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ORIGINAL ARTICLE Isra Med J. | Vol 13 - Issue 1 | Jan – Mar 2021
24
Factors influencing the treatment options for single
missing tooth: A patient preference-based study
Naseer Ahmed1, Maria Shakoor Abbasi2, Fiza Bibi Alavi3, Asma Naz4, Sabeen Masood3, Adil Bin Irfan5
ABSTRACT
Objective: To determine factors affecting the patients decision for selecting a particular treatment option for replacement of single
missing tooth
Study Design: Descriptive analytical study.
Place and Duration: Department of Prosthodontics, Altamash institute of dental medicine, Karachi, from 15 June’2019 to 14
December’2019.
Methodology: All new patients attending dental OPD in the age group of 18-60 years with only single missing tooth were included in
the study. A well-constructed and validated Performa was used to evaluate patient’s decision for three different types of prosthesis
against different influencing factors including, cost, pain and discomfort, duration, dental phobia, damage to the adjacent teeth and
number of visits.
Results: Out of the total 397 patients mostly were from 40-50 years with 56.2% males and 43.8% were females. Majority of the
participants preferred fixed partial dentures (59.2%) as compared to removable partial dentures (24.4%), dental implants (9.1%) and
(7.3%) preferred no treatment option. Cost of treatment (90.9%) was the most common factor in choosing a particular prosthesis
majorly with dental implants and fixed partial dentures.
Conclusion: The replacement of missing tooth is based on multiple factors amongst fixed partial denture, removable partial denture
and dental implants, among which duration of treatment and cost are the most common influencing factors considered by the patient.
Additionally, patient’s education and awareness level did affect the choice of treatment options.
Keywords: Cost, Dental implants, Dental phobia, Fixed partial denture, Pain and suffer, Single missing tooth
How to Cite This:
Ahmed N, Abbasi MS, Alavi FB, Naz A, Masood S, Irfan AB. Factors influencing the treatment options for single missing tooth: A patient
preference-based study. Isra Med J. 2021; 13(1): 24-28.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 4.0 International License
(http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
INTRODUCTION
Tooth loss is physically and psychologically a traumatizing
experience and it has a serious impact on the quality of life of an
individual. The two most common reported causes of tooth loss
are dental caries and periodontal problems; others are
accidental trauma, endodontic complications and congenitally
missing teeth1,2. Maintenance of oral health is very important
though neglected to the point where only emergency treatment
is pursued for pain relief and by that point, the only option left
is to extract that painful tooth, leaving a gap behind and making
the individual partially edentulous. This is probably due to the
lack of awareness of the consequences of missing teeth and
financial constraints as restorative treatment is expensive3,4.
This also corresponds to a study by Samuel AR et al in which the
patients neglected treatment as 70% of them felt it was
expensive and 94% were unaware of the consequences of
missing teeth5. In a study by Shetty M et al, 33.5% reported
treatment to be expensive, 24% reported lack of time and 22%
did not feel any need to replace a missing tooth6.
Several treatment options are available to restore a single
missing tooth which are broadly categorized under two main
domains: fixed and removable prosthodontics7. “Fixed
1. Associate Professor of Prosthodontics,
Altamash Institute of Dental Medicine, Karachi
2. Assistant Professor of Prosthodontics,
Altamash Institute of Dental Medicine, Karachi
3. House Officer,
Altamash Institute of Dental Medicine, Karachi
4. Associate Professor of Prosthodontics,
Jinnah Medical and Dental College, Karachi
5. Registrar of Prosthodontics,
Altamash Institute of Dental Medicine, Karachi
Correspondence:
Naseer Ahmed
Associate Professor of Prosthodontics,
Altamash Institute of Dental Medicine, Karachi
Email: naprosthodontist@gmail.com
Received for Publication: June 29, 2020
1st Revision of Manuscript: September 07, 2020
2nd Revision of Manuscript: September 15, 2020
Accepted for Publication: October 01, 2020
Naseer Ahmed et al Isra Med J. | Vol 13 - Issue 1 | Jan – Mar 2021
25
prosthodontic treatment includes conventional Fixed partial
dentures, Cantilevered fixed dental prosthesis, resin bonded
fixed dental prosthesis or implant supported fixed dental
prosthesis. Each option has its merits and demerits along with
particular indications8.
Timely restoration of edentulous spaces is needed to prevent
the adverse consequences of tooth loss. The choice of the
prosthesis for replacing a single missing tooth is determined by
various factors, such as; age, gender, socio economic status,
individual patient’s condition (medical or psychological),
location of the tooth in the arch, quality of ridge and alveolar
bone, empirical evidence of outcomes of treatment, experience
and expertise of clinicians and patient’s preference7,9. Usually,
the bias of the dentist plays a role rather than objective
assessment of the treatment modalities. Treatment decisions
should be made in close consultation with the patients and their
expectations should be addressed if they reflect reality10.
Otherwise, the practitioner will face rejection in their proposed
treatment plans as concluded by studies by Shrirao and Nayana,
where 82% and 73% of patients rejected the proposed
treatment plans in which their desires and requirements were
not addressed11,12. Therefore, in a nutshell, it is very necessary
to address the patient's requirements and desires to ensure the
patient's satisfaction.
Various studies have been carried out in which investigators have
evaluated the dentists’ role in choosing different treatment
modalities available for patients with complaints of a single
missing tooth but investigators have been ignoring the
importance of patients’ perception on deciding the choice of
treatment for the replacement of a single missing tooth as studies
related to patient’s decision are reported less in literature11-14.
Hence, this study was conducted with an objective to determine
the factors affecting the patient’s decision for selecting a
particular treatment option for replacement of single missing
tooth.
METHODOLOGY
This descriptive analytical study was carried out from 15
June’2019 to 14 December’ 2019 for a period of 6 months on the
patients visiting outpatient department (OPD) of Altamash
Institute of Dental Medicine and various dental institutes and
hospitals of Karachi. The participants were informed about
anonymous, voluntary, and non-compulsory nature of the study
and prior consent was taken before their participation in the
study. The simple random sampling technique was used in this
study. All new patients attending dental OPD in the age group of
18-60 years with only single missing tooth were included in the
study. Patients having periodontal diseases, smoking habits,
debilitating diseases, pregnancy and edentulous spaces at the
distal extension base or more than one missing tooth were
excluded.
A well-constructed and validated proforma was used for data
collection. The internal consistency of items analyzed through
Cronbach alpha was (α=0.71). The proforma was divided into
two sections; First section addressed the demographic details
including age, gender, education level along with the preferred
treatment option. The second section consisted of responses
related to treatment options patient did not opt along with the
factors or reasons that influenced their decision namely cost,
pain and suffer, duration, phobia, damage to the adjacent teeth
and the number of visits.
Data Analysis: The IBM SPSS version 21.0 was used for statistical
analysis. Descriptive analysis was carried out for frequency and
percentage calculation while independent T test and Paired T
test was used to analyze the effects of age, gender and
education with different treatment options. A p-value of (≤ 0.05)
was considered statistically significant.
RESULTS
In this descriptive analytical study 397 patients participated. 223
(563.2%) were males and 174 (43.8%) females. Most of the
participants, (57.9%) belonged to <40 years of age. Additionally,
207 (52.1%) were graduates and 197 (47.9%) undergraduates.
Furthermore, out of 397 participants only 26 (6.5%) were using
prosthesis for their missing tooth. When asked about a
treatment option that they will opt for replacement, FPD were
chosen by 235 (59.2%) participants, RPD by 97 (24.4%), Dental
Implants by 36 (9.1%) candidates while no treatment was opted
by 29 (7.3%) participants.
Moreover, cost or expense 361(90.9 %) was the most common
reason of not choosing a timely and particular treatment option
while pain and discomfort was recorded 230(57.9%), duration
64(16.1), compromised dental status such as weak abutment
80(20.1), phobia of dental treatment 96(24.1) and number of
visits by 4(6.34%) participants as described in Table-I.
The gender based distribution of treatment options are
presented in Table-II, the frequency of FPD, RPD, dental implant
and no treatment; opted by male was n=126 (56.5%),
n=57(25.5%), n=16(7.1%),n=24(10.7%) while in female n=109
(62.6%, n=40 (22.9%) , n=20(11.4%), n=5 (2.8%). Hence a
significant difference was found (p = 0.053).
Table -I: Factors Affecting Treatment Options in Relation to Prosthesis type (N=397)
Reasons of not choosing a
particular replacement option
Cost
n (%)
Pain and
suffer, n (%)
Duration
n (%)
Number of
visits, n (%)
Damage to the adjacent
abutments, n (%)
Phobia
n (%)
Fixed partial denture
70 (17.6%)
4 (1.0%)
4 (1.0%)
2 (0.5%)
76 (19.1%)
4 (1.0%)
Dental Implant
278 (70%)
8 (2%)
60 (15.1%)
2 (0.5%)
4 (1%)
5 (1.3%)
Removable partial denture
4 (1%)
214 (53.9%)
0
0
0
75 (18.9%)
Reason of opting No treatment
9 (2.30%)
4 (10%)
0
0
0
12 (3%)
Total
361(90.9%)
230(57.9%)
64(16.1%)
4(6.34%)
80(20.1%)
96(24.1%)
Naseer Ahmed et al Isra Med J. | Vol 13 - Issue 1 | Jan – Mar 2021
26
Table-II: Gender based distribution of Prosthetic treatment
options, (N=397)
Type of prosthesis
Gender
Total
(N)
p
value
Male n(%)
Female n(%)
Fixed Partial Denture
126 (56.5%)
109 (62.6%)
235
0.05
Removable Partial
Denture
57 (25.5%)
40 (22.9%)
97
Dental Implant
16 (7.1%)
20 (11.4%)
36
No treatment
24 (10.7%)
5 (2.87%)
29
Total
223 (100%)
174 (100%)
397
Similarly, when education level was compared with treatment
options such as FPD, RPD, dental implants and no treatment: The
frequency in undergraduate was n=100(52.5%), n=61(32.1%),
n=4(2.1%) and n=25(13.15) while in graduates n=135(65.2%),
n=36(17.3), n=32(15.4%) and n=4(1.9%). Hence, a significant
difference (p = 0.020) was seen subsequently as mentioned in
Table-III.
Table -III: Education level and treatment option consideration,
(N=397)
Type of prosthesis
Education level
Total
P
value
Undergraduate
n (%)
Graduate
n (%)
Fixed Partial
Denture
100 (52.6%)
135 (65.2%)
235
0.020
Removable Partial
Denture
61 (32.1%)
36 (17.3%)
97
Dental Implant
4 (2.1%)
32 (15.4%)
36
No treatment
25 (13.15)
4 (1.9%)
29
Total
190
207
397
The analysis of treatment options and age < 40 years was also
carried out as depicted in Table IV, 40-50 years and > 50 years
comparison revealed no significant difference (p= 0.75). The
majority 235 participants chosen FPD while RPD by (97) and
dental implant (36), no treatment by (29) subsequently.
Table -IV: Comparison of age groups and treatment options,
(N=397)
Type of
prosthesis
Age
Total
(N)
p
value
< 40
years (n)
40-50
years (n)
> 50
years
(n)
Fixed partial
denture
145
64
26
235
0.75
Removable
partial denture
40
36
21
97
Dental Implant
24
12
0
36
No treatment
21
8
0
29
Total
230
120
47
397
DISCUSSION
Out of the total 397 patients, 93.5% were new and had no
previous experience of any kind of prosthesis. For a single
missing tooth, a number of different treatment modalities are
present; with each having its own merits and demerits. As in this
study, patients were evaluated for three different types of
prosthesis against different influencing factors namely cost, pain
and suffer, duration, number of visits, compromised abutments
and phobias. Our study demonstrated that 59.2% of the
participants preferred fixed partial dentures as compared to
removable partial dentures (24.4%), dental implants (9.1%) and
(7.3%) preferred no treatment option which is in
correspondence with a common impression in restorative
dentistry is to go for a fixed prosthesis whenever possible15.
Pommer et al evaluated the advantages of fixed vs. removable
dentures and concluded that the majority (54%) of the
participants felt that Fixed prosthesis were less annoying in the
mouth, 49% were convinced that they were better esthetically,
43% equated fixed dentures with natural teeth in terms of
function and 38% said that they did not feel like foreign bodies16.
Also, a patient rarely accept or desire a removable partial
prosthesis as a replacement option for a single missing tooth15
which is also in agreement with a study by Satpathy et al17, in
which 71.24 % of the total patients expressed discontent with a
removable option as a replacement for missing tooth.
In our study, a significant difference was found (p = 0.05)
suggesting that gender can be one of the patient factors
affecting the decision for the selection of a particular treatment
option. As females are more inclined towards their facial
esthetics whereas males do not give importance to their
appearance much, for them comfort and functionality are prime
concerns. Also, it is difficult for them to take out time from their
busy schedule as in our study striking 10.7% of the males opted
for no treatment as an option which is in accordance with
Natarajan et al18 who concluded that 46.64% male reported lack
of time as the primary reason for not opting any treatment. Our
results were also in agreement with Al-Quran et al19 who
reported a significant difference (p=0.016) between both the
gender in removable partial denture group. Also, in a study by
Shrirao et al11, males opted for the reason “do not feel the need
of treatment” more than females; 11.6% as opposed to 5.5%.
Ahmed et al20 also concluded that esthetic rather than functional
factors determine an individual's subjective need for the
replacement of missing teeth.
In addition to this, the level of education also played a role in
opting for a treatment modality. In our study, a significant
difference (p = 0.020) was found between education levels in
regard to treatment modality chosen which is in accordance
with Al-Quran et al19 who also found significant differences
between levels of education with treatment modality chosen (p
= 0.024). Acceptance of RPD was also decreased with the level
of education (p = 0) in another study by Pommer et al16. In our
study 42.2% of the undergraduate group either opted for a
removable prosthesis or no treatment as an option; a merely 2%
opted for implant as an option as compared to graduate ones
where only 19% opted for removable or no treatment suggesting
the role of education could affect the patient's awareness
regarding the options and importance of tooth replacement17.
On the other hand the analysis of treatment options and age <40
years and 40-50 years and > 50 years the comparison revealed
no significant difference (p= 0.75) which is in contrast with a
study in which significantly higher percentage of young
participants rejected removable dentures (P =0)18. Whereas Al-
Naseer Ahmed et al Isra Med J. | Vol 13 - Issue 1 | Jan – Mar 2021
27
Quran et al19 reported no statistically significant differences
between age groups and preferred treatment option (p <0.05).
When patients were asked about factors affecting their choice
of treatment modality overall, cost or expense of the treatment
was the most common deciding factor for choosing a particular
treatment option (90.9 %), which is in accordance with the
research carried out by Samuel et al5, Shetty et al6, Nayana et
al12 and Mohapatra et al21where 70%, 33.5%, 43.2% and 52% of
the participants cited high expenditure as the most determining
factor for a particular choice of prosthesis.
Moreover in our study pain and discomfort was accounted as the
second most important factor (57.9%) followed by phobia of
dental treatment (24.1%), damage to the adjacent abutments
(20.1%), duration (16.1%) and the number of visits by (6.34%)
participants. These findings corroborated with other studies
including Kvale et al22, who found that 40% of the adult
population has been reported to be afraid of dental treatment.
Similarly, Shrirao ND et al11 reported fear of dental treatment as
the second most common deciding factor (17.1%) in their study.
Additionally, as far as Fixed dental prosthesis is concerned,
damage to the adjacent teeth (19.1%) and cost (17.6%) were
reported as the common reasons for not choosing Fixed Partial
denture which is in accordance with Mohapatra et al21 who
concluded that 52% of participants in his study had an objection
to the cost of FDP. It is a proven fact that fixed dental prosthesis
is associated with the risk for additional endodontic treatment
and discomfort because of hypersensitivity and difficult access
for plaque control15.
In the case of implant supported prosthesis 70% of the
participants reported cost as the most influencing factor
affecting its selection followed by duration (15%) which is
corroborated in other studies including; Tepper et al23 who
reported that 80% of the participants felt implants were too
expensive, whereas 15% complained the time for healing and
prosthodontic management was too long. In other
investigations conducted by Pommer et al16 and Satpathy et al17,
high costs were mentioned by 83% and 59% of the total subjects
while long treatment time by 16% and 26%. Hence these two
factors along with need for surgical procedure are major
disadvantages of implant therapy as reported in
literatute16,17,23,24. Similarly Bragger et al found that the required
time span for FPD reconstruction was (3.23±2.64) months
though more time was needed for the reconstruction with
dental implants (5.94±3.29) months and also concluded that
implant reconstruction is cost effective in cases of single‐tooth
replacement compared with conventional FPD24,25.
Furthermore, in this study 24% of the participants opted
removable dentures as a replacement option for single missing
tooth which is in accordance with Al-Quran et al19 in which 34%
of the subjects preferred RPD due to its cost-effectiveness.
Contrarily, 53.9% participants reported pain and discomfort
while 18.9% reported phobia as a major concern for not
selecting removable dentures this prosthesis which is also
supported by other from Shetty et al6, who reported 42.4%
subjects with discomfort and pain and Satpathy et al17 reported
71.24 % participants experiencing pain while wearing single
tooth replacing removable dentures.
In our study, only 7.3% opted no treatment, and they reported
pain and suffer (10%) as one of the leading cause for it followed
by phobia (3%) and high cost of treatment (2.3%) which in
contrast with Trepper et al23 in which 25% felt that replacing
missing teeth was only necessary if the gap was visible and with
by Shetty et al6, in which 33.5% reported treatment to be
expensive, 24% reported lack of time and 22% did not feel any
need to replace the missing tooth6.
Therefore, in a nutshell it is stated that there are multiple factors
that influence the selection of single tooth replacement
restorative options which must be put into Consideration during
the treatment planning phase as they directly affect the
patient’s acceptance of a particular option. In addition, patient’s
knowledge and awareness about the merits and demerits of
different treatment options also play an important role in
outcome of restoration.
CONCLUSION
The replacement of missing tooth is based on multiple factors
amongst fixed partial denture, removable partial denture and
dental implants, among which duration of treatment and cost
are the most common influencing factors considered by the
patient. Additionally, patient’s education and awareness level
did affect the choice of treatment options.
AUTHOR’S CONTRIBUTION
Ahmed N: Data analysis, Data interpretation, Critical review
Shakoor M: Conceived idea, Designed methodology, Manuscript
writing, Literature review
Alavi FB: Manuscript writing, Literature review
Naz A: Critical review, Final review
Masood S: Manuscript writing
Irfan AB: Data collection and Compilation
Disclaimer: None.
Conflict of Interest: None.
Source of Funding: None.
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