Knowledge and Perception of Oral and Maxillofacial Surgery as a Specialty Amongst Dental and Medical Students at a Public University in the Gulf Cooperation Council (GCC): A Comparative Study

Abstract

Purpose

Awareness about the oral and maxillofacial surgery (OMFS) specialty in the Gulf Cooperation Council has increased in recent years with the expanding scope of practice of the specialty. Nevertheless, the perception of OMFS has not yet been investigated among healthcare students. The aim of this study was to compare the perceptions and knowledge of dental and medical students about OMFS.

Materials and Methods

A cross-sectional study evaluating 100 dental and 100 medical students attending Kuwait University was conducted using a previously validated survey instrument. Students were instructed to select the most appropriate specialist to treat certain procedures across four disciplines: reconstruction, trauma, pathology and cosmetic procedures. Student year groups were compared statistically using Fisher’s exact test.

Results

The responses of both student groups showed disparities, with dental students showing overwhelmingly more awareness of the practice of OMFS. OMFS was preferred overall for most clinical scenarios in trauma (p < 0.001), pathology (p < 0.001), and reconstructive surgery (p < 0.001). Plastic surgery was preferred for cosmetic surgeries (p < 0.001).

Conclusion

Our findings prompt us to revisit our dental and medical school’s curriculum to increase the educational content related to OMFS procedures. Additional healthcare promotional campaigns and clinical awareness regarding OMFS are needed among healthcare professionals, university clinics and medical venues.

Electronic supplementary material

The online version of this article (10.1007/s12663-020-01491-z) contains supplementary material, which is available to authorized users.

Introduction

Oral and maxillofacial surgery (OMFS) is considered a relatively young specialty for treating many conditions related to the head and neck region, thus establishing countless bridges between dentistry and medicine [1–4]. The specialty has undergone significant transformations in recent years, leading to an expansion of its spectrum of clinical practice, including craniofacial traumatology, dentofacial deformities, head and neck oncology, temporomandibular joint disorders, head and neck reconstruction, distraction osteogenesis, implant surgery, tissue engineering, reconstruction, treatment of sleep apnea and aesthetic facial surgery [1–6].

Even though OMFS is now an established surgical specialty in many international centres of care, there are still differences with regard to the understanding of the scope of practice of OMFS and the familiarity with the treatment modalities delivered by oral and maxillofacial surgeons among students, healthcare professionals, and laypersons [1–3, 5, 6]. The modern teaching curriculum aims at providing students with the most advanced theoretical and practical clinical education to prepare them for clinical practice. This has mostly been the case in dental schools, since OMFS in most counties emerged as a dental specialty. Therefore, heterogeneous systems of educational schemes and curricula have been introduced across academic institutions internationally to enhance undergraduate education in the field of OMFS [7–9]. A step-wise approach to teaching practical procedures and thorough clinical assessments has allowed instructors to assess the educational level of the students and prepare them for the challenges to be faced in future surgical practice [7–10]. The integration of OMFS courses in medical schools has so far been falling behind, except in countries where OMFS instruction has relied solely on medical education or on dual qualifications in dentistry and medicine.

The practice of OMFS in Kuwait started 40 years ago with foreign specialists visiting or practicing as experts in the field. Throughout the years, the Kuwaiti nationalised healthcare and educational system has undergone major changes, with several OMF surgeons joining the healthcare workforce after completing their surgical training abroad [3]. In addition, there are also local dental professionals graduating from Kuwait University Faculty of Dentistry, which was started in 1997, with prior exposure to OMFS during their pre-doctoral training. The undergraduate OMFS teaching curriculum was introduced at Kuwait University Faculty of Dentistry in 2002, when the undergraduate dentistry students reached their clinical years [3]. Since then, many students have been trained to perform common minor oral surgery procedures, and some have been heavily exposed to routine office-based and hospital-based OMFS by OMFS board-certified faculty members.

The aim of this study was to compare the current level of knowledge, attitudes and perceptions about the specialty of OMFS among medical and dental students attending Kuwait University Health Sciences Centre in terms of its role in commonly performed surgical procedures in the head and neck region.

Materials and Methods

Participants and Questionnaire

Ethical approval for this study was obtained from the Ethical Committee at Kuwait University Health Sciences Centre. A cross-sectional survey was conducted with 100 dental students (n = 100) and 100 medical students (n = 100) attending the centre. Participants voluntarily consented to complete the questionnaire, filled it out and were assured that their responses would remain anonymous. A previously validated survey instrument with slight modifications was used in the study after obtaining electronic permission to use the questionnaire from the authors [11, 12]. The questionnaire included (1) a general demographic and participant characteristics section and (2) a general section, which is commonly used in reference to the head and neck region; some are specific to the practice of OMFS. The original questionnaire was modified by expanding the range of procedures to encompass the full spectrum of clinical scenarios. Participants were to choose one of four different alternatives of specialists with the added option of another specialty. Students were asked to choose only one option for who they thought would be most appropriate/competent in treating each of the clinical conditions. The procedures were categorised into groups according to the discipline for the statistical analysis: reconstruction, trauma, pathology and cosmetic procedures.

Statistical Analysis

Statistical analysis was performed using SPSS (IBM SPSS Statistics for Macintosh, Version 23.0. IBM Corp., Armonk, NY: IBM Corp.). Comparisons of the responses to the questionnaire were made between dental students and medical students. Questions were categorised into four categories: trauma, pathology, reconstructive surgery and cosmetic surgery. Categorical data were compared using the Chi square test or Fisher’s exact test (when cell counts < 5). A p value of < 0.05 was considered statistically significant.

Results

A total of 200 participants completed the questionnaire. There were 100 participants in each group. The respondents consisted of 51.5% males and 48.5% females, although there were significantly more females in the dental student group compared to the medical student group (65% vs. 47%; p < 0.001; Table 1). The vast majority of students were aged 18–25 years (99%). Most of the students were from Kuwait (57.5%) or Europe (28%). There were many more medical students in their 7th year of study compared to dental students (50% vs. 3%). Many students had received personal treatment from ENT or GS services (21% and 20%, respectively), but more dental students had personal experience with OMFS services compared to medical students (23% vs. 4%; p < 0.001). Of all the respondents, 51.5% reported not having had any personal medical treatment in the past.

Table 1.

Characteristics of respondents: number of participants, gender, age range, and years of study (programmes of study for dentistry and medicine in Kuwait are 7 years long)

	Dental student	Medical student	Total
Gender
Female	65	47	103 (51.5%)
Male	35	53	97 (48.5%)
Age group
18–25	98	100	198 (99%)
26–35	2	0	2 (1%)
Year of study
5th Year	33	33	66 (33%)
6th Year	46	11	57 (28.5%)
7th Year	3	50	53 (26.5%)

Each group contained 100 participants. Therefore, values within the cells represent both n and %

Responses to each of the questions by the dental and medical students relating to trauma are presented in Table 2. An OMF surgeon was preferred by both groups for treatment of a broken jaw, eye bone fracture, fracture of the skull, and trauma to the teeth. PS was more likely to be considered for cuts to the face. When it came to nose fractures, dental students preferred to consult a surgeon specialising in PS compared to medical students (35% vs. 19%; p = 0.011), while medical students preferred ENT surgeons (68% vs. 35%; p < 0.001).

Table 2.

Trauma: Each group contained 100 participants

Condition	Role	Plastic surgeon	Ear–nose-throat	Oral & maxillofacial surgeon	General surgeon	Others
Broken jaw	Dental student	4	0	92	2	2
	Medical student	4	4	90	2	0
	p	1.000	0.121	0.621	1.000	0.497
Cut on the face (laceration)	Dental student	52	0	29	17	2
	Medical student	66	2	12	16	4
	p	0.044	0.497	0.003	0.849	0.683
Eye bone fracture (orbit)	Dental student	10	6	67	11	6
	Medical student	10	14	34	20	22
	p	1.000	0.059	< 0.001	0.079	0.001
Fracture of the skull	Dental student	8	0	51	23	18
	Medical student	8	4	20	36	32
	p	1.000	0.121	< 0.001	0.044	0.022
Nose fracture	Dental student	35	35	26	2	2
	Medical student	19	68	6	7	0
	p	0.011	< 0.001	< 0.001	0.170	0.497
Trauma to the teeth	Dental student	4	0	63	7	26
	Medical student	0	0	82	0	18
	p	0.121	–	0.003	0.014	0.172

Therefore, values within the cells represent both n and %. Column p values were generated from a Chi square test or Fisher’s exact test if the cell count was less than five

For investigation of pathology, the majority of students would refer to an OMF surgeon for biopsy of oral lesions, cancer of the lip, mouth or tongue or a lump in the mouth (Table 3). For patients requiring biopsy of a skin lesion on the face, dental students preferred an OMF surgeon (40%; p < 0.001), while medical students preferred PS (34%; p = 0.003). Medical students considered an ENT surgeon most appropriate for the investigation of a lump in the neck (46% vs. 20%; p < 0.001) and did not really think that OMFS was appropriate, compared to dental students (7% vs. 44%; p < 0.001). Medical students also preferred PS for investigation of a mole or lump on the face (58% vs. 33%; p < 0.001), but dental students preferred OMFS (38% vs. 10%; p < 0.001). An ENT surgeon was preferred by medical students for salivary gland removal and sinus surgery, whereas dental students preferred an OMF surgeon for these procedures.

Table 3.

Pathology: Each group contained 100 participants

Condition	Role	Plastic surgeon	Ear–nose–throat	Oral & maxillofacial surgeon	General surgeon	Others
Biopsy of a skin lesion on the face	Dental student	16	0	40	30	14
	Medical student	34	6	10	32	18
	p	0.003	0.029	< 0.001	0.760	0.440
Biopsy of oral lesions	Dental student	4	0	61	13	22
	Medical student	0	20	67	5	8
	p	0.121	< 0.001	0.377	0.048	0.006
Cancer of the lip	Dental student	4	0	66	6	24
	Medical student	10	10	58	16	6
	p	0.164	0.002	0.244	0.024	< 0.001
Cancer of the mouth or tongue	Dental student	4	0	78	4	14
	Medical student	0	26	68	2	4
	p	0.121	< 0.001	0.111	0.683	0.024
Lump in the mouth	Dental student	4	0	72	14	10
	Medical student	6	24	60	10	0
	p	0.748	< 0.001	0.073	0.384	0.002
Lump in the neck	Dental student	6	20	44	22	8
	Medical student	6	46	7	39	2
	p	1.000	< 0.001	< 0.001	0.009	0.101
Mole or lump in the face (skin)	Dental student	33	0	38	19	10
	Medical student	58	4	10	24	4
	p	< 0.001	0.121	< 0.001	0.389	0.164
Salivary gland removal (parotid, submandibular)	Dental student	4	2	82	6	6
	Medical student	0	36	35	29	0
	p	0.121	< 0.001	< 0.001	< 0.001	0.029
Sinus surgery	Dental student	4	18	66	6	6
	Medical student	0	86	12	2	0
	p	0.121	< 0.001	< 0.001	0.279	0.029

Therefore, values within the cells represent both n and %. Column p values were generated from a Chi square test or Fisher’s exact test if the cell count was less than five

Table 4 presents the responses to questions relating to reconstructive surgery. There was a consensus between dental and medical students that an OMF surgeon was most appropriate for surgeries relating to dental implants, removal of wisdom teeth, temporomandibular joint surgery and intra-oral bone grafting. Compared to medical students, dental students were less likely to select PS for procedures involving cleft lips or palates (p < 0.001). Medical students were also more likely to choose PS for facial reconstructions, while dental students preferred an OMF surgeon.

Table 4.

Reconstructive Surgery: Each group contained 100 participants

Condition	Role	Plastic surgeon	Ear–nose–throat	Oral & maxillofacial surgeon	General surgeon	Others
Child with a cleft lip	Dental student	19	0	71	8	2
	Medical student	44	11	39	2	4
	p	< 0.001	0.001	< 0.001	0.101	0.683
Child with a cleft palate	Dental student	4	4	84	6	2
	Medical student	22	17	52	5	4
	p	< 0.001	0.005	< 0.001	0.756	0.683
Child with a cleft lip + palate	Dental student	6	4	84	4	2
	Medical student	24	15	52	2	7
	p	< 0.001	0.014	< 0.001	0.683	0.170
Dental implants	Dental student	4	0	71	3	22
	Medical student	4	0	60	0	36
	p	1.000	–	0.102	0.246	0.029
Facial reconstruction after facial trauma	Dental student	40	0	56	0	4
	Medical student	72	4	22	2	0
	p	< 0.001	0.121	< 0.001	0.497	0.121
Facial reconstruction with free flaps	Dental student	45	0	49	2	4
	Medical student	80	2	10	2	6
	p	< 0.001	0.497	< 0.001	1.000	0.748
Grafting bone in the face	Dental student	14	0	68	7	11
	Medical student	37	4	51	4	4
	p	< 0.001	0.121	0.014	0.537	0.105
Removal of wisdom teeth	Dental student	4	0	71	9	16
	Medical student	0	2	62	0	36
	p	0.121	0.497	0.178	0.003	0.001
Temporomandibular joint (TMJ) surgery	Dental student	4	1	91	2	2
	Medical student	2	6	82	8	2
	p	0.683	0.118	0.063	0.101	1.000
Taking bone from rib/hip for intra-oral grafting	Dental student	12	0	48	34	6
	Medical student	20	2	41	21	16
	p	0.123	0.497	0.319	0.040	0.024

Therefore, values within the cells represent both n and  %. Column p were values generated from a Chi square test or Fisher’s exact test if the cell count was less than five

PS was preferred by both groups for all cosmetic surgeries except chin correction surgeries, surgery for jaw deformities and discrepancies, problems with facial appearance and rhinoplasty (Table 5). For problems with facial appearance or asymmetry, dental students preferred an OMF surgeon (56%; p < 0.001) and medical students preferred PS (72% vs. 40%; p < 0.001). Dental students said they would refer patients requiring rhinoplasty to PS (73%; p < 0.001), while medical students preferred to refer such patients to an ENT surgeon (56% vs. 18%; p < 0.001).

Table 5.

Cosmetic Surgery: Each group contained 100 participants

Condition	Role	Plastic surgeon	Ear–nose–throat	Oral & maxillofacial surgeon	General surgeon	Others
Chin correction surgery	Dental student	28	0	70	0	2
	Medical student	43	0	55	2	0
	p	0.027	–	0.028	0.497	0.497
Eyelid surgery (blepharoplasty)	Dental student	50	2	22	6	20
	Medical student	44	10	4	7	35
	p	0.395	0.033	< 0.001	1.000	0.018
Face lift	Dental student	82	0	14	0	4
	Medical student	90	2	6	0	2
	p	0.103	0.497	0.097	–	0.683
Facial implants (silicone or other alloplasts)	Dental student	76	0	22	0	2
	Medical student	90	0	8	0	2
	p	0.008	–	0.006		1.000
Fat grafting to the face	Dental student	84	0	12	0	4
	Medical student	84	0	10	2	4
	p	1.000	–	0.651	0.497	1.000
Hair transplant	Dental student	77	0	2	6	15
	Medical student	66	0	2	8	24
	p	0.085	–	1.000	0.579	0.108
Injection of botox and fillers	Dental student	84	0	4	4	8
	Medical student	84	0	6	0	10
	p	1.000	–	0.748	0.121	0.621
Jaw deformities and discrepancy	Dental student	8	0	90	0	2
	Medical student	7	2	89	0	2
	p	0.788	0.497	0.818	–	1.000
Laser resurfacing of facial skin	Dental student	88	0	6	0	6
	Medical student	88	4	2	2	4
	p	1.000	0.121	0.279	0.497	0.748
Problem with facial appearance or asymmetry	Dental student	40	0	56	0	4
	Medical student	72	2	26	0	0
	p	< 0.001	0.497	< 0.001	–	0.121
Rhinoplasty (nose plastic surgery)	Dental student	73	18	7	0	2
	Medical student	44	56	0	0	0
	p	< 0.001	< 0.001	0.014	–	0.497

Therefore, values within the cells represent both n and %. Column p values were generated from a Chi square test or Fisher’s exact test if the cell count was less than five

The preferences for OMFS by dental and medical students for each question are summarised in Table 6. Figure S1 demonstrates that while an OMF surgeon was preferred overall for most clinical scenarios in trauma (p < 0.001), pathology (p < 0.001) and reconstructive surgery (p < 0.001), PS was preferred for cosmetic surgeries (p < 0.001).

Table 6.

Perception of when to consult an oral and maxillofacial surgeon for various conditions

Condition	Dental student	Medical student	p
Trauma
Broken jaw	92	90	0.621
Cut on the face (laceration)	29	12	0.003
Eye bone fracture (orbit)	67	34	< 0.001
Fracture of the skull	51	20	< 0.001
Nose fracture	26	6	< 0.001
Trauma to the teeth	63	82	0.003
Pathology
Biopsy of a skin lesion on the face	40	10	< 0.001
Biopsy of oral lesions	61	67	0.377
Cancer of the lip	66	58	0.244
Cancer of the mouth or tongue	78	68	0.111
Lump in the mouth	72	60	0.073
Lump in the neck	44	7	< 0.001
Mole or lump in the face (skin)	38	10	< 0.001
Salivary gland removal (parotid, submandibular)	82	35	< 0.001
Sinus surgery	66	12	< 0.001
Reconstructive surgery
Child with a cleft lip	71	39	< 0.001
Child with a cleft palate	84	52	< 0.001
Child with a cleft lip + palate	84	52	< 0.001
Dental implants	71	60	0.102
Facial reconstruction after facial trauma	56	22	< 0.001
Facial reconstruction with free flaps	49	10	< 0.001
Grafting bone in the face	68	51	0.014
Removal of wisdom teeth	71	62	0.178
Temporomandibular joint (TMJ) surgery	91	82	0.063
Taking bone from rib/hip for intra-oral grafting	48	41	0.319
Cosmetic surgery
Chin correction surgery	70	55	0.028
Eyelid surgery (blepharoplasty)	22	4	< 0.001
Face lift	14	6	0.097
Facial implants (silicone or other alloplasts)	22	8	0.006
Fat grafting to the face	12	10	0.651
Hair transplant	2	2	1.000
Injection of botox and fillers	4	6	0.748
Jaw deformities and discrepancy	90	89	0.818
Laser resurfacing of facial skin	6	2	0.279
Problem with facial appearance or asymmetry	56	26	< 0.001
Rhinoplasty (nose plastic surgery)	7	0	0.014

Each group contained 100 participants. Therefore, values within the cells represent both n and %. Column p values were generated from a Chi square test or Fisher’s exact test if the cell count was less than five

Discussion

Knowledge and consideration of the scope of OMFS is necessary to achieve fast and efficient treatment for patients. The cumulative knowledge and awareness of OMFS as a surgical specialty is related to the educational content presented in the medical and dental school curricula in any given country. There is a considerable difference in the clinical exposure to OMFS between medical and dental students at Kuwait University and throughout the world. In Kuwait, unlike most European countries, OMFS is a dental specialty, and the licensing process does not require a medical degree to perform head and neck surgeries. Guidelines on referrals are enforced for healthcare providers by healthcare authorities, which may affect referral behaviour. This may lead to overwhelming specific departments and depriving others from clinical exposure [13].

OMFS and other medical specialties evolve based on time and experience [14]. However, students who have not yet joined the workforce may have a more crude opinion of who to refer to. The vast majority of students who responded to this survey were in their 6th and 7th years of medical and dental school. Thus, it can be assumed that they should have had good insight into the different specialties available and seen in their stratified responses among various specialties in Tables 2, 3, 4 and 5.

OMFS overlaps heavily with ENT and plastic surgery [3]. In fact, almost all medical specialties overlap to some degree [14]. It is therefore important to acknowledge that medical students in Kuwait do not have direct exposure to OMFS services. This can be attributed to Kuwait considering OMFS a dental specialty [3]. In Ireland and the UK, for example, medical students are exposed to OMFS given the fact that OMFS is considered a medical specialty with a dental requirement [15, 16]. Despite this fact, medical schools in the UK provide limited exposure to OMFS in the undergraduate curriculum, and an evaluation of the last year for medical students in two UK centres by Hamid et al. demonstrated that medical students had minimal formal education about OMFS, with almost 90% of medical students not being involved in any OMFS rotation, and almost 50% not remembering attending lectures on the specialty [16–18]. In Kuwait, medical students received minimal curricular educational content about OMFS, and this can be reflected in their combined responses in each category: trauma, pathology, reconstructive surgery and cosmetic surgery, in which medical students selected OMFS less than their dental students counterparts in all categories, Figure S1.

Few OMF surgeons are double qualified in Kuwait. Collaboration between surgical services is occasional in the operation theatre. Dental students seem to be more knowledgeable about the wide scope of oral and maxillofacial surgery compared to medical healthcare professionals seen in their cumulative responses for each category as seen in Table 6 and Figure S1. This was evident insofar as dental students indicated that they would refer almost all traumatic cases to an OMF surgeon except for nasal fractures, Table 2. Among all the listed procedures, OMFS was the most commonly preferred service to treat such cases, with the exception of procedures that require soft tissue and cosmetic reconstructions. Medical students, to a lesser degree, indicated that they would refer all cases involving oral cavity, jaw and facial trauma to OMFS (Table 2). In our survey, medical student awareness towards OMFS was more noticeable compared to other studies as seen in their responses across all categories, Table 2-55 [2, 6, 10].

Both groups chose OMFS for the management of cleft lip and palate as see in Table 4. The Department of Plastic Surgery is currently providing this service in the centralised plastic surgery hospital in Kuwait. In previous publications, many healthcare professionals and medical students indicated that they would prefer plastic surgery for such cases [18, 19]. On this and many other points, our results seem to be very encouraging regarding the level of awareness that medical students have on the scope of OMFS as seen in their responses in all categories in Figure S1. This may be attributed to the evolution of social media platforms, where cases are posted and discussed by various OMF surgeons in Kuwait and throughout the world. Social media platforms target a larger audience that includes almost all populations in a given community.

Dental students preferred to refer neck pathology cases to OMFS, whereas medical students referred to ENT instead (Table 3). Goodson et al. found that time exposure to OMFS rotations was correlated with increased referrals to the service [18]. OMF surgeons routinely undertake neck dissections. In fact, in Europe and North America, it seems that OMFS is one of the main referral points for neck pathologies. Medical and dental students referred almost all procedures that require special attention to aesthetics to PS, Table 5. Plastic surgery usually manifests itself as a specialty dedicated to achieving excellence in the realm of aesthetics. Social media and popular culture reinforce this idea. Thus, there was a tendency to refer cosmetic surgery cases to PS, with similar results found in other publications [3, 11, 20].

In our study, a significant number of dental students thought general surgery was reasonably appropriate to manage grafting of bone from the rib/hip region to the oral cavity, Table 4. OMF surgeons are fully comfortable carrying out such procedures. Some may argue that oral surgeons may require the help of general surgery to harvest bone grafts, but it is also reasonable to think that this would be way more costly and inefficient. Most OMFS residencies offer extensive rotations in orthopaedic and general surgery where practitioners are exposed to the clinical anatomy of the body outside the head and neck region and carry out reconstructive procedures independently by having admission privileges for such cases.

Dental students need to be more aware of OMFS and its scope since it is one of the most widely recognised specialties in dentistry. Indeed, some dental students are interested in pursuing a career in OMFS, so it is helpful to gain more insight about the specifics of the discipline. This is the only cross-sectional study that has been done in Kuwait to measure the perception and awareness of medical and dental students in a GCC country of the specialty of OMFS.

Conclusions

In conclusion, medical and dental studies seem to have a high level of awareness about OMFS. In fact, they may be more aware than health professionals themselves in Kuwait and throughout the world. In Kuwait, referral guidelines may create a bias for referrals that is not in favour of OMFS. More effort in spreading awareness should be considered, and we recommend social media to be the main platform given its proven success over time. Kuwait University should consider exposing medical and dental students to OMFS theatres that involve head and neck surgeries. Medical students should also consider careers in OMFS, and this should be taken into consideration by the medical schools and the healthcare authorities.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

OMFS

Oral and maxillofacial surgery

ENT

Ear, nose, and throat

PS

Plastic surgery

GS

General surgery

Author Contributions

MK and MA conceived and designed the study. MK collected the data work on the acquisition and analyses. MK and AA interpreted the data. MK, AA and MA have drafted the work or substantively revised it. All authors read and approved the final manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Availability of Data and Material

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest and nothing to disclose.

Ethics Approval

Participating students gave their consent and voluntarily filled out the questionnaire, and their responses were kept anonymous. The Ethical Committee at Kuwait University approved the study in accordance with the Helsinki Declaration.