Awareness, knowledge, and attitude of patients toward dental implants - A questionnaire-based prospective study.

BACKGROUND: In developing nations like India awareness and education about dental implants as a treatment modality is still scanty. AIM: The study was conducted to determine the awareness, knowledge, and attitude of patients toward dental implants as a treatment modality among the general population and to assess the influence of personality characteristics on accepting dental implants as a treatment modality in general and as well as treatment group.
MATERIALS AND METHODS: A structured questionnaire-based survey was conducted on 500 randomly selected participants attending the outpatient department. The study was conducted in 2 parts. In the first part of the study, level of awareness, knowledge, and attitude was assessed. In the second part of the study, interactive educational sessions using audiovisual aids were conducted following which a retest was conducted. The participants who agreed to undergo implant treatment were followed up to assess their change in attitude towards dental implants posttreatment. Thus pain, anxiety, functional, and esthetic benefits were measured using visual analog scale. They were further followed up for 1 year to reassess awareness, knowledge, and attitude towards dental implants.
RESULTS: A total of 450 individuals completed the questionnaires. Only 106 individuals agreed to participate in the educational sessions and 83 individuals took the retest. Out of these, only 39 individuals chose implants as a treatment option. A significant improvement in the level of information, subjective and objective need for information, was noted after 1 year.
CONCLUSION: In this study, a severe deficit in level of information, subjective and objective need for information towards, dental implants as a treatment modality was noted. In the treatment group, a significant improvement in perception of dental implant as a treatment modality suggests that professionally imparted knowledge can bring about a change in the attitude.

INTRODUCTION

Dental implants have emerged as a very predictable treatment for missing teeth. However, in developing countries, limited numbers of people opt for dental implants. Several factors affect the choice of dental implant as a treatment modality in these countries.[1]

Some studies reported that there is severe knowledge deficit in the Indian population,[2] while others reported a higher level of awareness of 64.4%, 77%, and 79%, respectively.[345] Awareness, knowledge, and attitude survey are the preferred tools to attain both quantitative and qualitative information.[6]

Definition of successful implants is constantly changing. Currently, successful implant therapy is measured in terms of both functional and psychosocial acceptance by patients.[7] These patient-centered approaches to the assessment of treatment efficacy appear to be more realistic than physician centered approach.[89]

Personality profiles affect periodontal and implant health.[810] When the patient centered approach is used as the criteria for defining success, it is imperative that the practitioners should be aware of the multidimensional aspects of patients’ satisfaction including personality profile.

Hence, the aim of the study was to determine the awareness, knowledge, and attitude of patients towards dental implants and to assess the influence of personality characteristics on accepting dental implants as a treatment modality. We followed up the participants after educational sessions and assessed their expectations regarding pain, anxiety, function, esthetics before and immediately after placing dental implants. The participants were further followed up for 1 year. The change in the level of awareness, knowledge, and attitude was reassessed.

MATERIALS AND METHODS

This was a questionnaire-based prospective study conducted among the patients attending the outpatient department. Institutional ethical clearance and informed consent were obtained from all the subjects before the commencement of the study (ref no. YUEC154/20/11/2013). The study was registered with the clinical trial registry of India (Trial REF/2015/11/010071). A total of 13 males and 17 females participated in the pilot study. The mean age was 18.8 years.

The sample size was calculated after pilot study, using a power of 80%, α = 0.05 and a standard deviation of 0.46 mm. Simple random sampling was done, and a total of 500 (n = 500) individuals were recruited to the study between December 1, 2013, and July 31, 2015.

Systemically, healthy controls within the age group of 18–60 years with one or more missing teeth (other than third molars) were included in the study. Pregnant, lactating women, individuals with uncontrolled diabetes or hypertension and preexisting nerve injury or paresthesia were excluded from the study.

Questionnaires

Three sets of prevalidated questionnaires were used [Annexures I–III]

Dental implant knowledge, awareness, and attitude questionnaire

Eysenck personality inventory scale

Dental implant treatment assessment questionnaire.

All the questionnaires were designed in printed formats.[14] The primary language of the questionnaires was English and 2 translators from Social Welfare Department were recruited to translate the questionnaire in 3 local languages.

Dental implant knowledge, awareness, and attitude questionnaire

This was a closed-ended questionnaire with 12 questions divided into three sections:

Section A – Level of information about dental implants

Section B – Subjective need for information

Section C – Objective need for information.

For designing of the questionnaire refer Annexure I. Overall awareness, knowledge, and attitude were the summative score of all the responses in each section. Level of information, subjective need and objective need for information, was graded as very good (score of 90% and above), good (score 80%–89%), moderate (50%–75%), and poor (<50%). Fifty percent knowledge was kept as a benchmark based on the previous study.[13] The deficit in knowledge in each category was graded as complete deficit (0), severe deficit (<25%), and moderate deficit (25%–50%).

Eysenck personality inventory scale

This was a standardized printed questionnaire with reliability in the range of 0.84–0.94. It consisted of a brief case history, followed by 57 statements which were designed to give a ready measure of 3 important personality dimensions, i.e., extrovertism (E), introvertism (I), and neuroticism (N). For designing of the Questionnaire B refer Annexure II. Based on the norms provided by Eysenck, an individual can have more than one personality trait.

Dental implant treatment assessment questionnaire

The subject's pain and anxiety before implant placement, immediately, 1 day and 1 week after implant placement was evaluated. Their functional and esthetic expectations, before and after implant placement was also assessed [Annexure III].

Study design

The prospective study was conducted in 2 parts as shown in Figure 1. In the 1st part of the study, printed questionnaires A and B were distributed to all subjects. Data of the completed questionnaires was entered and a computer generated code starting from 1 to 450 was randomly given to all the subjects as their identity. The person allocating the number was completely blinded. According to this coding, 450 subjects (code nos.1-450) answered the questionnaires.

Figure 1

Consort flow chart of the study design

The lie scores of questionnaire B were totaled. If a subject scored ≥ 5, he / she were disqualified from the study. All those subjects who scored ≤ 4 were included in the study. 26 subjects were excluded from the study because of a high lie scores.

In the 2nd Part of the study, implant educational sessions were planned using an interactive audio visual aid (Dental Implant patient education video). A total of 106 (n=106) subjects were willing to participate in these educational sessions. The subjects were asked to participate in a re- test for Questionnaire A at the end of the educational sessions. Only 83 (n =83) subjects were willing to take a re-test. All the subjects were assessed based on their change in awareness, knowledge and attitude towards dental implants post implant educational sessions.

On completion of the re-test the subjects were asked for their willingness to undergo implant treatment. Out of 83 subjects, 39 chose implant as an option for the replacement of their missing teeth and Questionnaire C was distributed among them. These subjects were followed up and Questionnaire A was redistributed after 1 year. They were assessed based on their change in awareness, knowledge and attitude towards dental implants 1 year after undergoing treatment.

RESULTS

All the data was entered and tabulated into M. S Excel Spreadsheet (Version 2013). The data was analyzed using Statistical Package for Social Science software (SPSS, Version 20.0, IBM, USA). In the first part of the study, standard deviation and mean percentage were calculated. One-way ANOVA was used to ascertain the correlation between mean section-wise scores and age and occupation. Paired t-test was used to compare the mean section-wise scores with gender and educational qualification. In the second part of the study, Mann–Whitney U-test was done to compare the personality traits between the groups. Paired t-test was used to compare the mean section scores before and after educational sessions.

Results of the pilot study

Questions Q.4 and Q.13 were deleted from final questionnaire A. Calculated Cronbach's alpha of Q.8, Q.10, Q.11, and Q.12 after rephrasing was 0.498, 0.494, 0.445, and 0.509, respectively. The mean reliability score of questionnaire A was 0.515. A Revised Eysenck Questionnaire with 57 questions was included in this study.

Results of prospective study

Twenty-six subjects were excluded because the lie score was ≥5. The final sample size was n = 424 subjects. The demographic data of the participants are shown in [Table 1]. Mean percentage level of information was 48.76%. Moderate deficit in the level of information was noted [Table 2]. Only 15.1% of the subjects knew that their dentists practiced implantology, whereas 84.9% lacked the information. The mean section C score obtained was 3.20 ± 3.38. Mean percentage objective information was 26.65%. Severe deficit in subjective knowledge and objective information was noted [Table 3].

Table 1

Demographic data of the subjects (%)

Table 2

Section-wise percentage distribution of scores

Table 3

Percentage response to source of information, whether they know their dentist provides implants and barriers to dental implant as a treatment modality

Correlation of level of information, subjective need for information and objective need for information with age, gender, educational qualification and occupation

Age had no statistically significant correlation with section-wise score (one-way anova test, P > 0.05). Individuals within the age group of 18–30 years showed a higher mean section A and Section C scores. Whereas the individuals within the age group of 31–50 years showed a higher mean Section B score (mean = 3.46 ± 3.56, F = 120.75) [Table 4].

Table 4

Correlation of age with each section-wise score

Gender had no statistically significant correlation with section-wise score. Females showed statistically significant higher mean scores Section A, B, and C score (mean = 8.06 ± 2.61, 2.24 ± 1.09, and 3.37 ± 3.44) compared to males 7.54 ± 2.40 (t value=-2.14, P = 0.032) [Table 5].

Table 5

Correlation of gender with section-wise score

Group with higher education group showed statistically significant higher mean Section A, B, and C score of 8.35 ± 2.63, 2.35 ± 1.10, and 3.79 ± 3.52 (t = 2.35, P = 0.019). There was no statistically significant correlation with section B and C scores. The level of information was higher in subjects with higher educational background [Table 6].

Table 6

Correlation with qualification and section-wise score

Students and skilled workers showed a higher mean Section A (student mean = 8.38 ± 2.68; skilled worker mean = 8.27 ± 2.67) and Section B (student mean = 2.41 ± 1.14, skilled worker mean = 2.39 ± 1.12) scores. Occupation had statistically significant correlation with level of information (F = 3.53, P = 0.01) and subjective need for information (F = 196.66, P = 0.03) but not for objective need for information (F = 1.54, P = 0.20) [Table 7].

Table 7

Correlation of occupation with section-wise score

Comparison of personality traits between subjects who agreed and who did not agree for the educational sessions

No statistically significant difference in personality traits was seen between the two groups [Table 8]. The Individuals who agreed for the educational sessions showed a tendency toward extrovertism and neuroticism with a median score of 12 and 10, respectively.

Table 8

Comparison of personality traits between subjects who agreed and who did not agree for the educational sessions

Retest after educational session

Forty-five females and 38 males took part in the re-test [Tables 9 and 10]. A statistically significant increase in mean Section A, B, and C scores was noted. Mean percentage increase in level of information was 30.5. Mean percentage increase in subjective need for information was 17.75%. Overall, a statistically significant difference in their mean scores and percentage of information was noted after the educational sessions (P < 0.001).

Table 9

Comparison of scores before and after retest

Table 10

Percentage response to source of information, whether they know their dentist provides implants and barriers to dental implant as a treatment modality

Thirty-nine individuals out of this cohort chose implants as a treatment option (implant treatment group). Sixty-seven subjects did not choose implant as a treatment modality (nonimplant treatment group). In the implant-treated group, 24 were females and 15 were males. The mean age in this group was 30.77 years. In the nonimplant-treated group, 34 individuals were females and 33 were males. The mean age in this group was 30.58 years.

Pain, anxiety, functional, and esthetic scores before and after implant placement

A statistically significant decrease in pain and anxiety scores before and 1 week after the surgery was seen, statistically significant increase in mean functional expectation and esthetic expectation scores before and after implant treatment were noted. No statistically significant difference in mean pain, anxiety, functional expectation, and esthetic expectation scores were noted in different age groups and gender. Implant-treated groups showed significantly higher neurotic scores compared to nonimplant groups (P < 0.001). There was no statistically significant difference in other personality traits between the 2 groups.

Posttreatment retest was done to assess for change in their awareness, knowledge, and attitude toward dental implants 1 year after placement of implant. Paired t-test was used to compare the mean section scores [Table 11]. A statistically significant increase in mean scores for section A and B was noted. Mean percentage increase in the level of information was 33.12%. Mean percentage increase in objective need for information was 45.68%. There was no statistically significant difference in mean scores for subjective need for information. Mean percentage increase in subjective need for information was 0.94% [Table 12].

Table 11

Comparison of scores before and after 1 year retest

Table 12

Percentage response to source of information, whether they know their dentist provides implants and barriers to dental implant as a treatment modality

DISCUSSION

We conducted a questionnaire-based prospective study. The participants were followed up till the end of the implant treatment. In this study, an attempt was made to see if there was any influence of knowledge levels, personality traits, pain, anxiety, functional expectation, and esthetic expectations on subjects’ choice of treatment. Multimedia educational sessions were conducted to improve the knowledge. Pre- and post-test comparison of scores was done to assess the improvement of knowledge. Only 39 subjects among 424 participants underwent implant treatment.

Age had no statistically significant correlation with section-wise score. It has been noted that recall did not vary between age groups when prior knowledge was limited for both age groups.[14] This could be the possible explanation for lack of correlation between age and knowledge in our study. Gender had no statistically significant correlation with section-wise score. Females had comparatively higher mean scores than males. This finding is in agreement with other studies.[1516] Women tend to display better communication skills and have more opportunities to absorb new knowledge.[17]

Level of information was statistically higher in subjects with higher educational background. However, there was no statistically significant correlation with subjective and objective need for information. Similar results were reported in literature.[1819] Occupation had statistically significant correlation with level of information and subjective need for information but had no significant correlation with objective need for information. This is in agreement with a study conducted by Guarnizo-Herreño et al.[20] Higher the educational qualification higher is the metacognitive awareness of an individual and this might have led to better knowledge level.[21]

Our data indicate that knowledge deficits are widely distributed across age, gender, education, and occupation groups. Similar results were reported by Deinzer et al.[22] He stated that educational efforts should not be limited to specific target groups.

For objective assessment of knowledge, we set 50% knowledge level as the benchmark from our previous studies.[23] In this study, we considered knowledge level below 50% as knowledge deficit. Moderate deficit in the level of information was noted. The results are in agreement with other studies done.[1224] Unanswered responses were considered as knowledge deficit. This might have influenced the results of our study as it may not reflect the true knowledge of the respondents.

The source of knowledge of dental implants has a deep impact on the knowledge level. 4% felt that dentists were their main source of information. Similar results were found in another study.[2] Few studies reported that media was the main source of information.[325] About 55.07% of the individuals were willing to upgrade their knowledge about dental implants. Only 15.1% of the individuals knew that their dentists practiced implantology, whereas 84.9% lacked the information. Similar results were reported by Satpathy et al.[1]

Within the limited sample size, our data suggest that most of the individuals have a desire and positive attitude to improve their knowledge about dental implants. However, most of the subjects have impaired access to quality educational material. There is a necessity to disseminate the available scientific data among the general population. Furthermore, there is a need to improvise the existing educational material by employing current advances in technology.

Mean percentage objective information was 26.65%. Thus, a severe deficit in objective information was noted. When enquired about the potential barriers in accepting dental implants as a treatment modality, subjects stated that lack of clarity about the treatment procedure and high cost as the reasons for not opting dental implants as a treatment option. Similar results were reported by Chowdhary et al. and Satpathy et al.[12]

Interactive educational sessions using audiovisual aids highlighting dental implant indications, contraindications, treatment protocol, and postoperative maintenance regimen were carried out. Only 106 individuals agreed to participate in implant educational sessions. Totally, 318 individuals did not agree to participate. The common reasons cited were time constraint, job commitment, migration, and lack of interest. Twenty-three individuals refused to take the retest. Fear of being assessed objectively could be a possible reason why few subjects refused to participate in the retest.

A statistically significant increase in mean section score of level of information, subjective and objective need for information, was noted. Most of the subjects stated that they were not informed by their dentists about this treatment option. Subjects also opined that fear of surgery and high cost as disadvantages for accepting this form of treatment. A change in the test score was in agreement with other studies.[262728] Our data indicate that an interactive audiovisual aid as an educational tool did have a significant impact.

It has been hypothesized that an individual's personality trait influences the choices he/she makes.[29] In this study, we noted that there was no statistically significant difference in personality traits among people who chose implants or those who did not. Similar results were reported by Caspi et al.[30] Implant-treated group showed significantly higher neurotic scores compared to nonimplant groups. However, our sample size was small to derive meaningful inference. Contrasting results were reported by Hansen et al.[31]

A statistically significant decrease in pain and anxiety scores before and 1 week after the surgery was seen, statistically significant increase in mean functional expectation and esthetic expectation scores before and after implant treatment were noted.

The strengths of this study were that it was a comprehensive prospective study which included follow-up of subjects after assessing their knowledge, educational sessions, and retest was conducted to assess the change. Knowledge barriers such as personality traits, pain, and anxiety which could influence the choice of implant treatment were assessed. However, there was a significant dropout of participants during the study. Our results do provide some insight into various aspects of subject's knowledge that could influence treatment choice. However, the clinical setting, dropouts, and small sample size are the limitations of the study. The results of this study need to be validated by conducting studies involving larger population.

CONCLUSION

We found a significant severe knowledge deficit in all the section-wise scores of knowledge component. A single session of an educational intervention using interactive audiovisual aid had a significant improvement in knowledge. A single personality trait did not influence the subject's decision-making. There was a significant reduction in pain and anxiety scores post treatment.

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Table IIa

Scoring criteria of Eysenck Personality Inventory Scale

Table IIIa

Assessing pain scale expected from dental implant treatment

Table IIIb

Assessing anxiety scale expected from dental implant treatment

Table IIIc

Assessing functional benefits expected from the dental implant treatment

Table IIId

Assessing esthetic benefits expected from the dental implant treatment