A Comparison of Knowledge and Skills Related to Up-to-Date Implant Techniques Among Prosthodontists, Periodontists, and Oral Surgeons: A Cross-Sectional Study

Background A dental implant is used in the treatment of complete and partial edentulism. Implant application has increased significantly in modern dentistry. The anatomy, medical condition, practitioner knowledge, and surgical technique are key factors that eventually affect the overall outcome of dental implants. For a better treatment outcome for dental implants, adequate multidisciplinary communication, cooperation, and support must be achieved while considering the periodontics, prosthodontics, and oral surgery specialties. Objective This study aims to compare the knowledge and skills regarding up-to-date implant techniques among prosthodontists, periodontists, and oral surgeons in Riyadh, Saudi Arabia. Materials and methods The data were collected from prosthodontists, periodontists, and oral surgeons working in Riyadh, Saudi Arabia from April 2022 to August 2022. The targeted subjects were residents, specialists, and consultants working in Riyadh, Saudi Arabia. Results A total of 181 dentists were surveyed in the current study. A significantly higher proportion of oral surgeons have perceived that the BTI brand (BTI Biotechnology Institute, Álava, Spain) had a high load torque before screw fracture (p = 0.025). Periodontists had significantly higher knowledge levels related to the technique with the lowest marginal bone loss (p = 0.003). Knowledge levels were significantly higher among prosthodontists for the items related to the fact that both early and late implant placement following alveolar ridge placement would have the least changes in periodontal parameters (p = 0.013). Conclusion All the targeted specialties exhibited a comparable impression regarding implant techniques and their outcomes. Each specialty had its own aspect of treatment during the placement of dental implants depending on multiple factors. Significant knowledge was observed from each specialty regarding implant brands, techniques, and antibiotic prescriptions for dental implants.


Introduction
Dental implants were first introduced in the 1970s by Branemark and have become a common alternative treatment for replacing and rehabilitating missing teeth [1]. It is a structure made of alloplastic elements implanted into the oral tissues under the periosteum and within or through the bone to maintain and support a fixed or removable dental prosthesis [2]. The achievement of implant-supported rehabilitation is dependent upon the interaction between the bone and implant surface without the intervention of connective tissue or signs and symptoms of infection or inflammation [3]. A dental implant is used in the treatment of complete and partial edentulism, and its application has increased significantly in modern dentistry [2]. Previous reports demonstrated various techniques in implant placement, including immediate implant placement, which minimizes the number of surgical interventions and the shortening of the total treatment course. However, it has been shown to be associated with esthetic complications [4,5]. Furthermore, it increases the risk of infection and inadequate volume of soft tissue and may present some

Knowledge and skills of the overall sample
Based on the participant's responses, the BIOMET 3i® (Palm Beach Gardens, Florida) brand was the most commonly agreed brand that has a high load torque before screw fracture (47.5%). Clinical parameters were thought to be the most common risk factors, which would lead to a subsequent late failure of a dental implant (51.4%). From the dentists' points of view, conventional immediate dental implant placement was the most common technique that has the lowest marginal bone loss (51.4%) and the best aesthetic outcome of soft tissue around the implant (42.0%). Additionally, late implant placement following alveolar ridge preservation has the most significant changes in the midfacial mucosal margin (46.4%), the highest pink/white esthetic scores (45.9%), and the least changes in periodontal parameters (50.8%). The remaining responses to other questions are listed in Table 2

Discussion
Several studies discussed implant techniques and their outcomes; these studies illustrated that different implant techniques and their approaches could exhibit different survival rates. According to a previous study, which was done in the USA and aimed to analyze the evidence regarding the efficacy of soft tissue augmentation procedures, the results showed that an apically positioned flap (APF) in combination with a free gingival graft (FGG) is the most effective technique for peri-implant keratinized mucosa width augmentation [12]. However, in our study, all the targeted specialties considered that a free periosteal graft (FPG) is the most effective technique for peri-implant keratinized mucosa width augmentation with periodontists (44.1%) being the most common specialty to use this technique. The same previous study also illustrated that bilaminar techniques in combination with connective tissue grafts are the most superior technique in terms of mucosal thickness (MT) gain [12]. In correlation to our study, oral surgeons (57.1%) had a similar impression regarding this technique. However, most periodontists (61.8%) recommended the use of bilaminar techniques in combination with an acellular dermal matrix for better mucosal thickness (MT) gain. According to Sawase et al., the accuracy of digital scans with intraoral scanners was dependent on the optical scanning devices and software used [13]. Our study showed a similar impression from all specialties regarding the use of intraoral scanners, with periodontists (64.7%) being the most relatable specialty. A previous study by In't Veld M. et al aimed to identify the treatment outcome of immediate placement and loading of dental implants in the edentulous mandible of overdentures in head and neck cancer patients. This study demonstrated a high survival rate of dental implants placed during ablative surgery in head and neck cancer patients [14]. Our study showed that most specialties recommend the placement of dental implants during ablative surgery in head and neck cancer patients with oral surgeons (88.9%) being the most approved specialty. The majority of periodontists (85.3%) suggested that the time and costs involved with the diagnostic and planning procedures for computer-assisted implant planning and surgery are higher than for non-computer-assisted, which demonstrates a similar result to a previous study, which was done by Graf T et al. [10].
A recent study has shown that BTI® has more high load torque before screw fracture. However, in our study, most of the specialties considered that BIOMET 3i® has more load torque before screw fracture than the other brands [3]. The Velasco et al. study found that the socket-shield technique compared to the conventional technique has lower marginal bone loss and higher esthetic scores [15]. In our study, according to lower marginal bone loss, most periodontists (47.1%) agreed with the previous study and most of the oral surgeons (66.7%) and prosthodontists (52.0%) saw that the conventional technique has a lower bone marginal bone loss. For a higher esthetic score, most of the periodontists (52.9%) saw that the socket shield has a higher score compared to oral surgeons (30.2%) and prosthodontists (32.0%). For a more successful outcome, most of the oral surgeons (42.9%) recommended using guided implant placement compared to periodontists (42.6%) who recommended using both techniques, guided and freehand implant placement. However, Abdelhay et al. recommended a guided implant placement approach for a more successful outcome [9]. According to Lim et al., there is no difference in implant placement technique for non-molar extraction, which has more changes in a midfacial mucosal margin between early implantation (EP) and late implant placement following alveolar ridge presentation (LP/ARP) [3]. However, most of the specialties considered that late implant placement following alveolar ridge presentation has more changes in the discussed case [16]. In addition, the previous study showed that there is no difference between early implantation and late implant placement following alveolar ridge preservation in the pink/white esthetic scores [16]. However, in our study, most of the specialties (45.9%) considered that LP/ARP is associated with a more pink/white esthetic score. The same previous study found that EP and LP/ARP had no difference in the periodontal parameters [16]. However, in our study, 50.8% of the specialties considered that LP/ARP has fewer changes in periodontal parameters than EP. Regarding the use of antibiotics to reduce implant failure, some of the participants (30.9%) recommended giving patients just a single preoperative antibiotic, and the same study considered that there are no differences between them to reduce the failure rate in dental implants. In addition, 38.1% of our participants considered that it is better to give the patients both pre and postoperative antibiotics. In the Esposito M et al. and Roca-Millan E et al. study., they considered that there is no difference between a single preoperative antibiotic or both pre and postoperative antibiotics [17,18]. According to Gunes et al., they found that when using biomechanical osseointegration of titanium implants after guided bone regeneration (GBR) with a hydroxyapatite graft, deproteinized bovine bone graft, humanderived allograft, and calcium sulfate bone graft, none of the grafts used were distinctly superior to any of the others [19]. However, in our study, most of the specialties considered that allograft has superior biomechanical osseointegration compared to other types. A previous study that was done by Singh et al. aimed to compare bone healing in immediate implant placement and delayed implant placement. This study showed that delayed Implant placement had better clinical and radiographical bone healing than immediate implant placement [20]. However, in our study, most of the specialties (76.2%) considered that delayed implant placement had better bone healing than immediate implant placement. According to bone graft materials, 47.1% of periodontists and 42.9% of oral surgeons considered that freeze-dried bone allografts will increase the implant stability and marginal bone levels after immediate placement of the implant more than xenograft bone material. In addition, there are prosthodontists (38.0%) who agreed with the other specialties, and 38.0% of them considered no differences between the two materials for more stability. Conversely, the Jalaluddin M et al. study demonstrated that both bone grafting materials showed improvement in marginal bone levels of implant stability after immediate placement of an implant [21]. A previous study done by Dutta SR et al. showed that there is a need to increase the knowledge and awareness regarding the potential risk factors that could impact implant failures in those who are practicing dental implantology [22]. Our study showed that a large proportion of practitioners (91.2%) agreed with the need for increasing knowledge and awareness regarding the potential risk factors. The same study also showed that regular assessment of the theoretical and practical knowledge of implant dentistry is mandatory to improve their implant experience [22]. However, in our study, the majority (58%) considered dental education programs and workshops as the best way to achieve it while 40.3% considered regular assessment of the theoretical and practical knowledge of implants as the best way to achieve the aimed results. A study that was published by Tettamanti L et al. demonstrated that immediate loading implants showed a greater risk for implant failure when compared to conventional loading implants although the survival rates were high for both procedures [23]. Most practitioners (90.6%) agreed that immediate-loading implants have a greater risk of implant failure compared to conventional loading implants. Another study that was conducted by Momand P et al. concluded that antibiotic prophylaxis in conjunction with implant placement is likely of small benefit and thus should be avoided in most cases, especially given the unabated growth in antibiotic-resistant bacteria [24]. Our study showed that the majority of practitioners (80.7%) usually prescribe a prophylactic antibiotic for dental implants. A study by Melini M illustrated that analgesic use seemed to be associated with improved postoperative outcomes (pain, patient satisfaction, and need for rescue medication) when compared to placebo [25]. In correlation, most practitioners (95.6%) support the importance of using analgesics and the association between patient satisfaction and pain management with the prescription of these analgesics.

Conclusions
All the targeted specialties exhibited a comparable impression regarding implant techniques and their outcomes. Each specialty had its own aspect of treatment during the placement of dental implants depending on multiple factors. Significant knowledge was observed from each specialty regarding implant brands, techniques, and antibiotic prescriptions for dental implants. Different training schools could be the reason for different implant favorable approaches. Moreover, each technique has its own considerations, depending on multiple factors such as medical history, bone status, implant cost, and patient motivation.