JJOD 2461 1–8 journal of dentistry xxx (2015) xxx–xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.intl.elsevierhealth.com/journals/jden 1 2 3
Dental implants in the eyes of the public: A qualitative study
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Q1
Guihua Wang a, Xiaoli Gao b,*, Edward C.M. Lo b a b
The Kadoorie Institute, The University of Hong Kong, Hong Kong Special Administrative Region Dental Public Health, Faculty of Dentistry, The University of Hong Kong, Hong Kong Special Administrative Region
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article info
abstract
Article history:
Objectives: Dental implants have become a popular option for treating partially dentate or
Received 15 December 2014
edentulous patients. Information on dental implants is widely available in the public
Received in revised form
domain and is disseminated through industries and dental practitioners at various
18 March 2015
levels/disciplines. This qualitative study aimed to evaluate the public’s information acqui-
Accepted 24 April 2015
sition and their perceptions of dental implants and the effects of these on their care-seeking
Available online xxx
and decision making. Methods: A purposive sample of 28 adults were recruited to join six focus groups. To be
Keywords:
eligible, one must be 35–64 years of age, had never been engaged in dentally related jobs, had
Dental implant
at least one missing tooth, and had heard about dental implant but never received dental
Qualitative research
implant or entered into any dental consultation regarding dental implants. All of the focus
Information acquisition
groups discussions were transcribed verbatim and subjected to thematic content analysis
Expectations
following a grounded theory approach.
Care-seeking behaviours
Results: Participants acquired information on dental implants through various means,
Decision-making
such as patient information boards, printed advertisements, social media, and personal connections. They expected dental implants to restore the patients’ appearance, functions, and quality of life to absolute normality. They regarded dental implants as a panacea for all cases of missing teeth, overestimated their functions and longevity, and underestimated the expertise needed to carry out the clinical procedures. They were deterred from seeking dental implant treatment by the high price, invasive procedures, risks, and complications. Conclusions: Members of the public were exposed to information of varying quality and had some unrealistic expectations regarding dental implants. Such perceptions may shape their care-seeking behaviours and decision-making processes in one way or another. Clinical significance: The views and experiences gathered in this qualitative study could assist clinicians to better understand the public’s perspectives, facilitate constructive patient–dentist communication, and contribute to the creation of positive clinical experiences in implant dentistry. # 2015 Elsevier Ltd. All rights reserved.
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13 * Corresponding author at: Periodontology and Dental Public Health, Faculty of Dentistry, The University of Hong Kong, 3/F, Prince Philip Dental Hospital, 34 Hospital Road, Sai Ying Pun, Hong Kong Special Administrative Region. Tel.: +852 2859 0401; fax: +852 2858 7874. E-mail address: [email protected] (X. Gao). http://dx.doi.org/10.1016/j.jdent.2015.04.012 0300-5712/# 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Wang G, et al. Dental implants in the eyes of the public: A qualitative study. Journal of Dentistry (2015), http:// dx.doi.org/10.1016/j.jdent.2015.04.012
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1.
Introduction
Q2 Dental implants are considered to be one of the most
important innovations in contemporary dentistry.1 Since the introduction of titanium implants for intra-oral use in the late 1950s, dental implantology has become one of the most active and promising areas in dentistry and is a popular option for the oral rehabilitation of partially dentate or edentulous patients.1 The growing popularity of dental implant therapy has also led to an increase in the numbers of dentists trained in implant dentistry and the prosperity of the dental implant industry, with a projected annual growth rate of 20%.2,3 Osseointegrated dental implants are often preferable to conventional dentures for several reasons, such as the preservation of the structure of adjacent teeth and better comfort, aesthetic outcome, functions, and stability.4,5 In particular, for patients who are not able to adapt to conventional dentures or who have compromised local host bone, dental implant treatment offers a solution that may generate more satisfactory outcomes.6,7 The reported 10-year survival rate is approximately 90%, making it a fairly predictable modality of treatment.8 Despite the advantages, dental implants are not a panacea for all cases of missing teeth, and clinical success is only possible when the treatment plan is based on a thorough assessment of the patient’s condition and careful consideration of the indications and contraindications.8 Some risks are involved and possible complications can occur during the surgical and post-surgical phases and in the long term.9 In addition, the patient’s daily self-care habits, such as maintenance of good oral hygiene and abstinence from smoking, are essential for the longevity of dental implants.10 Information on dental implants is now widely available in the public domain.5 Patients may also receive information from the industry and practitioners at different levels (general practitioners and specialists) and in various dental disciplines. Thus, the general public may be confronted with confusing information that they acquire from various sources. Because of the complexity of dental implantology, information received from different sources may not always reflect evidence-based empirical data.11 The exposure of the public to such information may form a basis for their perceptions of dental implants and affect their intentions to consider dental implants as a treatment option when the need arises. In addition, such information may influence their communications with dentists and their decision-making between the different treatment options. Research on patients’ perceptions, expectations, and satisfaction with dental implant treatment predominantly draws upon quantitative methods, such as questionnaire surveys and the measurement of clinical outcomes.12 More recently, qualitative methods have been introduced into dental implant research and have generated valuable insights.13,14 As an important complement to quantitative methods, qualitative research can capture a wide range of views and experiences and help to gain an in-depth understanding of participants’ perspectives.15 Rather than generating numbers and statistics, qualitative studies interpret the deep meaning of the
informants and report the themes in a rich context using their own words.15 In a recent qualitative study, semi-structured interviews with nine patients revealed that ‘‘normality’’ was their main motivation for and expectation from dental implants.13 Patients expected implants to restore their life to ‘‘normal,’’ although their definitions of normality differed. In another qualitative study, patients favoured implant-supported overdentures rather than conventional dentures because they provided better functional improvement and increased social confidence.14 Previous qualitative studies in dental implantology only involved patients who had undergone dental implant treatment or consulted a dental practitioner about the possibility of replacing their missing teeth with dental implants.13,14 Nevertheless, how the general public were exposed to information on dental implants before entering into such a consultation with a dentist, how they processed such information, how the information shaped their perceptions of dental implants, and how such perceptions may have influenced their future intentions to seek dental implant treatment remain unknown. This qualitative study aimed to probe these questions to understand (i) the general public’s information acquisition on dental implants, (ii) their knowledge of dental implants, (iii) their perceptions of dental implants (the treatment process, treatment outcomes, and the advantages and disadvantages compared with traditional treatment modalities), and (iv) their careseeking behaviours and decision making with regard to dental implant treatment.
2.
Methods
2.1.
Recruitment of participants
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The protocol of this study was reviewed by the Institutional Review Board of The University of Hong Kong/Hospital Authority Hong Kong West Cluster. Ethical approval was obtained (#UW 13–086). A purposive sample of adults were recruited from two community centres located in Hong Kong Island and Kowloon, respectively. These community centres organise a wide variety of activities throughout the year, such as family support, career enrichment, educational programmes, cultural events, sports, leisure activities, and tours. The members enrolled in these centres span a wide variety of age groups, occupations, and social strata. To be eligible to join this study, one must fulfil the following criteria: (a) be 35–64 years of age, (b) be a Hong Kong resident, (c) be a fluent Cantonese speaker, (d) never been engaged in dental jobs or related industries, (e) have at least one missing tooth, (f) have heard about dental implants, and (g) never received dental implant treatment or consulted a dental practitioner about the possibility of replacing their missing teeth with dental implants. Both genders were eligible to join. Eligible participants who gave their written informed consent were then assigned into focus group sessions based on their preferred and/or available timeslot. The recruitment of participants was terminated when data saturation was reached, i.e., when no new facts or views were recorded during the thematic content analysis.16
Please cite this article in press as: Wang G, et al. Dental implants in the eyes of the public: A qualitative study. Journal of Dentistry (2015), http:// dx.doi.org/10.1016/j.jdent.2015.04.012
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2.2.
Focus group meetings
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All focus group meetings were moderated by the first author, who is a trained methodologist in qualitative research. A focus group guide was prepared to outline the aspects to be covered. Open-ended questions were asked to facilitate information sharing. Unclear expressions or vague meanings were probed for further clarifications. The moderator remained neutral and objective. There was a sound balance of closeness and detachment. The moderator helped participants to feel comfortable in sharing, strived to involve all participants, ensured the focus group was not dominated by any member, and maintained a positive group dynamic. All focus groups were conducted in a quiet meeting room at the centre and were not interrupted by other people. The staff members of the centres made the arrangement but were absent during the focus group meetings. All focus group discussions were digitally audio-recorded with the participants’ consent. Each participant received two boxes of dental floss and a supermarket coupon (HKD50; equivalent to US$6.5) as a token of appreciation for their participation.
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2.3.
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All focus group sessions were transcribed verbatim and were subjected to thematic content analysis, for which grounded theory principles17 were applied. Themes were mainly developed using an inductive method, i.e., the main themes and sub-categories emerged from the data. Meaningful ‘‘text units’’ were extracted manually by line-by-line coding. No data analysis software was used. To ensure rigour, the
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thematic interpretation was discussed among and crossvalidated by all of the authors.
Transcription and data analysis
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3.
Results
3.1.
Participants’ profiles and the focus group process
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A total of 28 participants (18 women and 10 men) were recruited into six focus groups. Their ages ranged from 35 to 64 years, with a mean (standard deviation) of 52.8 (9.4) years. All of the participants had completed at least a secondary school education; 11 (39%) were housewives, eight (29%) were service workers, three (11%) were administrative support workers, one (4%) was an operative worker, and five (18%) were retired citizens. Each focus group comprised 4–5 participants and lasted for 40–60 min (50 min on average). To maintain participant confidentiality, pseudonyms were used in the transcripts and this paper. For example, C1-FG1-P3 refers to participant #3 attending the first focus group in the first community centre, whereas C2-FG2-P4 refers to participant #4 attending the second focus group in the second community centre. Table 1 shows the main themes and sub-categories that emerged from the data.
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3.2.
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Sources of information
All members had heard about dental implants from various sources. Some participants were first introduced to information on dental implants when they visited dental clinics or dental
Table 1 – Main themes and sub-categories. Main themes
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Sub-categories
Sources of information
Patient information boards Print advertisements and social media (e.g. television, radio, newspaper and internet) Personal communication/social network
Knowledge of dental implants
Varied level of understanding Some ideas and confusions
Motivation for seeking dental implant treatment
Expectations regarding dental implants
Restoration of appearance, functions and quality of life to absolute normality Overestimation of the functions and longevity of dental implants Dental implant as a panacea Underestimation of the daily care needed Underestimation of the expertise required
Concerns against choosing dental implant as an treatment option
Medical tourism
Price difference Concerns on quality of service, surgical risk, inconvenience and lack of channels for resolving disputes
Improved comfort Aesthetic appearance Better stability and functions (chewing and pronunciation) Avoiding damage to the adjacent teeth Influence of positive cases (e.g. friends’ positive experiences/outcomes)
High price and unaffordability Pain and invasive procedures Risks and complications Lack of trust
Please cite this article in press as: Wang G, et al. Dental implants in the eyes of the public: A qualitative study. Journal of Dentistry (2015), http:// dx.doi.org/10.1016/j.jdent.2015.04.012
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departments of general hospitals, where materials posted on patient information boards provided them with some understanding.
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‘‘When I was waiting to see a dentist at the dental department of a public hospital, I saw some posters on the patient information board. These posters introduced some basics about dental implants. That was the first time I learned about dental implants.’’ (C2-FG1-P5)
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Participants also reported that printed advertisements and social media, such as newspapers, radio and television programmes, served as another source for learning about dental implants.
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‘‘Once when I crossed the border and travelled to mainland China, I saw a huge advertisement board about dental implants on the wall outside the Lowu Custom.’’ (C1-FG1-P5)
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‘‘The first time I heard about dental implants was from the advertisement rolled in television programs. You know, the one by XXX (a popular drama actress in Hong Kong).’’ (C2-FG1-P2)
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‘‘I heard about implants from the radio about 20 years ago, when I was still a teen. It sounded very magical to me.’’ (C2FG1-P5) The convenience of Internet connections enables the general public to obtain information from the Web freely, using either personal computers or mobile devices, such as smartphones.
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‘‘Nowadays, it is very convenient to surf the Internet and look for any information about dental implants.’’ (C2-FG2-P3)
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Some participants first heard about dental implants from their relatives, friends or colleagues. ‘‘One of my relatives has tried dental implants. I also heard my colleagues discussing about where to go for the cheapest dental implants.’’ (C1-FG1-P4)
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3.3.
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Some participants had a certain understanding of dental implants and were able to describe them in simple terms.
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‘‘If I understand correctly, dental implants are about placing a metallic rod into the jaw bone, so that it can support a replacement tooth.’’ (C2-FG2-P2)
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In contrast, some of them seemed to be clueless about what dental implants are and how they work. Several participants confused them with cell culture technology, conventional crowns, or orthodontic treatment.
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‘‘Dental implants sound unbelievable to me! . . . I cannot imagine they can stay in the mouth without capping the
Knowledge of dental implants
neighboring teeth as people usually do in bridges. How can they work?’’ (C2-FG1-P1)
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‘‘Umm . . . dental implants. Are they something related to cell culture techniques? Like cells that are cultured in the laboratory? Actually, I am not quite sure about it!’’ (C1-FG2-P4)
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‘‘Oh sorry, I am afraid I misunderstood the meaning of dental implants. I thought they referred to the conventional crown. Now I know they are different.’’ (C1-FG1-P4)
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‘‘Is a dental implant something like orthodontic treatment? These two terms sound the same to me.’’ (C1-FG4-P3)
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3.4.
Motivations for seeking dental implant treatment
Dissatisfaction with the outcomes of conventional prostheses and the expected advantages of implant–support prostheses prompted prospective patients to consider implant dentistry and encouraged them to seek further information through various means. Improved comfort, aesthetic appearance, stability, and better function (in terms of chewing and pronunciation) were reported to be the motives.
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‘‘I think dental implants make you feel more comfortable because they won’t give you the sensation of a foreign object; something that is usual when you are wearing a conventional denture.’’ (C1-FG1-P2)
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‘‘The implanted teeth look way better than the conventional dentures. I have seen a friend whose implanted teeth blend in her dentition very well and you can’t tell which tooth is the implanted one.’’ (C2-FG2-P1)
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‘‘I think dental implants are just like what you can see in the interior renovation. You drill a hole into the wall and then put in a screw or a nail to fix it up. And it is very stable. Dental implants should be the same thing. The dentist drills a hole into your jaw and fixes the implant with a screw. It is stable too. The ordinary denture is nothing comparable to this (implant). The implanted teeth allow you to chew food better.’’ (C1-FG1-P1)
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‘‘I tried hard to get used to my removable partial denture, but it affected my pronunciation so much. I had problems speaking clearly. Also, I couldn’t chew food properly. I discussed with my dentists about this. He told me it does take some time to adapt. He also advised me to consider implants if I can’t adapt after wearing the denture for a month.’’ (C1-FG1-P2)
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In addition, dental implants were considered preferable because no reduction of the adjacent teeth is required, while the preparation of the abutment teeth for making dentures was of great concern to them. The self-supported feature and the absence of damage to other teeth motivated participants to learn more about implant dentistry.
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Please cite this article in press as: Wang G, et al. Dental implants in the eyes of the public: A qualitative study. Journal of Dentistry (2015), http:// dx.doi.org/10.1016/j.jdent.2015.04.012
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‘‘If I understand correctly, implants stand alone and would not affect the neighboring teeth, while to make conventional dentures or bridges, the dentist has to cut the sound teeth to make them suitable for a crown cap.’’ (C2-FG1-P4)
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Moreover, the positive implant experiences of their relatives, friends and acquaintances tended to encourage them to explore implants in greater depth. ‘‘He (one of her friends who received a dental implant) said his (implanted) teeth were so good. He recommended me to save money and go for dental implants.’’ (C1-FG1-P4)
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from considering dental implants, because they felt dental implants were totally unaffordable.
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‘‘When the dentist told me the price of implants, I was really startled. We are talking about over ten thousand (Hong Kong dollars) for restoring a single tooth! There is no way I can afford it! So I stopping ask any further questions. Yep, the price is definitely the biggest problem for me!’’ (C2FG1-P2)
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Participants also shared their concerns over the invasive treatment procedures and the associated pain.
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‘‘I am really frightened. I guess put a metallic rod into my jaw bone must be very painful! I don’t want to try such treatment.’’ (C1-FG1-P2)
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3.5.
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Certain expectations were expressed during the focus group discussions. It was generally believed that dental implants restore one’s appearance, functions, and quality of life to absolute normality, while some overestimated their functions and longevity.
‘‘The photos in the poster look so scary. Imagine! The dentist is going to drill a hole in your jaw bone! I don’t dare to try it unless I have no choice.’’ (C1-FG3-P2)
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‘‘I think the problem (missing teeth) can be solved once and for all, if you choose dental implants.’’ (C1-FG2-P4)
In contrast, some of them worried about the uncertainty of the long-term outcome, the risks, and possible complications.
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‘‘You could chew normally and you can use them for the rest of your life! Quite a good deal actually!’’ (C1-FG1-P4)
‘‘Is there any chance that I have to remove the implanted tooth if it was decayed in the future?’’ (C2-FG1-P4)
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In addition, some participants considered dental implants to be a panacea for solving all missing tooth problems and believed that implanted teeth require equal or even less daily care than natural teeth.
‘‘Will my body reject the foreign object?’’ (C2-FG1-P5)
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‘‘When the dentist drills a hole into my jaw bone to insert the metal rod, will it hurt my nerves?’’ (C1-FG1-P2)
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‘‘I think everyone is suitable for dental implants.’’ (C2-FG2-P3)
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‘‘Dental implants are the solution to all dental problems.’’ (C1-FG3-P2)
Participants regarded implant dentistry as a highly profitable business, and thus raised doubts that dentists may ‘‘hard sell’’ implant-supported prostheses without considering the best interest of the patient, which might jeopardize the trust between patients and dentists.
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‘‘It would be so easy and convenient to take care of an implanted tooth as it doesn’t need any special care in daily life.’’ (C1-FG3-P5)
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‘‘Even if you don’t take good care of it and the implanted tooth gets any problem or is broken, you can simply replace it with a new one.’’ (C1-FG4-P1)
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Some participants underestimated the expertise required and believed that any dentist should be able to carry out dental implant treatment.
Expectations regarding dental implants
‘‘I don’t think they (the dentists) need to obtain a specific certificate on dental implant surgery. It should be part of their basic professional training. So I think all qualified dentists can do this.’’ (C2-FG2-P1)
‘‘Your dentist could earn real good money from your dental implant treatment. That’s why he asks you to go for implant.’’ (C1-FG1-P3)
3.7.
Medical tourism
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Some participants reported that they might travel across the border to mainland China to see a dentist if they were to seek dental implant treatment in the future. Such medical tourism seemed to be attractive but concerns about the quality of service, possible risks, inconvenience, and the lack of channels to resolve disputes should they arise, acted as deterrents to some extent.
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3.6. Concerns against choosing dental implants as an treatment option
‘‘One of the dentists I met in the mainland told me it (implanting a tooth) just costs seven thousand (Hong Kong Dollar)! In Hong Kong, even the cheapest dental implant costs twenty thousand!’’ (C1-FG1-P1)
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Although dental implants appeared to be an attractive option for replacing missing teeth, some concerns were raised. The extravagant cost of treatment discouraged some participants
‘‘I don’t dare to have (dental) treatment in the mainland. One of my friends was treated by a dentist when he was travelling there. Then he had a heart problem after his
Please cite this article in press as: Wang G, et al. Dental implants in the eyes of the public: A qualitative study. Journal of Dentistry (2015), http:// dx.doi.org/10.1016/j.jdent.2015.04.012
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return. He said it was because of the hygiene problem, and then bacteria invaded his heart. So scary!’’ (C1-FG1-P2)
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‘‘I won’t consider having the (dental implant) treatment in the mainland. It is too troublesome as you have to travel back and forth. Also, I doubt the dentists’ qualifications there. I am not sure whether they have the facilities for the (implant) surgery. In case you were unlucky, you don’t know how and where to complain to solve the problem. Too many uncertainties!’’ (C1-FG3-P2)
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4.
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This study was carried out in a purposive sample of adults who needed treatment for missing teeth but had not yet entered into any consultation or procedures for dental implant treatment. This allowed us to probe into the studied topic, i.e., the public’s information acquisition on and their original perceptions of dental implants before being influenced by professional opinions. The number of participants was considered to be sufficient for a qualitative study and data saturation was reached before the recruitment ceased. All of the participants were middle aged, which matched the age of the vast majority of the implant patient population, because this age group has both treatment need for missing teeth and disposable income.18 Our findings suggested that the primary sources of public information on dental implants included traditional media and new electronic media. Meanwhile, patient information materials that were disseminated by clinics and hospitals played a role in shaping the participants’ perceptions of dental implants, although the dental care they received during the visit was in other areas of dentistry. Our findings supported the significant influence of mass media in imparting knowledge on dental implants to the public. Nevertheless, information from these sources varied in quality, was often uncensored, and could be vague, abstract, and sometimes biased.19 It is therefore important that, during a first consultation, dentists try to understand patients’ existing perceptions and use them as a basis for further communications. Because dental implants represent a technological breakthrough and are associated with high costs, patients’ expectations are predictably high with regard to the aesthetics, functionality, and longevity of dental implants.20 Our findings suggested that regaining absolute ‘‘normality’’ was an over-riding desire among members of the public who might consider dental implants. They expected aesthetically flawless teeth with no physical abnormalities. Research in breast reconstruction has also revealed that the restoration of a natural appearance and function was the main motive for accepting invasive procedures.21 The increasing influence of the media might have further boosted such expectations. For example, dental implants are often called ‘‘the third set of teeth,’’22,23 which may have led to the fallacy that dental implants can restore the dentition to absolute normality. Patients who hold this view may be more inclined to treat their implants in the same way as they would natural teeth and may not perform thorough cleaning procedures. Because many
Discussion
patients may have lost their natural teeth due to poor oral hygiene and periodontal disease, the perception that dental implants are akin to natural teeth may result in a return to previous inadequate oral hygiene routines, and in turn increase the risk of peri-implant inflammation and implant failure.24,25 In addition, some other unrealistic expectations were heard in the focus groups. Participants were not aware of the necessity to assess their suitability for dental implant treatment and believed that dental implants are a panacea for all cases of missing teeth, which may create difficulties for dentists in explaining the indications and contraindications to patients. The above-mentioned unrealistic expectations held by members of the public may compromise their communications with dentists, affect their decision making, and lead to poor patient satisfaction.26,27 In addition, such misconceptions might lead to some unfavourable trends in treatment planning, where questionable but salvageable teeth may be extracted in favour of implant placement.28 Decision making in implant dentistry involves the patients’ preferences and values, the clinicians’ heuristics and biases, diagnostic and therapeutic uncertainties, and cost considerations.29 Several motives for considering dental implants were elaborated in the focus groups, including the avoidance of removable dentures, better preserved adjacent teeth, and predictability of the outcome. In contrast, participants were deterred from considering dental implants by the high cost, their low willingness to make significant additional payments, the invasive procedures and associated risks, and their lack of trust in dentists. Understanding these motives for and concerns about dental implants could help practitioners to communicate effectively with potential patients and help them to reach well-informed decisions. The rapidly growing dental implant industry presents both opportunities and challenges. Data collected in Taiwan have shown that dental implant cases accounted for nearly 40% of all dental disputes and the number is projected to increase further.30 This highlights the importance for dentists to improve their communication strategies to provide patients with comprehensible and legally tenable information, bridge knowledge gaps, help patients develop realistic expectations on the outcomes, and avoid becoming embroiled in a malpractice claim. Hong Kong is in close proximity to mainland China, and it is not uncommon for Hong Kong citizens to travel to the mainland to seek affordable medical and dental care. At the same time, Hong Kong is a popular destination for medical tourism, and attracts patients from and beyond the region who are searching for quality health care.31 This bi-directional medical tourism, both in-bound and out-bound, adds to the complexity of health-care services. Medical tourists are subject to a variety of risks, such as poor post-operative care and a lack of prompt follow-up, whereas dentists might be requested to deal with complications in implants placed elsewhere. The management and regulation of patient care under such medical tourism present another challenge to the practice of implant dentistry in many countries and regions. Providing successful dental implant treatment requires adequate clinical skills in various areas. In a representative opinion poll in Australia, most respondents believed that implants should only be placed by specialists or specially
Please cite this article in press as: Wang G, et al. Dental implants in the eyes of the public: A qualitative study. Journal of Dentistry (2015), http:// dx.doi.org/10.1016/j.jdent.2015.04.012
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trained dentists.11,32 In contrast, participants in our study believed that dental implants could be inserted by any dentist, implying an underestimation of the complexity of dental implant treatment and the training required to carry out the procedures. With the growing patient demand and need for treatment of the population, general dentists are increasingly integrating dental implants as a service. In a workshop organized by the Association of Dental Education in Europe, university teachers and opinion leaders reached a consensus that fundamental principles of implant dentistry should be included in the undergraduate curriculum.8 This would help students to obtain knowledge and competence in identifying the indications and contraindications, informing patients about the treatment options, and maintaining and treating straightforward cases, whereas specialized training can be directed at preparing practitioners for handling complex treatments. Such an improvement in dental education should ensure the quality of care and protect patient safety in implant dentistry. Our findings can be better interpreted in the light of the limitations of this study. The qualitative data were collected from a purposive sample of Hong Kong adults, and thus our findings cannot be directly extrapolated to other populations. However, some relevant implications can be drawn, especially for other economically affluent countries or regions and those with similar cultures or health-care systems. Because of the nature of the current data, the findings were mainly reported in a descriptive manner, as overt conceptualization may lead to certain risk of misinterpretation or overinterpretation. Further studies, such as in-depth interviews, should be considered to probe some conceptual areas further.
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5.
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This qualitative study used Hong Kong as a case scenario and showed that members of the public were exposed to information that varied in quality and had various unrealistic expectations regarding dental implants. As pointed out by Adshead and Thorpe, ‘‘We are engaging with a more articulate and educated consumer society with a keen interest in their own health and an increasingly active media.’’ While patients actively participate in decision making regarding the management of their tooth loss, the onus is on the dentists to convey information on dental treatment alternatives in an ethical and effective way so that patients can make well-informed decisions on their own dental care.
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Conclusions
Q3 Uncited
reference
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Acknowledgements The authors appreciate all participants for their willingness and time to share their views and experiences, which laid the Q4 basis for this study. Hong Kong Caine Road Caritas Centre and Hong Kong Federation of Women’s Centres (Chang Sha Wan Office) have lent their generous support to this study. We are
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grateful for the assistance of Mr. Darren Wong and valuable suggestions given by Professor Calvin Yunjie Xu.
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references
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1. John V, Chen S, Parashos P. Implant or the natural tooth – a contemporary treatment planning dilemma? Australian Dental Journal 2007;52(Suppl. 1):138–50. 2. Vasak C, Fiederer R, Watzek G. Current state of training for implant dentistry in Europe: a questionnaire-based survey. Clinical Oral Implants Research 2007;18:xiii–x. 3. Ng PCH, Pow EHN, Ching SH, Lo ECM, Chow TW. Dental implant practice among Hong Kong general dental practitioners in 2004 and 2008. Implant Dentistry 2011;20: 95–105. 4. Takanashi Y, Penrod JR, Lund JP, Feine JS. A cost comparison of mandibular two-implant overdenture and conventional denture treatment. International Journal of Prosthodontics 2004;17:181–6. 5. Mgbeokwere U, Okoye L, Ekwueme O. A survey of the knowledge of dental implants as a choice in treatment of edentulous jaws among health workers in government dental clinics in Enugu. Annals of Medical and Health Sciences Research 2011;1:91–5. 6. Aglietta M, Siciliano VI, Zwahlen M, Bragger U, Pjetursson BE, Lang NP, et al. A systematic review of the survival and complication rates of implant supported fixed dental prostheses with cantilever extensions after an observation period of at least 5 years. Clinical Oral Implants Research 2009;20:441–51. 7. Allen PF, McMillan A. Food selection and perceptions of chewing ability following provision of implant and conventional prostheses in complete denture wearers. Clinical Oral Implants Research 2002;13:320–6. 8. Mattheos N, Albrektsson T, Buser D, De Bruyn H, Donos N, Hjørting Hansen E, et al. Teaching and assessment of implant dentistry in undergraduate and postgraduate education: a European consensus. European Journal of Dental Education 2009;13(Suppl. 1):11–7. 9. Froum SJ. The team approach to managing dental implant complications: the periodontist’s point of view. Compendium of Continuing Education in Dentistry 2013;34:4–9. 10. Paquette DW, Brodala N, Williams RC. Risk factors for endosseous dental implant failure. Dental Clinics of North America 2006;50:361–74. 11. Tepper G, Haas R, Mailath G, Teller C, Zechner W, Watzak G, et al. Representative marketing-oriented study on implants in the Austrian population. I. Level of information, sources of information and need for patient information. Clinical Oral Implants Research 2003;14:621–33. 12. Thomason JM, Heydecke G, Feine JS, Ellis JS. How do patients perceive the benefit of reconstructive dentistry with regard to oral health-related quality of life and patient satisfaction? A systematic review. Clinic Oral Implants Research 2007;18(Suppl. 3):168–88. 13. Grey EB, Harcourt D, O’Sullivan D, Buchanan H, Kilpatrick NM. A qualitative study of patients’ motivations and expectations for dental implants. British Dental Journal 2013;214:E1. 14. Hyland R, Ellis J, Thomason M, El-Feky A, Moynihan P. A qualitative study on patient perspectives of how conventional and implant-supported dentures affect eating. Journal of Dentistry 2009;37:718–23. 15. Green J, Thorogood N. Qualitative methods for health research (Introducing qualitative methods series). Thousand Oaks, CA: Sage Publications Ltd.; 2004.
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16. Strauss A, Corbin J. Basics of qualitative research: techniques and procedures for developing grounded theory. 2nd ed. Thousand Oaks, CA: Sage Publications Ltd.; 1998. 17. Glaser B. Basics of grounded theory analysis. Mill Valley, CA: Sociology Press; 1992. 18. Mundt T, Polzer I, Samietz S, Grabe HJ, Messerschmidt H, Do¨ren M, et al. Socio-economic indicators and prosthetic replacement of missing teeth in a working-age population – results of the Study of Health in Pomerania (SHIP). Community Dentistry and Oral Epidemiology 2009;37:104–15. 19. Penta MA, Baban A. Mass media coverage of HPV vaccination in Romania: a content analysis. Health Education Research 2014;29:977–92. 20. Rustemeyer J, Bremerich A. Patients’ knowledge and expectations regarding dental implants: assessment by questionnaire. International Journal of Oral and Maxillofacial Surgery 2007;36:814–7. 21. Denford S, Harcourt D, Rubin L, Pusic A. Understanding normality: a qualitative analysis of breast cancer patients’ concepts of normality after mastectomy and reconstructive surgery. Psycho-Oncology 2011;20:553–8. 22. Rosenberg ES. Dental implants your third set of teeth. Dear Doctor Dentistry Oral Health Magazine 2008. Available from: http://www.deardoctor.com/articles/dental-implants/. 23. Our third set of teeth-dental implants. Camden Medical Center; 2014. http://www.camdenmedical.com/sites/ default/files/doc/Our_third_set_of_teeth_Dental_Implants. pdf [accessed 08.12.14]. 24. Ferreira SD, Silva GL, Cortelli JR, Costa JE, Costa FO. Prevalence and risk variables for peri-implant disease in Brazilian subjects. Journal of Clinical Periodontology 2006;33:929–35.
25. Serino G, Stro¨m C. Peri-implantitis in partially edentulous patients: association with inadequate plaque control. Clinic Oral Implants Research 2009;20:169–74. 26. Baracat LF, Teixeira AM, dos Santos MB, da Cunha VP, Marchini L. Patients’ expectations before and evaluation after dental implant therapy. Clinical Implant Dentistry and Related Research 2011;13:141–5. 27. de Lima EA, dos Santos MB, Marchini L. Patients’ expectations of and satisfaction with implant-supported fixed partial dentures and single crowns. International Journal of Prosthodontics 2012;25:484–90. 28. Mordohai N, Reshad M, Jivraj S, Chee W. Factors that affect individual tooth prognosis and choices in contemporary treatment planning. British Dental Journal 2007;202:63–72. 29. Flemmig TF, Beikler T. Decision making in implant dentistry: an evidence-based and decision-analysis approach. Periodontology 2009;50:154–72. 30. Tsai SY. Dental implant cases accounted for nearly 40% of all dental disputes. Liberty Times Net 2012. http://news.ltn. com.tw/news/life/paper/580138. 31. Ye BH, Qiu HZ, Yuen PP. Motivations and experiences of Mainland Chinese medical tourists in Hong Kong. Tourism Management 2011;32:1125–7. 32. Pommer B, Zechner W, Watzak G, Ulm C, Watzek G, Tepper G. Progress and trends in patients’ mindset on dental implants. I: level of information, sources of information and need for patient information. Clinic Oral Implants Research 2011;22:223–9. 33. Adshead F, Thorpe A. The role of the Government in public health: a national perspective. Public Health 2007;121:835–9.
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.intl.elsevierhealth.com/journals/jden 1 2 3
Dental implants in the eyes of the public: A qualitative study
4
5 6 7
Q1
Guihua Wang a, Xiaoli Gao b,*, Edward C.M. Lo b a b
The Kadoorie Institute, The University of Hong Kong, Hong Kong Special Administrative Region Dental Public Health, Faculty of Dentistry, The University of Hong Kong, Hong Kong Special Administrative Region
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article info
abstract
Article history:
Objectives: Dental implants have become a popular option for treating partially dentate or
Received 15 December 2014
edentulous patients. Information on dental implants is widely available in the public
Received in revised form
domain and is disseminated through industries and dental practitioners at various
18 March 2015
levels/disciplines. This qualitative study aimed to evaluate the public’s information acqui-
Accepted 24 April 2015
sition and their perceptions of dental implants and the effects of these on their care-seeking
Available online xxx
and decision making. Methods: A purposive sample of 28 adults were recruited to join six focus groups. To be
Keywords:
eligible, one must be 35–64 years of age, had never been engaged in dentally related jobs, had
Dental implant
at least one missing tooth, and had heard about dental implant but never received dental
Qualitative research
implant or entered into any dental consultation regarding dental implants. All of the focus
Information acquisition
groups discussions were transcribed verbatim and subjected to thematic content analysis
Expectations
following a grounded theory approach.
Care-seeking behaviours
Results: Participants acquired information on dental implants through various means,
Decision-making
such as patient information boards, printed advertisements, social media, and personal connections. They expected dental implants to restore the patients’ appearance, functions, and quality of life to absolute normality. They regarded dental implants as a panacea for all cases of missing teeth, overestimated their functions and longevity, and underestimated the expertise needed to carry out the clinical procedures. They were deterred from seeking dental implant treatment by the high price, invasive procedures, risks, and complications. Conclusions: Members of the public were exposed to information of varying quality and had some unrealistic expectations regarding dental implants. Such perceptions may shape their care-seeking behaviours and decision-making processes in one way or another. Clinical significance: The views and experiences gathered in this qualitative study could assist clinicians to better understand the public’s perspectives, facilitate constructive patient–dentist communication, and contribute to the creation of positive clinical experiences in implant dentistry. # 2015 Elsevier Ltd. All rights reserved.
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13 * Corresponding author at: Periodontology and Dental Public Health, Faculty of Dentistry, The University of Hong Kong, 3/F, Prince Philip Dental Hospital, 34 Hospital Road, Sai Ying Pun, Hong Kong Special Administrative Region. Tel.: +852 2859 0401; fax: +852 2858 7874. E-mail address: [email protected] (X. Gao). http://dx.doi.org/10.1016/j.jdent.2015.04.012 0300-5712/# 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Wang G, et al. Dental implants in the eyes of the public: A qualitative study. Journal of Dentistry (2015), http:// dx.doi.org/10.1016/j.jdent.2015.04.012
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1.
Introduction
Q2 Dental implants are considered to be one of the most
important innovations in contemporary dentistry.1 Since the introduction of titanium implants for intra-oral use in the late 1950s, dental implantology has become one of the most active and promising areas in dentistry and is a popular option for the oral rehabilitation of partially dentate or edentulous patients.1 The growing popularity of dental implant therapy has also led to an increase in the numbers of dentists trained in implant dentistry and the prosperity of the dental implant industry, with a projected annual growth rate of 20%.2,3 Osseointegrated dental implants are often preferable to conventional dentures for several reasons, such as the preservation of the structure of adjacent teeth and better comfort, aesthetic outcome, functions, and stability.4,5 In particular, for patients who are not able to adapt to conventional dentures or who have compromised local host bone, dental implant treatment offers a solution that may generate more satisfactory outcomes.6,7 The reported 10-year survival rate is approximately 90%, making it a fairly predictable modality of treatment.8 Despite the advantages, dental implants are not a panacea for all cases of missing teeth, and clinical success is only possible when the treatment plan is based on a thorough assessment of the patient’s condition and careful consideration of the indications and contraindications.8 Some risks are involved and possible complications can occur during the surgical and post-surgical phases and in the long term.9 In addition, the patient’s daily self-care habits, such as maintenance of good oral hygiene and abstinence from smoking, are essential for the longevity of dental implants.10 Information on dental implants is now widely available in the public domain.5 Patients may also receive information from the industry and practitioners at different levels (general practitioners and specialists) and in various dental disciplines. Thus, the general public may be confronted with confusing information that they acquire from various sources. Because of the complexity of dental implantology, information received from different sources may not always reflect evidence-based empirical data.11 The exposure of the public to such information may form a basis for their perceptions of dental implants and affect their intentions to consider dental implants as a treatment option when the need arises. In addition, such information may influence their communications with dentists and their decision-making between the different treatment options. Research on patients’ perceptions, expectations, and satisfaction with dental implant treatment predominantly draws upon quantitative methods, such as questionnaire surveys and the measurement of clinical outcomes.12 More recently, qualitative methods have been introduced into dental implant research and have generated valuable insights.13,14 As an important complement to quantitative methods, qualitative research can capture a wide range of views and experiences and help to gain an in-depth understanding of participants’ perspectives.15 Rather than generating numbers and statistics, qualitative studies interpret the deep meaning of the
informants and report the themes in a rich context using their own words.15 In a recent qualitative study, semi-structured interviews with nine patients revealed that ‘‘normality’’ was their main motivation for and expectation from dental implants.13 Patients expected implants to restore their life to ‘‘normal,’’ although their definitions of normality differed. In another qualitative study, patients favoured implant-supported overdentures rather than conventional dentures because they provided better functional improvement and increased social confidence.14 Previous qualitative studies in dental implantology only involved patients who had undergone dental implant treatment or consulted a dental practitioner about the possibility of replacing their missing teeth with dental implants.13,14 Nevertheless, how the general public were exposed to information on dental implants before entering into such a consultation with a dentist, how they processed such information, how the information shaped their perceptions of dental implants, and how such perceptions may have influenced their future intentions to seek dental implant treatment remain unknown. This qualitative study aimed to probe these questions to understand (i) the general public’s information acquisition on dental implants, (ii) their knowledge of dental implants, (iii) their perceptions of dental implants (the treatment process, treatment outcomes, and the advantages and disadvantages compared with traditional treatment modalities), and (iv) their careseeking behaviours and decision making with regard to dental implant treatment.
2.
Methods
2.1.
Recruitment of participants
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The protocol of this study was reviewed by the Institutional Review Board of The University of Hong Kong/Hospital Authority Hong Kong West Cluster. Ethical approval was obtained (#UW 13–086). A purposive sample of adults were recruited from two community centres located in Hong Kong Island and Kowloon, respectively. These community centres organise a wide variety of activities throughout the year, such as family support, career enrichment, educational programmes, cultural events, sports, leisure activities, and tours. The members enrolled in these centres span a wide variety of age groups, occupations, and social strata. To be eligible to join this study, one must fulfil the following criteria: (a) be 35–64 years of age, (b) be a Hong Kong resident, (c) be a fluent Cantonese speaker, (d) never been engaged in dental jobs or related industries, (e) have at least one missing tooth, (f) have heard about dental implants, and (g) never received dental implant treatment or consulted a dental practitioner about the possibility of replacing their missing teeth with dental implants. Both genders were eligible to join. Eligible participants who gave their written informed consent were then assigned into focus group sessions based on their preferred and/or available timeslot. The recruitment of participants was terminated when data saturation was reached, i.e., when no new facts or views were recorded during the thematic content analysis.16
Please cite this article in press as: Wang G, et al. Dental implants in the eyes of the public: A qualitative study. Journal of Dentistry (2015), http:// dx.doi.org/10.1016/j.jdent.2015.04.012
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2.2.
Focus group meetings
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All focus group meetings were moderated by the first author, who is a trained methodologist in qualitative research. A focus group guide was prepared to outline the aspects to be covered. Open-ended questions were asked to facilitate information sharing. Unclear expressions or vague meanings were probed for further clarifications. The moderator remained neutral and objective. There was a sound balance of closeness and detachment. The moderator helped participants to feel comfortable in sharing, strived to involve all participants, ensured the focus group was not dominated by any member, and maintained a positive group dynamic. All focus groups were conducted in a quiet meeting room at the centre and were not interrupted by other people. The staff members of the centres made the arrangement but were absent during the focus group meetings. All focus group discussions were digitally audio-recorded with the participants’ consent. Each participant received two boxes of dental floss and a supermarket coupon (HKD50; equivalent to US$6.5) as a token of appreciation for their participation.
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2.3.
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All focus group sessions were transcribed verbatim and were subjected to thematic content analysis, for which grounded theory principles17 were applied. Themes were mainly developed using an inductive method, i.e., the main themes and sub-categories emerged from the data. Meaningful ‘‘text units’’ were extracted manually by line-by-line coding. No data analysis software was used. To ensure rigour, the
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thematic interpretation was discussed among and crossvalidated by all of the authors.
Transcription and data analysis
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3.
Results
3.1.
Participants’ profiles and the focus group process
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A total of 28 participants (18 women and 10 men) were recruited into six focus groups. Their ages ranged from 35 to 64 years, with a mean (standard deviation) of 52.8 (9.4) years. All of the participants had completed at least a secondary school education; 11 (39%) were housewives, eight (29%) were service workers, three (11%) were administrative support workers, one (4%) was an operative worker, and five (18%) were retired citizens. Each focus group comprised 4–5 participants and lasted for 40–60 min (50 min on average). To maintain participant confidentiality, pseudonyms were used in the transcripts and this paper. For example, C1-FG1-P3 refers to participant #3 attending the first focus group in the first community centre, whereas C2-FG2-P4 refers to participant #4 attending the second focus group in the second community centre. Table 1 shows the main themes and sub-categories that emerged from the data.
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3.2.
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Sources of information
All members had heard about dental implants from various sources. Some participants were first introduced to information on dental implants when they visited dental clinics or dental
Table 1 – Main themes and sub-categories. Main themes
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Sub-categories
Sources of information
Patient information boards Print advertisements and social media (e.g. television, radio, newspaper and internet) Personal communication/social network
Knowledge of dental implants
Varied level of understanding Some ideas and confusions
Motivation for seeking dental implant treatment
Expectations regarding dental implants
Restoration of appearance, functions and quality of life to absolute normality Overestimation of the functions and longevity of dental implants Dental implant as a panacea Underestimation of the daily care needed Underestimation of the expertise required
Concerns against choosing dental implant as an treatment option
Medical tourism
Price difference Concerns on quality of service, surgical risk, inconvenience and lack of channels for resolving disputes
Improved comfort Aesthetic appearance Better stability and functions (chewing and pronunciation) Avoiding damage to the adjacent teeth Influence of positive cases (e.g. friends’ positive experiences/outcomes)
High price and unaffordability Pain and invasive procedures Risks and complications Lack of trust
Please cite this article in press as: Wang G, et al. Dental implants in the eyes of the public: A qualitative study. Journal of Dentistry (2015), http:// dx.doi.org/10.1016/j.jdent.2015.04.012
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departments of general hospitals, where materials posted on patient information boards provided them with some understanding.
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‘‘When I was waiting to see a dentist at the dental department of a public hospital, I saw some posters on the patient information board. These posters introduced some basics about dental implants. That was the first time I learned about dental implants.’’ (C2-FG1-P5)
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Participants also reported that printed advertisements and social media, such as newspapers, radio and television programmes, served as another source for learning about dental implants.
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‘‘Once when I crossed the border and travelled to mainland China, I saw a huge advertisement board about dental implants on the wall outside the Lowu Custom.’’ (C1-FG1-P5)
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‘‘The first time I heard about dental implants was from the advertisement rolled in television programs. You know, the one by XXX (a popular drama actress in Hong Kong).’’ (C2-FG1-P2)
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‘‘I heard about implants from the radio about 20 years ago, when I was still a teen. It sounded very magical to me.’’ (C2FG1-P5) The convenience of Internet connections enables the general public to obtain information from the Web freely, using either personal computers or mobile devices, such as smartphones.
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‘‘Nowadays, it is very convenient to surf the Internet and look for any information about dental implants.’’ (C2-FG2-P3)
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Some participants first heard about dental implants from their relatives, friends or colleagues. ‘‘One of my relatives has tried dental implants. I also heard my colleagues discussing about where to go for the cheapest dental implants.’’ (C1-FG1-P4)
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3.3.
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Some participants had a certain understanding of dental implants and were able to describe them in simple terms.
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‘‘If I understand correctly, dental implants are about placing a metallic rod into the jaw bone, so that it can support a replacement tooth.’’ (C2-FG2-P2)
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In contrast, some of them seemed to be clueless about what dental implants are and how they work. Several participants confused them with cell culture technology, conventional crowns, or orthodontic treatment.
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‘‘Dental implants sound unbelievable to me! . . . I cannot imagine they can stay in the mouth without capping the
Knowledge of dental implants
neighboring teeth as people usually do in bridges. How can they work?’’ (C2-FG1-P1)
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‘‘Umm . . . dental implants. Are they something related to cell culture techniques? Like cells that are cultured in the laboratory? Actually, I am not quite sure about it!’’ (C1-FG2-P4)
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‘‘Oh sorry, I am afraid I misunderstood the meaning of dental implants. I thought they referred to the conventional crown. Now I know they are different.’’ (C1-FG1-P4)
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‘‘Is a dental implant something like orthodontic treatment? These two terms sound the same to me.’’ (C1-FG4-P3)
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3.4.
Motivations for seeking dental implant treatment
Dissatisfaction with the outcomes of conventional prostheses and the expected advantages of implant–support prostheses prompted prospective patients to consider implant dentistry and encouraged them to seek further information through various means. Improved comfort, aesthetic appearance, stability, and better function (in terms of chewing and pronunciation) were reported to be the motives.
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‘‘I think dental implants make you feel more comfortable because they won’t give you the sensation of a foreign object; something that is usual when you are wearing a conventional denture.’’ (C1-FG1-P2)
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‘‘The implanted teeth look way better than the conventional dentures. I have seen a friend whose implanted teeth blend in her dentition very well and you can’t tell which tooth is the implanted one.’’ (C2-FG2-P1)
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‘‘I think dental implants are just like what you can see in the interior renovation. You drill a hole into the wall and then put in a screw or a nail to fix it up. And it is very stable. Dental implants should be the same thing. The dentist drills a hole into your jaw and fixes the implant with a screw. It is stable too. The ordinary denture is nothing comparable to this (implant). The implanted teeth allow you to chew food better.’’ (C1-FG1-P1)
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‘‘I tried hard to get used to my removable partial denture, but it affected my pronunciation so much. I had problems speaking clearly. Also, I couldn’t chew food properly. I discussed with my dentists about this. He told me it does take some time to adapt. He also advised me to consider implants if I can’t adapt after wearing the denture for a month.’’ (C1-FG1-P2)
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In addition, dental implants were considered preferable because no reduction of the adjacent teeth is required, while the preparation of the abutment teeth for making dentures was of great concern to them. The self-supported feature and the absence of damage to other teeth motivated participants to learn more about implant dentistry.
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Please cite this article in press as: Wang G, et al. Dental implants in the eyes of the public: A qualitative study. Journal of Dentistry (2015), http:// dx.doi.org/10.1016/j.jdent.2015.04.012
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‘‘If I understand correctly, implants stand alone and would not affect the neighboring teeth, while to make conventional dentures or bridges, the dentist has to cut the sound teeth to make them suitable for a crown cap.’’ (C2-FG1-P4)
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Moreover, the positive implant experiences of their relatives, friends and acquaintances tended to encourage them to explore implants in greater depth. ‘‘He (one of her friends who received a dental implant) said his (implanted) teeth were so good. He recommended me to save money and go for dental implants.’’ (C1-FG1-P4)
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from considering dental implants, because they felt dental implants were totally unaffordable.
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‘‘When the dentist told me the price of implants, I was really startled. We are talking about over ten thousand (Hong Kong dollars) for restoring a single tooth! There is no way I can afford it! So I stopping ask any further questions. Yep, the price is definitely the biggest problem for me!’’ (C2FG1-P2)
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Participants also shared their concerns over the invasive treatment procedures and the associated pain.
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‘‘I am really frightened. I guess put a metallic rod into my jaw bone must be very painful! I don’t want to try such treatment.’’ (C1-FG1-P2)
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3.5.
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Certain expectations were expressed during the focus group discussions. It was generally believed that dental implants restore one’s appearance, functions, and quality of life to absolute normality, while some overestimated their functions and longevity.
‘‘The photos in the poster look so scary. Imagine! The dentist is going to drill a hole in your jaw bone! I don’t dare to try it unless I have no choice.’’ (C1-FG3-P2)
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‘‘I think the problem (missing teeth) can be solved once and for all, if you choose dental implants.’’ (C1-FG2-P4)
In contrast, some of them worried about the uncertainty of the long-term outcome, the risks, and possible complications.
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‘‘You could chew normally and you can use them for the rest of your life! Quite a good deal actually!’’ (C1-FG1-P4)
‘‘Is there any chance that I have to remove the implanted tooth if it was decayed in the future?’’ (C2-FG1-P4)
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In addition, some participants considered dental implants to be a panacea for solving all missing tooth problems and believed that implanted teeth require equal or even less daily care than natural teeth.
‘‘Will my body reject the foreign object?’’ (C2-FG1-P5)
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‘‘When the dentist drills a hole into my jaw bone to insert the metal rod, will it hurt my nerves?’’ (C1-FG1-P2)
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‘‘I think everyone is suitable for dental implants.’’ (C2-FG2-P3)
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‘‘Dental implants are the solution to all dental problems.’’ (C1-FG3-P2)
Participants regarded implant dentistry as a highly profitable business, and thus raised doubts that dentists may ‘‘hard sell’’ implant-supported prostheses without considering the best interest of the patient, which might jeopardize the trust between patients and dentists.
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‘‘It would be so easy and convenient to take care of an implanted tooth as it doesn’t need any special care in daily life.’’ (C1-FG3-P5)
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‘‘Even if you don’t take good care of it and the implanted tooth gets any problem or is broken, you can simply replace it with a new one.’’ (C1-FG4-P1)
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Some participants underestimated the expertise required and believed that any dentist should be able to carry out dental implant treatment.
Expectations regarding dental implants
‘‘I don’t think they (the dentists) need to obtain a specific certificate on dental implant surgery. It should be part of their basic professional training. So I think all qualified dentists can do this.’’ (C2-FG2-P1)
‘‘Your dentist could earn real good money from your dental implant treatment. That’s why he asks you to go for implant.’’ (C1-FG1-P3)
3.7.
Medical tourism
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Some participants reported that they might travel across the border to mainland China to see a dentist if they were to seek dental implant treatment in the future. Such medical tourism seemed to be attractive but concerns about the quality of service, possible risks, inconvenience, and the lack of channels to resolve disputes should they arise, acted as deterrents to some extent.
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3.6. Concerns against choosing dental implants as an treatment option
‘‘One of the dentists I met in the mainland told me it (implanting a tooth) just costs seven thousand (Hong Kong Dollar)! In Hong Kong, even the cheapest dental implant costs twenty thousand!’’ (C1-FG1-P1)
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Although dental implants appeared to be an attractive option for replacing missing teeth, some concerns were raised. The extravagant cost of treatment discouraged some participants
‘‘I don’t dare to have (dental) treatment in the mainland. One of my friends was treated by a dentist when he was travelling there. Then he had a heart problem after his
Please cite this article in press as: Wang G, et al. Dental implants in the eyes of the public: A qualitative study. Journal of Dentistry (2015), http:// dx.doi.org/10.1016/j.jdent.2015.04.012
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return. He said it was because of the hygiene problem, and then bacteria invaded his heart. So scary!’’ (C1-FG1-P2)
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‘‘I won’t consider having the (dental implant) treatment in the mainland. It is too troublesome as you have to travel back and forth. Also, I doubt the dentists’ qualifications there. I am not sure whether they have the facilities for the (implant) surgery. In case you were unlucky, you don’t know how and where to complain to solve the problem. Too many uncertainties!’’ (C1-FG3-P2)
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This study was carried out in a purposive sample of adults who needed treatment for missing teeth but had not yet entered into any consultation or procedures for dental implant treatment. This allowed us to probe into the studied topic, i.e., the public’s information acquisition on and their original perceptions of dental implants before being influenced by professional opinions. The number of participants was considered to be sufficient for a qualitative study and data saturation was reached before the recruitment ceased. All of the participants were middle aged, which matched the age of the vast majority of the implant patient population, because this age group has both treatment need for missing teeth and disposable income.18 Our findings suggested that the primary sources of public information on dental implants included traditional media and new electronic media. Meanwhile, patient information materials that were disseminated by clinics and hospitals played a role in shaping the participants’ perceptions of dental implants, although the dental care they received during the visit was in other areas of dentistry. Our findings supported the significant influence of mass media in imparting knowledge on dental implants to the public. Nevertheless, information from these sources varied in quality, was often uncensored, and could be vague, abstract, and sometimes biased.19 It is therefore important that, during a first consultation, dentists try to understand patients’ existing perceptions and use them as a basis for further communications. Because dental implants represent a technological breakthrough and are associated with high costs, patients’ expectations are predictably high with regard to the aesthetics, functionality, and longevity of dental implants.20 Our findings suggested that regaining absolute ‘‘normality’’ was an over-riding desire among members of the public who might consider dental implants. They expected aesthetically flawless teeth with no physical abnormalities. Research in breast reconstruction has also revealed that the restoration of a natural appearance and function was the main motive for accepting invasive procedures.21 The increasing influence of the media might have further boosted such expectations. For example, dental implants are often called ‘‘the third set of teeth,’’22,23 which may have led to the fallacy that dental implants can restore the dentition to absolute normality. Patients who hold this view may be more inclined to treat their implants in the same way as they would natural teeth and may not perform thorough cleaning procedures. Because many
Discussion
patients may have lost their natural teeth due to poor oral hygiene and periodontal disease, the perception that dental implants are akin to natural teeth may result in a return to previous inadequate oral hygiene routines, and in turn increase the risk of peri-implant inflammation and implant failure.24,25 In addition, some other unrealistic expectations were heard in the focus groups. Participants were not aware of the necessity to assess their suitability for dental implant treatment and believed that dental implants are a panacea for all cases of missing teeth, which may create difficulties for dentists in explaining the indications and contraindications to patients. The above-mentioned unrealistic expectations held by members of the public may compromise their communications with dentists, affect their decision making, and lead to poor patient satisfaction.26,27 In addition, such misconceptions might lead to some unfavourable trends in treatment planning, where questionable but salvageable teeth may be extracted in favour of implant placement.28 Decision making in implant dentistry involves the patients’ preferences and values, the clinicians’ heuristics and biases, diagnostic and therapeutic uncertainties, and cost considerations.29 Several motives for considering dental implants were elaborated in the focus groups, including the avoidance of removable dentures, better preserved adjacent teeth, and predictability of the outcome. In contrast, participants were deterred from considering dental implants by the high cost, their low willingness to make significant additional payments, the invasive procedures and associated risks, and their lack of trust in dentists. Understanding these motives for and concerns about dental implants could help practitioners to communicate effectively with potential patients and help them to reach well-informed decisions. The rapidly growing dental implant industry presents both opportunities and challenges. Data collected in Taiwan have shown that dental implant cases accounted for nearly 40% of all dental disputes and the number is projected to increase further.30 This highlights the importance for dentists to improve their communication strategies to provide patients with comprehensible and legally tenable information, bridge knowledge gaps, help patients develop realistic expectations on the outcomes, and avoid becoming embroiled in a malpractice claim. Hong Kong is in close proximity to mainland China, and it is not uncommon for Hong Kong citizens to travel to the mainland to seek affordable medical and dental care. At the same time, Hong Kong is a popular destination for medical tourism, and attracts patients from and beyond the region who are searching for quality health care.31 This bi-directional medical tourism, both in-bound and out-bound, adds to the complexity of health-care services. Medical tourists are subject to a variety of risks, such as poor post-operative care and a lack of prompt follow-up, whereas dentists might be requested to deal with complications in implants placed elsewhere. The management and regulation of patient care under such medical tourism present another challenge to the practice of implant dentistry in many countries and regions. Providing successful dental implant treatment requires adequate clinical skills in various areas. In a representative opinion poll in Australia, most respondents believed that implants should only be placed by specialists or specially
Please cite this article in press as: Wang G, et al. Dental implants in the eyes of the public: A qualitative study. Journal of Dentistry (2015), http:// dx.doi.org/10.1016/j.jdent.2015.04.012
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trained dentists.11,32 In contrast, participants in our study believed that dental implants could be inserted by any dentist, implying an underestimation of the complexity of dental implant treatment and the training required to carry out the procedures. With the growing patient demand and need for treatment of the population, general dentists are increasingly integrating dental implants as a service. In a workshop organized by the Association of Dental Education in Europe, university teachers and opinion leaders reached a consensus that fundamental principles of implant dentistry should be included in the undergraduate curriculum.8 This would help students to obtain knowledge and competence in identifying the indications and contraindications, informing patients about the treatment options, and maintaining and treating straightforward cases, whereas specialized training can be directed at preparing practitioners for handling complex treatments. Such an improvement in dental education should ensure the quality of care and protect patient safety in implant dentistry. Our findings can be better interpreted in the light of the limitations of this study. The qualitative data were collected from a purposive sample of Hong Kong adults, and thus our findings cannot be directly extrapolated to other populations. However, some relevant implications can be drawn, especially for other economically affluent countries or regions and those with similar cultures or health-care systems. Because of the nature of the current data, the findings were mainly reported in a descriptive manner, as overt conceptualization may lead to certain risk of misinterpretation or overinterpretation. Further studies, such as in-depth interviews, should be considered to probe some conceptual areas further.
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This qualitative study used Hong Kong as a case scenario and showed that members of the public were exposed to information that varied in quality and had various unrealistic expectations regarding dental implants. As pointed out by Adshead and Thorpe, ‘‘We are engaging with a more articulate and educated consumer society with a keen interest in their own health and an increasingly active media.’’ While patients actively participate in decision making regarding the management of their tooth loss, the onus is on the dentists to convey information on dental treatment alternatives in an ethical and effective way so that patients can make well-informed decisions on their own dental care.
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Conclusions
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reference
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.
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Acknowledgements The authors appreciate all participants for their willingness and time to share their views and experiences, which laid the Q4 basis for this study. Hong Kong Caine Road Caritas Centre and Hong Kong Federation of Women’s Centres (Chang Sha Wan Office) have lent their generous support to this study. We are
7
grateful for the assistance of Mr. Darren Wong and valuable suggestions given by Professor Calvin Yunjie Xu.
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