Insight of New Generation Dentists towards the Shifting Trends of Three-dimensional Printing for Patient Management in the Kingdom of Saudi Arabia.

Background: There is a lack of information in the few studies reporting on the use of three-dimensional (3D) Printing for Patient Management. However, few studies have been found about recent advances in 3D printing technology, and biomaterials are revolutionizing medicine. The purpose of this study is to evaluate the knowledge and attitude of new generation dentist towards 3D printing and its application in various aspects in the field of Prosthodontics. Materials and
Methods: A cross-sectional study on dental practitioners/Prosthodontist throughout Saudi Arabia using a self-administered questionnaire, which had items to assess the knowledge attitude and practices of study participants toward the use of 3D printing in dental management.
Results: It was observed 17.5% of our participants had complete information and 10.5% had no information about 3D printers in the field of dental medicine. When assessed, male dentists had complete information about 3D printers (17.5%) than females (0%). 43.9% of our participants "strongly agreed" for 3D printers to be implemented in dentistry, 40.4% had "no idea" regarding the experience of 3D prints.
Conclusion: Very few dentists have knowledge of 3D printing application in dentistry. Hence we strongly recommend organizing continuing dental education programmed on 3D printing either with hand on workshops, conferences and regular updates on the use of this technology. Copyright:

INTRODUCTION

In general, the term three-dimensional (3D) printing is used to describe a manufacturing approach that constructs objects one layer at a time, adding multiple layers to form an object. This process is described more correctly as additive manufacturing and is also referred to as rapid prototyping. The term 3D has recently captured the imagination and hype of the public in dentistry. In the international press, we have seen headlines describing the use of 3D printing to produce everything from fashion wearing and architectural models to armaments. The reality, however, is different, 3D printed underwear would be uncomfortable today, and 3D printed guns are dangerous to the individual firing them. While we are a long way from seeing the production of viable 3D printed organs, dentistry and oral and maxillofacial surgery have been using 3D printing for years and have fully embraced the use of digital manufacturing technologies, in particular the use of computer-aided design and manufacturing.[12] Additive manufacturing exerts a considerable influence on patients' dental health and has the potential for many innovations. However, dental specialists need to be appropriately informed and trained to realize its potential. In addition, the required training and education initiatives should be in line with the particular needs of customers and patients, who also need to be properly informed about the 3D printing of existing opportunities.[34] Few studies have been found about recent advances in 3D printing technology and the lack of knowledge among dentists. Taking into account that not all dentists have full, direct access to the latest advances in additive technologies and the need for updating the scientific knowledge, we surveyed their opinion on 3D printing and knowledge in this area.

MATERIALS AND METHODS

After the approval of the institutional ethics committee at the Ministry of Health, Kingdom of Saudi Arabia, the present cross-sectional study was undertaken. Study length was determined to be 6 months to complete the registration of a sufficient number of participants. The sample size was calculated based on the previously published research on the same topic. The lowest outcome was taken for sample size calculation. The study requires a sample size of 114 to achieve a power of 80% and a two-sided significance of 5% for detecting a difference. Participants who are general dentists practicing Prosthodontics or should be a prosthodontics and at least practicing prosthetics for not <2 years were included in the study while the dentist not practicing prosthodontic care and not willing to participate were excluded from the study. Before the start of the study, a list of dentists working in different provinces under the ministry of health hospitals was drawn. Required number of participants selected based on inclusion and exclusion criteria of the study. An online consent was obtained from all the selected participants before the online survey and then subjected to a self-administered questionnaire. The study instrument (questionnaire) was developed by a panel of prosthodontics and clinical departments experts. Prior to the start of the study, the questionnaire was tested on 20 study subjects. Cronbach's alpha and test re-test was used to assess the reliability values for knowledge, and it was 0.762 and 0.646, while the values for questions on practice were 0.86 and 0.88. The pilot study results were excluded from and were used to assess the reliability and validity of study instruments. The final questionnaire included 12 multiple choice questions to assess study participants' knowledge, attitude, and practices toward the use of 3D printing in dental management.

All the data collection was done by an independent clinical assistant who was kept blinded throughout the study but trained to calibrate the conduction and collection and coding of survey question procedure by the department of community dentistry and oral epidemiology at the college of dentistry Qassim University, Buraydah, KSA. Further, the coded data sheet was handover to the statistician for data analysis. The collected data was entered and analyzed with the IBM SPSS Statistics 20.0 program (Armonk, NY, USA). Descriptive statistics and Chi-square tests were used for the data analyses. The level of statistical significance was set at a 95% confidence interval, and all of the statistical analyses involved 2-tailed tests.

RESULTS

Our study involved 114 dentists that included 79.9% (n = 90) males and 21.1% (n = 24) females. Our study had 26.3% general dentists, 22.8% prosthodontics, and 50.9% other specialties. The analysis showed that 17.5% of our participants had complete information, and 10.5% had no information about 3D printers in the field of dental medicine. When we assessed the relationship of the gender of participants with the responses, it had shown that male dentists had complete information about 3D printers (17.5%) more than females (0%), (P = 0.011). 43.9% of the participants had “strongly agreed” that 3D printers can be approved for printing objects for assistance such as models, surgical guides, etc., This was more comparatively seen in male dentists than females (P = 0.016). When the participants were asked to rate the 3D printing in dentistry, 54.4% had given an “excellent” rating for it, and there was no association seen with gender (P = 0.275). 24.6% of the participants had given an “excellent” rating, and 40.4% had “no idea” regarding the experience regarding 3D prints. When the participants were asked for the implementation of 3D printing in regular practice, 26.3% “always” recommended it, and 59.6% preferred to use it occasionally. There was no association of this recommendation with gender (P = 0.017). It was found that male participants preferred 3D printing over conventional procedures for designing prosthesis than females, and it was statistically significant (P = 0.027) [Table 1].

Table 1

Participants responses to 3D printing and their relationship with sociodemographic characteristics

	n (%)	P*
		Gender	Age	Designation
Information about 3D printers in the field of dental medicine
No information	12 (10.5)	0.011	0.316	<0.001
Just heard about it	28 (24.6)
Very little	54 (47.4)
Complete	20 (17.5)
Approval of 3D printing of objects for assistance (models, surgical guides)
Strongly agree	50 (43.9)	0.016	0.014	0.031
Mostly agree	44 (38.6)
Just agree	10 (8.8)
No idea	10 (8.8)
Approval of 3D printing for objects in dental medicine which are in prolonged contact with vital tissues (implants, bridge constructions)
Strongly agree	40 (35.1)	0.104	0.005	0.128
Mostly agree	44 (38.6)
Just agree	18 (15.8)
No idea	12 (10.5)
Rating of 3D printing in dentistry
Fair 0-3	4 (3.5)	0.275	0.542	0.001
Good 4-7	34 (29.8)
Excellent 8-9	62 (54.4)
No idea	14 (12.3)
Rating for the time span taken for the 3D prints procedure
Adequate	54 (47.4)	0.552	0.070	0.019
Prolonged	22 (19.3)
No idea	38 (33.3)
Rating for the financial cost of dental 3D prints
Expensive	52 (45.6)	0.471	<0.001	<0.001
Affordable	30 (26.3)
No idea	32 (28.1)
Recommend the 3D prints technology to your colleagues
High Likely	92 (80.7)	0.050	0.036	0.075
Not likely	22 (19.3)
Rating the experience about 3D prints
Fair 0-3	8 (7%)	0.862	0.001	<0.001
Good 4-7	32 (28.1)
Excellent 8-9	28 (24.6)
No idea	46 (40.4)
Preferred mode of CME on 3D print
Webinar	18 (15.8)	0.193	0.006	0.285
Hands on workshop	90 (78.9)
Conference	6 (5.3)
Agency convenient for attending workshops for 3D printing
Workshop by university	72 (63.2)	0.400	<0.001	0.913
Private convention center	14 (12.3)
Presentation by the representatives	28 (24.6)
Recommend implementing 3D printing in regular practice
Always	30 (26.3)	0.017	0.001	0.033
For special cases	68 (59.6)
Occasionally	16 (14)
Preference of 3D printing over the conventional procedures for the design of the prostheses
Always	30 (26.3)	0.027	0.011	0.597
For special cases	70 (61.4)
Occasionally	14 (12.3)

We found that participants who had “strongly agreed” the approval of 3D printing of objects for assistance belonged to the age group of 36–45 years (59.1%), and this was statistically significant (P = 0.014). When the participants were asked to rate the financial cost of dental 3D printers, 45.6% rated it as “expensive,” of which 53.6% (n = 28) were from the age group of 25–35 years, and this was statistically significant (P < 0.001). 80.7% of the participants mentioned that they would recommend 3D printing technology to their colleagues and the age group of 36–45 years had a statistically significant association with this (P = 0.036). The rating of experience in 3D prints showed that the age group of 36–45 years comparatively gave more “excellent” rating (n = 20) than other age groups that showed a statistically significant association (P = 0.001).

In our study, we found that out of 12 participants who had completely no information about the 3D printers, 66.6% (n = 8) were general dentists, and this showed a statistically significant relationship (P < 0.001). The majority of the participants who had “no idea” regarding the approval of 3D printing of objects for assistance were also general dentists (P = 0.031). When the participants were asked to rate the 3D printing, other specialists gave an “excellent” rating than prosthodontists and general dentists. Whereas 'good' ratings were given comparatively more by prosthodontists and these findings showed a statistically significant association (P = 0.001). Also, when the participants were asked for rating the financial cost of dental 3D prints, 45.6% of participants gave it as “expensive,” out of 69.2% (n = 36) were other specialties, and out of 28.1% who had “no idea” regarding the same 56.2% were general dentists, which showed a statistically significant association (P < 0.001). When asked to recommend implementing 3D printing in regular practice, prosthodontists and other specialties mentioned that it should be done for special cases only, and this response showed a statistically significant association (P < 0.033).

DISCUSSION

The inventory and use of 3D printing in the Prosthodontics field have led to precession and accuracy. This technology is used to achieve greater results in all prosthodontic branches, whether removable, fixed, implants, or oral and maxillofacial prosthodontics. It is commonly used for diagnostic prosthetics to scan impressions, duplicate casts, CAD/CAM milling, crown preparation, implant treatment planning, surgical stent development, etc.[3] The study on the knowledge and opinions regarding the use of 3D printing in dental medicine among general dentists, Prosthodontists, and other specialists is the first of its kind carried out in the Kingdom of Saudi Arabia. In most cases, the respondents were men, and when it was statistically analyzed for the predominance of gender, it showed a statistically significant relationship with the males because most of the practicing dentists in Saudi Arabia are males. One of the areas of 3D printing applications is to use this technology to make models and surgical guides for assistance in the field of Dentistry. When this aspect was surveyed and analyzed, the male dentists were found to be more than the female dentists. The use of 3D printing to make models of the dental structures with multi-material and 3D color prints is considered to be sufficiently anatomically more accurate for fabrication use. The availability of 3D printed models is more appreciated, and the efficiency of analysis and learning compared with dental stone, and other dental materials are also improved.[5]

However, there can be some minor inaccuracies in the 3D models, especially to check the minute details of the adjacent structures.[6] Dentists have expressed interest in using models printed with 3D technology. Since the knowledge of 3D printing is limited to a small percentage (24.6%), it cannot be ruled out the combined use of both 3D models and plaster models for fabrication of the prostheses, hence plaster models or surgical templates, etc., during the fabrication of various prostheses. Therefore, the routine laboratory procedures and steps used cannot be completely abandoned from the use of 3D models. Only 26.3% of the participants of the survey agreed to the implementation of 3D printing in regular practice, while 59.6% of them preferred to use it occasionally. No association was found between this and the gender comparison. However, the male participants preferred 3D printing over conventional procedures for designing the Prostheses than females.

The convenience of 3D preparations is the ability to prepare color prints, which some authors believe makes it easier for new dentists and specialists to learn.[7] Most of the participants who had the knowledge, a positive attitude, and a strong willingness to practice 3D printing for their assistance were in the age group of 36–45 years which constitutes about 59.1% of the total participants. This can be supported by the fact that the awareness is more in the younger generation, as this group has more exposure to the currently changing trends and advances in the field of clinical dentistry. Exactly designed surgical instruments and preoperative models may be created and used in the surgical implant placement procedure, e.g., single or multiple implant placement, one stage or two stages implant surgery as a way to practice a planned implant surgery course.[8] The major portion who rated that they had no knowledge of 3D printers were general dentists, and they showed a statistically significant relationship which can be explained by the fact that there should be more awareness among the general dentists. The other specialists made an excellent rating while the prosthodontists rated it as well, and this showed a statistically significant relationship. Thanks to 3D modeling, it is possible to preserve anatomical models for special educational values in the form of digital files. “Specimens” can also be created based on computed tomography and magnetic resonance imaging studies of patients, which further extends the scope of their use as 3D prints.[89]

Currently, the biggest limitation for the widespread use of 3D printing technology is price, but innovations in this field should make it more accessible in the near future, e.g., for printing models on a printer.[1011] These types of models would replace the regular time-consuming laboratory steps for following the various procedures involved in the designing analysis and fabrication of frostheses.[12]

Our study confirmed that participants showed interest in new technologies, especially those that expand the possibilities of personalized therapy and are innovative. Most of them who knew the advantages and limitations of 3D printing were specialists and Prosthodontists. 3D printing may be used in modern Dentistry printing prostheses or creating models etc., both as a teaching aid and preoperational planning. 3D printing technology should be included in the education curriculum, thereby providing this knowledge that will allow them to apply it independently in solving problems visible in patients to improve their comfort of life or accelerate the treatment process.

CONCLUSION

Based on this study we conclude saying that very few dentists had knowledge of 3D printing applications in dentistry. Hence, we strongly recommend organizing continuing dental education programs on 3D printing technology and its use either with hands-on workshops, in conferences and regular updates on the development and use of this technology.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.