Patients’ Perspectives of Grafting Materials in Implant Dentistry: A Qualitative Analysis
Year: 2021
Type: article
Abstract: INTRODUCTION Limited alveolar ridge height and width is a challenge in implant dentistry. Ridge augmentation is frequently considered before or simultaneously during implant placement. Grafting may entail harvesting bone from an extraoral or intraoral source and placing it on the jaw site, where an implant is later installed. Another possibility is through the foresight of socket preservation after the extraction of teeth. The possible materials used for augmentation or grafting are autogenous bone, derived from humans, or an allograft harvested from another person, either cadaver sourced from a bone bank or bone from living human donors, typically from hospital patients who have undergone elective total hip replacement surgery.[1] Although autogenous bone grafts are believed to be the most ideal for bone regeneration procedures,[2] the donor site morbidity, the limit of donor sites’ availability, the need for another surgery, as well as the potential, unpredictable resorption are among the shortcomings.[3] Therefore, bone substitute materials as a replacement for autogenous bone grafts are being increasingly used,[4] such as grafts from another species (xenogenic grafts), or synthetically produced grafts (alloplastic materials). Allogeneic grafts in their two formats, freeze-dried bone allografts (FDBA) and demineralized freeze-dried bone allografts (DFDBA), can be used with the advantage of the availability of sufficient amounts; these have predictable results with no additional donor site surgery.[5] Host incompatibility, potentially contaminated specimens, and possible disease transmission are the potential disadvantages.[5] Xenograft materials have been used with great success. Bio-Oss® (Ed. Geistlich Soehne, Wolhusen, Switzerland), from Bovine, is heat-treated and chemically extracted to eliminate the organic components while maintaining the typical architecture of cancellous bone.[6] Porcine bone use has also been reported to be as efficient as bovine-derived bone, particularly in sinus lift procedures.[78] Synthetic bone graft materials have also been developing, mostly made from hydroxyapatite or other calcium phosphate minerals, with natural minerals similar to those in human bone. With the increased use of dental implants by the profession, there is an increasing need for grafting, and there is consequently a need to understand patients’ attitudes and assess their decision-making process regarding the choice of grafting materials in implant dentistry. An individual’s belief, choice, and accordingly related behaviors may be influenced by their ethnic background, social and religious beliefs.[9] It is well established that religious and cultural factors are known to impact health-care delivery. We, therefore, need to keep in mind that the patients we treat bring along their individual cultural, religious, and spiritual influences. In this regard, the impact of religious practices and adherence to religious and cultural traditions may directly impact choices and influence treatment decisions.[10] In 2013, Ericson et al. surveyed religious and spiritual leaders of the six largest religions worldwide on the issue of human- and animal-derived products, and they indicated that it is a necessity to obtain informed consent specifically for any animal- or human-derived products for several religions since they may oppose the treatment. However, some religious groups may find some acceptable materials tolerable if there are no alternatives.[11] An investigation on the choices of grafting materials globally is important, since regions are becoming progressively multiethnic due to diversity, modern migration, and relocation flow. Accordingly, our understanding of such issues in health-care settings is becoming increasingly vital (WHO, Health of Migrants).[12] Consequently, our knowledge regarding multiculturalism, spirituality, and religion, regardless of what part of the world we are in, impacts our competence in providing an informed choice of the treatment options that we can provide and deliver. Several studies have used surveys and questionnaires to evaluate patients’ preference for grafting materials used in dentistry,[131415] but a qualitative analysis of patients’ choices of grafting materials in dentistry, to our knowledge, has not been conducted. This study’s primary objective was to evaluate the cultural, psychological, and religious influences on the choice of autografts, allografts, xenografts, and synthetic bone products for grafting procedures, in individuals with alveolar bone ridge deficiency who received implants as part of their treatment plan. In this study, using a qualitative methodology, we aim at evaluating the influences on the choice of grafting materials of individuals with similar cultural and religious beliefs. The research question is: Are there influences or factors that affect grafting material choices in implant dentistry? MATERIALS AND METHODS The qualitative methodology used in this study should increase our understanding of how patients perceive and understand their experiences; in this context, the choice of graft materials in implant dentistry. The interaction with a purposively chosen sample may also increase our understanding of the factors that influence the choice of grafting materials. The study was conducted at the Faculty of Dentistry, Kuwait University. The data were collected using detailed qualitative interviews; these interviews encouraged interviewees to freely converse in their own style and speed, while using the principles of the constant comparative method of the grounded theory (G.T.).[16] This is a systematic collection method of analyzing qualitative data to construct models or theories to suit people’s actions and reactions. The study protocol was approved by the Health Science Center Ethical Committee at Kuwait University. After informed verbal and written consent had been obtained, the interviews were conducted. The participants were assured anonymity of the interview data. To eliminate potential influences and bias, the interviewers were not involved, at any stage, in the clinical management of the interviewed patients. The interviews were conducted in an open conversational style, focusing on an individual’s feelings, perceptions, and thoughts about using the main available types of grafting materials, namely autografts, allografts, xenographs, and synthetic grafts. Interviewees were given explicit feedback, which helped in providing the kind of information needed to answer the research question. The interviewees were made up of a purposeful sample from patients who received grafts as part of their implant treatment. The individuals were explicitly (purposeful sample) recruited, because they had had the experience of receiving an implant and grafting. Patients’ willingness to participate in the study formed part of the inclusion criteria. The participants comprised a heterogenic group of males and females of different ages, educational backgrounds, and occupational status. The patients not requiring grafting or known to have a psychological disorder were excluded. Similar prompt questions were asked using an interview guide designed and agreed by all authors; additional questions were triggered by responses, and these were permitted as the interview’s policy.[17] The in-depth interviews also encouraged participants to communicate freely in their style and tempo.[18] The interview questions focused on the graft implant materials received during the process of implant installation. The interviews were audiotaped and transcribed verbatim. The transcriptions and analyses were made in a parallel process and terminated when saturation was reached.[16] In this regard, the topic was not broad in scope; the data were rich, firsthand, obvious, clear, and easily obtained, and, hence, saturation was confirmed by the tenth interview.[19] Also, given that the unit of analysis was the grounded theory, which studies thoughts and actions, the number of participants would be of lower significance, and instead it is the content and quality of the data that is significant. Verbatim transcripts were carefully read several times to understand the accurate meaning of the text. All interviews were conducted in Arabic and transcripted with forward–backward translation for linguistic validity. A descriptive and explorative approach was used.[16] The thematic analysis described by Braun and Clarke in 2006 was used to identify themes regarding spirituality.[20] Braun and Clarke’s (2006) six-stage approach was used to manage and evaluate data to understand the role of choice and influences related to the research questions. The themes were based on their importance in capturing essential aspects regarding the research question rather than quantifying measures. This involves familiarization with data, generating preliminary codes, searching for broad themes, reviewing themes, and ultimately identifying the themes and then reporting. To ensure trustworthiness of the data, the investigators, who are all bilingual (English and Arabic), thoroughly and systematically read and analyzed the data, in consideration of the research question. For rigor and validity, a code book was developed, which went through many iterations in an inductive process before the final version was agreed upon by the researchers.[21] The consistency of codes and themes was confirmed by independently reviewing the responses to ensure parallelism, reliability, and accuracy in identifying the themes. Two researchers trained in qualitative thematic analysis met several times to discuss and review codes and themes (investigator triangulation) until a consensus was reached. Reliability was tested using the formula reported by Miles and Huberman (1994),[22] and 84.6% reliability was attained. A qualitative research characteristic is that the investigation and analysis are not reliant on statistical power or quantification. The reliance is on the words and narrative and not the statistical data. RESULTS The three themes that emerged were: Grafting material preference Religious and psychological influences Trust the doctor and cost influences The respondents were aged 25 to 60 years; the choices of grafting materials in implant dentistry data did not show significant disparities, and the three emerged themes seemed to correlate. It is customary for qualitative data presentation to include direct quotations (in italic) from the participants to exemplify themes. THEME 1: GRAFTING MATERIAL PREFERENCE There was a general preference for autografts; however, the allografts’ choice was met with reluctance in some instances and it was deeply felt in other instances. There was a belief that autografts would have more enhanced performance and outcomes than other types of bone substitute: “I assume the one that is grafted from your own body would work better in your own body.” “It’s native to your body, so it was already part of your body, and it worked there, so when moved to another part of your body, it seems it would work there better than it would with something that’s foreign such as the animal” (Participant 2). Also, from another participant, “Okay, I think for me based on nothing, but I think, own bone from another more to (Participant The of body was the for the of It was in an bone graft that can be is from a human being to a human the can be in or if the are from a human being donor to a human being it be which the body not (Participant There were in preference in choice and allografts, and the seemed to be more “I allograft materials other types of because it is derived from human natural bone or (Participant There were choices based on the potential of autografts any other bone substitute are the by grafting it from your body because it two (Participant There was a narrative from those who had no issues with allografts, in and The and that since it is it be better more “I think that the human materials can well with the bone more than the other two types of (Participant Also, “I that the bone grafting material that can be is from a human being or from a person, because it be which the body not (Participant A preference for bone was in this “I to the from own body it from a human (Participant The for allograft choice is that it has the potential than other bone and is accordingly more to be “I that the human materials be well with (Participant Also, “I think that the human materials can well with the bone and then the materials, which in the as the are similar to (Participant there was some of of also be from using a bone graft from a human (Participant There was total for and bone material “I it from a body or from an animal” (Participant There was also a of other than autografts and allografts due to the belief of their “I that synthetic and materials not be well with I think the be the in quality and of the materials in (Participant participants made their choice based on a of Although with these all possible grafting materials were however, the preference had and This preference was more than synthetic bone substitute “Okay, synthetic I think the being an organic would be more similar to human organic I think the being an organic would be more similar to human organic (Participant 2). The other of preference was in this of to the graft from a if it is available if not to the graft from a synthetic (Participant However, there was some preference for “I material human because are than the human (Participant An of preference the three was choice be the bone graft from own body, choice be the bone graft from an bone and choice be the synthetic graft (Participant The for the choice was not clear, as in this preference “I think allograft and Xenograft are better than (Participant THEME AND religious, and spiritual are which may or may not be to religious There were many that to choice, based on religious, cultural, and psychological “I using materials, from or any (Participant The as was the choice of the or if I had I think the if to me have to the (Participant Another “I the of a part of an (Participant However, this preference was grafting material derived from with of “I using bone graft derived from a human body, but I can using a graft of that is derived from such as but not (Participant This was by another no using the bone graft but I the bone graft because of religious (Participant that the source be was also “I the materials no about the source of human bone but there are as to the source of materials, which be derived from (Participant The was in the of this who on how influences their “I because of religious if it was not using because the religious aspects have a great influence on (Participant A similar was also described in this is to think about I it from the because of religious as it is in (Participant It was also in the of preference of synthetic materials, if a substitute was the “I the because of religious I the synthetic (Participant in about it was or the was to from religious a religious about (Participant This religious influence on choice was confirmed in a two “I it from the because of religious as it is in but I can to the bone graft from a bone (Participant Also, the choice of the or if I had to I think the (Participant from the religious there was also the psychological influence or to one or another substitute: “I think there is a that are not in one or I but think to because when think of a think of a part of that in a the that your is in (Participant 2). The on psychological influence were also for “I can a bone but I a human body bone (Participant described the issue as the of an that the “I think if not religion, I would by the I would not an part on (Participant Religious and psychological influences were also described the religious and the cadaver bone graft is in “I allograft bone grafting materials, from human donors, because a psychological human cadaver bone (Participant The of was also I had some of tested as well and it because I have a that Also, we of the there is a possibility that be from bone or (Participant There was also the influence for the synthetic materials I what to the after some it it with something in our (Participant The of synthetic products was also but of the of the synthetic bone, and not (Participant and related to donor in autografts were is the that with grafting during the and (Participant 2). Two issues were one of which is the psychological of a bone from their “I think the from of is that I any part of body to be (Participant The was and related to the donor “I to the bone graft from any part of own body, because I to any in another part of body other than the implant (Participant Also, “I if it affect body it not affect your body, but it be I this (Participant THEME AND Trust is an and in health-care patients that their is related to the which is to that of the who use their the of I (Participant The belief that the was was in this is more in their and I their more than (Participant The was explicit and since this was to with the if it was their have to use human if the doctor using as the most for (Participant The in the the patients’ in many “I would with the if they me that the that a of materials is the I the of material the doctor and I if the doctor has to me the types of materials before the bone grafting (Participant The patients should be given the choice of the grafting material that and which is the and of informed the doctor me the choice, to what I would suit me I that the synthetic is the for I any knowledge about that before this interview from that there are three types of bone grafting (Participant The choice for was as their “I think the doctor their to the possible for their and that any of materials be analyzed and before the dental implant treatment is the what is for the individual (Participant The was rather that it was not to all but the the was being by and the or of a did not to be all to should I the of I (Participant The and psychological influences seems to while and the however, it was also on what they were is to doctor on which is the if they the bone graft from a human being bone I it if they the bone graft from an bone graft or from a from a synthetic material discuss with as to which one is the for (Participant There was also a in the that it assume if being then they have been tested that they would all In a similar the importance of the material has been used “I would to if it is a or a (Participant The and own and research were also “I have to and then which of the given types of materials is the for (Participant the cost of the grafting material influences their that did not as an aspects have no influence on (Participant Also, in cost to me The final is the most issue to and is to be and with the treatment (Participant However, there was some that the more the the better it is: “I think the be the most (Participant Also, “I would assume that the more the more and the the (Participant the other one was to find more about the material cost was there were cost involved, I would research more what the the options (Participant 2). The however, was mostly and outcomes rather than in cost to me The final is the most issue to and is to be and with the treatment (Participant This qualitative study the choice of grafting materials in implant dentistry, with a research question of religious, and psychological factors influence the choice of grafting material in implant To our knowledge, this is the qualitative of this The three themes that emerged that there are preference and which are of importance and which should more of our patients’ cultural and religious particularly when products are in with a or The choice and as well as the of have been reported to be influences on and were reported after with grafts in patients with with grafts were also however, they were in with the chosen allograft bone material to donor site materials, there was a with autogenous and and this was similar to what was reported by et al. 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Institutions: Kuwait University, University of Nevada, Las Vegas
Language: English
Subfield: Oral Surgery
Field: Dentistry
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W3187828273