Abstract
Background:
Implants have emerged as a successful treatment option for the replacement of lost teeth. As dentists are the important source of information regarding implants, their knowledge and understanding of treatment options have a beneficial impact on patients’ choice of treatments. The aim of the study is to evaluate the knowledge, attitude, and practice of dental implants among dental postgraduates and practitioners in Hyderabad city, Telangana.
Materials and Methods:
Out of total 599 samples, 286 were dental postgraduates and 313 were practitioners. A self-administered validated 27-item questionnaire containing demographic details and knowledge, attitude, and practice-based questions was used to collect the data through Google Forms or personal interview. Statistical analysis was performed using the SPSS software version 20.
Results:
The mean knowledge scores were notably higher among elderly dentists (7.69 ± 1.6), with over a decade of experience (7.8 ± 1.52) and had undergone implant training (8.07 ± 1.36). The majority of elderly dentists (89.7%) and with over 10 years of experience (89.4%) exhibited a positive attitude toward dental implants. Moreover, a significant proportion of elderly dentists (51.6%) and with more than 10 years of experience (62.6%), as well as institutional-based practitioners (60%) and who received implant training (76.4%), felt that they are competent enough to place implants significantly.
Conclusion:
Majority of subjects had knowledge on the various aspects of dental implants and preferred dental implants over removable partial denture or fixed partial denture (RPD/FPD). Mean knowledge level significantly increased with age, experience, and exposure to training. Dentist practice levels were significantly influenced by age, gender, experience, qualification, and implant training.
Keywords: Dental implants, dental practitioners, edentulous, implant training, postgraduates
INTRODUCTION
Tooth loss, being the consequence of oral disease remain the worldwide public health issue, affecting the quality of life.[1] According to the World Health Organization 2022, the global prevalence of tooth loss for 20 years and above was 7% and for 60 years and above was 23%, primarily due to dental caries, periodontal diseases[2] resulting in poor dietary intake, functional limitation, and psychological defects.[3] Over the centuries, the tooth loss was effectively managed through provision of removal or fixed partial denture (RPD/FPD).
While FPD offer long lasting, natural looking, and improve the function of teeth, RPD is affordable and used to restore edentulous spaces where fixed prosthesis may not be feasible due to inadequate support[4] but associated with certain drawbacks such as food accumulation, inability to eat certain foods, alteration of adjacent teeth, and increased risk of gingival inflammation.[5] A study done by Bilhan et al. reported high patient dissatisfaction due to factors such as poor retention (64.6%), ulcerations (47.5%), loss of artificial teeth (35.4%), and fracture of the denture base (26.3%) with RPD.[6] Ramaswamy et al. also observed dissatisfaction level among FPD patients, as a result of factors such as food lodgment (33.91%), compromised esthetics (3.04%), and pain postcementation (13.04%).[7]
Over the last few years, much research in osseointegration led implants as a successful treatment option for tooth loss.[8] An implant is a biocompatible alloplastic material surgically inserted into orofacial tissues to provide secure anchorage, functional support, therapeutic intervention, and/or esthetic enhancement,[9] known for their natural appearance, durability, strength, and functional effectiveness.[10] Implants, anchoring into the jawbone, prevent bone loss and enhance facial structure, improving speech and chewing ability, leading to better quality of life.[11]
In comparison to conventional prosthesis, dental implants boast higher success rates[9] (above 97% for 10 years) and wide patient acceptance.[12] The success depends on patient factors as well as implant factors, with dentist knowledge influencing decisions. According to Elani et al., there is a significant increase in the utilization of dental implants, rising from 0.7% in 1999–2000 to 5.7% in 2015–2016.[13] However, few studies in Enugu and Davangere by Mgbeokwere et al.[5] and Nagpal et al.[14] found low level of knowledge and attitude among health workers and dentists, respectively.
As dentists are the important source of information regarding dental implants, their knowledge and understanding impacts patient treatment choices.[12] Thus, aim of this study is to assess the knowledge, attitude, and practice of dental implants among pursuing dental postgraduates and practitioners in Hyderabad city, Telangana.
MATERIALS AND METHODS
A cross-sectional survey, utilizing a structured questionnaire, was undertaken to assess the perspectives of pursuing dental postgraduates and dental professionals in Hyderabad. Ethical approval was obtained from the Institutional Review board. The study fulfills the strengthening the reporting of observational studies in the epidemiology guidelines. Anonymity and confidentiality of the participant are maintained. Informed consent was obtained. The study was conducted from July 2022 to November 2022.
Based on the previous literature,[14] the sample size was 594 with expected proportion of 0.55 and at a confidence level of 95% and with precision of 5%. All the pursuing dental postgraduates and practitioners who are willing to participate in the survey and present on the day of data collection were included and those who are not willing to participate and incompletely filled pro forma were excluded from the study. The questionnaire was validated on a sample of 20 subjects, and these subjects were not included in the final sample. Cronbach’s alpha value was found to be 0.89, considered to be acceptable.
Data will be collected either through personal interview or Google forms based on the convenience. Questionnaire was structured into two sections, each including: Section A assessing demographic characteristics of the respondents such as age, gender, and dentist factors (academic positions, years of experience, whether or not any implant training received, and the type of practitioner). Section B assessing knowledge, attitude, and practice of dental implants by using a validated self-administered 27-item questionnaire adapted from a study done by Nagpal et al.[14] Questions 1–7 assessed the knowledge of dentists toward implants. All the correct responses were coded as 1 and the response “no” or “don’t know” as 0. Hence, the total awareness ranged from 0 to 9. The cutoff score was determined to be >6, to categorize the subjects as high and low awareness. Questions 8–17 assessed the attitude of dentists toward implants. All the positive responses were coded as 1 and negative as 0. The total attitude score ranged from 0 to 10. The cutoff score was determined to be >8, to categorize the subjects as positive and negative attitude. Questions 18–20 assessed the practice of dental implants by dentists.
Statistical analysis was conducted using the Statistical Package for Social Sciences (SPSS) package version 22 (IBM Corp. in Armonk, New York, USA). Descriptive statistics were carried out to obtain the demographic distribution of the study population. Mean comparison of knowledge and attitude was done using Mann–Whitney U-test and Kruskal–Wallis test. The comparison of practice based on the variables was done by the Chi-square test. Categorization of subjects based on the level of knowledge and attitude was carried out by the Chi-square test. P < 0.05 was considered to be statistically significant.
RESULTS
A total of 599 dentists participated in the present study. Majority of them were pursuing postgraduation (PG) 47.7%, followed by general dental practitioner (GDP) 36.7%, institutional-based practitioner (IBP) 10.9%, and institutional based nonpractitioner (IBNP) 4.7%. More than half of them were of <30 years (64.4%) and 35.6% were of ≥30 years. Majority of the participants were female (70.5%), whereas 29.5% are males. Half of the participants have <5 years of experience (49.9%), 29.5% of them have 5–10 years of experience and 20.5% of them have >10 years of experience. Majority (92.7%) practice in urban and only 7.3% practice in the semiurban areas. Around 67% did not receive implant training [Table 1].
Table 1.
Demographic distribution of study subjects
| Variables | n (%) |
|---|---|
| Age (years) | |
| <30 | 386 (64.4) |
| ≥30 | 213 (35.6) |
| Gender | |
| Males | 177 (29.5) |
| Females | 422 (70.5) |
| Experience (years) | |
| >5 | 299 (49.9) |
| 5–10 | 177 (29.5) |
| >10 | 123 (20.5) |
| Qualification | |
| PG | 286 (47.7) |
| Institutional-based practitioner | 65 (10.9) |
| Institutional-based nonpractitioner | 28 (4.7) |
| General dental practitioner | 220 (36.7) |
| Practice location | |
| Urban | 555 (92.7) |
| Semi-urban | 44 (7.3) |
| Received implant training | |
| Yes | 192 (32.1) |
| No | 407 (67.9) |
| Overall sample | 599 (100) |
n – Number of participants; % – Percentage; PG – Postgraduates
Almost all the participants (98.7%) have heard about dental implants. More than 3/4th of them knew that titanium material is used for implants (85.8%), types of implantation methods (77.1%), Branemark’s theory of osseointegration (78%), and different body designs (75%). Majority of them (63.9%) were aware of various surface modifications, wherein 53.4% of them knew about all the three materials, i.e., hydroxyapatite, ceramics, and titanium plasma sprayed. Majority of participants (79.6%) knew that shape of alveolar ridge, density of alveolar bone, and site of edentulous area determine the success of dental implants.
Although majority of dentists (96.8%) prefer dental implants over RPD and FPD, patients’ financial status (97.3%) and dentist experience and training (97%) influence choice of treatment. Among all participants, 32.4% of them prefer meta-analysis as clinical evidence, in comparison to randomized control trials, systematic reviews, clinical evidence, and case reports. In comparison to conventional therapy, majority of them (94%) felt implant therapy as superior treatment plan for replacing anterior and posterior teeth, has better chewing efficacy (97.2%) and better esthetic outcome (96.3%). Further, they also felt that implants are too expensive (89.1%), need maintenance (93.3%), and have technical and biological complications (88.3%).
On a negative note, only 31.4% of them have placed dental implants. Majority of the dentists (14%) use Bioline followed by Adin (10.68%), Ostem (8.84%) implants. Around 1/3rd of the dentists use two stage approach for implant placement (34.7%), wherein 29.9% wait for 2–4 months (mandible) and 19.2% for 4–6 months (maxilla) following their first surgery. Among the patients they placed implants, majority of them were middle aged (28.5%). Most of the dentists felt that they are not competent enough to place dental implants (61.9%) and felt the need for attending training courses (76%).
The mean knowledge scores were higher among elderly dentists (7.69 ± 1.60), males (7.19 ± 1.98), with >10 years of experience (7.80 ± 1.52), who are IBP (7.2 ± 1.86), practicing in urban location (7.01 ± 1.97) and who received implant training (8.07 ± 1.36). Significant comparison was seen only with respect to age, experience, and implant training. However, post hoc analysis of knowledge based on experience reveals no statistical significance between subjects with 5 and 10 years of experience and >10 years of experience [Table 2].
Table 2.
Mean comparison of knowledge and attitude based on variables
| Variables | Knowledge | Attitude |
|---|---|---|
| Age (years) | ||
| <30 | 6.61±2.07 | 8.07±1.12 |
| ≥30 | 7.69±1.60 | 8.14±0.67 |
| P | 0.000* | 0.609 |
| Gender | ||
| Males | 7.19±1.98 | 8.01±0.97 |
| Females | 6.91±1.98 | 8.13±0.99 |
| P | 0.058 | 0.223 |
| Experience (years) | ||
| >5 | 6.44±2.12 | 8.07±1.16 |
| 5–10 | 7.36±1.75 | 8.10±0.86 |
| >10 | 7.80±1.52 | 8.15±0.66 |
| P | 0.000* | 0.857 |
| Qualification | ||
| PG | 6.90±1.93 | 8.11±1.06 |
| IBP | 7.24±1.86 | 8.10±1.01 |
| IBNP | 6.57±2.13 | 8.28±0.85 |
| GDP | 7.09±2.07 | 8.04±0.90 |
| P | 0.198 | 0.287 |
| Practice location | ||
| Urban | 7.01±1.97 | 8.11±0.97 |
| Semi-urban | 6.72±2.11 | 7.84±1.18 |
| P | 0.314 | 0.097 |
| Received implant training | ||
| Yes | 8.07±1.36 | 8.10±0.75 |
| No | 6.48±2.03 | 8.09±1.08 |
| P | 0.000* | 0.772 |
*P≤0.05 is considered to be statistically significant. Test applied: Kruskal–Wallis test- experience, qualification; Mann–Whitney U-test - age, gender, practice location, and training. PG – Postgraduates; IBP – Institutional-based practitioners; IBNP – Institutional-based nonpractitioners; GDP – General dental practitioners; P – Probability value
The mean level of attitude [Table 2] was comparable based on age, gender, experience, qualification, practice location, and implant training with no statistical significance (P = 0.60, 0.22, 0.85, 0.28, 0.09, and 0.77, respectively). Significantly, subjects with age <30 years (79.3%, 85.5%), females (74.6%, 80.3%), subjects with <5 years of experience (80.9%, 86.6%), IBNP (92.9%, 92.9%) and who did not receive implant training (98.5%, 97.8%) have never placed dental implants and felt need for attending training courses, respectively. Subjects with ≥30 years of age (51.6%), males (48.6%), with >10 years of experience (62.6%), IBP (60%), who received implant training (96.4%) felt that they are competent enough to place implants significantly.
Categorization of subjects based on their level of knowledge revealed significant difference only for age, experience, and implant training. Wherein subjects with experience >10 years (83.7%), age group ≥30 years (80.3%), practicing in urban areas (66.3%), who received implant training (87.5%) had high level of knowledge. Majority of subjects with age group ≥30 years (89.7%), females (84.1%), with >10 years of experience (89.4%), GDP (85.9%), practicing in urban areas (84.3%), and who received implant training (87%) have positive attitude toward dental implants and significant comparison can be seen with respect to age, experience and practice location [Table 3].
Table 3.
Categorization of subjects based on level of knowledge and attitude
| Variables | Knowledge | Attitude | ||
|---|---|---|---|---|
|
|
|
|||
| Low (≤6), n (%) | High (>6), n (%) | Negative (<8), n (%) | Positive (≥8), n (%) | |
| Age (years) | ||||
| <30 | 162 (42) | 224 (58) | 80 (20.7) | 306 (79.3) |
| ≥30 | 42 (19.7) | 171 (80.3) | 22 (10.3) | 191 (89.7) |
| P | 0.000* | 0.001* | ||
| Gender | ||||
| Males | 52 (29.4) | 125 (70.6) | 35 (19.8) | 142 (80.2) |
| Females | 152 (36) | 270 (64) | 67 (15.9) | 355 (84.1) |
| P | 0.118 | 0.247 | ||
| Experience (years) | ||||
| >5 | 133 (44.5) | 166 (55.5) | 67 (22.4) | 232 (77.6) |
| 5–10 | 51 (28.8) | 126 (71.2) | 22 (12.4) | 155 (87.6) |
| >10 | 20 (16.3) | 103 (83.7) | 13 (10.6) | 110 (89.4) |
| P | 0.000* | 0.002* | ||
| Qualification | ||||
| PG | 105 (36.7) | 181 (63.3) | 55 (19.2) | 231 (80.8) |
| IBP | 17 (26.2) | 48 (73.8) | 10 (15.4) | 55 (84.6) |
| IBNP | 12 (42.9) | 16 (57.1) | 6 (21.4) | 22 (78.6) |
| GDP | 70 (31.8) | 150 (68.2) | 31 (14.1) | 189 (85.9) |
| P | 0.244 | 0.418 | ||
| Practice location | ||||
| Urban | 187 (33.7) | 368 (66.3) | 87 (15.7) | 468 (84.3) |
| Semi-urban | 17 (38.6) | 27 (61.4) | 15 (34.1) | 29 (65.9) |
| P | 0.505 | 0.002* | ||
| Received implant training | ||||
| Yes | 24 (12.5) | 168 (87.5) | 25 (13) | 167 (87) |
| No | 180 (44.2) | 227 (55.8) | 77 (18.9) | 330 (81.1) |
| P | 0.000* | 0.073 | ||
| Overall sample | 204 (34.1) | 395 (65.9) | 102 (17) | 497 (83) |
*P≤0.05 is considered to be statistically significant. Test applied: Chi-square test. PG – Postgraduates; IBP – Institutional based practitioners; IBNP – Institutional based nonpractitioners; GDP – General dental practitioner; P – Probability value; n – number
DISCUSSION
Missing teeth are typically restored through the use of dental prostheses, which include RPD or FPD. In order to address these challenges, dental implants are often employed as a viable alternative.[15] The treatment decision-making process is significantly influenced by a dentist’s expertise and perspective on the utilization of dental implants.[16] Therefore, this study was undertaken with the objective of appraising the comprehension, perspectives, and practical application of dental implants among pursuing dental postgraduates and practitioners, encompassing both general and institutional sectors, in Hyderabad.
In this study, it was observed that a high proportion of participants (98.7%) had awareness regarding dental implants. Among these, a significant majority (85.8%), identified titanium as the material commonly employed for implantation, while a substantial percentage, around 77.1%, demonstrated knowledge of various implantation methods. Furthermore, approximately 75% exhibited familiarity with diverse implant body designs. This awareness might be due to the continuing education, practical experience, access to resources, and market demand.
In the present study, 97% of them indicated that experience and training play a significant role in influencing treatment selection. Studies conducted by Chaudhary et al.[17] and Sharma et al.[18] wherein only 12.2% and 34.28% of the respondents, respectively, emphasized the importance of dentist experience in implant success. Furthermore, this study revealed that majority of dentists (96.8%) expressed a preference for dental implants over RPD/FPD. This preference is likely due to the advantages of dental implants, including enhanced esthetics, durability, strength, and functional effectiveness. These findings contrast with the research conducted by Akeredolu et al.[19] where 46.1% of participants recommended dental implants for patients requiring full or partial dentures and 31.8% suggested dental implants for those in need of single-tooth replacements.
In comparison to the findings of Chaudhary et al.[17] (63.3%), greater number of present study dentists (97.3%) felt that the financial status of the patient will affect their treatment choice. 93.3% participants feel that dental implants need maintenance. These findings align with the study conducted by Sharma et al.[18] where 81.78% of them concurred that maintaining optimal oral hygiene and care for dental implants demands a higher degree of attention and effort as compared to natural teeth.
Merely 31.4% of the participants in this study reported having experience in placing dental implants. Similarly, Akeredolu et al.[19] observed a notably low prevalence of implant dentistry practice. Conversely, a study conducted by Ng et al.[20] revealed that a significant majority, (61%) were engaged in implant dentistry, suggesting potential disparities in knowledge, skills, or confidence levels among dental practitioners. Consequently, 76% of the participants in this study expressed a desire to attend training courses. These findings were similar with those from previous studies done by Chaudhary et al.[17] and Ng et al.[20] where a majority of participants, i.e., 57.9% and 85%, respectively.
In this study, it was observed that among participants who were practicing implant dentistry, 62.6% of them had over a decade of experience, signifying accumulated knowledge and hands-on experience enabled them to handle complex cases more effectively, leading to better patient outcomes. In contrast, Akeredolu et al.[19] reported a significantly lower percentage, with only 32.5% of them having practiced implant dentistry for >10 years. Notably, the research done by Nagpal et al.[14] highlighted that dentists with <5 years of experience (15%) and who had received implant training (29%) were considered more competent in the placement of dental implants. On the other hand, the study conducted by Ng et al.[20] revealed that only few young practitioners, specifically those with <9 years of experience, engaged in clinical work related to implant dentistry, possibly due to adequate undergraduate training.
The present study shows that elderly dentists with >10 years of experience (83.7%), practicing in urban areas (66.3%), and who underwent implant training (87.5%) had high level of knowledge. Older dentists often have accumulated extensive professional experience and continuous exposure to advancements in dental techniques, contributing to a deeper understanding of implantology. Experience, regardless of age, enhances practical skills and familiarity with a broader range of clinical scenarios, reinforcing theoretical knowledge. Prior training specifically in dental implants provides a solid foundation and keeps practitioners abreast of the latest developments in the field. In addition, the area of residence impacts access to educational resources, professional networks, and opportunities for hands-on training, with urban areas typically offering more advanced facilities and continuing education programs. These factors collectively ensure a more comprehensive and updated knowledge base among present study dentists.
However, Sharma et al.[18] and Nagpal et al.[14] observed high level of knowledge among interns and in dentists with <5 years of experience respectively, which might be due to their contemporary education and training during their undergraduate curriculum. The observed differences in knowledge levels in these studies can be attributed to a combination of factors related to sample variation, timing, education, experience, and practice settings.
According to Chaudhary et al.,[17] a significant proportion of participants (73.3%) reported that they had not received adequate information about dental implants during their undergraduate curriculum. Similarly, Mgbeokwere et al.[5] noted a low level of knowledge (9.7%) concerning dental implants among health workers due to limited exposure to dental implantology practice. However, in this study, the high level of knowledge observed among dentists who did not receive formal implant training (55.8%) can be attributed to several factors. Dentists may have accessed extensive professional education resources, such as online courses, workshops, and seminars, which have become more prevalent and accessible. In addition, the informal transfer of knowledge through peer interactions, professional networks, and collaboration with colleagues who have implant training can significantly enhance understanding. The emphasis on continued professional development and staying updated with advancements in dental practices also plays a crucial role.
In this study, IBP (73.8%) has a high level of knowledge followed by GDP, pursuing PGs, and IBNP, although the difference was not statistically significant. In contrast, Nagpal et al.[14] reported that knowledge of dental implants was found to be maximum in pursuing PGs (36%) followed by IBP, GDP, and IBNP and these differences were statistically significant.
Considering the factor of attitude, this study revealed that elderly dentists (89.7%), with over a decade of experience (89.4%), and practicing in urban settings (84.3%) exhibited a positive attitude toward dental implants. These findings align with those of Sharma et al.[18] which indicated a prevailing positive attitude among the majority of participants toward obtaining information from various sources. Similarly, Nagpal et al.[14] study showed that individuals with over 15 years of experience had highly positive attitude but not significant.
However, the current study acknowledges certain limitations, notably self-reported nature of questionnaire, which might lead to social desirability bias. The study strength lies in the inclusion of participants from most of the dental institutions and dental clinics, thus highly representative of the region and the results provided a holistic view. Further studies are recommended to include a more comprehensive questionnaire, larger sample size, and an examination of dentist-related variables, particularly those pertaining to postgraduate specialization. Hence, the study concluded that majority of the subjects had knowledge on various aspects of dental implants and prefer over RPD/FPD. However, only 31.4% of them have placed dental implants. Mean knowledge level and their practice levels significantly increased with age, experience, and exposure to training. Upon categorization, 65.9% of them had high knowledge and 83% had positive attitude.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
We would like to thank all my study participants for their cooperation.
Funding Statement
Nil
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