Abstract
Background
Recently researches in the field of dental implantology have increased, in spite of that very limited knowledge is available to the patients about dental implants as an option for replacement of missing teeth. Goal of replacement of missing teeth is not only functional rehabilitation but overall improvement in quality of life of the patient.
Aim
To assess the awareness of dental implants and to compare oral health related quality of life (OHRQoL) in patients treated with implant supported fixed prosthesis (ISPs) and teeth supported fixed prosthesis (FPDs).
Methods
& Material: General implant awareness questionnaire was used to assess the awareness of dental implants in 500 participants. Oral health impact profile (OHIP) questionnaire was used to compare OHRQoL between 300 patients treated with ISPs and 300 patients treated with FPDs.
Statistical analysis
Sample size was taken to estimate difference between groups at 30 % & 80% power and 5% risk. IBM SPSS 20 (SPSS Inc., Chicago, IL) was used for statistical analysis. Chi square test and independent t- test was used to find statistical difference between variables.
Results
27.2% participants were aware about dental implants. 74.4% participants agreed that missing teeth should be replaced with prosthetic options. Dentists were primary source of knowledge (66%) of dental implants for patients. Parameters like functional limitations, psychological discomfort and pain during mastication were significantly (p < 0.05) higher in FPDs compared to implant supported prosthesis.
Conclusions
Awareness of dental implants in general population needs to be increased. Functional and psychological comfort was significantly higher in ISPs compared to teeth supported FPDs.
Keywords: OHRQoL, FPD, Implant supported prosthesis (ISPs)
Graphical abstract
1. Introduction
In recent times researches in the field of dental implantology has increased. Information about dental implant treatment and other treatment options should be easily available to the patients who are looking for replacement of the missing teeth. But limited knowledge is available to the patients about the dental implants.
Goal of replacement of missing teeth is not only restoration of masticatory function but also improvement in the overall quality of life of the patient. Oral health related quality of life is defined as an individual's perception of the impact of oral health on their quality of life (OHRQoL).1 Numerous research have assessed the effectiveness of dental implants to enhance prosthetic stability and retention, hence enhancing patients' overall oral comfort.2,3 However, very few clinical investigation have examined the effects of implant supported fixed prosthesis on patients' OHRQoL and compared them with teeth supported fixed partial dentures. Oral health impact profile (OHIP) was created in 1994 by Slade & Spencer and is one of the trustworthy questionnaires to assess the quality of life related to oral health.4 The goal of this study was to evaluate patients' knowledge of dental implants and to compare patients' oral health-related quality of life (OHRQoL) after receiving an implant-supported fixed prosthesis or tooth-supported fixed prosthesis.
2. Materials and methods
This study was an institution-based cross sectional questionnaire study. Participants were randomly selected from outpatient department. This study was approved by Institutional Ethics Committee letter number IEC/MPDC_204/PERIO-26/20.
2.1. Inclusion criteria
-
1.
Patients more than 18 years of age who were looking for replacement of missing teeth.
-
2.
Patients with at least one tooth replaced either with dental implant prosthesis or tooth supported fixed partial denture.
2.2. Exclusion criteria
-
1.
Patients who have not given consent for study.
-
2.
Patients with cognitive deficiency.
-
3.
Patients who have stopped treatment prematurely or with incomplete treatment by the operator.
2.3. Implant awareness questionnaire
Patients who were looking for replacement of their permanent missing teeth were included in dental implant general awareness questionnaire. A self-explanatory questionnaire (includes fourteen questions, both open ended and close ended questions) based on previous studies was used.5,6 First, the questionnaire's validity was checked. The participants were informed about the study and written consent was obtained. Questionnaire was prepared in both English and Gujarati language whichever was suitable for the patient.
2.4. Oral health impact profile (OHIP) questionnaire7
Patients who got at least one permanent tooth replaced with either dental implant fixed prosthesis or tooth supported fixed prosthesis were identified and randomly selected and informed about the study and questionnaires. Implant supported prosthesis and/or tooth supported fixed prosthesis patients treated by trained and experienced clinicians were included in the study. All patients were asked to fill the OHIP questionnaire on the basis of their experience with either of the treatment in last 3 months. The functional field (eating, speaking, mastication, and swallowing) and the psychosocial field (social concerns, functional discomfort, appearance, self-consciousness and social embarrassment) are two examples of the various criteria that constitute OHIP. The validity and reliability of the questionnaire were analysed. The 14-item OHIP questionnaire were responded using a five-response Likert scale model, with the following scores: Never (0), Seldom (1), Sometimes (2), Often (3), and Always (4). The final value was obtained by adding these scores. Lower the OHIP score, higher is the individual's satisfaction and OHRQoL. Questionnaire were made in both English and Gujarati language whichever was suitable for the patient. Patients with implant supported fixed prosthesis (ISPs) were considered as Group I and patients with teeth supported fixed prosthesis (FPDs) were considered as Group II.
2.4.1. Sample size estimation and data analysis
500 patients for implant awareness questionnaire and 300 patients for each group (Implant supported prosthesis and tooth supported prosthesis) for OHIP questionnaire were included. This sample size was taken to estimate difference between group at 30 %, at 80% power and 5% risk. IBM SPSS 20 (SPSS Inc., Chicago, IL) was used to conduct the statistical analysis. A General Linear Model Procedure (GLM) was used to assess data differences between two groups from the OHIP questionnaire. The demographic data were analysed and compared using chi-square test and independent t-test.
3. Results
3.1. Dental implant awareness questionnaire
Participants' mean age was 49.82 ± 14.74 years, maximum participants were between 26 – 55 years of age group and most of the participants were well educated and graduates (45.6%). Maximum numbers of participants were from urban area (89.2%) (Table 1).
Table 1.
Demographic details of participants participated in general implant awareness questionnaire.
| DEMOGRAPHIC DATA (n = 500) | n (%) | |
|---|---|---|
| GENDER | Male | 289 (57.8) |
| Female | 211 (42.2) | |
| AGE | 18–25 years | 34 (6.8) |
| 26–55 years | 275 (55.0) | |
| > 55 years | 191 (38.2) | |
| OCCUPATION | Student | 26 (5.2) |
| Uneducated | 15 (3.0) | |
| Housewife | 157 (31.4) | |
| Professional | 135 (27.0) | |
| Business | 55 (11.0) | |
| Retired | 112 (22.4) | |
| EDUCATION | Uneducated | 16 (3.2) |
| Primary school | 68 (13.6) | |
| Secondary school | 159 (31.8) | |
| Graduate | 228 (45.6) | |
| Post graduate | 29 (5.8) | |
| RESIDENCE | Urban | 446 (89.2) |
| Rural | 54 (10.8) | |
74.4% participants responded that it is necessary to replace the missing teeth, 24% participants feel that missing teeth should be replaced only when there are some problem. Graduates (39.8%) were more in favour of replacement of missing teeth (Table 2).
Table 2.
Distribution of responses of the participants to the questions in general implant awareness questionnaire. (n = 500).
| Q. No. | A n (%) | B n (%) | C n (%) | D n (%) | E n (%) |
|---|---|---|---|---|---|
| 1 | 372 (74.4) | 8 (1.6) | 120 (24.0) | __ | __ |
| 2 | 208 (41.6) | 156 (31.2) | 136 (27.2) | __ | __ |
| 3 | 42 (8.4) | 78 (15.6) | 98 (19.6) | 145 (29.0) | 137 (27.4) |
| 4 | 239 (47.8) | 261 (52.2) | __ | __ | __ |
| 5 | 217 (43.4) | 158 (31.6) | 125 (25) | __ | __ |
| 6 | 170 (34.0) | 89 (17.8) | 163 (32.6) | 78 (15.6) | __ |
| 7 | 330 (66.0) | 41 (8.2) | 129 (25.8) | __ | __ |
| 8 | 410 (82.0) | 90 (18.0) | __ | __ | __ |
| 9 | 82 (16.4) | 158 (31.6) | 184 (36.8) | 76 (15.2) | __ |
| 10 | 207 (41.4) | 103 (20.6) | 190 (38.0) | __ | __ |
| 11 | 271 (54.2) | 229 (45.8) | __ | __ | __ |
| 12 | 151 (30.2) | 349 (69.8) | __ | __ | __ |
| 13 | 117 (23.4) | 383 (76.6) | __ | __ | __ |
| 14 | 97 (19.4) | 47 (9.4) | 67 (13.4) | 29 (5.8) | 260 (60.0) |
41.6% participants were aware about tooth supported fixed partial denture, 27.2% participants were aware about dental implants as an option for replacement of missing teeth. 26–55 years age groups (15.8%), graduates (12.2%) and participants residing in urban areas (26.8%) were more aware about dental implants (Table 2, Table 3).
Table 3.
Comparison of knowledge of different teeth replacement options in different age, education and residence groups (n = 500).
| Question 2 | A n (%) | B n (%) | C n (%) | Χ2 | p-Value | |
|---|---|---|---|---|---|---|
| Age | 18–25 | 14 (2.8%) | 2 (0.4%) | 18 (3.6%) | 40.277 | 0.000 |
| 26–55 | 135 (27%) | 71 (14.2%) | 79 (15.8%) | |||
| >55 | 61 (12.2%) | 76 (15.2%) | 51 (10.2%) | |||
| Education | Uneducated | 5 (1%) | 8 (1.6%) | 3 (0.6%) | 69.659 | 0.000 |
| Primary school | 27 (5.4%) | 29 (5.8%) | 12 (2.4%) | |||
| Secondary school | 67 (13.4%) | 64 (12.8%) | 28 (5.6%) | |||
| Graduate | 115 (23%) | 52 (10.4%) | 61 (12.2 %) | |||
| Post graduate | 7 (1.4%) | 4 (0.8%) | 18 (5.6%) | |||
| Residence | Urban | 184 (36.8%) | 128 (26.5%) | 134 (26.8%) | 11.899 | 0.018 |
| Rural | 24 (4.8%) | 23 (4.6%) | 7 (1.4%) |
Chi square test; p < 0.05 significant.
Kennedy's classification was used to distribute participants according to area of missing teeth. It was found that maximum patients fall into class 3 category of Kennedy's classification. That shows that maximum number of patients were looking for replacement of teeth when their maxillary 27% and mandibular 10% posterior teeth were missing with natural teeth present anterior and posterior to it. Percentage of patients who were looking for replacement of missing teeth in aesthetic areas (Kennedy's Class 4 category) of maxilla and mandible were 7.0% and 6.6% respectively (Table 4).
Table No. 4.
Distribution of participants according to Kennedy's classification (n = 500).
| Kennedy's Classification | Maxilla n (%) | Mandible n (%) |
|---|---|---|
| Class 1 | 30 (6) | 7 (1.4) |
| Class 1 Mod 1 | 12 (2.4) | 7 (1.4) |
| Class 1 Mod 2 | 8 (1.6) | 2 (0.4) |
| Class 2 | 17 (3.4) | 3 (0.6) |
| Class 2 Mod 1 | 5 (1.0) | 7 (1.4) |
| Class 2 Mod 2 | 5 (1.0) | 3 (0.6) |
| Class 3 | 135 (27) | 50 (10) |
| Class 3 Mod 1 | 17 (3.4) | 24 (4.8) |
| Class 3 Mod 2 | 9 (1.8) | 4 (0.8) |
| Class 4 | 35 (7.0) | 33 (6.6) |
| Completely Edentulous | 46 (9.2) | 41 (8.2) |
Different OHIP questionnaire parameter comparison between group I & group II (Table 5 & Graph. 1).(see Table 6)
Table 5.
Comparison of various OHIP 14 questionnaire parameters between group I and II.
| Comparison of Group I and II | Mean | Standard Deviation | p-Value | |
|---|---|---|---|---|
| Ease of Speaking (Question1) | Group I | 0.10 | 0.36 | 0.000 |
| Group II | 0.28 | 0.58 | ||
| Altered Taste (Question 2) | Group I | 0.09 | 0.34 | 0.559 |
| Group II | 0.08 | 0.27 | ||
| Social Disability (Question 5,6,10,11,12) | Group I | 0.09 | 0.28 | 0.043 |
| Group II | 0.15 | 0.42 | ||
| Functional Limitation (Question 3,4,7,8,9,14) | Group I | 0.68 | 1.40 | 0.000 |
| Group II | 1.29 | 1.98 | ||
| OverallSatisfaction (Question 13) | Group I | 4.00 | 0.00 | – |
| Group II | 4.00 | 0.00 | ||
| OHIP Score | Group I | 5.75 | 2.84 | 0.000 |
| Group II | 6.80 | 3.50 | ||
Independent t- test; p < 0.05.
Graph. 1.
Comparison of various OHIP 14 questionnaire parameters between group I and II.
Table 6.
Comparison of OHIP scores among different study parameters.
| Study Group | Mean OHIP Score (Mean ± S.D.) | t value | P value | Interpretation |
|---|---|---|---|---|
| Anterior FPD | 7.10 ± 4.8 | 1.53 | 0.127 | Not Significant p > 0.05 |
| Anterior Implant | 6.11 ± 3.6 | |||
| Posterior FPD | 6.92 ± 3.7 | 3.40 | 0.001 | Significant p < 0.05 |
| Posterior Implant | 5.84 ± 3.06 | |||
| Male FPD | 6.93 ± 3.9 | 2.64 | 0.009 | Significant p < 0.05 |
| Male Implant | 5.9 ± 3.17 | |||
| Female FPD | 6.66 ± 2.9 | 3.52 | 0.000 | Significant p < 0.05 |
| Female Implant | 5.48 ± 2.39 | |||
| Urban FPD | 6.84 ± 3.7 | 3.8 | 0.000 | Significant p < 0.05 |
| Urban Implant | 5.73 ± 2.9 | |||
| Rural FPD | 6.59 ± 2.24 | 0.465 | 0.229 | Not Significant p > 0.05 |
| Rural Implant | 5.96 ± 2.12 | |||
| Long Span FPD | 8.26 ± 6.8 | 0.863 | 0.366 | Not Significant p > 0.05 |
| Long Span Implant | 7.05 ± 5.25 | |||
Independent t- test; p < 0.05.
3.2. Ease of speaking
Participants of group I experienced statistically significant (p < 0.05) more ease of speaking compared to group II.
3.3. Altered taste
No significant difference found between two groups (p = 0.559).
3.4. Social disability
Participants of group I had a statistically significant pleasant experience with their prosthesis (p = 0.043) as compared to group II.
3.5. Functional limitation
Participants from group II had experienced statistically significant (p = 0.000) functional limitation compared to group I.
3.6. Overall satisfaction
There was no statistically significant difference between the two groups for the overall satisfaction criteria.
3.7. Comparison of prosthesis in anterior region between group I & group II (Table No. 6)
There was no statistical difference between OHIP score of anterior FPD and anterior implant prosthesis (p Value = 0.127).
3.8. Comparison of prosthesis in posterior region between group I & group II (Table No. 6)
Statistical difference was observed in OHIP score between posterior FPD and posterior implant prosthesis (p Value = 0.001) with better results in group I.
3.9. Comparison between group I & group II in male & female participants (Table No. 6)
In both gender group, group I participants had significantly better experience with their prosthesis compared to group II.
3.10. Comparison between group I & group II in urban & rural area participants (Table No. 6)
Among patients residing in urban areas, more satisfactory results (lower OHIP score) were in group I compared to group II. Among rural area patinets there is no significant difference between group I & group II.
3.11. Comparison between long span implant prosthesis & long span FPD (Table No. 6)
Satisfactory score were obtained in long span implant supported prosthesis compared to long span teeth supported FPDs but the difference is not statistically significant.
4. Discussion
An increasing use of dental implants in metropolitan areas and among those with higher socioeconomic background was predicted by earlier studies on dental implant awareness in different regions of India.5,7 The same is not true for second-tier cities and rural communities. Therefore, a questionnaire based cross sectional survey was conducted to check the awareness and acceptability of dental implants as a permanent solution for replacement of missing teeth.
74.4% of study participants believe that missing teeth should be replaced. This suggests the awareness of major population about necessity of replacement of missing teeth. 27.2% of participants were aware about dental implants and 41.6% participants were aware about FPDs as an option to replace the missing teeth. Jayshinghe MR et al. 20178 reported that 76.2% of the study group believed that missing teeth should be replaced by prosthetic means. 32.9% participants were aware about dental implants. Siddique EA et al., 2019's9 findings revealed that 84.4% of patients felt the need to replace their missing teeth, 93.4% patients were aware about dental implants. Therefore, knowledge of implant differs in different population and areas of studies conducted. Hussain AA et al. 202310 in a study at Swiss university clinic reported that 78% participants were aware about dental implants as a treatment option for replacement of missing teeth and consider them as prioritized solution. Salim NA 202111 in a survey on Syrian refugee reported that 81.8% of the interviewees had missing teeth, however, only 26.2% replaced them. 16.6% of participants had never/hardly heard about implants. Females who never heard of dental implants were more than males.
There is a need for more awareness among elderly and less educated patients who live in rural areas since in the current study the majority of patients were in the age range of 26–55 years, graduates and from urban residency who were more conscious about dental implants. We have to look out for the mode of educating rural population about dental implants through newspaper, dental camps and awareness at dental departments at primary health centre and community health centre levels.
43.4% participants believed that higher treatment charges were the main limitation of dental implants, followed by fear of surgery (31.6%). This is in accordance with the studies done by Zimmer et al.12 and Akagawa et al.13 Therefore, having dental insurance will definitely increase patients' willingness to accept the dental implant procedure.
66% participants had information about dental implants via their dentists followed by magazine, newspaper, social media etc. This is in accordance with studies like Chowdhary et al.14 and Satpathy et al.15 which stated that the primary source of information of dental implants for patients are dentists. Hussain AA et al. 202310 in a study at Swiss University clinic reported that primary source of information are dentists (59%) followed by the internet (50%), relatives and friends (40%). Salim NA 202111 in a survey on Syrian refugee reported that friends were main source of information (61.4%).
41.4% participants stated that the care of dental implant should be taken similar to that of the natural teeth. Therefore, it is equally important to stress about dental implant cleanliness and maintenance.
In the past, clinician-based outcomes were given more importance compared to subjective patient based measures.16 In order to better understand how treatment affects patients' quality of life, dentists have recently begun to place more emphasis on patients' perceptions of their oral health and oral treatment.17 Research suggests that clinicians and patient have different perspective about success of prosthetic replacement.17,18
Functional limitations were significantly higher in FPDs compared to ISPs. This indicates that in patients who received FPDs, natural teeth abutment were still tender or may have dentinal hypersensitivity issues. This in turn may also affect their concentration levels and irritability during their working hours in office.
The patients who received ISP felt minimal functional chewing limitation, pain or psychological problem compared to FPD group. The likely reason for that might be as a postoperative instruction clinician advice patients to be very careful about breakage of any parts of dental implants that is why patient becomes conscious about chewing from the implant side. Moreover, increased cost and longer treatment durations make patient psychologically careful about chewing and they avoid chewing hard food from that side during initial months after prosthesis placement. Later on, patient becomes used to it and gradually they start chewing hard food comfortably on implant side.
Ease of speaking was higher with implant groups compared to fixed partial denture group, this may attribute to more bulk of prosthesis in teeth supported fixed partial denture and less importance was given to contour in pontic and abutment areas.
Common problems we came across in FPD group patients were trouble flossing because of the tight contacts of the crown and sensitivity in abutment teeth region.
Previous studies found that OHRQoL have significantly improved in both ISPs and FPDs after treatment and posttreatment ISPs and FPDs OHRQoL scores are comparable.19, 20, 21, 22 Xuereb A et al., 2023 in a study concluded that there was no statistically significant difference in OHIP-14 scores between FPD & implant prosthesis.23
Present study had good number of participation rate and sample size of 500 participants in implant awareness questionnaire and 300 participants in each group of prosthesis OHRQoL is the strength of the study. OHIP questionnaire is worldwide accepted and sensitive method to assess OHRQoL. Another strength of the study is that group I & II were compared under subheadings of different regions (anterior & posterior), in different genders and different residential areas. Significantly better results (lower OHIP score) were found in implant supported prosthesis group in posterior region compared to teeth supported fixed partial denture, among both gender groups and in urban population.
Since only post treatment OHIP questionnaire was obtained, it is unclear whether OHRQoL has improved compared to pre treatment stage. A pre treatment assessment would have provided additional useful information. One of the limitations of the study observed is the follow up period of 3 months. Future studies can be performed with further long term follow up.
5. Conclusion
Awareness about dental implants was less compared to other prosthetic options like FPDs and RPDs. Although patients did show positive attitude and enthusiasm towards knowing more about dental implants, high cost of dental implant treatment was a major limitation. Functional limitations, psychological discomfort and pain while functioning was significantly higher in FPDs compared to implant supported prosthesis. In posterior region implant supported fixed prosthesis turned out with better acceptance by patients compared to teeth supported FPDs.
Presentation at meeting
None.
Declaration of competing interest
None.
Acknowledgement
THIS RESEARCH IS APPROVED AND ACCEPTED BY ICMR AS A PART OF STS – 2020 PROGRAMME.
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