Attitudes Towards Replacement of Teeth Among Patients at the Institute of Dental Sciences, Belgaum, India

Kamal Shigli, B.D.S., M.D.S.; Mamata Hebbal, B.D.S., M.D.S.; Gangadhar Shivappa Angadi, B.D.S., M.D.S.
Abstract: The purpose of this study was to assess the attitude towards replacement of teeth among patients who reported to the department of prosthodontics in the Institute of Dental Sciences, Belgaum, which is located in the northwestern part of the state of Karnataka in the southern region of India. A fourteen-item, closed-ended questionnaire was completed by 365 volunteer patients who were then examined by a clinician and existing and missing teeth were charted. All the patients who reported to a dental clinic in a period of two months with at least one missing tooth were included in the study. Collected data were statistically analyzed using chi-square test at a significance level of p<0.05. The age of the subjects ranged from sixteen to eighty-four years (mean age 51.06 16.47 years). Among these 365 patients, 228 were in a waiting period for soft tissue healing after extraction of tooth/teeth; 19.7 percent of the patients gave financial constraints as the reason for not replacing teeth; 7.1 percent reported that they lacked the time to have teeth replaced; 6.9 percent had low felt needs; and 3.8 percent indicated they did not know that teeth could be replaced. Subjects with different levels of socioeconomic status reported different reasons for not replacing the teeth and these differences were statistically significant (2=61.16, P<0.001). Knowledge about the equivalence of artificial teeth with natural teeth (2=23.01, P<0.05) and problems with artificial teeth (2=17.25, P<0.05) were also significantly different among subjects from different socioeconomic categories. The findings indicate that awareness needs to be increased regarding the other functions of teeth like esthetics and phonetics because many subjects in this study were only aware of the function of mastication performed by teeth, especially among individuals in the lower socioeconomic group. Attitudes of patients should be taken into consideration to improve patient compliance with and acceptance of prostheses. Dr. Shigli is a former Professor, Department of Prosthodontics, Karnataka Lingayat Education Societys Institute of Dental Sciences, Belgaum, Karnataka State, India, and presently works at Modern Dental College and Research Centre, Indore, Madhya Pradesh; Dr. Hebbal is Lecturer, Department of Preventive and Community Dentistry, Karnataka Lingayat Education Societys Institute of Dental Sciences; and Dr. Angadi is a former Professor and Head, Department of Prosthodontics, Karnataka Lingayat Education Societys Institute of Dental Sciences and presently works at Rural Dental College, Loni, Maharastra. Direct correspondence and requests for reprints to Dr. Kamal Shigli, B-205 Staff Quarters, Modern Dental College and Research Centre, Opposite Gandhi Nagar, Nainod Gram, Airport Road, Indore-453112, Madhya Pradesh, India; 91-731-2882511 phone; 91-731-2882700 fax; kamalshigli@yahoo.co.in. Key words: attitude, replacement of teeth, socioeconomic status, awareness, patient education Submitted for publication 2/8/07; accepted 8/8/07

e live in a social world and how we look influences our interactions with others. The face and smile play a crucial role in the creation and maintenance of positive attitudes about ones self and have a tremendous emotional significance. The face has become a symbol for the total self. A smile is a window into ones personality. Today, a modern view of dentistry is one that recognizes the emotions or psychological essence of the patient in relationship to the dental situation, dental health care, and, especially, esthetics.1 Teeth play an important role in the maintenance of a positive self-image.2 The loss of teeth results in significant disabilities, which can profoundly disrupt social activities. Tooth loss is very traumatic and upsetting and is regarded as a serious life event that requires significant social and psychological readjust-

ment.3,4 It has been suggested that adverse reactions towards edentulousness as well as the individuals feelings about dentures are important for the acceptance of the new dentures.5 The attitude towards tooth loss is changing. Adults have greater expectations of their dental health than in the past.6 Research has demonstrated that several non-disease factors such as attitude, behavior, dental attendance, and characteristics of the health care system play an important role in the decision to become edentulous. In addition, a significant relationship exists between the edentulous state and fiscal concerns that are usually associated with low occupational levels. It is therefore reasonable to conclude that edentulism is due to various combinations of cultural, educational background, financial, and dental disease attitudinal determinants, as well

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as to treatment received in the past.7 For example, regardless of age and gender, Chinese people in the United Kingdom believe that they are susceptible to dental disease, that one should expect to lose teeth in the older age group, and that nothing can be done to prevent it.8 The best way to obtain the information necessary to analyze a patients attitudes is to establish, as do many psychiatrists, a permissive, noncritical climate that will reduce the patients resistance to saying what he or she thinks.9 Generally, the three major areas that determine acceptability of treatment are comfort, function, and esthetics. Mechanical and biological factors determine comfort and function. However, a variety of social and cultural influences, attitudes, and beliefs may determine patients acceptance of the esthetic aspects of prosthodontic treatment.10 More emphasis is being placed on patientmediated concerns in prosthetic treatment planning. Consequently, more information has been published on realistic treatment needs and sociodental treatment needs of different populations.11 Patients attitudes toward dentures, measured by means of a questionnaire prior to the patients receiving new dentures, could be a prospective tool to determine satisfaction with new dentures.12 In India, the attitude of patients toward replacement of teeth has not been investigated as much as in Western countries. Therefore, the purpose of our study was to conduct a survey to assess attitudes towards replacement of teeth among patients who reported to the Institute of Dental Sciences, Belgaum, which is located in the northwestern part of the state of Karnataka in the southern region of India. This institute provides selective basic dental treatments free of cost as a service to society.

Materials and Methods

A cross-sectional survey to determine patients attitudes about replacement of teeth was conducted. Ethical clearance was obtained from the Institute of Dental Sciences. A fourteen-item, closed-ended questionnaire was recorded, followed by a clinical examination in which the chief complaints were recorded and existing and missing teeth were charted. Missing teeth were classified as anterior and posterior, so that a distinction could be made between esthetic and functional needs. Since premolars are important for both esthetics and function, they were

included in both classifications. At least one missing anterior tooth (incisor, canine, or premolar) constituted a need for esthetic restoration; at least three missing posterior teeth (premolar, first molar, second molar) constituted a need for functional restoration.11 The questionnaire consisted of two parts. Part A included questions on sociodemographic factors. Kuppuswamys socioeconomic classification, which includes education level, monthly income, and occupation, was used to classify the socioeconomic status of the patients.13 Accordingly, the socioeconomic status was divided from class I to class V: Upper (I),Upper Middle (II), Lower Middle (III), Upper Lower (IV), and Lower (V). Part B included six questions designed to determine the patients attitudes regarding replacement of teeth. Of these six questions, four were on a three-point scale (yes, no, do not know), and the remaining two questions had four options (financial reason, did not feel need, no time, did not know for the first; appearance, speech, function, and combination for the second). A pilot study was carried out with twenty patients to check the feasibility of the study, and the questions were modified accordingly. These subjects were excluded from the final study. All the patients who reported to the department of prosthodontics in the Institute of Dental Sciences, Belgaum, over a period of two months with at least one missing tooth (excluding third molars) were included in the study after they were informed of the nature of the investigation and gave their consent. A total of 365 patients (185 females and 180 males) from sixteen to eighty-four years of age (mean age 51.06 16.47 years) fulfilled these criteria. A single trained investigator recorded answers from the patients followed by a clinical examination. Collected data were statistically analyzed using chi-square test at a significance level of p<0.05. The power of the study was 80 percent. All the data analysis was performed using statistical software (SPSS for Windows, version 11; SPSS Inc., Chicago, IL).

Results
The questionnaire was answered by 365 patients, which included 185 females and 180 males; 215 patients were completely edentulous, 150 were partially edentulous; 125 patients were using a prosthesis, and 240 patients were not using a prosthesis (Table 1). About 25 percent of the patients were in

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the forty-six to fifty-five years age group, followed by 23.3 percent in the fifty-six to sixty-five years age group (Table 2). About 52 percent of the patients belonged to class IV socioeconomic status, followed by 20.8 percent in class III socioeconomic status (Table 3). In addition, 80.5 percent of the patients had allocated money for health care (Table 4). All 365 patients perceived that they had missing teeth that needed to be replaced (Table 5). A total of 228 were in a waiting period for soft tissue healing after extraction of tooth/teeth. Approximately 20 percent of the patients gave financial constraints as the reason for not replacing teeth, followed by 7.1 percent expressing lack of time, 6.9 percent with low felt needs, and 3.8 percent who said they lacked knowledge about treatment options available for replacement of teeth. Fifty percent of the patients in the class I socioeconomic status did not feel the need for replacement of teeth, whereas the majority of patients in class II to class V were in a post-extraction healing period (55.3 percent, 55.3 percent, 67.5 percent, 63.8 percent, respectively). Subjects with different levels of socioeconomic status reported different reasons for not replacing extracted teeth, and these differences were statistically significant (2=61.16, P<0.001). Subjects with lower socioeconomic status reported financial reason, whereas subjects with

higher income did not feel need or had no time for replacement (Table 6). Around 65 percent of patients who had lost teeth only in the anterior segment needed tooth replacement for appearance; 83.0 percent of patients who had lost teeth in the posterior segment needed tooth replacement for mastication, while 56.2 percent of patients who had lost teeth in both the anterior and posterior segment needed tooth replacement for mastication (Table 7). Though an approximately equal number of patients felt that artificial teeth were equivalent, not equivalent, or had no idea regarding the appearance and functioning of artificial teeth in comparison to natural teeth, a statistically significant difference was found when equivalence of artificial to natural teeth was assessed according to socioeconomic status (2=23.01, P<0.05) (Table 8). About 56 percent of the patients knew that artificial teeth create no problems, 38.1 percent had no idea regarding problems with artificial teeth, and 5.5 percent said that artificial teeth created problems. Knowledge

Table 3. Distribution of patients according to SES

SES I II III IV V Total Number of Patients % of Patients 4 47 76 191 47 365 1.1 12.9 20.8 52.3 12.9 100.0

Table 1. Distribution of patients according to gender, dentition status, and prosthetic status
Characteristic Male Female Completely edentulous Partially edentulous Not using prosthesis Using prosthesis Number of Patients % of Patients 180 185 215 150 240 125 49.3 50.7 58.9 41.1 65.8 34.3

Table 4. Distribution of patients according to money allocated for health care

Money Spent on Health Care Yes No Total Number of Patients % of Patients 294 71 365 80.5 19.5 100.0

Table 2. Distribution of patients according to age

Age 16-25 26-35 36-45 46-55 56-65 66-75 76-85 Total Number of Patients % of Patients 35 42 43 92 85 51 17 365 9.6 11.5 11.8 25.2 23.3 14.0 4.6 100.0

Table 5. Distribution of patients according to need for tooth replacement

Need for Replacement Number of Patients % of Patients Yes No Total 365 0 365 100.0 0.0 100.0

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about the equivalence of artificial teeth with natural teeth (2= 23.01, P<0.05) and problems with artificial teeth (2=17.25, P<0.05) were also significantly different among subjects from different socioeconomic categories (Table 9).

Discussion
In India, epidemiological data on patients attitude towards tooth replacement are scanty. Therefore,

Table 6. Distribution of patients according to SES and reasons for not replacing tooth/teeth
Reasons for Not Replacing Tooth/Teeth Financial reason Did not feel need No time Did not know Post-extraction healing period Total Chi-square=61.16 p=0.00000, S I 0 2 1 0 1 4 % 0.0 50.0 25.0 0.0 25.0 100.0 II 0 6 12 3 26 47 % 0.0 12.8 25.5 6.4 55.3 100.0 III 12 7 10 5 42 76 % 15.8 9.2 13.2 6.6 55.3 100.0 IV % V % Total %

45 23.6 8 4.2 3 1.6 6 3.1 129 67.5 191 100.0

15 31.9 2 4.3 0 0.0 0 0.0 30 63.8 47 100.0

72 19.7 25 6.9 26 7.1 14 3.8 228 62.5 365 100.0

Table 7. Distribution of patients according to the segment in which tooth was lost and the reason for tooth replacement
Reason for Tooth Replacement Appearance Speech Function Combination Total Anterior 19 0 2 8 29 % 65.5 0.0 6.9 27.6 100.0 Posterior 1 1 44 7 53 % 1.9 1.9 83.0 13.2 100.0 Combination 9 1 159 114 283 % 3.2 0.3 56.2 40.3 100.0 Total 29 2 205 129 365 % 8.0 0.5 56.2 35.3 100.0

Table 8. Distribution of patients according to SES and equivalence of artificial to natural teeth
Equivalence of Artificial to Natural Teeth Yes No Do not know Total Chi-square=23.01 p=0.00336, S I 4 0 0 4 % 100.0 0.0 0.0 100.0 II 18 21 8 47 % 38.3 44.7 17.0 100.0 III 29 20 27 76 % 38.2 26.3 35.5 100.0 IV % V % Total %

66 34.6 64 33.5 61 31.9 191 100.0

9 19.1 14 29.8 24 51.1 47 100.0

126 34.5 119 32.6 120 32.9 365 100.0

Table 9. Distribution of patients according to SES and problems with artificial teeth
Problems with Artificial Teeth Yes No Do not know Total Chi-square=17.25 p=0.02761, S I 0 3 1 4 % 0.0 75.0 25.0 100.0 II 4 32 11 47 % 8.5 68.1 23.4 100.0 III 2 42 32 76 % 2.6 55.3 42.1 100.0 IV % V % Total %

13 6.8 111 58.1 67 35.1 191 100.0

1 2.1 18 38.3 28 59.6 47 100.0

20 5.5 206 56.4 139 38.1 365 100.0

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an attempt was made to find out the attitude towards replacement of teeth among patients reporting to the Institute of Dental Sciences, Belgaum. Three hundred sixty-five patients reported for the study, with an equal number of female and male patients. Most of the patients belonged to the forty-six to fifty-five years age group. There were fewer patients in the sixty-six to seventy-five and seventy-six to eighty-five years age groups because geriatric patients give a lower priority to dental health. Older people make extensive use of medical facilities, but they seem to underuse dental facilities. Mobility problems, lack of information, and misconceptions about the value of dental visits have been mentioned as contributing to this apparent disinterest in dental care among geriatric patients.14 Perceptions associated with increasing age such as feelings that they are too old to adapt to dentures and lack of interest in esthetics may also be contributory factors for low perceived needs in the higher age group.15 The availability of free denture treatment in the Institute of Dental Sciences, Belgaum, may have influenced the results of this study as a majority of the patients reported from the class IV socioeconomic status. Individuals with greater financial resources have better access to dental care. Those who have attained higher levels of education are more apt to have greater financial opportunity and to place a higher priority on dental health. Lack of education about the importance of oral health, the need for preventive services, and the consequences of neglect appear to constitute a significant barrier to dental health care.16 A majority of the patients reported that they had reserved money for health care, which may have been for general health rather than oral health because in India dental health insurance is not very common. In India, overall health insurance coverage is low; less than 10 percent of the population is estimated to have access to health insurance. For the most part, the health care demands of the rural poor and informal workers have been largely unmet. However, several initiatives and experiments have been tried. The Yeshaswini Health Insurance Scheme (YHIS) administered by the Yeshaswini Trust was introduced in 2003 throughout rural Karnataka State, India. For a premium payment of only Rs. 5 (~$.11) per month or Rs. 60 (~$1.30) annually, participants are covered for all surgical interventions, major or minor, and for outpatient services at a network of private and government hospitals.17

Since the patients in our study had reported on their own to the institute for replacement of teeth, it was not surprising to find that all the subjects expressed that missing teeth had to be replaced. The results obtained in our study were in contrast to that of Akeel,11 whose study found only 82 percent of the subjects perceived a need for tooth replacement. The difference in the results may be because the investigator had selected subjects from the screening clinic of the King Saud University College of Dentistry. The majority of the patients in our study gave economic reasons for not replacing teeth. Cost was the main barrier for obtaining dentures and is in agreement with the findings of Macek et al.18 Very few patients expressed lack of knowledge regarding replacement of teeth. Osterberg et al.19 reported that esthetic rather than functional factors determined an individuals subjective need for the replacement of missing teeth. The demand for replacement of missing teeth is strongly related to the position of the missing teeth. Replacement of missing posterior teeth, and cosmetic dental treatment in general, depends on the perception of the patient. Even in countries with highly developed dental care systems, open spaces in the premolar and molar regions are well accepted by people of all ages. The prospect of a good esthetic result frequently motivates the patient to wear a new denture, and esthetics can be more important than function for many individuals.2,20 In our study, patients who had lost teeth only in the anterior segment needed tooth replacement for esthetics; those who had lost teeth only in the posterior segment needed tooth replacement for mastication; and patients with teeth missing in both the anterior and posterior segment needed tooth replacement for mastication. These findings could be explained by the fact that most people in India are aware of only the mastication function served by the teeth. They are less aware of the esthetics and phonetics functions of teeth. Moreover, the geriatric population gives less priority to esthetics and more importance to mastication. According to Leake et al.,21 the subjective need for prosthetic replacement of teeth, particularly posterior teeth, is often low because such replacements seldom improve the individuals social status. Moreover, as tooth loss usually occurs gradually over a period of time, it allows the individual to adapt to the situation with no apparent complaints. Therefore, many older individuals may not perceive a need for dentures in spite of losing significant numbers of

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teeth because they have adapted to their missing teeth over time.15 When a question regarding equivalence of artificial teeth to natural teeth was asked, it indirectly represented the expectation of the patient. Expectations represent attitudes that are complex and often difficult to change.22 In our study, a higher number of patients said that artificial teeth were equivalent to natural teeth. They might have perceived this because of the matching of the color and anatomy of the artificial teeth to the natural teeth, the resiliency of the acrylic tooth material, or the care taken by the operator during tooth selection. The sense of touch may have been the reason for 32.6 percent of the patients expressing differences between artificial and natural teeth. A majority of the patients knew that artificial teeth create no problems. Patient education before, during, and after prosthodontic treatment may have prevented the expected problems with the artificial teeth or prosthesis. Patients perceptions regarding replacement of teeth may have been better appreciated if differences in attitude among denture-wearers and non denture-wearers had been analyzed in our study. An appreciation for the perceptions and attitudes of patients towards the replacement of teeth would prepare a prosthodontist more completely to provide a satisfying prosthesis. Through increased awareness of patient expectations, prostheses can be planned, made, and placed in harmony with the hard and soft oral tissues and in harmony with the patients expectations as well.10 Future studies should determine how the dental profession and society might address an increased demand for services among people who have limited financial resources. These studies would provide important insights into the various types of assistance and insurance programs that might be designed and implemented to benefit older adults.18 Also, studies can be conducted that take into consideration various cultural aspects of a wider population to learn their influence on attitudes towards replacement of missing teeth.

to be created regarding the other functions of teeth like esthetics and phonetics because many subjects in this study were only aware of the masticatory function performed by teeth, especially among individuals in the lower socioeconomic group. Attitudes of patients towards replacement of teeth should be assessed to educate the patient accordingly and improve patient compliance with acceptance of prostheses.

REFERENCES
1. Levinson NA. Psychological facets of esthetic dental health care: a developmental perspective. J Prosthet Dent 1990;64:486-91. 2. Roessler DM. Complete denture success for patients and dentists. Int Dent J 2003;53:340-5. 3. Omar R, Tashkandi E, Abduljabbar T, Abdullah MA, Akeel RF. Sentiments expressed in relation to tooth loss: a qualitative study among edentulous Saudis. Int J Prosthodont 2003;16:515-20. 4. Fiske J, Davis DM, Frances C, Gelbier S. The emotional effects of tooth loss in edentulous people. Br Dent J 1998;184:90-3. 5. Al Quran F, Clifford T, Cooper C, Lamey PJ. Influence of psychological factors on the acceptance of complete dentures. Gerodontology 2001;18:35-40. 6. Allen PF, McMillan AS. A review of the functional and psychosocial outcomes of edentulousness treated with complete replacement dentures. J Can Dent Assoc 2003;69(10):662. 7. Zarb GA, Bolender CL. Prosthodontic treatment for edentulous patients. 12th ed. St. Louis: Mosby, 2004:6-23. 8. Kwan SYL, Williams SA. Dental beliefs, knowledge, and behavior of Chinese people in the United Kingdom. Community Dent Health 1999;16:33-9. 9. Collett HA. Influence of dentist-patient relationship on attitudes and adjustment to dental treatment. J Am Dent Assoc 1969;79:879-84. 10. Conny DJ, Tedesco LA, Brewer JD, Albino JE. Changes of attitude in fixed prosthodontic patients. J Prosthet Dent 1985;53:451-4. 11. Akeel R. Attitudes of Saudi male patients toward the replacement of teeth. J Prosthet Dent 2003;90:571-7. 12. Van Waas MAJ. Determinants of dissatisfaction with dentures: a multiple regression analysis. J Prosthet Dent 1990;64:569-72. 13. Mishra D, Singh HP. Kuppuswamys socioeconomic status scale: a revision. Indian J Pediatr 2003;70:273-4. 14. Maupome G, MacEntee MI. Prosthodontic profiles relating to economic status, social network, and social support in an elderly population living independently in Canada. J Prosthet Dent 1998;80:598-604. 15. Pallegedara C, Ekanayake L. Tooth loss, the wearing of dentures, and associated factors in Sri Lankan older individuals. Gerodontology 2005;22:193-9. 16. Marcus PA, Joshi A, Jones JA, Morgano SM. Complete edentulism and denture use for elders in New England. J Prosthet Dent 1996;76:260-6.

Conclusion
The present results may serve as a baseline for the future evaluation of attitudes towards replacement of teeth. The findings indicate that awareness needs

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17. Cornell University. The Karnataka Yeshaswini health insurance scheme for rural farmers and peasants: towards comprehensive health insurance coverage. At: www. johnson.cornell.edu/internationaleducation/politics/cases/ Yeshwani teaching case doc. Accessed: February 8, 2007. 18. Macek MD, Cohen LA, Reid BC, Manski RJ. Dental visits among older U.S. adults, 1999: the roles of dentition status and cost. J Am Dent Assoc 2004;135:1154-62. 19. Osterberg T, Hedegard B, Sater G. Variation in dental health in 70-year-old men and women in Goteborg, Sweden: a

cross-sectional epidemiological study including longitudinal and cohort effects. Swed Dent J 1984;8:29-48. 20. Mazurat NM, Mazurat RD. Discuss before fabricating: communicating the realities of partial denture therapy. Part I: patient expectations. J Can Dent Assoc 2003;69(2): 90-4. 21. Leake JL, Hawkins R, Locker D. Social and functional: impact of reduced posterior dental units in older adults. J Oral Rehabil 1994;21:1-10. 22. Davis EL, Albino JE, Tedesco LA, Portenoy BS, Ortman LF. Expectations and satisfaction of denture patients in a university clinic. J Prosthet Dent 1986;55:59-63.

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APPENDIX
Attitudes Towards Replacement of Teeth Among Patients at the Institute of Dental Sciences, Belgaum, India 1. Name: 2. Age: 3. Gender: M/F 4. Address: Part A 5. Completed Education: 1) Illiterate 2) Primary education 3) High school education (till Xth Std.) 4) Higher education (Diploma/Degree/Post-Graduation) 6. Income: 7. Occupation: Part B 8. Is money being spent for health care: Yes/No/Do not know If Yes, in what form and amount: 9. Reasons for not replacing the missing teeth (if lost for more than three months): 1) Financial reason 2) Did not feel need 3) No time 4) Did not know 10. Do you think you need to replace the missing tooth (teeth)? Yes/No/Do not know 11. If yes, replacement is needed for: 1) appearance 2) speech 3) function 4) combination (more than one) 12. Do you think artificial teeth are equivalent to natural teeth in appearance and function? Yes/No/Do not know 13. Do you think artificial teeth create problems? Yes/No/Do not know Clinical Examination 14. Chief complaints (in patients own words): Patient Code:

15. Existing teeth:

16. Missing teeth:

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INFORMED CONSENT FORM

I,

Address:

Dentists name: The dentist has informed me about the study procedure and my involvement in it. 1) I agree to give my personal details like name, age, gender, address, medical history, previous dental history, and the details required for the study to the best of my knowledge. 2) I permit the operator to utilize the information given by me and results obtained from this study for presentation and publication. 3) I permit the doctor to make my photographs to utilize them for the study purpose if required. 4) I will not claim any returns for my cooperation in the study, even if it is being sponsored by any agency. I am participating with my own will and wish for the betterment of the community. 5) If for any reason I am unable to participate in the study, for reasons unknown, I can withdraw from the study. I have read, gone through, and understood the above information given by the doctor about the above study. I have entered and signed this application. Dentist name: Address: Phone no:

Dentist Signature

Patient Signature

Witness

Witness

Date:

Place:

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