This was a cross-sectional observational study conducted among dental interns from all Riyadh dental schools, Saudi Arabia in 2020 after obtaining approval from the Institutional Review Board (IRB) committee at Princess Nourah bint Abdulrahman University, Saudi Arabia. (IRB log number: 19-0162).

Around 300 participants belonging to five Riyadh dental schools comprised the study population. The dental schools were selected based on the original location of the study, Riyadh city. All current interns were asked to participate. All interns were included in the study after obtaining informed consent.

Study procedure: The survey was developed based on existing literature [8-11]. however, some questions were modified because they were not relevant to our particular region. Content validity and reliability was checked by experts, Cronbach’s alpha value was 0.75-0.8. The electronic survey tool was administered in English language. The survey included 23 items divided into three parts. The first part included the informed consent and demographic data: gender, college, and previous summer training in Oral and Maxillofacial Surgery (item 1-3). The second part consisted of 10 case scenarios to assess the knowledge of graduates in carrying out a range of minor surgical procedures in oral surgery (item 4-13) [10,11], and the third part was developed to self-rate their confidence level in performing simple dentoalveolar procedures (item 14-23). The possible responses regarding knowledge of graduates were classified as ‘correct’ and ‘incorrect’. A correct answer was given 1 point, while the incorrect answer was given 0 points. A high score indicated excellent knowledge of the respondent. In order to quantify data, a self-designed scale was used and it was based on the percentage. The results of the survey were represented as follows: 10-8, good knowledge; 8-5, average knowledge; <5, below-average knowledge. For confidence level in performing simple dentoalveolar procedures, the survey instrument utilised a self-designed scale where 2=Confident, 1=Neutral, 0=Not confident. While the result of the confidence was represented as 20-15, high confidence; 14-9, moderate confidence; 8-0, low confidence. The scale was self-designed based on minimum and maximum scores.

The electronic survey had a greeting letter detailing the purpose of the study and informed the participants that their participation was optional.

All statistical analyses were performed using SPSS version 21.0. (SPSS Inc., Chicago IL) and Microsoft Excel 16.16. Statistical significance was defined as p<0.05. The descriptive statistics included count (percent) and mean (standard deviation). Groups were compared using Pearson’s chi-square and unpaired sample t-test. Pearson’s correlation coefficient was computed to study the relationship between two continuous variables. Unpaired sample t-test analysis was used to assess significant differences between the means of two variables.

The response rate was 70% (N=210), the final study population included 117 (56%) females and 93 (44%) males. A total of 111 (53%) belonged to governmental college, and 99 (47%) belonged to a private college [Table/Fig-1]. Only 5% of the study subjects underwent summer training for oral and maxillofacial surgery.

[Table/Fig-2] represents the total knowledge scores of female and male dental interns, respectively. A total of 56% (117) females had a mean knowledge score of 5.32 (±2.016), and 44% (93) males had a mean knowledge score of 5.02 (±1.939) both of which indicated average knowledge. There was no statistically significant difference between females and males in total knowledge score (p=0.272).

Interns revealed the highest level of knowledge in prescribing an appropriate medication 76% (160) and the lowest in knowing the list of classification of impacted teeth 12% (25).

In addition, responses regarding the following knowledge questions revealed significant results. The appropriate anaesthetic technique (p=0.029), postextraction management (p=0.026), management of open extraction in proximity to vital structures (p=0.013), and classification of impacted teeth (p=0.005).

[Table/Fig-3] represents that 111 (53%) interns belonged to government college with mean knowledge score of 5.86 (±1.949) and 99 (47%) interns belonged to private college with mean knowledge score of 4.44 (±1.751). There was a statistically significant difference in knowledge between government and private colleges (p<0.001).

Furthermore, responses regarding the following knowledge questions showed significant results. Management of open extraction in proximity to vital structures (p<0.001), management of case with an intraoral abscess (p=0.007), management of case with pericoronitis (p<0.001), antibiotic prophylaxis of patient with history of bacterial endocarditis (p<0.001), classification of impacted teeth (p<0.01), and diagnosis of chronic sinusitis (p<0.001).

While [Table/Fig-4] showed 56% (117) females had a mean confidence score of 13.85 (±3.246), and 44% (93) males had a mean confidence score of 13.95 (±3.777) both of which indicated moderate confidence. There was no statistically significant difference between females and males in total score confidence (p=0.850).

Also, interns showed the highest level of confidence in giving effective local anaesthesia 76% (160) and they were least confident in managing cases of an intraoral abscess 29% (60).

However, response regarding confidence to extract a tooth showed significant result (p=0.009).

A total of 111 (53%) interns who belonged to government college reported mean confidence score of 14.64 (±2.642) and 99 (47%) interns who belonged to private college reported mean confidence score of 13.06 (±4.088) [Table/Fig-5]. There was a statistically significance difference in confidence between government and private colleges (p<0.001).

However, responses regarding the following confidence questions showed significant results. Writing an appropriate referral letter (p<0.001), management of intraoral abscess (p=0.02), management of acute pericoronitis (p<0.001), management of postextraction haemorrhage (p=0.013), medication prescription (p<0.049), and assessment of impacted teeth (p<0.001).

A weakly positive significant correlation was found between the total score knowledge and the total score confidence in performing surgical procedures (r=0.217, n=210, p=0.002) [Table/Fig-6].

In dentistry, the undergraduate dental curriculum is prepared in a way that offers adequate training for students to be competent and well-equipped after graduation and during clinical practice. It also trains them to be committed to continuous learning throughout their careers. It is very important for dental graduates to be able to evaluate their confidence throughout their internship and during practice, doing so will help them define and identify the areas of weakness and shortage that they need to work on [12].

Oral surgery procedures are technique sensitive, technique demanding and irreversible. Competency in skills and knowledge are of a major importance in this speciality. As the skills improve and increase, the confidence also increases. Successful treatment outcomes are achieved by enough knowledge, competence and confidence [13]. The present study focuses on the importance of applying adequate knowledge to clinical training in order to achieve competency and overcome shortages. To the best of the authors’ knowledge, no study has been conducted on correlation between the knowledge and the confidence level in the speciality of oral surgery in Saudi Arabia. This study has been done in Riyadh, the capital of Saudi Arabia which has the maximum number of dental interns and dental colleges. The results of the study indicated that female interns reported lesser self-confidence than males regarding extraction (p=0.009). It is a self-reported confidence.

The main findings of the study revealed that the more knowledge the interns had, the more confidence they gained in performing oral surgery procedures. A weakly positive correlation (r= 0.217) between the knowledge scores and confidence scores in performing surgical procedures of 210 dental interns was found. A study by Gilmour AS et al., highlighted the importance of competence and the perception of it (confidence), both terms are different in such a way that a person might have the competence but might not have the perceived ability (confidence) to achieve a required procedure. It’s important to note and understand that the level of confidence in oneself should be assessed in such a way that an over-confident practitioner might risk the safety of their patients by attempting procedures beyond their scope of competence and in contrast under-confident individuals are slow in progress and over-rely on other practitioners. Self-based competence and confidence assessment is important [14].

In the present study, no statistically significant difference between females and males in total knowledge score and total confidence score was found (p=0.272). Gilmour AS et al., found gender differences in the confidence level in which the female students reported a lower confidence level compared to their male colleagues [14]. Interns revealed the highest level of knowledge in prescribing an appropriate medication 76% (160) while showed the lowest in knowing the list of classification of impacted teeth 12% (25). The study showed that interns were knowledgeable in prescribing an appropriate medication. And they were confident in giving effective local anaesthesia. All in all, interns had a superficial knowledge in knowing the list of classification of impacted teeth and they were least confident in managing cases of an intraoral abscess.

Also, interns showed the highest level of confidence in giving effective local anaesthesia 76% (160), and they were least confident in managing cases of an intraoral abscess 29% (60). A study’s findings of Al-Dajani M showed increased confidence with the increased practical experience. When students extracted more teeth, they had more confidence in clinical competence. This can be traced to the contribution of both clinical instructors’ supervision and interaction with their patients [4]. A study by Cabbar F et al., indicated that students were confident about their capacity to extract teeth, nonetheless, they needed self-assurance in performing careful surgical extractions and its related techniques. This may result from the absence of suitable cases for students to take part in [8].

This is also similar to the findings of Al-Dajani M which depicted that, the students were highly confident in carrying out simple oral surgery clinical procedures and they were less confident in doing the complex ones such as, surgical extractions, raising flap, removal of bone or tooth sectioning [4]. Performing complex oral surgery procedures is considered difficult at the level of students or dental interns because it’s not in their scope of competency [4].

Further results showed a statistically significant difference in knowledge score and confidence level between government and private colleges (p≤0.001).

The present study had the following strengths, the correlation between knowledge and confidence level was used for the first time in this type of study, it also involved the participation of a large group of dental interns from Riyadh city, Saudi Arabia. Sufficient interns were included to analyse the correlation between objectively assessed knowledge and self-rated confidence.

The present study had some limitations; hence the results of this cross-sectional study should be interpreted with caution. We recognise that most participating interns belonged to different colleges that differed in their teaching strategies and curriculums and it was conducted in one region of Saudi Arabia, this may have hampered generalising the study to all dental interns in Saudi Arabia. Rating self-confidence (subjective certainty) is a personal perception that doesn’t necessarily mean competence in clinical skills. The results also might have been affected by the response rate, in which government colleges showed a higher response compared to private colleges.

The study showed that there was no statistically significant difference between females and males in total knowledge and confidence score, respectively. However, a statistically significant difference in knowledge and confidence between government and private colleges was found. Further training is needed so they can overcome the deficiencies. It is important to encourage interns to take part in continuous education programs and workshops to fill knowledge gaps in certain areas where they lack experience in oral surgery. Future researches should investigate the important role of internship in enhancing graduates’ clinical skills (competence), clinical experience and confidence by conducting a national survey. Also, it is important to identify the attitude, perception, and knowledge of fresh graduates about their internship training program.