleep. Patients with OSA often suffer from poor work performance, compromised sleep quality, and low quality of life which may lead to a life-threatening event. Adequate knowledge and a positive attitude toward OSA among medical and dental practitioners are crucial to the initial diagnosis and treatment.

OBJECTIVE:

This study aimed to identify the differences in knowledge and attitude toward OSA between medical and dental practitioners working in North-Eastern Peninsular Malaysia.

METHODS:

A comparative cross-sectional study was performed from February 2020 to February 2021. A total of fifty-two medical practitioners and fifty-two dental practitioners working at university-based outpatient clinics, government health clinics, and oral health clinics located in Kelantan State of Malaysia participated in the study, and data were collected by the structured questionnaire including sociodemographic inquiry and OSAKA questionnaire by non-probability stratified random sampling. The Mann-Whitney U test was used to compare knowledge and attitude scores between the two groups.

RESULTS:

The mean age of the respondents was 34.6 years. The current study shows that 92.3% of medical doctors and 96.1% of dental doctors were able to correctly answer the question “Most of the patients with OSA snore” a significant finding in our study. Only 1% of medical professionals could answer seventeen questions correctly with a median score of 11, and only 1% of dental professionals could answer sixteen questions correctly with a median score of 9. None of them could provide an accurate answer to all the knowledge questions. Medical and dental practitioners exhibited different knowledge levels on OSA (z- statistics=–4.39, U = 827.00 with p < 0.05, and effect size, r = 0.61). However, no significant differences were found in total knowledge score by gender (p-value>0.05), ethnicity (p-value>0.05), total service years (p-value>0.05), and training attended. In addition, significant differences in attitude levels between medical and dental practitioners have been observed (z-statistics=–3.42, U = 725.00 with p < 0.05, and effect size, r = 0.47). Nevertheless, no significant differences have been seen 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).

CONCLUSION:

A Significant difference is evident concerning knowledge and attitude toward OSA diagnosis and management between medical and dental practitioners working in North-Eastern Peninsular Malaysia. Medical practitioners in this study recorded a higher knowledge and attitude score compared to dental practitioners.

Keywords

Sleep apnea sleep-disordered breathing continuous positive airway pressure temporomandibular disorders

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

2.1 Study design

A comparative cross-sectional study design was applied to conduct the study. The study period was from February 2020 to February 2021.

2.2 Sample size calculation

The sample size was calculated using PS software 2014, where a 27% difference in the prevalence of knowledge and attitude among general dental practitioners (P₀ = 42% versus P₁ = 15%) has been considered [3]. With 80% power, the value of alpha at 0.05, and anticipation of a 20% drop-out rate, the estimated sample size was fifty-two medical professionals and fifty-two dental professionals required in each group. The total sample size of the study was one hundred and four respondents. The study settings were one university-based outpatient clinic, government health clinics (Klinik Kesihatan), and oral health clinics (Klinik Pergigian) located in four main districts Kota Bharu, Bachok, Pasir Puteh, and Pasir Mas in Kelantan state. All the medical and dental practitioners working at the university-based outpatient clinics government health clinics (Klinik Kesihatan) and oral health clinics (Klinik Pergigian) located in these four districts of Kelantan state were enlisted from websites, the hospital director’s office and their email addresses have been collected. Ninety-five medical practitioners and eighty-two dental practitioners were enlisted. Fifty-two medical practitioners and fifty-two dental practitioners were selected randomly from these ninety-five medical practitioners and eighty-two dental practitioners for data collection.

2.3 Sampling technique

Non-probability stratified random sampling method was used for data collection (medical and dental practitioners).

2.4 Inclusion criteria

Participants were from different professional statuses including junior doctors of the medical and dental department, medical officers (MOs), dental officers (DOs), and medical and dental specialists working in four main districts Kotabharu, Bachok, Pasir Puteh, and Pasir Mas in Kelantan state.

2.5 Exclusion criteria

The exclusion criteria comprised non-clinical lecturers and medical and dental practitioners with diagnosed OSA.

2.6 Data collection process

The data collection process started after obtaining clearance from the ethical committee of Universiti Sains Malaysia. The research team obtained the email addresses of the participants through the Hospital Director’s office and related websites, securing permission for data collection in the process. After that, the outline and purpose of the study were explained and a link containing the questionnaire and a detailed consent form were attached to the email and sent to all the potential respondents. The questionnaire was created using Google Forms, together with a built-in Timer (Quilgo^®). The timer was used to ensure the respondents answered truthfully without exposure to any external sources and to eliminate any chances of bias among respondents. The questionnaire required them to identify themselves. As official email is confidential, they do not allow anyone else to use it, that’s why we can perceive that the person completing the survey was who they said they were.

The obstructive sleep apnea knowledge and attitude (OSAKA) questionnaire was utilized in this study to assess the knowledge and attitude of clinical-attending medical and dental practitioners in Malaysia which is a validated questionnaire to assess knowledge and attitude regarding sleep apnea. The questionnaire consisted of three parts. The first part consists of socio-demographic questions, the second part consists of 18 questions about knowledge of OSA, and the third part consists of four questions about attitudes towards OSA-related questions. The OSAKA questionnaire is a self-administered questionnaire, developed by Schotland and Jeffe in 2003. The internal consistency of the items was 0.76 for the knowledge scale and 0.79 for the attitude scale considered impressive. [24]. Questions regarding knowledge of OSA consisted of Eighteen true or false statements about OSA with ‘I Don’t Know’ as a third option. The answer “Yes” was scored to be “One” while “No” and ‘I Don’t Know’ were scored as “zero.” Later during statistical analysis, we analyzed the frequency of correct and incorrect answers. Questions regarding attitude towards OSA management consisted of 2 questions for determining the importance of treating OSA by the respondents and answered via a 5-point Likert scale: 0 = Not Important; 1 = Somewhat Important, 2 = Important, 3 = Very Important, 4 = Extremely important. Additionally, the last three questions were asked to determine their confidence in identifying and managing OSA patients, and knowledge was determined via 5-point Likert scale answers: 0 = strongly disagree, 1 = disagree, 2 = neither agree nor disagree, 3 = agree, 4 = strongly agree.

2.7 Data analysis

Data analysis was performed with the software “IBM SPSS version 26.0.” The significance level was set at p = 0.05. Descriptive analysis was performed to assess the median of the knowledge and attitude of OSA among dental and medical practitioners working in Kelantan state. As the data did not follow a normal distribution, the Mann-Whitney U test was utilized to compare the mean knowledge score and mean attitude score between the two groups.

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 1
Sociodemographic characteristics of medical and dental practitioners (n = 104)

Socio-demographic variable Frequency (Percentage)

Age (years)

25–35 66(63.5)

36–45 31(29.8)

46–55 7(6.7)

Gender

Male 63(60.6)

Female 41(39.4)

Ethnicity

Malay 68(65.4)

Non-Malay 36(34.6)

Professional Field

Medical 52(50)

Dental 52(50)

Professional status

Junior doctor 3(2.9)

Medical/Dental Officer 68(65.4)

Medical/Dental Specialist 33(31.7)

Working Duration

<1 year 6(5.8)

1–10 years 68(65.4)

>10 years 30(28.8)

Attended workshop/training

Yes 3(2.9)

No 101(97.1)

Socio-demographic variable	Frequency (Percentage)
Age (years)
25–35	66(63.5)
36–45	31(29.8)
46–55	7(6.7)
Gender
Male	63(60.6)
Female	41(39.4)
Ethnicity
Malay	68(65.4)
Non-Malay	36(34.6)
Professional Field
Medical	52(50)
Dental	52(50)
Professional status
Junior doctor	3(2.9)
Medical/Dental Officer	68(65.4)
Medical/Dental Specialist	33(31.7)
Working Duration
<1 year	6(5.8)
1–10 years	68(65.4)
>10 years	30(28.8)
Attended workshop/training
Yes	3(2.9)
No	101(97.1)

Table 2

OSAKA knowledge responses among medical and dental practitioners (n = 104)

OSAKA Knowledge Question	Number of correct
	responses
	Medical	Dental
1. Women with Obstructive sleep apnea may present with fatigue alone. (True)	26 (50%)	14(26.9%)
2. Uvulopalatopharyngoplasty is curative for the majority of patients with OSA. (False)	20(38.5%)	6(11.5%)
3. The estimated prevalence of OSA among adults is between 2 and 10%. (True)	23 (44.2%)	17 (32.6%)
4. The majority of patients with OSA snore. (True)	48 (92.3%)	50 (96.1%)
5. SA is associated with hypertension. (True)	41 (78.8%)	28 (53.8%)
6. An overnight sleep study is the gold standard for diagnosing OSA. (True)	44 (84.6%)	38 (73%)
7. CPAP (continuous positive airway pressure) therapy may cause nasal congestion. (True)	14 (26.9%)	15 (28.8%)
8. Laser-assisted uvuloplasty is an appropriate treatment (False)	6 (11.5%)	9 (17.3%)
9. The loss of upper airway muscle tone during sleep contributes to OSA. (True)	49 (94.2%)	32 (59.2%)
10. The most common cause of OSA in children is the presence of large tonsils and adenoids. (True)	49 (94.2%)	41 (78.8%)
11. A craniofacial and oropharyngeal examination is useful in the assessment of patients with suspected OSA. (True)	44 (84.6%)	41 (78.8%)
12. Alcohol at bedtime improves OSA. (False)	34 (65.4%)	26 (50%)
13. Untreated OSA is associated with a higher incidence of automobile crashes. (True)	41 (78.8%)	30 (57.6%)
14. In men, a collar size 17 in. or greater is associated with OSA. (True)	29 (55.7%)	19 (36.5%)
15. OSA is more common in women than in men. (False)	34 (65.3%)	33 (63.4%)
16. CPAP is the first line therapy for severe OSA. (True)	34 (65.3%)	26 (50%)
17. Less than 5 apneas or hypopneas per hours is normal in adults. (True)	19 (36.5%)	10 (19.2%)
18. Cardiac arrhythmias may be associated with untreated OSA. (True)	41 (78.8%)	28 (53.8%)

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 3

OSAKA attitude responses among medical and dental practitioners (n = 104)

Attitude regarding OSA	Frequency (Percentage) of Medical Practitioner	Mean (SD)	Frequency (Percentage) of Dental Practitioner	Mean (SD)
As a clinical disorder, OSA is
Not Important	0(0.0%)	2.9(0.7)	1(1.9%)	2.6(0.9)
Somewhat important	0(0.0%)		7(13.4%)
Important	18(34.6%)		14(38.4%)
Very important	20(38.4%)		19(36.5%)
Extremely important	14(26.9%)		11(21.1%)
Identifying patient with OSA
Not Important	0(0.0%)	3(0.7)	0(0.0%)	2.7(0.9)
Somewhat important	0(0.0%)		6(11.5%)
Important	15(28.8%)		15(28.8%)
Very important	22(42.3%)		18(34.6%)
Extremely important	15(28.8%)		13(25%)
I feel confident in identifying patients with OSA
Strongly disagree	1(1.9%)	2.6(0.8)	1(1.9%)	2(0.9)
Disagree	5(9.6%)		16(30.7%)
Neither agree nor Disagree	11(21.1%)		21(40.3%)
Agree	31(59.6%)		10(19.2%)
Strongly agree	4(7.6%)		4(7.6%)
I am confident in my ability to manage patients with OSA
Strongly disagree	1(1.9%)	2(0.9)	8(15.3%)	1.4(0.8)
Disagree	15(28.8%)		27(51.9%)
Neither agree nor Disagree	19(36.5%)		9(17.3%)
Agree	15(28.8%)		6(11.5%)
Strongly agree	2(3.8%)		2(3.8%)
I am confident in my ability to manage patients on CPAP therapy
Strongly disagree	49(7.6%)	1.7(0.9)	10(19.2%)	1.3(0.9)
Disagree	18(34.6%)		27(51.9%)
Neither agree nor Disagree	21(40.3%)		8(15.3%)
Agree	7(13.4%)		5(9.6%)
Strongly agree	2(3.8%)		2(3.8%)

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

Comparison of knowledge and attitude profiles among medical and dental practitioners (n = 104)

	Professional Field	n	Median	Mann-Whitney U	z-score	p
Knowledge on OSA	Medical	52	11	867.5	–3.165	.002
	Dental	52	9
Attitude on OSA	Medical	52	5	713	–4.198	0.00
	Dental	52	3

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).

Table 5

Differences in knowledge score regarding sociodemographic variables and OSA training among medical and dental practitioners (n = 104)

Variable	n	Median	Kruskal-Wallis H	Mann-Whitney U	z-score	df	p
Age (Years)				–		2
25–35	65	10	2.66
36–45	32	11					0.26
46–55	7	11
Gender
Male	40	11		1033.50	–1.65		0.09
Female	64	10
Ethnicity
Malay	68	10		1220.50	–.024		0.98
Non-Malay	36	10
Professional Status
Junior doctor	3	10	6.990
Medical/Dental Officer	68	11				2	0.03
Medical/Dental Specialist	33	12
Working Duration (Total service years)
<1 Year	6	9	.709
1–10 Years	67	10				2	0.70
>10 Years	31	11
OSA course attended
Yes	3	10		43.000	–2.117		0.35
No	101	2

Table 6

Differences in attitude scores regarding sociodemographic variables and OSA training among medical and dental practitioners (n = 104)

Variable	n	Median	Kruskal-Wallis H	Mann-Whitney U	z-score	df	p
Age (Years)				–		2
25–35	65	4	.329
36–45	32	4					.849
46–55	7	4
Gender
Male	40	6		751.500	–3.568		0.00
Female	64	4
Ethnicity
Malay	68	4		1185.0	–.269		0.78
Non-Malay	36	4
Professional Status
Junior doctor	4	10	3.744
Medical/Dental Officer	4	11				2	0.15
Medical/Dental Specialist	7	12
Working Duration
<1 Year	6	4	.241
1–10 Years	67	4				2	.887
>10 Years	31	4
Have attended OSA course attended
Yes	3	4		146.500	–.098		0.92
No	101	3

4 Discussion

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.

4.1 Limitations of the study

The findings of this study must be interpreted considering the limitations, which included the small sample size of the study population. Another limitation observed is the lack of surveillance when the respondents were answering the question. Although a timer had been incorporated within the digital questionnaire, the risk of bias in answering the question may still arise due to the wide range of information they tend to obtain through the internet within a short timeframe. In this study, we only included respondents from Kelantan state, and we excluded Terrenganu state, another state of North-Eastern Peninsular Malaysia due to lack of time and permission from authority. However, we believe as both states represent North-Eastern Peninsular Malaysia and share the same healthcare culture, data would not vary much if we could include both.

4.2 Recommendations of the study

Further studies are recommended, with larger sample sizes and more convincible monitoring methods that can assess the skills of the medical and dental practitioners in performing diagnosis and treating OSA patients.

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.

Footnotes

Acknowledgments

We express our gratitude to the reviewers and editors of Work for their invaluable comments and suggestions, which greatly enhanced the quality of this article. We also extend our gratitude to the hospital director of Hospital Universiti Sains Malaysia for authorizing the collection of data for this research.

Informed consent

Signatures were taken from all the respondents in the consent form prior to data collection.

Ethics statement

The study was approved by the Human Research Ethics Committee of Universiti Sains Malaysia (USM/JEPeM/19120921).

Conflict of interest

Not applicable.

Funding

Not applicable.

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