Abstract
Background
Oroantral communication (OAC) and its chronic form, oroantral fistula (OAF), are significant complications primarily associated with the extraction of maxillary posterior teeth. Delayed diagnosis or inadequate primary management often leads to persistent maxillary sinusitis and secondary morbidities. Despite their clinical relevance, there is a lack of evidence regarding the factors influencing dentists’ diagnostic accuracy and therapeutic decision-making. This study provided a nationwide evaluation of dentists’ objective knowledge, clinical approaches, and self-perceived competence regarding the management of OAC and OAF in Turkey.
Methods
This nationwide cross-sectional study included 400 dentists, divided into two equal groups: 200 general dental practitioners (Group 1) and 200 participants in the oral and maxillofacial surgery group (Group 2). A structured 35-item questionnaire collected data on professional experience and OAC/OAF-related knowledge across three subdomains: general, diagnostic, and treatment-oriented. Furthermore, the survey assessed clinical referral thresholds and self-perceived educational and diagnostic competence using a specialized scale. Statistical analysis included comparative tests and multiple linear regression models to identify independent predictors of clinical knowledge levels.
Results
Group 2 demonstrated significantly higher scores across all knowledge subdomains compared to Group 1 (p < 0.05), with mean total scores of 0.81 ± 0.08 and 0.57 ± 0.12, respectively. Significant disparities were observed in etiology, preoperative risk assessment, and radiographic interpretation. Group 1 exhibited a higher tendency toward referral-based management, while Group 2 more frequently performed direct clinical management.
Multiple linear regression revealed that being in Group 2, prior postgraduate training, and previous clinical case experience were independent positive predictors of higher knowledge scores. Conversely, a lack of preference for specific closure materials was a negatively associated with overall knowledge.
Conclusions
Knowledge levels regarding OAC/OAF management were significantly associated with professional group and clinical exposure. While Group 2 showed higher overall proficiency, knowledge gaps were also identified in specific domains. Within the context of dental education and clinical practice in Turkey, these findings support the need for strengthened undergraduate and postgraduate educational approaches to improve preparedness for OAC/OAF management.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12903-026-08864-9.
Keywords: Clinical decision-making, Oroantral communication, Oroantral fistula, Tooth extraction, Maxillary sinusitis, Knowledge level
Introduction
Oroantral communication (OAC) is defined as an abnormal connection between the oral cavity and the maxillary sinus, usually occurring after perforation of the thin bony partition separating these two structures [1]. If spontaneous closure does not occur or appropriate treatment is not provided, the communication may remain patent, undergo epithelialization, and progress to an oro-antral fistula (OAF), frequently accompanied by maxillary sinusitis [2]. The timing of treatment is a major prognostic factor in the management of OAC. When treatment is initiated within 24 to 48 h, the success rate of closure may reach 90% to 95%; however, after 48 h, the likelihood of sinus infection and fistula formation increases substantially [3]. If OAC/OAF is not managed properly, approximately 50% of patients develop sinusitis within 48 h, whereas this rate may rise to 90% after 2 weeks without treatment [2, 3]. If left untreated, the defect may result in sinus contamination, leading to infection, chronic sinusitis, and impaired healing. For this reason, prompt confirmation of the diagnosis and early management are strongly recommended to facilitate successful closure [4].
Tooth extraction is one of the most common procedures performed by both general dental practitioners (GDPs) and oral surgeons [5]. Tooth extraction remains the most frequent cause of oroantral communications [6]. OAC and OAF occurs most commonly after extraction of the maxillary first and second molars, although canines and premolars may also be involved [7]. Other causes of OAC and OAF include maxillary cyst or tumor removal, maxillofacial trauma, surgical procedures such as Le Fort osteotomies and the Caldwell–Luc operation, iatrogenic injury during endodontic or periodontal treatment, implant-related complications, and pathological or inflammatory bone conditions [8–10]. OAF may also develop secondary to sinus infection, the presence of a foreign body within the sinus, unsuccessful treatment or inadequate healing of OAC [4].
Clinical manifestations of OAC may include epistaxis, leakage of fluids between the oral cavity and the nose, pain, postnasal discharge, alterations in voice resonance, difficulty with suction, escape of air from the mouth to the nose during sucking, and the appearance of small bubbles on a mirror during the Valsalva maneuver [3, 4, 11]. OAF is characterized by the presence of a persistent opening associated with serous or purulent discharge [2, 3, 8]. In larger defects, a polypoid protrusion originating from the antral mucosa may be observed [3, 11]. Patients with OAF may also present with leakage of fluids from the oral cavity into the nose, especially during drinking, changes in voice resonance, hoarseness, unilateral nasal discharge, recurrent odontogenic maxillary sinusitis, halitosis, unpleasant taste, headache, anosmia, cacosmia, fever, malaise, and nocturnal cough [2, 4, 8, 11]. Radiographic examination of the OAC and OAF is necessary to confirm the clinical findings and to investigate the presence of a foreign body within the maxillary sinus [4]. For this purpose, periapical radiography, panoramic radiography, occipitomental radiography, computed tomography, and cone-beam computed tomography may all be used in the radiographic assessment of OAC and OAF [4, 8, 10].
Decisions on how to treat an OAC/OAF are based on several clinical variables, including defect size, time of diagnosis, the presence of sinus infection, the quantity and quality of tissue available for repair, and the future restorative plan for the affected site [12]. Closure of an oroantral communication or fistula following extraction of a maxillary tooth may represent a challenging clinical problem for both dentists and oral and maxillofacial surgeons [4]. Small communications, usually 2 mm or less in diameter, can often be managed conservatively because of their relatively high likelihood of spontaneous closure [1]. Larger defects (> 2 mm), as well as persistent communications associated with sinus infection, generally require surgical intervention [1]. Various treatment approaches have been described in the literature, including buccal flaps, palatal flaps, buccal fat pad flaps, guided tissue regeneration techniques, and non-surgical approaches [3, 13, 14]. Clinical decision-making determines the optimal strategy in a particular clinical situation. Consequently, it requires a combination of knowledge, experience, and appropriate information gathering [4].
From an educational perspective, evaluating the knowledge level of dental professionals regarding OAC and OAF is highly important. Recognition of deficiencies in diagnostic and therapeutic principles may contribute to improvements in undergraduate curricula as well as continuing professional education programs. This may ultimately enhance patient safety by reducing the risk of chronic complications associated with delayed or inadequate management. Although many previous studies have primarily concentrated on surgical techniques and treatment outcomes in OAC and OAF, data regarding the knowledge level and clinical decision-making patterns of dental professionals in the management of these conditions remain limited. Evaluating dentists’ knowledge and clinical approach patterns in relation to the diagnosis and management of OAC and OAF may provide valuable information on current educational needs and gaps in clinical practice. Comparing (GDPs) and dentists in the field of oral and maxillofacial surgery (OMFS Group) may further clarify whether these needs differ according to professional background and clinical experience.
The aim of the present study was to evaluate dentists’ knowledge levels, clinical approaches, decision-making tendencies, and self-perceived educational and diagnostic competence regarding the diagnosis and management of OACs and OAFs that may develop following tooth extraction, using a structured questionnaire. The study additionally aimed to compare these findings between GDPs and OMFS Group, and to investigate whether variables such as professional experience, participation in postgraduate training, and previous case experience influenced knowledge levels. In this respect, the study is expected to contribute to increasing clinical awareness and to inform both undergraduate and postgraduate educational planning.
Materials and methods
Ethical approval
The study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Gazi University Ethics Committee (Approval number and date: 2024 − 1008, 11.06.2024). Written informed consent was obtained from all participants prior to enrollment.
Study design and participants
This nationwide questionnaire-based cross-sectional survey was designed to evaluate the knowledge levels and clinical approaches of dentists in Turkey regarding the diagnosis and management of OACs and OAFs following tooth extraction.
Sample size estimation was performed using G*Power software (version 3.1.9.2) based on the chi-square test for contingency tables. Assuming a medium effect size (w = 0.30), a significance level of 0.05, a statistical power of 0.95, and 11 degrees of freedom, the minimum required sample size was calculated as 280 participants.
Participants were recruited face-to-face in faculty settings, public hospitals, private clinics, congresses, and scientific meetings. In total, 438 dentists were approached. Of these, 22 declined participation, 11 returned incomplete questionnaires and were excluded, and 5 were excluded because they reported no prior familiarity with the concepts of OAC/OAF. Consequently, 400 dentists were included in the final analysis, yielding a final analyzable response rate of 91.3%.
The final study sample was equally divided into two groups (n = 200 each): Group 1 (GDPs) and Group 2 (OMFS group). Group 2 included residents, research assistants, specialists, associate professors, and professors. This grouping enabled a balanced comparison between the two study groups. All included participants provided voluntary consent to participate and completed the questionnaire in full.
Questionnaire development and structure
After written informed consent had been obtained, the questionnaire was administered face-to-face to all participants. The survey was conducted between 1 August 2024 and 14 January 2026. The questionnaire was developed specifically for this study following a review of the relevant literature on the diagnosis and management of OAC and OAF.
The questionnaire comprised a total of 35 items and consisted predominantly of closed-ended items; however, some items assessing clinical approach and treatment options (Q13, Q14) were semi-closed in structure. The questionnaire items were classified into four main domains: (1) demographic and professional characteristics, (2) knowledge level related to OACs/OAFs, (3) self-perceived educational and diagnostic competence and (4) clinical approach, referral, and treatment-related preferences.
Demographic and professional items included gender, professional experience, sector of practice, specialty training status, and academic title where applicable. Additional items explored prior awareness of OAC/OAF-related concepts, participation in seminars or training activities related to OAC/OAF diagnosis and treatment, previous clinical experience with post-extraction OAC/OAF cases, referral preferences, and self-reported management tendencies.
Knowledge based items were classified into three subdomains: general knowledge (6 items), diagnostic knowledge (4 items), and treatment knowledge (11 items). The general knowledge subdomain covered basic concepts, etiological factors, and general principles related to OACs and OAFs. The diagnostic knowledge subdomain included items assessing knowledge of clinical and radiographic evaluation, diagnostic methods, and recognition of relevant signs and symptoms. The treatment knowledge subdomain included items related to treatment planning, timing of intervention, surgical and non-surgical treatment options, and other considerations relevant to the clinical management of OACs and OAFs.
In addition, participants’ self-perceived educational and diagnostic competence was evaluated using 3 items with a 5-point reverse Likert-type response format. These items assessed participants’ perceptions regarding the adequacy of their undergraduate education on this topic and their confidence in diagnosing OAC/OAF both at the time of occurrence and in patients referred from another center. In this reverse Likert-type format, response options were scored from 1 to 5, where 1 indicated the most positive self-assessment and 5 indicated the least positive self-assessment. Accordingly, lower scores reflected greater perceived educational and diagnostic competence, whereas higher scores indicated lower perceived competence.
One item addressing material preference in the management of OAC/OAF was included as a preference-based question. Since this item reflected participants’ treatment preference rather than directly measuring factual knowledge, it was not included in the calculation of the total knowledge score.
The internal consistency of the questionnaire domains was good, with Cronbach’s α = 0.927 for the total knowledge scale, α = 0.834 for the general knowledge subdomain, α = 0.829 for the diagnostic knowledge subdomain, α = 0.866 for the treatment knowledge subdomain, and α = 0.862 for the self-perceived educational and diagnostic competence scale. The full questionnaire is provided in Supplementary Material.
Outcome measures and scoring
The primary outcome measure of this study was the total knowledge score. The total knowledge score was calculated using items that directly assessed factual knowledge related to the diagnosis and management of OACs and OAFs. For this purpose, a combined dichotomous and proportion-based partial-credit scoring system was used.
Knowledge-based items were scored using three different formats. For binary yes/no items, affirmative responses were scored as 1 and negative responses as 0. For knowledge items with “Yes/No/I do not know” response options, correct responses were scored as 1, whereas incorrect or uncertain responses were scored as 0. For items containing multiple correct components, participants received a score ranging from 0 to 1 according to the proportion of correctly identified components. Accordingly, participants who identified all correct components received a score of 1, whereas those who identified only some of the correct components received partial credit proportional to the number of correct components selected. Unselected correct components did not lead to any further reduction beyond the proportion-based score. Matrix-style items with Yes/No response options for each listed component were scored using the same proportion-based partial-credit approach. Responses marked as “No” were not penalized separately beyond their effect on the proportion-based score. Unselected correct components did not lead to any further reduction beyond the proportion-based score.
The total knowledge level score was derived by calculating the mean of the scores obtained from all items that directly assessed knowledge. Likewise, subdomain scores for general knowledge, diagnostic knowledge, and treatment knowledge were calculated separately using the mean scores of the relevant items within each domain. Higher scores indicated a higher level of knowledge regarding OACs and OAFs.
The three 5-point reverse Likert-type items evaluating self-perceived educational and diagnostic competence were not included in the total knowledge score and were treated as a separate scale. The score for this scale was calculated as the mean of the item scores obtained from Q8, Q10, and Q11. The interpretation of this scale was made in accordance with the reverse Likert-type structure of the items.
Item Q28, which addressed material preference in the management of OAC/OAF, was treated as a preference-based item and was therefore excluded from the calculation of the total knowledge score because it did not directly measure factual knowledge. Items addressing clinical approach and referral preferences (Q12–Q14), as well as demographic and professional variables, were analyzed descriptively and were not included in the calculation of the total knowledge score.
A detailed classification of questionnaire items, subdomains, scoring procedures, and inclusion in the total knowledge score is provided in Table 1.
Table 1.
Classification of Questionnaire Items
| 1 |
Demographic and Professional Characteristics (7 Items) |
Q1a, Q2a, Q3a, Q4a, Q5a, Q9b, Q18b |
| 2 |
Knowledge-Based Items (21 Items) |
General Knowledge Items Q6c, Q7c, Q15d, Q16d, Q17d, Q23e |
|
Diagnostic Knowledge Items Q19d, Q20d, Q21d, Q22d | ||
|
Treatment Knowledge Items Q24e, Q25e, Q26f, Q27f, Q29f, Q30f, Q31e, Q32d, Q33e, Q34e, Q35e | ||
| 3 |
Self-perceived Educational and Diagnostic Competence (3 Items) |
Q8g, Q10g, Q11g |
| 4 |
Clinical approach, management, referral, and treatment-related preferences (4 Items) |
Q12h, Q13h, Q14h, Q28i |
ᵃ Demographic/professional items
ᵇ Background/experience items
ᶜ Binary yes/no items, “Yes” = 1 and “No” = 0 Included in the total knowledge score
ᵈ Item containing multiple correct components; scored using a proportion-based partial-credit approach (0–1). Included in the total knowledge score
ᵉ Knowledge item with “Yes/No/I do not know” response options; scored dichotomously (correct = 1, incorrect or “I do not know” = 0). Included in the total knowledge score
ᶠ Matrix-style knowledge item in which each listed component was evaluated separately using Yes/No responses; scored using a proportion-based partial-credit approach (0–1) and included in the total knowledge score
ᵍ 5-point reverse Likert-type item; evaluated as part of the separate perceived educational and diagnostic competence scale and not included in the total knowledge score
ʰ Clinical approach/management/referral item; analyzed descriptively and not included in the total knowledge score
ⁱ Preference-based item related to treatment/material preference
Statistical analysis
All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) for Windows, version 27 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were presented as number, percentage, mean ± standard deviation (SD), median, and interquartile range (IQR), as appropriate. Associations between categorical variables were evaluated using the chi-square test. Comparisons between two independent groups were performed using the Mann–Whitney U test. Correlations between continuous or ordinal variables were assessed using Spearman’s correlation analysis. To determine the independent predictors of the total knowledge score, multiple linear regression analysis was performed, and variable selection was carried out using the stepwise method. Statistical significance was set at α = 0.05. Because several item-level knowledge scores were bounded between 0 and 1 and showed discrete distributions with floor or ceiling effects in some items, item-level between-group comparisons were interpreted as exploratory, distribution-based non-parametric comparisons.
Results
A total of 400 dentists were included in the study, comprising 200 participants in Group 1 and 200 participants in Group 2. Participants’ 52.5% were female (n = 210) and 47.5% were male (n = 190). With regard to professional experience, 57.0% of the participants had 5 years or less of experience (n = 228), 23.25% had 5–10 years of experience (n = 93), and 19.75% had more than 10 years of professional experience (n = 79). Most participants worked in the public sector (75.75%, n = 303), whereas 24.25% worked in the private sector (n = 97). The proportion of participants who reported attending a seminar or training program related to OAC/OAF was 18.75% (n = 75), while 71.5% (n = 286) reported previous experience with post-extraction OAC/OAF cases (Table 2).
Table 2.
Demographic and professional characteristics of the participants
| Variable | Group 1 (n = 200) | Group 2 (n = 200) | Total (n = 400) |
|---|---|---|---|
| Gender, n (%) | |||
| Female | 132 (66.0) | 78 (39.0) | 210 (52.5) |
| Male | 68 (34.0) | 122 (61.0) | 190 (47.5) |
| Professional experience, n (%) | |||
| ≤ 5 years | 128 (64.0) | 100 (50.0) | 228 (57.0) |
| 5–10 years | 41 (20.5) | 52 (26.0) | 93 (23.25) |
| > 10 years | 31 (15.5) | 48 (24.0) | 79 (19.75) |
| Sector of practice, n (%) | |||
| Public | 117 (58.5) | 186 (93.0) | 303 (75.75) |
| Private | 83 (41.5) | 14 (7.0) | 97 (24.25) |
| Participation in OAC/OAF-related seminar or training, n (%) | |||
| Yes | 30 (15.0) | 45 (22.5) | 75 (18.75) |
| No | 170 (85.0) | 155 (77.5) | 325 (81.25) |
| Previous experience with post-extraction OAC/OAF cases, n (%) | |||
| Yes | 98 (49.0) | 188 (94.0) | 286 (71.5) |
| No | 102 (51.0) | 12 (6.0) | 114 (28.5) |
| Academic title within the OMFS group, n (%) | NA | ||
| Resident | NA | 126 (63.0) | 126 (31.5) |
| Research assistant | NA | 33 (16.5) | 33 (8.25) |
| Specialist | NA | 19 (9.5) | 19 (4.75) |
| Associate professor | NA | 12 (6.0) | 12 (3.0) |
| Professor | NA | 10 (5.0) | 10 (2.5) |
OAC oroantral communication, OAF oroantral fistula, NA not applicable
Regarding the descriptive statistics of the knowledge-based scales and subdomains, the mean general knowledge subscore was 0.79 ± 0.15 (median = 0.80, IQR = 0.21), the mean diagnostic knowledge subscore was 0.57 ± 0.18 (median = 0.58, IQR = 0.29), and the mean treatment knowledge subscore was 0.68 ± 0.20 (median = 0.73, IQR = 0.27). The mean total knowledge score was 0.69 ± 0.16 (median = 0.72, IQR = 0.24). The mean score of the 3-item self-perceived educational and diagnostic competence scale was 2.37 ± 0.82 (median = 2.33, IQR = 1.17) (Table 3).
Table 3.
Descriptive statistics of the main scales and subdomains according to study groups
| Scale/Subdomain | Group 1 | Group 2 | Total | |||||
|---|---|---|---|---|---|---|---|---|
| Median (IQR) | Mean ± SD | Median (IQR) | Mean ± SD | Median (IQR) | Mean ± SD | Comparison test | p value | |
| General knowledge level subscore | 0.71 (0.17) | 0.69 ± 0.12 | 0.90 (0.10) | 0.89 ± 0.09 | 0.80 (0.21) | 0.79 ± 0.15 | Mann–Whitney U test | < 0.001* |
| Diagnostic knowledge level subscore | 0.44 (0.19) | 0.46 ± 0.14 | 0.71 (0.18) | 0.68 ± 0.15 | 0.58 (0.29) | 0.57 ± 0.18 | Mann–Whitney U test | < 0.001* |
| Treatment knowledge level subscore | 0.56 (0.25) | 0.54 ± 0.18 | 0.83 (0.11) | 0.82 ± 0.09 | 0.73 (0.27) | 0.68 ± 0.20 | Mann–Whitney U test | < 0.001* |
| Total knowledge level score | 0.58 (0.16) | 0.57 ± 0.12 | 0.82 (0.10) | 0.81 ± 0.08 | 0.72 (0.24) | 0.69 ± 0.16 | Mann–Whitney U test | < 0.001* |
| Self-perceived educational and diagnostic competence scale score | 3.00 (1.00) | 2.90 ± 0.63 | 2.00 (1.00) | 1.84 ± 0.62 | 2.33 (1.17) | 2.37 ± 0.82 | Mann–Whitney U test | < 0.001* |
IQR interquartile range, SD standard deviation
* indicates statistical significance (p < 0.05)
Group 1 and Group 2 differed significantly across all knowledge subdomains’ subscores and in the total knowledge score (all comparisons, p < 0.001). The general knowledge level subscore was 0.69 ± 0.12 (median = 0.71, IQR = 0.17) in Group 1 and 0.89 ± 0.09 (median = 0.90, IQR = 0.10) in Group 2. Diagnostic knowledge level subscores were 0.46 ± 0.14 (median = 0.44, IQR = 0.19) in Group 1 and 0.68 ± 0.15 (median = 0.71, IQR = 0.18) in Group 2, whereas treatment knowledge level subscores were 0.54 ± 0.18 (median = 0.56, IQR = 0.25) and 0.82 ± 0.09 (median = 0.83, IQR = 0.11), respectively. Likewise, the total knowledge level score was 0.57 ± 0.12 (median = 0.58, IQR = 0.16) in Group 1 and 0.81 ± 0.08 (median = 0.82, IQR = 0.10) in Group 2 (Table 3). For the self-perceived educational and diagnostic competence scale, the mean score was 2.90 ± 0.63 in Group 1 and 1.84 ± 0.62 in Group 2; in accordance with the reverse Likert-type structure of the scale, lower scores indicated greater self-perceived educational and diagnostic competence.
At the item level, between-group comparisons indicated that differences between Group 1 and Group 2 were particularly evident in items related to etiology, extraction-related risk assessment, radiographic evaluation, and treatment planning (Table 4). For Q16, which assessed knowledge of OAF etiology, the mean score was 0.49 ± 0.21 in Group 1 and 0.74 ± 0.20 in Group 2. Similarly, for Q17, which evaluated knowledge of extraction-related risk, the mean score was 0.50 ± 0.20 in Group 1 and 0.85 ± 0.18 in Group 2. A marked difference in favor of Group 2 was also observed for the radiographic evaluation item (Q20) (0.41 ± 0.23 vs. 0.67 ± 0.20). This pattern was more pronounced in treatment-related items; in particular, knowledge of surgical flap selection (Q26) and surgical methods (Q27) was 0.34 ± 0.17 and 0.42 ± 0.25, respectively, in Group 1, compared with 0.75 ± 0.19 and 0.80 ± 0.24 in Group 2. Likewise, for Q25, which assessed the relationship between defect size and the need for treatment, the mean score was higher in Group 2 than in Group 1 (0.88 ± 0.16 vs. 0.69 ± 0.34). However, in Group 2, some items did not reach the maximum score; the mean score was 0.64 ± 0.22 for Q32, which assessed pharmacological approach, and 0.38 ± 0.20 for Q29, which assessed material-related knowledge. In contrast, all participants in both groups answered Q6 and Q7 correctly.
Table 4.
Comparison of item-level knowledge scores between the study groups
| Item | Group 1 | Group 2 | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Content | Median (IQR) | Mean ± SD | Median (IQR) | Mean ± SD | Z | p value | |||
| Q6 | OAC concept | 1 (0) | 1.00 ± 0.00 | 1 (0) | 1.00 ± 0.00 | 0.000 | 1.000 | ||
| Q7 | OAF concept | 1 (0) | 1.00 ± 0.00 | 1 (0) | 1.00 ± 0.00 | 0.000 | 1.000 | ||
| Q15 | OAI etiology | 0.5 (0.29) | 0.55 ± 0.22 | 0.86 (0.29) | 0.81 ± 0.19 | -10.825 | < 0.001* | ||
| Q16 | OAF etiology | 0.43 (0.14) | 0.49 ± 0.21 | 0.71 (0.29) | 0.74 ± 0.20 | -10.433 | < 0.001* | ||
| Q17 | Extraction-related risk | 0.4 (0.2) | 0.50 ± 0.20 | 1 (0.2) | 0.85 ± 0.18 | -13.458 | < 0.001* | ||
| Q19 | Detection methods | 0.5 (0.17) | 0.46 ± 0.18 | 0.5 (0.17) | 0.59 ± 0.19 | -6.443 | < 0.001* | ||
| Q20 | Radiographic evaluation | 0.4 (0.4) | 0.41 ± 0.23 | 0.6 (0.2) | 0.67 ± 0.20 | -10.434 | < 0.001* | ||
| Q21 | Acute symptoms | 0.6 (0.4) | 0.63 ± 0.23 | 1 (0.2) | 0.88 ± 0.18 | -10.672 | < 0.001* | ||
| Q22 | Chronic symptoms | 0.33 (0.17) | 0.34 ± 0.16 | 0.58 (0.33) | 0.61 ± 0.22 | -11.763 | < 0.001* | ||
| Q23 | Epithelialization | 1 (1) | 0.59 ± 0.49 | 1 (0) | 0.94 ± 0.25 | -8.097 | < 0.001* | ||
| Q24 | Effect of defect size | 1 (0) | 0.79 ± 0.41 | 1 (0) | 1.00 ± 0.00 | -6.932 | < 0.001* | ||
| Q25 | Size–treatment | 0.67 (0.33) | 0.69 ± 0.34 | 1 (0.33) | 0.88 ± 0.16 | -5.424 | < 0.001* | ||
| Q26 | Surgical flap | 0.33 (0.17) | 0.34 ± 0.17 | 0.75 (0.33) | 0.75 ± 0.19 | -15.130 | < 0.001* | ||
| Q27 | Surgical method | 0.25 (0.25) | 0.42 ± 0.25 | 0.75 (0.25) | 0.80 ± 0.24 | -12.283 | < 0.001* | ||
| Q29 | Material-related knowledge | 0.25 (0.25) | 0.27 ± 0.20 | 0.25 (0.25) | 0.38 ± 0.20 | -5.098 | < 0.001* | ||
| Q30 | Non-surgical treatment | 0.5 (0.5) | 0.57 ± 0.38 | 1 (0.5) | 0.81 ± 0.31 | -6.486 | < 0.001* | ||
| Q31 | Requirement for pharmacological treatment | 1 (1) | 0.71 ± 0.45 | 1 (0) | 0.96 ± 0.20 | -6.727 | < 0.001* | ||
| Q32 | Pharmacological agents knowledge | 0.5 (0.25) | 0.50 ± 0.20 | 0.5 (0.25) | 0.64 ± 0.22 | -5.880 | < 0.001* | ||
| Q33 | Necrosis potential | 0 (1) | 0.43 ± 0.50 | 1 (0) | 0.84 ± 0.37 | -8.597 | < 0.001* | ||
| Q34 | Vestibular depth | 1 (0) | 0.82 ± 0.39 | 1 (0) | 0.98 ± 0.16 | -5.213 | < 0.001* | ||
| Q35 | Vascularity/Blood supply | 1 (1) | 0.54 ± 0.50 | 1 (0) | 0.93 ± 0.26 | -8.826 | < 0.001* | ||
IQR interquartile range, SD standard deviation, Z Mann-Whitney U test statistic
* indicates statistical significance (p < 0.05)
Significant differences between Group 1 and Group 2 were also observed with respect to clinical approach, referral, and management preferences (Table 5). The proportion of participants who stated that they would refer to the patient when OAC/OAF was detected was 100.0% (n = 200) in Group 1, compared with 9.0% (n = 18) in Group 2 (p < 0.001). Referral to oral and maxillofacial surgery was preferred by 89.0% of participants in Group 1 (n = 178) and 2.0% of those in Group 2 (n = 4) (p < 0.001). No significant difference was found between the groups in referral to an ear, nose and throat (ENT) specialist [11.0% (n = 22) in Group 1 and 7.0% (n = 14) in Group 2; p = 0.162]. In contrast, the proportion of participants who reported that they would manage the case themselves was 71.0% (n = 142) in Group 2, whereas no participant in Group 1 selected this option (p < 0.001). In addition, 20.0% of participants in Group 2 (n = 40) reported that they would consult a senior clinician, whereas this option was not selected by any participant in Group 1 (p < 0.001). These findings show that participants in Group 1 more frequently preferred referral-based management, whereas those in Group 2 more often reported direct clinical management of the case.
Table 5.
Clinical approach, referral, and management preferences according to study groups
| Variable | Group 1 n (%) | Group 2 n (%) | Total (n = 400) n (%) | p value |
|---|---|---|---|---|
| Would refer the patient when OAC/OAF is detected? (Q12) | < 0.001* | |||
| No | 0 (0.0) | 182 (91.0) | 182 (45.5) | |
| Yes | 200 (100.0) | 18 (9.0) | 218 (54.5) | |
| If yes, would refer to oral and maxillofacial surgery (Q13) | < 0.001* | |||
| No | 22 (11.0) | 196 (98.0) | 218 (54.5) | |
| Yes | 178 (89.0) | 4 (2.0) | 182 (45.5) | |
| If yes, would refer to (ENT) (Q13) | 0.162 | |||
| No | 178 (89.0) | 186 (93.0) | 364 (91.0) | |
| Yes | 22 (11.0) | 14 (7.0) | 36 (9.0) | |
| If no, would manage the case personally (Q14) | < 0.001* | |||
| No | 200 (100.0) | 58 (29.0) | 258 (64.5) | |
| Yes | 0 (0.0) | 142 (71.0) | 142 (35.5) | |
| If no, would consult a senior clinician (Q14) | < 0.001* | |||
| No | 200 (100.0) | 160 (80.0) | 360 (90.0) | |
| Yes | 0 (0.0) | 40 (20.0) | 40 (10.0) |
p values were obtained using the chi-square test
* indicates statistical significance (p < 0.05)
Findings related to the materials first preferred for surgical management are presented in Table 6. In Q28, 26 participants (6.5%) did not indicate any material preference or left the relevant section unanswered; therefore, the responses of 374 participants were evaluated. Participants were asked to indicate their first preferred options across four material categories: autogenous, xenogeneic, allogeneic, and synthetic materials. Among autogenous materials, platelet-rich fibrin (PRF) was the most frequently selected first-preference option, chosen by 70.86% of respondents (n = 265), followed by retromolar bone and mandibular symphysis grafts (12.03% each, n = 45) and iliac crest grafts (5.08%, n = 19). Among xenogeneic materials, collagen membrane was the most frequently selected first-preference material at 66.58% (n = 249), followed by bone grafts (25.67%, n = 96) and gelatin film (7.75%, n = 29). Within allogeneic materials, fibrin glue showed the highest first-preference rate at 81.02% (n = 303), followed by dura (18.98%, n = 71). Among synthetic materials, titanium mesh ranked first at 50.0% (n = 187), followed by hydroxyapatite blocks (27.27%, n = 102), polymethyl methacrylate (19.79%, n = 74), and metal foils/plates (2.94%, n = 11).
Table 6.
Preferred material options for the surgical management of OAC/OAF (Q28)
| Material category | Preferred option | n (%) |
|---|---|---|
| Autogenous materials | Platelet-rich fibrin (PRF) | 265 (70.86) |
| Retromolar region | 45 (12.03) | |
| Mandibular symphysis | 45 (12.03) | |
| Iliac crest | 19 (5.08) | |
| Ear cartilage | 0 (0.00) | |
| Septal cartilage | 0 (0.00) | |
| Zygomatic bone | 0 (0.00) | |
| Xenogeneic materials | Collagen membrane | 249 (66.58) |
| Bone graft | 96 (25.67) | |
| Gelatin film | 29 (7.75) | |
| Allogeneic materials | Fibrin glue | 303 (81.02) |
| Dura | 71 (18.98) | |
| Synthetic materials | Titanium mesh | 187 (50.00) |
| Hydroxyapatite blocks | 102 (27.27) | |
| Polymethylmethacrylate | 74 (19.79) | |
| Metal foils and plates | 11 (2.94) | |
| No material preference indicated / item left unanswered | — | 26 (6.50) |
The relationship between the self-perceived educational and diagnostic competence scale and the total knowledge score was assessed using Spearman correlation analysis (Table 7). A strong, negative, and statistically significant correlation was found between the two variables (r=-0.685, p < 0.001). Considering the reverse Likert-type structure of the scale, this finding indicates that greater self-perceived competence was associated with higher objectively measured knowledge.
Table 7.
Self-perceived educational and diagnostic competence by group and their correlation with total knowledge level score
| Variable | Group 1 | Group 2 | Total | |||||
|---|---|---|---|---|---|---|---|---|
| Median (IQR) | Mean ± SD | Median (IQR) | Mean ± SD | Median (IQR) | Mean ± SD | Correlation with total knowledge score (r) | p value | |
| Self-perceived educational and diagnostic competence score | 3.00 (1.00) | 2.90 ± 0.63 | 2.00 (1.00) | 1.84 ± 0.62 | 2.33 (1.17) | 2.37 ± 0.82 | -0.685 | < 0.001* |
IQR interquartile range, SD standard deviation
Correlation was assessed using Spearman’s correlation analysis. The self-perceived educational and diagnostic competence scale was based on reverse Likert-type items; therefore, lower scores indicated greater self-perceived competence. Group-specific descriptive values for both variables are presented to facilitate comparison between self-perceived competence and objectively measured knowledge. The overall correlation between the self-perceived educational and diagnostic competence scale and total knowledge score was r = -0.685, p < 0.001
* indicates statistical significance (p < 0.05)
Other variables associated with the total knowledge score are presented in Table 8. A weak but statistically significant positive correlation was found between years of professional experience and total knowledge score (Spearman r = 0.144, p = 0.004). Participants who had previously attended a seminar or training program related to OAC/OAF had significantly higher total knowledge scores than those who had not [median = 0.81 (IQR = 0.14), compared with 0.67 (IQR = 0.26); Mann–Whitney U test, p < 0.001]. Similarly, participants with previous experience of post-extraction OAC/OAF cases had significantly higher total knowledge scores than those without such experience [median = 0.77 (IQR = 0.21), compared with 0.55 (IQR = 0.17); Mann–Whitney U test, p < 0.001]. Participants who did not indicate a material preference or left the relevant item unanswered also had significantly lower total knowledge scores [median = 0.40 (IQR = 0.14), compared with 0.73 (IQR = 0.23); Mann–Whitney U test, p < 0.001].
Table 8.
Variables associated with total knowledge score
| Variable | Analysis type | Group / association result | Median (IQR) | Mean ± SD | Reported statistic | p value |
|---|---|---|---|---|---|---|
| Years of professional experience | Spearman correlation | Positive correlation with total knowledge score | — | — | r = 0.144 | 0.004* |
| Participation in OAC/OAF-related seminar or training | Mann–Whitney U test | No prior training | 0.67 (0.26) | 0.67 ± 0.16 | Z = -6.200 | < 0.001* |
| Prior training | 0.81 (0.14) | 0.79 ± 0.11 | ||||
| Previous experience with post-extraction OAC/OAF cases | Mann–Whitney U test | No previous case experience | 0.55 (0.17) | 0.56 ± 0.13 | Z = -10.149 | < 0.001* |
| Previous case experience | 0.77 (0.21) | 0.74 ± 0.14 | ||||
| No material preference indicated / item left unanswered (Q28) | Mann–Whitney U test | Material preference indicated | 0.73 (0.23) | 0.71 ± 0.14 | Z = -7.719 | < 0.001* |
| No material preference indicated / item left unanswered | 0.40 (0.14) | 0.40 ± 0.10 |
OAC oroantral communication, OAF oroantral fistula, IQR interquartile range, SD standard deviation, r Spearman correlation coefficient, Z, standardized test statistic for the Mann–Whitney U test
Years of professional experience was analyzed using Spearman’s correlation analysis. Group comparisons were performed using the Mann–Whitney U test
* indicates statistical significance (p < 0.05)
Multiple linear regression analysis was performed to identify factors independently associated with the total knowledge score. In the initial stage, all candidate variables were entered into the model, including the study group variable (Group 1 vs. Group 2), years of professional experience, gender, sector of practice, attendance at OAC/OAF-related seminars or training, previous OAC/OAF case experience, and non-response regarding material preference. A stepwise procedure was then applied, and the final model retained only variables with statistically significant independent associations (Table 9). The final model was statistically significant (F = 237.171, p < 0.001) and explained 70.6% of the variance in the total knowledge score (R²=0.706; adjusted R²=0.703). In the final model, the study group variable (Group 2 vs. Group 1) was positively associated with the total knowledge score (β = 0.603, p < 0.001). Attendance at an OAC/OAF-related seminar or training program (β = 0.200, p < 0.001) and previous OAC/OAF case experience (β = 0.117, p < 0.001) were also positively associated with higher total knowledge scores. In contrast, non-response regarding material preference was negatively associated with the total knowledge score (β=-0.274, p < 0.001). Although years of professional experience showed a weak positive correlation with total knowledge score in the bivariate analysis, it was not retained in the final regression model after adjustment for the other variables included in the model. Gender and sector of practice were likewise not retained in the final model.
Table 9.
Multiple linear regression analysis of factors associated with total knowledge score (N = 400)
| Variables | Standardized coefficient (β) |
t | P-value | 95% CI for B Lower /Upper |
|---|---|---|---|---|
| Constant | — | 61.728 | < 0.001* | 0.544 / 0.578 |
| Study group (Group 2 vs. Group 1) (Q4) | 0.603 | 19.665 | < 0.001* | 0.173 / 0.213 |
| No material preference indicated / item left unanswered (Q28) | -0.274 | -9.690 | < 0.001* | -0.214 /-0.142 |
| Participation in OAC/OAF-related seminar or training (Q9) | 0.200 | 7.188 | < 0.001* | 0.059 / 0.105 |
| Previous experience with post-extraction OAC/OAF cases (Q18) | 0.117 | 3.649 | < 0.001* | 0.019 / 0.064 |
Model statistics: R² = 0.706, adjusted R² = 0.703, F = 237.171; p < 0.001, Durbin–Watson = 1.738. CI Confidence Interval
* indicates statistical significance (p < 0.05)
Discussion
Tooth extraction is a frequently reported etiological factor for OACs and OAFs, accounting for the majority of cases [8, 15]. The incidence of OAC and OAF is associated with individual anatomical variations and the degree of maxillary sinus pneumatization. In cases with advanced pneumatization of the maxillary sinus, the risk of developing an oroantral communication/fistula increases during tooth extractions performed in the posterior maxilla [16].
In this study, the knowledge levels, clinical approach tendencies, and self-perceived educational/diagnostic competencies of dentists in Turkey regarding the diagnosis and management of OAC and OAF were evaluated. Given that GDPs are the group that frequently performs tooth extractions and encounters complications [17, 18], their inclusion in this study is of significant importance. The number of participants was balanced by including an equal number of dentists from the OMFS group.
Because the study was conducted exclusively in Turkey, the findings should be interpreted within the context of the Turkish dental education and healthcare system and should not be directly extrapolated to other countries. In Turkey, OAC/OAF-related concepts are generally addressed within undergraduate oral surgery training; however, the depth of instruction and the degree of clinical exposure may vary across institutions.
The findings indicate that the OMFS group had significantly higher scores in terms of general knowledge level subscore, diagnostic knowledge level subscore, treatment knowledge level subscore, and total knowledge level scores compared to GDPs; however, they also demonstrate that the knowledge gap is not limited solely to GDPs and persists in some sub-fields within the surgery group. In this respect, the study not only presents a comparison between two professional groups but also reveals which areas of knowledge in OAC/OAF management have more prominent educational requirements.
Early diagnosis and correct management of OACs are crucial. There is a risk of progression to OAF when appropriate criteria are not met [1, 3, 19]. Furthermore, if OACs are not recognized in the early stages, odontogenic maxillary sinusitis can develop in the sinus contaminated by oral flora [20, 21]. A noteworthy finding of this study is that the inter-group disparity becomes particularly pronounced in topics directly reflecting clinical practice. Item-level analysis revealed lower scores in the GDPs in areas such as etiology, extraction-related risk assessment, radiographic examination, and treatment planning. This situation suggests that in OAC/OAF management, educational differentiation is more pronounced in the stages of clinical interpretation of the complication and selection of the appropriate intervention rather than basic conceptual awareness. This finding is clinically significant. In other words, the issue regarding OAC/OAF is not merely knowing the concept, but the competence to safely determine the appropriate diagnostic approach, first-line management, and referral threshold in a suspicious post-extraction case.
The clinical management of OACs and OAFs remains a major challenge in dentistry due to the diversity in findings, etiology, chronicity, and anatomical considerations [8].
The lack of knowledge among GDPs in all treatment-oriented questions is quite remarkable. Moreover, the fact that the surgery group did not reach full scores in these questions should not be interpreted as the presence of specialist training providing a homogeneous level of knowledge in all sub-fields. Specifically, the lack of full proficiency in sub-headings related to pharmacological approach and material knowledge suggests that OAC/OAF management does not consist solely of surgical closure principles; components such as medical support, material selection, and case-based decision-making may also constitute a separate area of training. Therefore, while our findings emphasize the deficiencies in undergraduate education, they also indicate that postgraduate and specialist-level training could be restructured in terms of specific subject headings.
In our study, the significant relationship between specialist training, postgraduate education, and clinical case exposure with the total knowledge score supports the multidimensional nature of knowledge levels. In the regression analysis, being in the OMFS group, having participated in seminars or training related to OAC/OAF, and having encountered such cases before remained in the model as independent predictors. These findings suggest that theoretical education, clinical experience, and repeated case exposure are effective together. A recently published survey study reported that the field of expertise is the variable most strongly associated with the management approach, and that experience and self-confidence also influence treatment choice [22]. In this regard, the present study aligns closely with our findings. Similarly, other recent data in the literature point to the critical role of case exposure on professional competence. For example, Miller et al. (2026) examined the confidence of oral surgeons in their postoperative follow-up practices after OAC closure and found that this confidence is directly shaped by clinical experience [23]. Although our current study does not directly cover postoperative follow-up processes, the ‘experience-confidence’ relationship emphasized by Miller et al. [23] is in conceptual harmony with the high knowledge scores exhibited by our participants with case experience. This similarity demonstrates the critical importance of postgraduate education and scientific meetings (congresses, case presentations, etc.) that merge theoretical knowledge with clinical experience in strengthening the decision-making skills of clinicians at every stage of OAC/OAF management.
Management of OAFs accompanied by odontogenic maxillary sinusitis often requires a multidisciplinary approach involving ENT specialists and dentists [20]. Indeed, the results of the clinical approach and referral preferences obtained in our study support this framework and the distribution among professional roles. The fact that GDPs are more inclined to refer the patient when OAC/OAF is detected (frequently to oral surgery, less frequently to ENT), whereas the OMFS group tends to manage the case directly and refers to ENT less frequently, can be seen as an expected professional role distribution. However, this difference is too pronounced to be explained by professional definition alone; it is also related to clinical self-confidence, experience, and scope of practice. The 2026 OAC survey study also reported that more conservative approaches for small defects and referral or more advanced flap-based approaches for large defects come to the fore [22]. In our study, the distinct divergence of referral and management tendencies according to the field of expertise suggests that clinical behavior may be linked not only to knowledge level but also to practical experience and role perception. In addition, institutional context and the perceived boundaries of routine practice may also contribute to referral decisions, even though these factors were not directly measured in the present study.
Various grafts/materials can be used in the treatment of OAC and OAF. These can be classified as autologous, allogeneic, xenogenic, and synthetic according to their structure [4, 11]. Findings regarding material preferences constitute another original aspect of the study. In our sample, options such as PRF, collagen membrane/sponge, fibrin glue, and titanium mesh were preferred more frequently than other materials within their respective categories. However, material selection in OAC/OAF management is inherently context-dependent and may vary according to defect size, infection status, tissue conditions, and whether the procedure involves primary or revision repair. Because the questionnaire item assessed first preferred material without a defined clinical scenario, the observed distribution may reflect familiarity, accessibility, ease of use, prior training, or routine surgical habits rather than a strictly evidence-based material choice. In the 2026 OAC management survey, “ease of use” was reported as the most important factor influencing material and product selection, followed by application habits and material type. The authors interpreted this situation as a reflection of the potential divergence between evidence-based ideal choice and real-life practice [22]. In our study, participants who did not specify a material preference had lower total knowledge scores. Although this finding should be interpreted cautiously, it may suggest that uncertainty regarding material selection coexists with broader knowledge limitations. Taken together, these findings indicate that material selection may have cognitive and educational dimensions in addition to its technical aspects.
The strong relationship between the self-perceived education and diagnostic competence scale and the objective knowledge level score is also important. Considering the reverse Likert structure, the fact that higher perceived competence is associated with a higher level of objective knowledge indicates that subjective assessment is not entirely misleading. However, this finding should not be interpreted as direct evidence of clinical performance. Subjective perception of competence can be influenced by many elements such as specialist training, previous case experience, clinical role expectations, and self-confidence. In the educational literature, it is emphasized that the relationship between self-assessment and objective performance is not always linear and that individuals can sometimes deviate from their actual performance when evaluating their own competencies (Dunning-Kruger effect) [24]. Nevertheless, our data suggest that the self-perception competence is significantly related to the objective knowledge level, at least in this sample.
Within the limited literature focusing directly on OAC/OAF, a 2017 study is also noteworthy. In this descriptive study, the knowledge level of dentists regarding the early-stage management of maxillary sinus perforation was evaluated, and it was reported that the majority of participants were classified as “knowledgeable.” However, in the same study, it is observed that accuracy rates regarding the recognition of early complications and some first-line approach decisions were lower [25]. These findings are consistent with our data in suggesting that basic conceptual knowledge and practice-oriented knowledge may not always follow the same level. Our study, on the other hand, goes beyond this framework by not only describing the level of knowledge but also revealing the relationship of this level with the specialty group, previous case experience, educational status, and material preference.
Limitations
Regarding limitations, several points in this study should be considered. First, the study was based on self-reported survey data; therefore, social desirability bias and self-reporting bias cannot be entirely excluded, particularly for items related to clinical approach, referral tendency, and subjective competence. Although the final analyzable response rate was high, non-response bias cannot be entirely excluded, as the characteristics of dentists who declined participation were not available for comparison. Second, the survey-based design examined knowledge levels, preference patterns, and subjective evaluations rather than actual clinical outcomes or success rates in practice. Therefore, a higher knowledge score or a specific management preference should not be interpreted as directly equivalent to better clinical outcomes. Third, the material preference item may have reflected not only knowledge level but also participants’ previous clinical exposure, habits, personal tendencies, educational background, and material accessibility. In addition, this item was not presented within a defined clinical scenario; therefore, clinically relevant contextual factors such as defect size, infection status, and whether the repair was primary or revision treatment were not specified. Accordingly, the responses may have reflected familiarity or routine preference rather than a strictly evidence-based material choice, and should not be interpreted as the exact equivalent of a clinical decision. Fourth, due to the cross-sectional design of the study, the relationships between variables cannot be interpreted causally. Therefore, associations identified between factors such as prior training, case experience, or group membership and knowledge level should be interpreted carefully in terms of direction and causality. In addition, because the study was conducted exclusively in Turkey, the generalizability of the findings to other countries and healthcare settings may be limited. Moreover, Group 2 included participants at different stages of oral and maxillofacial surgery training and academic seniority, including residents, research assistants, specialists, associate professors, and professors. Because these subgroups were numerically unbalanced, further subgroup comparisons within Group 2 were not considered sufficiently robust for formal inferential analysis. Therefore, potential within-group variation according to level of experience should be interpreted with caution.
Conclusion
This study showed that dentists’ knowledge of the diagnosis and management of OACs and OAFs varies significantly according to professional background, clinical experience, and prior educational exposure. OMFS group’s participants demonstrated higher overall knowledge scores and subscores, greater self-perceived educational and diagnostic competence, and a stronger tendency to assume direct clinical management, whereas GDPs were more likely to prefer referral-based approaches. Nevertheless, certain knowledge gaps persisted even within the OMFS group, particularly in specific treatment-related domains, suggesting that the need for further education is not limited to GDPs alone. The findings also indicate that postgraduate training and previous case experience are positively associated with objective knowledge levels, highlighting the value of targeted continuing education and clinical exposure. Overall, these results support the need for more structured undergraduate and postgraduate educational strategies, as well as clearer practice-oriented guidance, to improve consistency and preparedness in the management of OAC and OAF.
Supplementary Information
Acknowledgements
The authors would like to thank all dentists who participated in this study for their valuable contributions.
Abbreviations
- OAC
Oroantral Communication
- OAF
Oroantral Fistula
- GDP
General Dental Practitioner
- OMFS
Oral and Maxillofacial Surgery
- PRF
Platelet Rich Fibrin
- ENT
Ear, Nose and Throat
- IQR
Interquartile Range
- SD
Standard Deviation
- CI
Confidence Interval
Authors’ contributions
Authors’ contributionsABÖ contributed to the conception and design of the study, data collection, interpretation of the findings, drafting of the manuscript, and preparation of the final version. İRK contributed substantially to the conception and design of the study, supervised the overall research process, guided the methodological framework and interpretation of the findings, critically revised the manuscript for important intellectual content, and approved the final version of the manuscript. Both authors read and approved the final manuscript.
Funding
Not applicable.
Data availability
The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. The full questionnaire is provided in the Supplementary Material.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Gazi University Ethics Committee (Approval number and date: 2024 − 1008, 11.06.2024). Written informed consent was obtained from all participants prior to enrollment.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. The full questionnaire is provided in the Supplementary Material.