Knowledge and attitude of dental students toward immediate implant placement and delayed loading

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1 Research Article Knowledge and attitude of dental students toward immediate implant placement and delayed loading S.Keerthika, Ashish R. Jain* ABSTRACT Background: Dental implants are alloplastic material which is placed surgically into residual alveolar bone. As there is increasing demand for implant placement, there is need to understand clinical difference between early and conventional loading protocols for dental implants. Aim: The aim of the study was to assess knowledge, attitude, and practice on immediate and delayed loading of implants among dental students. Materials and Methods: A total of 100 dental students were asked about loading protocols of immediate and delayed implants using a questionnaire and collected from the respondents in the same visit. Filled questionnaire was collected and analyzed. The data were entered into Microsoft Excel, and descriptive analysis was done. Results were represented in the form of charts. Results: Among the respondents, 72.5% of the respondents are aware of loading protocols of immediate implants and delayed loading, and 27.5% were not aware about the loading protocols. When asked about factors that lead to immediate implant implacement in the anterior region, only 14% of the respondents quoted for the absence of anatomical constraints and 68% of the respondents quoted for esthetics as an important factor which was contradictory to a clinical study conducted by Pommer et al., in which it was found that immediate implants are mostly indicated in the anterior teeth region due to the absence of anatomical constraints such as maxillary sinus and inferior alveolar nerve. Conclusion: From the present study, it can be concluded that there are limited knowledge and awareness about loading protocols and clinical criteria for immediate and delayed implants among dental students of this institution, though their knowledge and awareness about implants are appreciable. These facilities the need for strengthening education in dental students to reinforce their knowledge and awareness about loading protocols of various types of implants in their curriculum implants. KEY WORDS: Esthetics, Dental implants, Knowledge, Loading protocols, Periapical infection INTRODUCTION Prosthodontic treatment aims toward restoring function and esthetics of edentulous patients without compromising oral and psychological health of the individuals. Conventional rehabilitation of partial or complete teeth loss with removable partial dentures, fixed partial dentures, or composite retained onlay partial dentures, has limitations for many people and such devices can cause mastication disturbances, psychological problems and other problems related to esthetics, retention, and stability of prosthesis. These problems may decrease patient s self-confidence and may develop other psychological problems. [1] In addition to the risk of complications, most of these treatment requires removal of substance of adjacent Access this article online Website: jprsolutions.info ISSN: healthy teeth. Moreover, reduction of tooth structure also compromises the longevity of the tooth structure and may also result in periodontal, endodontic, and mechanical complications. [2] To overcome these problems, dental implants came into existence in modern dental practice. Dental implant is alloplastic materials which are surgically placed into the residual alveolar bone chiefly as a foundation for the prosthesis. [3] Preservation of tooth (does not require reduction of adjacent tooth structure), provision of additional support, resistance to disease (lesser incidence of recurrent caries which occur beneath or at the margins of the restoration on the root surface), recent advances in biomaterials and clinical techniques, etc., lead to great expansion in the indication of dental implant as treatment options in prosthodontics. [4] Moreover, implantsupported prosthesis has proven more advantages Department of Prosthodontics, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India *Corresponding author: Ashish R. Jain, Department of Prosthodontics, Saveetha Dental College, Saveetha University, 162, Ponnamalle High Road, Chennai , Tamil Nadu, India. Phone: dr.ashish_r@yahoo.com Received on: ; Revised on: ; Accepted on:

2 including increased masticatory efficacy, maintenance of bone, improved function, phonetics, esthetics, etc. According to an estimate in 2010, about 100, ,000 dental implants are placed per year. [5] Conventional loading of implants requires healing period of 3 months in mandible and 4 6 months in the maxilla, to achieve predictable osseointegration. Direct contact between living bone and the load-carrying implant at the histological level is referred as osseointegration, and it is considered to be a prerequisite in implant stability, implant, and clinical success of implants. Albrektsson et al. in his study reported that strength of osseointegrated implant is far greater than that of a encapsulated implant. [6] Immediate implants, delayed loading, and conventional loading are three main loading protocols in implants. Moreover, conventional loading protocol has some advantage which includes extraction site preservation and allows time for soft tissue healing. However, waiting period of 4 6 months for osseointegration (early loading) and the prosthesis fabrication following a two-stage surgery were the biggest disadvantage, since most of the patient wish that their lost teeth should be replaced as early as possible. Furthermore, this long waiting period is associated with unavoidable bone loss leading to difficulties such as insufficient bone at the time of implantation. Insufficient bone necessitates bone grafting procedures thereby increasing morbidity, chairside time and cost of the treatment. [7] Schulte and Heimke. described about immediate placement of dental implant in an extraction socket more than 30 years ago in a clinical report. [8] With the advent of immediate single stage implant placement, edentulous patient can receive replacement in the same surgical visit, thereby reducing the time that has elapsed between tooth extraction and implant placement. [9] However, these benefits come at the cost of associated risk factors including increased risk of infection, the need for bone augmentation procedure to solve disturbances between implant surface and alveolar bone, esthetic complications, mucosal recession which occurs due to the paucity of facial bone wall to support the facial soft tissues. It also requires more chairside time for both dentist and patients at the time of implant placement. [10] There are various literature which show various levels of awareness among of dental implants among patients, general population, and undergraduate students. There is a scarcity of literature which assesses dental student s knowledge about loading protocols of implants. Therefore, this study aims to assess knowledge and attitude of dental students toward immediate implant placement and delayed loading. MATERIALS AND METHODS A multiple choice questionnaire consisting of 12 questions were framed and distributed to dental students of Saveetha Dental College and Hospitals who have entered their clinical practice with primary objective to determine their awareness toward loading protocols of immediate and delayed implants. A total of 100 dental students of the institution participated in the study. Exclusion criteria for the study were as follows: Dental students who have not entered into their clinical practice. Dental students who are not willing to participate in the study. The questions were based on simple answers that the objects could answer easily by choosing any one of the options given accordingly. Self-administered questionnaire was distributed to the participants and collected in the same visit. Filled questionnaire was collected and analyzed. The data were entered into Microsoft Excel, and descriptive analysis was done. The result was represented in charts [Figure 1]. Sample size calculation. RESULTS The results were reported by summarizing responses to each of the 12 questions. The participants consist of 73% of female respondents and 27% of male respondents. Figure 2 shows awareness toward dental implants. Most of the respondents 72.5% of the respondents are aware about the loading protocols and 27.5% of them are not aware. Figure 3 shows that 76% of the respondents are aware that immediate implants are placed immediately on the day of extraction. Figure 4 shows that most of the respondents quote esthetics (68%) as an important reason for immediate placement in the anterior teeth region, followed by preservation of soft tissue (14%) and absence of anatomical constraints (18%). Figure 5 shows most of the respondents (48%) quoted that all the factors such as socket preservation, soft tissue management, and less occurrence of trauma are important factor held in implant placement. 594

1) Are youaware about immediate placement, immediate loading and delayed loading of implant?yes/no.

a) No anatomicalconstraitsb)aesthetics c)preservation ofinterdental papillae 4) Important factor held in immediate implant placement is a) socket preservationb)soft tissue managementc)less traumatic

a) traumatic loss of teeth with small amount of bone loss b) appropriate location of extracted tooth for planned restoration c) bone availability apical to extractionfor stabilization of implant 6)

7) Which among the following advantages of immediate loading of implant are you aware of?

3 1) Are youaware about immediate placement, immediate loading and delayed loading of implant?yes/no. 2) Immediate implants are placed on the day of extractionyes/no 3) Immediate placement of implantafter extraction is most commonly indicated in anteriors?yes/no If yes,why? a) No anatomicalconstraitsb)aesthetics c)preservation ofinterdental papillae 4) Important factor held in immediate implant placement is a) socket preservationb)soft tissue managementc)less traumatic extraction 5) Which among the following Indications of immediate placement of implantare you aware of? a) traumatic loss of teeth with small amount of bone loss b) appropriate location of extracted tooth for planned restoration c) bone availability apical to extractionfor stabilization of implant 6) which among the followingimplant loading protocol, do you think will have more success rate in the anterior region? a) immediate loading b) delayed loadingc) both A and B. 7) Which among the following advantages of immediate loading of implant are you aware of? a) Reduced number of surgical proceduresb) width and height of alveolar bone are preservedc) provides better esthetics for the patient. 8) Which among the following disadvantages of immediate loading of implant are you aware of? a) difficuity in maintaining primary stability b) inadequate soft tissue coverage c) socket expansion during extractiond) all the above. 9) which among the following advantages of delayed implants are you aware of? a) allowed adequate time forosseointegration to take place b) less risk of implant fracture / failurec) extraction site preservationd) enhanced soft tissue healing 10) Does presence of periapical infection influence survival rate of immediate implants?yes/no Figure 1: Self-administered questionnaire distributed to the participants Figure 2: Awareness of dental students toward immediate and conventional loading of implants Figure 4: Response toward reasons for immediate implant placement in the anterior teeth Figure 5: Response toward important factor held in immediate implant placement Figure 3: Response toward immediate implant placement on the day of extraction Figure 6 shows that most of the respondents are aware that there is a significant difference in crestal bone resorption between immediate and delayed implants. Figure 7 shows that 75.5% of the respondents agree that presence of periapical infection influence survival rate of implants. Figure 8 shows that 48% of the respondents quote that preservations of width and height of alveolar bone as the most common advantage of immediate implants. DISCUSSION The prevalence of dental implants is increasing in modern dental practice due to simplification of clinical procedures and shortening of treatment time with such 595

Figure 6: Response toward difference in crestal bone resorption between immediate and delayed loading of implants Figure 7: Response toward influence of periapical infection in the survival rate of

5% of the respondents are aware of loading protocols of immediate implants and delayed loading and 27.5% were not aware.

which reported that immediate implants are gaining more popularity in replacing anterior missing teeth because (keratinized mucosa width) in patients treated by immediate implants combined with

4 Figure 6: Response toward difference in crestal bone resorption between immediate and delayed loading of implants Figure 7: Response toward influence of periapical infection in the survival rate of delayed implants Figure 8: Response toward advantages of immediate implants developments including immediate implants, flap surgery, etc. [11] Figure 2 shows that 72.5% of the respondents are aware of loading protocols of immediate implants and delayed loading and 27.5% were not aware. Figure 4 shows that most of the respondents think that immediate implants are placed in the anterior region. This is in accordance with a study conducted by Krump et al. which reported that immediate implants are gaining more popularity in replacing anterior missing teeth because (keratinized mucosa width) in patients treated by immediate implants combined with subepithelial connective tissue grafts had values >3 mm at the end follow-up. With immediate implants there is also minimized need for angled abutments as implants in fresh extraction sites can be placed in the same location of the extracted tooth, more favorable osseointegration, waiting period for primary healing of soft tissues, and regeneration of soft tissues are eliminated. Furthermore, immediate implants keep contaminants away from the extraction socket. [12] When asked about factors that lead to immediate implant implacement in the anterior region, only 14% of the respondents quoted for absence of anatomical constraints and 68% of the respondents quoted for esthetics as an important factor which was contradictory to a clinical study conducted by pommer et al. in which it was found immediate implants are mostly indicated in the anterior teeth region due to the absence of anatomical constraints such as maxillary sinus and inferior alveolar nerve. [13] These suggest that there is need to raise awareness regarding implant loading protocols among dental students Figure 5 shows that majority of the respondents (48%) think that all the factors (socket preservation, soft tissue management, and less traumatic extraction) determine immediate implant placement. [14] When asked about the difference in crestal bone resorption between immediate and delayed implants, most of the respondents (72%) agreed that there is difference in crestal bone resorption between immediate and delayed implants. However, in a study done by Botticelli et al. it was found that mean and standard deviation of crestal bone resorption with immediate loading and delayed loading is 0.14 ± and ± 0.09 which shows there is statistical significance in the crestal bone resorption between immediate and delayed implants. [15] Periapical infections represent areas of inflammatory reaction due to the presence of pathological agents on the infected root canal, which on radiographic examination shows the presence of granulation tissue, neutrophil infiltrates near the apical foramen delimiting the bacteria on the apical part of root canal. [16] This makes various authors to consider periapical lesions as a risk factor which interferes with the success rate of implants. Hence, when asked about the influence of periapical infection on survival rate of implants, 75.5% of the respondents quoted that presence of periapical infection has influence on the survival rate of implants. The same finding was observed in a study by Cafiero et al. which reported that implants are not placed immediately in the presence of periapical infection, but instead a delayed placement protocol was implemented. Significant loss of vertical bone height at the adjacent teeth and at the implant site, gingival recession, etc., is considered to be attributing factors to failures of immediate implants in case of periapical pathology. [17] On the other hand, Siegenthaler et al. in his prospective randomized study comparing the placement of immediate implants in sites with periapical lesions with delayed implantation, reported a success rate of 100% for delayed implants and 92 % for immediate implants. There was no statistical difference although there was numerical difference. [18] This shows that, chronic periapical infection is a risk factor, but not an absolute contraindication for implant placement. However, the 596

5 alveolus should not be completely debrided and the periapical infection should be carefully monitored for enhanced success rates of implants. [19] Figure 8 shows that 48% of the respondents think that preservation of width of the alveolar bone as the most important advantage of immediate implants, 30% of the respondents quoted for esthetics, and 22% of the respondents quoted for reduced number of surgical procedures as an advantage of immediate implants. Darby et al. in his study to evaluate clinical esthetic outcomes of non-submerged immediate implants reported that preservation of alveolar bone at the site of extraction provides space for the formation of blood clot. These blood clot subsequently reorganize into provisional connective tissue matrix which supports the formation of newly formed woven bone. Preservation of alveolar is also associated with less crestal bone height reduction. [20] CONCLUSION From the present study, it can be concluded that there are limited knowledge and awareness about loading protocols and clinical criteria for immediate and delayed implants among dental students of this institution, though their knowledge and awareness about implants are appreciable. These facilities the need for strengthening education in dental students to reinforce their knowledge and awareness about loading protocols of various types of implants in their curriculum implants. Moreover, dental student s awareness regarding loading protocols and clinical criteria helps in eradicating any negative reflection of this procedure that may have been caused due to lack adequate information. REFERENCES 1. Anil S, Preethanath RS, Al-Moharib HS, Kamath KP, Anand PS. Impact of osteoporosis and its treatment on oral health. Am J Med Sci 2013;346: Walton TR. An up to 15 year longitudinal study of 515 metalceramic FPDs Part 1. Outcome. Int J Prosthodont 2002;15: Chowhary R, Horsadettu SR, Chankar NA. Survey on the use of techniques, materials in dental implantology practise. Indian J Dent Res 2012;23: Lindh T, Gunne J, Tillberg A, Molin M. A meta-analysis of implants in partial edentulism. Clin Oral Implants Res 1998;9: Gupta A, Dhanraj M, Sivagami G. Status of surface treatment in endosseous implant: A literary overview. Indian J Dent Res 2010;21: Albrektsson T, Jansson T. Osseointegrated dental implants. Dent Clin North Am 1986;30: Tarnow D, Elian N, Fletcher P, Froum S, Magner A, Cho SC, et al. Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants. J Periodontol 2003;74: Schultz W, Heimke G. Outcomes of immediate implants. Quests Senz 1976;27: Niklai JA, Zarb GA. Immediate and early implant loading pro-tocols: A literature review of clinical studies. J Prosthet Dent 2005;94: Esposito M, Felicle P, Worthigton HV. Intervention for replacing missing teeth: Dental implants in fresh extraction sockets. Aust Dent J 2011;56: Narby B, Bagewitz IC, Soderfeldt B. Factors explaining desire for dental implant therapy: Analysis of the results from a longitudinal study. Int J Prosthodont 2011;24: Elias AC, Sheiham A. The relationship between satisfaction with mouth and number and position of teeth. J Oral Rehabil 1998;25: Belser UC, Grütter L, Vailati F, Bornstein MM, Weber HP, Buser D, et al. Outcome evaluation of early placed maxillary anterior single-tooth implants using objective esthetic criteria: A cross-sectional, retrospective study in 45 patients with a 2-to 4-year follow-up using pink and white esthetic scores. J Periodontol 2009;80: Hermann JS, Buser D, Schenk RK, Higginbottom FL, Cochran DL. Biologic width around titanium implants. A physiologically formed and stable dimension over time. Clin Oral Implants Res 2000;11: Barzilay I. Immediate implants: Their current status. Int J Prosthodont 1993;6: Siegenthaler DW, Jung RE, Holderegger C, Roos M, ha Mmerle CH. Replacement of teeth exhibiting periapical pathology by immediate implants. A prospective controlled clinical trial. Clin Oral Impl Res 2007;18: Thaler DS, Jung RE, Holderegger C, Roos M, Hammerls CH. Replacementof teeth exhibiting periapical pathology by immediate implants: A prospective, controlled clinical trial. Clin Oral Implants 2007;18: Chen ST, Darby IB, Reynolds EC. A prospective clinical study of non-submerged immediate implants: Clinical out-comes and esthetic results. Clin Oral Implants Res 2007;18: Block MS, Mercante DE, LIrette D, Mohamed W, Ryser M, Castellon P. Prospective evaluation of immediate and elayed provisional single tooth restoration. J Oral Maxillofac Surg 2009;67 Suppl 3: Waasdorp JA, Evian CI, Mandracchia M. Immediate placement of implants into infected sites: A systemic review. J Periodontal 2010;81: Source of support: Nil; Conflict of interest: None Declared 597

The International Journal of Periodontics & Restorative Dentistry

The International Journal of Periodontics & Restorative Dentistry 3 Influence of the 3-D Bone-to-Implant Relationship on Esthetics Ueli Grunder, DMD* Stefano Gracis, DMD** Matteo Capelli, DMD** There are