Flexible Removable Partial Dentures: Insights into Knowledge, Attitudes, and Practices of Dentists in Tunisia

Abstract

Objective

This article aims to assess and analyze the knowledge, attitudes, and practices of Tunisian dentists regarding flexible removable partial dentures (RPDs).

Materials and Methods

A cross-sectional study was conducted over an 8-month period, from March 1 to October 30, 2023, among dentists throughout Tunisia. A structured questionnaire was distributed via email to evaluate knowledge of flexible RPDs, which was scored.

Statistical Analysis

Data were analyzed using SPSS version 20.0. Frequencies and percentages were calculated for qualitative variables, while means and standard deviations were determined for quantitative variables. Student's t-test was used for mean comparisons, and Pearson's chi-square or Fisher's exact test for categorical variables. A p-value of < 0.05 was considered statistically significant.

Results

A total of 98 dentists participated, with a majority being women (64.3%) and working in the private sector (87.8%). Most participants (76.53%) were unfamiliar with the trade names of flexible resins. Regarding clinical indications based on edentulism type and prosthetic treatment, 60% achieved a score of at least 75%. The overall knowledge score was 16 or lower for 65.3% of respondents. Additionally, 33.74% expressed the need for further training, while 36% frequently prescribed flexible RPDs, mainly for esthetic purposes. There was no significant correlation between knowledge level and clinical experience (p = 0.23), but the adoption rate of flexible RPDs significantly varied with experience (p = 0.045).

Conclusion

Tunisian dentists' knowledge of flexible RPDs remains limited, necessitating improvement. Clinical practices should be updated in accordance with current recommendations, given the limited scientific evidence available.

 

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Keywords

attitudes - flexible dentures - knowledge - practices - thermoplastic resin

Introduction

Removable partial dentures (RPDs) with metallic frameworks and conventional heat-polymerized polymethyl methacrylate (PMMA) resin dentures were the only treatment options in RPDs until the 1950s. It was then that thermoplastic nylon-type resin dentures appeared in the United States as a new prosthetic solution. They were proposed as an alternative to conventional acrylic resin RPDs, overcoming some of their disadvantages, mainly the frequent fracture of their prosthetic bases and their rigidity in certain clinical situations. This new material also offers a solution for patients allergic to acrylic monomer or to the cobalt-chromium alloy of the metal framework. These dentures are mainly promoted for their flexibility and they are commonly referred to as “flexible dentures,” providing ease of insertion/removal and comfort while meeting the patients' esthetic requirements.[1] [2]

However, these dentures have several drawbacks, including the change in color, surface roughness that appears after a certain period of use, and probable adverse effects on the dental and osteo-mucosal supporting tissues.[3] [4] [5]

Several studies, mainly in vitro, have been published with regard to this topic.[1] [6]

In 2014, the Japan Prosthodontic Society published a practical guideline, but a consensus with respect to their indications and clinical use has not yet been established because of the lack of evidence and randomized clinical trials. Practitioners are therefore faced with the lack of evidence-based guidlines.[7]

Despite these uncertainties, flexible RPDs have gained rapid popularity worldwide, including in Tunisia. However, little is known about how Tunisian dentists understand and utilize these prostheses in clinical practice. To address this knowledge gap, we conducted a knowledge, attitudes, and practices (KAP) survey among Tunisian dentists. This is the first study in Tunisia to investigate dentists' knowledge, attitudes, and clinical practices regarding flexible RPDs. The aim was to assess these three dimensions and to compare the results with current scientific evidence and international recommendations.

 

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Materials and Methods

This cross-sectional study was conducted among Tunisian dentists over an 8-month period, from March 1 to October 30, 2023. Participants were selected from a list provided by the Tunisian National Dental Council, including dentists from both the private and public sectors, while specialists not involved in prosthodontics were excluded. The sample size was calculated using the formula:

Assuming a 95% confidence level (Z = 1.96), an estimated proportion (p) of 0.5, and a margin of error (i) of 0.05, the minimum required sample size was 96. To account for potential nonresponses, the final sample size was increased to 120 participants, selected using simple random sampling.

Data were collected via an online questionnaire created with Google Forms, structured into four sections: sociodemographic data (gender, professional sector, and years of clinical experience), knowledge of flexible RPDs (trade names, material families, indications, manufacturer recommendations, insertion techniques, repair, and maintenance), attitudes toward flexible RPDs (need for additional training, preferred sources of continuing education, and prosthetic treatment preferences), and clinical practices (frequency of use and common indications). The questionnaire comprised 23 questions, including 20 mandatory questions and 3 multiple-choice responses, with some including an “Other” option for additional specifications. Prior to distribution, the questionnaire was pretested among a small group of dentists to ensure clarity and relevance, with no subsequent modifications.

The survey was conducted in two phases: an initial email distribution from March 1 to August 31, 2023, followed by reminder emails from September 1 to October 30, 2023, for nonrespondents. A scoring system was implemented to assess participants' knowledge of flexible RPDs, where each correct answer was assigned 1 point, and incorrect or “I don't know” responses received 0 points, with a total possible score of 33. Participants were categorized into two groups: limited knowledge (score ≤ 16), indicating minimal awareness of flexible resin types, indications, and recommendations, and acceptable knowledge (score > 16), representing a basic understanding of flexible RPDs and their clinical applications. Data were entered and analyzed using SPSS software version 20.0, with descriptive statistics computed as frequencies and percentages for categorical variables, and means, standard deviations, and range (minimum–maximum) for quantitative variables. Comparative analyses were conducted using the Student's t-test for independent groups, while the Pearson's chi-square test was used for categorical comparisons, with Fisher's exact test applied when chi-square assumptions were not met. A p-value of < 0.05 was considered statistically significant. The study posed no risks to participants, and participation was entirely voluntary, with dentists having the right to withdraw at any time without justification. Informed consent was obtained through Google Forms, where participants had to select “Yes” to proceed with the questionnaire, while those selecting “No” were excluded from further questions. Ethical approval for the study was obtained from the Institutional Ethics and Research Committee of the University Hospital Farhat Hached in Sousse, Tunisia (Reference Number: IORG 0007567 ERC04122023).

 

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Results

A total of 98 dentists participated in the survey, representing an 82% response rate from the 120 dentists contacted. The sample was predominantly female (64.3%), and most respondents (87.8%) practiced in the private sector. Geographically, 51% of the dentists were based in northern Tunisia, 33.7% in the central region, and 15.3% in the south. Regarding clinical experience, 30.6% of the dentists had more than 11 years of practice, while 24.5% had less than 2 years. [Table 1] provides a detailed overview of the demographic and professional characteristics of the respondents.

Table 1 Demographic characteristics of the study population

Variables	Categories	Frequency (%) (n = 98)
Gender	Male	35 (35.7)
	Female	63 (64.3)
Health care sector	Public health sector	12 (12.2)
	Private dental practice	86 (87.8)
Region of practice	North of Tunisia	50 (51)
	Center of Tunisia	33 (33.7)
	South of Tunisia	15 (15.3)
Years of clinical experience	< 2 years	24 (24.5)
	From 2 to 5 years	22 (22.4)
	From 5 to 10 years	22 (22.4)
	From 6 to 15 years	15 (15.3)
	> 15 years	15 (15.3)

Regarding their knowledge of flexible resins, 17.35% of the dentists correctly identified one or more trade names, such as Duraflex, Flexite, Vertex Unbreakable, Valplast, and Tcsiflex, with Tcsiflex being the most recognized. However, 76.53% were unfamiliar with any of these trade names, and 6.12% provided incorrect names, such as acetal resin, acrylic resin, Peek acetal, Promoscience, and Duralay. [Table 2] illustrates the dentists' level of knowledge about flexible resins. Among the participants, 63% were familiar with one to three thermoplastic resin families, scoring between 1 and 3 out of 5. However, 23% of respondents were unaware of any type of thermoplastic resin. Notably, 63% of the dentists recognized acrylic resin, while 46% were familiar with acetal resin.

Table 2 Responses regarding knowledge of flexible resins and RPDs

No.	Question		Yes n (%)	No n (%)	Do not know n (%)
1	“There are several families of flexible thermoplastic resins. Do you know the ones that are listed below?	Polyamides	27 (28)	71 (72)	−
		Polyesters	25 (26)	73 (74)	−
		Polycarbonates	19 (19)	79 (81)	−
		Thermoplastic acrylic resin	62 (63)	36 (37)	−
		Acetal resin	45 (46)	53 (54)	−
2	Knowledge of polyamide resin properties	Less rigid than PMMA	48 (48)	21 (21)	31 (31)
		Easy to insert/remove	56 (56)	16 (16)	28 (28)
		Permanent bending deformation beyond elastic limit	31 (31)	30 (30)	40 (40)
		Less resistant to fracture than PMMA	26 (26)	47 (47)	28 (28)
		More resistant to surface wear than PMMA	33 (33)	32 (32)	36 (36)
		Mechanical properties deteriorate over time	50 (50)	24 (24)	26 (26)
		Greater surface roughness than PMMA	35 (35)	38 (38)	28 (28)
		Can cause allergies	35 (35)	33 (33)	32 (32)
		Favors bacterial accumulation more than PMMA	33 (33)	36 (36)	32 (32)
		Undergoes color degradation over time	44 (44)	26 (26)	31 (31)
3	Indications of flexible RPDs	After surgery during healing	21 (21.4)	28 (28.6)	49 (50)
		For patients intolerant to acrylic/metal	61 (62.2)	1 (1)	36 (36.7)
		When vertical prosthetic space is < 5 mm	21 (21.4)	20 (20.4)	57 (58.2)
		In presence of osteo-mucosal undercuts	38 (38.8)	16 (16.3)	44 (44.9)
		When VDO is not preserved	17 (17.3)	32 (32.7)	49 (50)
4	Indications for flexible RPDs	Recommended as temporary dentures	58 (59.2)	31 (31.6)	9 (9.2)
		Recommended for small bounded edentulous spaces	88 (89.8)	5 (5.1)	5 (5.1)
		Recommended for small distal extension edentulism	50 (51)	35 (35.7)	13 (13.3)
		Recommended for large distal extension edentulism	21 (21.4)	68 (69.4)	9 (9.2)
5	Recommendations for hybrid design (metal framework + flexible resin clasps)	Unfavorable osteo-mucosal factor	16 (16.33)	23 (23.47)	59 (60.20)
		Small number of teeth on the arch	22 (22.45)	20 (20.41)	56 (57.14)
		Unilateral large distal edentulism	25 (25.51)	16 (16.33)	57 (58.16)
		Bilateral large distal edentulism	30 (30.61)	11 (11.22)	57 (58.16)
		Bounded edentulous area of large extent	30 (30.61)	18 (18.37)	50 (51.02)

Abbreviations: PMMA, polymethyl methacrylate; RPD, removable partial denture; VDO, vertical dimension of occlusion.

When asked about the trade names and resin families used by their prosthetists, 86.8% either answered “I don't know” or provided incorrect names, and 77% were unaware of the resin family they were using. [Table 2] shows the distribution of responses, revealing that 22% of the dentists scored 10 out of 10, while 42% scored below 4. A third of the respondents admitted to not knowing the answer to each proposed property.

Regarding the clinical indications for flexible RPDs, 32% of respondents scored 0, and 34% scored less than 3 out of 5. [Table 2] presents the responses, with the most common answer being “I don't know” for all proposed indications, except for allergies to acrylic resin or metal, which 62.2% of practitioners correctly identified. These findings are also summarized in [Table 2].

In terms of indications for flexible RPDs based on prosthetic treatment and edentulism, 60% of respondents scored above 3 out of 4, while only 5% did not know the indications. Additionally, 53% of respondents were unfamiliar with the indications and manufacturer's recommendations for TCS iflex resin, scoring 0, while 26% scored below 3 out of 5. [Table 2] further details these results. Only 22% of practitioners knew that flexible RPDs should be soaked in hot water on the day of insertion. When it comes to repairing, relining, and adding teeth to flexible RPDs, 74.5% of respondents were unaware of these possibilities, with 63.3% believing that repairing was impossible.

Regarding maintenance, 69% of respondents knew that flexible RPDs should not be cleaned with toothpaste and a hard-bristle toothbrush, and 93% understood that they should be rinsed with running water, not hot water. Overall, 65.3% of the dentists had a total knowledge score of 16 out of 33 or less, while 34.7% scored above 16. The scores ranged from 1 to 26, with a mean score of 14 out of 33. No significant difference was found in knowledge based on gender, region of practice, health care structure, or years of clinical experience (p > 0.05), as shown in [Table 3].

Table 3 Total knowledge according to gender, health care structure, region of practice, and clinical experience

Variables	Categories	Mean total knowledge score	Standard deviation	p-Value
Gender	Male	13.74	6.33	0.88
	Female	13.56	5.84
Health care structure	Public health care structure	16.33	5.99	94
	Private dental practice	13.24	5.5
Region of practice	The north	12.34	5.71	0.1
	The center	14.61	5.69
	The south	15.73	6.9
Years of clinical experience	< 2 years	13.42	6	0.23
	From 2 to 5 years	15.95	4.87
	From 6 to 10 years	13.18	6.18
	From 11 to 15 years	12.93	5.86
	> 15 years	11.87	7

In terms of attitudes, 74.47% of respondents expressed a need for further training in flexible RPDs, with many relying on various options for continuing education. Among the practitioners, 63.26% used the Internet, and 45.92% attended conferences and training days. Additionally, 12.24% cited university courses and information provided by their prosthetists as sources of training. When compared with resin RPDs, 49% of respondents considered flexible RPDs superior, while 48% were uncertain. Similarly, 49% preferred flexible RPDs over metal framework RPDs, while 38% were unsure and 13% disagreed. These attitudes are summarized in [Table 4].

Table 4 Distribution of the respondents according to their attitudes and preferences on flexible RPDs

No.	Questions	Clinical experience	I totally agree, n (%)	I am not sure, n (%)	I disagree, n (%)	p-Value
1	Need for training in flexible RPDs	−	73 (74.47%)	−	25 (24%)	−
2	Flexible RPDs are better than acrylic RPDs	< 2 years	54.2%	41.7%	4.2%	0.84
		2–5 years	36.4%	59.1%	4.5%
		6–10 years	54.5%	45.5%	0%
		11–15 years	46.7%	53.3%	0%
		> 15 years	53.3%	40%	6.7%
		Total	48 (49%)	47 (48%)	3 (3%)	−
3	Flexible RPDs are better than metal framework	< 2 years	45.8%	29.2%	25%	0.3
		2–5 years	45.5%	45.5%	9.1%
		6–10 years	40.9%	40.9%	18.2%
		11–15 years	46.7%	46.7%	6.7%
		> 15 years	73.3%	26.7%	0%
		Total	48 (49%)	37 (38%)	13 (13%)

Abbreviation: RPD, removable partial denture.

When comparing different treatment options for RPDs, regardless of clinical experience, the dentists were divided into two groups. However, 73.3% of respondents with more than 15 years of experience believed that flexible RPDs were superior to metal framework RPDs in certain clinical situations, as illustrated in [Table 4].

Regarding current practices, 8% of dentists never prescribed flexible RPDs, 52% rarely used them, and 36% often prescribed them as a prosthetic treatment. Flexible RPDs were considered a definitive treatment by 49% of respondents, a provisional treatment by 27%, and either definitive or provisional, depending on the clinical situation, by 24%. The primary indications for flexible RPDs included esthetic concerns related to the visibility of metal hooks (84.04%), avoidance of allergies to PMMA resin or metal (40.43%), and lower cost and better esthetics compared with combined prostheses (35.11%). Other reasons included lightness, flexibility, fracture resistance, and patient acceptability, as shown in [Table 5]. The adoption of flexible RPDs varied significantly with clinical experience (p = 0.045). [Fig. 1] demonstrates the adoption of flexible RPDs, with 62.7% of dentists with 2 to 15 years of experience rarely using them, compared with more experienced practitioners who frequently used them.

Fig. 1 The frequency of adopting flexible removable partial dentures (RPDs) according to the years of clinical experience.

Table 5 Distribution of the respondents according to their current practices with regard to flexible RPDs

No.	Dentists' current practices	Frequency (n)	Percentage (%)
1	Frequency of adoption of flexible RPDs
	Never	7	8.2
	Rarely	51	52
	Often	36	36
	Very often	4	4
2	Indication according to the type of treatment
	Temporary treatment	26	27
	Definitive treatment	48	49
	Provisional and definitive treatment	24	24
3	Reasons for indicating flexible RPDs
	Technical facility	31	31.91
	Lower cost and better esthetics compared with combined prostheses	34	35.11
	Temporary prosthesis before the realization of the definitive prosthesis	31	31.91
	Mouth opening limitation	13	13.83
	Allergy to PMMA resin or Metal	39	40.43
	Better esthetics	82	84.04

Abbreviations: PMMA, polymethyl methacrylate; RPD, removable partial denture.

 

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Discussion

The findings offer valuable insight into Tunisian dentists' knowledge and clinical use of flexible RPDs, highlighting the need for clearer guidelines and enhanced training. Encouragingly, participants showed strong engagement, with none reporting difficulty completing the questionnaire.

The response rate was 82%, which is considered high for survey-based studies. Generally, a response rate of 60% or more is acceptable in health care research, while rates above 70% are regarded as very good.[8] This strong participation adds credibility to the study's findings.

Regarding knowledge, 76.53% of practitioners were unfamiliar with any trade names of flexible RPDs, 6.12% cited incorrect names, and 23% could not identify any of the five proposed resin families. The most frequently mentioned trade name was Tcsiflex, a thermoplastic resin from TCS. However, most respondents were unaware of the trade names of the resins used by their prosthetists and did not know to which resin family the one they used belonged. A 2017 study in India showed that 52% of respondents knew the trade names of the flexible prostheses they used.[9] [10]

Regarding properties, only 22% of practitioners scored well, while 42% scored less than or equal to 3. The best-known properties were fracture resistance and flexibility, but the disadvantages of polyamide resin, such as its wear resistance and surface roughness that encourages bacterial accumulation, were less understood. Studies show that polyamide resin can undergo permanent deformation beyond its elastic limit, with lower bending strength compared with PMMA resin.[3] [11] [12] [13] [14]

Regarding clinical indications, knowledge was poor, with 32% unable to answer correctly. However, 62.2% reported allergies to acrylic or metal resins. Flexible RPDs are helpful for osteo-mucosal undercuts and limited mouth opening.[7] Nevertheless, they are contraindicated in the temporization phase following implant surgery and for immediate prostheses, as their relining is technically challenging.. Additionally, they are also contraindicated when the available vertical prosthetic space is less than 5 mm, since the retention of the artificial teeth to the polyamide base is purely mechanical, increasing the risk of detachment during function.[15] [16] [17] [18] [19] [20]

They are also not recommended for extensive edentulous areas, defined as edentulous spans involving more than three missing teeth or two or more molars according to the Prosthodontic Diagnostic Index of the American College of Prosthodontists. Although 69.4% of respondents correctly identified flexible RPDs as suitable for small edentulous spaces, knowledge about flexible RPD insertion and maintenance was limited, with 78% unaware that soaking in hot water improves adaptation.[15] [16] [17] [18] [19] [20] [21]

Regarding attitudes, 74.47% of dentists expressed a need for training on flexible RPDs. The Internet was the primary source of information (60%), followed by books and manuals (16.3%). As for preferences, 49% of dentists preferred flexible RPDs over conventional treatments, while 38% were unsure, and 13% preferred metal frameworks. This contrasts with a European study in which most practitioners preferred metal frameworks, likely due to their greater familiarity with conventional designs and the presence of clearer clinical guidelines supporting their use. Dentists with over 15 years of experience were more likely to prefer flexible RPDs than those with less experience.[7] [22]

Regarding practices, 52% of dentists rarely used flexible RPDs, likely due to their recent introduction in Tunisia, with 40% using them frequently. Although flexible RPDs are recommended for provisional treatments, 49% of respondents used them as definitive treatments. The main reasons for choosing flexible RPDs were esthetics and allergies to acrylic or metal resins.[22]

This study had several limitations. The data collection method, based on self-reported questionnaires, may introduce information bias, as responses rely on the participants' understanding and willingness to provide accurate information. Furthermore, the study's findings may not be generalizable to all dentists in Tunisia due to regional variations in practice and experience.

Further study might be needed to enrich the understanding of the practical use and challenges related to flexible RPDs. This study could serve as a preliminary step for further research, which will be beneficial as a source for improving dental education and clinical practices in Tunisia. It would be interesting for future research to reach a broader audience of practitioners, including those in rural areas, to assess the general knowledge and application of flexible RPDs. The results of this study highlight the need for improvements in the quality of dental education, particularly in the area of prosthodontics, to enhance practitioners' knowledge and skills. It would also be beneficial to develop and disseminate clear clinical guidelines on flexible dentures to ensure consistent and evidence-based practice among all dentists.

 

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Conclusion

This KAP survey with regard to flexible RPDs was performed to investigate the knowledge, attitudes, and current practices of dentists in Tunisia as these prostheses are increasingly indicated these days despite the lack of practical rules for their use in the literature.

Given the limited scientific evidence, the findings issued from the literature need to be validated by evidence and long-term clinical trials to have “practical guidelines.” This study retains its originality in being the first conducted in Tunisia on this topic. Further studies including larger samples are required. A multivariate analysis highlighting the links between KAP could also be enriching.

 

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Conflict of Interest

None declared.

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Publication History

Article published online:
03 October 2025