Patient Knowledge and Expectations Prior to Receiving Implant-Supported Restorations Anja Nyland Simensen, DDS1/Olav E. Bøe, DDS, MSc2/ Einar Berg, BDS, Dr Odont3/Knut N. Leknes, DDS, PhD4 Purpose: Implant dentistry has revolutionized the treatment of partially and completely edentulous patients. The aims of this study were to explore what made patients choose implant treatment and their prior knowledge and expectations of this treatment option. Materials and Methods: A study population of 117 subjects was selected from 248 referred possible candidates for implant therapy. The subjects answered a questionnaire regarding implant dentistry prior to professional consultation at two hospital/university-based centers and one private implant center. Results: In most cases, the choice of treatment was motivated by expectations of improved chewing/function (46.0%), appearance (19.5%), or both (18.6%). Improved chewing/function and improved appearance were rated “very important” by 96.5% and 86.1% of patients, respectively. Surprisingly, 57.4% reported that the cost of treatment did not play a role in their decision. Only 6.0% claimed to have much prior knowledge about the treatment and 33.6% had a realistic perception about the length of anticipated service. Patients first received implant-related information primarily (62.9%) from dentists, and 75.2% thought their dentist gave the most useful information. Significant positive associations were found between knowledge about the treatment, the need for periodic professional oral health maintenance, and expected treatment time. Conclusion: Patients seek implant therapy primarily to improve chewing function and esthetics, whereas cost seems to be less important. Prior to treatment, many patients lack precise information on the importance of necessary implant-related hygiene measures and implant longevity. The general dentist is the primary source of information. Int J Oral Maxillofac Implants 2015;30:41–47. doi: 10.11607/jomi.3511 Key words: dental crowns, dental health services, dental implantation, dental implants, dental prostheses, dental restoration, dentist-patient relations, implant-supported dentures, interprofessional relations, patient expectations

D

ental health plays an important role in people’s perception of esthetics and general well-being.1

1Private

Practice, Bodø, Norway. Professor Emeritus, Faculty of Medicine and Dentistry, Department of Clinical Dentistry – Dental Research, University of Bergen, Bergen, Norway. 3 Professor Emeritus, Faculty of Medicine and Dentistry, Department of Clinical Dentistry – Prosthodontics, University of Bergen, Bergen, Norway. 4Professor, Faculty of Medicine and Dentistry, Department of Clinical Dentistry – Periodontics, University of Bergen, Bergen, Norway. 2 Associate

The project was presented at the general session for the International Association of Dental Research in Seattle, Washington, March 20, 2013. Correspondence to: Dr Knut N. Leknes, Faculty of Medicine and Dentistry, Department of Clinical Dentistry – Periodontics, University of Bergen, Årstadveien 19, N-5009 Bergen, Norway. Fax: +47-55-58-64-92. Email: [email protected] ©2015 by Quintessence Publishing Co Inc.

As personal prosperity increases, more patients are willing and can afford to invest in preserving or acquiring “flawless teeth.” Implant dentistry has therefore become an accessible option for an increasing number of patients globally. In Norway alone, more than 18,000 dental implants were placed in 2012, and the total number placed in Europe exceeded 4.7 million (personal communication, Nobel Biocare, 2013). Indications for implant dentistry include anchorage for removable or fixed prosthetic reconstructions and orthodontic appliances.2 The functional, esthetic, and psychosocial conditions of patients with missing teeth that are not restored or replaced with conventional removable dentures are improved when the restorations are supported by implants.3,4 Nevertheless, the success of treatment critically depends on informed, motivated patients, as effective execution of oral hygiene measures is essential for stable long-term results.5–7 Because in most cases implant treatment is an elective procedure, complete disclosure regarding the procedure and therapeutic alternatives must be provided.8 The International Journal of Oral & Maxillofacial Implants 41

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Simensen et al

MATERIALS AND METHODS

were older than 18 years were included. All patients who subsequently accepted treatment received implant-supported single crowns or implant-supported fixed partial dentures. Data collection included two periods: May to September 2009 and March 2011 to March 2012. A questionnaire including 37 multiple-choice questions, together with an informed consent form, was mailed to the participants. The questionnaires included items on demographics and smoking (Table 1), referral of the patient and prior knowledge of implant dentistry (Table 2), and expected outcomes (Table 3) and had to be completed before their evaluation at the implant centers/clinic. The items were selected by the research group, all of whom were experienced in regard to the questions raised in the present study. The questionnaire was subsequently tested on 20 randomly selected individuals to ascertain that all items were easily understood, and any necessary corrections were then made. In this study, data from 18 relevant questions are reported. The exact wording of the questions and their predetermined categories are shown in Tables 1 to 3 and Fig 1. The primary outcome variable in the present investigation was which factors affected the choice of treatment involving dental implants. In the first part of the study, the questionnaire was distributed; the patients returned the questionnaire at the next appointment. In the second part of the study, this practice was changed to improve the response rate. Stamped return envelopes were provided to facilitate participants’ return of the completed questionnaires by mail, and reminder telephone calls were made. All patients were provided with detailed information about the study. If they agreed to participate, their signed informed consent form was returned together with their completed questionnaire. The study was conducted in accordance with the Helsinki Declaration of 1975, as revised in 1983 and 2008. The study protocol was approved by the Institutional Medical Research Ethics Committee (049.09), University of Bergen, Norway.

Study Protocol

Statistical Analysis

Table 1  Distribution of Demographic Variables and Smoking Habits Among Respondents Variables

Women

Men

Total

Sex

58

59

117

Mean age (y)

47.2

54.0

Marital status Married/cohabiting Single

43 15

38 21

81 36

Education Primary school Secondary school University Other

7 19 27 5

11 29 16 3

18 48 43 8

Smoking Smoker Nonsmoker

17 38

13 41

30 79

Patients must not only be informed about the prospective longevity of the reconstruction and the economic aspects of treatment, but also potential surgical risks and complications.9 Most reports have retrospectively reviewed patient opinion following completion of the prosthetic treatment.10–15 In one report, more than 90% of patients were very satisfied with function and esthetics 10 years after treatment, and 89% would recommend implant dentistry to friends and family.14 In a recent publication, it was concluded that implant dentistry improved function and enhanced self-esteem and social life and thus increased overall quality of life.16 Few studies have focused on the patient’s level of information prior to professional consultation for implant dentistry.1,17 Accordingly, there is a critical need for further studies exploring this level of information. The aims of the present study were to explore what made patients choose implant dentistry and the degree of their knowledge and expectations for this option prior to treatment.

The population from which the study sample was recruited included patients who were either referred by a general practitioner or who self-referred to one of two hospital/university-based implant centers (Haukeland University Hospital Department of Oral Surgery; Specialist Clinic, University of Bergen School of Dentistry) or to a private clinic dedicated to implant dentistry (Tannlegesenteret Madlagaarden, Stavanger). These clinics were selected for their potential to recruit patients for the study. Only patients who had never received a professional consultation regarding implant dentistry, had never received a dental implant, and

A precision estimate, based on a pilot study,17 was used to calculate an adequate sample size.18 The estimate was defined as half the length of the confidence interval (CI) and determined to be at most 0.1. Based on the worst-case value of the estimate of P (0.5), the minimum sample size would be 97. Since n = 117 in the present study and the estimates of P were all different from 0.5, the precision will be better than 0.1 (< 0.1).18 The material collected was described by frequency tables and cross-tabulations for categorical variables and by means and standard deviations for continuous

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Simensen et al

Table 2  Sources of Information and Prior Knowledge About Implant Dentistry Question How did you get an appointment to a specialist?

How were you first informed?

Where did you get the most useful information?

Has anyone in your social circle (friends/family) been treated with implants?

Have you heard about experiences with implants from friends or acquaintances? How much do you know about treatment with implants?

Measure

n (%)

General dentist Direct contact Other Dentist Friends/acquaintances Newspapers/magazines Other Dentist Television/radio/Internet Relatives/friends/acquaintances Other dental personnel Other Yes No Do not know Yes, positive experiences No Yes, negative experiences Little knowledge Intermediate knowledge Much knowledge

97 (82.9) 18 (15.4) 2 (1.7) 73 (62.9) 14 (12.0) 12 (10.3) 17 (14.7) 85 (75.2) 5 (4.4) 5 (4.4) 4 (3.5) 14 (12.4) 36 (30.8) 41 (35.0) 40 (34.2) 33 (28.2) 81 (69.2) 3 (2.6) 75 (64.1) 35 (29.9) 7 (6.0)

Table 3  Treatment Outcomes and Expectations Question How do you rate the importance of the functional result?

How do you rate the importance of the esthetic result?

How long do you think the treatment with implants will take from first examination until your treatment is completed?

How long do you think you can retain your implants?

Is the cost decisive/or critical for your choice of treatment? How do you believe the cleaning of the implant will be compared with natural teeth?

variables. The chi-square test of independence was used to test the associations between pairs of categorical variables. Cells with frequencies that did not satisfy the requirements for testing such associations were combined appropriately before the testing was done. The t test for independent samples was applied to test the difference between mean values in two groups. If more than two groups existed, one-way analysis of variance was used, followed by the Bonferroni post hoc test if the overall P value was less than the chosen level of significance of .05. The null hypothesis in all comparisons was that there were no significant

Measure

n (%)

Of major importance Of some importance Of little importance Of major importance Of some importance Of little importance 1 year 6 months 1 month 1 day Other The rest of my life More than 25 years Between 21 and 25 years Between 10 and 20 years Cost not decisive/critical Cost decisive/critical Similar to natural teeth More will be required than natural teeth Do not know

111 (96.5) 4 (3.5) 0 (0.0) 99 (86.1) 11 (9.6) 5 (4.3) 10 (8.8) 61 (54.0) 19 (16.8) 3 (2.7) 20 (17.7) 62 (54.9) 11 (9.7) 2 (1.8) 38 (33.6) 66 (57.4) 49 (42.6) 77 (67.0) 13 (11.3) 25 (21.7)

Chewing/function: 52 (46.0%) Appearance/esthetics: 22 (19.5%) Chewing and appearance: 21 (18.6%) Others: 18 (15.9%)

Fig 1   Answers of 113 patients to the question: “What was the most decisive/critical factor for your choice of treatment option?”

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Simensen et al

differences between the groups. An average of 1.5% of the data were missing. The statistical software package SPSS (version 15.0, SPSS Inc) was used for data analysis.

RESULTS Study Population

A total of 248 subjects satisfied the inclusion criteria. In the first part of the study, the questionnaire was distributed to 139 subjects, and 69 responded (49.6% response rate). In the second part, the questionnaire was distributed to 109 subjects, and 48 responded (44.0% response rate). The total study population thus consisted of 117 subjects, and the overall response rate was 47.2%. Of the 117 respondents, 58 were women. The mean age for women was 47.2 years, and the mean age for men was 54.0 years. A majority of respondents were married or cohabiting (69.2%), whereas a minority were single (30.8%). A total of 56.4% had primary school or secondary school as their highest level of education, whereas 36.8% had obtained a university degree (Table 1). Only age showed a borderline significant difference between sexes (P = .047).

Factors in Choice of Treatment

The most decisive/critical factors in the choice of implant dentistry were satisfactory chewing/function (46.0%), appearance/esthetics (19.5%), or both factors with equal importance (18.6%; Fig 1). The category “other” (15.9%) encompassed longevity of the implant, treatment time, cost, and cleaning.

Referral Sources and Previous Knowledge of Implant Dentistry

All responses regarding the source of information and prior knowledge about implant dentistry are shown in Table 2. Most (82.9%) of the respondents were referred by a general dentist; 15.4% were self-referred. The most common source of information about implant dentistry was the respondent’s dentist (62.9%). Almost 25% of the respondents were first informed through friends/acquaintances or newspapers/magazines. Useful information regarding implant dentistry was provided most often by dentists (75.2%). Only a few responses indicated other sources, including television, radio, or the Internet. According to the respondents, 30.8% of those within their social circle (friends/family) had received dental implant treatment, and their experiences were almost exclusively positive. A total of 64.1% of the respondents reported that they had little knowledge about implant dentistry, whereas 29.9% believed they had intermediate knowledge.

Treatment Outcomes and Expectations

Responses regarding treatment outcomes, longevity, cost, and implant hygiene are shown in Table 3. The importance of a functional outcome was rated as very important or important by nearly all respondents (96.5%). The importance of an esthetic outcome was rated somewhat lower (86.1%). The respondents’ assessments of the time needed to complete the treatment ranged between 1 day and 1 year. However, most (54.0%) believed that 6 months would suffice. Similarly, their beliefs about how long the implants could be supported ranged between 10 and 20 years (33.6%) and the rest of their life (54.9%). More than half of the respondents (57.4%) claimed that cost was not a decisive or critical factor in the choice of treatment. Regarding implant hygiene, 67.0% of the respondents believed that the implants would require the same level of hygiene as natural teeth, and 11.3% answered that implants would require even greater hygiene measures.

Differences Between Clinics and Observation Intervals

In terms of factors affecting choice of treatment, there were no significant differences between patients treated at private vs university/hospital-based implant centers (P = .580). There were no differences between responders in the first and second observation intervals (P = .750).

Relationships Between Primary Outcome and Other Variables

Marital status, education, and smoking habits did not have a significant effect on the most decisive/critical factor for choice of treatment option (P values ranged from .09 to .21). Women tended to be more ambiguous in their responses than men in that they tended to favor categories such as “other” (which was combined with “longevity”) and “chewing plus appearance” (P < .001). Analysis of variance showed significant age-related differences among the response categories (P < .001). The most important finding in the post hoc analyses was that those who responded with “appearance/esthetics” were significantly younger (13.5 years) than those who responded with “chewing/function.” Other significant age differences were between “appearance/ esthetics” and “chewing/function” (P = .018), “appearance/esthetics” and “chewing/appearance” (P = .026), “chewing/function” and “others” (longevity included) (P = .022), and “others” and “chewing/appearance” (P = .029). Those who listed chewing function as their main reason for choosing implant treatment regarded the esthetics as less important than those who gave other responses (P = .010).

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Other Relationships

Cross testing of the questions “How much do you know about dental implants?” and “How do you believe the cleaning of the implants will be compared with natural teeth?” showed a positive and significant relationship (P < .001). Similarly, a borderline significant relationship was found between the former variable and expected treatment time (P = .046).

DISCUSSION The aims of this study were to explore what made patients choose implant dentistry and their prior knowledge and expectations of this treatment option. In brief, patients chose implant dentistry because this option was primarily believed to improve function and secondarily esthetics. The cost of treatment was less critical than expected. Overall, the patients exhibited a low knowledge level about implant dentistry, and general dentists were the main source of information. Some limitations of this study are acknowledged. It should be noted that the response rate of only 47.2% was relatively low. One of the reasons may be that the questionnaires were sent by mail to the participants, who were supposed to complete and return them to the clinic at their first examination. However, many forgot to bring the completed questionnaires. Despite the inclusion of stamped envelopes, which were provided during the second part of the study to allow the participants to return the completed forms by mail, and telephone calls to remind patients, the response rate did not improve. The main problem with low response rates is the risk of selection bias. This may be critically important if the questions are of a sensitive nature or might be construed to imply a possible disgrace toward the responder, but few if any of the present questions seem likely to be of this nature. The fact that the results of a pilot study17 compare well with the present findings also strengthens the assumption that bias seems unlikely. The reasons for recruiting patients from both hospital/university centers and a private clinic dedicated to implant dentistry and the use of two observation periods were to secure a sufficiently large representative sample. The use of two geographic settings would tend to compensate for the fact that indications for implant dentistry may vary considerably among dentists from different regions of Norway. The patients were most often referred to the centers by general practitioners, who are distributed throughout the western region of Norway. Consequently, patients from both urban and rural areas were recruited. The fact that the choice of treatment option was unaffected by the type of clinic or time of recruitment indicates that these approaches

did not cause bias and justifies the pooling of all subsamples in the analyses. The nature of the definitive prosthetic treatment was not recorded. However, the common denominator for all patients was that they had accepted being possible candidates for implant dentistry. Also, at the time of data collection, the nature of the possible implantsupported prosthetic restoration, as well as whether a restoration would be possible or appropriate, was unknown. It therefore seems unlikely that this circumstance would seriously influence the patients’ level of knowledge regarding this treatment option. For practical reasons as well as expedience, the point of view of the patients on implant dentistry was not explored. However, all questions were formulated as the result of a discussion among experienced clinicians. Furthermore, on average, only 1.5% of the data were missing, and there were no more than four missing data for any variable. This indicates that the questions were easily understood. In line with previous findings,1,10 the almost unanimous primary reason for choosing implant dentistry was chewing/function. These results tally with the fact that the main clinical benefit gained with an implantsupported restoration is greatly improved function, particularly when compared with conventional removable dentures. More at odds with clinical reality, 20% of the respondents indicated that esthetics was the exclusive reason for seeking implant therapy. Also, the importance of the esthetic result was rated very highly, although lower than functional importance. However, satisfactory esthetics with implant-supported restorations may be compromised by unfavorable implant positions and diameters, bone resorption, impaired gingival relationships, or visibility of access holes. Nevertheless, in a 10-year follow-up study, 90% of patients thus treated were satisfied with both chewing function and esthetics.14 This indicates that functional aspects are of overriding importance and that esthetic imperfections caused by such clinical problems appear to be reasonably well tolerated. Typically, another important aspect in the choice of implant dentistry is cost. In the present study, 57% of the respondents stated that cost was not a decisive consideration. One reason for this perhaps unexpected result may be that respondents had already chosen this treatment when answering the questionnaire and that those who thought the cost might be too high had already rejected implant dentistry in favor of alternative treatments. Treatment involving dental implants is, with a few notable exceptions, not reimbursed by the Norwegian health or insurance systems. This means that patients must meet the total expense of such treatment. The International Journal of Oral & Maxillofacial Implants 45

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Simensen et al

However, Norway is one of the richest countries in the world, and its population is to a large extent motivated and able to pay for oral health and comfort. There are two important exceptions to this general rule: Replacement of teeth lost because of periodontal disease or to accidental trauma is reimbursed to approximately 40% of the cost by the Norwegian Social Security System. This may have contributed to the lesser importance of the cost of dental restorations with implants in this population. The estimated cost of restoring a lost single tooth with an implant and a crown in Norway is equivalent to US$4,600. Even 60% of such an amount still represents a considerable expense. Possibly more universal results regarding cost have been published in two representative Austrian studies, in which approximately 76% of the participants thought that high cost was the strongest argument against implant dentistry.19,20 The discordance between patients’ concepts of what can realistically be achieved and the clinical realities supports the hypothesis that the level of knowledge among the general public about implant dentistry is low and that information is vitally needed. This was also recognized from the responses; almost two-thirds of patients admitted that their knowledge was limited. The fact that the most decisive factor in choosing implant dentistry was unaffected by respondents’ education leads to the same conclusion. The patients’ limited knowledge was further mirrored by the responses regarding the longevity of prosthetic reconstructions supported by dental implants. As many as 55% of the respondents optimistically believed that they would last for life, and none that they would last fewer than 10 years. These responses must be seen in relation to the fact that the mean age of the present patient sample was 51 years, and life expectancy in Norway is around 80. However, the rate of implant loss has been reported to be approximately 5% after 5 years and 13% after 10 years in function,21 indicating that implant survival is not absolutely assured, even in a short-term perspective. Other comparable results show that at least every 10th implant is lost over a 10-year period and that 30% to 40% of patients with implants suffer peri-implantitis.5,6 For this reason, it is imperative to communicate this information to patients so that they acquire realistic expectations. It is equally important to communicate realistic expectations of alternative treatments, so that the patient can make an informed choice of therapy. The patients’ unsatisfactory level of knowledge was further evidenced by their incomplete understanding of the importance of implant-focused oral hygiene measures, as 22% had no opinion and 67% believed that implants needed no additional hygiene measures compared with natural teeth. However, those who

claimed to be most knowledgeable were more likely to respond that the implants needed more cleaning than natural teeth. The responses regarding how long the patients believed the treatment would take until it was completed revealed considerable uncertainty. However, this is understandable in view of the many options and procedures that are currently available. For the same reason, a referring general practitioner cannot—and should not—give specific information with regard to treatment time. Of considerable interest is the fact that 63% of the respondents reported that the dentist was their primary source of information about implant treatment and that 75% felt that the dentist gave the most useful information. Surprisingly, only five respondents received the most useful information from television/radio or the Internet, which one might assume to be a convenient source of pertinent information. Limited access to the Internet is an unlikely explanation, as 80% of the Norwegian population used this service daily in 2011.22 One can but speculate about the differences in results had the respondents’ mean age been lower (mean age, 51 years). Similar findings were published recently.1,23 Others have reported considerably smaller proportions (17% to 36%) of patients who were first informed by dentists about implant treatment.8,24,25 These reports are 15 to 25 years old and thus were conducted before the Internet was in common use. Therefore, the information must have originated from other sources. Zimmer et al25 reported back in 1992 that 77% of respondents first heard about implants from media and friends. These diverging results may possibly be a result of cultural differences. Regardless, information from the media and friends can be of varying quality and is often popular. Thus, it must be regarded as a positive finding that most patients receive information from professional sources. In the present study, only 36 of the respondents had heard about experiences with dental implants from friends and acquaintances, and with three exceptions, all experiences were positive. The fact that so few communicated negative experiences is of obvious interest and corresponds with the findings of a study in which 89% of the patients reported that they would recommend this treatment to friends and acquaintances.14 Similar results have been reported by several others.10,11,13,26

CONCLUSIONS In the surveyed population, the decision to undergo implant treatment was primarily motivated by chewing/function and appearance/esthetics. The cost of

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treatment was not a decisive factor. Dentists were the primary source of information about implants. Prior to implant treatment, patients lacked information on the importance of effective execution of oral hygiene measures and implant longevity.

ACKNOWLEDGMENTS The authors are grateful to Dr Inger-Johanne Nyland for managing the study; to Drs Kristin S. Klock, Maren J. Rishaug, and Harald Nesse for their considerable contributions to the pilot study; to Drs Knut A. Selvig and Ulf M.E. Wikesjö for reviewing the manuscript; and to Ms Randi Sundfjord for data management. The authors report no conflicts of interest related to this study. The study was self-funded by the authors and their institution.

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11. Buch RS, Weibrich G, Wegener J, Wagner W. Patient satisfaction with dental implants. Mund Kiefer Gesichtschir 2002;6:433–436. 12. Eli I, Schwartz-Arad D, Baht R, Ben-Tuvim H. Effect of anxiety on the experience of pain in implant insertion. Clin Oral Implants Res 2003;14:115–118. 13. Vermylen K, Collaert B, Lindén U, Björn AL, De Bruyn H. Patient satisfaction and quality of single-tooth restorations. Clin Oral Implants Res 2003;14:119–124. 14. Pjetursson BE, Karoussis I, Bürgin W, Brägger U, Lang NP. Patients’ satisfaction following implant therapy. A 10-year prospective cohort study. Clin Oral Implants Res 2005;16:185–193. 15. Johannsen A, Wikesjö UME, Tellefsen G, Johannsen G. Patient attitudes and expectations of dental implant treatment—A questionnaire study. Swed Dent J 2012;36:7–14. 16. Johannsen A, Westergren A, Johannsen G. Dental implants from the patient’s perspective: Transition from tooth loss, through amputation to implants—Negative and positive trajectories. J Clin Periodontol 2012;39:681–687. 17. Rishaug MJ, Simensen AN, Klock KS, Bøe OE, Nesse H, Leknes KN. Implant treatment: An assessment of factors having an impact on the choice of therapy. Nor Tannlaegeforen Tid 2010;120:1036–1041. 18. Daniel WW. Biostatistics. Basic Concepts and Methodology for the Health Sciences, ed 9. New York: John Wiley & Sons, 2010:192. 19. Tepper G, Haas R, Mailath G, et al. Representative marketing-oriented study on implants in the Austrian population. I. Level of information, sources of information and need for patient information. Clin Oral Implants Res 2003;14:621–633. 20. Pommer B, Zechner W, Watzak G, Ulm C, Watzek G, Tepper G. Progress and trends in patients’ mindset on dental implants. II: Implant acceptance, patient-perceived costs and patient satisfaction. Clin Oral Implants Res 2011;22:106–112. 21. Pjetursson BE, Brägger U, Lang NP, Zwahlen M. Comparison of survival and complication rates of tooth-supported fixed dental protheses (FDPs) and implant-supported FDPs and single crowns (SCs). Clin Oral Implants Res 2007;18:97–113. 22. Statistics Norway, Norwegian Media Barometer from 2011. Available at: www.ssb.no/medie/sa128/internett.pdf. Accessed September 16, 2012. 23. Pommer B, Zechner W, Watzak G, Ulm C, Watzek G, Tepper G. Progress and trends in patients` mindset on dental implants. I: Level of information, sources of information and need for patient information. Clin Oral Implants Res 2011;22:223–229. 24. Akagawa Y, Rachi Y, Matumoto T, Tsuru H. Attitudes of removable denture patients toward dental implants. J Prosthet Dent 1988;60: 362–364. 25. Zimmer CM, Zimmer WM, Williams J, Liesener J. Public awareness and acceptance of dental implants. Int J Oral Maxillofac Implants 1992;7:228–232. 26. Nkenke E, Eitner S, Radespeil-Tröger M, Vairaktaris E, Neukam FW, Fenner M. Patient-centred outcomes comparing transmucosal implant placement with an open approach in the maxilla: A prospective, non-randomized pilot study. Clin Oral Implants Res 2007;18:197–203.

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Patient knowledge and expectations prior to receiving implant-supported restorations.

Implant dentistry has revolutionized the treatment of partially and completely edentulous patients. The aims of this study were to explore what made p...
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