Interprofessional collaboration for the management of orofacial pain: a delphi study in the Netherlands

Abstract

Background

Depending on the cause of the orofacial pain, different specialists can be involved in the healthcare process. In case the pain is not, or only partly, caused by dental structures, an interprofessional approach is warranted due to the complex nature of most of these complaints. Collaboration between (specialized) dentists, (specialized) physiotherapists, and other healthcare providers like the general medical physician, Ear Nose Throat (ENT) specialist, maxillofacial surgeon, neurologist, psychologist, and/or speech therapist can be necessary. For successful a collaboration, the specific roles of each member of the multidisciplinary team should be clear, both for the care providers and for the patient. The aim of this study was therefore to explore the role of different healthcare providers and their collaboration in the care of patients with orofacial pain. The secondary aim was to describe the when, how, and why regarding interprofessional collaboration for the management of orofacial pain.

Methods

A three-round e-Delphi study was conducted from May 2023 to November 2023. There were three rounds, and all surveys were collected using the online program Qualtrics. Consensus was reached when ≥ 75% of the expert panel members agreed.

Results

There were 14 expert panel members actively participating in this study: 4 orofacial pain dentists, 5 orofacial physiotherapists, and 5 patients. In the Netherlands, non-complex orofacial pain complaints can be managed by the general dentist or general medical physician. In the case of complex orofacial pain complaints, the orofacial pain dentist and orofacial physiotherapist are essential members of the interprofessional team. Then, based on the specific needs of the patient, collaboration with other healthcare providers can be initiated. By incorporating interprofessional collaboration, experts believed that the patient would receive the right care sooner, which would benefit treatment outcomes.

Conclusion

Interprofessional collaboration in the form of communication and, for complex cases, interprofessional consults, is recommended for patients with complex orofacial pain. All healthcare providers have their own role during the diagnostic and management process, depending on the complaints and needs of the patient.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-026-08196-8.

Background

Orofacial pain is a common complaint that can be attributed to disorders of dentoalveolar and anatomically related structures (e.g. teeth and gums), other parts of the masticatory system (muscles or temporomandibular joint), nerve lesions, or idiopathic in nature [1]. Dental pain is the most common cause of orofacial pain and the most common reason for people to visit their dentist. However, approximately one in five people visiting the dentist also experiences pain complaints related to other parts of the masticatory system [2], which can be a sign of a temporomandibular disorder (TMD) [3]. It has been reported that many general dentists, especially newly graduated dentists, do not feel like they have enough knowledge or competences to manage these complaints [4–6]. Even though general dentists do receive training on the management of TMD and when to collaborate with specialists, the American Academy of Orofacial Pain has suggested an upgrade of the dental curricula to improve knowledge on this topic [7, 8]. In addition, orofacial pain is a recognized dental specialty in several countries including the United States of America, Canada, United Kingdom, Australia, Brazil, and the Netherlands [9]. In the Netherlands, physiotherapists can also specialize in the field of orofacial pain, by a completing a specific master program. Because of this, physiotherapists in the Netherlands play an important role, together with the specialized dentist, in the management of orofacial pain.

Depending on the cause of the orofacial pain, other specialists besides the dentist and physiotherapist can also be involved in the healthcare process. In case the pain is not, or only partly, caused by dental structures, an interprofessional approach is warranted due to the complex nature of most of these complaints [10, 11]. Collaboration between (specialized) dentists, (specialized) physiotherapists, and other healthcare providers like the general medical physician, Ear Nose Throat (ENT) specialist, maxillofacial surgeon, neurologist, psychologist, and/or speech therapist can be necessary. However, it often still is unclear to professionals when and how to collaborate, and for which subgroup of orofacial pain patients this might be most beneficial. The challenge to provide optimal care lies in an efficient diagnostic process, and collaborating with the right specialists for either additional diagnostics and/or management. Especially in patients with persistent orofacial pain, it is difficult to find the right healthcare provider. This may lead to frustrated patients trying to get help for their complaints [12]. It is therefore important to clarify the role of different healthcare providers during the diagnostic and management phases of orofacial pain patients. Additionally, it should be described even when these roles are clearly defined, how and when collaboration should take place for optimal care for patients with orofacial pain.

The aim of this study was therefore to explore the role of different healthcare providers and their collaboration in the care of patients with orofacial pain, followed by describing the when, how, and why regarding interprofessional collaboration for the management of orofacial pain in the Netherlands.

Methods

The study was conducted in accordance with the Helsinki guidelines and approved by the Ethics Committee of the Academic Centre for Dentistry Amsterdam (2022–9958). All participants signed an informed consent form before participating in the study.

Study design

An e-Delphi study was designed and conducted following reported guidelines and similar studies [13–16]. A consensus-seeking descriptive design was used to answer the research questions. The data collection time frame was from May 2023 to November 2023. There were three rounds, and all surveys were collected using the online program Qualtrics (Qualtrics, Provo, UT) [17], hence the term e-Delphi [16]. An ‘all-rounds invitation’ approach was used, where experts could participate in each subsequent round irrespective of their participation of the previous round [18].

Focus group and expert-panel members

In the Netherlands, most of the patients with orofacial pain are seen by dentists or physiotherapists specialized in orofacial pain [19]. Therefore, these two disciplines were invited to participate as experts in either the focus group or as expert-panel members. Additionally, patients with orofacial pain are experts by experience, and were also invited to join the panel.

For the focus group, a local interprofessional network of specialized dentists and physiotherapists was invited to participate. This local network of 10–15 people meets 3 to 4 times a year to discuss newest developments in the field, as well as complex clinical cases. All members of the network were invited to join the focus group discussion.

For the expert panel, inclusion criteria for the orofacial pain dentists were having completed their specialty training in orofacial pain (3 years, full-time) and a minimum of two years of working experience with patients with orofacial pain. Physiotherapy experts were required to have a master’s degree (3 years, half-time) in orofacial physiotherapy and a minimum of two years of working experience with patients with orofacial pain. Patients had to be minimally 18 years of age, to experience orofacial pain, and have seen minimally two specialists for their complaints. Both orofacial pain dentists and orofacial physiotherapists were recruited through their specialists’ associations and the personal network of the researchers. Patients were recruited through the clinics of the participating dentists or physiotherapists, and of the researchers. To allow unbiased answers and to ensure the responses were treated equally, all responses were collected online and anonymously. Furthermore, panel members were encouraged to revise, improve, or add additional comments during each survey round.

The recommendations for the size of a Delphi panel are between 10 and 18 experts [13] Thus, for each group (dentists, physiotherapists, patients) five participants were recruited.

Data collection and analysis

Focus group discussion

To design the survey for the Delphi rounds, an online focus group discussion with a group of experts (orofacial pain dentists and orofacial physiotherapists), who did not participate in the e-Delphi rounds was held. This group of experts was presented with different patient cases and their patient journey [20] (timeline of their complaints, healthcare providers visited, therapies followed, and results of these therapies). The experts were asked to share their thoughts on this patient journey, the collaboration between care providers during this journey, and where the healthcare process could be improved. The discussion was guided by participant interactions, with the researcher posing follow-up questions for deeper insights. The principal investigator (HvdM) with a background in qualitative analysis took notes during the discussion about important topics. The focus group discussion was recorded, so that these notes could be verified and topics confirmed. Furthermore, a second researcher (AvdW) was present during this meeting as well and discussed the answers together with the principal investigator to ensure the interpretation of the discussion was similar between researchers before constructing the questions. Based on the information gathered from this focus group, open-ended questions were created for the first e-Delphi round based on identified important topics: general information on OFP, role of different healthcare providers (who), and interprofessional collaboration (when, how, and why). The questions were initially constructed by the principal investigator, after which the research team provided feedback so the questions would be clear to participants and provide the information needed for the next rounds.

First round of e-Delphi

For the dentists and physiotherapists, the first round consisted of open-ended questions regarding general knowledge of orofacial pain, the role of different healthcare providers, and when and how to start interprofessional collaboration. The patients received a modified version of the survey, to fit the general knowledge level of people without special training in this field. The answers were qualitatively analyzed and restructured into statements for the second round. All answers were extracted into a Microsoft Excel sheet so the answers to the same question were in the same row for a good overview. Key words or messages from the answers were highlighted in bold, and specific topics or themes were highlighted in different colors by the principal investigator. When key words, topics or themes were consistently present in the answers, the research team constructed a statement about this topic.

Second round of e-Delphi

During the second round, all panel members received statements that they could rate for their level of agreement to using a Likert scale from 1 (completely disagree) to 5 (completely agree). These statements were on the same topics as the open-ended survey. If a statement was rated with a score of 1 or 2 by 75% or more of the experts, this statement was determined to be a ‘false’ situation. If 75% or more of the experts rated a statement with a score of 4 or 5, this statement was determined to be a ‘true’ situation. Any other outcome was considered a lack of consensus. Missing data was excluded from the analysis.

Third round of e-Delphi

For the third round, all panel members were shown which statements from the second round reached consensus, and which statements did not. They were given the opportunity to change their initial rating of the statements that had not reached consensus yet, to reach the cutoff point of 75% consensus. Expert panel members were discouraged to rate statements with a neutral score during this round. In the case they would rate it neutrally, they were encouraged to give an explanation as to why a neutral score was given. Criteria for consensus were identical to the second round. Missing data was excluded from the analysis. Based on the consensus statements from the second and third round, results are summarized in figures. An additional analysis was performed to determine the percentage of consensus for the different consensus levels 70% and 80%, to determine the robustness of the findings.

Results

Focus group interview

The focus group interview was held with two orofacial pain dentists and eight orofacial physiotherapists. Based on their input, the survey of the first Delphi round was created.

Expert-panel members

Ten healthcare providers agreed to participate in the study, of which four orofacial pain dentists and five orofacial physiotherapists completed one or more Delphi rounds. Eight patients were invited to the study, of which five agreed to participate and completed one or more Delphi rounds. Thus, in total, there were 14 expert panel members actively participating in this study.

The average age of the dentists was 50 years, of the physiotherapists 40 years, and of the patients 55 years. Of the orofacial pain dentists, two were female, and the working experience of the dentists within the domain of OFP ranged from 2.5 to 25 years. There was one female physiotherapist participating, and the working experience within the domain of OFP ranged from 4 to 16 years. In the patient group, four out of five participants were female, and the duration of the pain complaints of all patients ranged from several months to over 20 years. All patients had seen a physiotherapist before, three visited their general dentist, three visited an orofacial pain dentist, and two visited other healthcare providers such as the general medical physician or a massage therapist. Table 1 provides an overview of the expert-panel characteristics.

Table 1.

Expert-panel characteristics

	Orofacial Pain Dentists (n = 4)	Orofacial Physiotherapists (n = 5)	Orofacial Pain Patients (n = 5)
Age; mean ± SD (range)	49.8 ± 11.7 (38–63)	40.2 ± 4.1 (34–44)	55.0 ± 7.9 (45–64)
Sex; n female	2	1	4
Years of working experience in the field of OFP; mean ± SD (range) years	12.6 ± 11.1 (2.5–25)	10 ± 5.2 (4–16)	-
Weekly patient contact hours in the field of OFP; mean ± SD (range)	18.0 ± 2.3 (16–20)	26.2 ± 7.4 (14–32)	-
Work setting; n - Private clinic - Hospital or specialized clinic	2 3	5 1	-
Healthcare provider visited; n - General dentist - Orofacial pain dentist - Physiotherapist - Other	-	-	3 3 5 2
Setting received care; n - Private clinic - Hospital or specialized clinic	-	-	5 4

First round of e-Delphi

The open-ended first round was completed by four orofacial pain dentists, four orofacial physiotherapists and five patients.

General information on OFP

When asked what the healthcare providers consider ‘orofacial pain’, the definitions varied from pain in the head- and neck region, to only pain of the masticatory system. Some considered dental pain as part of orofacial pain, whereas others did not. Most healthcare providers stated they use the diagnostic criteria for TMD (DC/TMD) [3] for masticatory problems, and some also used the International Classification of Orofacial Pain (ICOP) [1] to classify orofacial pain. When asked for common risk factors, most described that there is not one specific risk factor for orofacial pain as orofacial pain is a multifactorial complaint.

Role of healthcare providers

All panel members were asked specifically about the role of the general dentist, the orofacial pain dentist, general physiotherapist, orofacial physiotherapist, general medical physician, and the patient. In most cases, the panel members wrote that the role was dependent on the type and complexity of orofacial pain. For instance, general dentists had a big role in dental problems, whereas the orofacial pain dentist was more needed for complex complaints and TMD. They were then asked which other healthcare providers should be considered as being an integral part of the care of orofacial pain patients, and the following were mentioned by more than one expert: maxillofacial surgeon, neurologist, ENT specialist, speech therapist, psychologist, psychosomatic physiotherapist, and manual therapist.

Interprofessional collaboration: when, how, and why

All panel members already work with other disciplines for orofacial pain. Some only exchange information through referral letters or applications for communication such as an encrypted messaging system, others are involved in interprofessional consultation hours. Most describe collaboration as needed for complex patients, and that it has many benefits for the patients, as well as for themselves as healthcare providers.

Second round of e-Delphi

Based on all information from this first round, statements were made regarding the three identified themes: (1) general information on orofacial pain, (2) role of healthcare providers in orofacial pain care, and (3) interprofessional collaboration: when, how, and why. In total, six healthcare providers and three patients completed the second round.

General information on OFP

There was consensus in 75% of the statements regarding general information on OFP. The statement that healthcare providers should work with the same definition of orofacial pain reached consensus (78% agreed), but there was no consensus on which definition to use (only 66% agreed on the use of the ICOP definition of orofacial pain). Panel members stated that psychosocial distress, disturbed sleep, and trauma were possible risk factors for orofacial pain (78–89% agreed). Overuse of the masticatory system as a risk factor did not reach the consensus level (56% agreed).

Role of healthcare providers

When asked about the specific role of the patient or different healthcare providers, there was consensus on 45% of the statements. Panel members agreed that patients need to have an active role in myalgia, arthralgia, and facial headache (consensus levels 75% − 100%), but no consensus was reached on their role for dental, neuropathic, or idiopathic pain. The general medical physician needs to refer patients with dental pain to the general dentist, patients with myalgia to a (specialized) physiotherapist, and patients with neuropathic pain to the neurologist (consensus levels:75% – 87.5%). There was no consensus on referrals for patients with arthralgia, facial headache, or idiopathic pain. The general dentist was appointed as the primary healthcare provider for dental pain (100% consensus) and the panel agreed that they are not the primary healthcare provider for neuropathic pain or facial headache (76% − 100% consensus). The orofacial pain dentist does not have to be involved in all cases with non-complex orofacial pain (88% consensus), but they should be involved in complex cases (76% consensus) just as the physiotherapist specialized in orofacial pain (88% consensus). When it comes to medical specialists, there was consensus that the ENT specialist, maxillofacial surgeon, and neurologist do not automatically have to be involved in all cases with non-complex OFP (76% − 100% consensus). They should be part of the interprofessional team when there is tinnitus present (ENT specialist; 75% consensus), idiopathic pain (maxillofacial surgeon; 75% consensus), or neuropathic pain (neurologist; 88% − 100% consensus). When it comes to the allied health professionals, there was only consensus on the role of the speech therapists in patients with orofacial pain and bad oral habits (100%), but for none of the other disciplines consensus was reached on their specific role. In case of high levels of psychological complaints, such as anxiety or depression, the psychologist should be part of the team (100% consensus).

Interprofessional collaboration: when, how, and why

There was consensus in 51% of the statements regarding interprofessional collaboration. All panel members agreed that every healthcare provider should recognize and acknowledge their own competences and shortcomings and refer patients when needed. Interprofessional collaboration was not seen as needed for dental pain (75% consensus), but it is needed for neuropathic pain (75% consensus), facial headache (75% consensus), and idiopathic pain (100% consensus). Important findings from the additional comments were that the healthcare providers stated that not the diagnosis, but the complexity of the complaints was the most important reason to approach orofacial pain specialists in an interdisciplinary setting. Additionally, the panel members stated that the specific needs and complaints of the patients are most important in choosing the level of involvement of the different disciplines. To determine if there was consensus on this finding, this was added as a statement in the third round.

All panel members agreed that communication is essential for proper interprofessional collaboration. In complex orofacial pain, healthcare providers need to consult with each other (100% consensus), but there was no consensus whether this consultation should be organized during interprofessional consultation hours (63% agreed). Regarding the statements related to the ‘why’ of interprofessional collaboration, there was 88% consensus reached that interprofessional statement is essential for providing good care for patients with orofacial pain. All panel members agreed that patients will receive proper care faster and that their complaints will decrease quicker with interprofessional collaboration. There was no consensus on possible reasons why interprofessional collaboration might not be working (e.g., lack of easy interprofessional communication platform, lack of time, conflict of interests, or large distances).

Third round of e-Delphi

The final round was completed by five orofacial physiotherapists, three orofacial pain dentists and three patients. All findings of the second and third rounds combined are presented in Appendix 1.

General information on OFP

New topics on which consensus was reached were (1) the ICOP definition as a good definition of orofacial pain (88% consensus), and (2) overuse of the masticatory system as an important risk factor (90% consensus). The overall consensus was in 88% of the items with both the 70% and 75% cut-off level, whereas this percentage dropped to 38% when applying the alternative 80% cut-off level. The four statements that would not be included in the consensus with the 80% cut-off level all had a consensus level of 78%.

Role of healthcare providers

In the third round, new statements the panel members reached consensus on were on various roles of the patient and healthcare providers. Panel members agreed that the patient needs to have an active role in idiopathic pain (100% consensus), but no consensus was reached on their role in dental pain or neuropathic pain, even with a lower consensus-level cut-off of 70%. The general medical physician has a screening function in case of orofacial pain (82% consensus) and they should be able to differentiate different types of orofacial pain (82% consensus). No consensus was reached on who the general medical physician should refer to in the case of arthralgia, facial headache, or idiopathic pain for any of the consensus levels. For the role of the general physiotherapist, further consensus was reached for one statement on the focus of their treatment, which would be general activity levels, relaxation, and pain education (100% consensus). In 75% of the statements regarding the general physiotherapist consensus was reached with both the 70% and 75% level, compared to 50% agreement with the 80% level. With regard to the role of the psychologist, consensus was reached on the statement that the psychologist should be involved in all cases with complex orofacial pain for further diagnostics on psychological issues (91% consensus), reaching 58% total consensus on the statements regarding the psychologist. For the medical specialists, the panel members came to a consensus that there is no need to involve ENT-specialists in the case of neuropathic pain (82% consensus). Instead, a neurologist should be involved in these cases (82% consensus). A maxillofacial surgeon should be involved in all cases with complex orofacial pain for further diagnostics (80% consensus). For the statements of the medical specialists, there was a variety of consensus reached between the three different cut-off levels, ranging from 38% (80% cut-off for maxillofacial surgeon) to 89% (70% cut-off for ENT). There was no additional consensus on statements on the role of the general dentist, orofacial pain dentist, orofacial physiotherapist, psychosomatic physiotherapist, manual therapist, or speech therapist.

Interprofessional collaboration: when, how, and why

Regarding the ‘when, how, and why?’ questions on interprofessional collaboration, consensus was reached on several more statements. In total, consensus was reached in 71% of the statements regarding the ‘when’ with the 70% and 75% cut-off levels, compared to 29% using the 80% cut-off level. The three statements that were not included in the stricter cut-off level, all had 75% consensus. The panel members reached consensus on a new statement that described that persistent complaints more often warrant an interprofessional approach than acute complaints (91% consensus), and that the primary reason for collaboration is not the diagnosis but the complexity of the complaints (100% consensus). When asked about which healthcare provider should be the case manager, the experts came to consensus that this should be the orofacial physiotherapist in the case of myogenous pain (91% consensus) and the orofacial pain dentist in the case of idiopathic pain (82% consensus). For the other causes of orofacial pain, consensus ranged from 55% to 64%. Other new topics on which consensus was reached were (1) similar diagnostic assessment (e.g. oral history, questionnaires, and physical examination) by all healthcare providers (91% consensus), (2) the need for an interprofessional consultation for patients with complex orofacial pain (91% consensus), (3) the necessity for healthcare professionals to meet in person (for example during conferences or courses) to improve collaboration (91% consensus), and (4) that interprofessional online courses contribute to better collaboration (75% consensus). However, there is still no consensus on many statements on barriers for interprofessional collaboration.

Summary of findings

Based on the Delphi rounds, two summary figures were made to depict the summary of findings on the roles of healthcare providers and patients (Fig. 1), as well as on interprofessional collaboration (Fig. 2). The information below is based on the consensus ratings, as well as additional information expert panel members provided after the third round to explain their rating.

Fig. 1.

– Orofacial pain management in a multidisciplinary setting (current situation): the role of different healthcare providers explained, based on consensus of three interprofessional Delphi rounds

Fig. 2.

– Interprofessional collaboration for orofacial pain: When, Why, and How (recommendations)

The panel members reached consensus that the patient should have an active role in the specific case of TMD, headache in the facial region, and idiopathic pain, for management of these complaints to have any effect. Trying to help these patients with orofacial pain, different healthcare providers were identified by the panel members, each with their own suggested role.

The role of specific healthcare providers is summarized in Fig. 1. It is suggested by the panel members that all healthcare providers are aware of the differential diagnoses possible for orofacial pain, but general medical physicians and general dentists need to specifically be able to screen for them and then refer patients to specialists when indicated. Non-complex orofacial pain complaints can be managed by the general dentist or general medical physician, though more training on these subjects may be needed. If the cause of the orofacial pain is due to dental problems, the general dentist is the primary care provider according to the panel members. In the case of complex orofacial pain complaints, the orofacial pain dentist and orofacial physiotherapist are essential parts of the interprofessional team, and the panel members suggest that these complex patient are seen by both professions. The examinations of these disciplines are complementary to each other: where the orofacial pain dentist is able to perform full diagnostics on the dental structures and temporomandibular joint (also using imaging), the orofacial physiotherapist also considerers the neck and shoulder when examining the patient. Then, based on the specific needs of the patient, collaboration with other healthcare providers can be initiated.

A summary of findings regarding the when, how, and why of interprofessional collaboration is depicted in Fig. 2. Collaboration on specific patient cases can be organized through written reports or phone-calls in non-complex OFP cases, while for complex orofacial pain patients interprofessional consultation is considered needed. By incorporating interprofessional collaboration, experts believed that the patient would receive the right care sooner, which would benefit treatment outcomes. Additionally, work-related happiness is believed to increase by collaborating with other disciplines.

Discussion

Patients with orofacial pain often experience a long journey before they receive the right diagnosis and treatment for their specific complaints [12, 21, 22]. To improve patient care for these patients, this study was developed to explore the role of different healthcare providers in the field of orofacial pain in the Netherlands. The outcomes of the Delphi study on the specific roles of the different disciplines and ways to collaborate can be used to as a starting point improve the journey of patients with more complex complaints, both nationally and internationally.

General information

The first part of this Delphi study aimed to determine if there was consensus on general issues and the approach to orofacial pain across different disciplines in the Netherlands. The panel members agreed that all healthcare professionals should work with the same definition of orofacial pain. They reached consensus in the third round that the definition from the ICOP is a good working definition.1 Not all risk factors known from the literature were mentioned by the panel members, such as genetics, immunity factors or other biomarkers [23, 24]. Risk factors for orofacial pain that were agreed upon were disturbed sleep and oral habits leading to overuse of the masticatory system. From the literature, it is known that there is a bidirectional relationship between sleep deficiency and chronic pain [25], and that it can both be an important risk factor and a prognostic factor for TMD [26]. The Delphi panel members also agreed that overuse of the masticatory system is one of the possible risk factors for orofacial pain, but only in the third round. During the second round there was no consensus based on the input from both healthcare providers and patients. During the third round, the healthcare providers changed their input so all healthcare providers agreed that overuse of the masticatory system was an important risk factor for orofacial pain. In the literature, this has only been described for TMD and not for other types of orofacial pain [27, 28]. For which specific orofacial pain disorders overuse truly is a risk factor should be studied further, as this will have implications for treatment [28].

The reason that these questions regarding risk factors were asked were not to reach consensus on what a risk factor is, but to determine if different disciplines considered the same factors as risk factors. If orofacial pain dentists, orofacial physiotherapists, and patients with orofacial pain all consider the problem to come from something different, then interprofessional communication and successful treatment may be more of a challenge. After all three rounds, there was consensus on the general information statements, which shows that the starting point of looking at the problem is similar for the expert panel members.

Roles of healthcare providers

In order for interprofessional collaboration to be successful, the roles of the different healthcare providers involved should be clear, including who the case manager of the patient is [29]. Since orofacial pain embodies many different disorders and complaints, there was not one specific case manager appointed for all orofacial pain. This study shows that in the primary care setting, the general medical physician and general dentist should be able to screen for different types of orofacial pain and treat the non-complex cases. However, the outcomes of the e-Delphi study confirm earlier findings that, according to the panel members, general knowledge of orofacial pain is limited among primary healthcare providers [4–6, 21, 30–32]. Increasing the general knowledge of orofacial pain could possibly improve patient journey and interprofessional collaboration.

When there is a more complex orofacial pain present, patients should at least be seen by the orofacial pain dentist and by the orofacial physiotherapist. In the Netherlands, orofacial pain is a specialty within the field of dentistry that requires three years of additional training after an undergraduate degree in dentistry [180EC]. Physiotherapists can obtain a master’s degree in orofacial physiotherapy [90EC] after three years of additional education after their bachelor’s degree in general physiotherapy. Even though the specialty programs for dentists and physiotherapists differ between countries, consensus is that both disciplines are recommended to be involved in orofacial pain care for many disorders, including TMD and headaches [10, 33]. Collaboration remains integral, as each of these specialists has their own unique competences and together, they can provide a full examination and treatment plan for the patient. Future research should compare this interprofessional collaboration between specialized dentists and physiotherapists from the Netherlands to other countries where these specializations may not be as prominent or even existent. By exploring similarities, differences, and experiences between different countries, all healthcare providers may learn from each other and systems for collaboration may be improved.

Even though there currently is no consensus on which of these specialists should be case manager for different types of orofacial pain in the Netherlands, it can be debated if the role of a case manager should be in the hands of specialists or rather the general medical physician or general dentists in the primary care facilities. A case manager’s role is to reduce barriers to care and involve the patient in the process of assessment, care coordination, and evaluation; all tuned to the patient’s individual healthcare needs [34, 35]. This holistic approach requires a healthcare professional who can fulfil this, such as a general medical physician [34]. However, not all general medical physicians feel they have enough time to adequately take on this role for their patients [36]. This aspect of orofacial pain care in the Netherlands should be studied further to determine which healthcare provider(s) can take on the role of case manager.

For example, the panel members reached consensus that the orofacial pain dentist should be the case manager for patients with idiopathic pain. However, this diagnosis may not be known until the patient has visited (many) other healthcare providers before the orofacial pain dentist, in which case they cannot be the case manager from the start of the problems. Future research should determine who should be the general case manager, and if there are specific case managers once there is a clear diagnosis.

Even though the orofacial pain dentist was not appointed as case manager for complex orofacial pain, the panel members reached consensus that they are responsible for starting up interprofessional collaboration. This further collaboration can be done with different specialties, all depending on the specific needs of the patient. As psychosocial factors play an important role in a lot of pain complaints as risk- and prognostic factors, adding a health psychologist is often recommended [10, 37–39]. The experts of the current study stated that a psychologist should not necessarily be involved for every complex patient, but only when high levels of psychological issues are present. In the case of neuropathic pain or comorbid headaches, the neurologist is recommended to be added to the team. Neuropathic pain and neuralgias are classified in both the ICOP and the International Classification of Headache Disorders [1, 40]. Neuropathic orofacial pain is a general term that covers many different clinical syndromes and causes for the pain [41]. It is therefore important that the healthcare provider working with these complaints has extensive knowledge on this subject, as well as on possible differential diagnoses. Often a specialized dentist is involved in the management of orofacial neuropathic pain, but the neurologist can also play an important role when it comes to assessment and medical management [41, 42].

Headaches are also multifactorial complaints that require interprofessional collaboration [43] and are frequently present in patients with orofacial pain, especially in patients with TMD [44]. Since the presence of (primary) headaches may interfere with the efficiency of TMD treatment [45] proper diagnostics and management is essential and is often done in a multidisciplinary team led by a neurologist specialized in headaches [43] Interestingly, even though the neurologist is often seen as the case manager for patients with headache, the panel members did not reach consensus on such a role for the neurologist in the case of facial headache. Only two-thirds of the panel members stated that the general medical physician should refer patients with facial headache to the neurologist. This may be because neurologists are not too familiar with orofacial pain syndromes [42] or because some of the facial headaches (e.g., tension-type orofacial pain) are described as being too similar to myofascial orofacial pain [1]. In the latter case, the patient should be seen by the general medical physician or general dentist in case of non-complex TMD complaints, or by the orofacial pain dentist and orofacial physiotherapist in case of complex TMD complaints. Either way, more research, which includes the perspective of neurologists, is needed to describe the role of the neurologist in patients with orofacial headaches.

Another prevalent complaint in patients with orofacial pain is tinnitus [46]. In some cases, the tinnitus is directly related to TMD and can be decreased by successful treatment of the TMD [47, 48]. However, a full examination of the tinnitus by a specialist, such as an ENT specialist, is warranted as there is not always an association between the tinnitus and TMD and a specialist should determine if the tinnitus is related to TMD or something else [49]. This is in line with the findings of the current Delphi study, where panel members stated that the ENT-specialist should be involved in patients with orofacial pain and tinnitus.

Interprofessional Collaboration

When patients experience persistent or complex orofacial pain, interprofessional collaboration should be started. In the current organisation of healthcare, very often healthcare providers work from a multidisciplinary setting, meaning multiple disciplines work together but they all maintain their own perspective and methods. This is different from interprofessional collaboration, where according to the literature, it should consist of patient-centered care, where the different disciplines collaborate to make a treatment plan and work together to execute this plan [50]. The results of this study align with this statement, as the panel members describe improved patient care as one of the positive effects of collaboration. Additional positive effects of collaboration determined by the panel members are increased work-related happiness, and increased knowledge of other closely related disciplines. This is also found in other studies regarding interprofessional or multidisciplinary approaches in patient care [29, 51]. One of the important aspects to make this type of collaboration work, is effective communication [29, 51, 52]. To optimize interprofessional communication, healthcare providers need to use the same terminology, which can be realized by educating all providers beyond their respective disciplines [52]. Experts in the current study describe that working from the same diagnostic framework, in this case the ICOP, and having courses or conferences together, will contribute optimal collaboration. In that context, it is important to differentiate between multidisciplinary and interprofessional collaboration. Currently, healthcare providers often work from a multidisciplinary perspective, where each discipline works separately on the same problem. Actual interprofessional collaboration could lead to higher patient care quality and increased health professional job satisfaction, due to the teamwork nature of collaboration [50] The Delphi members identified the need for interprofessional consultations for patients with complex orofacial pain. It was believed that consulting the patient as an interprofessional team would improve accurate diagnosis and tailored treatment strategy more easily, resulting in a faster reduction in complaints for the patient. A next step towards improvement of patient care for chronic orofacial pain patients is to study the feasibility and cost-effectiveness of such interprofessional collaboration.

Strengths and limitations

The Delphi method is a good way to start working in a collaborative manner to reach consensus, but always needs to be put in perspective based on the recruited participants. One of the limitations is that the starting survey of the current study is based on a focus group interview with only two orofacial pain dentists and eight orofacial physiotherapists. Focus group interviews could invite more dominant participants to have a stronger input, which could further skew the data from this session. However, the focus group participants were familiar with each other and comfortable discussing the topics addressed by the moderator, and the ratio between orofacial pain dentists and orofacial physiotherapists is comparable to the national ratio of registered orofacial pain dentists and orofacial physiotherapists in the Netherlands. Furthermore, the expert panel members were invited to add their own input to the first survey round, decreasing the chance of possible bias from the focus group members.

By including orofacial pain dentists, orofacial physiotherapists, and patients with orofacial pain to the expert panel, a first interprofessional consensus for the Netherlands was described. This was based on the specific specialties within the Netherlands, as well as these being the two most visited specialized healthcare providers by patients with orofacial pain in the Netherlands [19]. Inclusion of patients with orofacial pain with a complex patient journey can be considered one of the strengths of this study, to broaden the perspective of answers beyond the viewpoints of healthcare providers. However, one of the limitations of the current study is that the perspective of these three expert groups was used to describe the role of other healthcare providers as well. This means that the findings of the current study should be interpreted with this limitation in mind, as they may not be representative of all described disciplines. During this Delphi study, other professionals such as the maxillofacial surgeon, ENT specialist, psychologist and neurologist were identified by the panel as important disciplines in the management of orofacial pain. Ideally, these healthcare providers that did not participate in this study will be asked for their own perspectives in future research, to reach further interprofessional consensus and increase generalizability of results.

Another possible limitation of the study is that only experts from the Netherlands were included in the study. However, as the organisation of care can be different in each country, doing a Delphi study from one specific country can create a good starting point to translate the findings to international situations. When using the findings of the current study in another country, the findings have to be put in context of that specific country, as the healthcare system and organization of healthcare is different between countries. For example, in the Netherlands, the orofacial pain dentist and orofacial physiotherapist are appointed as the primary healthcare providers for orofacial pain, whereas in the UK this is often the maxillofacial surgeon [37]. Based on the perspective of the experts of the current e-Delphi study, maxillofacial surgeons are only added to the team when there is idiopathic pain, or when the orofacial pain is so complex that additional diagnostics like further imaging or an arthroscopy of the temporomandibular joint are needed. However, the description of their role (and that of other healthcare providers) might have been different if the Delphi study had been done in another country. Yet, the more general outcomes of this study, like the advice to adapt the healthcare organisation from a referral based multidisciplinary collaboration towards a more direct interprofessional collaboration might be generalized towards other countries. This may especially be helpful as the patient experiences regarding received care and interprofessional collaboration appears to be similar in other countries such as the UK and Sweden [12, 22, 53].

Furthermore, the expert panel of the current study was very heterogenous and had input from 4 to 5 people per discipline. Even though Delphi panels of 10–18 are recommended and accepted,¹³ future studies may include that number of experts per expertise rather than in total, to have a stronger foundation for consensus. One of the limitations of this study is that there was loss of data in the second Delphi round, where only six out of nine healthcare providers, and three out of five patients filled out the survey. In the last round, eight healthcare providers and three patients completed the survey. Even though this loss of data is not uncommon, it does make the panel size smaller than would be preferred, also encouraging larger expert panel sizes in future studies.

Lastly, the topic of this Delphi study was ‘Orofacial Pain’ and everything that falls under this umbrella term. This includes both acute and chronic pain, originating from different pain disorders. Even though the expert panel members were asked for their definition of orofacial pain, there was no differentiation between acute and chronic pain. Making this distinguishment might have changed the answers of the panel members for acute pain compared to chronic pain. In future research, a further specification related to the chronicity of the various orofacial pain diagnoses is recommended, as the panel did describe that the complexity and duration of complaints determine the need for interprofessional collaboration.

Conclusion

In the Netherlands, the general medical physician and general dentist should be able to screen for different types of orofacial pain, start treatment for the non-complex cases, and refer patients who have complex orofacial pain complaints. Orofacial pain dentists and orofacial physiotherapists should be involved in complex orofacial pain patients. Dependent on the specific needs of the patient, other allied health professionals, psychology professionals, or medical specialists (ENT specialist, maxillofacial surgeon, neurologist) should take part in the interprofessional team. Interprofessional collaboration in the form of communication and, for complex cases, interprofessional consults, is recommended for patients with complex orofacial pain to help patients with their complaints faster and to support professional development.

Abbreviations

DC/TMD

Diagnostic Criteria for Temporomandibular Disorders

e-Delphi

Electronic Delphi

EC

European Credits

ENT

Ear, Nose, Throat

ICOP

International Classification of Orofacial Pain

OFP

Orofacial Pain

TMD

Temporomandibular Disorder

Authors' contributions

HvdM was involved in the conception, design, acquisition, analysis and interpretation of data, writing of the manuscript, and submission of the manuscript. AvdW was involved in the conception, design, analysis and interpretation of data, and writing and reviewing of the manuscript. FL was involved in the design, interpretation of data, and writing and reviewing the manuscript. AR was involved in the conception, design, interpretation of data, and writing and reviewing of the manuscript. CV was involved in the conception, design, interpretation of data, writing and reviewing of the manuscript. All authors have approved the submitted version.

Funding

This study was funded by the Scientific College Physical Therapy (WCF) of the Royal Dutch Society for Physical Therapy (KNGF).

Data availability

The data that support the findings of this study are available on request from the corresponding author.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the Helsinki guidelines and approved by the Ethics Committee of the Academic Centre for Dentistry Amsterdam (2022-9958). All participants signed an informed consent form before participating in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.