Perception, Knowledge, and Attitude of Individuals from Different Regions of Saudi Arabia toward Dental Implants and Bone Grafts.

AIM: The aim of this study was to assess the perception, knowledge, and attitude of individuals from different regions of Saudi Arabia toward dental implants and bone grafts.
MATERIAL AND METHODS: An online, self-oriented, and cross-sectional-based questionnaire with 21 items was given to 1622 individuals from different regions of Saudi Arabia. The questionnaire recorded the perception, knowledge, and attitude of participants and their agreement or rejection of dental implants and various kinds of bone grafts. The responses were compared with age, sex, and educational level. Descriptive statistical analysis was performed for the collected data and P < 0.05 was considered statistically significant.
RESULTS: Most of the males (35.8%) and females (39.8%) reported that the major source of data regarding dental implants is friends and families. Majority of the participants (approximately 75% males and 73% females) support the idea that dental implants last for lifetime, whereas majority of the participants (approximately 49% males and 56% females) displayed their unawareness regarding materials used for dental implants. The overall acceptance rates of participants for autografts, alloplasts, xenografts from the cow, xenografts from the horse, and allografts were 40%, 15.9%, 2.5%, 2.2%, and 1.6%, respectively.
CONCLUSION: The expense of dental implants was considered the foremost reason for avoiding the procedure. Most of the participants think that fixed dental prostheses last longer than removable prosthesis. Autograft was the most accepted bone graft, whereas allograft was the least accepted bone graft over the responded participants. Copyright:

INTRODUCTION

Dental implants, also called as an endosseous implants, have been used for many years as a convenient solution to replace missing teeth in dental practice. Their introduction to dentistry is considered significant because of their high success rate.[1] A dental implant is an artificial root that is integrated to the jawbone by surgical procedure to anchorage a single tooth replacement (crown), fixed partial or complete denture, or maxillofacial prosthesis.[2]

The success rate of dental implants relies on the implant material to osseointegrate with the adjacent bone. However, dental implant osseointegration is affected by multiple factors such as implant material, patient's bone quality and quantity, and the implant loading condition.[1]

Dental implant is becoming a common treatment option with a promising success rate. The introduction of dental implants has improved the overall oral health-related quality of life. Dental implants have been accepted by patients undergoing the procedure, who have reported a positive experience.[3]

The decision of undergoing dental implant treatment depends on patients' preferences and attitude, doctors' knowledge and skills, diagnostic and therapeutic expertises, and financial considerations.[4]

Bone graft is indicated in different dental procedures to regain the bone volume that has undergone resorption because of medical condition, periodontal diseases, tooth loss, or any other problem.[5] Bone grafting procedures are considered the most frequent tissue transplantation following the blood transfusion, with more than 2 million bone grafting procedures done yearly.[6] Bone graft can be defined as the introduction of a material either alone or in combination with other materials into the defective site to replace the missing bone and enhance bone healing. The bone graft materials are categorized into four major classes: autografts, allografts, xenografts, and alloplasts.[7]

Alloplasts are synthetic and are derived from biologically based tissue-engineered materials; and a combination of these substitutes is also used as graft material.[8] Autogenous grafts are harvested bone grafts from various anatomical sites of the same patient, whereas allografts are bone grafts taken from another genetically different individual of the same species.[9] Xenografts are naturally derived deproteinized cancellous bone from different species such as bovine or porcine.[10]

Only a few studies have been conducted on patients' knowledge, attitude, and perceptions regarding various bone graft materials and their motivation to allow the use of these biomaterials in their procedures. The origin of the bone graft material could be unacceptable to patients because of religious, ethical, and cultural believes. Some studies on patient attitude toward grafts have been conducted in the medical field,[11] whereas in dentistry, research has mainly concentrated on evaluating the effectiveness of bone grafts rather than patient attitude. Similarly, scientific information on patient expectations and motivation regarding the acceptance or rejection of dental implants are low. Some research has been conducted on patient's perception, knowledge, and attitude toward dental implants in some regions of Riyadh and Al-Qassim cities, and a study has also been conducted on bone graft preference in Al-Qassim.[1213] These studies were limited to only one region of the city, such as patients visiting a university hospital, and had a limited sample size.

Therefore, the aim of this study was to assess the knowledge, attitude, and perception of patients from different regions of Saudi Arabia toward both dental implants and bone graft material.

MATERIALS AND METHODS

The present cross-sectional study, conducted using an online questionnaire, was designed to assess the patient's knowledge, attitude, and perception toward the dental implant and bone graft. The questionnaire was adapted from a study conducted by Agrawal et al.[14]

The online questionnaire comprised 21 questions and assessed the following aspects:

Knowledge and information regarding the use of dental implants as an option to replace missing teeth

Acceptance of dental implants as a treatment option compared with other alternative procedures

Acceptance and preference of different types of bone graft.

The inclusion criteria include both female and male Saudi citizens from different regions in Saudi Arabia., whereas the exclusion criteria are non-Saudi individuals. The online questionnaire was translated into the Arabic language to facilitate completion and comprehension of questions by respondents. A pilot test on 10 people was performed to evaluate the efficiency of the questionnaire prior to its finalization. Online questionnaires were prepared in June 2020 and distributed to individuals residing in the northern, central, western, eastern, and southern regions of Saudi Arabia to ensure the inclusion of a wide range of population.

RESULTS

A total of 1622 individuals take apart in the study. Table 1 exhibits the demographic details of participated subjects. Majority of the participants in the survey were male (67.3%) and possessed university-level education (71%). The highest percentage of participants belonged to the central region (31.9%) [Table 1].

Table 1

Distribution of the collected descriptive data

Parameters	Subparameters	Frequency (%)
Sex	Male	1090 (67.3)
	Female	530 (32.7)
Age	20-30	406 (25.1)
	31-40	400 (24.7)
	41-50	494 (30.5)
	Above 50	320 (19.8)
Region in Saudi	Northern region	316 (19.5)
	Central region	516 (31.9)
	Eastern region	252 (15.6)
	Western region	341 (21)
	Southern region	195 (12)
Place	Rural	286 (17.7)
	Urban	1334 (82.3)
Education	None	7 (0.4)
	Up to high school	250 (15.4)
	University education	1150 (71)
	Postgraduate and above	213 (13.1)

The major source of data about dental implant in both males (35.8%) and females (39.8%) was reported to be friends and families, followed by social media and dentists, with the source of least information reported to be other sources.

Majority of the people (approximately 75% males and 73% females) believed that the dental implants last for a lifetime. Males demonstrated a significantly higher knowledge (67.7%) of the durability of dental implants than females (32.3%) and this difference was statistically significant (P = 0.001). Approximately 47%, 44%, 48%, and 38% of participants belonging to the northern, central, eastern, and western regions, respectively, exhibited unawareness regarding dental implant and considered it a screw, whereas 46% of participants belonging to the southern region exhibited their awareness but failed to correctly describe the dental implant. The association between knowledge of dental implant when compared in different regions was statistically significant (P = 0.001).

Around 48% of 20–30 years of age groups, 60% of 31–40 years of age groups, 53% of 41–50 years, and above 50 age groups in Saudi Arabia found that implant is costly and the cost factor is the major hindrance to utilize dental implant procedure (P > 0.05).

Urban population, 79% (683), consider implant to be costly compared to the rural population, 21% (182) (P = 0.002). Majority of the people residing in different regions of Saudi Arabia were unaware of the materials used for dental implants. The correct knowledge of the material used for dental implants was observed in 22%, 35%, 47%, and 28% of the inhabitants of the northern, central, eastern, and western regions, respectively. Chi-square analysis demonstrated a statistically significant association (P = 0.001) between material knowledge of the dental implant and different regions of Saudi Arabia [Table 2].

Table 2

Distribution of knowledge and perception about bone grafts

Question	Parameter	Frequency (%)
What do you know about bone graft in dentistry?	I didn’t hear about it before	1105 (68.2)
	I heard about it but I don’t have the knowledge about it	298 (18.4)
	I heard about it but I have some knowledge about it	217 (13.4)
When do you think bone graft is needed during dental implant placement?	To support implant in resorbed jaw bone	486 (30)
	It is indicated in every dental implant procedure	39 (2.4)
	When more than 1 implant is needed	55 (3.4)
	I don’t know	1040 (64.2)
What type of bone graft will you prefer if it is indicated during any dental procedure?	Auto-graft (from the same person)	648 (40)
	Xenograft (from cow)	40 (2.5)
	Xenograft (from horse)	36 (2.2)
	Allograft (from another person)	26 (1.6)
	Alloplast (synthetic)	257 (15.9)
	I will never go through surgical procedures	613 (37.8)
Which donor site do you prefer if you or your doctor chooses auto-graft type?	Intraoral (from different region from the mouth like chin)	477 (29.4)
	Extra-oral (from different region from the body like hip)	245 (15.1)
	None of the above	898 (55.4)
Would you like to do extra-oral bone graft to have dental implant if it was the only option?	No	1070 (66)
	Yes	550 (34)

Around 59% of males and 43% of females in Saudi Arabia found that implant is costly and the cost factor is the major hindrance to utilize dental implant procedure. Among people who consider implant is a costly procedure to utilize the service, 74% (640) were males and 26% (225) were females [Table 3].

Table 3

Contribution of different parameters and associated reasons that prevent the utilization of dental implants among Saudi population

Parameter	Which of the following reasons will prevent you from going ahead with implant procedure?				P
	Implant is costly, I can’t offer it	It doesn’t worth it, I prefer an alternative treatment	I don’t like going through surgical procedure	It is a long and complicated need multiple appointments
Sex
Male	640 (58.70)	46 (4.20)	136 (12.50)	268 (24.60)	0.001*
Female	225 (42.50)	17 (3.20)	166 (31.30)	122 (23.00)
Age groups
20-30	194 (47.80)	20 (4.90)	117 (28.80)	75 (18.50)	0.001*
31-40	239 (59.80)	12 (3.00)	78 (19.50)	71 (17.80)
41-50	264 (53.40)	16 (3.20)	71 (14.40)	143 (28.90)
Above 50	168 (52.50)	15 (4.70)	36 (11.20)	101 (31.60)
Region in Saudi Arabia
Northern region	152 (48.10)	13 (4.10)	73 (23.10)	78 (24.70)	0.249
Central region	284 (55.00)	15 (2.90)	86 (16.70)	131 (25.40)
Eastern region	126 (50.00)	9 (3.60)	54 (21.40)	63 (25.00)
Western region	195 (57.20)	15 (4.40)	57 (16.70)	74 (21.70)
Southern region	108 (55.40)	11 (5.60)	32 (16.40)	44 (22.60)
Place
Rural	182 (63.60)	9 (3.10)	39 (13.60)	56 (19.60)	0.002*
Urban	683 (51.20)	54 (4.00)	263 (19.70)	334 (25.00)
Education
None	4 (57.10)	1 (14.30)	1 (14.30)	1 (14.30)	0.489
Up to high school	135 (54.00)	15 (6.00)	47 (18.80)	53 (21.20)
University education	611 (53.10)	38 (3.30)	220 (19.10)	281 (24.40)
Postgraduate and above	115 (54.00)	9 (4.20)	34 (16.00)	55 (25.80)

*: Highly significant

Most of the males (68.3%) and females (67.9%) were unaware of bone grafts in dentistry. Both males (66%) and females (61%) displayed that they were unaware of the necessity of the use of bone grafts during the dental implant procedure. Participant of all levels of education, including uneducated (71.4%), high school (64%), university (63.9%), and postgraduate or higher (65.7%) displayed their unawareness toward the use of bone grafts during the dental implant procedure.

Most of the males (40.1%) and females (39.8%) opted for “Autograft (from the same Person)” if bone graft was indicated during any dental procedure. Majority of the males (55%) and females (57%) opted for “None of the above” in response to the question “Which donor site do you prefer if you or your doctor chooses autograft type?” which was statistically significant (P = 0.017). Most of the inhabitants belonging to the northern (66%), central (68%), eastern (73%), western (62%), and southern (60%) regions disagreed with the use of extraoral bone graft during the dental implant procedure if indicated as the only option, and the association was statistically significant (P = 0.016) [Graph 1].

Graph 1

Distribution of associated preference of bone graft for dental procedures among different age groups of the Saudi population

When compared between the rural population (41%) and urban population (40%) in opting for bone graft indicated during any dental procedure displayed no statistical significance (P > 0.05).

DISCUSSION

The present study provides information on the perception, knowledge, and attitude of individuals toward the dental implant and bone graft as a treatment option in dental settings, in which the response of numerous individuals from different regions of Saudi Arabia was recorded.

Regarding the longevity of dental implants, 42% of patients in a study by Agrawal et al.[14] and 59% of patients in a study by Hof et al.[15] believed that implants could last for a lifetime. However, 74.1% of patients in the present study believed the same, indicating that knowledge among people is increasing with time.

Several studies have reported that the cost factor plays a major role and is one of the determinants of preventing patients undergoing dental implant procedures.[15]

Only 3.8% of the participants opted for removable prosthesis as the first treatment option for replacing missing teeth, which indicates that most patients do not prefer removable prosthesis for replacing their missing teeth regardless of their clinical condition. Zimmer et al. and Tepper et al. have also reported that only a few patients prefer removable to fixed prostheses.[1617]

This study demonstrated that the major sources of data regarding dental implants were families and friends, followed by the social media, dentists, and others. A survey conducted by Zimmer et al. also demonstrated that media is the main source of information for dental implants, and dentists were reported to be the source of information by only 17% of patients.[16]

In this survey, 40% of participants choose autologous bone augmentation as the first option to restore bone volume. The result is consistent with that of Agrawal et al. and Hof et al.[1415] Autografts are considered as the gold standard to regain bone quality and quantity and the cornerstone in evaluating other types of bone grafts and substitutes. Autogenous graft predictability can be attributed to their osteoconductive, osteoinductive, and osteogenic properties, due to which they rapidly and completely integrate into the host tissue.[18]

The least preferable bone grafts were the xenograft from the horse (2.2%), xenograft from the cow (2.5%), alloplasts (15.9%), and allograft (1.6), whereas 37.8% responded with “I will never go through surgical procedures.” Alloplasts are synthetic bone substitutes that have the advantage of avoiding the use of donors for patients. Moreover, xenografts have the risk of transmission of zoonotic diseases and aggravate the risk of graft rejection.[19]

Zeynep et al. also showed increased rejection rates for allografts and xenografts over participated individuals, whereas autogenous and alloplasts become the most accepted bone grafts.[20]

CONCLUSION

With the limitation of the study, the expense of dental implants was considered the foremost reason for avoiding the procedure. Most of the participants think that fixed dental prostheses last longer than removable prosthesis. Autograft was the most accepted bone graft, whereas allograft was the least accepted bone graft over the responded participants.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.