Key-words:
Care and maintenance - fixed prosthesis - Libyan - oral hygiene - patients' expectation - satisfaction
Introduction
Tooth loss is a common finding among individuals.[[1]] Despite the ongoing progress in the offered oral health service worldwide which lead to the drop in the number of partially dentate individuals, the demanding care has in reality widened.[[2]] The main patients' complaints are usually related to compromised oral functions and facial esthetics.[[3]]
Generally, patients are interested in prosthodontic replacement of missing teeth for esthetic and functional reasons as well as for enhancing their self-confidence.[[3]] Numerous prosthetic options are available for tooth replacement such as removable partial denture,[[4]],[[5]] fixed partial denture (FPD),[[6]] or dental implant.[[7]] Each prosthetic device has its specific advantages and disadvantages.[[8]] Fixed prosthodontic treatment can vary from a restoration of a single destructed tooth with a crown, replacement of one or more missing teeth, with a conventional tooth-supported FPD, an implant-supported restoration, or a more sophisticated prosthesis for a number of teeth or for a whole dental arch.[[9]]
Inserting a fixed implant to replace a missing tooth has become a favorable treatment choice worldwide, especially with their noticeable high success rates.[[10]] Using a fixed implant as an anchor to rehabilitate a single-unit crowns or bridges reveals an effective procedure to restore partially edentulous oral cavities.[[11]]
Patients' expectations of prosthetic treatment vary, which noticeably would have a great influence on the magnitude of satisfaction with their apparatus. Some patients' priority is to restore masticatory function.[[11]] Others seek treatment mainly for esthetic concerns.[[5]] Therefore, clinicians need to identify and understand patients' expectations during their early consultations and explain any misconceptions or idealistic expectations.[[4]]
Although there are a vast number of publications related to fixed prosthesis, there is a paucity of research exploring patients' expectation of and satisfaction with their prostheses in different countries, such as Australia,[[12]] India,[[13]] Singapore,[[14]] and Netherland.[[15]] Furthermore, similar research studies in the Arabic countries are sparse.[[16]],[[17]] Up to date, Libyan patients' expectations of and satisfaction with fixed prosthesis have not been explored. Thus, the present study aimed to evaluate Libyan patients' expectations of and satisfaction with fixed prosthesis and to explore the level of patient awareness and application of oral hygiene care.
Materials and Methods
This was a cross-sectional descriptive survey carried out from June 2016 to June 2018 at both the prosthodontics departments, Faculties of Dentistry, University of Benghazi, Libya and the Libyan International Medical University, Libya. In addition to multiple private dental clinics.
The present study was approved by both Dental Faculties. Benghazi is a city of almost one million inhabitants. However, this study was conducted at a time of security instability which forced more than a quarter of the citizens to move out.
All patients wearing fixed prosthesis (crowns, veneers, FPD, or dental implants) were invited to participate in this study (500 patients). A total of 320 male and female patients agreed to participate. Verbal informed consents were obtained from the participants.
Development of the questionnaire
Self-reported questionnaires were administered to patients wearing fixed prosthesis. The questionnaire was adjusted from similar undertaken surveys.[[17]],[[18]] This questionnaire was translated to Arabic language by the first two authors and compared. Subsequently, the staff at the department of prosthodontics was consulted, and their advice was taken into consideration.
The questionnaire included a unit on sociodemographic data comprising sex, age, and level of education. The second part encompassed closed questions looking at whether patients' expectations of the prosthesis had been met or not in addition to the evaluation of the level of patients' satisfaction with subjective clinical outcome including esthetics, speech, and masticatory function. The third part comprised questions evaluating the level of patient attitude toward oral health care, as well as, simplicity and frequency of application of oral health measures. A single open-ended question was added, which asked participants whether they would recommend a fixed prosthesis as a restorative option to their family members and friends.
Statistical analysis
Statistical analysis was performed using Social Package of Statistical Science software (SPSS, version 17, Chicago, III, USA). Validity test was undertaken by intraclass correlation coefficient tests (ICC). Descriptive statistical analysis including frequencies Spearman's rank correlation coefficient tests was employed to evaluate the correlation between sociodemographic factors, patients' expectations of with their satisfaction from fixed prosthesis and with oral hygiene care. The level of significance was determined at P < 0.05.
A pilot study was undertaken on 20 patients to evaluate the reliability of the questionnaire. The questionnaires were redistributed for the same patients after 2 weeks. The two versions of the answers were statistically analyzed to check the level of agreement between both attempts. ICC tests revealed an excellent level of agreement (0.90) reflecting a high level of internal consistency.
Results
The response rate of the present study was 64%, of which 21.6% were males (mean age = 47.4 years, standard deviation [SD] =14.5) and 78.4% were females (mean age = 42.7 years, SD = 10.2). There was a significant difference in the male/female ratio (P < 0.05). Almost one-third of the patients (32.2%) were ≥50 years of age and 67.8% were <50 years of age. A total of 35% of the patients had crowns, 48.1% with bridges, 1.9% used veneers, while only 15% had got more than one type of the previously mentioned restorations [[Figure 1]]. Majority of the patients (87.8%) were treated with conventional tooth-supported fixed prosthesis, while only 12.2% had implant-supported fixed prosthesis (5.3% single implant; 3.1% implant-supported FPD, and 3.8% multiple implants).
Figure 1: Bar graph illustrating the distribution of the used fixed prosthesis among the participants
Almost two-thirds of the participants achieved a university graduate qualification or more, while only 8.2% left school at year 9 or before. Others (23.4%) achieved a vocational training or secondary school certificate. However, the correlation between the level of education and patients' expectations (r = 0.031, P = 0.581) and the magnitude of their satisfaction with their prosthesis (r = −0.021, P = 0.714) was weak and not statistically significant [[Table 1]].
Table 1 Correlation coefficient (r) between the level of patient satisfaction and the analyzed factors
Overall, 38.8% of the participants had their fixed prosthesis for ≤3 years. About one-third (33.1%) wore the appliance for 4 to 7 years and only 27.5% had their restoration for ≥10 years. However, the correlation between the level of satisfaction and the duration of having fixed prosthesis was weak and nonsignificant (r = 0.118, P = 0.850).
In general, the majority of the patients (80.9%) were satisfied with their fixed prosthesis, and nearly, one-fifth (19.1%) were not satisfied [[Figure 2]]. When the participants were questioned in detail about their satisfaction, <1 quarter of the sample (21.6%) were not contented with the masticatory function; 9% complained of pain during eating, 4.1% reported intermaxillary malocclusion, 6.6% expressed food impaction, and 5.3% felt uncomfortable with their fixed prosthesis while eating. Furthermore, more than half of the participants, i.e., 60.6% noticed altered phonation. Only 14.7% found their fixed restoration esthetically unpleasant for the following reasons: mismatch in color with the natural teeth (9.1%), mismatch of shape and size, or improper artificial tooth position in the fixed prosthesis (4.4%) whereas 1.2% of the participants were told by other people that their prosthesis did not look good.
Figure 2: Bar chart displaying the percentage of satisfied patients with their fixed prosthesis and the percentage of each of the concerns of the unsatisfied patients
There was nonsignificant correlation between the level of satisfaction and whether the prosthesis was conventional or implant supported (r = 0.065, P = 0.245). In addition, the correlation between the level of patient satisfaction and sex (r = 0.034, P = 0.543) and age (r = 0.045, P = 0.424) was not statistically significant.
Overall, the fixed prosthesis met the expectations of 71.9% of the participants and met the partial expectations of 10.9% of the patients. Only 17.2% reported that their fixed prosthesis did not meet their expectations. Furthermore, the majority of the participants (80.9%) seemed to be satisfied by their appliance. There were moderate but significant correlation between patients' expectations of their prosthesis and their level of satisfaction (r = 0.387, P < 0.0001).
Most of the participants reported that they were conscious of and practice oral hygiene measures (90.7%). Only 9.3% of the sample did not follow proper oral health care; 8.1% because of laziness, 0.6% were not informed by the dentist about the importance of the oral hygiene procedure, and 0.6% due to lack of knowledge of using dental aids. Of the majority who practiced oral hygiene measures, 60.3% used toothbrush as a cleaning tool. Only 15.3% preferred to use dental floss with toothbrush. On the other hand, merely, 6.3% chose to use toothpicks as an aiding tool combined with toothbrush. A limited number (8.8%) of patients reported that they were using all the described oral hygiene aids [[Figure 3]].
Figure 3: Bar graph displaying the percentage of patients practicing oral hygiene measures and the percentage of patients using each of the reported oral hygiene aids
There was nonsignificant correlation between applying oral hygiene measures and each of the variables given in [[Table 2]]: level of education (r = 0.007, P = 0.895), age (r = 0.051, P = 0.361), and sex (r = 0.01, P = 0.075). However, the weak correlation between patients' satisfaction and practicing their oral hygiene measures (r = 0.130) was significant (P = 0.020).
Table 2 The correlation coefficient (r) between the application of oral hygiene measures and sociodemographic factors
Majority of the sample (86%) thought that they would recommend fixed restorations to their friends and relatives to restore and replace their damaged or missing teeth. While the remaining of the participants (14%) revealed that they would decline to offer such an advice.
Discussion
This was the first survey to be undertaken in Libya that aimed to explore the level of expectation of and satisfaction with fixed prosthesis among 320 Libyan patients living in the city of Benghazi.
Baruch and Holtom[[19]] reviewed 1607 published questionnaire-based studies from 2000 to 2005. They concluded that an average response rate of 52.7% is considered to be acceptable. The response rate in the present study was 64%. This ratio is considered reasonable especially that this study was undertaken during a phase of instability. Wagner and Kern[[20]] reported in their retrospective study a lower response rate of 50.3%. Aljabri et al.[[21]] described a much lower response rate of 11% in their Saudi phone interview survey. However, Hakestam et al.[[22]] succeeded in achieving an excellent response rate of 88.2%.
The number of female participants in the present study was more than triple the number of males. Similar sex difference was observed in comparable studies.[[17]],[[18]] One reason for the greater number of female participants might be that usually, females are more conscious about their appearance and might be more interested in restoring their teeth compared to males.[[17]] Another aspect could be that females might have more helpful approach to participate and support research studies.
The mean age in the present study was 45 years (ranged from 20 to 75 years). This study did not observe a significant correlation between patients' age and the level of expectations or satisfaction with their fixed restoration. This finding agreed with some previous research outcome[[17]] and contradicted with other.[[12]]
The current study focused on subjective patient-based outcomes, while the clinician aspect was not explored. Anderson[[23]] asserted that the level of satisfaction of both clinicians and patients have to be taken into consideration. However, many researchers found that the level of patients' satisfaction exceeded that of their dentists.[[4]],[[24]],[[25]],[[26]],[[27]] This finding might be the result of the different criteria used for the evaluation by each of the dentist and the patient. Dentist evaluation mainly emphasizes the technical characteristics of the prosthesis, while patients' reflection is usually subjective including convenience, esthetics, and well-being.[[28]] It will be interesting to undertake another study in Libya where the level of satisfaction of both the patient and dentists are assessed and statistically compared.
The present study found that the majority of the participants (80.9%) were satisfied with their prosthesis. This similar level of patient satisfaction with their fixed prosthesis was described in a number of other studies.[[4]],[[5]],[[7]],[[17]] This high satisfaction level could be attributed to the fact that fixed restorative treatment might had restored the feeling of “normality” to the patient, as he/she felt the prosthesis more like a natural tooth. Furthermore, patients who were using removable prosthesis preferred their FPDs. This was observed by Al-Quran et al.[[29]] who assessed patient satisfaction with several treatment options and the factors that would affect the treatment decision to replace a single missing tooth.
Patient satisfaction with their prosthesis is usually related to esthetic, function, convenience, and phonetics.[[4]],[[5]],[[7]],[[17]] Comparable published studies reported a variable hierarchy of patients' concerns relating to FPD. Geiballa et al.[[17]] reported that more than 90% of their individuals had no phonetic alteration with their FPD. In this study, almost two-thirds of the participants reported altered phonetics after having the fixed prosthesis. This number contradicts with their reported high level of satisfaction from fixed prosthesis (80.9%). This might indicate that their concerns did not raise up to the level that affected their overall level of satisfaction. Another reason of their complaints might be that they might have compared their fixed prosthesis with their natural teeth. It is recommended in future study to involve the clinicians to evaluate patients' concerns objectively.
There are many aspects that have to be considered when masticatory function with fixed prosthesis is evaluated such as inaccurate vertical dimension, intermaxillary malocclusion between the prosthesis and natural teeth, and pain during mastication. Geiballa et al.[[17]] described that almost half of their patients had noticed improvement in their masticatory function. Furthermore, Tan et al.[[14]] reported that the majority of their samples were satisfied with FPD function. In the present study, around one-fifth of the group were not happy with their masticatory function. Thus, patients have to be aware that having the continuous checkups after receiving their prosthesis is important to avoid additional impairment to their masticatory ability.
Attitude and awareness toward dental esthetics vary between different populations and individuals. Therefore, it is expected to find a disparity in the level of satisfaction with esthetics in the published investigations. Geiballa et al.[[17]] reported that 20% of their patients were not satisfied with the esthetic aspect of their prosthesis. In the present study, only 14.7% found their fixed restorations esthetically unpleasant. Their dissatisfaction was related to the following reasons: mismatch in color with the natural teeth (9.1%), mismatch of shape and size or improper artificial tooth position in the fixed prosthesis (4.4%) whereas 1.2% of the participants were told by other people that their prosthesis looks not good. Therefore, it is important for the clinician to pay a great attention to select the proper shade of the prosthetic teeth particularly where anterior teeth are involved. Another important aspect is matching the position and angulation of the prosthetic teeth and natural teeth.
In the present study, about two-thirds of the participants were <50 years of age; this could be interpreted by that the young and middle age groups seeking to restore and replace their defected and missed teeth with fixed prosthesis more than the old age people. Whereas old age group may prefer to replace their missed teeth with a removable partial dentures as it is simpler in the clinical procedures, sessions, time, and less cost when compared to a fixed one. In addition to the age and sex, this evaluation showed that there was no correlation between the level of education and patient satisfaction.
In the present study, about 12.2% of the participants had with dental implants as follows: 5.3% treated with single implant, 3.8% with multiple implants, and only 3.1% with implant-supported FPD, while the majority (87.8%) had conventional tooth-supported fixed restoration. In this evaluation, the increased ratio of individuals treated with conventional fixed appliance in comparison to implant might be related to the cost.[[29]] Actually, in spite of the exaggerated cost of implant when compared to FPD, its main advantage is that no abutment teeth have to be prepared avoiding the risk for additional endodontic treatment and discomfort because of hypersensitivity and difficult access for plaque control.
Patien's' expectations of dental prosthesis have a great influence on the level of their satisfaction with treatment outcome.[[14]] The present study observed that majority of patients' expectations were fulfilled or partially fulfilled their expectations. This finding was observed in the examined Sudanese patients,[[17]] Singaporian individuals,[[14]] and Australian cohort.[[12]] Hereby, it is important for the dentist to understand patients' expectations of various types of replacement modalities and thereby explain and clarify the misunderstandings and the unrealistic expectations for the same.
Maintaining a high level of oral hygiene care is critical to avoid periodontal problems.[[30]] Most of the present cohort were conscious of and follow oral hygiene procedures (90.7%). This satisfactory result might be related to the posttreatment oral hygiene instructions explained by the dentists. This was supported by finding that 8.1% of the patients did not care about their oral hygiene because of laziness and not due to shortage of instructions. However, this assessment was based only on the patients' perception of adequate oral hygiene practice without undertaking clinical opinion. It will be useful if clinical evaluation was performed to this group to compare between patient perception and clinician evaluation of the required good oral health care.
More than half of the participants (60.3%) were only using toothbrush as a cleaning tool, whereas 15.3% employed the dental floss and 6.3% applied toothpicks in addition to the toothbrush to clean interproximally and under the pontic of the FPD; at the same time, 8.8% were using all of the previously mentioned cleaning aids. This result exhibits that Libyan patients were more aware of and practice oral hygiene measures relating to their fixed prosthesis compared to Geiballa et al.[[17]] study where the majority of their patients (94%) did not practice oral hygiene measures after having their prostheses.
According to Tan et al.,[[14]] 95% of their FPD examined patients would certainly or to some extent be willing to suggest the same management to relatives and friends. Most of the present participants (86%) as well were ready to advise their families and friends to use a fixed prosthesis for restoring their decayed teeth and replacing their missing teeth. This indicates that the participants' level of dissatisfaction was not up to the extent of not recommending the same treatment to their close circle.
Conclusions
The fixed prosthesis met or nearly met the expectations of the majority of the surveyed patients. Furthermore, more than two-thirds of the patients expressed their satisfaction. There was a weak but significant correlation between patient expectations and satisfactionThe majority of the patients were taking good care of their oral hygiene with a weak but significant correlation between patients' satisfaction and practicing their oral hygiene measures.
