Awareness, Knowledge, and Acceptance of Dental Implants among the Geriatric Population of Jeddah, Saudi Arabia.

Background: Dental implants (DI) are gaining popularity among the general population, and special consideration has been given to the geriatric population in the replacement of missing teeth subject to their medical stability. The study aimed to assess the awareness, knowledge, and acceptance regarding DI among the geriatric population of Jeddah, Saudi Arabia. Methodology: A cross-sectional survey was carried out through face-to-face interviews using a pretested and standardized questionnaire by calibrated interviewers. Participants of age >58 years who have not undergone any implant or bone graft procedures attending different prosthodontic clinics in Jeddah were recruited according to availability after obtaining consent. Responses received were converted into digital format and subjected to statistical analysis.
Results: The knowledge related to DI was not satisfactory, and only 4.5% showed good knowledge. The willingness to replace the current prosthesis with DI was found in 49.6%, and it was also observed that 40% of the participants were using some tooth-supported fixed dental prosthesis. Only 41.3% and 31% were aware of bone graft and sinus lift procedures related to DI.
Conclusion: Even though most participants were aware of DI, the knowledge related to it was little satisfactory. Older people should be appropriately explained about the best treatment choice for teeth replacement by connecting to their current systemic health condition with its benefits and long-term effects. Unexpectedly, the awareness related to bone graft and sinus lift procedures related to DI was found to be relatively acceptable as well as the willingness to accept bone graft if needed for DI placement was observed. Copyright:

INTRODUCTION

Tooth loss is still a serious oral health burden affecting the geriatric population despite advancements in restorative techniques and oral health promotive activities.[1] Dental care in the geriatric population is similar to other younger people except for special consideration for age-associated tissue changes in the oral cavity, chronic diseases, social and economic characteristics.[2] Dental implants (DI) have got good acceptance to replace missing teeth due to their superior masticatory efficiency, long-term care, and preservation of natural teeth.[3]

Currently, DIs are widely accepted as prosthetic treatment of completely or partially edentulous patients. With careful diagnosis and proper treatment planning in elderly patients, DI could be the right choice for tooth replacement.[4] However, studies show that the prevalence of DI in the geriatric population is less compared to other age groups.[56] Reports from the US, New Zealand, Switzerland, and Japan show that the peak age for implant placement is between 60 and 75 years, thus indicating its acceptance among the geriatric population.[78910]

In the Kingdom of Saudi Arabia, the exact data on the prevalence of dental implant use among the elderly population are not available. Even recent studies in the region do not include the geriatric dental patients[11] DI are becoming popular and a choice of treatment in edentulous among the Saudi population due to their improved denture retention, stability, functional efficiency, and quality of life. However, region-wise studies show that there is a lack of awareness regarding the benefits of such treatment.[1213]

The prevalence of missing teeth among the adult population in Saudi Arabia is very high, and studies report that the same population has a prevalence of 69% one or more teeth missing, and approximately 2.6% of them were completely edentulous.[141516] There is a need for understanding the knowledge and attitude among the elderly population regarding the DI used for prosthetic replacement. This would help the dentists, health administrators, policymakers, and other stakeholders to understand the concerns and perceptions regarding DI, which would enable them to offer better prosthetic rehabilitation for the elderly population. The study aimed to assess the awareness, knowledge, and acceptance of DI among the elderly population aged 58 years and above attending prosthodontic clinics in the city of Jeddah, Saudi Arabia.

METHODOLOGY

A survey was designed using a pretested and validated questionnaire in Arabic language after obtaining ethical approval from the Research and Ethics Committee of the institution. Participants who were attending different Prosthodontic clinics in Jeddah for removable and fixed dental prosthetic treatment were recruited for our study after obtaining consent. The inclusion criteria of this study included only elderly population above 58-year-old and those who have not undergone and dental implant and bone grafts procedures previously. We used a convenience sampling method to recruit the sample during November 2019–February 2020. A face-to-face-interview was done using the prepared questionnaire by calibrated interviewers after a short clinical examination and dental history as a confirmation for the inclusion criteria.

The Questionnaire was initially constructed in English language and was subjected to a validation process. Face validity and content validity were done by group of experts including two prosthodontists, one biostatistician and one language expert. The construct validity was done using factor analysis using principal component analysis that showed a good correlation coefficient (r = 0.781). An expert translator who is proficient in both the languages then translated the original English version to Arabic. We pilot tested the Arabic Questionnaire on 20 participants to assess the practicality of the study. The Arabic version was then back-translated into English by another expert who was also proficient in both the languages, which showed excellent linguistic validity. The final version of the questionnaire included five sections: Part A-Sociodemographic details; Part B-Mode of replacing missing teeth; Part C-knowledge about DI and source of information; Part D-willingness to replace removable prosthesis with implants supported and stopping reasons.

The responses obtained were entered into Microsoft Excel and were subjected to data cleaning to make the analysis easy. The data were then subjected to statistical analysis by an independent biostatistician. We used SPSS version 23 (IBM Corp.; Armonk, NY, USA) for carrying out the required statistical analysis. Continuous variables were expressed as means with standard deviations and categorical variables were presented as frequencies and percentages. The association between categorical variables was tested using Pearson's Chi-square test. A P < 0.05 was considered to be statistically significant.

RESULTS

The study was done in the geriatric population to assess the awareness, knowledge, and acceptance related to DI. The study included 155 participants, of which 50.3% were females and 49.7% were males. The age distribution showed that 63.9% belonged to 58–68 years, 32.3% to 69–78 years, 2.6% to 79–88 years, and only 1.3% were more than 88 years. The educational level showed that 5.2% had only primary school level education, 11.6% had middle school, 24.5% had a high school, 6.5% had diploma/graduate level and 40.6% had a postgraduate level of education [Table 1].

Table 1

Sociodemographic characteristics (n=155)

	Frequency (%)
Gender
Female	78 (50.3)
Male	77 (49.7)
Age (years)
58-68	99 (63.9)
69-78	50 (32.3)
79-88	4 (2.6)
>88	2 (1.3)
Educational level
Primary school	8 (5.2)
Middle school	18 (11.6)
High school	38 (24.5)
Graduate/diploma	10 (6.5)
Postgraduate	63 (40.6)
Illiterate	18 (11.6)

The prevalence of using a fixed dental prosthesis (FPD) in one form or other was found to 40% (n = 60) and 9.7% have reported that they use a combination of both removable and fixed dental prostheses (C-removable partial denture [C-RPD] and FPD). Their usage of FPD was comparatively more in females (44.9%) than males (35.1), but there was no statistically significant difference seen. It was observed that FPD usage was more seen participants who belonged to age group 58–68 years (49.5%) and Removable complete denture (RCD) usage was more in 69–78 years (46%) that showed a statistically significant association (P < 0.001) [Table 2]. When we assessed the usage of different types of prosthesis based on the education level of the participants, it was observed those who had postgraduate level had shown comparatively more usage of FPD (66.7%) than others and the participants who had high school level education used RPD (36.8%) and RCD (21.1%) more than others, which both showed statistically significant association (P < 0.001) [Table 2].

Table 2

Type of current prosthesis used and sociodemographic characteristics

	Type of prosthesis used					Total, n (%)	P
	RPD, n (%)	RCD, n (%)	FPD, n (%)	C-RPD and FPD, n (%)	I don’t know, n (%)
Gender
Female	18 (23.1)	15 (19.2)	35 (44.9)	4 (5.1)	6 (7.7)	78 (50.3)	0.313
Male	21 (27.3)	13 (16.9)	27 (35.1)	11 (14.3)	5 (6.5)	77 (49.7)
Age (years)
58-68	28 (28.3)	4 (4.0)	49 (49.5)	8 (8.1)	10 (10.1)	99 (63.9)	<0.001
69-78	9 (18.0)	23 (46.0)	12 (24.0)	6 (12.0)	0	50 (32.3)
79-88	0	1 (25.0)	1 (25.0)	1 (25.0)	1 (25.0)	4 (2.6)
+88	2 (100.0)	0	0	0	0	2 (1.3)
Education
No school education	3 (16.7)	13 (72.2)	1 (5.6)	0	1 (5.6)	18 (11.6)	<0.001
Primary school	7 (87.5)	1 (12.5)	0	0	0	8 (5.2)
Middle school	8 (44.4)	5 (27.8)	1 (5.6)	3 (16.7)	1 (5.6)	18 (11.6)
High school	14 (36.8)	8 (21.1)	11 (28.9)	5 (13.2)	0	38 (24.5)
Graduate/diploma	0	0	7 (70.0)	2 (20.0)	1 (10.0)	10 (6.5)
Postgraduate	7 (11.1)	1 (1.6)	42 (66.7)	5 (7.9)	8 (12.7)	63 (40.6)

P<0.05 is considered statistically significant. RPD: Removable partial denture, RCD: Removable complete denture, FPD: Fixed dental prosthesis, C-RPD: Combination-RPD

When assessed the type of the desired prosthesis to be used in the future, it was found that 41.3% (n = 64) and 38.1% (n = 59) mentioned it as FPD-Implant bore (FPD-I) and FPD-tooth bore (FPD-T) respectively. In our study FDP-T was opted by comparatively more by females (43.6%) and FPD-I by males (54.5%), both of these associations showed a statistically significant relationship (P < 0.001) [Table 3]. The relationship between the age of participants and type of implant desired has shown that those who were in 58–68 years of age wanted to use FPD-I (48.5%) and FPD-T (38.5%) comparatively more than others and this showed a statistically significant relationship (P < 0.001). Participants who had postgraduate or more level of education had opted more for FPD-I (61.9%) and those who had high school level and graduate/diploma preferred to use FPD-T to others (P < 0.001) [Table 3].

Table 3

Type of prosthesis desired to use and sociodemographic characteristics

	Type of prosthesis desired to use						Total, n (%)	P
	RPD, n (%)	RCD, n (%)	FPD-I, n (%)	FPD-T, n (%)	C-RPD and FPD, n (%)	I don’t know, n (%)
Gender
Female	2 (2.6)	5 (6.4)	22 (28.2)	34 (43.6)	3 (3.8)	12 (15.4)	78 (50.3)	0.020
Male	1 (1.3)	3 (3.9)	42 (54.5)	25 (32.5)	0	6 (7.8)	77 (49.7)
Age (years)
58-68	1 (1.0)	0	48 (48.5)	38 (38.4)	3 (3.0)	9 (9.1)	99 (63.9)	<0.001
69-78	7 (14.0)	1 (2.0)	15 (30.0)	19 (38.0)	0	8 (16.0)	50 (32.3)
79-88	0	0	1 (25.0)	2 (50.0)	0	1 (25.0)	4 (2.6)
+88	0	2 (100.0)	0	0	0	0	2 (1.3)
Education
No school education	2 (11.1)	4 (22.2)	2 (11.1)	4 (22.2)	0	6 (33.3)	18 (11.6)	<0.001
Primary school	0	1 (12.5)	1 (12.5)	6 (75.0)	0	0	8 (5.2)
Middle school	0	0	5 (27.8)	8 (44.4)	0	5 (27.8)	18 (11.6)
High school	1 (2.6)	3 (7.9)	15 (39.5)	17 (44.7)	0	2 (5.3)	38 (24.5)
Graduate/diploma	0	0	2 (20.0)	4 (40.0)	3 (30.0)	1 (10.0)	10 (6.5)
Postgraduate	0	0	39 (61.9)	20 (31.7)	0	4 (6.3)	63 (40.6)

P<0.05 is considered statistically significant. RPD: Removable partial denture, RCD: Removable complete denture, FPD: Fixed dental prosthesis, C-RPD: Combination-RPD, FPD-I: FPD-implant borne, FPD-T: FPD-tooth borne

There was a total of 17 items in the questionnaire that measured the knowledge related to DI and its associated factors. Participants who correctly answered each item were given a score “1” and for wrong answers, a score “0” were given thus the maximum score one could score is 17. The total mean score in our study was found to be 4.47 ± 3.85 (Min: 0.0, Max: 15.0), which was very less. The total scores were then categorized based on the percentages into “Good” (≥75%), “Fair” (51%–74.9%), and Poor (≤50%) that showed only 4.5% had “good” knowledge related to dental implant prosthesis and most of the participants were shown to have poor knowledge (87.7%). The knowledge related to DI when compared between two genders it was found that males had comparatively more “good” knowledge (6.5%) than females (2.5%) that showed a statistically significant association (P = 0.007) Table 4. The age of the participants did not show any significant association with the knowledge related to DI (P = 0.183). The education level of the participants showed that those who had a postgraduate level of education had exhibited “good” knowledge than others and those who had high school or less level of education had shown more “poor” knowledge compared to others, both of this association was found to be statistically significant (P = 0.003) [Table 4].

Table 4

Knowledge related to dental implants and sociodemographic characteristics

	Knowledge			Total, n (%)	P
	Good, n (%)	Fair, n (%)	Poor, n (%)
Gender
Female	2 (2.6)	11 (14.1)	65 (83.3)	78 (50.3)	0.007
Male	5 (6.5)	1 (1.3)	71 (92.2)	77 (49.7)
Age (years)
58-68	3 (3.0)	11 (11.1)	85 (85.9)	99 (63.9)	0.183
69-78	3 (6.0)	1 (2.0)	46 (92.0)	50 (32.3)
79-88	1 (25.0)	0	3 (75.0)	4 (2.6)
>88	0	0	2 (100.0)	2 (1.3)
Level of education
No school education	0	0	18 (100.0)	18 (11.6)	0.003
Primary school	0	0	8 (100.0)	8 (5.2)
Middle school	0	0	18 (100.0)	18 (11.6)
High school	0	0	38 (100.0)	38 (24.5)
Graduate/diploma	0	2 (20.0)	8 (80.0)	10 (6.5)
Postgraduate	7 (11.1)	10 (15.9)	46 (73.0)	63 (40.6)

P<0.05 is considered statistically significant

The awareness related to bone graft and sinus lift procedures related to DI was found to be 41.3% and 31%, respectively. The willingness to accept bone graft if needed for DI placement was observed in only 36% of the participants. When we recorded the source of information related to DI, it was found that 45.8% reported it as self-education and 25.2% had heard it from dentists or doctors [Figure 1]. It was also found that 49.6% of the participants were willing to replace the current prosthesis with DI if it is indicated or possible to do so. Furthermore, 41.3% of the participants believed that placing DI would improve the quality of life in them.

Figure 1

Sources of information related to DI

DISCUSSION

The knowledge related to dental implant was not satisfactory among the study population. This could be related to less awareness regarding the benefits of DI, which should be correlated with the study population's socioeconomic status and education level. The participants with lower education levels exhibited comparatively poor knowledge regarding the same. Some studies in the kingdom evaluated the knowledge regarding DI, but this study is peculiar as its scope and sample population is distinctive. The inadequate knowledge in this elderly population could be attributed to the source of information they depend on.[17] According to different reports, the common source of information nowadays is dentists, and the Internet (social media) followed, and very little has been attributed to newspapers or television.[1218] The use of the Internet and social media for health-related information are comparatively less among the elderly population, and most of them depend upon newspapers and/or television.[19] In another study done by Ozçakır Tomruk et al., dentists were the primary source of information regarding DI, followed by friends and media.[20]

The findings showed that the prevalence of fixed partial denture usage among the elderly population was 40%, and 41.3% desired to keep an implant-bore FPD, which was comparatively more reported in participants with higher education level (postgraduate) than others. A study was done in Norway among people aged 45 years and above reported that those with high education and high income significantly had better awareness compared to those who had a lower level of education and low income.[21] These findings indicate that older people with low education are skeptical and may have a negative evaluation of DI. The results also suggest that even though the knowledge was not good among this population, they were somehow aware of the benefits of implant-borne FPDs. This would mean that patients with lower educational levels should be adequately explained about the benefits and advantages of DI in the future to improve their awareness and make an informed decision. A study was done in Riyadh among adult dental patients (>18 years) reported that 61.5% chose DI as the best treatment to replace missing teeth, whereas 35.2% and 3.3% chose it as the best treatment to replace missing teeth tooth-born FPD and RPD, respectively.[18]

One of the prognostic factors in the success of DI is the age of the patient. In older people, factors such as longer healing time, compromised bone condition, presence of chronic diseases, and other systemic health factors influence implants' success.[2223] With a careful diagnosis, appropriate case selection, and treatment planning, DI can offer many advantages over other fixed prostheses such as high success rate, bone maintenance in the edentulous site, minimized risk of caries and endodontic problems with adjacent teeth.[2425] Some of the factors that negatively influence the selection of implants by patients are fear of surgery, high cost, longer duration of treatment.[2627] All these factors may have influenced the elderly population in this study in opting for nonimplant type prostheses.

This study has some shortfalls that need to be considered when interpreting the results.First, we used a convenience sampling method, and this might have incurred sampling bias. Second, there could be a possibility of recall or memory bias in the responses given as our participants were geriatric population, and we did not do a screening for dementia. Third, we used a new questionnaire that was tested on a small sample only and was not used on a larger population. Finally, as this is a cross-sectional study, it could have limitations about the causal inferences.

The use of a dental implant to replace missing teeth is gaining wide acceptance, and there is a need to disseminate available scientific data to the public, especially the geriatric population. Furthermore, there is a need to include and improvise exciting educational material by adding current advances and benefits of dental implant technology.

CONCLUSION

The knowledge regarding DI in this elderly population was not good compared to findings from other countries. Dentists, public health managers, policymakers, and other stakeholders should impart positive knowledge regarding DI through appropriate media. We also advocate further training and workshops for dental undergraduates regarding DI to increase their knowledge and skill.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.