REFERRALS | BarbaraCastleDental

1 Abstract

This study investigates patient knowledge, attitudes, and perceptions surrounding dental implant treatments by analysing survey responses from a representative sample of a single dental practice. The survey examined various factors, including the understanding of the procedure, perceived costs, potential barriers, and facilitators to treatment acceptance. Moreover, the survey assessed the overall willingness of respondents to consider dental implant treatment. A robust dataset was collected and analysed using descriptive and inferential statistics. The survey was anonymous and used the Qualtrics platform to collect the data.

Key findings reveal that while a significant number of respondents are open to considering dental implant treatment, the comprehensive understanding of the procedure and its associated costs remains limited. The cost was identified as a predominant factor influencing treatment acceptance, suggesting a potential barrier due to financial constraints. Additionally, it was observed that patients have varied perceptions about treatment timelines, underlining the need for improved communication and patient education strategies.

The study also identified the dentist or operator as the primary source of information for over 70% of patients, underscoring the healthcare provider's role in patient education.

Interestingly, the location of the missing tooth emerged as an influential factor in the decision-making process for dental implant treatment.

This research offers valuable insights that could guide future strategies in patient education, cost management, and improved patient-professional communication. However, the study also acknowledges certain limitations, such as potential response bias, limited sample size, and generalizability issues, urging caution in extrapolating the findings to broader populations.

Overall, the study's findings contribute to a better understanding of patients' perceptions of dental implants and the factors that may influence their decision-making process, setting the stage for more targeted research in this area.

Key words: dentistry; survey; patient satisfaction

2 Introduction

Advances in dental implantology and its predictability have helped many people in improving their quality of life and standard of living (Pennington and Parker, 2012; Howe, Keys, and Richards, 2019). Dental implant treatment is a widely accepted method for replacing missing teeth, but it can be costly for patients (Takanashi et al., 2004; Carlsson, 2016). The financial cost is not the only barrier that patients face when considering implant treatment, and other factors such as stigma surrounding patients with blood-borne conditions and smoking status may also play a role in patients' reluctance to opt for implant treatment (Logan and Marek, 2006). Smoking can also negatively impact bone healing, increase the risk of implant failure and lead to higher rates of complications, that's why smokers are often advised to quit smoking before and after the implant placement (Klokkevold and Han, 2007; Chrcanovic, Albrektsson and Wennerberg, 2015). Older patients may also be less likely to opt for dental implant treatment due to concerns about their overall health and the length of the treatment process. They may believe that they are not healthy enough to undergo the procedure or that the recovery period will be too long (Kullar and Miller, 2019). Furthermore, patients may also be hesitant to undergo implant treatment due to cultural reasons, a lack of awareness about the procedure or a lack of knowledge about their eligibility for treatment (Al-Johany et al., 2010). Nonetheless, with the wide availability of information and the internet, patients have the opportunity to learn about the procedure. However, this often proves to be more problematic and confusing to the patient as every implant has its custom treatment plan with its associated risks, so it is imperative for the public to be able to access tailored advice from dental practitioners (Tepper et al., 2003).

A patient’s perception can at times be unrealistic and it is our responsibility as dental operators (AlSarhan et al., 2021) to manage expectations during the process of consent and to especially highlight any limitations that might be present (Farsai, 2017; Sanz, Azabal and Arias, 2022). An examination of patient perceptions regarding dental implants revealed that

they often view the treatment as a means of achieving normalization, leading to unrealistic expectations that the resulting prosthesis will closely resemble natural teeth (Kashbour et al., 2015).

In a qualitative study conducted by Kashbour, the experiences of patients with dental implants were examined through a literature review. The scope of the reconstruction and the number of implants required were found to greatly impact patients' experiences of the treatment process before and after. In contrast, patients who required more extensive work tended to focus on the functional benefits that the implants would provide. Notably, the study found that there was a lack of research on the perceptions of younger patients who were missing one or two teeth. As such, the study concludes that further investigation is needed to fully understand patients' perceptions of implant placement procedures (Kashbour, W. A., 2016).

Another key barrier to treatment is the pain of the surgery itself. Findings by Kashbour et al. suggest that patients in the UK may have overestimated the trauma associated with the procedure and underestimated the discomfort associated with the healing phase. Both issues could be covered in a tailored educational campaign (Kashbour et al., 2015).

Al-Johany et al. conducted a survey to assess patients' awareness of dental implants as a viable option for replacing missing teeth. The study found that only around 60% of participants had heard of dental implants. However, when questioned further, approximately 80% of those surveyed expressed a high level of interest and desired more information. Upon further analysis, it was revealed that the majority of participants who had heard of dental implants had obtained their knowledge from family and friends, and the information they received was often inaccurate. When asked about potential barriers to obtaining dental implants, the three most commonly cited reasons were cost, length of treatment, and fear of the surgery. This study highlights the importance of providing accurate and accessible information about dental implant treatment options to patients to alleviate misconceptions and fears associated with the procedure (Al-Johany et al., 2010).

Wang et al. conducted a qualitative focus-group-based study in Hong Kong, examining the perception of 28 participants about receiving dental implants. Findings from this study suggest that in this day and age, most patients have access to knowledge from a myriad of sources which is usually influenced by social media and the experiences of those around them. Participants had varying levels of understanding, and there was some misinformation detected, which reinforces the importance of widely educating the public on the pros and cons of dental implants. The researchers found that as well as cost, factors such as pain of the procedure, risks and complications, and lack of trust were identified as barriers to seeking a dental implant. Interestingly, the researchers also found that to overcome the issue of high prices, patients were seeking medical tourism which may or may not be advisable in some geographies with the varying scrutiny of laws and regulations. In the UK, we have seen similar dental tourism, with the widely criticised “Turkey teeth” recently appearing in the media (Misch, 2020). It is imperative we educate our patients about the risks associated with medical tourism and try to find local solutions to barriers we identify, via engaging both the public and commissioning policy-makers (Wang, Gao and Lo, 2015).

A survey conducted by P. Farsai aimed to evaluate the level of patients' perceptions regarding dental implant treatment. One noteworthy finding was that when asked if dental implants last longer than natural teeth, there was a notable disparity in responses between genders, with 76% out of the females surveyed disagreeing. This suggests that there may be significant differences in perception between genders. The study revealed that approximately 32% of participants held misinformation or unrealistic expectations regarding the outcomes of dental implant treatment. This highlights the importance of providing accurate and comprehensive information to patients to ensure that they have realistic expectations and an understanding of the treatment (Farsai, 2017).

Research by McCrea found that patients that were well informed at the start of the treatment, including about risks and complications, had more realistic expectations and this was statistically correlated with a high degree of satisfaction. The study also found a significant

relationship between the quality of interpersonal communication between patients and the dentist in determining the satisfaction level at the end of treatment. This learning from post treatment perception is essential for planning future treatments and helps form the basis of

encouraging dentists to provide research-based information to their patients via local education initiatives (Mccrea, 2017).

The aforementioned findings reveal a gap in patients' knowledge and understanding of dental implant treatment. To address this, it is of paramount importance to investigate the potential barriers to treatment acceptance among patients. This is an area poorly understood and further research is needed to gain a comprehensive understanding of patients' perceptions and decision-making processes in regards to dental implant treatment (John, Chen and Parashos, 2007).

2.1 Aims and Objectives

This study aims to investigate how a sample of the UK population perceives the obstacles and factors that facilitate or hinder receiving implant treatment. In the UK, the healthcare system is unique in that it includes both a private and a government-funded scheme called the National Health Service (NHS) banding. However, dental implants are not covered by the NHS bands, meaning that patients must pay for them out-of-pocket. As well as the expected financial barrier, this study aims to identify other contributing factors when accessing implant treatment.

By doing so, the results of the study can help in developing tailored healthcare campaigns that can improve access to implant treatment for all patients. This study's results could be beneficial for healthcare providers, policymakers, and patients, as they can inform the development of policies and programs that aim to make dental implant treatment more accessible for everyone. (Selvaranjan, Macmillan and Lewis, 2020).

3 Methodology

In this study, a quantitative research design was utilized to investigate the public's perception of barriers to receiving dental implant treatment in the UK. This investigation was conducted through a web-based survey.

3.1 Ethical Considerations

Before conducting this study, ethical approval was granted by Aston University’s Research Ethics Committee. All data were handled in line with the General Data Protection Regulation, 2018 (European Information commisisioners office, 2021). All data collected were anonymous and securely stored, ensuring that individual responses could not be linked back to the participant, thus preserving their privacy.

Participants were informed that their participation was entirely voluntary, about the purpose of the study, respecting their autonomy and ensuring their informed consent. Their rights as participants, including the right to withdraw at any time without facing any repercussions, were communicated meticulously.

3.2 Setting and Participant Recruitment

The study took place at Affinity Dental Clinic, a single-site dental practice located at 88 Town Square, Basildon, Essex, SS14 1BN.

The recruitment of participants was initiated by the researcher informing eligible patients about the ongoing research project during their visit to the practice.

The inclusion criteria for participants were as follows: privately registered patients over the age of 18 who had one gap or more in their teeth.

Exclusion criteria were established at the same level of clinical implant exclusion and included the following: patients who had been treated with bisphosphonates in the past 5 years, received radiotherapy to the jaw, undergone chemotherapy within the past 12 weeks, were immunocompromised, or had severe bleeding disorders.(Kullar and Miller, 2019). As well as patients who have had a dental implant treatment in the past as their opinions would be biased.

Patients who expressed interest in participating were subsequently provided with detailed patient information sheets (Appendix 1). These documents were designed to transparently outline the purpose, potential benefits, and implications of the study, enabling an informed decision-making process.

The survey link was emailed to interested participants for them to complete the study on their personal devices. Alternatively, if participants preferred, a tablet device (Samsung, SF, California) was provided with the survey pre-loaded on it.

3.3 Survey Design

To achieve the study objective, a thorough online survey was developed using Qualtrics (Qualtrics, Provo, Utah, 2005), an online survey platform widely recognised in academic and market research spheres. Screenshots of the survey are available in Appendix 2.

Informed consent was integrated into the online Qualtrics survey. Various question types, including multiple-choice, Likert scale, and closed questions, were implemented to ensure a comprehensive assessment of participants' perspectives. Additionally, features such as the ability for participants to navigate back and forth, the option to end the survey if they did not consent (skip logic), and mechanisms to ensure participants selected only one appropriate answer and did not skip questions were utilized. These features enhanced the survey experience and ensured data completion (Hamilton, Marshall and Broadbent, 2018).

3.3.1 Survey content

The survey was structured around several core themes that encompassed a wide range of areas related to dental implant treatment. The first component of the survey aimed to gauge the respondents' understanding of the dental implant procedure. This portion of the survey comprised questions targeting the depth and breadth of the respondents' knowledge, ranging from their understanding of the surgical procedure to the postoperative care required.

The second section of the survey was dedicated to gaining insights into the perceived costs of dental implant treatment. This section had questions about the respondents' awareness of the cost, their perception of value for money, and potential sources of funding or reimbursement, such as personal savings or dental insurance.

The third segment of the survey was constructed to identify potential barriers that might prevent people from opting for dental implant treatment. These included psychological factors such as fear of pain or surgical procedures, societal factors such as perceived stigma, and practical considerations like the time required for recovery.

In contrast, the fourth section focused on perceived facilitators, factors that might encourage individuals to opt for dental implant treatment. These included the accessibility and availability of comprehensive information about the procedure, the presence of dental insurance coverage, the proximity of qualified dental professionals, and more.

Lastly, the survey also attempted to measure the overall willingness of respondents to undergo dental implant treatment. This was gauged using a series of questions that explored the respondents' perceived need for the treatment, their willingness to consider it as an option, and their readiness to undertake the procedure in the near future.

3.3.2 Data Collection and Statistical Analysis

Data collection took place over a four-week period between June and July 2023 and surveys were sent to patients on working days only, namely Monday to Friday 9 am to 5 pm.

Upon completion of the data collection period, the data were cleaned to remove incomplete responses and extracted from Qualtrics. The data were then imported into OriginPro 2023 software(Origin Pro, Northampton, MA, 2023) for graphical visualization and statistical analysis including descriptive statistics and hypothesis testing.

Normality test (Shapiro-Wilk) was conducted on the dataset to check on the whether the data was normal or not. That would further indicate the use of parametric or non-parametric tests.

Kruskal-Wallis Analysis of Variance (ANOVA) followed by a Chi-square test were used on different sections of the data set.

For questions 4, 5, 6, and 8, the ordinal responses were changed to numerical data for graphical representation into a box-plot, as follows:

• Not at all = 1

• Slightly = 2

• Very/highly = 3

• Extremely = 4.

The fusion of both descriptive and inferential statistical methodologies ensured a comprehensive analysis of the collected data, aiding in the understanding of the patients' knowledge, attitudes, and perceptions surrounding dental implant treatment.

4 Results

4.1 Statistical Analysis

100 patients were originally contacted and 40 responses were recorded for the survey. Of those, two did not consent, and one was a wholly incomplete response, leaving 37 responses for analysis.

Normality test (Shapiro-Wilk) was conducted on the dataset and normality was rejected, hence non-parametric statistical tests were used.

4.1.1 Age Distribution

The initial question in the survey gathered information about the age of the respondents. Figure 1 displays the distribution of age groups among the respondents, with the largest group falling into the 65 and above category. This finding suggests that there is a significant representation of older adults within the sampled patient population, who may be more likely to have gaps in their teeth. Alternatively, it could also indicate their willingness to participate in the survey. Regardless, this demographic factor holds great importance as it can influence the specific dental care needs and necessitate customized approaches when providing education about implant treatment.

On the contrary, the youngest group of 18-24 did not record any responses out of 11 that were contacted. This suggests either a low probability of these patients having gaps in their teeth or a reduced willingness to participate in the survey.

The pattern generally observed was that as age increased, so too did the number of participants who completed the survey about filling tooth gaps. However, this trend was not observed in the two youngest age groups. This discrepancy could be due to the fact that data collection occurred exclusively on weekdays, when individuals from these age groups

are typically at work. It's plausible that they would be more likely to consider seeking implant treatment and participate in such surveys on weekends.

6 4 2 0

(13.5%)

(21.6%)

(10.8%)

(21.6%)

(32.4%)

25-34 35-44 45-54 55-64 65+

Age (Years)

Figure 1. A bar chart of age distribution amongst the survey respondents. The central numbers shows the absolute number of responses as well as the percentage.

4.1.2 Smoking Risk

The second question aimed to assess patients' understanding of the smoking risks associated with implant treatment. This is a vital consideration given the well-documented detrimental effects of smoking on oral health, particularly the success of dental implant procedures.

Upon analysis, the data indicated that the majority (30/37) of the sample that took the survey, accounting for 81%, demonstrated awareness of the associated risk. This is a

positive finding, suggesting a certain degree of pre-existing knowledge regarding the impact of lifestyle factors on dental health among our patients.

However, it is crucial to note that almost a fifth (7/37) of respondents expressed unawareness of the specific risk smoking poses to dental implant treatment. This non-trivial proportion of our patient population with a gap in their understanding underscores the need for proactive measures to address this lack of awareness.

The findings suggest that a focused discussion regarding the risks of smoking, specifically in relation to dental implant procedures, may need to be incorporated into our practice's oral health education efforts. This could be done through individual counselling, educational materials in the waiting room, or informational segments during routine check-ups.

4.1.3 Duration of Treatment

The third question of the survey aimed to assess patients' expectations regarding the timeframe for dental implant treatment. The distribution of responses is shown in Figure 2. This question holds immense importance as it allows our practice to understand patient perspectives and manage expectations accordingly.

Upon analysing the responses, it was observed that the majority of the patients surveyed 32% (12/37) expected a timeframe of 1-3 months for dental implant treatment. This indicates a general perception that aligns with a typical treatment course, considering the necessary procedures, healing periods, and follow-ups associated with dental implants.

However, a large proportion of patients 24% (9/37) expressed the expectation that the treatment could be completed in less than a month. On the other hand, the smallest proportion of patients 19% (7/37) envisioned a longer timeframe, estimating the procedure to span 3-6 months. These variations highlight the diversity in patient expectations and knowledge about dental implant treatment timescales.

y c

6 4 2 0

(24.3%)

(32.4%)

(18.9%)

Not sure Less than 1 Month 1-3 Months 3-6 months

Duration of Treatment Perception (Months)

Figure 2. A bar chart showing the distribution of patients' awareness of the typical treatment length for implant treatment. The central numbers show the absolute number of responses as well as the percentage.

Interestingly, 24% (9/37) of the respondents were not sure of a typical treatment length. The varied responses underscore the need to individualize patient education and manage expectations appropriately during consultations. Each patient's treatment plan and timeframe are subject to their unique oral health conditions, personal circumstances, and the specificities of their dental implant procedure. Therefore, it's imperative to clarify that the duration of the treatment may differ from their initial expectations.

These findings emphasize the importance of transparent communication and patient education in our practice. Implementing such strategies will ensure that patients are well

informed and that their expectations accurately align with the reality of dental implant procedures, thereby fostering satisfaction and trust within our patient community.

Using a Kruskal-Wallis ANOVA to analyse the difference between the number of participants per perception of duration of treatment was not found to be statistically significant (p-value = 0.391).

4.1.4 Effect of Number of missing teeth, Cost, Age and Process familiarity

Combined graphical representation of the data for questions 4 (number of missing teeth), 5 (cost), 6 (age) and 8 (process familiarity) is shown in Figure 3.

25% to 75%

Min to Max

Q4 Q5 Q6 Q8

Median Line

Figure 3. Box-plot figure of data for Q4, Q5, Q6, and Q8. The boxplot shows the median response shown by the thick black line, and the box itself represents 25% to 75% of the dataset. The whiskers represent the min and max responses, which in this case are also outliers.

Combined graphical representation of the data for questions 4, 5, 6 and 8 is shown in Figure 3. Q4 enquired about influence of number of missing teeth, Q5 about importance of

cost, Q6 about familiarity with the process and Q8 about influence of age when pursuing implant treatment.

Overall, it can be seen that for Q4 and Q5, the median answer was 3, or very influential/important. For Q6 and Q8, the median answer was 2 or slightly familiar / influential. The specific results of each question will be discussed in more detail in the following sections.

Using a Kruskal-Wallis ANOVA it was found that the medians between these four different questions was found to be statistically significant (p-value=0.0014). This indicates that the respondents’ value certain parameters when making the decision for implant treatment more than others, and this difference is indeed significant. The median ranking shows that cost is the most significant parameter when deciding whether or not to go for implant treatment, which may not be very surprising.

4.1.4.1 Influence of Number of Missing Teeth

62% (23/37) of the respondents selected the number of missing teeth as extremely influential (4) or highly influential (3) when deciding whether or not to pursue dental implant treatment. This indicates that for a significant portion of the sample patient population, the number of missing teeth is a key determinant in their decision to opt for dental implant treatment. This could be due to a range of reasons, from functional concerns such as eating and speaking to aesthetic considerations and overall quality of life.

The data revealed that 19% (7/37) of respondents considered the factor of the number of teeth missing as 'not influential' in their decision to get dental implants. An equal number of respondents rated this factor as slightly influential. This subset of the patient population may

perceive dental implants as unnecessary, or they may rely on other factors to determine their treatment decisions, highlighting the important of patient education.

4.1.4.2 Importance of Cost

The subsequent query in the survey delved into the significance of cost in patients' decision making process regarding dental implant treatment. This question is of paramount importance, considering that financial considerations often play a critical role in healthcare decisions.

Upon data analysis, it was observed that a minority of the respondents, 11% (4/37), reported that cost was 'not influential' in their decision-making process. This subset of patients may have other priorities or financial resources that make the cost of the procedure a less significant factor.

However, the majority of the respondents indicated that cost held varying degrees of influence on their decision to opt for dental implants. Specifically, 24% (9/37) classified the cost as 'slightly influential', indicating that while they do consider the cost, it is not necessarily the primary factor in their decision-making process.

The data further revealed that a considerable portion of our patient population, totalling 65% (24/37), reported cost as either 'highly influential' or 'extremely influential' in their decision making process. This suggests that for a substantial part of the sample patient population, the financial implications of dental implant treatment are a significant determinant in their choice of treatment.

4.1.4.3 Process Familiarity

When patients were asked about their familiarity with the treatment process, a notable diversity in the level of familiarity amongst our patient population became apparent. A significant subset, 43% (16/37), professed to be 'not familiar at all' with the dental implant treatment process. This indicates a sizeable fraction of our patients could be operating with a

potentially limited understanding of the procedure. Such a lack of familiarity could impact their ability to make thoroughly informed decisions and manage expectations regarding their dental healthcare.

Similarly, the second largest group of the respondents, approximately 27% (10/37), self reported as being 'slightly familiar' with the process. While this group seems to possess a rudimentary understanding, their knowledge could likely benefit from further augmentation and refinement to promote a more comprehensive grasp of the treatment.

On the higher end of the familiarity spectrum, an aggregate of 30% (11/37) of respondents claimed to be 'very familiar' or 'extremely familiar' with the dental implant process. This suggests a strong foundational knowledge within this group, potentially facilitating informed decision-making and the management of realistic expectations regarding the treatment outcome.

4.1.4.4 Influence of Age

Upon examination of the responses, 30% (11/37) of respondents stated that age was 'not at all' a factor in their decision.

Furthermore, a noteworthy proportion of respondents, 38% (14/37), considered age as 'slightly' influential. This suggests that while age may play a role in their decision-making process, it is not necessarily the deciding factor.

Meanwhile, a total of 32% (12/37) of respondents viewed age as 'highly' or 'extremely' influential in their decision to opt for dental implant treatment. This group clearly places substantial weight on age as a determinant in their dental healthcare decisions.

4.1.5 Overall Health Perception

In Question 7, the survey explored patients' self-rated overall health status, a subjective but impactful measure linked to health-related behaviours, healthcare utilisation, and treatment outcomes. The results are shown in Figure 4.

(51.4%)

(29.7%)

(10.8%)

(2.7%)

(5.41%)

Excellent Good Average Poor Terrible

Overall Health

Figure 4. A bar chart showing the frequency distribution of respondents’ perception of their overall health, rated from excellent to terrible. The central numbers show the absolute number of responses as well as the percentage.

The analysis revealed that the majority of respondents rated their health positively, with 11% (4/37) considering their health as 'excellent' and 51% (19/37) as 'good'. This positive health perception is encouraging and suggests that a large proportion of our patients may be more

inclined to pursue dental implant treatment if they believe they are more fit to undergo the procedure.

However, it was noteworthy that almost 30% (11/37) of respondents rated their health as 'average', indicating a moderate self-perception of health. Additionally, a total of 8% (3/37) of the surveyed patients categorised their health as 'poor' or 'terrible'. This group represents individuals who perceive their health negatively, which could potentially impact their healthcare engagement and outcomes.

4.1.6 Information Source

The next question on the survey explored patients' preferred sources of information when desiring to learn more about dental implants, an inquiry aimed at understanding their information-seeking behaviours and the trustworthiness of different information sources.

Figure 5 shows a pie chart displaying the proportions of the responses.

Dentist/dental

Online sources

Friends or family

Social Media

5 (14%)

4 (11%)

26 (70%)

2 (5%)

Figure 5. A pie-chart showing the different proportions of where the survey participants get their information about dental implants from.

A majority of the respondents, precisely 70% (26/37), indicated that their first point of contact would be their dentist. This finding underscores the significant role dental healthcare providers play as a trusted source of information for their patients. It also stresses the

importance of ensuring that dentists are well-equipped with up-to-date, comprehensive, and clear information about dental implants to adequately fulfil this educational role.

Internet sources were the second most popular choice, with 14% (5/37) of respondents indicating their preference for seeking information online. This reveals a reliance on digital media for health-related information, highlighting the importance of accurate, accessible, and easy-to-understand online content on dental implants.

Friends and family were chosen by 11% (2/37) of the respondents. This selection reflects that the sample surveyed values a dentist, or the internet, higher than their peers, which is an important finding. o

A small fraction of respondents, 5% (2/37), selected social media such as Facebook or Instagram as their go-to source for information. Although this is a minor proportion, it represents a growing trend in healthcare information-seeking behaviours and emphasizes the need for accurate and reliable health information on these platforms.

4.1.7 Perceived Pain

Perceived pain associated with dental implant treatment was explored and the results are shown in Figure 6. This subjective assessment was measured on a scale from 1 to 5, with 5 representing 'extreme pain' and 1 being ‘no pain at all. Perception of pain is a pivotal factor influencing patient apprehension and decision-making in dental treatments.

Analysis of the responses unveiled a normal distribution of perceptions. A marginal subset of respondents, 5% (2/37), categorised the treatment as having no pain, rating it as 1 on the scale. This segment of the patient population seems to have either minimal fear of the procedure, has prior experiences that have led to low pain perception, or are unaware of the full extent of the procedure.

10 (27%)

(32.4%)

(21.6%)

(13.5%)

(5.41%)

1 2 3 4 5

Perceived Pain

Figure 6. A bar chart showing the frequency distribution of respondents’ perception to pain associated with implant treatment, rated from 1 (no pain at all) to 5 (extreme pain). The central numbers show the absolute number of responses as well as the percentage.

A considerable portion of respondents, 27% (10/37), rated the anticipated pain level at 2, suggesting a relatively low expectation of pain. Another 32% (12/37) placed their expectation at the central level of pain, rating it as 3. Combined, these groups constitute the majority of respondents, indicating a general perception of mild to moderate pain associated with dental implant procedures.

However, a large percentage of patients anticipated higher levels of pain. Specifically, 22% (8/37) rated their expected pain level as 4, while 14% (5/37) perceived it as 'extremely painful', scoring it as 5 on the scale. This indicates a group of patients who harbour substantial apprehension about the pain associated with the procedure.

These findings emphasize the importance of effectively addressing pain management and setting realistic expectations during preoperative discussions with patients considering

dental implant treatment. Moreover, it underscores the need to provide comprehensive information about procedural pain and methods for its management, considering that perceptions of pain can significantly influence patients' decisions to opt for dental implant treatment.

4.1.8 Factors Important when Pursuing Implant Treatment

The survey sought to gauge the most important factors considered by patients when contemplating dental implant treatment. Respondents were allowed to select more than one factors, which means the results will be higher than 37 data points. The results are shown in Table 1. This evaluation illuminates what patients prioritize, guiding patient-centred care and decision-making strategies.

Table 1. A frequency distribution table of the most important factors when deciding whether or not to pursue dental implant treatment.

Factor Frequency mentioned

Cost 26

Trust in Dentist 21

Age 17

Potential Pain 14

Recovery Time 14

Comorbidity factors 6

Health status 6

Smoking status 3

Total 107

Cost emerged as the most significant factor, with it being mentioned 24% (26/107) of the time. This suggests that financial implications play a considerable role in patients' decisions, underlining the need for transparent pricing information and potentially flexible payment options or financial assistance programs.

Trust in the dental surgeon was the second most frequently cited factor, prioritized by 20% (21/107) of the answers given. This finding accentuates the importance of building strong patient-provider relationships characterized by trust and confidence, which could potentially sway the decision-making process.

Age was rated very highly, appearing as the 3rd most important factor, cited 16% or 17/107, although not possible to modify, it is highly influential in the decision-making process,

The potential pain associated with the procedure was identified as a crucial consideration as it appears 13% (14/107) of the time, reaffirming the importance of effective pain management strategies and clear communication about what to expect.

Recovery time was an important factor appearing at the same frequency as potential pain, suggesting that the duration and pain of post-procedure recovery might influence patients' readiness to undergo the treatment.

The remaining factors – comorbidity, health and smoking status- were selected the least amount of times at 6%, 6%, and 3%, respectively. These factors underscore the role of personal health circumstances and lifestyle choices in the decision-making process and it shows that patients do not highly use these datapoints to decide about their implant treatment.

4.1.9 Motivation for Implant Treatment

This question allowed for multiple responses, so in total, 43 selections were made. It assessed the patients' primary priorities when contemplating replacing a gap in their teeth. The results are shown in Figure 7.

The most prevalent response, "All of the above," selected 30% (13/43) of the time, underscores that many patients do not prioritize one single factor over others, but instead consider aesthetics, functionality, and feeling of completeness as equally important. This

emphasizes the complexity of patients' motivations and the need for comprehensive dental care that satisfies all these factors.

Functionality was the most individually selected option, prioritized by 23% (10/43) of the responses. This finding indicates that a substantial segment of patients values the practical aspects of dental health, such as chewing efficiency and speech clarity, over aesthetic considerations.

All of the above

Functionality

I have no desire to replace my gap

Aesthetics

Feeling of completeness

10 (23%)

8 (19%)

10 (23%)

2 (5%)

13 (30%)

Figure 7. A pie-chart showing the different proportions of what the survey participants valued the most as the motivational factors for pursuing dental implant treatment.

Aesthetics was the second most chosen individual priority, selected by 19% (8/43) of the responses. This highlights the importance patients place on the visual appeal of their teeth, correlating with the increasing societal emphasis on appearance and its impact on self confidence and quality of life.

The sense of completeness was prioritized by only 5% (2/43) of the responses, reflecting that this parameter is not a priority to the participants we sampled. Nonetheless, this sentiment emphasizes the necessity for holistic dental healthcare approaches that consider not only physical but also psychological well-being.

23% (10/43) of the responses expressed no desire to replace their dental gap. This response highlights the varied attitudes towards dental interventions, underlining that dental healthcare decisions are highly individual and may be influenced by personal preferences, cultural beliefs, or previous experiences.

4.1.10 Gap Location

The survey incorporated a question intended to ascertain the location of the dental gap among the respondents. This query provided valuable insights into the distribution of dental gaps and their relative prevalence in different regions of the mouth.

The majority of respondents, 51% (19/37), identified the back of the mouth as the location of their dental gap. This aligns with the generally higher prevalence of tooth loss in the posterior regions due to factors such as dental caries and periodontal disease. This suggests that treatments addressing gaps in these areas, such as posterior implants, may constitute a significant proportion of the dental implant treatments needed within the patient population.

Meanwhile, only 16% (6/37) of respondents reported a gap in the front of the mouth. The relatively low prevalence of gaps in the anterior region may reflect the higher visibility of these areas and thus, the priority often given to preserving or replacing teeth in the front region due to aesthetic considerations.

The middle region of the mouth was identified as the gap location by 14% (5/37) of the respondents, demonstrating that mid-oral tooth loss may not be a considerable concern within the patient population.

Furthermore, 19% (7/37) of respondents reported gaps in multiple areas, indicating a subset of patients with more complex dental needs that may require comprehensive treatment plans addressing several areas in the oral cavity.

4.1.11 Previous Consideration of Treatment

The survey incorporated a closed question probing whether respondents have ever considered implant dental treatment. This query is crucial in assessing the patient’s receptiveness towards this type of dental intervention.

Interestingly, almost half of the respondents, 43% (16/37), affirmed that they had considered dental implant treatment. This demonstrates a relatively high level of acceptance or at least contemplation about this therapeutic option. However, this leaves a majority of respondents, 57% (21/37), who have not considered this treatment previously.

Examining these findings in conjunction with responses to earlier questions can offer more profound insights. For instance, the high proportion of patients who have considered implant treatment could be influenced by the level of trust in the surgeon, the prioritisation of functionality, and the desire to replace gaps regardless of their location.

On the other hand, the majority number of patients who have not contemplated dental implant treatment may reflect factors such as cost, potential pain, and perceived recovery time. The notable percentage of respondents unfamiliar with the implant treatment process also suggests that a lack of awareness or understanding could contribute to the reluctance to consider this option.

Moreover, the lack of desire to replace dental gaps expressed by 27% (10/37) of respondents, coupled with the perception that dental implants might cause significant pain could further explain the sizeable proportion of respondents not considering dental implants.

This indicates a mixed reception of dental implant treatment within the patient population, with a myriad of factors influencing the likelihood of patients considering this treatment option.

4.1.12 Income Range

The survey inquired about the household income range of the respondents, a question essential for understanding the economic context of the patients and its potential influence on their dental health decisions.

Two out of the 37 respondents did not answer this question, giving a total of 35 answers. The results are shown in Table 2.

Table 2. Frequency distribution table of the income ranges of the survey respondents.

Income Range The proportion of respondents and frequency < £25 K 31% (11/35)

£25 K - £ 50 K 23% (8/35)

£50 K - £ 75 K 23% (8/35)

> £100 K 9% (3/35)

Undisclosed 14% (5/35)

The largest segment of respondents, 31%, reported a household income of less than £25,000. Following this, 23% of respondents reported an income in the £25,000-£50,000 range, and 23% in the £50,000-£75,000 range. A minority of respondents, 9%, reported an income of more than £100,000. There is a clear inversely proportionate relationship seen here, as the income range increases, the number of participants falling in that bracket decreases, which is expected as the rest of the population follows a similar pattern. Remarkably, a considerable percentage of respondents, 14%, preferred not to disclose their income.

When this data is interpreted alongside other survey findings, interesting correlations emerge. For instance, the largest segment of respondents with an income of less than £25,000 aligns with the cost being a significant factor when considering dental implants, suggesting financial constraints may pose a barrier to considering or opting for dental

implant treatment. This is further corroborated by the finding that cost was rated as highly or extremely influential by a majority of the respondents in their decision-making process about dental implants.

5 General Discussion

Dental implants can have a significant impact on a patient's quality of life both physically and mentally. Compared to other tooth replacement options such as dentures or bridges, dental implants provide a more stable and permanent solution. With dental implants, patients can chew and eat food more easily, which can improve their overall nutrition and health. Additionally, dental implants can be customized to match the colour and shape of surrounding teeth, which can provide an aesthetically pleasing smile and boost self confidence.

The insights gleaned from the data set underscore the complexity and diversity of factors influencing patient decisions related to dental implant treatments. Notably, the diverse range of perspectives and motivations within the sample population highlights the importance of a patient-centred approach to providing dental care. As healthcare providers, understanding these individual factors is pivotal in guiding patients towards the most suitable treatment options for their specific circumstances.

Comparing different methods from the Best-Worst Scaling (BWS) and Likert scales within the Peer-to-Peer (P2P) Accommodation context, the emphasis was not on which scale was superior but on understanding their differences. The findings revealed that while Likert scales are intuitive and widely recognized, they can sometimes result in respondent fatigue when rating multiple attributes. In contrast, BWS is adept at discerning relative importance among a multitude of items, offering improved discrimination among attributes and a more manageable cognitive burden for respondents. BWS also presents advantages for cross-

cultural studies due to its simplicity and reduced lexical challenges. In the context of tourism and hospitality, the BWS method can efficiently identify key attributes, especially in complex systems or broad concepts, translating academic insights into actionable strategies for industry practitioners. This methodological approach aligns with the dental patient data discussed earlier, emphasizing the importance of understanding varied perceptions and preferences to deliver tailored, patient-centred services, thus showcasing the applicability of such scales across different domains (Heo et al., 2022).

One crucial aspect that emerged from the findings was the role of financial considerations in patients' decision-making process. Therefore, transparent communication regarding treatment costs and the availability of potential financing options is critical. Such measures could alleviate financial barriers and empower patients to make decisions that align with their health and financial interests.

The results also reveal varied perceptions of age and self-rated health status, demonstrating the importance of these factors in patient-centred dental care. Dental healthcare providers can use this information to tailor individualised treatment plans and preventive strategies that align with patients' health perceptions and needs. This insight can also help optimise patient education efforts and shape the delivery of dental care services.

The diverse locations of dental gaps within the patient population reinforce the necessity for tailored treatment strategies that accommodate unique dental needs. As dental practitioners, understanding these variations can aid in developing personalised treatment plans, thereby enhancing patient-centred care.

Furthermore, the intricate relationship between socioeconomic factors and health decisions, particularly concerning dental implant treatment, was made evident through these findings. The results suggest a need for a comprehensive approach to patient education, including transparent communication about costs. This approach could potentially mitigate financial barriers, enhancing accessibility to dental implant treatments.

In conclusion, these findings underscore the multi-faceted considerations involved in patients' decision-making processes regarding dental implant treatment. These insights will guide us, as dental professionals, in providing care that respects and responds to our patients' unique priorities and needs.

In terms of mental health, dental implants can also provide emotional benefits to patients. Many people who have missing teeth or wear dentures can feel self-conscious about their appearance and may avoid social situations. Dental implants can improve a patient's smile and give them more confidence in their appearance, which can improve their self-esteem and mental well-being. Overall, dental implants offer a more comprehensive solution to tooth loss, which can have a positive impact on a patient's quality of life (Sanz, Azabal and Arias, 2022). The results of a recent survey have highlighted the tendency of patients to overestimate both the eligibility and longevity of dental implants, emphasizing the importance of meticulous treatment planning by experienced practitioners. Given the complexity of the procedure and the fact that dental implants may not always be the most appropriate solution, this underscores the need for careful assessment and decision-making by both patients and clinicians (Chaturvedi et al., 2019).

Expanding on the findings, this study has effectively highlighted several key areas of focus for enhancing the public's understanding and acceptance of dental implant treatment. However, it is important to note that a comprehensive understanding of the treatment and its costs remains elusive for a significant number of respondents. This underlines the pressing need for effective patient education strategies within dental practices. Educational initiatives could encompass a variety of tools, including illustrative pamphlets, interactive digital content, or even personalized counselling sessions to guide patients through the process, risks, benefits, and expected outcomes of dental implant treatments (Court, Robinson and Hocken, 2011).

The findings also point towards the role of socio-economic factors in treatment acceptance. A considerable number of respondents cited cost as a major influence on their decision-

making, revealing a potential barrier to treatment access. This observation can propel future studies to explore mechanisms that can alleviate financial barriers, including alternative payment plans, insurance coverage, or lobbying for better dental health policies that could subsidize such treatments for certain populations (Benova, Campbell and Ploubidis, 2015).

Interestingly, over 70% of patients when asked how would go about seeking further information about dental implants have chosen the dentist or operator as their primary source of information which highlights that we have a significant role to play in educating and informing patients about what is available and what is possible (Hogikyan et al., 2021).

The varying perceptions of treatment timelines indicate a disconnect between professional estimates and patient expectations. Future work should emphasize better communication between dental professionals and patients regarding the expected treatment duration, including the surgical procedure and recovery time. Patient-specific timelines could be developed using predictive models, considering individual patient factors such as age, overall health, and specific dental needs (Comerford Freda, 2014).

Finally, the influence of missing teeth on decision-making opens an avenue for future research to determine optimal intervention points in dental care. Studies could be conducted to understand at what stage of tooth loss patients are more inclined to opt for implants and whether early intervention could help in better oral health outcomes and potentially lower treatment costs. In essence, the findings from this study set the stage for more targeted research, focusing on patient education, cost management strategies, and patient professional communication, to enhance the acceptance of dental implant treatments.

6 Strengths and Limitations

This study, while revealing significant insights into patient perceptions and understanding of dental implant treatments, possesses inherent strengths and limitations that merit discussion.

The key strength of this study lies in its broad-based survey design, which allowed for the collection of comprehensive data across various dimensions. The survey was meticulously crafted to encompass diverse areas of concern, ranging from understanding the procedure to cost implications and potential barriers. The robustness of the dataset enabled detailed and multifaceted analysis, revealing rich and valuable insights. Furthermore, the exclusive focus on patients from the same dental practice ensured a consistent level of exposure to information about dental implants, adding to the reliability of the responses.

However, this study is not without limitations. Firstly, the sample size, while sufficient for exploratory analysis, may not be representative of the larger population. Secondly, the survey's self-reported nature could potentially lead to response bias, as respondents might have answered in ways they perceived as socially desirable or acceptable. Thirdly, as the survey was only disseminated among patients from a single dental practice, the findings may not be generalizable across different settings or geographic locations. Fourthly, NHS patients were not included in this survey due to regulations imposed by the NHS for the Aston university ethics committee to approve. Finally, the survey did not capture some potentially influential factors like specific health concerns, past dental experiences, and individual oral hygiene practices.

Therefore, while this study provides useful initial insights, future research could benefit from addressing these limitations, perhaps by using a larger, more diverse sample, and employing strategies to minimize response bias and capture more detailed information about individual health profiles and experiences.

7 Conclusions and Future Works

The findings from this quantitative study shed substantial light on the public's perception of dental implant treatment and highlight the varied information-seeking behaviours of patients. This offers significant insight into multifaceted trust dynamics in healthcare information sources, demonstrating the essential role of healthcare providers in disseminating accurate and helpful information about dental implant treatment across various channels.

These insights are anticipated to contribute significantly to future interventions, policy formulation, and professional practice. A better understanding of patient perspectives and information-seeking behaviours could enhance the accessibility and acceptability of dental implant treatment, thereby improving oral health outcomes and overall public sentiment towards the procedure.

Consequently, this study stands to make a meaningful contribution to dental healthcare practice, policy, and research. It underscores the importance of being cognizant of patient behaviours and preferences in healthcare settings and points towards the need for effective strategies to bolster trust and facilitate accurate information flow regarding dental implant treatment.

8 References

Al-Johany, S. et al. (2010) ‘Dental patients’ awareness and knowledge in using dental implants as an option in replacing missing teeth: A survey in Riyadh, Saudi Arabia’, Saudi Dental Journal, 22(4), pp. 183–188. doi:10.1016/j.sdentj.2010.07.006.

Benova, L., Campbell, O.M.R. and Ploubidis, G.B. (2015) ‘Socio-economic inequalities in curative health-seeking for children in Egypt: Analysis of the 2008 Demographic and Health Survey’, BMC Health Services Research, 15(1), pp. 1–14. doi:10.1186/s12913-015-1150-3.

Carlsson, G.E. (2016) ‘Some issues related to evidence-based implantology’, Journal of Indian Prosthodontist Society, 16(2), pp. 116–123. doi:10.4103/0972-4052.179318.

Chaturvedi, S. et al. (2019) ‘CBCT analysis of schneiderian membrane thickness and its relationship with gingival biotype and arch form’, Nigerian Journal of Clinical Practice, 22(10), pp. 1448–1456. doi:10.4103/njcp.njcp_186_19.

Chrcanovic, B.R., Albrektsson, T. and Wennerberg, A. (2015) ‘Smoking and dental implants: A

systematic review and meta-analysis’, Journal of Dentistry, 43(5), pp. 487–498. doi:10.1016/j.jdent.2015.03.003.

Comerford Freda, M. (2014) ‘Issues in patient education’, Journal of Midwifery and Women’s Health, 49(3), pp. 203–209. doi:10.1016/j.jmwh.2004.01.003.

Court, E.L., Robinson, J.A. and Hocken, D.B. (2011) ‘Informed consent and patient understanding of blood transfusion’, Transfusion Medicine, 21(3), pp. 183–189. doi:10.1111/j.1365- 3148.2011.01069.x.

European information commisisioners office (2021) ‘Guide to the General Data Protection Regulation ( GDPR )’, European data protection, p. 295.

Farsai, P.S. (2017) ‘Although Limited Evidence Suggests Patient Perceptions and Expectations for Dental Implants Are Realistic, Many Misconceptions Remain’, Journal of Evidence-Based Dental Practice, 17(3), pp. 290–292. doi:10.1016/j.jebdp.2017.06.011.

Hamilton, C., Marshall, C. and Broadbent, M. (2018) ‘Online consent for upper limb surgical procedures – Is this the way forward’, International Journal of Surgery, 55(2018), pp. S74–S75. doi:10.1016/j.ijsu.2018.05.348.

Heo, C.Y. et al. (2022) ‘A comparison of Best-Worst Scaling and Likert Scale methods on peer-to-peer accommodation attributes’, Journal of Business Research, 148(September 2020), pp. 368–377. doi:10.1016/j.jbusres.2022.04.064.

Hogikyan, N.D. et al. (2021) ‘Patient perceptions of trust formation in the surgeon-patient relationship: A thematic analysis’, Patient Education and Counseling, 104(9), pp. 2338–2343. doi:10.1016/j.pec.2021.02.002.

Howe, M.S., Keys, W. and Richards, D. (2019) ‘Long-term (10-year) dental implant survival: A systematic review and sensitivity meta-analysis’, Journal of Dentistry, 84(December 2018), pp. 9–21. doi:10.1016/j.jdent.2019.03.008.

John, V., Chen, S. and Parashos, P. (2007) ‘Implant or the natural tooth - A contemporary treatment planning dilemma?’, Australian Dental Journal, 52(1 SUPPL.). doi:10.1111/j.1834- 7819.2007.tb00521.x.

Kashbour, W. A., N.R. (2016) ‘Patients’ perceptions of implant placement surgery, the post-surgical healing and the transitional implant prostheses: a qualitative study’. Clinical Oral Implant Research.

Kashbour, W.A. et al. (2015) ‘Patients’ experiences of dental implant treatment: A literature review of key qualitative studies’, Journal of Dentistry, 43(7), pp. 789–797. doi:10.1016/j.jdent.2015.04.008.

Klokkevold, P.R. and Han, M.S.T.J. (2007) ‘How do smoking, diabetes and periodontitis affect outcomes of implant treatment?’, British Dental Journal, 203(6), pp. 333–333. doi:10.1038/bdj.2007.841.

Kullar, A.S. and Miller, C.S. (2019) ‘Are There Contraindications for Placing Dental Implants?’, Dental Clinics of North America, 63(3), pp. 345–362. doi:10.1016/j.cden.2019.02.004.

Logan, H. and Marek, C.L. (2006) The Anxious or Fearful Dental Patient. Second Edi, Treatment Planning in Dentistry. Second Edi. Mosby, Inc. doi:10.1016/B978-0-323-03697-9.50017-X.

Mccrea, S.J.J. (2017) ‘An Analysis of Patient Perceptions and Expectations to Dental Implants: Is There a Significant Effect on Long-Term Satisfaction Levels?’, International Journal of Dentistry, 2017. doi:10.1155/2017/8230618.

Misch, C.M. (2020) ‘Dental tourism for implant treatment: Dream vacation or nightmare?’, International Journal of Oral Implantology, 13(3), pp. 203–204. Available at:

https://search.ebscohost.com/login.aspx?direct=true&db=ddh&AN=145483704&site=ehost-live.

Origin Pro, Northampton, MA, U. (2023) ‘Origin Pro’. Available at:

https://www.originlab.com/index.aspx?go=Company&pid=1130.

Paul S, A. et al. (2018) ‘Assessing perceptions of oral health related quality of life in dental implant

patients. Experience of a tertiary care center in India’, Journal of Oral Biology and Craniofacial Research, 8(2), pp. 74–77. doi:10.1016/j.jobcr.2018.05.003.

Pennington, J. and Parker, S. (2012) ‘Improving quality of life using removable and fixed implant prostheses.’, Compendium of continuing education in dentistry (Jamesburg, N.J. : 1995), 33(4), p. 8509.

Qualtircs, Provo, Utah, U. (2005) ‘Qualtrics’. Available at: https://www.wualtrics.com.

Sanz, E., Azabal, M. and Arias, A. (2022) ‘Quality of life and satisfaction of patients two years after endodontic and dental implant treatments performed by experienced practitioners’, Journal of Dentistry, 125(September), p. 104280. doi:10.1016/j.jdent.2022.104280.

Selvaranjan, P., Macmillan, N. and Lewis, N. (2020) ‘Audit of acceptance criteria for NHS funded dental implants at the Royal Surrey County Hospital’, British Journal of Oral and Maxillofacial Surgery, 58(10), p. e184. doi:10.1016/j.bjoms.2020.10.151.

Takanashi, Y. et al. (2004) ‘A cost comparison of mandibular two-implant overdenture and conventional denture treatment’, The Journal of Prosthetic Dentistry, 92(2), p. 199. doi:10.1016/j.prosdent.2004.06.016.

Tepper, G. et al. (2003) ‘Representative marketing-oriented study on implants in the Austrian population. I. Level of information, sources of information and need for patient information’, Clinical Oral Implants Research, 14(5), pp. 621–633. doi:10.1034/j.1600-0501.2003.00916.x.

Wang, G., Gao, X. and Lo, E.C.M. (2015) ‘Public perceptions of dental implants: A qualitative study’, Journal of Dentistry, 43(7), pp. 798–805. doi:10.1016/j.jdent.2015.04.012.

Appendix 1 Exploring factors affecting patients’ decision to replace missing teeth

Participant Information Sheet

Invitation

I would like to invite you to take part in a study forming part of an MSc dissertation project.

Before you decide if you would like to participate, take time to read the following information carefully and, if you wish, discuss it with others such as your family, friends or colleagues.

Please ask the study team, whose contact details can be found at the end of this information sheet, if there is anything that is not clear or if you would like more information before you make your decision.

I would like to reassure you that the standard of care and options of treatment will not be affected whether you agree to be in the study or not.

What is the purpose of the study?

This project aims to comprehensively explore the influential factors in the decision-making process regarding the replacement of missing tooth or teeth.

This specific study aims to facilitate a tailored and informed approach to patient communication, ensuring a clear and seamless journey from treatment plan deliberation to successful tooth replacement, should that be desired by the patient. The findings of this investigation hold the potential to significantly enhance dental practice by identifying key determinants that shape patients' preferences and priorities, thereby fostering a better understanding of their decision making process and enabling more effective patient-centred care.

Why have I been chosen?

You are being invited to take part in this study because:

• You are above 18 years of age;

• You are privately registered at the Affinity dental practice;

• You have a gap where you lost a tooth in the past or very near future

What will happen to me if I take part?

If you decide to participate, you will be asked to complete the following anonymous online questionnaire which focuses on your thoughts on what might motivate you to replace your tooth gap, and/or what factors might influence your decision to fill it if you wanted.

Do I have to take part?

No. It is up to you to decide whether you wish to take part, and no element of your care will be affected if do or do not decide to take part.

If you do decide to participate, you will be asked to read a series of consent statements regarding the use of the data you provide in response to the questionnaire. If you agree to the conditions, please click the ‘next’ button to continue to the questionnaire questions, your completion and submission of which confirm consent. If you are unable to agree, please shut down your browser. You would still be free to withdraw from the study at any time up until you submit your responses without giving a reason; after submission, because your responses will be anonymous, it will not be possible to extract your data.

Will my taking part in this study be kept confidential?

Yes. The data collected will be anonymous.

If we need to collect personal data (such as a name and contact details) we will only use this to contact you to invite you to participate.

The data we collect will be stored in a secure document store (paper records if applicable) or electronically on a secure encrypted mobile device, password-protected computer server or secure cloud storage device.

To ensure the quality of the research, Aston University may need to access your data to check that the data has been recorded accurately, e.g., for audit. If this is required, your data will be treated as confidential by the individuals accessing your data.

What are the possible benefits of taking part?

While there are no direct benefits to you of taking part in this study, the data gained will help to better understand why patients decide to have dental implants versus patients who decide not to. What are the possible risks and burdens of taking part?

Given the topic of the questionnaire combined with the fact that the data collected from you will be anonymous, we feel there is minimal risk to you in participating.

In terms of burden, participation will require approximately 10 minutes of your time.

What will happen to the results of the study?

The results of this study will be published in the MSc dissertation report of the researcher, wherein your identity will remain confidential.

The results of this study may be published in scientific journals and/or presented at conferences. If the results of the study are published, your identity will remain confidential. Expenses and payments

No expenses or payments are being provided for participation.

Who is funding the research?

The study is being funded by Aston University.

Who is organising this study and acting as the data controller for the study?

Aston University is organising this study and acting as the data controller for the study. Research data will be used only for the purposes of the study or related uses identified in this Information Sheet or Appendix A.

Who has reviewed the study?

This study was given a favourable ethical opinion under the delegated authority of the Health and Life Science Research Ethics Committee.

What if I have a concern about my participation in the study?

If you have any concerns about your participation in this study, please speak to the researcher and s(he) will do his/her best to answer your questions. Contact details can be found at the end of this information sheet.

If the researcher is unable to address your concerns or you wish to make a complaint about how the study is being conducted you should contact the Aston University Research Integrity Office at research_governance@aston.ac.uk or telephone 0121 204 3000.

Research Team Details

Morad Shafy

220355175@aston.ac.uk

07713492044

Irene Siekpe

i.siekpe@aston.ac.uk

Program Lead

Dan Green

Dan.green3@aston.ac.uk

Thank you for taking the time to read this information sheet. If you have any questions regarding the study please don’t hesitate to ask one of the research team.

Transparency Statement

Aston University takes its obligations under data and privacy law seriously and complies with the Data Protection Act 2018 (“DPA”) and the General Data Protection Regulation (EU) 2016/679 as retained in UK law by the Data Protection, Privacy and Electronic Communications (Amendments etc) (EU Exit) Regulations 2019 (“the UK GDPR”).

Aston University is the sponsor for this study based in the United Kingdom. We will be using information from you in order to undertake this study. Aston University will process your data in order to register you as a participant and to manage your participation in the study. It will process your data on the grounds that it is necessary for the performance of a task carried out in the public interest (GDPR Article 6(1)(e). Aston University may process special categories of data about you which includes details about your health. Aston University will process this data because it is necessary for statistical or research purposes (GDPR Article 9(2)(j)). Aston University will keep identifiable information about you for 6 years after the study has finished.

Your rights to access, change or move your information are limited, as we need to manage your information in specific ways for the research to be reliable and accurate. If you withdraw from the study, we will keep the information about you that we have already obtained. To safeguard your rights, we will use the minimum personally identifiable information possible.

You can find out more about how we use your information at

https://www.aston.ac.uk/about/statutes-ordinances-regulations/publication-scheme/policies regulations/data-protection or by contacting our Data Protection Officer at dp_officer@aston.ac.uk.

If you wish to raise a complaint on how we have handled your data, you can contact our Data Protection Officer who will investigate the matter. If you are not satisfied with our response or believe we are processing your personal data in a way that is not lawful you can complain to the Information Commissioner’s Office (ICO).

When you agree to take part in a research study, the information about you may be provided to researchers running other research studies in this organisation and in other organisations. These organisations may be universities, NHS organisations or companies involved in health and care research in this country or abroad.

This information will not identify you and will not be combined with other information in a way that could identify you. The information will only be used for the purpose of research, and cannot be used to contact you.

Appendix 2