Knowledge and Awareness of Dental Implants among Elderly

People in Croatia
Josip Kranjcic, DMD,1 Anja Mikus,2 Ketij Mehulic, DMD, PhD,1,3 & Denis Vojvodic, DMD, PhD1,4
1

Department of Fixed Prosthodontics, School of Dental Medicine, University of Zagreb, Zagreb, Croatia
Sixth year Undergraduate Student, School of Dental Medicine, University of Zagreb, Zagreb, Croatia
3
University Dental Clinic, University Hospital Centre Zagreb, Zagreb, Croatia
4
Department of Prosthodontics at Clinical Hospital Dubrava, Zagreb, Croatia
2

Keywords
Dental implants; prostheses; implants; aged;
dental implant awareness; implant costs.
Correspondence
Josip Kranjcic, Department of Prosthodontics
at Clinical Hospital Dubrava, School of Dental
Medicine, University of Zagreb, Av. G. Suska
6, 10000 Zagreb, Croatia. E-mail:
kranjcic@sfzg.hr
The authors deny any conflicts of interest.
This article originates from scientific project
Investigation of materials and clinical
procedures in prosthetic dentistry grant
No. 06506504450413 supported by the
Ministry of Science, Education and Sports of
the Republic of Croatia.
Accepted November 23, 2013
doi: 10.1111/jopr.12172

Abstract
Purpose: The use of inserted dental implants is growing every day in order to improve
retention and stability of complete removable dental prostheses (RDPs), especially
in the mandible. Therefore, the aim of this study was to examine the knowledge and
awareness of dental implants among elderly people wearing complete RDPs.
Materials and Methods: This study, based on answers from a questionnaire designed
for the purpose of this study, included 301 participants wearing complete RDPs from
elderly care homes with average age of 74 years.
Results: The awareness of dental implants was statistically significantly (p < 0.05)
affected by the participants age, residence size, and their level of education. Younger
participants (x = 70 years) had heard about dental implants (56.5%; p < 0.05) and
believed in the possibility of retaining complete RPDs using dental implants (56.1%;
p < 0.05). Among participants living in places with populations of 10,000 or fewer
residents, more had not heard about dental implants (59.4%; p < 0.05). Among
participants who had completed college/university or high school, there were a higher
number of participants who had heard about dental implants (82.4%; p < 0.05).
Conclusion: Although more than half of the participants had heard of dental implants,
this did not mean they were well informed about the implant insertion procedure and
the costs for such a treatment. In conclusion, awareness of dental implants in studied
participants was insufficient. The results reinforce the need for better education and the
provision of proper information to elderly people about dental implants and implant
treatment options.

Despite the rapid development of dentistry and improvements

in general oral health care, tooth loss is still a significant problem not just among elderly people and individuals compromised
by certain medical conditions1,2 but in the general population
as well. Therefore, the replacement of missing teeth is very
important for restoring full function and esthetics. In clinical
cases where more treatment options are possible, the levels
of patients education and their awareness of different treatment modalities have a significant effect on the final treatment
decision.3
After tooth extraction, the process of alveolar bone resorption begins. This process often leads to a clinical situation where
there is no longer sufficient bone support for the proper functioning of the complete removable dental prosthesis (RDP).4
The problem is especially expressed in the mandible,4 where,
due to the complete RDPs poor retention and stability, its function will also become insufficient, thus affecting the patients
satisfaction and oral health-related quality of life (QoL). In such

cases, this problem can be solved by fabricating a complete

RDP retained on dental implants (DIs). The use of osseointegrated DIs has become a successful procedure for the treatment
of complete and partial edentulism.5-9 With about one million
implants inserted annually worldwide, implantology has become an integral part of dental practice.10 The problem that
cannot be ignored is the actual level of patient knowledge and
awareness of therapy with DIs and the opportunities offered
by such therapy, especially when the patients are elderly people who often suffer from some chronic illness. At this time,
when implantology is used widely, it is problematic that patients
are often confronted with confusing information provided by
the media and the dental industry, which is, at times, deliberately misleading and marketing oriented.10 This problem is
especially present in developing countries, where dentists and
other health authorities are not doing enough to educate patients and spread the awareness of DIs and implant therapy.11,12
Data on patients knowledge of DIs helps to match the patients

C 2014 by the American College of Prosthodontists

Journal of Prosthodontics 24 (2015) 3742 

37

Knowledge of Dental Implants

Kranjcic et al

expectations with objective implant therapy achievements, and

so, helps to change the sometimes negative image of implant
treatment caused by a communication gap and by consumer
discontent.10
The level of knowledge and awareness of DIs and implant
treatment varies among several studies performed in different
countries.10-22 Public awareness, positive attitude, and the acceptance of DIs were found to be high in a study conducted by
Zimmer et al in America,21 while a low level of awareness about
DI treatment was found among patients in Finland.16 Best22 reported that in Australia significantly more patients attending
private dental practices had heard of DIs. Pommer et al23 compared the results of their study with the results of a similar study
conducted 7 years earlier in Austria and found that during the
7-year period the subjective level of patient information about
implant dentistry had significantly increased, with the present
patients implant awareness being 79%.23
Intrigued by various results from the literature and by lack
of data on patient knowledge about DIs in Croatia, the authors
conducted this study to examine the knowledge and awareness
of elderly patients (wearing complete RDPs) from Zagreb and
Slavonski Brod about DIs and implant treatment options and
the possibility of retaining complete RDPs using DIs. Another
aim of this study was to investigate any correlation between the
awareness of DIs and the participants age, gender, residence
size, level of education, and oral health impact profile (OHIP)
summary score.

Materials and methods

This cross-sectional study included 301 participants between
the ages of 60 and 99, who wore mandibular and/or maxillary
complete RDP. The participants included in this study were residents of elderly care homes in the area of Zagreb and Slavonski
Brod in Croatia. They were of good mental and cognitive health
(capable of understanding and filling out the questionnaire). All
participants were informed about the objectives and aims of this
study, after which a written consent was obtained for their participation. This study was approved by the Ethics Committee of
the School of Dental Medicine, University of Zagreb, Croatia.
The questionnaire was specifically designed to assess the
knowledge and awareness of DIs among elderly people wearing
complete RDPs. One of the authors (the examiner) interviewed
all participants by the face-to-face method; therefore, the response rate was 100%, with all questions answered. The questionnaire used in this study consisted of two sections. In the first
section were questions about age, gender, population of residents hometownoriginal place from where participants came
to Zagreb or Slavonski Brod (up to 10,000 residents; 10,000
to 50,000 residents; 50,000 to 100,000 residents, 100,000 to
300,000 residents, and more than 300,000 residents) and the
participants level of education (no school completedNS,
completed elementary schoolES, completed high school
HS, and college/university degreeCO).
The second section of the questionnaire consisted of 12 questions designed to assess the participants knowledge and awareness of DIs:
(1) Have you ever heard of DIs? (2) Have you ever heard
about the possibility of retaining complete RDPs using DIs?
38

(3) Do you believe in the method of retaining complete RDPs

by using DIs? (4) Do you understand the insertion procedure
of DIs? (5) Do you think that the insertion procedure and the
healing period of DIs are painful? (6) Are you afraid of the DI
insertion procedure? (7) Does the insertion of DIs require local
or general anesthesia? (8) Is the insertion of DIs performed in
dental surgery or does it require hospitalization? (9) Do you
think that the costs of insertion procedures for DIs as retainers
for complete RDP in one jaw exceed an amount of US$1000
(cca 5500 Croatian kunas)? (10) Would you decide on such a
procedure if your financial situation would allow it? (11) Would
you agree to pay the costs of up to US$1000 (cca 5500 Croatian
kunas) for such a procedure? (12) Would you agree to pay the
costs of up to US$2000 (cca 11000 Croatian kunas) for such a
procedure? All questions had dichotomous answers.
The OHIP questionaire consisted of 49 questions (OHIP49).24 All participants filled out the Croatian version of the
OHIP-49 questionnaire25 to assess the correlation between the
knowledge of DIs and the quality of oral health and participants satisfaction/dissatisfaction with complete RDP. For each
question, the participants were asked to rate how frequently
they had experienced the investigated variable during the past
month. Responses were rated using a Likert-type scale (0 =
never, 1 = hardly ever, 2 = occasionally, 3 = fairly often, 4
= very often). Zero indicated the absence of any problems.
The higher scores indicated more impaired oral health.25 The
results from the OHIP-49 questionnaire were used as the OHIP
summary score.
The results obtained were statistically analyzed using SPSS
15.0 (SPSS Inc., Chicago, IL) by descriptive statistics method,
and the differences were tested for significance by the independent sample Students t-test, 2 test. The correlation between
the variables was tested with Spearmans and Pearsons coefficient of correlation with a significance level of 0.05.

Results
The study group included 301 participants between the ages of
60 and 99 (with an average age of 74); 67 participants (22.3%)
were younger than 65 years of age, 88 (29.2%) were aged
between 66 and 75 years, 84 (27.9%) were aged between 76 and
85 years, while 62 (20.6%) were older than 85 years (Table 1).
There were 202 female (67%) and 99 male (33%) participants
in the study group.
The participants from elderly care homes in Zagreb and
Slavonski Brod were grouped into five categories, according
to the their hometown (original place from where participants
came to Zagreb or Slavonski Brod) population: 64 (21.3%)
participants were from places with up to 10,000 residents;
32 (10.6%) from places with 10,000 to 50,000 residents, 100
(33.2%) from places with 50,000 to 100,000 residents, 12 (4%)
from places with 100,000 to 300,000 residents, and 93 (30.9%)
from places with more than 300,000 residents (Table 1). Also,
participants were grouped by the level of education: 56 (18.6%)
CO, 139 (46.2%) HS, 78 (25.9%) ES, and 28 (9.3%) NS
(Table 1).
The participants awareness of DIs was statistically significantly (p < 0.05) affected by age, town size, and education
level. According to age groups (Table 1), the majority of

C 2014 by the American College of Prosthodontists

Journal of Prosthodontics 24 (2015) 3742 

C 2014 by the American College of Prosthodontists

Journal of Prosthodontics 24 (2015) 3742 

E
n = 64
F
n = 32
G
n = 100
H
n = 12
I
n = 93
%
P

J
n = 56
K
n = 139
L
n = 78
M
n = 28
%
p

O
n = 99
R
n = 202
%
p

301
100%

Place

Education

Gender

Total

No

170
56.5%

131
43.5%

62
37
20.6%
12.3%
108
94
35.9%
31.2%
56.5
43.5
0.140

45
11
15%
3.6%
95
44
31.6%
14.6%
21
57
7%
18.9%
9
19
3%
6.3%
56.5
43.5
0.000

26
38
8.6%
12.6%
21
11
7%
3.7%
67
33
22.3%
11%
8
4
2.7%
1.3%
48
45
15.9%
14.9%
56.5
43.5
0.009

59
8
19.6%
2.7%
44
44
14.6%
14.6%
43
41
14.3%
13.6%
24
38
8%
12.6%
56.5
43.5
0.000

Yes

2
No

119
39.5%

182
60.5%

40
59
13.3%
19.6%
79
123
26.2%
40.9%
39.5
60.5
0.900

31
25
10.3%
8.3%
67
72
22.3%
23.9%
12
66
4%
21.9%
9
19
3%
6.3%
39.5
60.5
0.000

23
41
7.6%
13.6%
11
21
3.7%
7%
44
56
14.6%
18.6%
4
8
1.3%
2.7%
37
56
12.3%
18.6%
39.5
60.5
0.799

39
28
13%
9.3%
32
56
10.6%
18.6%
30
54
10%
17.9%
18
44
6%
14.6%
39.5
60.5
0.004

Yes

3
No

169
56.1%

132
43.9%

61
38
20.3%
12.6%
108
94
35.9%
31.2%
56.1
43.9
0.216

45
11
15%
3.7%
93
46
30.9%
15.3%
17
61
5.6%
20.3%
14
14
4.6%
4.6%
56.1
43.9
0.000

36
28
12%
9.3%
17
15
5.6%
5%
51
49
16.9%
16.3%
9
3
3%
1%
56
37
18.6%
12.3%
56.1
43.9
0.476

50
17
16.6%
5.6%
46
42
15.3%
14%
41
43
13.6%
14.3%
32
30
10.6%
10%
56.1
43.9
0.006

Yes

No

46
15.3%
25
8.3%
72
23.9%
10
3.3%
60
19.9%
70.8
0.462

41
13.6%
66
22%
58
19.3%
48
16%
70.8
0.161

88
29.2%

213
70.8%

31
68
10.3%
22.6%
57
145
18.9%
48.2%
29.2
70.8
0.592

26
30
8.6%
10%
46
93
15.3%
30.9%
8
70
2.7%
23.2%
8
20
2.7%
6.6%
29.2
70.8
0.000

18
6%
7
2.3%
28
9.3%
2
0.7%
33
11%
29.2

26
8.6%
22
7.3%
26
8.6%
14
4.6%
29.2

Yes

5
No

218
72.4%

83
27.6%

67
32
22.3%
10.6%
151
51
50.2%
16.9%
72.4
27.6
0.218

33
23
11%
7.6%
102
37
33.9%
12.3%
59
19
19.6%
6.3%
24
4
8%
1.3%
72.4
27.6
0.044

45
19
15%
6.3%
21
11
7%
3.7%
74
26
24.6%
8.6%
8
4
2.7%
1.3%
70
23
23.2%
7.6%
72.4
27.6
0.816

48
19
15.9%
6.3%
67
21
22.3%
7%
59
25
19.6%
8.3%
44
18
14.6%
6%
72.4
27.6
0.830

Yes

6
No

195
64.8%

106
35.2%

56
43
18.6%
14.3%
139
63
46.2%
20.9%
64.8
35.2
0.041

25
31
8.3%
10.3%
88
51
29.2%
17%
59
19
19.6%
6.3%
23
5
7.65%
1.7%
64.8
35.2
0.000

41
23
13.6%
7.6%
21
11
7%
3.7%
68
32
22.6%
10.6%
6
6
2%
2%
59
34
19.6%
11.3%
64.8
35.2
0.796

37
30
12.3%
10%
63
25
21%
8.3%
58
26
19.2%
8.6%
37
25
12.3%
8.3%
64.8
35.2
0.120

Yes

7
Ga

159
52.8%

142
47.2%

52
47
17.3%
15.6%
107
95
35.5%
31.6%
52.8
47.2
1,000

46
10
15.3%
3.3%
79
60
26.2%
20%
23
55
7.6%
18.3%
11
17
3.7%
5.6%
52.8
47.2
0.000

35
29
11.6%
9.6%
14
18
4.7%
6%
37
63
12.3%
20.9%
10
2
3.3%
0.7%
63
30
20.9%
10%
52.8
47.2
0.000

43
24
14.3%
7.9%
31
57
10.3%
19%
50
34
16.6%
11.3%
35
27
11.6%
9%
52.8
47.2
0.001

La

8
Ho

148
49.2%

153
50.8%

43
56
14.3%
18.6%
105
97
34.9%
32.2%
49.2
50.8
0.178

41
15
13.6%
5%
71
68
23.6%
22.6%
26
52
8.6%
17.3%
10
18
3.3%
6%
49.2
50.8
0.000

29
35
9.6%
11.6%
13
19
4.3%
6.3%
36
64
12%
21.3%
10
2
3.3%
0.7%
60
33
19.9%
11%
49.2
50.8
0.000

39
28
12.9%
9.3%
33
55
11%
18.3%
40
44
13.3%
14.6%
36
26
12%
8.6%
49.2
50.8
0.029

Ds

>1000

41
13.6%
16
5.3%
65
21.6%
7
2.3%
80
26.6%
69.4
0.000

45
15%
46
15.3%
64
21.3%
54
17.9%
69.4
0.000

92
30.6%

209
69.4%

31
68
10.3%
22.6%
61
141
20.3%
46.8%
30.6
69.4
0.894

11
45
3.7%
15%
44
95
14.6%
31.5%
28
50
9.3%
16.6%
9
19
3%
6.3%
30.6
69.4
0.230

23
7.7%
16
5.3%
35
11.65
5
1.7%
13
4.3%
30.6

22
7.3%
42
14%
20
6.6%
8
2.6%
30.6

<1000

10
No

95
31.6%

206
68.4%

31
68
10.3%
22.6%
64
138
21.3%
45.8%
31.6
68.4
1.000

21
35
7%
11.6%
54
85
17.9%
28.2%
14
64
4.7%
21.3%
6
22
2%
7.3%
31.6
68.4
0.006

28
36
9.3%
12%
9
23
3%
7.6%
32
68
10.6%
22.6%
3
9
1%
3%
23
70
7.6%
23.3%
31.6
68.4
0.144

35
32
11.6%
10.6%
29
59
9.6%
19.6%
21
63
7%
21%
10
52
3.3%
17.3%
31.6
68.4
0.000

Yes

No

39
13%
27
9%
67
22.2%
10
3.3%
70
23.2%
70.8
0.078

37
12.3%
61
20.2%
65
21.6%
50
16.6%
70.8
0.005

11

88
29.2%

213
70.8%

31
68
10.3%
22.6%
57
145
18.9%
48.2%
29.2
70.8
0.592

21
35
7%
11.6%
47
92
15.6%
30.6%
14
64
4.7%
21.2%
6
22
2%
7.3%
29.2
70.8
0.031

25
8.3%
5
1.7%
33
11%
2
0.7%
23
7.6%
29.2

30
10%
27
9%
19
6.3%
12
4%
29.2

Yes

No

40
13.3%
103
34.2%
69
22.9%
24
8%
78.4
0.034

43
14.3%
30
10%
77
25.6%
10
3.3%
76
25.2%
78.4
0.038

47
15.6%
67
22.3%
70
23.2%
52
17.3%
78.4
0.154

12

65
21.6%

236
78.4%

24
75
8%
24.9%
41
161
13.6%
53.5%
21.6
78.4
0.458

16
5.3%
36
12%
9
3%
4
1.3%
21.6

21
7%
2
0.7%
23
7.6%
2
0.7%
17
5.6%
21.6

20
6.6%
21
7%
14
4.7%
10
3.3%
21.6

Yes

Questions: 1. Have you ever heard about DIs? 2. Have you ever heard about the possibility of retaining complete RDPs using DIs? 3. Do you believe in the retaining method of complete RDPs by using DIs? 4. Do
you understand the DI insertion procedure? 5. Do you think that the insertion procedure and the healing period of DIs are painful? 6. Are you afraid of the DI insertion procedure? 7. Does DI insertion require local
or general anesthesia? 8. Is DI insertion performed in dental surgery or does it require hospitalization? 9. Do you think that the costs of insertion procedure for DIs as complete RDP retainers in one jaw exceed an
amount of cca US$1000? 10. Would you decide on such a procedure if your financial situation would allow it? 11. Would you agree to pay the costs of up to US$1000 for such a procedure? 12. Would you agree to
pay the costs of up to US$2000 for such a procedure? A-up to 65 years of age, B-66 to 75 years of age, C-76 to 85 years of age, D- more than 86 years of age, E- up to 10,000 residents, F-10,000 to 50,000 residents,
G-50,000 to 100,000 residents, H-100,000 to 300,000 residents, I- more than 300,000 residents, J-completed college/university, K-completed high school, L-completed elementary school, M- no school completed,
O-male, R-female, La-local anesthesia, Ga-general anesthesia, Ds-dental surgery, Ho-hospitalization, N-total number of participants, p- value of statistical significance.

A
n = 67
B
n = 88
C
n = 84
D
n = 62
%
P

Age
groups

N = 301

Questions

Table 1 Distribution of answers from questionnaire about participants awareness of dental implants with regard to age groups, residence place size, level of education, and gender (percentages
expressed as percent of total population)

Kranjcic et al
Knowledge of Dental Implants

39

Knowledge of Dental Implants

Kranjcic et al

participants from the age group younger than 65 years had

heard about DIs (88.1%; p < 0.05). They had also heard about
the possibility of retaining complete RDPs using DIs (58.2%;
p < 0.05) and believed in the possibility of retaining complete
RDPs using DIs (74.6%, p < 0.05). Most participants from each
age group thought that the costs of insertion procedure for DIs,
as retainers of complete RDP in one jaw, exceeded US$1000
(p < 0.05), and they would not agree to pay the costs of up to
US$1000 (p < 0.05) or US$2000 (p < 0.05) for such a treatment
(Table 1). More of the younger participants had heard about DIs
(56.5%; p < 0.05; x = 70 years; SD = 12.74) and believed in
the possibility of retaining complete RDPs using DIs (56.1%;
p < 0.05; x = 72 years; SD = 13.02). On the contrary, the
older participants were more uninformed about the possibility
of retaining complete RDPs using DIs (60.5%; p < 0.05; x =
76 years; SD = 11.08) and expected the required costs for such
a treatment in one jaw to be over US$1000 (69.4%; p < 0.05;
x = 75 years; SD = 12.52). Even if their financial situation
would allow it, they would not opt for DI insertion for retaining
complete RDPs (68.4%; p < 0.05; x = 76 years; SD = 11.02)
and would not pay even US$1000 (70.8%; p < 0.05; x = 75
years; SD = 11.42), or more (78.4%; p < 0.05; x = 75 years;
SD = 11.94) for such a treatment. According to gender, there
were more female participants (139, 71.2%) who were afraid
of the placement procedure of DIs (p < 0.05).
Among participants coming from places with 10,000 residents or fewer, the majority had not heard about DIs (59.4%; p
< 0.05). Among participants with the opinion that the implant
insertion procedure requires general anesthesia and hospitalization, there were many more participants (57%; 54.2%; p <
0.05) from smaller residence areas (10,000 to 50,000 residents
and 50,000 to 100,000 residents). In each group of participants
(according to the size of place of residence), there were more
of those with the opinion that the costs for DI insertion in one
jaw would be more than US$1000 (69.4%; p < 0.05), and also
those who would not be willing to pay for this treatment up to
US$2000 (78.4%; p < 0.05).
Among CO and HS participants, a higher number of participants had heard about DIs (82.4%; p < 0.05) and believed in
the success of retaining complete RDPs using DIs (81.7%; p
< 0.05). They also considered DI insertion as a dental surgery
treatment (75.7%; p < 0.05) performed under local anesthesia (78.6; p < 0.05). In all groups (divided according to education level), more participants who did not understand the
implant insertion procedure (70.8%; p < 0.05), were afraid of
the mentioned procedure (72.4%; p < 0.05). Also, the majority of participants in all educational groups would not opt for
the implant treatment procedure even if their financial situation
would allow it (68.4%; p < 0.05). They would not be willing
to pay up to US$1000 (70.8%; p < 0.05), or more (78.4%; p <
0.05) for such a treatment. The detailed results of the answers to
the questionnaire (according to the age groups, residence place
size, level of education, and gender) are shown in Table 1.
The mean OHIP summary score value obtained in this study
was 26.52 (minimum value 0.0 and maximum value 175.0).
Spearmans coefficient of correlation between age groups, gender, size of place of residence, participants education level,
and answers from the questionnaire (as well as Pearsons coefficient of correlation between the OHIP summary score and the
40

answers about the knowledge of DIs) reveal weak correlation

or no correlation among variables.
Some correlation coefficients between the 12 answers about
the knowledge of DIs reveal a strong correlation. Participants
who had heard about DIs had also heard about the possibility of
retaining complete RDPs using DIs (r = 0.600; p < 0.05), and
believed in the success of this method (r = 0.602; p < 0.05).
Those who heard about the possibility of retaining complete
RDPs using DIs also understood the DI insertion procedure
(r = 0.675; p < 0.05). Participants who considered implant
insertion to be painful were also afraid of this procedure (r
= 0.526; p < 0.05). Participants with the knowledge that the
implant insertion is performed under local anesthesia also knew
that it is a treatment performed in dental surgery (r = 0.743; p
< 0.05). Those who would decide to opt for such a treatment
would pay for up to US$1000 (r = 0.852; p < 0.05) or even
more (r = 0.738; p < 0.05).

Discussion
DIs are increasingly used in the prosthetic treatment of edentulous patients to improve denture retention, stability, and functionality, thereby affecting the oral health-related QoL.9,12,13
This statement is supported by Grogono et al,26 who reported
that 88% of the individuals studied had an increase in selfconfidence after implant treatment, 89% would accept implant
procedure treatments again, and 98% stated that their oral
health had generally improved.26 However, the information
available to patients regarding the implant insertion procedure
and its success is often fragmentary, especially in developing
countries.11,12 If there is an insufficient awareness of DI therapy possibilities among the patients, they often think there is
no limit for implant treatments, and therefore, their expectations about implant therapy possibilities (based on incorrect
knowledge) will also increase.15
Searching the literature for studies on the topic of DI awareness, the possible disadvantages and limitations of such studies
could be perceived, such as the variable sample size, manner
in which the participants were interviewed, and the selection
of participants. Tepper et al9 discussed the aforementioned factors, thus listing the range of the participant number in different
studies, from 61 to 5000 participants.10 The number of questions asked also varies; more details could be elicited if the
questionnaire is more extended.10 In this study, one examiner
completed the questionnaire face to face with each participant.
This method is more time consuming and cost intensive, but
the response rate was very high, compared to other methods of
data collecting, such as public interviews, where time is a limiting factor, or through mailed or handed out questionnaires.10
A common feature of all the participants in this study was
complete edentulism, at least in one jaw, regardless of the participants satisfaction with the existing complete RDP. Due to
the possibility of retaining complete RDPs using DIs5-8 (also
improving the stability and functionality), it seemed important
to examine whether elderly people knew what DIs really are,
what they could be used for, or whether the participants (patients) need adequate education. All participants in this study
lived in elderly care homes in Zagreb and Slavonski Brod because it was the simplest way to gather elderly people with

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Journal of Prosthodontics 24 (2015) 3742 

Kranjcic et al

various education levels, who actually originate from different residences due to the assumption that these factors affect
the patients DI awareness. Participants in other studies were
mostly younger and usually received dental care at university
or private dental clinics.11-13,17
This study confirmed the assumption that age, size of place of
residence, and education level affects the participants awareness and knowledge of DIs and the procedure of implant insertion. More than a half (56.5%) of participants included in
this study had heard about DIs. These participants, with regard to average age, were in a younger age group (average
age of 70 years), and many of them were younger than 65
years. Kaurani and Kaurani11 conducted a similar study among
the urban Indian population and stated that only 38% of participants had heard about DIs as a treatment modality. Most
participants informed about DIs were also in the younger age
group (25 to 44 years), while all participants older than 80
years were uninformed.11 Al Johany et al13 reported that the
subjective level of information about DIs varied, ranging from
66.4 to 77% of the investigated participants, with the majority of participants under 30 years of age. In contrast, Kumar
et al,17 Satpathy et al,12 and Chowdary et al19 reported very
low awareness and knowledge level of DIs in India, but also
among younger participants (mostly between 30 and 50 years
of age), than in our study (including the advantages and disadvantages of such a treatment), with just 12.5%,17 15.91%,12
and 23.24%,19 respectively. Results from this study could be
compared with the results of other studies worldwide, with low
levels of awareness about DI treatment procedures among 55year-old patients in Finland,16 and with a higher awareness rate
in Austria (72%),9 where 37.8% of participants were over 50
years old. In a study by Berge et al20 conducted in Norway
with almost half of the participants over 45 years of age, 70.1%
had heard of oral implants, while 56.7% would consider oral
implants as a treatment suitable for themselves, if needed. Also,
many patients are unaware of the complexity of the planning,
realization, and aftercare of an implant-supported overdenture.
The fallacy that implants are less care intensive than natural
teeth is not widespread among patients,15 and only 7% of patients expect a lower need for care.15 Concerning the lack of
awareness among Indian people regarding DIs, Kaurani and
Kaurani reported no statistical difference in the awareness between men and women.11 That finding is in accordance with the
results of our study, where women were more afraid of the DI
insertion procedure. As expected, the fear of DI insertion was
also present in the participants with lower levels of education
and in the NS group of participants.
According to the results of this study, the level of participants
education is a serious factor affecting the awareness of DIs.
Data that more participants from HS and CO groups were informed about the possibility of retaining complete RDPs using
DIs, and that the implant insertion is a procedure performed in
dental surgery under local anesthesia supports this observation.
Kaurani and Kaurani11 also reported that educated participants
with a university/college degree were mostly better informed.
Regarding the size of the place of residence, more than half
the residents from smaller places (up to 10,000 residents) had
not heard about DIs (unlike participants from more populated
places), but in all the participant groups, the prevailing opin-

Knowledge of Dental Implants

ion was that costs for the DI insertion procedure for retaining
complete RDPs are much higher than they really are. These
findings are in accordance with the hypothesis that factors such
as living in urban areas (more populated), a higher level of
education, and age can be considered as the main factors affecting DI awareness among the population.11 A higher rate
of awareness among younger and more educated populations
may be attributed to the better information availability with
the use of newer technologies (e.g., the internet),11 although
some authors report that dentists, printed media, family, and
friends are the main information source, followed by the internet, radio, and TV.10,11,13-15 The abovementioned sources of
information,10,11,13-15 as well as the data from this study, should
be a stimulation for dentists to educate their patients about DIs
and treatment possibilities, individually in their practices or
even through organized lectures in elderly care homes.
Although more than half the participants in this study had
heard of DIs, it did not mean that they are well informed about
the procedure of implant insertion and the costs for such a
treatment. Therefore, it can be concluded that they were insufficiently informed. The prevailing opinion (69.4%) that the
costs of DI insertion treatment for one jaw are over US$1000
is wrong due to the fact that patients pay just the costs of implants, while the insertion procedure (together with production
of RDPs) is paid by the Croatian Institute for Health Insurance.
In addition, most likely due to poor awareness, most participants
would decide not to opt for such treatment options, even if their
financial situation would allow it. The problem also exists in
the Croatian Institute for Health Insurance, which only partially
covers the costs for such a treatment (insertion procedure but
not the implants), while they pay in full the surgical treatment
of vestibuloplasty, which is much more invasive, and provides
worse results in retaining complete RDPs according to authors observations through decades of practice in prosthodontics. Also, Raghoebar et al27,28 compared retention, esthetic
satisfaction, comfort, and ability to eat and speak between
patients wearing implant-retained mandibular RDPs, conventional RDPs, and RDPs after vestibuloplasty. Their findings
also support the thesis that implant-retained overdentures are
a favorable treatment modality for edentulous patients needing
mandibular complete RDPs.27,28 In Rustemeyer et als study,
most of the patients/participants were prepared to make an additional payment for conventional implants of up to Euro2000
(US$2500),15 while participants in our study generally would
not bear the costs even to US$1000. This value is approximate,
and represents what patients would be (or not be) prepared to
pay for the insertion of DIs, thus improving complete RDP
retention. For patients, the cost is often the primary focus of
interest.15 That is, costs are often the major limiting factor for
treatment.11 Therefore, it is necessary to explain and illustrate
to the patients the connection between the costs and the results
of treatment.15 As the participants included in this study were
generally not well informed about DIs, and the correlation coefficients with the OHIP summary score were very weak, it
could be assumed that more dissatisfied participants wearing
poorly fitting removable prostheses (with higher OHIP summary scores) were also poorly informed about DIs and their
possibilities of complete RDP retention. That leads to the assumption that dissatisfied participants were disappointed with

C 2014 by the American College of Prosthodontists

Journal of Prosthodontics 24 (2015) 3742 

41

Knowledge of Dental Implants

Kranjcic et al

previous prosthetic treatment, but not interested in and not looking for other treatment options to improve their oral health.

Conclusion
Based on the results of this study, it can be concluded that the
participants were not well informed about DIs and the possibility of retaining complete RDPs using DIs. Due to the poor
knowledge and lack of awareness of DIs among participants,
causeless fear and wrong opinions regarding the treatment costs
prevailed. Age, level of education, and size of place of residence are factors affecting patient knowledge and awareness
of DIs. Dissatisfaction with previous prosthetic modality, and
thus, with the quality of oral health was not a conclusive factor
that affected the participants awareness of DIs. Generally, the
obtained results urge the need for better education and proper
provision of information to the population about DIs.

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C 2014 by the American College of Prosthodontists

Journal of Prosthodontics 24 (2015) 3742