Dr. Shrishrimal Mahavir D. 1, Dr. Dixit Santosh Y.2, Dr. Deshpande Varun A.3, Dr. Rathod Vikram E. 3,Dr. Jain Pooja4,Dr. Waychal Sejal1
1(BDS) Post Graduate Student,
2(MDS) Head of the Department,
3(MDS) Reader,
Department of Prosthodontics, Pandit Deendayal Upadhyay Dental College, Solapur, India.
4(BDS)Post Graduate Student
Department of Prosthodontics, Government Dental College and Hospital, Ahmedabad, India
ABSTRACT
AIM
This study aims to assess the knowledge, attitude, and practice of students and dental practitioners in the state of Maharashtra towards digital approach used in Implantology.
Materials and methodology:
The study was conducted as a questionnaire-based survey amongst dental students and dental practitioners in the state of Maharashtra India. A questionnaire consisting of 14 close ended questions was prepared to obtain information about their knowledge, attitude, and practice towards various digital approaches available in today’s scenario regarding implantology right from diagnosis to implant placement. A total of 500 people involving dental students and dental practitioners were chosen as the participants. The questionnaire was sent to the participants via Google forms and their responses on the same were collected. The data was then analysed.
Results:
The response obtained from the participants was a reflection of their knowledge, attitude, and practice on digitization in the field of Implantology. It was observed that interns and those with limited clinical experience weren’t much updated about the advances in digitization when compared to post- graduates and established practitioners who were quite updated.
Conclusion:
Considering the method of dental implant placement, most of the participants agreed to the fact that the digital approach is a better approach when compared to the conventional one, but at the same time, they also accepted that they weren’t much aware or exposed to the newest advancements in the field of digitisation. Digitally fabricated surgical templates, digital planning, impression techniques, are the factors that might lead to simple yet effective implant procedures in terms of prosthodontically driven surgeries. Therefore, it should be considered of utmost importance to initiate and spread awareness at a larger scale and right from the beginning so that more and more number of patients can be benefited by the same. Various courses and CDE programs can help to update their knowledge and skill regarding digital implant dentistry
Keywords:Digital workflow, Implantology, Awareness, STL, Questionnaire survey
Citations: Shrishrimal M, Dixit S, Deshpande V, Rathod V, Jain P, Waychal S. Assessment of Knowledge and Awareness of Dentists Regarding Digital Implantology in The State of Maharashtra-A Questionnaire Based Survey. J Prosthodont Dent Mater 2022;3(1):9-23.
INTRODUCTION
Implant dentistry is going through a digital revolution. Through the development of new types of equipment and their corresponding workflows, the diagnosis and treatment of our patients are becoming simpler and more efficient. Digital technology has become assimilated into every part of our daily life. The nearly universal acceptance and use of smartphones, tablets, and other technologies have made our lives more productive and efficient. A similar trend has made its way into our clinical practice as well. The leveraging of digital tools and technologies has produced workflows that can make our delivery of care more productive as well as efficient. Implant dentistry is one clinical area where digital technology can be used to its fullest extent. With the advent and dissemination of intra-oral (IO) scanning devices, cone beam computed tomography (CBCT), implant planning software, and dental laboratory software to design and manufacture restorative components, the ability to harness and apply these technologies on a daily clinical basis has never been greater. Ultimately, by learning the proper use and application of these tools, our patients can benefit from more streamlined and effective workflows. 1
Implant dentistry is one clinical area where digital technology can be utilized to its fullest extent. Guided implant surgeries bestowed enhanced therapeutic workflow and safety. With increasing availability, reduced radiation and lower costs of three-dimensional imaging because of cone-beam computer tomography, pre-operative three-dimensional implant planning is becoming more popular in dentistry. Navigated implant surgery provides for improved implant positioning at anatomically sensitive structures such as the maxillary sinus, the mandibular canal, and the mental foramen. Recently a radiological template free implant guided surgery workflow has been introduced for partially edentate patients. As soon as the techniques and advantages flourished, the current decade of activity by early adopters fueled innovation. Digital technology is driving a remarkable change in the practice of dental implantology.2
The Benefits of Digital Technology-
1. A Most important advantage of digital workflow is it makes a positive impact on the patient’s mind.
2. The Patient can simulate the final outcome of the treatment with the help of a digital workflow.
3. Digital scanners are helpful to avoid messy conventional impression techniques. Accuracy of these digital impressions provides a precise recording of hard and soft tissues.
4. Because of the proven accuracy of digital scanners, final restorations also obtain a better marginal fit.
5. It provides us an easy way to communicate with the lab and patient itself.
6. Electronically recorded .STL file can be sent to the other specialties to discuss and deliver the best possible treatment to a patient.
The questionnaire for the current research
Name (Optional):
Age/ Gender:
Designation:
Years of Practice-
1. Do you use digital technologies in your practice? (e.g.-RVG, CBCT, Intraoral Scanner)
□ Yes
□ No
2. Are the currently available digital technologies users friendly?
□ Yes
□ No
3. Do you think, using digital technology yields better precision in diagnostics?
□ Yes
□ No
4. Which imaging modality do you prefer while implant planning?
□ OPG
□ CBCT
□ OPG+CBCT+CT
□ OPG+ CBCTT+ CT+ Routine Blood Tests
□ Any Other. Please Specify ( )
5. Do the patients in your clinic/practice prefer going for implant placement over conventional methods for replacement of tooth?
□ Yes
□ No
6. Do you prefer digital over conventional method for implant placement?
□ Yes
□ No
7. Have you received any professional training in implant placement?
□ Yes
□ No
8. Do you believe that digital approach will have additional benefits over the conventional approach?
□ Yes
□ No
9. Are you aware about the recent advances in the field of digital implantology?
□ Yes
□ No
□ May be
10. Are you aware of any software for digital implantology?
□ Yes
□ No
□ May be
□ Please Specify ( )
11. Have you heard about digital impression making?
□ Yes
□ No
12. If yes, have u made digital impression in your practice?
□ Yes
□ No
12 (A). How was the patient response for the same?
□ Pleasant
□ Unpleasant
13. Do you think introduction of digital techniques might improve the quality and function of rehabilitation?
□ Yes
□ No
□ May be
14. Which of the following terms are you aware of?
METHODOLOGY
A web-based survey was conducted through an online questionnaire (prepared in Google forms software) comprising of 14 close-ended questions and assessed using percentage with the intention of evaluating awareness among 800 participants. The Questionnaire was framed in English to encourage participation and to serve better understanding of the questions by the respondents. All the respondents were informed about the aims and objectives of the study which were mentioned along with the questionnaire. The questions were directed towards the evaluation of knowledge and assess how far the participants are updated about the recent advances in the field of digital implantology. Of the 800 participants, only 500 reverted to the questionnaire, thus participated in the study. A total of 115 dental students and 387 dental practitioners participated in this current study. The questionnaire survey for dental students was distributed among interns and postgraduate students.
A web-based questionnaire assisted in ease of data collection, compiling, and maintenance of data. The additional advantage was that since the survey was conducted online it allowed participants to participate in the study as per their own convenience. The data obtained was easily available instantly and could be easily transferred into specialized statistical software or spreadsheets for further analysis. A Descriptive analysis was carried out to evaluate the responses.
RESULT
The response obtained from the participants was a reflection of their knowledge, attitude, and practice on digitization in the field of Implantology. It was observed that interns and those with limited clinical experience weren’t much updated about the advances in digitization when compared to Postgraduates and established practitioners who were quite updated. The detailed response of the participants to each question is discussed as under.
Regarding the first question, use of digital tools such as RVG, CBCT, etc. in the dental office, most of the dental students and dental practitioners (85%) had the knowledge and are currently using it in their routine practice successfully. On the other hand, 15% of the participants still use conventional tools in their office. (Fig. 1)
In response to the second question on ease of handling such digital modes, 432 participants (86.4%) found it easy to use whereas 68 participants (13.6%) opted ‘No’ which makes us infer that they may be coming across some difficulty with these digital tools. (Fig. 2)
In response to the third question based on the opinion regarding the precision of digital technology over the conventional one, 448 participants (89.6%) agreed that digital technology yields better precision regarding diagnosis and treatment planning in the dental field. On the other hand, 52 participants (10.4%) still prefer conventional modes when it comes to diagnostics and thinks they are better as compared to digital. (Fig. 3)
Regarding the fourth question about the most commonly used imaging modality prescribed in dental clinics while planning implant placements, 333 participants (66.6%) chose to prescribe some additional hematological tests along with OPG and CBCT. 64 responses (12.8%) were in favor of imaging modalities like OPG, CBCT, and CT. 46 participants (9.2%) opted for OPG and CBCT whereas 57 participants (11.4%) chose to prescribe just a single radiographic evaluation i.e., OPG. (Fig. 4)
According to Figure 5, 59.8% (299) participants conveyed that patient in their practice are aware and prefer going for digital implant placement whereas 201 participants (40.2%) reported that their patient still chose with conventional methods. Additional Cost pertaining to the use of digital tools could be the reason for patients still opting for conventional over digital placement.
Regarding the 6th question about preference of the clinicians for opting digital methods over the conventional, 55.4% of participants (277 participants) preferred digital technology. 35.4% of participants (177 participants) were in a dilemma about it, whereas 9.2% of participants (46 participants) chose conventional methods. (Fig-6)
In response to the question about the professional training for implant placement, 362 participants (72.4%) stated that they did not receive any professional training in implant placement whereas 138 participants (27.6%) have received professional training in implant placement. (Fig.7)
Simultaneous insertion of multiple implants may exhibit suboptimal positions, especially in edentulous jaws considered for a fixed restoration. Arısan et al. carried out a study to compare the incidence of and confounding factors in implant positioning errors related to the use of freehand and computer-aided treatment methods and stated that the highest probability of positioning error (88%) was associated with the use of the freehand method, whereas the lowest (6%) was associated with single-type, mucosa- supported guides with other significant confounding factors.4
Regarding the opinion of clinicians whether any additional benefits will be provided by digital workflow, 88.6% (443) of participants believed it to be true. On the other hand, 11.4% participants (57) believed that there will be no advantage of digital technology regarding implant placement. (Fig.8)
In response to the question to clinicians about their awareness about recent advances in field of digital implantology, 102 (20.4%) participants said they were unaware that, 37.6% were unsure (188 response). Whereas 210 responses (42%) were suggestive of awareness regarding digital implantology. (Fig.9)
In 1988, a breakthrough concept was introduced. Dental software that reformatted CBCT images in a way that was useful planning. The software continued to evolve. In 1993, software was introduced allowing overlay virtual implants on cross-sectional images. The most powerful way to use CBCT technology is in concert with implant planning software. These programs allow the user to view all of the characteristics of a future implant site by allowing for the precise assessment of bone volume, bone density, and restorative space in conjunction with the ability to identify and mark anatomic landmarks such as nerves, sinuses, and proximal teeth (Fig.11). Beyond site assessment, the most useful tool is the ability to virtually place an implant into the proposed site. This allows for accurate implant width, depth, and size determinations prior to surgery to aid in the pre- surgical planning stages.(1) After the CBCT data are acquired, the images are exported into DICOM (Digital Imaging and Communications in Medicine) files, a standard for the distribution and viewing of medical images regardless of their origin. For implant planning purposes, the cross-section is the primary diagnostic image used for the assessment of bone volume and quality. All the software programs allow the visualization of the data set in the multiplanar reconstruction view, which is the default visualization mode in CT and CBCT imaging. 9
Based on Fig 10, regarding the question, if they knew any software about digital planning of implant placement, it has been shown that 198 participants (39.6%) were unsure about it. 180 participants (36%) didn’t know about any software, whereas 22.4% (112 responses) of participants were aware of software and hardly 10 participants (2%) could enumerate some of them.
Regarding the question based on digital impression making, the percentage of participants having ‘Yes’ as an answer to this question is approximately 87.6% (438 responses). Whereas the percentage of participants for ‘No’ as the answer is approximately 12.4% (62 responses). (Fig.12)
Digital techniques of impression making demonstrated superior outcomes in comparison with conventional methods, and the direct technique was better than the indirect conventional technique. Connection type and implant angulation were other factors that influenced accuracy in the conventional impression making. However, when the digital impression was applied, accuracy was not affected by the type of connection and angulation 5. The percentage of participants who have used scanners for digital impression is approximately 36.9% (184 responses). Whereas 63.1% (315 responses) of participants have not made a digital impression (Fig 13). Those who have made digital impressions convey that patient’s response was pleasant after the impression making (Fig 14).
According to Figure 14, the majority of participants 75.8% (379 responses) stated that the introduction of digital technology would improve the quality and function of rehabilitation. Whereas 9 respondents (1.8%) stated there would be no difference, and 22.4% (112 responses) stated that they were unsure about it (Fig.14).
About 85.2% of the participants were aware of the term CBCT, irrespective of its usage, they are fairly aware of the benefits of the same. The least known term to the participants was robotic/navigation surgery (26.4%) and. STL (standard tessellation file) format (32%). Scan bodies function as digital impression copings which allow for the implant brand, position, and timing to be registered and transferred to a digital model. All the needed information relative to provisional treatment, opposing arch, and bite registrations can be captured with intra-oral scanning devices 1. This was known only by 38.2% of participants. Although 72.2% of participants know the intraoral scanners term it doesn’t provide any info whether they use or not. The most common hindrance faced by participants for the use of scanners might be cost and unavailability of the same.
DISCUSSION
Successful implant placement is influenced by many factors such as type of impression material, implant impression technique, implant angulation, the skill of the operator, etc. The major goal of all the procedures is to allow clinicians to work effectively and to serve the patient in the best way possible. The present study gives us an overview of the knowledge, attitude, and practice of various digital techniques available for dental implants among dental students and dental practitioners. According to the current study, it was reported that dental students had a lower level of awareness regarding various digital technologies available compared to dental practitioners. The difference of this awareness could be contributed to the fact that they have a lower level of education of digital workflow compared to the dental practitioners. Yet, some of them still exposing or just exposed to clinical years. Among the participants who have made a digital impression, only 36.9% of participants gave a positive response. This is maybe because INDIA still being a developing country and additional cost of tool participants had less clinical experiences.
CBCT has become the standard of care for implant placement. CBCT scans have the capacity to capture 3D structures with short scan times and ultra-low dosages. The accuracy of these scans has been verified in the literature. In comparison to direct measurements, Timok AM et al 6 demonstrated its ability to discriminate alveolar bone thicknesses between 0.13 to 0.3 mm, and without over or underestimation. Precise knowledge of oral radiology along with CBCT in the dental fraternity is important due to its wide applications and profound potential of CBCT in different specialties of dentistry. According to Rai et.al 7, it was found that a maximum of 94.7% of clinicians advised CBCT to their patient for a successful diagnosis which is having similar results to our study (89.6%).
On the contrary, a study conducted by R. Chowdhary 8 Computed tomography (CT) was the preferred diagnostic technique by 33.3% implantologists in Japan, 26.32% in Russia, 23.58% in Europe, 96.59% of Americans, 98.62% European Union dentists.
At present, computer-based technologies are well established in designing and manufacturing dental appliances and prostheses but they are still too expensive and their maintenance and repair costs are high like any other new technology. Apart from the reason mentioned above, a lack of awareness about the complications and usage of tools, etc. are the main influencing factors. 10 This has similar patters with our study.
Focusing only on the prosthodontics curriculum, educators are engaging in emerging digital technologies. A recent survey of US dental school deans conducted by Brownstein et al (2015) reported that greater penetration of digital technology occurred in preclinical didactic courses and the lowest was in preclinical laboratories. CAD/CAM has reached the clinical environment as well. One important observation regarding digital dentistry in the academic environment is that technology adoption in US dental schools is keeping pace with or exceeding the early adoption in private practices. This type of system should also be implied in India.
CONCLUSION
Within the limitation of the study few questions were framed on the practitioner’s opinion, but not literature evidence. The findings of this study clearly point out a need for a high level of awareness among students. However, a large number of participants were interested in using digital tools to provide successful restoration and to work in a hassle-free environment. High costs, lack of knowledge were the main disadvantages of digital implant treatment according to participants. With web-based surveys, the respondents are able to answer the questionnaire by means of inputting their answers while connected to the Internet. Then, the responses are automatically stored in a survey database, providing hassle-free handling of data and a smaller possibility of data errors.
It can be concluded from the survey that; High percentage of participants prefer digital impression. It also showed the need for providing more information and knowledge about impression techniques available for dental implants among dental students. Hence, proper dental education with an interesting way of delivering is necessary to develop a positive attitude among the dental student population toward dental implants holistically. It can also be observed from the survey, lack of awareness, and lower level of education related to the digitization in the field of prosthodontics brings the negative attitude in the practitioners. This situation can be improved by guiding and motivating students to use digital techniques from the dental school itself and by undertaking various CDE programs for practitioners to keep their knowledge updated and serve the patients in the best way possible.
REFERENCES
1. Ludlow M, Renne W. Digital workflow in implant dentistry. Current Oral Health Reports. 2017 Jun;4(2):131-5.
2. Suresh Kamble., Ajit Jankar. SF, ., Dishita Chokhani. SG and, Patil G and S. International Journal of Current Advanced Research. Notes. 2017;1(01):444.
3. Arcuri L, Lorenzi C, Cecchetti F, Germano F, Spuntarelli M, Barlattani A. Full digital workflow for implant-prosthetic rehabilitations: A case report. ORAL Implantol. 2016;8(4):114–21.
4. Arısan V, Karabuda CZ, Mumcu E, Özdemir T. Implant Positioning Errors in Freehand and Computer-Aided Placement Methods: A Single-Blind Clinical Comparative Study. Int J Oral Maxillofac Implants. 2013;28(1):190–204.
5. Alikhasi M, Siadat H, Nasirpour A, Hasanzade M. Three-Dimensional Accuracy of Digital Impression versus Conventional Method: Effect of Implant Angulation and Connection Type. Int J Dent. 2018;2018.
6. Timock AM, Cook V, McDonald T, Leo MC, Crowe J, Benninger BL, Covell Jr DA. Accuracy and reliability of buccal bone height and thickness measurements from cone-beam computed tomography imaging. American journal of orthodontics and dentofacial orthopedics. 2011 Nov 1;140(5):734-44.
7. Shalu Rai, Deepankar Misra, Ayush Dhawan, Kuber Tyagi, Mukul Prabhat MK, Department. Knowledge, Awareness, and Aptitude of General Dentists Toward Dental Radiology and CBCT: A Questionnaire Study. J Indian Acad Oral Med Radiol. 2019;31(1):36–9.
8. Chowdhary R, Hosadettu SR, Chandrakar N. A survey on the use of techniques, materials in dental implantology practice. Indian journal of dental research. 2012 Mar 1;23(2):297.
9. Mora MA, Chenin DL, Arce RM. Software tools and surgical guides in dental-implant-guided surgery. Dent Clin North Am. 2014;58(3):597–626.
10. Raja’a M, Farid F. Computer-based technologies in dentistry: types and applications. Journal of Dentistry (Tehran, Iran). 2016 Jun;13(3):215.
11. Brownstein S, Murad A, Hunt R. Implementation of New Technologies in U.S. Dental School Curricula. Journal of Dental Education. 2015;79(3):259-264.
Based Survey