Assessment of Current Knowledge, Awareness and Attitude Towards Dental Implants as a Treatment Option for Replacement of Missing Teeth in Riyadh, Saudi Arabia

Objective: To assess the current level of knowledge, awareness, and attitude towards dental implants as a treatment option for the replacement of missing teeth in Riyadh, Saudi Arabia. Material and method: A random sample of 1000 Saudis (including both males and females) from Riyadh, Saudi Arabia, was selected. In accordance with research ethics codes, informed consent was obtained from research participants before approaching them via a structured online questionnaire using Google Forms; additionally, questionnaires were distributed in public places and promoted on social media to be answered anonymously. The data were coded, tabulated, and analyzed using Statistical Package for Social Sciences (SPSS; IBM Corp., Armonk, NY, USA) software. Descriptive statistics were calculated. Results: Around more than half of the study population (56.3%) opted for dental implants as a treatment option if they had to choose among the various options, and for those who did not choose dental implants, high cost was the major factor. The Pearson correlation between dental implant information and whether it was provided by their dentists and age was significant, and the majority of those who heard about dental implants are between the ages of 30 and 50. Also, it was noted that many of the participants who were working in the government sector (49.5%) had dental implants and were aware that dental implants as a treatment option were provided by their dentist when compared to those who were working in the private sector (12.1%) and the unemployed (24.7%), and this difference was statistically significant. Conclusion: It was also observed that there is inadequate knowledge regarding the longevity of dental implants, and participants who were working in the government sector had dental implants and were aware that dental implants as a treatment option were provided by their dentist when compared to those who were working in the private sector, and around half are not aware that dental implant treatment can be covered by insurance.


Introduction
The field of dentistry is constantly advancing, and as new treatments to restore, remediate, or rehabilitate natural dentition are introduced, patients' treatment options are growing by the year. One of these options is dental implants, which were proposed first in 1965 by Brenmark, who initiated experimental studies to understand and explain the concept of osseointegration [1]. Ever since that era, the fields of both implantology and dental prosthetics have garnered significant attention from the public as a fixed option to remediate the loss of dentition and become more viable. Throughout the years, an increase in dental implant prevalence has been noted in several areas in the United States of America (USA) [2]. Dental implants have become the preferred option for restoring missing teeth due to their high success rate and excellent longevity [3][4][5]. Additionally, dental implants in both edentulous and partially edentulous patients increased their quality of life and enhanced their masticatory functions [6]. Moreover, they have enhanced denture preservation, stability, functional effectiveness, and quality of life since they were first used to treat edentulous patients, where new age changes such as the use of zirconia implants, use of various implant modifications, digital protocols can prove to be very helpful [7][8][9]. Dental implants made of zirconia might be an alternative to titanium ones, which could exhibit a dark, unattractive color through the surrounding soft tissues. Zirconia has the ability to sufficiently eliminate plaque on the implant and surrounding tissues, which is essential for soft tissue healing and implant success at the bone level [9]. However, due to a lack of awareness and knowledge, some patients may overlook dental implants as a treatment option [10]. Despite the previously done studies on the knowledge and awareness of dental implants in Saudi Arabia [11], limited

Inclusion and exclusion criteria
All the Saudi citizens in Riyadh, aged 18 and above, were included in the study. Other nationalist dentists, dental specialists, and dental students with dental knowledge were included in the study. Validation of the questionnaire: A modified version of a pre-existing questionnaire was used. Questions are obtained from the existing research studies, and a few questions were added that were assessed for face validity by an experienced prosthodontist ( Table 1).

Statistical analysis
The data were coded, tabulated, and analyzed using Statistical Package for Social Sciences (SPSS) software version 23 (IBM Corp., Armonk, NY, USA). Descriptive statistics were calculated. There is insufficient knowledge and awareness among the Saudi Arabian population about dental implants as a treatment option for replacing missing teeth in Riyadh.

Results
Out of 1182 responses, 1135 were included after the application of the exclusion criteria. The majority of participants were female: 75.4% were female and 24.6% were male (   Knowledge and awareness of dental implants 40.2% of the participants were aware of the availability of various treatment options for the replacement of missing teeth, like removable appliances, fixed appliances, and dental implants. More than half of the study population, around 56.3%, have opted for dental implants as a treatment option if they had to choose among the various options, and for those who did not choose dental implants, high cost was the major factor. Around 83.3% didn't have a dental implant, which was statistically significant. Although the majority of them (51.2%) chose that a dental implant is a screw, approximately 26.2% stated that they have heard about it but cannot clearly explain what it is. Although many have responded correctly that implants are placed within the jawbone, around 26.4% don't know where they are placed, and an alarming number of participants (63.4%) don't know what the implant is made of. More than half of the study participants are unaware of which portion of teeth the dental implant replaces. About 57.8% of people don't know about the longevity of dental implants, and when it was compared with the various professional results, statistically significant results were found. Also, 34.2% are not aware of the reason for the failure of dental implants, and among the various reasons implant type and quality were considered to be a major factor for implant failure, only 17.7% believe that dental implants fail due to poor oral hygiene. The difference in knowledge regarding the etiology of the failure of dental implants among the various professions is also found to be statistically significant (

TABLE 4: Responses related to the knowledge of dental implants
The Pearson correlation with respect to the information on dental implants and whether it was provided by their dentists and the age was significant, and the majority of those who heard about dental implants fall in the age range of 30 to 50 years. Also, it was noted that many of the participants who were working in the government sector (49.5%) had dental implants and were aware that dental implants as a treatment option were provided by their dentist when compared to those who were working in the private sector (12.1%) and the unemployed (24.7%), and this difference was statistically significant. The majority of the study participants are not sure if the dental implant treatment is provided by their dentist. A vast majority of the participants think that oral surgeons are the most qualified to place dental implants. Also, around half of the study population is not aware that dental implants can be covered by their insurance plan.

Attitude toward dental implant treatment and willingness to learn
60.5% think that dental implants need special care and hygiene as compared to natural teeth. Dentists were the primary source of information for approximately 41.9% of respondents, followed by the internet (15%), friends and relatives (13%), social media (10.6%), newspapers/magazines (0.4%), and television (0.7%). The majority of them (54.6%) are willing to learn more about dental implants ( Table 5).

Discussion
Since the inclusion of dental implants as a treatment option, dental practice has undergone a significant transformation. With long-term success and improved patient satisfaction, dental implants are growing in popularity as a treatment option among the general public. Riyadh, Saudi Arabia, has seen a rise in the acceptance and popularity of dental implants over the past several years. Therefore, this cross-sectional study aimed to assess and evaluate the level of knowledge and awareness of dental implants as a treatment option for the replacement of missing teeth among the Saudi population in the central region of Saudi Arabia. Our assessment included participants who exceeded the age of 18, had Saudi citizenship, and lived in Riyadh, with the exclusion of dental professionals and dental students. The inclusion of dental professionals and dental students was made with the aim of ensuring the garnering of representative responses from the general public.
Unlike previous cross-sectional studies in Saudi Arabia, our obtained data indicated that the major source of information regarding dental implants chosen by our sample is dental professionals, followed by the internet. This is opposite to the results of Abdulrahman Alajlan et al. [12], where friends and relatives were the main sources of information (38%, 31%, and 30%, respectively), highlighting a change in the public's knowledge of the last few years. In this study, the participant's level of awareness regarding dental implants as a treatment option was 40.2%. In previous studies done by Al-Johany et al. [13] and Al-Rafee et al. [4], which were done in Riyadh, Saudi Arabia, they found a higher level of awareness among participants (56% and 66%, respectively). In 56.5% of cases, dental implants are the preferred treatment option for replacing missing teeth. Surprisingly, 55.5% of the participants knew the proper location of the dental implant, in contrast to other studies done by Al-Rafee et al. and Al-Johany et al., in which 51% and 50.1% of the participants did not know the proper location of the dental implant, respectively [4,13].
Correspondingly with previous assessments of the public's knowledge of dental implants, the most significant factor preventing patients from undergoing dental implant procedures is the financial cost of the procedure, followed by a fear of surgery, which is similar to Al-Rafee et al., Hosadurga et al., and Mously et al. [4,7,14]. Additionally, the participants selected dental implants as the treatment they would opt for, followed by a fixed dental prosthesis in case of partial or full dentition loss. Studies have shown that the Saudi population in Riyadh has a huge knowledge gap regarding nearly every aspect of dental implants [11,13], and the public's knowledge and awareness level regarding the usage of dental implants as a tooth replacement alternative need to be raised through educational programmes by dental care experts and specialists.
When asked about the material of dental implants, a significant number of participants (63.4%) admitted to a lack of knowledge, and 15.1% answered ceramics (7.4%), stainless steel (9.6%), and porcelain (4.5%). 29.6% of the respondents don't know the dental professionals who are most qualified to perform such procedures; this finding is in contrast with one of the research studies done by Kinani et al. in Jazan Province of Saudi Arabia [15], where the majority of the respondents said that only specialists can place dental implants. Furthermore, the participants also failed to answer questions regarding the longevity of dental implants, highlighting a need for dental professionals to educate the general public regarding the technical, surgical, and general knowledge of dental implants [15]. It is well noted that the long-term success of dental implants depends highly on maintaining healthy tissue around the implants. The peri-implant disease can be avoided with proper dental hygiene practices, such as using soft toothbrushes, interproximal brushes, hard plastic cleaning tools, and mouth rinses. The current study population (60.5%) agreed that dental implants require more special care and hygiene as compared to natural teeth [15]. The vast majority of the general public agreed that replacing missing teeth is critical. At the same time, the majority of them (44.3% of participants) stated that the high cost of dental implants is the reason they do not choose them as a treatment option. This finding is consistent with the three studies mentioned in the dental implant literature [16][17][18]. The majority of them (54.6%) are willing to learn more about dental implants. In their questionnaire-based study of the Nigerian population, Ajayi et al. [19] found that dental health professionals (41.5%) were the primary sources of knowledge on dental implants, followed by friends (17.7% of the study group). Only 14.6% of the subjects demonstrated awareness about dental implants, while 35% of the survey participants lacked this expertise. Additionally, those with higher education levels knew more about implants. Other significant disadvantages of implant treatment included higher costs and more surgical requirements. The replacement of anterior teeth with implants was chosen over posterior teeth by the subjects. However, even among responders with greater education levels, a lower awareness level was seen. Additionally, implant-based prosthesis replacement was not preferred because it was more expensive and required surgical intervention [19]. In contrast to other studies where dental professionals were found to have played a significant role in disseminating knowledge about this treatment modality, Sakshi et al., in their study on knowledge among undergraduate dental students on dental implants, estimated that 99% of the study group had prior knowledge about dental implants. This knowledge was primarily gleaned from audio-visual resources and the Internet. A maximum lifespan of 10 years was reported by 55.68% of students, while a 10-to 20-year lifespan was reported by 18.75%, and a lack of knowledge about this by 26.7% of subjects, respectively. Additionally, implant pricing played a significant role in this decision to pursue implants as a kind of treatment [20]. Only 32.5% of the study subjects in Mathuriya et al.'s questionnaire-based study of dental patients in Bhopal were aware of dental implants as a treatment option, and the majority of them were unaware of the procedure's details or the benefits and drawbacks of utilising dental implants [21]. Only 25.8% of the study cohort knew anything about dental implants, according to Kumar and Chauhan's assessment of 620 Indore, India-based participants' knowledge and awareness of dental implant use. The majority of patients who chose implants as a therapy option did so because of their superior aesthetics (70%). However, because of their expensive price, 70% of people also preferred not to replace their implantsupported prosthetics [22].
In a six-month study of 220 Nigerian participants, Gbadebo et al. [23] discovered that 71.1% of the cohort had no idea what dental implants were, while just 28.9% were aware of their availability. 13.3% of study participants opposed this course of treatment, whereas 22.6% preferred implant-based prostheses. However, 61.9% of respondents were unsure about this form of treatment. Following other sources, including audiovisual media, the Internet, and peer groups as secondary sources of information about dental implants, 68% of the participants cited dental professionals as the primary source [23]. According to Pommer et al., 79% of Austrians are in favor of receiving dental implant treatment [24]. In their investigation, Chowdhary et al. only found 23.24% awareness [25]. Various researchers from throughout the world have reported varying findings regarding people's understanding, attitudes, and general awareness of dental implants [26][27][28][29][30]. The acceptance and popularity of dental implants as a treatment option may be connected to the vast differences in dental implant knowledge between various nations. In Austria, 64% of patients were aware of implant treatments [31], followed by 27.7% in Turkey [32], 23.24% in India [33], and 66.4% in Saudi Arabia [13], according to studies looking at patient comprehension of dental implants globally. The American public has a high level of awareness of and favorable perceptions of dental implant therapy [34]. The way the public views and feels about implant therapy depends on the information source. The mass media is more likely to report on implant failures and malpractice, which could lower public support for the procedure. On the other hand, information from experts in dentistry and patients who have had implants may change how the public views and supports the procedure [35].
The clinical implication of the study tells that knowledge and awareness are tested in this study for the population which can help to generate a list of the points where the knowledge and awareness about dental implantology can be improved amongst the selected population. By telling about the benefits of the treatment by not having any effects on the adjacent tooth when we go for fixed partial dentures, we could increase the awareness amongst the individuals and so also insurance can be advocated amongst the middleclass people so that they can have the benefits of the treatment.
The limitations of the study are a very small sample population and consideration of only one geographical area. The findings of this research need to be confirmed by larger population investigations. Less awareness and information regarding implants is learned through literature or from the patient's dentist. As they play a significant role in further educating their patients about treatment alternatives, it is thought that brief courses should be offered to boost their understanding regarding dental implants.

Conclusions
Although the information regarding dental implants obtained from the study population is general, a number of conclusions can be drawn from our study. For starters, over the study population's lifespan, there has been a shift in the source of information from the internet, social media, and family and friends to dentists. It was also observed that there is inadequate knowledge regarding the longevity of dental implants, and participants who were working in the government sector had dental implants and were aware that dental implants as a treatment option were provided by their dentist when compared to those who were working in the private sector, and around half are not aware that dental implant treatment can be covered by insurance. Moreover, the results of our study also emphasized the need for providing more general and correct information to patients about dental implants and the substantial need for providing communitybased awareness programs regarding the knowledge and awareness of dental implants by undergraduate and postgraduate dental students.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Riyadh Elm University issued approval SRP/2022/112/770/728. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.