Assessment of knowledge and clinical attitudes of Indian dentists in the diagnosis and management of oral traumatic neuroma: a case-based online questionnaire study

Introduction

Orofacial pain is a widespread issue affecting many people, with a notably high prevalence rate. Research indicates that 56.7% of patients seeking hospital care report orofacial pain as their primary concern, with 90% of these cases originating from odontogenic problems. Common odontogenic causes include pulpal disease (21.9%), impacted teeth (20.6%), and dental caries (9.0%) [1]. While there are numerous reasons for orofacial pain, one infrequent condition to consider is traumatic neuroma.
Traumatic neuroma, a hyperplastic lesion of peri­pheral nerves resulting from nerve trauma, is characterized by a reparative nerve reaction rather than malignant growth [2]. Initially documented by Wood in 1828, traumatic neuroma represents a chronic inflammatory response during nerve injury healing, leading to nerve fiber entrapment within scar tissue [2]. This condition can be categorized as terminal neuroma or neuroma in continuity; terminal neuroma occurs when a nerve is completely severed, precluding regeneration and innervation restoration, while neuroma in continuity involves a fusiform swelling at an injury site [3]. Intraoral traumatic neuromas are rare, but can appear in the lip, tongue, and mental nerve area following trauma from dental procedures, including surgical extraction or local anesthesia injection [4]. Clinically, oral traumatic neuromas may appear as small lesions or neuralgic pain without evident lesions, accompanied by symptoms, such as paresthesia, burning, and gnawing pain exacerbated by palpation. Pain starts immediately after trauma, and does not improve with painkillers or subsequent dental treatments, making it a diagnostic challenge due to its varied clinical manifestations [5].
Diagnosis of traumatic neuroma is based on a history of trauma, and can be confirmed by eliciting pain during examination. The patient may report a pain level of 7-8 out of 10 on a visual analogue scale [6]. A positive Tinel’s test, which elicits pain or tingling sensation upon palpation of the lesion, can help locating the area of neuroma. Traumatic neuroma may be mistaken for conditions, e.g., trigeminal neuralgia, but unlike trigeminal neuralgia, traumatic neuroma lacks reproducible pain from slight touch and refractory periods [7]. Traumatic neuromas mainly occur in young or middle-aged individuals, with females having twice the risk compared with males [8].
Intraosseous traumatic neuromas can be diagnosed using radiography, and may be mistaken for odontoge­nic or non-odontogenic cysts. A histopathological exami­nation can distinguish these conditions, revealing nerve fiber and Schwann cell proliferation within a collagen matrix, typically devoid of a capsule, occasionally associated with chronic infection. Histological differential diagnosis can include mucosal neuromas, neurofibromas, and pali­sading neuromas. Mucosal neuromas show an absence of any inflammatory cells in the fibrous connective tissue matrix, unlike traumatic neuromas [9]. Neurofibromas, although similar to traumatic neuromas, display a serpi­ginous profile of mast cells, and do not contain a haphazard arrangement of axons [10]. Whereas palisading neuromas can be differentiated by the presence of spindle cells arranged in a palisade pattern [11].
Surgical excision is considered only when an evident lesion is present. Conservative treatments, such as phy­siotherapy, local anesthetic or alcohol injection, cryotherapy, and electric stimulation, aim to provide symptomatic relief without treating the underlying cause [3]. Local anesthetic injections, followed by the use of a custom-made neuropathic stent to retain topical anes­thetic at the site, are preferred for intraoral traumatic neuromas. This method involves using the stent twice daily with weekly re-evaluations for 2-3 months to moni­tor the progress [6].
Oral traumatic neuromas are extremely rare, with a prevalence rate of 0.3% in the head and neck region, as also seen in a study by Jones and Franklin in 2005, which identified only 149 cases among 44,007 oral and maxillofacial cases [2, 5]. Due to its rarity, many dentists lack awareness of this condition, as it is not commonly addressed in undergraduate curricular textbooks. Therefore, it is crucial to correctly recognize this condition to avoid misdiagnosis and subsequent inadequate treatment.

Objective

The current study aims to assess Indian dental practitioner’s knowledge and clinical approach towards the diagnosis and management of traumatic neuroma through a case study.

Material and methods

Study settings

The study was carried out among Indian dentists registered under the regulatory governing body.

Study design

A cross-sectional online structured questionnaire-based study was conducted after obtaining proper approval from the institutional ethical committee (No. MRIIRS/MRDC/SDS/IEC/2024/102). Responses were collected from June 2024 to October 2024.

Sample size

Sample size was calculated using a proportion formula, considering a 95% confidence interval, and based on a pilot study of 15 experts, out of whom 20% had good knowledge about traumatic neuroma and 20% demonstrated good clinical attitudes to diagnose and treat the same. Considering the 20% with 15% relative precision on either side, a sample of 683 subjects was needed.
n = (Z_(1 – α⁄2)2 × p × (1 – p))/ε2
Z_(1 – α⁄2) = 1.96; p = 0.20; ε = 0.2 × 0.15 = 0.03
n = ([1.96]2 × 0.2 × (1 – 0.2))/[0.03]2 = 683
Since the survey was conducted online and expected that 50% of participants might not reply to it:
Sample size need = sample calculated × 2 = 683 × 2 = 1,366
Therefore, we contacted 1,400 dentists for participation in this study.

Inclusion and exclusion criteria

All dentists, whose dental degree was recognized by the Indian regulatory body, and who were willing to participate were included in the study. Dental students and interns, whose internships were not complete or whose degree was not registered in the governing body during the survey period, were excluded.

Questionnaire

Based on the available previous data, the questionnaire was originally developed by 3 dentists (K.R., M.K., M.M.) in English and Hindi languages. The questionnaire consisted of 16 questions divided into 4 parts. The first part obtained consent from each participant. The second part consisted of 7 demographic questions, followed by case study-based questions in the third part to understand the clinical approach of participants. The last section consisted of knowledge-based questions to evaluate their understanding of the topic.
A preliminary pilot study was conducted among 15 dental professionals; these data were not included in the survey. The questionnaire was pretested for content validity and internal consistency, with a conduct validity index of 0.9 and Cronbach’s α 87%, calculated by distri­buting the questionnaire to 15 experts in the field who were not part of the research team. Every question was rated by the participant as “Yes” or “No” for clarity and relevance. At the end of the questionnaire, completeness was assessed through the participant’s review. Any question rated as clear by less than 7 out of 15 participants was reworded according to the participant’s comments. Hence, the final questionnaire with necessary modifications was framed.

Proforma

An electronic Google form with study information, informed consent, and a questionnaire was developed. Study team identified the registered dentists list through a DCI website. The questionnaire was equally distri­buted among dentists from all 5 zones of India. Sharing of the questionnaire was done through assigned social media platforms to a randomly selected sample of dental Indian professionals (n = 1,400). This ensured the control of potential selection bias.

Criteria for evaluation of clinical attitude and knowledge of participants regarding traumatic neuroma

In the knowledge section, 5 questions were included, and each question was based on a 5-point Likert’s scale, ranging from “Strongly disagree (1)” to “Strongly agree (5)”, with a total score ranging from 5 to 25. The average of marks was made and decided on the following scoring criteria: poor knowledge (5-11), mode­rate knowledge (12-18), and good knowledge (19-25). The clinical approach section consisted of 4 questions: 2 questions were based on a 5-point Likert’s scale, ranging from “Strongly disagree (1)” to “Strongly agree (5)”, with a total score ranging from 5 to 25. This listed less needed investigations and approaches to the given case. The other two open-ended questions were on whether any participant had any other approach, which was not registered. The following scoring criteria was made: good attitude (5-11), fair attitude (12-18), and poor atti­tude (19-25).

Statistical analysis

Categorization of different qualifications was done using Student’s t-test, while one-way ANOVA test was performed to determine the distribution of questionnaires among private practitioners, academicians, and both. To correlate between degree with knowledge about traumatic neuroma, to correlate between specialty/BDS/MDS degree with clinical attitude towards diagnosis and management of traumatic neuroma, and to correlate between years of experience with knowledge and clinical attitude towards diagnosis and management of a case of traumatic neuroma, c2 test was done. Data analysis was performed with statistical software SPSS version 16.0. Descriptive statistics were applied for data summarization, and continuous variables were presented as mean (SD) and median (IQR), whereas categorical variables were shown with numbers and percentages.
The proportion of knowledge and clinical attitude were reported with a 95% confidence interval, considering the proportion of good in clinical attitude and knowledge. Univariable and multivariable logistic regression was done to find the association between knowledge and clinical attitude with participants’ characteristics, such as occupation, qualification, year of experience, and age.

Results

The questionnaire was sent to 1,400 participants, out of which 703 responses were obtained. The study included participants aged 20 to 40 and above years. 48% of the dentists were in the age group of 20-25 years, followed by 29% aged between 25 and 30 years, and 5% aged 35-40 years. 73% of the participants had experience of 0-5 years, followed by the experience of 15-20 years (8%) and 20 years and above (8%). In the group with 5-10 and 10-15 years of experience, age was 5% and 6%, respectively. 50% (n = 348) of the dentists were academicians, and 31% (n = 221) were private practitioners. However, 19% of the parti­cipants were involved in both activities. 55% (n = 389) of the dentist had a BDS degree, while 45% (n = 313) of them had an MDS degree (Table 1). Nearly 50% of the participants selected “Strongly disagreed” with the knowledge question responses (Figure 1, Table 2). Out of a total of 702 participants, 503 (71.7%) had poor knowledge, 186 (26.4%) had moderate knowledge, and only 14 (2.0%) had good knowledge. Since the number of good knowledge participants was only 2%, we combined the good and moderate knowledge dentists, and named “The knowledge” to find an association with the participants’ characteristics. 28.3% of the dentists knew about traumatic neuroma, with a 95% confidence interval of 25.0 to 31.6% (Table 3). There was no significant association of age, experience, and qualification of the participants with knowledge. However, the occupation of private practitioner had higher odds of bad knowledge about traumatic neuroma compared with the academic occupation 1.64 (95% CI: 1.06-2.55; p = 0.025). Hosmer-Lemeshow goodness-of-fit test showed a p-value of 0.571. The overall model predictivity was 71.7%, with 100% sensitivity but 0% specificity (Table 4). Out of the total of 702 participants, 405 (57.7%) had a poor attitude, 266 (37.9%) had a moderate attitude, and only 31 (4.4%) had a good attitude. Since the number of good attitude participants was only 4.4%, we combined the good and fair attitudes, and named “The presence of clinical attitude” to find an association with the dentists characteristics. 42.3% of the participants had a fair plus good attitude, with 95% CI: 38.6-46.0 (Tables 5-7). The results of multivariable logistic regression revealed no significant association between age, occupation, and qualification of the participants with attitude. However, the 15-20 years experienced clinicians had lower odds of a bad attitude of about 0.24 (95% CI: 0.070-0.082; p = 0.025) compared with the 0-5 years experiences. In other words, dentists with 15-20 years of experience had a significantly higher likelihood of a good attitude than those with 0-5 years of experience (Table 8).

Discussion

In dentistry, traumatic neuromas, often referred to as amputation neuromas, are painful swellings often incorrectly diagnosed as neurofibromas, Schwannomas, or even periodontal lesions [12, 13]. Tooth extraction has been suggested as the most common etiologic factor in the development of oral traumatic neuroma, but intra­osseous lesions are stated to be rare [14]. Typically, the lesion appears in the soft tissues on the tongue, lower lip, and in mental foramen region [7]. Most often, the condition pre­sents itself in a 2 : 1 ratio, suggesting that women are more inclined than men in young to middle age [2, 15].
There is a lack of awareness amongst dentists about traumatic neuromas, leading to their misdiagnoses. The data collected in the current study reveals that 71.7% of the participants had poor knowledge, and that there is a statistically significant (95% CI: 25.0-31.6) regression association between the participants’ characteristics and knowledge about traumatic neuroma.
Multivariable logistics regression association of the dentists’ characteristics with knowledge of traumatic neuroma revealed that private practitioners had higher odds of bad knowledge compared with academic occupation, with a p-value of 0.025. The study sample consisted predominantly of academicians (n = 348), who are typically well-versed in medical concepts due to their professional training and continuous exposure to educational resources. This composition likely played a signi­ficant role in shaping the knowledge patterns observed in the study.
There have been multiple cases where the initial dia­gnosis based on clinical symptoms and history were not indicatives of traumatic neuroma, and the diagnosis was confirmed by post histopathological evaluation of an excised tissue from the target site. A case report published by Jham et al. [7] showed a young female reported to the hospital to assess a mandibular osteolytic lesion found on an OPG taken for orthodontic records. The primary diagnosis was a traumatic bone cyst based on radiological and cli­nical findings. Only after a histopathologic exa­mination, it was confirmed that the condition was traumatic neuroma. In another case report by Lopes et al. [8], a 42-year-old female reported to the dental school with chief complaint of painful swelling, with no history of surgery or trauma. Based on clinical features, it was deemed a neural benign tumor. However, after an excisional biopsy and microscopic evaluation, the diagnosis was confirmed as traumatic neuroma. The diagnosis was specifically difficult in a case reported by Kodama et al. [16], where a 52-year-old female patient with a history of five TMJ surgeries developed pain, and various radiographic assessments were inconclusive of the diagnosis. Post biopsy, the diagnosis of traumatic neuroma was established.
Additionally, traumatic neuromas can imitate vascular lesions, as reported by Ribeiro et al. [17], where clini­cal examination showed a vascular lesion, but the excised tissue presented nerve bundles, concluding that the condition, in fact, was a traumatic neuroma. The above-mentioned studies have one thing in common: each final diagnosis was made after conducting biopsy and histopathological examination. The tests done included CBCT, computed tomography, and panoramic radiograph, but none of the studies performed a Tinnel’s test to determine any neurological involvement. Only after a biopsy was the diagnosis of traumatic neuroma confirmed. These findings are similar to the results obtained in this study, where majority of participants opted for radiographic tests, such as CBCT or fremitus test for diagnosing the condition, but no Tinnel’s test was chosen as the participants were not aware of traumatic neuroma.
In a survey study conducted by Devi et al. [18] assessing the knowledge and attitude of dental practitioners in the management of traumatic neuroma, 89.1% of the dentists were found to be aware of the traumatic neuroma’s origin. On the contrary, the data collected in our study revealed that more than half (57.7%) of the dentists had a poor clinical attitude, indicating that the lack of knowledge about the disease caused an unsatisfactory clinical attitude towards the same. For the management of traumatic neuroma, the data collected showed that the participants opted for extraction of the involved tooth (n = 139), followed by root canal intervention, scaling, or using antibiotics and analgesics. There is a scarcity of knowledge about traumatic neuroma diagnosis, which leads to poor management of patients. Therefore, there is a need for dentists to be aware of traumatic neuroma in order to provide better oral care to patients.
The results of the multivariable logistic regression association of patient characteristics with clinical attitude demonstrated that with new case management and experience gained, the participants with 15-20 years of experience had significantly higher odds of good clinical attitude, with a p-value of 0.025. As practitioners accumulate more years of experience, they gain not only technical expertise but also a greater sense of confidence in managing complex cases. This result is likely due to their accumulated practical knowledge and refined clini­cal decision-making skills.
The findings of this study are based on a sample with an unequal representation of age groups, with only around 10% of dentists being older than 40 years. Therefore, the generalizability of the results is limited, and it cannot be conclusively stated that the clinical experience influences the ability of clinicians to diagnose and treat traumatic neuroma cases.

Conclusions

The present study underscores the significant gaps in both the knowledge and clinical attitudes of Indian dentists towards the diagnosis and management of traumatic neuroma patients. This study highlights the need for targeted educational initiatives to improve awareness of this condition. Also, it emphasizes the importance of incorporating appropriate diagnostic tools, such as the Tinel’s test, to aid in the accurate identification of traumatic neuroma. Furthermore, the overall lack of knowledge and suboptimal management strategies suggest that systematic improvements in training and professional development are essential. Due to variations in sample size related to age, years of practice, and profession, further studies are needed to standardize the current findings.

Disclosures

1. Institutional review board statement: This study was approved by the Research Ethics’ Committee of the Manav Rachna Dental College (No. MRIIRS/MRDC/SDS/IEC/2024/102).
2. Assistance with the article: We would like to gratefully acknowledge Dr. Rajeev Kumar Malhotra, Senior Scientist at All India Institute of Medical Sciences, New Delhi, India, for helping us with the statistical analysis.
3. Financial support and sponsorship: None.
4. Conflicts of interest: The authors declare no potential conflicts of interest concerning the research, authorship, and/ or publication of this article.

References