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Year : 2017  |  Volume : 15  |  Issue : 3  |  Page : 258-262

Patients' perception about dental implant and bone graft surgery: A questionnaire-based survey

1 Department of Periodontics and Community Dentistry, Dr. Z. A. Dental College, AMU, Aligarh, Uttar Pradesh, India
2 Department of Conservative Dentistry and Endodontics, Dr. Z. A. Dental College, AMU, Aligarh, Uttar Pradesh, India
3 Department of Conservative Dentistry and Endodontics, K. D. Dental College, Mathura, Uttar Pradesh, India

Date of Web Publication18-Sep-2017

Correspondence Address:
Neha Agrawal
Department of Periodontics and Community Dentistry, Dr. Z. A. Dental College, AMU, Aligarh, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_89_17

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Introduction: The decision toward dental implant – an elective procedure in most cases depends on patients' preferences, values, as well as cost considerations. Patients' participation and codetermination, as well as realistic patient expectations, have been associated with improved subjective treatment outcomes, and health professionals are increasingly encouraged to involve their patients in treatment decisions. However, scientific data on patient expectations and motivation to choose or refuse dental implants are scarce. Aim: The aim of this study is to assess perception about the dental implant and bone graft surgery among patients seeking dental implants. Materials and Methods: A cross-sectional questionnaire study was carried out in OPD of Dental College, Aligarh. One hundred and twenty patients participated in this study. The patients were asked to answer a questionnaire on implant and bone graft surgery including cost and time concerns and second-opinion behavior. Descriptive statistics were calculated for the different variables, and absolute frequencies and percentages were evaluated. A value of P< 0.05 was selected as the threshold for statistical significance. Results: The highest priority was given to treatment predictability and avoidance of the removable dentures by the patients. On an average, the total treatment time was estimated to be 6 months. Patients' opinion regarding 10-year implant success rate was 81%. Autologous bone grafts was accepted by 61% of interviewees (the majority preferring the retromolar area). Young patients, especially males showed higher second opinion-seeking behavior. Conclusions: There is a growing interest in patients' perspectives and expectations of dental implants and bone graft surgeries. Patient expectations on implant success and predictability were found to be high.

Keywords: Bone graft, implant, perception, satisfaction

How to cite this article:
Agrawal N, Gupta ND, Tewari RK, Garg AK, Yadav P. Patients' perception about dental implant and bone graft surgery: A questionnaire-based survey. J Indian Assoc Public Health Dent 2017;15:258-62

How to cite this URL:
Agrawal N, Gupta ND, Tewari RK, Garg AK, Yadav P. Patients' perception about dental implant and bone graft surgery: A questionnaire-based survey. J Indian Assoc Public Health Dent [serial online] 2017 [cited 2023 Feb 8];15:258-62. Available from: https://www.jiaphd.org/text.asp?2017/15/3/258/215070

  Introduction Top

Quality assurance of health-care delivery has been emphasized in the importance of patient's perceptions of medical interventions and treatments since 1970s.[1] The view that patient expectations from a treatment play a potential role to their final satisfaction from the treatment outcomes has intrigued clinicians and researchers.[2] This is crucial today, as the current practice of evidence-based medicine requires active engagement of the patients in the decision making with regard to their treatment. This need is even more pronounced with regards to treatments with dental implants, where expensive therapy is proposed for the rehabilitation of function and esthetics of patients with missing teeth.[3]

Dental implant is an artificial root that is surgically inserted into the jawbone to support a single tooth replacement (crown), fixed partial or complete denture, or maxillofacial prosthesis.[4] Implant treatment is an increasingly popular treatment option with a high success rate. The overall aspiration for improved oral health-related quality of life has become a truth after the arrival of dental implants. Replacement of missing teeth with implant-supported prosthesis has been accepted and rated as a positive experience by patients who have undergone implant treatment.[5],[6]

Decision-making in implant dentistry involves patients' preferences and values, clinicians' heuristics and biases, diagnostic and therapeutic uncertainties, as well as cost considerations.[7] In addition, it has become the focus of the patients' interest hence for dentist, it is vital to assess their level of knowledge with regard to dental implants and whether their perception of dental implants does in fact reflect reality to guide patients who do not have the education or background knowledge to make an informed decision between implant-supported dentures and removable dentures.[5],[8],[9],[10]

At present, bone graft is required in many procedures to replace or recover bone volume that has been lost due to systemic pathologies,[11] periodontal defects,[12] tooth loss,[13] or other conditions. Progress in modern medicine has led to increase in the availability of new biomaterials that can be used to recover the lost bone volume. These biomaterials may be obtained from the patient's own body, other humans, animals, or can even be synthetically produced.[14] Regardless of this progress made, little research has been conducted regarding the patients' opinions and perceptions about the different bone graft materials available or their motivation to use these biomaterials in their surgeries. The source of the bone graft may be unacceptable to the patient due to religious, ethical, and/or cultural concerns. Some patient perception studies related to grafts have been conducted in medical field;[15],[16] however, in dentistry, such research has primarily focused on evaluating the effectiveness of bone grafts rather than on patient perceptions. Similarly, scientific data on patient expectations and motivation to choose or refuse dental implants are scarce.[17] Therefore, the aim of the present study was to assess patients' perception about dental implant and bone graft surgery.

  Materials and Methods Top

This cross-sectional study was a questionnaire-based survey which was carried out on patients seeking implant treatments at the OPD of the Department of Periodontics and Community dentistry, Dental College, Aligarh, using convenience sampling method from august 2014 to august 2016. Out of 153, only 120 respondents agreed to participate in the survey with the nonresponse rate 21.56%. The study protocol was approved by the Institutional Ethical Review Committee.

The survey form included self-explanatory questions which were in correspondence to previous studies.[5],[18] The questionnaire was translated in Hindi to facilitate completion and to get better understanding of the questions by the respondents'. The face validity of translation version was evaluated by conducting pilot study on 10 patients seeking implant treatment before the start of the study. The ease of understanding to the questions was assessed using a 4-point ordinal scale (– very easy, somewhat easy, somewhat difficult, and very difficult) and was found to be suitable. Those patients who participated in pilot study were excluded from the main study.

The questionnaires were handed over to the patients seeking implant treatment during their regular dental visits. All the respondents were informed about the objectives of the study. Written informed consent was obtained from all patients. Patients with local or systemic contraindications to implant therapy, recent myocardial infarction and cerebrovascular accident, valvular prosthesis surgery, immune suppression, bleeding issues, active treatment of malignancy, drug abuse, psychiatric illness, as well as intravenous bisphosphonate use or the history of previous implant surgery were excluded from the study.

In the first section of the questionnaire,[18] the patients were asked to rank their concerns regarding implant therapy by priority (1 = most important to 5 = least important). The list of concerns involved predictability of treatment success, time, and cost-efficiency of treatment as well as avoidance of removable dentures or bone grafting. The second section contained 16 closed as well as two estimation questions on patient expectations, acceptance, preferences, and second-opinion behavior.

Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS, version 16.0, SPSS Inc., Chicago, IL, USA). Descriptive statistics were calculated for the different variables, and absolute frequencies and percentages were evaluated. Differences regarding patient age, gender, profession categories, type of prosthetic restoration, and denture satisfaction were investigated using Fisher's exact tests and Mann–Whitney U-test in case of ordinal data. P< 0.05 was selected as the threshold for statistical significance.

  Results Top

A total of 120 patients participated in the survey. Demographic details have been described in [Table 1]. Most of the patients who participated in study were male (65%). The mean age of patients was 30.7 ± 5.2 years. One-third of the patients (30%) were having removable partial dentures, 12% were having fixed partial dentures, and 4% were fully edentulous. Most (74%) of the patients were having education level up to university and above.
Table 1: Demographic detail of the study patients

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In the present survey, it was found that treatment predictability and avoidance of removable dentures were ranked as first and second priority and time efficiency and avoidance of bone grafting were ranked as last priority [Table 2].
Table 2: Patient's rankings regarding implant therapy by priority

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Most of the patients (79%) anticipated fixed dentures to last longer than removable [Table 3] whereas 21% assumed no difference. Implant prosthesis was expected to last longer than tooth-supported dentures by 64% patients. 42% expected implants to last for a lifetime, 29% for at least 10 years, and 8% shorter. Nearly 92% patients anticipated a healing period of at least 2 months after implant placement. Acceptance of implants among fully edentulous patients (62%) was significantly lower (P = 0.0415, Fisher's exact). Estimated total treatment time before prosthetic restoration was around 4 months.
Table 3: Patient's expectations regarding dental implants (percentage of positive responses)

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Merely 8% were ready to accept a higher risk of failure to shorten total treatment duration. More than half of the patients (59%) were willing to undergo bone graft surgery to enable dental implant treatment. Only 5% of patients agreed to undergo bone harvesting from the hip (iliac crest). Most of the patients (82%) preferred the posterior mandible (retromolar region) and 15% preferred bone harvesting from the chin (mandibular symphysis). There was no statistically significant difference among patient age and gender concerning the choice of donor site. Around 45% patients agreed that they will elect the use of synthetic bone substitute material to avoid bone graft surgery. Only 12% patients accepted additional costs of guided implant surgery to avoid bone graft surgery [Table 4].
Table 4: Patient's acceptance and preferences (percentage of positive responses)

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In the present survey, it was found that 52% patients would opt for a second opinion if told that implants are essential for their fixed dentures. If the patient did not qualify for dental implant treatment, their motivation to obtain the second opinion was high (41%), especially among men (P = 0.001, Fisher's exact) and patients younger than 40 years of age (P = 0.001, Fisher's exact). Nearly 32% and 56% would challenge the information that placement of dental implants was not possible without previous bone graft surgery or computed tomography, respectively [Table 5].
Table 5: Survey questions on second-opinion seeking: “Would you seek a second opinion if you were told that...” (percentage of positive responses)

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  Discussion Top

In India, epidemiological data on awareness and attitudes of patients toward the replacement of teeth and various surgical modalities are scanty. Therefore, an attempt was made to find out the patients' perception about dental implant and bone graft surgery. Replacement of missing teeth by means of implant-supported prosthesis for esthetic and functional rehabilitation has turn out to be an established and extensively used treatment modality in dentistry.[19] It is a treatment type which the patients have little experience and understanding of before becoming recipients of implants.[3] Among the 120 respondents in the present survey-seeking implant treatment, majority were among the 21–30 years of age group (64%). This can be attributed to the increased interest in dental treatment amongst the younger generation and changing attitudes toward the advancements in medical and dental technology.[5]

In the present survey, treatment predictability, i.e., predictability of treatment success, time and cost efficiency of treatment, and avoidance of removable dentures were found to be the major interest of patients seeking dental implant therapy while interviewees considered time and cost-efficiency as well as avoidance of bone grafting less important. These results were in line with the other study.[18] Modern research in oral implantology, paradoxically, puts substantial scientific focus on treatment time reduction,[20] economic analyses,[21] and minimally invasive surgical techniques.[22] However, very less is known about factors that motivate patients to choose or refuse implants.[17]

For the longevity of dental implants, 42% patients believed implants could last for a lifetime. Similar results were obtained by Hof et al. (59%).[18] However, 24% patients in Pommers' study[22] and 7% of the participants in Rustemeryer's study believed implants could last longer than 25 years.[23] Most current studies pointed out that patients believed the cost was one of the determinants to hinder patients from making treatment decisions.[18],[22],[23] The need for supplementary bone grafting procedures may produce added apprehension.

Bone grafts have made it possible to resolve the problems of the insufficient thickness or height of the jawbone in many patients who require dental implants for either functional or esthetic reasons. Autologous bone is currently considered the “gold standard” for bone regeneration due to its osteoconduction, osteoinduction, and osteogenesis-inducing properties.[14] However, autologous bone grafts occasionally have significant drawbacks, such as increased postoperative morbidity, the need for a second surgery, and the lack of sufficient bone mass at the donor site.[24]

In the present survey, 59% of patients accepted autologous bone augmentation (mostly preferring the retromolar area) similar to the study done by Hof et al.[18] Almost half of patients (45%) would prefer synthetic bone substitute material to avoid bone graft surgery. It may be assumed that patients choose minimally invasive treatment alternatives if applicable.[25] Only 12% of patients accepted the additional costs of guided implant surgery to avoid bone graft surgery. The result was in line with study done by Johannsen et al.[26]

Patient acceptance of dental implant may also be limited by the time-intensive and multi-step process involved in the implant treatment.[27] Most of the patients (87%) in the present study had no issue with waiting at least 2 months between tooth extraction and implant insertion and 92% claimed to accept the healing period before prosthetic restoration. This was in agreement with the study done by Brägger et al.[28] Few interviewees in the present study (5%) rated time issues first priority and only 8% were willing to tolerate increased risk of implant failure for the sake of shortening treatment duration.

In the present survey, most of the young and male patients were motivated to seek a second opinion. Although reasons for opting second-opinion consultations may differ significantly,[29] it seems essential to gain further insights into patient preferences and expectations.

Most clinicians make their decisions on the basis of their experience and areas of expertise and often forget to ask the patient's opinion or describe the advantages and disadvantages of the different procedures and any alternative material that may be used.[30] These kinds of omissions result in a contravention of autonomy of the patient. Patients have the right to reject a specific product or treatment if it is in opposition to their philosophical or religious principles. Therefore, it is mandatory that patients participate in decision-making that the clinician's role should be minor and constrained to presenting the current scientific data about the potential treatment options[30] and that the clinician should listen to the patient's preferences and views before a decision concerning the “best alternative” is made. Many procedures and treatments require patients to provide informed consent which is a patient's ethical and legal right[31] and requires that clinicians describe to the patient the procedure, origin and type of material to be used in the bone graft surgery.[32] The patient's denial to undergo a treatment proposed by the clinician may prevent the treatment from proceeding and may also become an obstacle to a satisfactory clinician–patient relationship. Therefore, the patient's opinion and preferences must be taken into account before implementing any treatment.[33]

As this study was carries out in Aligarh, the education and awareness of the patients may vary from the other part of India so the results cannot be generalized. The sample size of the study was small. A multicentric study using a large sample size and standardized questionnaire will increase the level of evidence regarding patients' perception about dental implant and bone graft surgery.

  Conclusions Top

Patients' expectations on implant success and predictability were high in comparison to their reluctance toward treatment costs and duration, and minimally invasive treatment alternatives were generally preferred. Is suggests that views and perceptions of patients should be taken into consideration to improve patient compliance with and acceptance of prostheses. Patient-based assessment of treatment alternatives may point the way to enhanced satisfaction and acceptance of dental implants.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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