Fear of dental implants among edentulous patients
by
Jordan Nemes, B.Sc.
Faculty ofDentistry, McGill University, Montreal
April 2007
A thesis submitted to McGill University in partial fulfillment of the requirements of the degree of Master' s in Dental Science
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ABSTRACT
Fear of dental implants among edentulous patients
Despite implant-supported overdentures' advantages over conventional dentures,
edentulous patients often refuse dental implants for reasons that may be related to fear.
Objective: The purpose of this study was to uncover and explain the various forms and
sources of dental implant-related fear among edentulous patients. Methods: A convenient
sample of 8 edentulous/semi-edentulous participants was used. Participants were recruited
from a current study at McGill University's Faculty of Dentistry, posting of recruitment
flyers, and local homes and community centers for seniors. One-on-one interviews were
conducted in Montreal from March 2005 to February 2006, transcribed verbatim, and
coded into multiple theme~based sections. Results: Three categories of implant-related
~ .. fear were identified: 1) fear of dental implant surgery; 2) fear of the recovery period; and
3) miscellaneous fears. As weIl, four main sources of dental implant-related fear were
uncovered: 1) past negative experiences at the dentist; 2) "horror stories" of dental
implant surgery; 3) having relatively little knowledge of dental implants; and 4) po or
dentist-patient relationship. Discussion: The various forms of dental implant-related fear
seem to play a substantial role in influencing a patient's decision to undergo implant
surgery. IV
RÉSUMÉ
Malgré les avantages des implants dentaires sur les dentiers conventionnels, les patients
édentés refusent souvent les implants dentaires pour des raisons qui peuvent être reliées à la peur. Objectif: Le but de cette étude était de découvrir et d'expliquer les diverses formes et sources de peurs reliées aux implants dentaires parmi les patients édentés.
Méthodes: Un échantillon pratique de 8 participants édentés/semi-édentés a été utilisé pour cette recherche. Les participants ont été recrutés à partir d'un groupe de personnes d'une étude de l'Université de Mc Gill (Faculté de médecine dentaire), à l'aide de prospectus et en demandant dans des maisons et centres communautaires pour personnes
âgées. Des entrevues individuelles ont été menées à Montréal entre mars 2005 et février
2006. Elles ont été retranscrites mot par mot et codées dans des sections basées selon des thèmes multiples. Résultats: Trois catégories de la peur d'implants dentaires ont été identifiées: 1) la peur de la chirurgie de l'implant dentaire; 2) la peur reliée au temps de guérison; et 3) peurs diverses. De même, 4 sources principales reliées à la peur de l'implant dentaire ont été également identifiées: 1) une expérience passée négative chez le dentiste; 2) des « histoires d'horreurs» entendues sur la chirurgie d'implants dentaires;
3) une connaissance très limitée sur les implants dentaires; et 4) une mauvaise relation entre le dentiste et son patient. Discussion: Les diverses formes de peurs reliées aux implants dentaires semblent jouer un rôle important dans la décision du patient de subir ou non une chirurgie d'implants. v
Acknowledgements rd like to thank Dr. Christophe Bedos for aIl the support and guidance he has given me over the past two years. His expertise knowledge in qualitative research and public health dentistry were invaluable in helping me realize the results of this study. Moreover, his thorough and intuitive approach to research has helped me further my own research skills and develop as a Master's student. FinaIly, his patience, kindness, and willingness to help have driven me to perform at my best.
Secondly, l would like to thank the ITI Foundation for their funding and contribution to my research. Without their help, this study would not be possible. As weIl, l would like to thank Drs. Mark Thomason and Jocelyne Feine for allowing me to be part of their ITI research team. The past two years have been a great educational experience and l am truly appreciative for this opportunity.
Furthermore, the involvement of the Cummings Jewish Centre for Seniors was pivotaI in this study's participant recruitment process. l would like to thank Benita Goldin for granting me permission to use the facilities, Linda Strohl for her cooperation and help in finding potential participants, as weIl as aIl the administration, staff and volunteers at the centre who have helped contribute to my research. l would also like to thank Drs. Alissa Levine and Steven Jordan for their contributions to the development of this research project, as weIl as their guidance and knowledge of qualitative research. In addition, thank you to Nicolas Drolet and Mrs. Marta Hauptman for their facilitation of additional participant recruitment. Furthermore, l' d like to thank
Dr. Antoine Chehade for allowing me the opportunity to observe dental implant surgery first hand. VI
As weIl, 1 would like to thank aIl the participants of this study for taking the time to meet with me and discuss their dental-related experiences. 1 would also like to thank
Quintessence Publishing Co, Inc. for permission to use their pictures. These pictures are copyrighted and cannot be reproduced without the permission of the publisher.
FinaIly, l' d like to thank my family for their endless support and continuous motivation in helping me see this project to fruition. As weIl, a very special thank-you to my fiancée
Naomi Hauptman for aIl of her editing contributions, empathy, love and support, and for always being there for me. VIl
TABLE OF CONTENTS
1 Introduction ...... 1 2 Literature Review ...... 2 2.1 Edentulism ...... 2 2.2 Dentures ...... 5 2.3 Dental Implants ...... 7 2.4 Fear of Dental Implants ...... 13 2.5 Summary ...... 15 3 Objective ...... 17 4 Methods...... 18 4.1 Research Design ...... 18 4.2 Sample Recruitment ...... 20 4.2.1 Sample Criteria ...... 20 4.2.2 Recruitment ...... 20 4.3 Interview Procedure ...... 24 4.4 Data Analysis ...... 26 5 Results ...... 30 5.1 Fear of dental implant surgery ...... 30 5.1.1 Fear ofPain ...... 30 5.1.1.1 Fear ofNeedles and Anesthetic ...... 30 5.1.1.2 Fear of Dental Instruments ...... 32 5.1.1.3 Fear ofGum-Pain ...... 32 5.1.1.4 Fear of Suffering ...... 33 5.1.1.5 Fear of Lengthy Surgery ...... 33 5.1.1.6 Age-Related Fear ...... 34 5.2 Fear of the recovery period following dental implant surgery ...... 36 5.2.1 Fear ofPain...... 36 5.2.2 Fear of Infection ...... 37 5.2.3 Fear of Complications ...... 37 5.3 Miscellaneous Fears ...... 39 V111
5.3.1 Foreign Objects in the Body ...... 39 5.3.2 Fear of Drugs ...... 40 5.3.3 Fear of Change in Lifestyle ...... 42 5.3.4 Fear ofWaiting Room Time ...... 44 5.4 Picture Response ...... 45 5.5 Source of Fear of Dental Implants ...... 47 5.5.1 Past negative experiences at the dentist ...... 48 5.5.2 "Horror stories" of dental implant surgery ...... 50 5.5.3 Lack of Dental Implant-related Knowledge ...... 52 5.5.4 Poor dentist-patient relationship ...... 54 6 Discussion ...... 57 6.1 Limitations ...... 57 6.2 Fear of Dental Implants ...... 58 6.2.1 Fear of dental implant surgery ...... 58 6.2.2 Fear of the recovery period following dental implant surgery ...... 60 6.2.3 Miscellaneous fears ...... 62 6.3 Origins of Dental Implant-Related Fear...... 67 6.3.1 Past negative experiences at the dentist ...... 67 6.3.2 "Horror stories" of dental implant surgery ...... 68 6.3.3 Having relatively little knowledge of dental implants ...... 69 6.3.4 Poor dentist-patient relationship ...... 70 7 Conclusion ...... 72 7.1 Recommendations for Dentists ...... 72 7.2 Future Studies ...... 75 References ...... 76 ix
Appendix 1: Interview Guide
Appendix 2: Consent Form
Appendix 3: BriefInterview Reports 1-8
Appendix 4: Coding List x
LIST OF TABLES
Table 4-1: Participant Recruitment ...... '" ...... 23 Table 4-2: Interview Location ...... 24 Table 5-1: Sample Study ...... 29 Xl
LIST OF FIGURES
Figure 2-1: Two dental implants with baIl attachrnents situated in the lower anterior mandible ...... 7 Figure 2-2: Mandibular denture situated on top oftwo dental implants with baIl attachrnents ...... 7 Figure 2-3: Two dental implants with healing abutments ...... 10 Figure 2-4: After 3 months following surgery, the healing caps are removed and replaced with baIl attachrnents ...... l 0 Figure 2-5: Underside ofISO showing the two baIl attachrnent sockets ...... 10 Figure 2-6: Illustration of ISO clipping onto two dental implants with baIl attachrnents ...... 10 Figure 5-1: Two dental implants with baIl attachrnents situated in the lower anterior mandible ...... 45 Figure 5-2: Mandibular denture situated on top oftwo dental implants with baIl attachrnents ...... 45 1
1 Introduction
Edentulism (total tooth loss) is a common dental-related disability typically found among
the elderly population (1-3). This disability must be given substantial consideration from
dentists since edentulism can negatively affect one's quality of life (4, 5). To this end,
dentists have employed conventional dentures as the primary treatment for edentulism for
the last several decades. However, conventional dentures can never truly replace the full
functionality of one's natural teeth. Consequently, sorne edentulous individuals benefit
from using conventional dentures, while others may experience a multitude of problems.
Sorne of these problems, which usually occur in the mandibular denture involve:
Soreness, pain, instability, discomfort, and difficulty eating and speaking (6, 7). As well,
such difficulties may translate into stress and negative emotional responses among the
edentulous patient (5, 8, 9).
In order to improve sorne conventional denture shortcomings, dentists have
employed the implant-supported overdenture as a safe, reliable, and successful alternative
treatment. Moreover, implant-supported overdentures may offer unsatisfied conventional
denture wearers improvements in denture stability, mastication, speech, comfort,
nutrition, overall satisfaction, and oral health-related quality of life (10-12). However, for
reasons that remain unclear, unsatisfied denture wearers are often reluctant to undergo
dental implant surgery. To this end, it is important to critically analyze the reasons for
implant refusaI. One possible reason which will be addressed in this study is fear of dental
implants; specifically, the variations and sources of dental implant-related fear.
.r--. 2
2 Literature Review
2.1 Edentulism
Edentulism, defined as having no teeth, is a common oral condition among elderly individuals. It is often the result of tooth extractions associated with certain oral diseases and health conditions. Although edentulism might seem like a disability to the layman, it is nonetheless considered as a physical impairment according to the World Health
Organization (4). This is due to the fact that edentulism involves the loss of a body part
(an 32 teeth), an essential criteria in defining physical disabilities. To this end, edentulism can significantly affect oral health-related quality oflife (5). In particular, edentulism may impair two vital functions of the mouth: Eating and speaking.
Furthermore, edentulism can also lead to negative psychological effects and emotional states, and certain health conditions (5). One study by Fiske et al. identified several negative emotional reactions as a consequence of total tooth loss. Sorne of these emotional responses were feelings of bereavement and lowered self-confidence, dislike of appearance, secretive behavior, and altered behavior during socialization (8). As a result of these emotional responses, edentulous individuals may experience difficulty in socializing. Moreover, edentulous individuals are often labeled "toothless" or "denture wearer", which can lead to isolation and further social embarrassment (9).
Edentulism is also associated with certain health conditions. For example, a study conducted in the United Kingdom observed that edentulous individuals refrained from eating certain types of food (Ex: Fruits, vegetables, and certain sources of dietary fibers)
(9). Due to the absence of these foods in their bodies, blood tests among the participants showed lower levels of plasma ascorbate and plasma retinol, which may increase the risk 3 of dermatological and visual problems (9, 13). To this end, sorne health conditions among edentulous people are often the result of malnutrition, which is a consequence of food avoidance. In fact, when compared to dentate adults, edentulous individuals consume less non-starch polysaccharides, protein, carbohydrates, fiber, calcium, iron, and vitamins BI,
B6 and C (14-16). Consequently, edentulous individuals may be vulnerable to certain health problems resulting from po or nutrition.
Therefore, edentulism can negatively affect both the physical and mental health of an edentulous individual and thus it is important to identify the population most at risk of developing this disability. One population that is commonly associated with edentulism is the elderly; it is known that the rate of edentulism increases with age. More specifically, individuals aging over 65 are most likely to suffer from edentulism among the general population (1). In spite of this fact, tooth loss is not considered to be part of the natural aging process. Rather, tooth loss coincides with dental carries and periodontal disease which are cumulative with age. Furthermore, exponential models show rapid increases in the rate of edentulism after 70 years of age (2, 3). This rapid increase in the rate of edentulism is often the result of extractions of the last remaining teeth (which are usually done in a single treatment).
Gender differences III the rates of edentulism have also been reported. For instance, it has been shown that women are more likely to 100se their teeth than men (17).
In fact, worldwide data for all age groups show that the rate of edentulism in females is
3% higher than the rate of edentulism among males at a statistically significant difference
(P < .001) (1). On the contrary, surveys conducted in several countries show higher rates of edentulism among men (18). Furthermore, it has aiso been shown that gender 4 differences in the rates of edentulism seem to be disappearing altogether (1). To this end, the exact gender differences in the rates of edentulism remain unclear.
Socioeconomic factors, specifically education and income, are also known to affect the rate of edentulism. For one thing, greater education in society promotes the importance of preserving one's own teeth. To this end, the rates of edentulism among more educated populations tend to be lower than that of lesser educated populations. For instance, one study by Brodeur et al. showed that individuals with less education were three times more likely to be edentulous than individuals with higher levels of education
(19). In addition, the Canadian Health Promotion Survey from 1990 showed that the 10% of the population aged 15-98 who attended college had an edentulous rate of only 4%, while 50% of those with the least education (elementary school or less) were edentulous
(1).
Income is also strongly associated with edentulism (20). For example, tooth extraction is a relatively inexpensive dental procedure, as well as a means to preparing the mouth for full dentures. Furthermore, edentulous individuals are able to restore masticatory function and have an aesthetically pleasing look through the use of full dentures, which costs only a fraction of the price of alternative treatments (i.e.: Root canal therapy, crowns, veneers etc ... ) (21). Therefore, those with lower levels of income are more likely to be edentulous than those with higher levels of income because complete tooth extraction, combined with full dentures, is often the most economical intervention of choice (1).
Finally, edentulism is a common dental-related disability in Quebec, Canada. In fact, Quebec has one of the highest rates of edentulism across Canada and the world. It has been observed that approximately 67% of the 65+ age group in Quebec are 5 edentulous (1). In another survey, the rate of edentulism in Quebec was found to be approximately 58% among a similar population. Furthermore, there exists a significantly higher rate of edentulism in Quebec among specific high risk groups (i.e.: Low income, low levels of education, etc ... ) (19). To this end, it is clear that edentulism represents a significant oral healthcare problem in Quebec.
2.2 Dentures
For the greater half of the twentieth century, the majority of edentulous people used conventional dentures as a means of complete tooth replacement. The mandibular denture has a simple horse-shoe shaped appearance; it retains to the mouth either through natural suction and/or adhesives (used with unstable dentures), and can provide an aesthetically pleasing look. In addition, conventional dentures may partially restore the mouth with the ability to chewand grind food. Moreover, the mandibular denture is considered to be a co st-effective treatment for edentulous individuals (21). Conventional dentures are also preferred by edentulous individuals since they do not require any surgical intervention.
To this end, people suffering from edentulism may opt for the conventional denture since it can be an effective and relatively inexpensive treatment.
However, in spite of the benefits of conventional dentures, edentulous people often experience various problems with the mandibular denture. Sorne of these problems include: Poor fit and retention, instability, pain, discomfort, soreness and inflammation in the supporting mucosa and underlying bone, difficulty chewing, and even altered facial appearance (6, 7). One study by Tallgren showed how the residual ridge supporting the mandibular denture can become unstable due to resorption after complete tooth removal
(6). As a result' denture wearers may find their dentures to be both uncomfortable and 6 poor fitting, which can lead to unwanted movement of the denture while retained in the mouth. This unwanted movement may irritate the surrounding mucosa and lead to even further resorption of the residual alveolar ridges. Consequently, the height of the denture wearer's face may also be negatively effected (22).
Furthermore, CUITent research asserts that dentures may cause sorne individuals soreness and pain in the sUITounding mucosa and mandible in general (7, 9, 14, 23).
Consequently, denture wearers experiencing such discomfort may remove their dentures when in the comforts of their homes. Therefore, day-to-day usage of complete dentures may prove to be a difficult and uncomfortable task for sorne edentulous individuals.
Another concem of denture wearers is the difficulty to chew and grind food. For instance, it is known that the denture support offered by the residual ridge is less than a quarter of the support that the periodontium offer to natural teeth (9). Therefore, it seems unlikely that conventional dentures can fully replace the masticatory function of natural teeth. Furthermore, denture wearers often have difficulty biting and chewing certain foods. Millwood and Heath outlined sorne of these foods: Fruits (especially apples), vegetables, dietary fibers, and certain meats (roast beef and overcooked meat) (24). In fact, the same study showed that 69% of 54 edentulous people interviewed felt that their food choice was restricted because of their chewing difficulties. Consequently, most of the participants of this study chose to eat softer foods that were easier to chew.
As a result of the negative consequences of wearing conventional dentures, edentulous individuals are often affected in ways that negatively impact their quality of life. One obvious example of this negative impact is the difficulty that sorne denture wearers have when speaking. For example, sorne denture wearers experience difficulties in pronouncing certain words and letters, whereas others experience general speech 7 difficulties (25, 26). Food choice restriction is also an important factor when evaluating the quality of life among edentulous people. For instance, the avoidance of certain foods among denture wearers with masticatory difficulties is among the main causes of involuntary weight loss in elderly individuals (9). Subsequently, this restricted diet may also lead to malnutrition as it affects the denture wearer' s nutritional state. Furthermore, sorne edentulous people may even avoid eating outside their homes as they fear the embarrassment of the prolonged time that it takes for them to finish eating their meals
(24). Therefore, since eating and speaking contribute to both pleasure and integral functions of life, it is clear that a hindrance in these two necessary functions may negatively impact the quality of life among edentulous individuals.
2.3 Dental Implants
Due to recent advancements III dental sCIence, edentulous individuals are no longer restricted to conventional dentures as the sole treatment for edentulism. An optional alternative to the conventional denture is an implant-supported overdenture (herein referred to as ISO). In this denture system, dentures are fabricated to conform to the mouth and adjusted to easily clip onto osseointegrated dental implants (See Figures 2-1
& 2-2).
Figure 2-1: Two dental implants with ball Figure 2-2: Mandibular denture situated on attachrnents situated in the lower top of two dental implants with anterior mandible (27). ball attachrnents (28). 8
Two variations of osseointegrated dental implants are typically used in
conjunction with ISO's. These variations consist of bar and ball attachments. The
decision to use one attachment system over another depends on the experienced
clinician' s judgment on which implant system would be most suitable to their patient
(29). To this end, each dental implant variation has its advantages and disadvantages, and
can be equally successful providing they are employed correctly and are properly suited
to their patient's oral condition. Furthermore, few dental implants are required to deliver
adequate support to the overdentures. In fact, several studies have shown that two dental
implants with ball attachments are usually sufficient in facilitating proper ISO
functionality (28-30). However, in the case of patients with advanced oral conditions,
additional implants may be required to minimize excessive overdenture movement.
In order to determine one's suitability for dental implants, the patient must first ~-
consult with their dentist and regular physician. The dentist then conducts panoramic
radiographs in order to assess whether or not the patient has sufficient residual bone
available for implant placement (30). As weIl, the patient must be in good overall health
since certain health conditions may prevent proper osseointegration of the dental
implants. Sorne of these health conditions include: uncontrolled diabetes and other
metabolic diseases, certain hematological and immunological diseases, and chronic use of
systemic steroids (30). Furthermore, advanced age and tobacco use can also limit
successful implantation under certain circumstances (29, 30).
Once the patient's suitability for dental implants has been confirmed, an
appointment should be made with the dental surgeon to proceed with implant surgery.
During surgery, the dental implants are usually placed in the anterior mandible and are
located in the lateral incisor positions (30). However, the exact positioning of the dental 9
implants may vary depending on the needs of the patient. Furthermore, implant surgery is
conducted under local anesthetic and usually lasts for approximately 45-75 minutes
depending on the complexity and difficulty of each patient' s surgery requirements (31,
32). Moreover, pain levels both during and after surgery are kept to a minimum pro vi ding
that the patients follow all post-surgical instructions and take the necessary pam
medication (32). Upon completion of implant surgery, patients are left with
osseointegrated dental implants with healing abutments, which will be replaced by ball
attachments after the initial 3 month healing period is complete (See Figures 2-3 & 2-4)
(28). As well, patients are advised not to wear their existing mandibular dentures for the
first 2 weeks following surgery in order to ensure adequate healing of the implant site.
After these 2 weeks, patients can wear their existing mandibular dentures providing the
undersurface has been coated with a tissue conditioning material and that patients eat only ~-
soft foods for the next 6 weeks. Once the initial 3 month recovery period is complete and
the ball attachments have been fixed onto the implants, patients will need to return to the
dentist for 5-6 additional appointments in which the 1SO's are fabricated and adjusted to
the mouth and monitored for a seamless integration with the dental implants (28). Patients
are then instructed on how to use the ball attachment mechanism of their 1SO's (See
Figures 2-5 & 2-6), as well as on how to c1ean their 1SO's and implants nightly using a
soft bristle tooth brush.
/~ ! 10
Figure 2-3: Two dental implants with healing Figure 2-4: After 3 months following surgery, abutments (28). the healing caps are removed and replaced with baIl attachments (as seen in Figure 2-1) (28).
Figure 2-5: Underside ofISO showing the 2 baIl Figure 2-6: Illustration ofISO clipping onto attachment sockets (29). two dental implants with ball attachments (33).
The ISO is an appropriate intervention for individuals who: are completely edentulous, have wom complete dentures for several years, reqU1re a more stable prosthesis, and are uncomfortable and overall unsatisfied with their CUITent dentures (29).
To this end, ISO's improve on many of the drawbacks associated with conventional dentures. Sorne of these improvements include: greater stability and mastication, improved comfort, and better quality of life (10, Il, 34). Therefore, making the switch to
ISQ's can be most advantageous.
For one thing, ISO's offer greater stability and comfort than conventional dentures. One study comparing ISQ's with conventional dentures showed a significant 11 improvement (P < 0.05) in comfort and stability among individuals fitted with 180's (35).
In a similar study by Kapur et al., participants fitted with I80's showed significant improvements over participants fitted with conventional dentures in both chewing comfort (P = 0.002) and denture security (P = 0.007) (36). To this end, edentulous individuals fitted with 180's may experience a more comfortable and stable denture- . . weanng expenence.
8econdly, I80's offer greater chewing ability and speech capability than conventional dentures. In one study by Geertman et al., implant recipients reported significant improvements (P < 0.0001) in their ability to chew hard foods at one year posttreatment in comparison to those who received conventional complete dentures (12,
14,37). It has also been shown that edentulous people fitted with 180's require 1.5 to 3.6 times fewer chewing strokes than individuals fitted with conventional dentures in order to obtain similar reduction in food particle size when eating (38). As a result of this increased chewing ability, individuals fitted with I80's may be less restricted in their food choice than individuals fitted with conventional dentures, which may result in greater nutritional states and general health (12).
8peech improvement is also considered to be a major advantage of I80's over conventional dentures. In one study conducted by Kapur et al, 37 participants received maxillary and mandibular conventional dentures and 52 participants received a maxillary conventional denture and a mandibular implant overdenture (12, 14, 36). Individuals fitted with implant overdentures showed a significant improvement in speech function. It has also been shown that satisfaction with both conventional dentures and implant overdentures is dependant on the individual's ability to chew and speak (39, 40).
Therefore, greater chewing and speech capability with I80's may lead to higher levels of 12 satisfaction among implant recipients when compared to edentulous people fitted with conventional dentures.
FinaIly, ISO's offer edentulous individuals greater overaIl satisfaction than do conventional dentures, as weIl as a greater quality of life. For instance, studies show that individuals fitted with ISO's report significantly higher general satisfaction scores than do conventional denture wearers (37, 41). In one study by Awad et al., 30 of 60 elderly edentulous individuals received conventional dentures, while the other 30 participants received ISO's (35). At approximately 2 and 6 months post-treatment, individuals who received ISO's reported significantly (P < 0.01) higher rates of general satisfaction than the conventional denture group. Another study showed that patients fitted with ISO's might have greater satisfaction than those fitted with conventional dentures, for implant overdentures feels more similar to integral body parts (42).
Furthermore, edentulous people with ISO's may have a better quality of life than those who wear conventional dentures. Another study conducted by Awad et al. used the
Oral Health Impact Profile (OHIP) to compare oral health-related quality of life among patients fitted with ISO's and those who received conventional dentures (40). This OHIP measured aspects of function, daily living, social interactions, as weIl as impact on oral health conditions (12, 14,43). According to the OHIP profile, at 2 months posttreatment, participants fitted with implant overdentures had a significantly improved oral health related quality of life than the conventional denture group. To this end, ISO's could potentially improve the quality of life in edentulous individuals who experience problems with their conventional dentures. 13
2.4 Fear of Dental Implants
Regardless of all the advantages that ISO's have over conventional dentures, edentulous people often refuse to receive dental implants for reasons that are still not entirely understood, but often relate to a general fear of dentistry. In fact, one study measuring pain of dental implant surgery reported that nearly 50% of their implant patients claimed to have fear of dental implants (32). Furthermore, a previous research project conducted by Bedos, Thomason, and Feine at McGill's Faculty of Dentistry (Montreal), found that
12% of its subjects ultimately refused to participate in their clinical trial of dental implants because of fear of implant surgery. Therefore, it is possible to assume that perhaps fear of dental implants may play a substantial role in influencing a patient' s decision of whether or not to undergo implant surgery. To this end, dentists must understand the patient's fears with respect to dentistry, and more specifically, dental implants.
For one thing, a visit to the dentist may be viewed as a frightening ordeal to many people. Studies show that more than 40% of the population are fearful of dental treatment.
Furthermore, 5-15% report extreme fear and avoidance of treatment altogether (44-46).
Fear and avoidance reaction must be taken seriously as it may prevent individuals from receiving much needed oral care. In the case of edentulous people who are unsatisfied with their conventional dentures, fear of dental implants may prevent them from making the switch to ISO's.
In order to understand fear of dental implants, it is important to first examine the initial causes of dental-related fear. For instance, studies show that increased levels of dental-related fear are often attributed to aversive conditioning of dental experiences, which usually occur during childhood (46, 47). In addition, individuals who have po or 14 oral health may be even more likely to develop dental-related fears as their oral conditions may require more aversive dental treatment. In another study by Poulton at al., individuals who experienced dental carries at age 15 were more likely to report dental related fears at a later age (46). Therefore, early negative dental experiences seem to have an effect on the onset of dental-related fears among dental patients as they age.
Consequently, early negative dental experiences of edentulous individuals may subject them to fear of dental procedures later in their lives; including fear of dental implant surgery.
One study by Muller and Calvo measured fear of dental implants by recording implant-related fear 2 days prior to implant surgery (32). In order to establish the level of fear for each participant, a scale from 1 (no fear) to 10 (maximum fear) was used. The results were as follows: 4% answered level 1, 25% answered level 2, 23% answered level
3, 33% answered level 4, 11% answered level 5, and 4% answered level 6. To this end, fear is present among these prospective dental implant patients.
One common dimension of dental-related fear is the fear of pain. For instance, studies show that dental-oral pain can cause a physiological fear reaction where patients may experience a sense of emergency and anxiety towards the dentist and treatment (32).
With regards to dental implants, patients may fear the pain that they associate with dental implant surgery. Therefore, one hypothesized dimension offear among prospective dental implant patients may be the pain experienced during or post dental implant surgery.
Moreover, practicing dentists must address the fear of pain among potential dental-implant patients because such a fear can be quite disabling. For instance, it has been speculated that fear of pain might cause subjects to overestimate the intensity levels of certain painful stimuli, which could result in the patient avoiding treatment (48, 49). In 15 addition, fear can worsen the experience of pain, often resulting in further disability and cognitive interference (50). To this end, pain-related fear may lead sorne prospective dental implant patients to exaggerate the degree of pain involved in both implant surgery and its recovery period (51). As a result, the disabling effects of fear may create a high level of difficulty for dentists in proposing dental implants as an alternative treatment to edentulous patients.
The literature reveals that sorne edentulous individuals fear dental implants.
However, the different types of dental implant-related fear have yet to be explored.
Moreover, identifying fear of dental implants is not a simple task as fear can be very subjective. To this end, prospective dental implant patients may experience a variety of dental implant-related fears since each individual may perceive dental implants and implant surgery differently. Therefore, it is essential to identify the various dimensions of dental implant-related fear among potential dental implant patients.
2.5 Summary
In summation, edentulism is a prevalent disability among the elderly and can significantly affect one's oral health-related quality of life. Moreover, treatment options such as conventional dentures are frequently employed, but ultimately may prove uncomfortable and overall unsatisfying to its users. In particular, edentulous patients often experience difficulties with their mandibular conventional dentures. These difficulties include: pain, discomfort, instability, and difficulty eating and speaking. Fortunately, CUITent research has proven implant-supported overdentures to be a promising and functional alternative to conventional dentures. Specifically, patients fitted with implant-supported overdentures have shown significant improvements in denture stability, mastication, speech, comfort, 16 overall satisfaction, nutrition, and oral health-related quality of life. However, despite these improvements, edentulous patients often refuse implant-supported overdentures. A possible reason for this reluctance is the fear of dental implants. Furthermore, to the best of our knowledge, relatively little attention has been paid to this important issue. 17
3 Objective
The purpose of this study is to uncover and explain the various forms and sources of dental irnplant-related fear arnong edentulous patients. 18
4 Methods
4.1 Research Design
This study used a qualitative approach based on the methodology of naturalistic inquiry in
order to identify dental implant-related fears among potential dental implant patients.
Firstly, naturalistic inquiry was employed since it focuses on studying the real world as it
naturally unfolds without manipulation by the researcher (52). Similarly, this qualitative
approach would uncover true dental implant-related fears experienced by potential dental
implant patients. The main disadvantages of using this methodology are such that in order
for the researcher to study the phenomenon of interest as it naturally unfolds, he/she
would not be able to manipulate this phenomenon of interest or predetermine an
established course of action that would normally occur in a laboratory or other controlled
setting (52). Essentially, the researcher is forced to relinquish a certain degree of control
over the study. However, this methodology is well-suited for this study due to the
openness and exploratory nature of this research.
Secondly, naturalistic inquiry may employ a very informative data collection
technique: The one-on-one interview. This technique can allow participants to freely
express their emotions, thoughts, and experiences pertaining to the subject without being
pressured by the interviewer into saying a particular response (52). Furthermore, one-on
one interviews are effective in gaining in-depth information on specifie issues since the
interviewer has only one participant on which to focus. To this end, one-on-one
interviews allow the researcher to probe the participant on both pre-determined topics and
issues that arise during the interview. In addition, one-on-one interviews are an extremely
,--", valuable tool when conducting qualitative research, since vast amounts of information can 19 be obtained while using a relatively small sample size. To this end, 1 chose to use one-on one interviews since my research topic, fear of dental implants, is quite specific, and would therefore require the focused and thorough discussion reflective of one-on-one interviews.
Finally, the type of one-on-one interview used in this study is a combination of two interviewing styles: The informaI conversational interview and the interview guide approach (52). The informaI conversational-style interview allows the researcher to conduct a smooth flowing interview by asking open-ended questions and probing the participant on any new and/or relevant issues that may arise during the interview. In doing so, participants are encouraged to speak freely without being coerced into particular responses by the researcher. Furthermore, the informaI ad-lib style of this interview provides participants with easy conversation-like banter, which distinguishes this unique style from that of a formaI interview (52). To this end, participants may feel quite comfortable, thus making them more likely to reveal personal feelings, thoughts, and experiences regarding fear of dental implants.
ln addition, each interview was conducted using an interview guide in order to facilitate and encourage discussion on pre-determined topics. This interview guide consists of dental implant-related themes to be discussed in order to meet the study's objectives. It is important to note that this interview guide was not meant to be used as a checklist, but rather, as a topic guide from which to build the interview conversation.
Furthermore, the interview guide was subject to change as each interview spurred additional dental implant-related themes. These additional themes were then inc1uded in the interview guide for subsequent interviews (See Appendix 1). 20
4.2 Sample Recruitment
4.2.1 Sample Criteria
The participants for this research project had to (1) reject the notion of receiving dental implants and have not received dental implants themselves; (2) exhibit fear towards dental implants; (3) have at least one edentulous arch; (4) be English-speaking; and (5) acknowledge dental implants as a potential treatment for themselves either in the present, or in the near future. To this end, participants who met the above criteria were chosen to participate in this study in order to explore their perceptions and fears of dental implants.
No specific age or gender requirement was necessary since it is possible for young, old, male, or female individuals to be edentulous and exhibit fear of dental implants.
Moreover, by abstaining from specifying criteria for both the age and gender of the participants, it may be possible to identify age and gender-specific fears as they relate to dental implants. However, l wanted the participants to be either completely edentulous, or have at least one edentulous arch in order to explore perceptions of individuals who were potential ISO patients. Essentially, potential ISO patients may be those edentulous or partially edentulous individuals who are likely to be ISO candidates as indicated by their dentists. In addition, actual dental implant recipients were not recruited for this study since their fears did not prevent them from receiving dental implants. Furthermore, only those individuals whose fears acted as a barrier to receiving dental implants were considered.
4.2.2 Recruitment
Participant recruitment took place between March 2005 and February 2006. Initially, l wanted a convenient sample of edentulous individuals who met the above criteria. 21
However, due to the specificity of this sample criteria and the French-speaking majority of Montreal, Quebec, it became difficult to recruit participants who were both completely edentulous and English-speaking. Therefore, it was necessary to maintain a flexible approach throughout the recruitment process. To this end, l included partially edentulous individuals with at least one edentulous arch since their oral conditions are similar to completely edentulous individuals, and thus, they are most likely to share similar perceptions of dental implants. Furthermore, the exploratory nature of this study made it possible to adopt various recruitment methods. These sampling strategies included: recruitment of participants from a CUITent ISO study at Mc Gill University's Faculty of
Dentistry (Montreal, Canada), snowball sampling, posting recruitment flyers in several locations across Montreal, Canada (local stores, community centers, old-age homes, and hospitals), as weIl as active recruitment in local old-age homes and community centers for seniors (See Table 4-1).
Firstly, sorne participants were recruited through a clinical trial being conducted by Dr. Jocelyne Feine (McGill University, Faculty of Dentistry), titled "The Effect of
Improved Oral Prostheses on the Nutritional State of Elderly Edentulous Individuals".
The purpose of this study was to test for nutritional benefits in individuals fitted with
ISO's compared to individuals who were fitted with conventional dentures. In this study, participants were selected at random to receive either a new set of conventional dentures or ISO's. Sorne individuals refused to participate in this study once they discovered that they themselves could be fitted with dental implants. These dental implant "refusers" were then screened and recruited for my own research project. This screening process involved identifying those participants who were identified as "English-speaking", "Does not want implants", and "Edentulous". Furthermore, these individuals were screened over 22 a telephone conversation in order to determine whether or not they fit my sample criteria.
However, recruitment through this method was not very successful as only one participant who met the sample criteria was willing to participate. Furthermore, other individuals who met the sample criteria either avoided recruitment, or refused to discuss their fears of dental implants.
Consequently, a second sampling strategy - snowball sampling - was used in order to recruit additional participants for this study. This method of recruitment involved asking friends, family, and acquaintances, as weIl as already recruited participants if they knew of any suitable candidates for this research. It was important to employ this recruitment method throughout the research project since new contacts were continuously being forrned. This sampling strategy yielded two participants.
In addition, flyers were posted throughout several locations across Montreal in order to find additional participants. These locations included popular grocery stores and pharmacies (IGA, J&R Kosher Meat, Pharmaprix), local community centers and old-age homes (Cummings Jewish Center for Seniors, The Waldorf, The Castel, Cote St. Luc
Community Center), apartment buildings (Tiffany Towers), and hospitals (Jewish
General Hospital and the Montreal General Hospital), all of which l had access to. These above locations were chosen for their convenience and relative short distance from my home. Furthermore, l knew several individuals at these locations who granted me easy access. Individuals who responded to the flyers were then screened over the telephone in order to determine whether or not they fit the sample criteria. However, screening potential participants over the telephone proved to be somewhat difficult since sorne individuals were either untruthful, or were unwilling to divulge certain information via telephone. These circumstances lead to several false screenings, as well as further 23 unsuccessful participant recruitment in pers on. To this end, a more involved sampling strategy became necessary.
Finally, the most successful recruitment method used in this study involved active recruitment in local community centers for seniors. In particular, most participants (four) were recruited through The Cummings Jewish Centre for Seniors (Montreal), where staff members facilitated meetings with groups of seniors and recommended suitable participants. Furthermore, in order to recruit additional participants I presented my research interests to groups of seniors during popular activities at the center. In addition, 1 sat at a table organized with recruitment flyers in front of the community center's busy cafeteria, which provided for interaction with the community center's members and supporting staff. Although this recruitment method proved to be most successful, it was also the most difficult and demanding sampling strategy to pursue. For one thing, I did not have previous contacts with any of the facility's directors, and thus, I was required to meet with several of the community center' s administrators in order to be granted full access to the facility. Moreover, since certain seniors attended the center only on specific days, I made sure to visit the center during varied times throughout the course of the week to ensure I could potentially attract a diverse group of participants.
Table 4-1: Participant Recruitment
Recruitment Method # of Participants ISO study at McGill Dentistry 1 Snowball Sampling 2 Recruitment Flyers 1 Active recruitment at Cummings 4 Jewish Centre for Seniors 24
4.3 Interview Procedure
AlI efforts were made to conduct interviews in locations that were relatively quiet, easily accessible, and above aIl, comfortable for the participants. These locations consisted of a public coffee shop, the participants' home, and a private interview room in the Cummings
Jewish Centre for Seniors (See Table 4-2). In most cases, the interview conversation was between the participant and me (primary researcher). However, in two interviews where the participants chose to meet in their home, a close family member asked to accompany the discussion. During the se interviews, the participants' family member often abstained from the discussion and simply observed the conversation. However, in one interview for example, the participant's family member contributed to the discussion. Consequently, the participant's family member stimulated further conversation by encouraging the participant to speak. Although these conditions do not allow for a strict application of a one-on-one interview, a certain degree of flexibility was necessary since it can make the participant feel more comfortable, and thereby promote a more natural discussion.
Table 4-2: Interview Location
Interview Location # of Participants Participant's home 3 Local café 1 Interview Room at Cummings 4 J ewish Centre for Seniors
At the beginning of each interview, the participants were briefed on the study's objectives, as weIl as their expected level of participation and their rights (as described in the consent form). After this initial briefing, all participants signed a consent form approved by the Institutional Review Board of McGill University Faculty of Medicine 25
(See Appendix 2). Each interview was conducted in English and lasted approximately
30-60 minutes. The time variation in each interview was dependent on the depth of the interview' s content, as well as the participation level of each participant. At the end of each interview, the participants were also asked several questions pertaining to sociodemographic factors in order to identify the sample. In addition, all interviews were recorded using a digital tape recorder in order to be transcribed verbatim. Essentially, transcription was carried out in as thorough and as detailed a manner as possible whereby aU conversation and gestures were written and described exactly as they occured during the interview.
The interviews were conducted by me using an interview guide containing a list of selected themes specifically chosen to stimulate discussion on fear of dental implants (See
Appendix 1). Sorne of the themes selected for the interview guide were based on a current study conducted by Dr. Mark Thomason, Dr. Jocelyne Feine, and Dr. Christophe
Bedos (McGill Faculty of Dentistry), which focused on reasons for implant refusaI, including fear of dental implants. It is also important to note that although this study discussed pertinent reasons for implant refusaI, the themes listed on my interview guide focused only on fear of dental implants and not on other reasons for implant refusaI, such as cost of ISO's. Additional themes were then selected based on their relevance to fear of dental implants and their propensity to generate in-depth discussions on related issues.
These themes included: prior knowledge of dental implants, dentures and ISO's, reasons for implant refusaI, knowledge of dental implant surgery and recovery period, expectations of implant surgery, pain, fear of dental implants, fear of dental implant surgery, fear of the dentist, fear of surgical complications, past experiences at the dentist, 26
/--- dentist-patient relationship, age, and opinions on CUITent dental science and how it has
evolved over the years.
Essentially, each interview began with general questions on these topic areas and
were followed by more specifie questions in order to probe the participants for additional
information. For example, aIl interviews started with the question "so what do you know
about dental implants?" This initial question was then followed up with questions like
"what kind of dental implants?" and "where did you learn about dental implants?" Most
of these follow-up questions were open-ended so that the participants felt free to discuss
their thoughts, and thus, not feel pressured into divulging an expected response. In
addition, most follow-up questions were constructed during the interview in order to
adapt to the different response patterns of each participant and take into account new
themes. Furthermore, aIl participants were encouraged to speak as much as possible in
order to fully exp and on aIl of the pre-selected themes and additional themes that were
brought up during the course of each interview. Moreover, it was necessary to incorporate
these additional topics in the interview guide for aIl subsequent interviews in order to
fully exhaust aIl issues related to fear of dental implants.
4.4 Data Analysis
Post-interview analysis included brief interview reports, complete interview
transcriptions, and coding of the transcripts into multiple theme-based sections for easy
data retrieval and further analysis. Firstly, brief interview reports were conducted
following each interview in order to assess the overall effectiveness of the interview in
obtaining pertinent information (See Appendix 3). To this end, the assessment focused on
the tone of the interviewer, both the questions and themes that were addressed and not 27 addressed, the responsiveness of the participants, as well as the overall quality of the data.
In turn, it was possible to identify the interviewer' s strengths and weaknesses, as well as new themes and interview techniques that may be included in subsequent interviews.
Secondly, following the brief reports and interview transcriptions, each interview was coded into multiple theme-based sections using NVivo co ding software. Essentially, this coding process involved the identification and labeling of all themes and sub-themes from the interviews. In tum, it was possible to quickly access specific themes or cross reference themes with each other for a more in-depth analysis. Initially, codes were largely based on the themes found in the interview guide, as well as the themes that were discussed in the brief interview reports. In addition, several new codes were created throughout the co ding process in order to take into account additional themes that were not previously recognized in the briefreports. To this end, l was able to label and retrieve all interview themes in a quick and organized fashion (See Appendix 4).
Finally, upon completion of the coding process, a detailed analysis of the research themes was conducted. This extensive analysis described all main themes and sub-themes and included direct quotes from the interview transcripts in order to validate key points and give the reader a more holistic sense of the participants' thoughts and experiences. In sorne cases where there was considerable overlap of the data, it was necessary to compile several sub-themes into one larger theme. To this end, it was possible to determine the most prominent themes as they related to fear of dental implants. For instance, although several distinctive types of implant-related fear were identified, many of these themes could be grouped under three larger categories of implant fear. Furthermore, it was important to de scribe each theme individually by using as much detail as possible in order to differentiate among similar themes. For example, fear of pain was described in several 28 ways as it related to the actual implant surgery, recovery period following dental implant surgery, as well as post-surgical complications. In turn, it was possible to compare fear of pain among all the main categories of dental implant-related fear, and therefore, distinguish between the divergent ways in which participants relay their fear of pain related to dental implants. 29
Table 5-1: Sample Study
N Sex: Male 4 Female 4 Total number of participants: 8 Age: 35-50 years 1 51-60 years 1 61-70 years 1 71-80 years 3 81-90 years 2 Average Age: 69 years Mother tongue: English 4 French 1 Other 3 Educationallevel (last level of schooling completed): Secondary school 5 Technical diploma 1 College 1 University 1 Marital status: Married 2 Single 2 Widow/widower 4 Number ofyears during which the current-complete dentures have been worn: 0-5 years 4 6-10 years 1 11-15 years 1 35-50 years 2 Number ofyears complete dentures have been worn: 0-20 years 3 21-40 years 2 41-60 years 3 The current complete dentures were made by: A dentist 4 A denturologist 4 30
5 Results
A total of eight interviews were conducted between March 2005 and February 2006. The study sample consisted of these 8 participants. The average age of the participants was 69 years, with the youngest participant being 35, and the oldest participant being 85. The ratio of males to females was 1: 1; however, no sex differences were noticed. Furthermore, although English was not the mother tongue for 4 of the participants, the participants aU spoke fluent English. (See Table 5-1)
Three main categories of dental implant-related fear have been identified among the 8 participants. These general categories include: 1) fear of dental implant surgery; 2) fear of the recovery period foUowing dental implant surgery; and 3) miscellaneous fears.
5.1 Fear of dental implant surgery
5.1.1 Fear of Pain
This particular category encompasses a broad range of pain-related fear, such as: fear of pain associated with needles, dental drills, scalpels, miscellaneous dental tools, anesthetic, gum-pain, lengthy surgery times, and age.
5.1.1.1 Fear ofNeedles and Anesthetic
Firstly, sorne participants expressed a genuine fear towards the pain that they associated with needles being inserted into their gums. For instance, one participant expressed a great deal of anxiety when recounting past dental experiences that involved needles. This participant explained how her heart would begin to palpitate at the sight of a needle and the thought of having a needle being inserted into the gums. In addition, the participant 31 explained how her anxiety could also be attributed to her perceived pain of a needle prick, as well as the mere thought of anesthetic being administered into her mouth. T0 this end, the participant translated her fear of needles from past dental experiences to the use of needles in dental implant surgery. Moreover, one participant assumed that none, or relatively little anesthetic was administered prior to dental implant surgery and was therefore afraid of the pain that could arise due to the absence of anesthetic.
Interviewer: "Ok. And what did you hear about the surgery?" Participant: "No anesthetic. Only like this. They open the [pointing to mouth). .. They uncover the bone and make like a hole and they put a screw or something like that. And they said that it's very very ... Don 't do it. " Interviewer: "Ok." Participant: "That 's il. 1 don 't know. " Interviewer: "Ok. And where did you hear this froin?" Participant: "Likefrom conversation. My conversations withfriends." Interviewer: "And they toid you that there was no anesthetic?" Participant: "No. No anesthetic. " Interviewer: "Ok." Participant: "And it 's very pairiful. " [Interview #8]
.. .1 was always afraid of the pain. Because when 1 go to the dentist, or when 1 go to a hospital and 1 see the needles, right away my stomach [making patting motions to his stomach). .. And 1 don't want to see any blood or something. 1 run away. [Interview #8]
And in the beginning, right away 1 spoke to the dentist and 1 said "do 1 even need a needle?" Because 1 said that 1 would fal! down if 1 even see a needle. [Interview #8] 32
5.1.1.2 Fear of Dental Instruments
Secondly, participants also expressed pain-related fear associated with dental drills.
Essentially, sorne participants were afraid of the dentist drilling their mouths in order to place the dental implants. This fear of the dental drill was initiated in sorne participants by looking at the drill, hearing the drilling sound, and feeling the vibration of the drill while being operated on. In addition, participants expressed a fear of pain associated with aU kinds of dental instruments and tools. However, not all ofthese tools were named. Rather, they were referred to generally as "dental tools and instruments".
Oh, ail thatfiling, and that drilling ... [Interview #1]
5.1.1.3 Fear of Gum-Pain
Furthermore, most of the participants displayed a genuine fear of the pain that they associated with both cutting the gums during implant surgery, as well as inserting the
"metal screws/implants" into the gums. For example, one participant said she was afraid
"because you have to put them [dental implants] into the gum. They have to go somewhere. They have to go into the gum, so they have to cut somewhere to put them in.
So that has to be pain" [Interview #2]. Participants also expressed "well they cut the gums, and they put them in. Those screws or whatever the implants are. And that sounds very scary to me" [Interview #5]. To this end, fear of gum-associated pain seems to be a prominent source of dental implant-related fear.
Interviewer: "Ok. Weil, before you were saying that if there was one thing you were afraid of about implants, il was the pain?" 33
Participant: 'Ta. Probably the pain. This was painful enough [pointing to denture]. Probably the thought of doing something like that again scares me. l really don'tfeellike going through with ail that pain." [Interview #1]
5.1.1.4 Fear of Suffering
Moreover, these participants explained how they did not want to suffer as a result of dental implant surgery. Consequently, they displayed a high level of sensitivity while discussing their fears, which was easily identified by their frightened and emotional reactions during the interviews (Nervous speech, anxiety, frightened facial reactions, etc ... ). Furthermore, sorne participants who displayed significantly more dental implant- related fear than others were quite hesitant when discussing their fears and often required extensive probing in order to stimulate further discussion.
Interviewer: "Nothing would change your mind [about getting dental implantsj? " Participant: "No, no. l wouldn't make il. Even ifthey paid me. " Interviewer: "Really?" Participant: "I wouldn't make il. " Interviewer: "Even ifthey paid you?" Participant: "No. l wouldn't make il. 1 suffered enough. " [Interview #4]
1 don't want to suffer. That's the story. [Interview #4]
5.1.1.5 Fear of Lengthy Surgery
Fear of a lengthy dental implant surgery was also evident among sorne participants.
Although this fear was not nearly as prominent as fear of gum pain or dental instruments, sorne participants were quite afraid of the possibility of experiencing a prolonged surgery.
Essentially, sorne participants assumed that dental implant surgery would require an 34
extensive amount of time to complete. However, participants' expectations of the exact
duration of implant surgery were not specified. Furthermore, these participants were also
fearful of experiencing pain during implant surgery, and were therefore afraid of being
exposed to high levels of pain for a prolonged duration of time.
Participant 1: "Weil first ] would think that it would take a while to get the surgery. ] mean, you don't go sitting in the dentist's chair and then leave 15 minutes later. " Interviewer: "Ok, so you think that you would be sittingfor a substantial amount oflime?" Participant 1: "Weil, if il were me, ] would say to put me to sleep [laughter1". Interviewer: 'Tou wouldfall asleep? Or you would say, put me to sleep?" Participants 1&2 [simultaneously]: "Put me to sleep!" Participant 1: "] would say put me to sleep, you know what l'm saying? " Interviewer: "Why would you tell him that? " r .- Participants 1&2 [simultaneously]: "Because of the pain. " Participant 1: "Because] don't want pain at al!. " [Interview #2]
5.1.1. 6 Age-Related F ear
Another important factor related to fear of pain among the majority of participants was
age. Participants explained how they experienced a heightened level of pain-related fear
of dental implants as a result of their old age. Specifically, participants claimed that this
increased fear of pain was a direct result of their lower pain thresholds which they
attributed to old age. To this end, it seems as though these participants were fearful ofnot
being physically and mentally strong enough to endure dental implant surgery. Moreover,
the se participants were not willing to tolerate the pain that they associated with dental
implant surgery. In turn, participants were quick to express their fear and aversion
towards the procedure. 35
20 years aga l had a lot of wark dane on my teeth. l had gum surgery, l had ail these teeth filed down, and it was very painful. Gum surgery was very painful, because l had my complete mouth done, and then caps, and ail the cutting and filing down of ail your teeth. It wasn /t pleasant. But maybe l recovered faster, l could take it better. Now l don't have the same energy. [Interview #1]
Tm afraid, and l said it 's not worth it. Tm not young. Tm 85 years old How long am l going ta survive? It's not worth it to suifer. [Interview #4]
.. .l'm getting too oldfor ail this pain. [Interview #1]
... at 70 years ald, we dan't need that. [Interview #2]
However, most of the participants experiencing age-re1ated fear c1aimed that had they been younger, they might have been less fearful of implant surgery and the pain that they associated with it. Essentially, participants explained how their attitudes were different when they were young. For instance, sorne participants said that they were more care-free as younger adults. Others explained how they were braver in their early adulthood, and thus, were able to tolerate more pain. To this end, most participants c1aimed that had they been younger, they would not have been as afraid of dental implants as they were currently. Therefore, age seems to play an important role in whether or not a potential implant patient fears dental implant surgery.
When you 're younger you don 't have any questions. You just go ahead And like l say, "en force. " Yaujust charge it. Yau don 't have any fear. [Interview #6] 36
5.2 Fear of the recovery period following dental implant surgery
5.2.1 Fear of Pain
Sorne of the participants were afraid of the pain and suffering that they associated with the recovery period following dental implant surgery. In particular, participants were afraid of physical suffering, swelling, and jaw and gum pain. In addition, sorne participants assumed that the recovery period following dental implant surgery would also be a lengthy one. Specifically, participants expected the recovery period to last for a number of weeks up to several months. To this end, these participants were afraid to suffer for a prolonged period of time.
What scared me was the six month healing lime. Sa l thought that it might be very bad ifyou need sa much time ta heal. [Interview #5]
The thing tao that makes me think about it is how long Pm gonna be home, or in bed. [Interview #8]
Interviewer: " ... when you were saying that you were afraid of the pain and the sufferingfrom the implants, was that during the surgery? Or after?" Participant: "After the surgery. After the surgery, the two stif.fs [implantsJ that they put in are very painful. " [Interview #4]
Interviewer: " ... When someone says dental implants, what cames ta mind right away? " Participant: "1 think of the long recovery. " Interviewer: "Ok. And when you say recovery, what are you thinking about? What's painful? " Participant: "The healing is painful. l don't know. You can't eat anything solid ... It's tao complicated. " [Interview #5] 37
~ / Interviewer: "Ok. So you think it takes a long time to heal you were saying?" Participant: ''Yes. It takes a long time. It takes months and months. " [Interview #4]
5.2.2 Fear of Infection
Two participants were afraid of developing an infection following dental implant surgery.
In particular, these participants were afraid of the susceptibility of an infection, as weIl as
the disabling affects that an infection in the mouth could have on an implant recipient.
Furthermore, these participants said that should an infection arise, they would be afraid of
the possibility of experiencing pain, swelling, or having the dental implants removed
altogether.
But the real thing that l would be afraid of would be the infection. That would be it. Because l hear people saying that it 's very painful and that there 's a lot of discornfort in if... Once you get infection, what happens? You know, like do you have to have if al! over again? Or do you have to have it removed? And then what happens? That would be a real big thingfor me. [Interview #6]
It is also interesting to note that this particular participant (quoted above) cited his
professional environment - a hospital - as the main source of his fear of infection from
dental implants. This participant described his experiences dealing with patients who had
been hospitalized due to sorne sort of surgery-induced infection; these experiences made
him fearful of developing an infection himself as a result of dental implant surgery.
5.2.3 Fear of Complications
Participants were afraid of the possibility of complications which they associated with the
recovery period following dental implant surgery. For instance, sorne participants were 38 afraid that their mouth might reject the dental implants, and they would be forced to undergo further dental treatment to correct the problem. One participant said, "1 know. l've heard that people say that they take [receptive implants] or that they don't take [non- receptive implants], and that it is a very painful process" [Interview #1]. To this end, participants continuously asked the same question, "What could happenT' Sorne participants even referred to stories of implant recipients who had similar unwanted complications following dental implant surgery, which forced them to undergo corrective treatment. Furthermore, participants were particularly afraid of the consequences that they associated with non-receptive implants. These negative consequences included: pain, discomfort, sore gums, difficulty healing, broken jaw bone, infection, holes in the gums and bones, and weak implant/gum support.
Interviewer: " ... Do any complications go through your head? Like if something could go wrong? Do you ever think that something could go wrong? " Participant: "Yeah. " Interviewer: "Ok. What kinds ofthings?" Participant: "For example, you're gonna make a hole in my right [pointing to lower right mandible). So what happens if the bone breaks or you damage the hole. Like is there gonna be a hole here? If the hole is gonna be too big, where am 1 going to put my screws? What's gonna happen if 1 have some damage in my bones?" Interviewer: "Ok. " Participant: "And that's my question. What happens if these things happen? .. .1 know it can happen. Mistakes. But, rm ajraid of that. That maybe he would make the hole too big. " [Interview #8]
rd like to know, what cauld happen. If samething could go wrong later on, and if rd have to do something aver again. That sort ofthing. So like, with a bridge, yau know you're gonna go, and they're going to file and adjust it. 1 would want to know everything, like for the future. 1 wauld like ta knaw what would happen. So 39
these are things that l would question... What could go wrong? What could happen? [Interview #1]
5.3 Miscellaneous Fears
Sorne additional themes extracted from the data could not be c1assified within the headings of fear of dental implant surgery and its accompanying recovery period. These additional themes consisted of important issues revolving around fear of foreign objects in the body, drugs, lifestyle changes, and waiting room time.
5.3.1 Foreign Objects in the Body
Several participants were afraid of the mere thought of having two dental implants being permanently inserted into the gums. These participants referred to dental implants as
"the se things", "metal pins", as well as "foreign objects" being drilled into their mouth.
Moreover, these participants viewed dental implants as being "not normal" and
"unnatural" to the human body. For example, one participant said, " ... having screws for example, being put into your mouth. l can't see if' [Interview #7]. Another participant exc1aimed, "So, with me, sorne one with false teeth, an implant would mean something foreign going into my gums, and l don't want that" [Interview #2]. To this end, these participants were afraid of dental implants because they felt it was not natural for the mouth to receive such a "foreign object" and that dental implant surgery is not something that anyone should have to experience. One participant made an analogy to the sexual stimulating drug, Viagra, in an attempt to describe his view on dental implants as being
"not normal". 40
Anything that's not normal ta me is ... 1t's like taking Viagra. You know. People say that man after a certain age, you begin ta lose your fertility and al! that. SA 1 went ta my doctor one time, this guy that 1 said 1 can talk ta. 1 said ta him, so doctor, what do you think of Viagra for me? He says, "let me tell you something." He says, "if a guy gave me $100 right now on the table for a prescription for me, 1 wouldn 't take it. 1 wouldn 't do it. " He says, "because 1 want ta sleep nights. " He says, "1 don 't believe in anything not normal... " But actually, it can do you a lot of harm. ifyou have high blood sugar, or diabetes ... if you have a bad heart. Imagine if a guy didn 't [engage in sexual activityJ for say, ten years, and al! of a sudden he takes this Viagra, and he 's getting al! hepped up, and his heart is beating at a hundred miles an hour... The guy's gonna get a heart attack. Is it worth it? And the same thing with this here [dental implants). [Interview #7]
It is also interesting to note that only one participant acknowledged the fact that dentures themselves are considered to be unnatural to the human body. To this end, perhaps the participants of this study view dental implants as being more unnatural than conventional dentures.
See when 1 said not normal, 1 was surprised. 1 thought you were going ta ask me,
weil why do you wear dentures? They're not normal. 1 have no other choice.
[Interview #7]
5.3.2 Fear of Drugs
One participant in particular was quite fearful of the drugs that he associated with the recovery period following dental implant surgery. SpecificaIly, the participant explained how he was afraid of becoming addicted to these drugs (pain killers), as weIl as the negative consequences that accompany a developing drug addiction. When the participant 41 was asked where this fear originated, he mentioned how his experiences working in the health care environment were partly to blame. The participant explained how he encountered several drug abusers within his working environment (ho spital) , sorne of which became accidentally addicted to strong pain medications that were prescribed to them by their doctors following medical procedures. In addition, the participant also claimed that his fear of drugs partly originated from his own personal experiences, which involved the death of a close friend as a result of drug addiction/abuse. In turn, the participant' s exposure to these negative consequences of drugs from his working environment and personal relationships caused him to develop a fear of drug addiction specific to prescription pain medication. In the case of dental implants, the participant was fearful of becoming addicted to the pain medication that the dentist might prescribe to him following dental implant surgery.
Participant: " ... How long it's going to be painful for? " Interviewer: "Ok." Participant: "And then, what resource you would have to cure the pain?" Interviewer: "Ok." Participant: "Because you would have to start taking a medication. And... There's always thatfear of .. Weil, when you work in the health care system, you always hear stories ofpeople getting hooked on these drugs. " Interviewer: "Right." Participant: "And that would be enough ... Like, 1 have a neighbor who's hooked on Demerol. And they have to go every day to get their fix ofDemerol. And so, that would be another concern. You know, getting hooked on drugs." Interviewer: "Ok." Participant: "And that's not good. It scares me." [Interview #6] 42
5.3.3 Fear of Change in Lifestyle
Sorne participants were afraid of having to change their general lifestyle as a result of dental implant surgery. Sorne of these lifestyle changes included: changes in eating habits, denture use, as well as confinement to one's home. Firstly, three participants were fearful of being forced to change their eating habits as a result of receiving dental implants. For instance, participants were concerned with whether or not they would be able to eat normally once they received dental implants. For example, two participants were afraid of developing sensitivity towards hot and cold food. Furthermore, participants were afraid of masticatory pain, especially with hard to chew foods (i.e. nuts and meat) .
... Is it something that is going to last? ... Like, will l be able to eat with it after? Will l be able to take the heat? Or take the cold? [Interview #6]
... you cannot eat for a year like you used to eat everyday. They say you change your habits. It's automatic. What you eat. You have to take care of this. When you drink cold, it's pain. When you drink hot too you have to be careful. So you change your life. [Interview #8]
Interviewer: "Ok. So you're saying that you're qfraid that it might change certain things ... " Participant: "Yeah. Pain. fear, pain. And second, l don 't want to change my habits. " Interviewer: "Right." Participant: "Like when l eat. When l eat meat. When l eat things like nuts, or peanuts, or soup everyday for the next year. l don't know ... " Interviewer: "Ok. So you're really afraid that it may change the way you eat and ... " Participant: "Yeah. Change the way l eat, and the pain. That's it. " [Interview #8] 43
Secondly, sorne participants had concems that they would not be able to wear their dentures throughout the recovery period. To this end, the se participants explained how their dentures were an integral part of their appearance, and thus, not being able to wear them for a prolonged period of time would be very disconcerting. Consequently, these participants were afraid of being confined to their homes in order to avoid the social embarrassment of appearing toothless in public. In tum, participants felt that this confinement would interfere with their everyday lives, including work and social interaction.
Participant: " ... How long do you have to be home? And maybe they have to stay home for a week or two ... This is why Pm saying before you decide on an implant; can you afford to do that? " Interviewer: "Ok." Participant: " ... lt's a big question. You know? 1 know you don't want to talk about money, but money is the main factor besides fear and besides everything else. The guy that is a salesman, or something else, 1 don't know. If a lot of people are calling him, and he tells you that you can't see youfor about two weeks. 1 don't know. How long does it take for you to recover from this? " Interviewer: "Ok. " Participant: "How long does it take? Two weeks? Three weeks?" Interviewer: "Something like that. It depends on the person. " Participant: "Can he afford to take three weeks offfrom? Does he make $900.00 a week? That's already $2700 for the implants, plus the pain and everything else" [Interview #7]
The recovery, as 1 said If 1 didn't put my teeth back in, [laughterJ, 1 wouldn't want to walk around for 2 or 3 weeks with just two pegs [dental implants]. Because as soon as you take your plates out, your mouth sinks, eh. [Interview #2] 44
5.3.4 Fear ofWaiting Room Time
One participant described how she became extremely afraid of dental implant surgery while sitting in her dentist's waiting room prior to a scheduled dental implant surgery.
While recounting this experience, the participant expressed her anxiety and fear towards dental implants:
Participant: "And 1 made an appointment with a dentist. With the one who does il [dental implant surgery]. " Interviewer: "Ok." Participant: "And he took X-rays, and he gave me an appointment. And 1 was al! set. And 1 went there. " Interviewer: "Ok." Participant: "And 1 was sitting. And when they called my name, 1 got so scared, 1 left· " Interviewer: "Hmm." Participant: "And 1 went home. " Interviewer: "And that was it? You never called them back? " Participant: "No. 1 never cal!ed them back because 1 knew that 1 wouldn't be able ta do it." Interviewer: "Ok." Participant: "Sa that's ail. " [Interview #5]
It is interesting to note that when interviewing this participant, she appeared to be fearful of dental implants and yet she still made an appointment with the dentist to receive them.
However, her dental implant-related fear seemed to have significantly increased specifically while sitting in the waiting room at the dentist prior to her appointment for dental implant surgery. 45
5.4 Picture Response
At the end of each interview the participants were shown two pictures of dental implants in order to capture their immediate visual perceptions. One picture (See Figure 5-1) showed two dental implants with ball attachments situated on the lower mandible of an edentulous mouth. The other picture (See Figure 5-2) showed a mandibular denture on top of two dental implants with ball attachments. In this second picture the area on the dentures corresponding to the location where the implants clip in was revealed, which gave viewers a sense of how the "clip-in and clip-out" system works. This was eventually explained to the participants in order to prevent them from making any false perceptions.
Figure 5-1: Two dental implants with ball attachments situated in the lower anterior mandible (28).
Figure 5-2: Mandibular denture situated on top oftwo dental implants with ball attachments (28). 46
Most of the participants expressed sorne form of fear towards dental implants
simply from viewing these pictures. Participants expressed their fear through varied
forms; for instance, sorne participants expressed their fear through their facial reactions,
others through their body language, and finally, sorne orally communicated their response
to the pictures. Specifically, facial expressions consisted of shock, confusion, and fear.
For example, participants often opened their eyes very wide as if they were surprised.
Furthermore, one participant seemed so afraid from these pictures, it appeared as though
his face was turning pale. To this end, dental implant pictures seemed to instill a sense of
fear among the participants. Moreover, sorne participants were confused when viewing
the pictures since they expected to see single tooth implants. However, despite this
confusion most participants were still afraid of dental implants.
/ And you have two ofthese? [Interview #2]
Participant: "Yeah. They put them [dental implants] in. They insert them in [the participant shows a confused and bewilderedface). Into the gum." Interviewer: "Yeah. SA these right here are the two implants. " Participant: "Yeah." Interviewer: "What do you think about that picture?" Participant: "1 don't know. l still think it's terrible [laughter)." Interviewer: "Ok." Participant: "Ta put that in. " Interviewer: "That they go in?" Participant: "Yeah." [Interview #5]
It 's tao much trouble. l don 't know. l don 't want it. [Interview #4]
Furthermore, these ISO pictures were effective in stimulating further conversation
on dental implants. For instance, after viewing these pictures, participants became more 47 inclined to speak about their knowledge of dental implants and how these photos reflected their expectations. Moreover, in sorne interviews, it seemed as though these pictures exacerbated certain fears among participants; specificaIly, fear of foreign objects in the body, as weIl as the fear of pain from dental implants being inserted into the gums. In addition, these photos generated a great deal of curiosity among the participants as many of them began asking questions pertaining to dental implants. These questions were often specifie to certain aspects of dental implant surgery.
How do they stay there? How do they stay in your jaw? [Interview #2]
Iwouldn't like to have it ... Anything that's not normal, that you're putting into your own body. [Interview #7]
Interviewer: "When you see these pictures, what do you think about? What comes to your mind? " Participant: "1 don't know. Pain ... [long pause] Pain." Interviewer: " ... How come?" Participant: "The work that they have to do in there to put in the implants [Participant pauses while staring at the pictures ofthe dental implants]." Interviewer: "So you think of the pain because of the work that's involved? " Participant: "Yeah." Interviewer: "When they put them in? " Participant: "Yeah ... " [Interview #8]
5.5 Source of Fear of Dental Implants
Upon analyzing the data from each interview transcript, we identified four main sources of dental implant-related fear: 1) Past negative experiences at the dentist; 2) "horror stories" of dental implant surgery; 3) having relatively little knowledge of dental implants; and 4) Poor dentist-patient relationship. 48
5.5.1 Past negative experiences at the dentist
Most of the participants identified past negative experiences at the dentist as a major source of dental implant-related fear. For instance, the majority of participants had negative experiences at the dentist in their past, which often involved pain, fear, and/or discomfort. These experiences consisted of painful tooth extractions, gum surgeries, drillings, and root canal treatment, complications from anesthetic, absence of anesthetic, dysfunctional dentures, misdiagnosis, and even materials being dropped down a patient' s throat during treatment. Participants then generalized those negative experiences to future dental procedures, including dental implant surgery. For example, one participant said
"because you remember the pain of having work done in past experiences, and that' s the pain that stays with you" [Interview #2]. Another participant explained how "you remember that pain, and think that's what you're concemed about. .. .1 mean, we had school dentists who were like butchers" [Interview #2]. Moreover, sorne participants described how they eventually came to fear the dentist in general due to past negative experiences .
... you know l've had other work done to my teeth, and 1 know it's very painful. And l've had gum surgery many years ago, and it was very painful. So l've kind of always had a bit of a fear of going to the dentist. Let 's put il that way. [Interview # 1]
Interviewer: "And what about now? Would you consider getting them [dental implants] now?" Participant: HI don ft know if1 want to go through with the pain again. 1 don ft think 1 want to get that freezing and sitting in that chair, and going through that again. 1 don ft want to do that now. " [Interview # 1] 49
Furthermore, when asked about how recent improvements in dental techniques have affected their fear towards dental implants, most participants said that they are less fearful of dental procedures today than in the past, including dental implant surgery.
Participants claimed that dental treatment in the past was more painful and overall more unpleasant than today's general dental treatment. However, despite general improvements in dental care, participants still expressed a heightened level of fear specifically towards dental implants.
Participant: "But dentists in those days, l remember, when we went to school, and if someone had an abscess, which was quite common. You would get an abscess under your teeth. If you didn 't treat it right away, you would be in a lot ofpain and l think that's the pain my sister remembers. . ../ remember going to school with an abscess, and doing something to rem ove the abscess first, and then they pulled the teeth. And of course, the freezing, or whatever they used in those days. But that's going back over fifty years. Pain was there. And it's worse than having a pregnancy. .. ./ mean in those days. Weil, l know now that there are al! sorts of things that have improved. " Interviewer: " ... Ok, so when you're thinking about pain, that's one thing that ... " Participant: "Yeah. Wel!, to me, that's what l would think. l can visualize it and remember. They were no good to us. " [Interview #2]
Interviewer: " ... Remember when we were talking about your fear of when you went to the dentist in the past, and the regular things that you go to the dentist for and that some people are afraid of implants. Can you compare those two kinds of fear? Are they very similar types offear?" Participant: "No. This is more fearful. " Interviewer: "The implants?" Participant: "Yeah." [Interview #5] 50
5.5.2 "Horror stories" of dental implant surgery
Several participants attributed sorne of their knowledge of dental implants to stories that were told to them by either friends or family who have experienced dental implant surgery. In sorne of these cases, the individuals who received dental implants may have experienced a great deal of pain or discomfort during, and/or after implant surgery and often spoke about their experiences with their friends and family (participants of this study). For sorne participants, their friends or family who had dental implant surgery were their only source of information regarding dental implants and effectively created dental implant-related fear among them. Those family members and friends recounted elements of the implant procedure to the participants that involved pain, soreness, and suffering.
However, when the participants were asked if their friends or family were satisfied with their implants, most of them answered in the affirmative. Moreover, despite their satisfaction, participants claimed that their family or friends who received dental implants were still adamant about the entire procedure as being "not worth it." Specifically, the participants were quite fearful of the pain and suffering that their friends or family described as accompanying dental implant surgery.
Interviewer: "Yeah. Weil, from what you can remember from what they said about it [implant surgeryj. What did they say about the pain?" Participant: "Just saying that... [LaughterJ It hurts. That it hurts." Interviewer: "Ok. " Participant: "They wouldjust hold their jaws and say urs so painful. " [Interview #6]
.. .1 refused to make the operation because 1 had a friend who had it, but she suffered a lot. [Interview #4] 51
Other participants said that they heard stories from their friends of particular cases where dental implant surgery was not successful. ''l've heard that people say that they take [receptive implants] or that they don't take [non-receptive implants], that it is a very painful process" [Interview #1]. These "unsuccessful dental implant surgery" stories were also effective in creating implant-related fear among sorne participants. Conversely, one participant heard only positive comments pertaining to dental implants. This participant explained how her daughter was very satisfied with the dental implants she received. She also described how she knows people who have received dental implants and that they too were satisfied with them. However, this woman's fear of dental implants was so strong that even these "good stories" were ineffective in alleviating her fears.
Participant: " ... he [friend with implants] told me that had he known what he had ta go through, then he wouldn't have gone and done it. " Interviewer: "Really?" Participant: "Yeah. He wouldn't have gone and done if... the implants were good after. But he said il was the pain and everything that he had ta go through. He said that had he had known he would have gotten a bridge or something else ... " [Interview #7]
... some people say that it's successful and some people say that it's not. People that have had it told me that it's quite painful when getting it done during the time that it's implanted. [Interview # 1]
Participant: "And like 1 said, for the mouth, 1 think if would be very painful. 1 guess. l don 'f know how it would be in the end, because you don't hear about the end. Youjust hear, 1 guess youjust hear the bad side ofit. 1 suppose ifyou hear the good side of it maybe it would be dif.ferent. " Interviewer: "Ok. " 52
Participant: "You know. When you just hear people you know, about their experience ofhaving it. " Interviewer: " ... Ok. So you don't hear too many good things? " Participant: "No. Weil that's what Pm saying. You know? Like, you just hear the horror stories, the bad things. " [Interview #6]
5.5.3 Lack of Dental Implant-related Knowledge
Another source of implant-related fear may be the lack of dental implant-related knowledge. It seemed as though the majority of participants had relatively little knowledge of dental implants. For example, most participants thought ISQ's involved multiple single tooth implant replacements, lengthy and painful surgeries, suffering, long recovery periods and several complications. Furthermore, these participants explained how most of their dental implant-related knowledge carne from watching dental implant commercials on television, reading dental implant advertisements in magazines, and speaking to their dentists, friends and family regarding dental implant treatment. Overall, the television and magazine ads offered participants little valuable information pertaining to dental implants.
Moreover, it seemed as though the participants who discussed dental implants with their dentists were either given limited information, or only spoke with their dentists for very brief periods of time. Furthermore, sorne participants were falsely informed of dental implants from friends or family who had undergone the procedure. In these cases, friends or family of the participants might have had negative experiences regarding their own dental implant treatment, and thus, gave biased and over-exaggerated recounts of their experiences. To this end, participants often lacked factual knowledge pertaining to dental implants. 53
As well, sorne participants created their own assumptions regarding dental implants and dental implant surgery. These assumptions were frequently negative, which may have lead to the various fear responses among the participants. Furthermore, participants atlributed their lack of dental implant knowledge as causing them to "fear the unknown." Moreover, the participants explained how the less information they had pertaining to dental implants; the more they would likely fear the surgery.
Weil you always have afear ofthe unknown. So let's put it that way. [Interview #1]
.. .1 guess with implants, 1 don't know. 1 really don't know what to think. [Interview #6]
Participant: "Well 1 was lold by this fellow who told me he had an implant. He said that they put a post. A post, and lhat then the teeth are built around il. " Interviewer: "Ok." Participant: "Weil 1 asked him the same question. 1 asked him, while you are eating and something gets underneath the ... 1t can 't get into the post, because the post is set. But what happens ifsomething goes beneath the teeth. Because the teeth go around il. How do you get it out? " Interviewer: "Ok." Participant: "He didn 't answer me. And 1 still don 't know what the answer is. And 1 asked myself if it 's worth it. If1 had a bridge 1 could go and take it out, and wash it. But lhat could cause a lot of trouble. " Interviewer: "No, weil il 's important that you mention it. Because il 's important in terms of how much the dentist informs you about the procedure ... " Participant: "As far as 1 know, the he didn 't inform him very much. Because as far as 1 know, the guy hardly knew anything. He heard about implants, and he decided he 's gonna have it. " [Interview #7] 54
5.5.4 Poor dentist-patient relationship
Sorne participants explained how their dentist-patient relationship contributed to their fear of dental implants. For instance, participants claimed that in sorne of their past dental experiences, the dentist did not project good bedside manners. In these cases, the participants described how the dentist did not always communicate with them, comfort them, or even describe their actions while in the midst of dental procedures. Not only did this make sorne of the participants uncomfortable, but it also exacerbated their fear of the dentist; consequently, participants then generalized this fear towards dental implant surgery.
Participant: "Well he [dentist] would really have to know what he was doing. And he would have to explain everything. You know what l'm saying? Just, when he pulls some teeth, or makes the plate, just he should try and comfort you. " Interviewer: " ... So to really try and make you feel comfortable. " Participant: "Yeah, and so that you/re not to be afraid" [Interview #2]
Furthermore, participants related their perception of poor bedside manners to their loss of confidence in their dentists, thereby creating greater dental-related fear.
Interviewer: "And do you think you would be more fearful of the procedure [dental implant surgeryJ with the specialist? Or with the dentist that you know?" Participant: "Weil] would probably feel more comfortable with the person that] know. But] also feel that the dentist that ] would choose to see would talk to me, and explain everything to me, and] think that gives you a lot of confidence in the person who is doing the work for you. So you build up, not a friendship, but more confidence, because he /s explaining everything to you, and you might trust him more. Probably if someone ] knew went to this dentist and told me what they're like, that would help me too. But] think if] was going for another opinion, it's very important that the dentist should be able to talk. Because if they don /t talk to you, then you just don't build up anything with him. A rapport, or anything, to 55
build up confidence with him. It helps you. And white he's doing it, if he talks to you, it also helps." [Interview # 1]
[The dentist-patient relationship is] very, very important. Like l said. Ifyou don't have confidence in somebody, then you get fear. And ifyou have confidence, then there 's no fear. [Interview #6]
T 0 this end, sorne participants described how their dentists' bedside manners, as well as their confidence in their dentist were very influential in managing their level of dental- related fear. Similarly, these participants explained how the dentist-patient relationship plays a substantial role in contributing to their fear of dental implant surgery.
Interviewer: "What about in terms ofhow they [dentist] speak to you?" Participant: "Again, il depends how ... Bedside manners are the first thing l think they should learn because it is a very big factor because like l said before. l will not deal with a doctor, l don't care what your reputation is, if l cannot tell you what's wrong with me... Like l had a urologist, when l came in he had a big name, and l wouldn't mention his name. It's weil known in Montreal. He puts up his hands like this here, and says, let me do the talking. l saül, Doc, but you don't know what's wrong with me. He says J'Il find out. You can never ... l went to him for a year. And then l said no way am l going to this guy. And everyone says this guy is a good doctor and he operates well, but ... " Interviewer: 'Tou got to be able to state your case?" Participant: "If l cannot talk to you, and tell you what's wrong wilh me. This is what l think ... Bedside manners are very important. Especially when you're talking to a patient, to take that fear away. Plus you got that, everybody has that fear of going to the dentist. A fear of going to a doctor. You have that fear." [Interview #7]
You know, l learned one thing. Going to school, and the things that you learn in the books is one thing. But it's only the little things. There's so many other things besides books and they take into consideration wh en you're dealing with a 56 dentist... Sorne dentists haven 't got the faintest idea of bedside rnanners. Al! he knows is about pulling, andfilling, that's al!. [Interview #7] 57
6 Discussion
6.1 Limitations
This study outlines sorne of the various fears potential dental implant patients faced.
However, the data obtained in this study reflects only a small and limited sample size, and therefore cannot yet be generalized to a larger population. The participants of this study reflect a convenient sample of English-speaking individuals from different social and ethnic backgrounds spanning several communities across Montreal, Quebec. However, due to both the time restrictions of my master's research program and the specificity of my sample criteria, only eight participants could be recruited. Nonetheless, much information was acquired from this relatively small sample size due to the informative qualitative approach ofthis study (52).
Furthermore, to the best of my knowledge, this study is one of the first to analyze in depth the fear of dental implants, and thus, it was necessary for the study to be exploratory in nature. To this end, this study maintained a flexible approach in exploring dental implant-related fear, which allowed for modifications throughout the research process. Modifications were made to: the adoption of new interview techniques, recruitment methods, and sample criteria.
Initially, the sample criteria consisted of completely edentulous individuals who were English-speaking, had rejected dental implant surgery, exhibited fear towards dental implants, and had perceived dental implants as a potential treatment for themselves either in the present, or in the near future. However, given both the limitations of my master's pro gram and the French-speaking majority population of Montreal, Quebec, it was especially difficult to recruit participants who were both English-speaking and completely 58 edentulous. Therefore, the decision to inc1ude partially edentulous individuals who had at least one edentulous arch was made since they were potentially eligible for ISQ's. This research project can therefore serve as a pilot study on which to base: 1) larger studies focusing on specific dental implant-related fears; or 2) educational programs geared towards the betierment of implant treatment for dentists and patients. Larger studies may also want to focus solely on completely edentulous individuals rather than partially edentulous persons since they are more likely to be implant candidates, and therefore, project more accurate fears and perceptions regarding dental implant surgery.
6.2 Fear of Dental Implants
In this research project, various forms of dental implant-related fear have been identified and grouped into three main categories: 1) Fear of dental implant surgery; 2) Fear of the recovery period following dental implant surgery and; 3) Miscellaneous fears.
6.2.1 Fear of dental implant surgery
The first category of dental implant-related fear is fear of dental implant surgery, which confirms the hypothesized dimension of pain-related fear among prospective dental implant patients. In fact, fear of pain in general seemed to be one of the most prominent types of fear across all participants in this study. Essentially, participants feared the pain that they associated with dental implant surgery, which contributed either solely or partially to their refusaI of dental implants. This fear of pain is not surprising considering most dental implant patients begin to exhibit fear towards the pain of dental implant placement once they become aware of the surgical procedures involved (32).
Furthermore, the broad category of fear of pain encompasses a wide range of specific 59 pain-related fear, which indudes fear of pain associated with needles, dental drills, gums, lengthy surgery times, and age. Nonetheless, these fears are quite common among dental patients (47, 53-56).
However, reported fear of gum-associated pain, as weIl as the fear of pain due to older age was very interesting in the context of dental implant surgery. For instance, sorne participants were terrified of the pain that they believed would result from their gums being cut open and having "metal screws" (dental implants) inserted. Furthermore, these participants continued to fear gum-associated pain regardless oftheir knowledge that their gums would be completely anesthetized and thus pain would be numbed. The participants' failure to realize the effects of anesthetic with regard to this procedure is also consistent with Keefe et al's findings that fear of pain can cause cognitive interference
(50). EssentiaIly, Keefe et al explained how the fear of pain under certain circumstances can impede an individual's judgment or appraisal of a given situation. Similarly, the anxiety and fear of gum-associated pain among the participants of my study may have hindered their ability to make an accurate appraisal of dental implant surgery altogether.
To this end, sorne participants refused to process the fact that their mouths would be anesthetized. As a consequence, this specific fear was one of the irrational factors causing participants to refuse dental implant treatment.
In addition, fear of pain due to old age was quite influential in determining whether or not a potential implant patient feared dental implant surgery; participants claimed that they were "too old" for dental implant surgery. Moreover, it seemed as though these participants were afraid of being physically unable to endure the pain that they associated with this procedure. For instance, sorne participants claimed to have lower pain thresholds due to their old age, which rendered them incapable of tolerating the pain 60 they expected to experience from dental implant surgery. Furthermore, these participants maintained the belief that had they been younger, they would have been able to tolerate this pain and thus would have been more likely to receive the surgery. For example, participants described how they exhibited a braver and more care-free attitude when they were young, and thus, they might have agreed to dental implant surgery with less hesitation. In addition, participants explained how they felt physically stronger and more tolerant to pain when they were young. In fact, current research supports the daims of the se elderly participants who daim to have lower pain thresholds than younger persons, and are therefore more sensitive to pain (56, 57). To this end, age may play an important role in whether or not a potential implant patient fears dental implant surgery.
6.2.2 Fear of the recovery period following dental implant surgery
The second category of dental implant-related fear is fear of the recovery period following dental implant surgery, which indudes fear of pain, as weIl as fear of post surgical complications such as non-receptive implants and infection. Essentially, participants' fear of pain associated with the recovery period was quite similar to their fear of pain during dental implant surgery. Participants were afraid of physical suffering, swelling, and jaw and gum pain. However, the literature on dental implants asserts that patients who actually received dental implants were usually surprised as to the relatively little amount of post-surgical pain they experienced. To this end, implant recipients often expected to experience a greater degree of post-surgical pain (32). This is not to say that patients do not experience any pain. In fact, sorne implant recipients reported high levels of post-surgical pain; however, it was easily controlled through pain medication. 61
Moreover, learning that sorne participants were especially afraid of suffering through a long recovery time was quite interesting. These participants assumed that the recovery period following dental implant surgery could last from a few weeks up to several months. To this end, the participants' predictions of the healing period following dental implant surgery were consistent with actual healing times which range between three and six months (28, 58). Therefore, most participants had somewhat realistic expectations with respect to the duration of the recovery period. Furthermore, their assumptions often originated from vague implant information obtained from dentists, as weIl as from friends or family that might have experienced dental implant surgery.
Nevertheless, sorne participants were aware of the possible improvements ISO's could endow them with regarding their oral health-related quality of life; yet, their fear of the recovery process contributed to a further unwillingness on their part to undergo the dental implant procedure.
Furthermore, sorne participants were especially afraid of the possibility of ensuing complications following dental implant surgery. For instance, participants were predominantly concemed with whether or not their mouths would be receptive to dental implants. Moreover, these participants feared the possibility that their mouths might reject dental implants, which could force them to undergo either corrective treatment or have their dental implants removed. However, recent studies have shown that implant recipients experience a very low percentage of implant failure. For instance, one study by
Kourtis et al, found the failure rate of dental implants among 1692 implant recipients to be just 4.4% (59). Other sources reported similar implant failure rates of 3 to 7% over a five year period (60). Furthermore, most implant failure was attributed to patients with metabolic diseases, poor bone quality, insufficient oral hygiene, and patients who smoke 62
(59). It is also interesting to note that a greater proportion of these implant failures occurred in patients who received implants in the maxilla. Advanced age is also considered one of the primary predictors of complications leading to implant failure (61).
Despite this fact, the survival rate of dental implants among elderly edentulous patients is over 92%, which is comparable to the 90-100% implant survival rate among younger individuals (29, 62).
In addition, sorne participants were afraid of developing an infection following dental implant surgery. Specifically, these participants were afraid of the negative consequences that a resulting infection could have on their mouth (i.e.: Swelling, soreness, pain etc). In turn, participants feared that such complications would only add to their stressors and ultimately prolong the recovery process. However, the literature posits that it is usually the patients who are already pre-disposed to infections of the mouth who are the most likely to develop an infection following dental implant surgery (63).
Furthermore, although periimplant infections caused by implant abutments represent a risk factor for the longevity of an implant, they can usually be prevented through proper oral hygiene and plaque control (64). In light of these facts, it is possible to argue that the se patients' fear of infection is not properly founded. Perhaps patients would be more able to control their fear of infection if they were provided with such information.
6.2.3 Miscellaneous fears
The third category of dental implant-related fear is miscellaneous fears, which include fear of foreign objects in the body, drugs, change in lifestyle, and irrational fears. Firstly, several participants were afraid of dental implants as they viewed them as foreign objects being inserted into their body. In essence, the se participants perce ive dental implant 63 surgery as an unnatural process that the human body was not meant to expenence.
However, this outlook is somewhat contradictory considering the fact that all participants in this study wear dentures, which is also an unnatural process. In fact, only one participant acknowledged this paradox. To this end, participants are willing to accept the foreignness of dentures, but not the foreignness of dental implants. Perhaps edentulous individuals are not yet comfortable with the notion of dental implants and ISO's, since they recognize conventional dentures as the standard for treating edentulism.
Consequently, it may take sorne time before edentulous patients can perceive ISO's as the new standard for the treatment of edentulism, and thus, recognize ISO's as a "normal" process. Perhaps if the overwhelming evidence supporting the superiority of ISO's over conventional dentures were to be made more accessible to edentulous people, edentulous patients might become more accepting of ISO's as the primary treatment for edentulism.
In addition, adequate financial support from the government and health msurance companies may help speed up this accessibility of educational information.
Secondly, participants were afraid to change their lifestyle and daily habits as a result of dental implant surgery. For instance, one participant displayed fear towards the pain medication that the dentist might prescribe to a patient following dental implant surgery. To this end, this participant was afraid of becoming addicted to these drugs and the ensuing negative consequences which accompany drug addiction. Although this notion is not uncommon among potential surgi cal patients, to the best of my knowledge, there have been no reports of addiction to pain medication following dental implant surgery (65). Furthermore, fear of addiction to post-operative pain medication usually develops as a result of the lack of knowledge pertaining to pain management (65).
Similarly, a participant of this study who feared such an addiction to pain me di cation 64 displayed relatively little knowledge of dental implant surgery and its recovery period. In addition, loosely recounted stories and personal experiences were also influential to one participant in creating a fear of addiction to pain medication. To this end, dental practitioners must diligently address patients' possible concems with the prescription of pain medication following dental implant surgery.
Participants were also afraid of developing extreme sensitivity to hot or cold foods as a result of dental implant surgery. Also, participants feared that dental implants could make them more vulnerable to masticatory pain, particularly when chewing hard foods
(I.e.: nuts). However, contrary to these predictions, studies have shown significant improvements in chewing ability among ISO patients when compared to conventional denture us ers (12, 66). Moreover, these masticatory enhancements extend not only to hard and tough foods, but to aIl food types as weil.
Furthermore, sorne participants were especially fearful of being prohibited from wearing their dentures for an extensive amount of time during the recovery period.
Specifically, these participants feared experiencing the social embarrassment of appearing toothless in public or with their friends and family. However, ISO patients are generally permitted to wear their current dentures following implant surgery (28). Another concem shared by sorne participants is that they would be unable to eat properly without their dentures; this fear was well-founded since ISO patients are permitted to eat only soft foods immediately following implant surgery. Hence, the fear of change in lifestyle - whether it was a justifiable fear or not - seemed to be quite effective in deterring participants from considering dental implant surgery as a viable treatment option.
Finally, several participants were somewhat illogical when discussing their fear of dental implants. For instance, these fearful participants overestimated the pain that an 65 implant patient would normally experience both during and after implant surgery. They even made the assumption that the pain of dental implant surgery would be intolerable, when in fact; pain levels are usuallY quite minimal for this type of a dental procedure. For example, it has been shown that pain in the implanted area is generally of low intensity.
To this end, pain medication is usually not required for more than 24 hours following implant surgery (32). Moreover, the likelihood of the onset of pain may be associated with the level of trauma inflicted during the surgical procedures. For instance, any additional incisions or other surgical procedures conducted on particularly sensitive are as may result in further pain for the patient. Therefore, a smooth and non-traumatic implant surgery would necessitate little post-surgical pain (32). Furthermore, the findings of this research project are consistent with the conclusions of another study conducted by Eli et al, who examined the inter-relationship between anxiety and pain perception with regards to dental implant surgery (67). This study showed that patients who displayed more fear and anxiety towards dental implant surgery expected significantly greater pain during the actual Surgery than participants who displayed no fear at aIl. However, immediately after dental implant Surgery, those fearful participants reported experiencing less pain then they had originally anticipated.
Furthermore, sorne participants even made the assumption that little or no anesthetic was administered during dental implant Surgery, and were therefore afraid of the pain that could arise due to the absence of anesthetic. These types of assumptions are not uncommon among patients preceding dental treatment. For instance, a study conducted by Weiner et al., which measured people's fear of the dentist, showed that fear of non-effective local anesthetic rated within the top four most common causes of dental- 66 related fear at 43% among 158 patients (54). However, anesthetic is normally administered during dental implant surgery and therefore limits pain to a minimum (32).
In addition, another participant became extremely fearful of dental implant surgery while sitting in the waiting room at the dentist prior to implant surgery. This fear was so great that it caused the participant to leave the dentist' s office and never return. It seemed as though the participant's fear increased dramatically as she anticipated her forthcoming implant surgery. Similarly, another study involving periodontal surgery offered an explanation for this type of behavior. In this study, patients reported significantly increased anxiety levels immediately before periodontal surgery, which is also known to be a stressful procedure (67, 68). The authors explained how this anxiety was significantly associated with the participant's expectation of pain during surgery.
Furthermore, the patient's state of anxiety proved to be the greatest predictor of pain at each point in time. To this end, fear may cause potential dental implant patients to overestimate the degree of pain experienced during dental implant surgery, and thus, make it difficult for dentists in proposing ISO's as a treatment option for edentulism.
The participants of this study were also shown two pictures of dental implants with baIl attachments (See Figures 5-1 & 5-2) and were asked to give their immediate impressions. After simply viewing these pictures, participants expressed their fear of dental implants by their shocked, disgusted, and confused facial reactions and through their verbal comments. Clearly, fear of dental implants is evident among the participants of this study. Moreover, this fear can be elicited in numerous ways. To this end, when proposing dental implant treatments to prospective patients, dentists must be alert for any verbal responses, body language, and facial cues which can signify patient fear. 67
6.3 Origins of Dental Implant-Related Fear
Four main sources of dental implant-related fear were identified in this study: 1) Past
negative experiences at the dentist; 2) "horror stories" of dental implant surgery; 3)
having relatively little knowledge of dental implants; and 4) poor dentist-patient
relationship. It is important to note that although each of the aforementioned sources were
influential in creating dental implant-related fear on their own, most of the participants'
fear originated via a combination of two, three, or even aIl four of these sources.
Furthermore, the exact combination of sources of fear varied from participant to
participant. It is also interesting to note that these sources of dental implant-related fear
are quite similar to the common causes of dental fear in general. For instance, the
literature shows that the most common causes of dental fear are past negative experiences
at the dentist, negative dental information from friends or family, being uninformed by
the dentist, worrying about the effectiveness of anesthetic and neglected patient feelings
(46, 47, 54). To this end, the causes of fear of dental implants follow a similar pattern as
that to general causes of dental fear.
6.3.1 Past negative experiences at the dentist
Consistent with my hypothesis, past negative dental experiences of edentulous individuals
may cause fear of dental implant surgery. EssentiaIly, when the participants of this study
discussed their thoughts on dental implant surgery, they recounted past negative
experiences at the dentist. These negative experiences involved botched surgeries (i.e.:
Tooth extractions and root canal therapy), pain, swelling, discomfort, lack of anesthetic,
~ ... as weIl as several others. Participants then generalized these past negative experiences to
dental implant surgery, which partially resulted in their fear and ultimate refusaI of dental 68
implants. In fact, heightened levels of dental-related fear are most often attributed to
aversive conditioning experiences from the dentist, usually occurring during childhood
(46). Furthermore, other studies have also confirmed that past dental experiences are one
of the main factors determining whether or not an individual will refuse dental implant
surgery (32). Moreover, although participants claimed to be overall less fearful of the
dentist today vs. when they were younger, they were still afraid of dental implant surgery
and were adamant about refusing ISO's. To this end, past dental experiences of dental
implant patients cannot be ignore d, especially when considering their powerful impact on
people's perceptions of dental implant surgery.
6.3.2 "Horror stories" of dental implant surgery
The second main source of dental implant-related fear was "horror stories" of dental
implant surgery from friends and family who have either undergone or heard about the
procedure. Sorne of these "horror stories" came from the participant's friends or family
who experienced unsuccessful dental implant surgery. In these cases, participants' friends
or family member described the implant surgery as being horrifie and painful, and thus,
claimed the unsuccessful results of the surgery did not warrant the suffering they had
experienced. However, sorne "horror stories" came from participants' friends or family
who underwent successful dental implant surgeries. It is very interesting to note that
although these implant recipients claimed to be very satisfied with their ISO's, sorne of
them still deemed the surgery as horrifie and not justifiable. Consequently, these "horror
stories" instilled greater implant-related fear among the participants ofthis study. Current
research shows similar results in that a great proportion of dental implant-related fear can ~ ..
be attributed to the abundance of hearsay comments pertaining to implant surgery (32). 69
Therefore, it is important to fully examine the true nature of such stories since they can be somewhat exaggerated, and thus, misleading to potèntial implant patients.
For instance, it is known that dental implant surgery increases fear and anxiety among patients, and can therefore cause them to overestimate the degree of pain experienced during surgery (67). Furthermore, over time the se individuals are most likely to remember their initial more inaccurate perceptions of dental implant surgery as opposed to their actual and usually less painful experiences. Therefore, potential dental implant patients must be wary when conversing with implant recipients since recall of dental implant surgery may re:flect one's initial perceptions and expectations of the procedure and not one' s actual experiences. Thus, it is possible that sorne of these
"horror stories" may not accurately re:flect actual experiences of dental implant surgery.
In addition, these "horror stories" conjure sorne interesting similarities with the notion of urban legends and how they are founded and persist on the basis of emotional selection (69). Essentially, urban legends recount detailed descriptions of events that elicit specific emotional responses. In the case of dental implants, these emotional responses consist of fear and disgust. Furthermore, urban legends that elicit the greatest amount of fear and disgust are most likely to be passed on from pers on to person. To this end,
"horror stories" of dental implants, which recount gruesome details of implant surgery and its recovery period, may induce a fear reaction among potential implant patients.
6.3.3 Having relatively little knowledge of dental implants
The third source of dental implant-related fear may be an individual's lack ofknowledge pertaining to dental implants. As previously mentioned, most participants had relatively little prior knowledge of dental implants. Therefore, participants made their own 70 assumptions of dental implant surgery and the recovery period, often resulting in false perceptions and irrational fears. Furthermore, it is very important to recognize this lack of knowledge among potential implant patients since people tend to fear the unknown.
Therefore, in the absence of information, potential implant patients will not know what to expect from dental implant surgery, and they might assume the worst. Other studies have shown similar findings where dental fear was associated with lack of knowledge. For example, Weiner et al. found that one of the most common causes of dental fear was when a patient was not properly informed about their dental treatment (54). Similarly, a study on pain and dental implants conducted by Muller and Calvo, found that one of the main sources of dental implant-related fear was the patient's lack of correct information pertaining to dental implantology (32). To this end, it is important to recognize why patients are not properly informed of dental implant surgery. One possible explanation may be that dentists do not always take the necessary time to adequately inform their patients regarding possible treatments. In fact, it has been shown from a patient's perspective that properly informing the patient is a frequent concem among dental patients (70). A second hypothesis may be that dental implants and ISO's are still considered a relatively new procedure among elderly patients, and thus, correct information pertaining to dental implants might not be as widespread as information on more conventional treatments for edentulism (i.e.: conventional dentures).
6.3.4 Poor dentist-patient relationship
The fourth main source of dental implant-related fear among sorne participants was their poor dentist-patient relationship. Essentially, sorne participants were not comfortable with the way their dentists interact with them. These participants felt their dentist did not speak 71 to them sufficiently or comfort them during dental procedures. In turn, participants experienced greater fear and anxiety towards the dentist in general. Moreover, these participants translated this fear of the dentist to dental implant surgery. These findings seem to be congruent with recent literature on the subject. For instance, Weiner et al. showed similar findings where dentists neglecting their patients feelings is considered to be one of the main sources of dental fear (54). Moreover, this fear might arise in potential dental implant patients providing the dentist maintains a poor dentist-patient relationship.
In fact, Muller and Calvo found that the dentist-patient relationship was a primary predictor of whether or not an edentulous person accepts or rejects dental implant surgery
(32). To this end, it is important for dentists to critically analyze their interaction with the patient, especially when considering their influence over patient comfort and satisfaction.
After aIl, it is the dentist that controls the overaIl tone of the dental environment, and subsequently, patient anxiety and fear. 72
7 Conclusion
As the results of this study show, the myriad forms of dental implant-related fear may play an influential role in an edentulous individual' s reluctance to undergo dental implant surgery. These fears include fear of dental implant surgery and the recovery period, as weIl as miscellaneous fears. Furthermore, this study outlined the different sources of dental implant-related fear. These sources consisted of past negative experiences at the dentist, "horror stories" of dental implant surgery, having relatively little knowledge of dental implants, and poor dentist-patient relationship. To this end, dentists should be mindful of the various fears of dental implants when proposing ISO's to their edentulous patients.
7.1 Recommendations for Dentists
Firstly, dentists must be vigilant when evaluating their patients for dental implant surgery.
Dental implant-related fear may not be so easy to recognize since the indicators of fear are not always readily cognizable. Moreover, because sorne people can hide their anxiety, sorne fears might only be recognized upon speaking to the patient and probing the issue.
To this end, dentists should familiarize themselves with common dental implant-related fears so as to improve on its recognition among their own patients. In order to facilitate this recognition, dentists can use this study' s findings when evaluating patient fear.
Dentists will have detailed descriptions of common dental implant-related fears with which to form a comparison. Furthermore, dentists may want to encourage free discussion with their patients regarding their past experiences at the dentist in order to uncover deeply-routed fears that the patient may have generalized to implant surgery. In doing so, 73 dentists may be able to provide patients with a c1ear distinction between their past dental experiences and dental implant surgery.
8econdly, dentists may help alleviate the fear of prospective implant patients by providing them with sufficient information regarding dental implant surgery and its recovery period. In turn, prospective implant patients will have a more realistic idea of what to expect during and after dental implant surgery, and thus, be less likely to make any false assumptions. In addition, dentists should be careful when showing pictures or models of dental implants in order to avoid shocking their patients. Moreover, dentists could provide patients with additional information in the form of an informational pamphlet that specifically addresses dental implant surgery. One such pamphlet is currently being developed at McGill University, Faculty of Dentistry, and has yet to be published. This pamphlet will address the different types of dental implants, reasons for receiving ISO's, dental implants and old age, dental implant surgery, pain levels, the recovery process, denture use following surgery, complications of dental implants, dental care with ISO's, cost of dental implants and I80's, restrictions regarding possible implant candidates, and fear of dental implants. Patients could take such a pamphlet to read over in the comforts oftheir own homes in order to make a well-informed decision ofwhether or not to undergo the procedure. As weIl, sorne informational pamphlets regarding dental implants are currently available from dental implant manufacturers such as Straumann and Nobel Biocare. However, these informational pamphlets fail to address certain issues, inc1uding: dental implants and old age, implant-supported overdenture use following surgery, complications such as non-receptive implants, and fear of dental implants as they are described in this study. Furthermore, to the best of my knowledge, there are no 74 currently available informational pamphlets that specifically address fear of dental implants and ISQ's in detail as they are discussed in this research project.
FinaIly, dentists may also decrease dental implant-related fear in their patients by improving their dentist-patient interactions. As the results of this study indicate, the dentists' attitude and interactions with their patients have a direct effect on patient fear.
For example, dentists can create fear among their patients through insufficient communication before and during dental treatment. Participants of this study stressed this point by explaining how their dentists did not always take the necessary time to speak with them and sufficiently explain the details of their upcoming dental procedures. As a result, sorne participants felt rushed when consulting with their dentists prior to dental implant surgery. Participants also explained how their dentists did not speak to them or comfort them during dental treatment. To this end, patients may have felt somewhat neglected, which resulted in exacerbated fear of the dentist. Therefore, when suggesting dental implants as a possible treatment, dentists with particularly fearful and/or sensitive patients should take the necessary time to speak with their patients and inform them of aIl the appropriate details with regards to dental implant surgery. In doing so, dentists may gain their patient's trust, and subsequently, further patient cooperation. Dentists can also try to decrease patient fear by making a conscious effort to comfort their patients during dental implant surgery. This may be achieved simply by communicating with the patient throughout the procedure.
Moreover, dentists may further reduce fear among prospective implant patients by scheduling particularly fearful patients at times that better suit their needs. For instance, dentists can schedule fearful patients early in their work week in order to ensure patients of their availability immediately after surgery should they have any questions or 75 concerns. Dentists may also want to provide patients with a phone number to a twenty four hour dental clinic should they require emergency medical attention after normal working hours. Furthermore, dentists may wish to schedule dental implant surgery as their first appointment of the day in order to limit the amount of time that a patient can spend in the waiting room. In doing so, patients will have less time where they could potentially build up anxiety and anticipatory fear prior to dental implant surgery. To this end, dentists might help reduce fear among their implant patients simply by taking the time to follow such precautionary measures. In turn, both the dentist and patient may benefit.
7.2 Future Studies
One potential future study may be to test the efficacy of an ISO informational pamphlet on reducing dental implant-related fear among fearful implant refusers. In doing so, it may be possible to identify the factors that are most responsible for eliminating fear as a reason for implant refusaI. This study may also evaluate the effectiveness of the informational pamphlet on different types of people. To this end, perhaps variations of this informational pamphlet can be created in order to cater to various personalities.
Furthermore, the results of such a study may contribute to the publication of ISO informational pamphlets and their eventual distribution to dental offices for practical use. 76
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70. Kulich KR, RydeÂn 0, Bengtsson H. A descriptive study ofhow dentists view their profession and the doctor-patient relationship. Acta Odontologica Scandinavica 1998;56:206-209. APPENDIXI - Interview Guide ~. Interview Guide
• State objectives • Prior knowledge of implants • Implants - What cornes to mind? • Dentures & Implants • Dentures - Experiences • Why not implants? • Knowledge of implant surgery • Expectations of implant procedure • Pain • Fear of implant surgery / implants. What are you afraid of? Why? • Where does the fear come from: o Word o Past experiences o Stories from people • Fear of implants vs. fear of regular dental procedures • Past experiences • Past surgeries other than dental. • Dental procedures in general • Dentist - Patient relationship • Fear of dental procedures? Why? Always? • Fear of the dentist • Concems of recovery period, after implant surgery • Complications of implant surgery • Infection • Today's medical and dental science. Eg: Medicine, Surgeries, and treatments. • Age and fear of implants • What could change your mind about implants? • At what point would you decide to get implants? APPENDIX2 Consent Form Consent Form
Overcoming the barriers to provision of implant supported overdentures
Principal researchers: Dr Christophe Bedos and Dr Jocelyne Feine (Faculty of Dentistry, McGill University) Duration of the study: October 2003 - September 2005 This research is funded by the ITI F oundation (F oundation for the Promotion of Oral Implantology, Base1, Switzerland).
Patient Information Sheet Many patients who wear complete dentures have problems eating or speaking, or experience soreness under their denture. Until recently, we had very few solutions to offer that might remedy the problems associated with denture wear. But recently, we have been able to show that dental implants placed in the jaw can he1p many patients. However sorne, like you, are reluctant to have implants placed. As researchers we are interested to know the reasons why patients don't want implants. We would therefore very much appreciate your participation in an interview to he1p us to better understand these reasons.
What will participation in the study involve? You will meet with an interviewer and discuss issues related to dentures and implants. The discussion should last about one hour. Ifnecessary, we might contact you again for more information.
Where will the interview take place? The interviewer will meet with you in a convenient setting of your choosing, such as your home.
What will happen at the meeting? The interviewer will briefly introduce himse1f and explain the purpose of the discussion. He will ask you questions over the course of the interview that are meant to encourage discussion about dentures and implants. He will also take notes and tape record the discussion, to make sure that no important information is missed. The recording will be typed for purposes of analysis. In order to guarantee absolute confidentiality, your name will be replaced by a code: thus, your identity will remain confidential.
Why should 1 participate? While you may not benefit directly from your participation, we hope that as a result of this research we will understand patients' concems about implants better. This will allow us to improve the information we give to future patients. You would have the satisfaction of knowing you had helped to improve one aspect of dental care for future patients.
Do 1 have to take part? No. You are in no way obligated to take part in this study and your refusaI to do so will not prejudice further medical or dental treatment. You may de cline to take part now or at any time in the future.
However, your involvement would be appreciated as it will greatly benefit oral health research.
Ifl need any further information, whom can 1 speak to? The research assistant will be able to answer most ofyour questions (398-7203, extension 00059#). However, if you require further information, you may speak to Dr Christophe Bedos (398-7203, extension 0129#) at the Faculty of Dentistry, McGill University.
Overcoming the barriers to provision of implant supported overdentures
Patient Consent Form
1, ______
Of______(city)
Agree to participate in the above-mentioned study. 1 have read the attached information sheet and my questions conceming the study have been answered to my satisfaction.
Signature of participant: ______
Signature of interviewer: ______
Date: ______
the Institutionn! rcview hoard of i\!cGi!I üfMedicine ] 2005 _ 10-Ir2 Interview #1: Brief Report Date: Saturday, March 19,2005.5:30 pm Duration: 44:06 min. Location: Interviewee's Apartment, kitchen. Cote St. Luc, Montreal. Interviewer (J): Jordan Nemes Interviewee (P): 78 year old female, edentulous, refuses to consider implants (as mentioned in telephone conversation when requesting an interview). Setting: The interview was conducted at the home of the participant on Sat., Mar. 19, 5:30 pm. Both the participant and l sat at the kitchen table on two chairs. The tape recorder was placed on the table between both of us for optimal recording. The participant's home was an apartment building situated in Cote St. Luc. Informant: The participant was a 78 year old woman who l have known for quite sorne time as she is also my step-grand-mother. Prior to the interview, l confirmed that the participant was a good candidate for my research via a short telephone conversation as she met my sample inclusion criteria; completely edentulous (no teeth), CUITent denture user, and refusaI of implants and/or refused to consider implants. The participant was very friendly and was very open to the interview when l asked her. Her only hesitation was at the beginning of the interview when l explained to her that l would need to record the interview. At first, the participant was self-conscious of her voice and felt uncomfortable being recorded. However, after explaining to her that her name would be kept confidential and that the audio would be transcribed to writing, the participant felt more comfortable and gladly agreed to the recording. As the interview topics were sensitive to the informant, she went through various emotions throughout the interview. For instance, when reminiscing of past dental experiences, the participant expressed feelings of anxiety, fear, and discomfort. However, while speaking about her CUITent dentist whom the participant likes, her tone of voice seemed more calm and pleasant. It was clear that the participant's emotions were significant as they almost dictated the way she responded to my questions. The Interview: Overall, the interview went rather smoothly. Before starting, l kept with me one sheet of paper which had written on it the different themes that l had wanted to cover throughout the interview. The participant responded very well to aU questions and seemed comfortable speaking to me about the various topics related to dental implants. l did not feel that nervous since l knew the participant very well and was aheady comfortable speaking with her, but at the same time l wanted to be very sensitive when speaking to her as l knew she considered her teeth as a private and more sensitive issue. l also felt somewhat nervous at the beginning of the interview when asking the participant for permission to record her as l did not know how she would respond. l knew that she would most likely say yes as she knows my schoolwork is important to me, but she is also very sensitive, and might have been more self-conscious about personal issues. The interview started with me asking the participant general questions about implants and her knowledge of them. From the answers that she gave me, l began to probe certain topics, and issues that might have been more important to the participant. In doing so, l believe certain topics that the participant brought up were discussed in addition to purely the themes on my list. However, l did notice at times that the conversation was getting off topic and thus often found myself trying to guide the conversation more towards my outlined themes. After re-listening to the interview, l also noticed myself cutting off the interviewee a few times. l believe l did this in order to guide the conversations to better suit my themes, or to bring the conversation back on topic, but perhaps l should not have interrupted so quickly. Had l given the interviewee more time to respond during these few instances, perhaps more important data could have been collected. In addition, while re listening to the interview, l found several instances where l could have probed for more information while staying on topic, but instead l changed topics. Once again, l believe l did this because during the interview, l might not have wanted to stray too far from the main themes. For my next interview, l will try to pay closer attention to the direction of the conversation during the interview so as not to stray too far from the topic of implants. Overall, all the themes outlined in my interview guide were covered. Interview #1 FoIlow-up: Brief Report * This interview is a follow up of interview #1, using the same participant. The purpose of this interview was to discuss several themes and questions that were raised in the tirst interview, as weIl as to gain information that could be useful in formulating a more complete interview guide for subsequent interviews with other participants. Date & Time: Sunday, April 17, 2005.7:04 pm Duration: 30 min. Location: Interviewee's Apartment, kitchen Interviewer (J): Jordan Nemes Interviewee (P): 78 year old female, edentulous, refuses to consider implants (as mentioned in telephone conversation when requesting an interview). Setting: The interview was conducted at the home of the participant on Sunday, April 17, at 7:04 pm. Both the participant and l sat at the kitchen table on two chairs. The tape recorder was placed on the table between both of us for optimal recording. The participant's home was an apartment building situated in Cote St. Luc. Interviewee: The participant for this interview was the same woman as in my first interview. She was very kind, talkative, and seemed to be very honest in her responses. However, although the information obtained in this second interview is new and seems quite useful, l feel that the interviewee's experience from our first interview may have somewhat influenced her responses in this second one. For instance, several times when l asked about a specific issue, the participant would not only answer the question, but she would also continue to talk as if she were answering questions and issues that were discussed in our previous interview. This is observed in the beginning of the interview when l ask about pain. The participant responds by explaining not only her concems about pain, but also by explaining what would have made her get implants in the past. This sort of response can be seen several times throughout the interview. It was almost as if she was formulating sorne ofher responses to what she thought l wanted to hear, and/or to themes that were discussed in our previous interview. Discussion: OveraIl, this additional follow up interview proved to be very informative. For one thing, the participant revealed more in depth fears and concems about dental implants. Furthermore, in this interview, the participant offered a c1earer explanation of the causes for her fear and concem for dental implants. At a quick glance, it seemed that the participant's past experiences at the dentist, as weIl as her relationship with the dentist played a key role in her fearing dental implants. However, when l tried to exc1ude these two factors in order to single out specific fears of dental implants, the participant explained that she did not know enough information about them. In tum, she also said that this "fear of the unknown" was one of her major concems regarding implants. In trying to further probe the matter, the participant expressed that she had fears of long term complications. In particular, the patient c1aimed she was afraid that the implants would have to be removed after a year' s time. Secondly, the participant also revealed that in her present state, if the conditions were met, she could be persuaded into getting dental implants. This can be seen near the end of the interview where the participant explains that if she was completely uncomfortable with her permanent dentures, and if the dentist told her that implants would offer her greater comfort, she would get implants. l was actually surprised that the participant said this since her original attitude towards implants was quite negative. Perhaps the participant' s attitude may have changed from the first interview, and throughout the second one. It may also be possible that in revealing her frustrations with her current dentures, the participant may have began to see her CUITent denture situation as being even more unpleasant than she had initially thought. This in tum, may have made her more open to the possibility of getting dental implants. Interview #2: Brier Report Date & Time: Wednesday, Sept. 14,2005,2:00 pm Duration: 34:35 min. Location: lnterviewee's Apartment, kitchen. City: Verdun. *Note: After my initial phone call with the interviewee, it was understood that it would just be the interviewee and l at her apartment. However, as l entered the participanfs apartment, her sister was sitting at the table in the kitchen, which we ended up using for the interview. Although the participant's sister was not the main interviewee, she sat at the same table throughout the entire interview, and contributed to the conversation at several instances during the interviewas well. l did not expect the participanfs sister to leave, nor did l ask her to, as this probably would have made the participant uncomfortable, and could have possibly altered her mood. This consequently could have affected the interviewee's overall participation. Although this scenario did not perfectly match my initial methodology, it ended up proving useful, as the participanfs sister ended up furthering the conversation by jogging the participant's memory at times, and thus, allowing her to contribute more to the interview. Interviewer (J): Jordan Nemes Interviewee (Pl): 70 year old female, edentulous, refuses to consider implants (as mentioned in telephone conversation when requesting an interview) Interviewee 2: (P2): Main interviewee's sister. Report: Overall, the interview went rather well. Although it was only 34 minutes in duration, it was still very informative. As l have previously mentioned, the interview did not go exactly according to plan. Instead of interviewing just the main participant, it seemed as though l was getting somewhat of a secondary interview from the participant's sister, who remained sitting at the same table for the entire interview. Although most questions were stilled addressed towards Pl, P2 answered sorne of them as well. Although l would have liked to have kept it simple, and only interview Pl, sorne of the information from P2 seemed useful and thus l began to probe her as well for more information. The interview guide that was used was essentially a compilation of the 2 interview guides used in my first interview, and the second follow-up interview. At this time, l don't see anything major to add to the interview guide for the next interview, as this one seemed to work rather weIl. However, after further data analysis of this interview, perhaps more topics will stand out as ones to add to the interview guide. *Note: l did add another element to this interview that was not do ne in the 2 previous interviews. l showed both Pl and P2 sorne pictures of dental implants near the end of our conversation. *(1 will continue to do tbis for ail future interviews) l chose to only show them the pictures near the end of the conversation so that they could first tell me about what they thought, or rather, what they assumed about dental implants, before being fully explained what they actually were. In this way, l was able to get an idea of someone's first thoughts and initial impressions of dental implants, and thus a good idea of their fears towards dental implants based on these thoughts and assumptions. It was very interesting to see their initial reactions to the pictures, because they had initially assumed that the dental implants were of the individual implanted teeth variety. The pictures also seemed to be useful in reinforcing Pl 's thoughts about the surgery, and the pain that she associated with it. Near the end of the conversation, after fully explaining to both participants what the dental implants actually were, their thought still seemed to be consistent with their initial ones. Pl essentialIy, still remained afraid ofthe implants, primarily because ofthe pain that she associated with the procedure. P2 also agreed with this. Several other factors regarding Pl & P2's fears of dental implants were evident, but fear of pain seemed to stand out as the primary source offear. Interview #3: BrieC Report Date & Time: Wednesday, Nov. 23, 2005, 12:00 pm Duration: 38:45 min. Location: Cavendish MalI, Al Van Houte cafe. City: Cote St. Luc Participant: The participant was a married 71 year old male. He seemed very sociable and talkative, and in good physical health. The participant also seemed to be well informed about several health issues as both he and his wife attend special Medical topics seminars at McGill University's faculty of Medicine. The participant lives in Cote St. Luc, Montreal. Recruitment: The participant responded to a flyer that was posted in J&R Kosher Meat store in Cavendish MalI. Upon screening the participant over the phone, it seemed like the participant fit my sample criteria. OveraIl, the interview went weIl. 1 first met the participant at the entrance of J&R Kosher Meat store in the Cavendish MalI. 1 recognized the participant by his WRX baseball cap that he mentioned he would be wearing from our telephone conversation. The participant seemed friendly at first, but still a little bit reserved. We walked to the Al Van Houte café that was located at the other end of the Cavendish MalI as this was probably the quietest place in the MalI where we could sit down and have a conversation. 1 purchased the participant a cup of coffee and we both sat down at a table in a relatively quiet area. The participant signed the consent form without hesitation and had no problems with being recorded. OveralI, the conversation ran smoothly. The interview began with the participant talking about his experiences at the dentist, his CUITent denture situation, and what made him think about dental implants. After that, we basically went through aIl of the interview guide topics, as weIl as several other issues that came about during the conversation. 1 feel that 1 did a good and thoroughjob at probing particular topics, but 1 do feel that when it came to issues regarding pain, and fear, the participant was not so quick to respond. Although 1 could tell that the participant did have sorne concems regarding these issues, it seemed as though he was trying to hide them, almost to make sure he seemed tough. However, with enough probing, 1 was able to reveal the main concems of the participant with regards to dental implants, which seemed to be the dentist-patient relationship. From what l can remember, the participant was unable to fully commit to getting dental implants because of his dentist. The participant explained how he had stability problems with his current dentures, but would not go through with implants as his past dentist did not make him feel comfortable. The participant further described how he recently switched dentists because his old dentist basically never spoke to him or told him anything that he was doing to him during an appointment. It therefore, seemed as if the participant was afraid of the procedure with his past dentist because he did not know enough about what was being done to him, and therefore was too uncomfortable to go through with the procedure. Although the participant recently switched dentists to one that was more soothing and explanatory of what he was doing, the participant was still not ready to fully commit to dental implants. Midway through the interview, the participant seemed more comfortable with me and was starting to joke around a little bit. This was good, because he loosened up more, and probably allowed himself to open up to me a bit more than earlier on in the interview. After the interview, the participant thanked me, and told me that he enjoyed the conversation. He mentioned how the conversation was very helpful and informative for him. He also told me that perhaps his friend, and/or his friend's brother might be a good candidate for my research and that he would speak to them to see if they were interested. This interview also made me think about sex differences as a sub-section in my research, with regards to fear of dental implants. So far, l have interviewed 2 women, and 2 men (only one of which l will use in my research, as the first male did not seem to fit my criteria). l know l can't be making assumptions so freely, but it does seem like the women were quicker to talk about fears and pain. They did not seem to hide these issues as much as the men, and seemed more concerned with pain as a factor. l know from past experiences and papers that l've read that there are sex differences in perceptions of pain, and so perhaps this may have sorne effect here. Either way, all of these issues will be considered when writing my analysis. Interview #4: Brier Report Date & Time: Wednesday, Jan. 18,2006.10:00 am Duration: Approx. 35 min. Location: Interview room at the Cummings Jewish Centre for Seniors. 5700 Westbury, Montreal. Participant: The participant was an 85 year old female who has been having difficulties with her dentures, particularly her lower dentures. She is very afraid of implants and would not consider them under any circumstances. Recruitment: This participant was recruited through the Cummings Seniors Centre. After meeting with the director of research at the centre, l was granted permission to recruit participants from sorne of their seniors groups. l met with one of the groups on Wed. Jan. Il,2006 to discuss my research and recruit individuals. On this day, l recruited 2 participants to interview for the following week Jan. 18,2006. Although this participant mentioned right away how she was very afraid of dental implants, she was still quite reluctant to agree to an interview. The participant was afraid that l was trying to convince her to receive the implants, and that l was "seUing" them to her. After trying to convince the participant of my intentions to just speak to her, she eventually agreed to an interview. At approximately 9:45 am on Wed. Jan. 18,2006, l met with the seniors group in the auditorium of the Cummings Centre. In the auditorium, l spoke with the participant for 5 minutes, as well as the other group members over sorne coffee and cookies. Shortly after, the participant walked with me to the interview room. Overall, the interview went rather well. However, the participant was somewhat hesitant at the beginning as it seemed as though she was still unsure what to expect. Eventually she signed the consent form, and was quite comfortable having her voice recorded. However, once the interview began, the participant began to talk freely without hesitation. The participant began to feel more comfortable as the interview progressed. Initially, l was quite impressed with the fact that the participant knew about implant-supported overdentures, and that when she referred to dental implants, she referred to them as implant-supported overdentures. This surprised me because most of the other participants that l've interviewed immediately thought of dental implants as the individual implanted teeth, and not the two implants for overdentures. The participant' s knowledge of implants could be attributed to the fact that she discussed the option with a dentist before, but refused to consider them due to her fear. As well, the participant's son in law is a dentist and has spoken to her on several occasions about the possibility of receiving implant-supported overdentures. This provided for a smooth conversation without having me to explain implant-supported overdentures too much to the patient. From the interview, it was clear that the patient was mainly afraid of the pain that she associated with the implant procedure. She continuously referred to the two posts that would be inserted into the gums as her main source of fear. Despite the fact that the patient knew she would be kept frozen during the procedure, she still displayed a strong fear towards the implants being inserted into her gums. The participant was also quite aware that implants could help her denture problems and that they are more advantageous than conventional dentures. The other main source of fear for the participant came from her discussions with other individuals that have received implants. The participant explained that both her daughter and sorne of her friends received dental implants and that they were very happy with them. However, they told the participant about all the pain and suffering that they had to go through for a short period of time. This pain and suffering, even for just a short period of time, was enough to deter the participant from receiving dental implants. Age also seemed to play a role in the participant's decision of not to get dental implants. Similar to other participants, this woman made statements referring to implants as pointless since she did not know how long she would remain living for. She also explained how she would receive dental implants had she been younger, simply because she was much less fearful when she was younger. Interview #5: BrieC Report Date & Time: Wednesday, Jan. 25, 2006.9:30 am Duration: Approx. 25 min. Location: Interview room at the Cummings Jewish Centre for Seniors. 5700 Westbury, Montreal. Participant: The participant was an 83 year old female. She does not have many problems with her dentures. However, she claims she is very afraid of dental implants and would not receive them under any circumstance. Recruitment: This participant was recruited through the Cummings Seniors Centre. After meeting with the director of research at the centre, 1 was granted permission to recruit participants from sorne of their seniors groups. 1 met with one of the groups on Wed. Jan. Il,2006 to discuss my research and recruit individuals. On this day, 1 recruited 2 participants to interview for the following week Jan. 18, 2006. This participant was quick to volunteer for my research and openly admitted she was afraid of dental implants in front of the rest of the seniors group. This woman has been coming to the centre for a few years now since her husband passed away. OveraIl, 1 was quite happy with this interview. Although it seemed a bit shorter than sorne of the other interviews, it was still very informative. Perhaps upon further analysis after the interview has been transcribed, 1 will be able to find areas that 1 might have been able to focus on more, or to speak about a bit more. 1 should mention that several times throughout the interview 1 find the participant cutting the answers short and 1 was forced to continuously encourage her to speak more. This required a lot of probing in certain topics, as weIl as asking sorne leading questions as a last resort. The participant was very friendly and nice to speak with. She was helpful and cooperated with me. The participant was not quite sure what to expect at the beginning of the interview. However, she was quite talkative once we sat down to speak. Similar to my previous interview participant, this participant was also very aware of the implant supported overdentures. Unlike other participants, she did not refer to implants as the individual teeth implants. Rather she was weIl aware of implant-supported overdentures since she was scheduled to receive them from her dentist. 1 found her story to be very interesting. She basically described to me that she saw the dentist about implants (which he recommended), she took x-rays, and was ready for surgery. On the day that she came to the dental office to receive implants, she gave in her name and was told to wait in the waiting room. While waiting, she became very afraid of the procedure and left the room. This is interesting, because perhaps the waiting period before the dental implant surgery may have an affect on the patient' s fear of dental implants. Perhaps dentists should be more aware of fearful patients and make them as comfortable as possible, with as little waiting time as possible before the procedure. These are sorne ideas for the analysis. This fear of dental implants was quite similar to sorne of the participant's past experiences at the dentist where she was scheduled for fillings for her cavities and did not show due to fear. However, this fear had nothing to do with the dentist's personality. Rather, it strictly involved the procedures involved with the dental treatment. The participant also claimed that although her past experiences at the dentist may affect the way in which she fears dental implants, she is still much more afraid of dental implants than any of her past dental experiences. There were several aspects of dental implants that the participant was afraid of. It is difficult to sayat the moment which aspect is the most fearful to her. However, it does seem that the recovery time after the implant procedure might be the most feared aspect of dental implants for the participant. The participant claimed that there was a long recovery time after the surgery and she did not want to suffer for so long. She mentioned pain during this recovery time, as well as not being able to wear her dentures. Most of this information was given to her by her dentist. She claimed that the recovery time was approximately 6 weeks long. The participant also claimed that she was afraid of the entire surgery. This included needles, pain, and drilling into the gums. She also referred to the entire surgery as being very complicated for her. She was afraid to suffer from the surgery. Furthermore, it seemed as though the participant was afraid of the mere thought, or idea of having two implants (foreign objects) being permanently inserted into her gums. This point was further confirmed when 1 showed the participant a picture of dental implants. The participant looked at the picture where one could see two implants in a fully healed edentulous mouth. The participant explained how she did not like how these "things" would stay in the gums. Interview #6: Brier Report Date & Time: Friday, Jan. 27, 2006.3:00 pm Duration: Approx. 45 min. Location: Interviewee's home in downtown Montreal. In the dining room ofhis home. Participant: The participant is a 55 year old male. He does not have any difficulties with his dentures, which he has not changed for 37 years. However, the interviewee did express a great deal of fear towards dental implants. Recruitment: This participant was recruited through snowball sampling. A friend of mine approached the participant about my research since she knew that he had dentures and may be a potential candidate. The participant then called me on the phone. 1 eXplained to him about my research and deducted that he was a suitable candidate since he expressed a genuine fear of dental implants. The participant works in a hospital environment and is therefore quite familiar to many aspects of general health care. l was very pleased with the way this interview went. The participant was very informative and spoke for quite sorne time without having to be pushed into conversation too much by myself. The interviewee had no problem signing the consent form, and was quite comfortable being tape-recorded. Our conversation began with the interviewee talking about what he feared most about dental implants. He then spoke about several related issues that would be covered later in the interview. Since 1 was unable to probe all of the issues that the participant brought up, we began at the beginning of my interview guide and spoke about his thoughts on dental implants. The participant explained to me that he would not consider dental implants, and that he would need to have an extreme reason for even considering them. For example, in the case of emergency where only dental implants could fix his jaw. Overall, the participant did not know too much about dental implants. He first began to speak about the individual teeth implants vs. implant-supported overdentures. Implant-supported overdentures were talked about later in the interview when l brought them to the participant' s attention. In terms of his main fears, the participant expressed an extreme fear of infection due to the intervention. For example, the participant was afraid that the dental implants were permanent, and therefore, should an infection arise, he wouldn't know what could happen. The participant claims that his work in the hospital may have affected his perception of medical procedures and the chances of obtaining infections. Moreover, the participant explained that he is also afraid of the drugs and pain medication that he would have to take to prevent infection or pain due to the implant procedure. The participant works in a health care environment and has seen many people who have become addicted to prescription medication. He is afraid of becoming addicted to the drugs that the dentist might prescribe. The participant also has friends who have experienced drug addictions due to prescription medication, and is therefore very afraid of the drugs that he associates with the implant procedure. Other fears of dental implants expressed by the patient include a great deal of fear of pain. The participant explained how he was afraid of the pain from the procedure and recovery period. Upon probing this issue, the participant claimed that he has friends and co-workers that have had the procedure done and that they complained of horrible pain and swelling of the face. According to his friend's descriptions, the participant made the procedure out to be unbearable. These people of course, were a source from which the participant learned about dental implants. To this end, the participant explained how he had only heard bad stories about dental implants. He also explained something to the affect of, "only those with negative experiences speak about it, but those who are satisfied remain silent." Other than these stories, the participant did not have any source of knowledge of dental implants. He therefore made his own assumptions regarding implants, based purely on what he thought and what people told him. The recovery period was also a source of fear for the participant since he was afraid of the lengthy period it could take for the implants to heal and the pain that he associated with this recovery period. The drugs that an implant patient would have to take during this time was also a fear for the participant. It was also interesting to note that the participant claimed he did not have any past traumatic experiences at the dentist, nor did ever have any painful ones. He explained how he does not have a general fear of the dentist or dental procedures. Rather, his fear is specifie to dental implants. However, the participant did claim that his confidence in his CUITent dentist does play a large role in his experiences. He explained how his dentist seemed very confident and competent in what she was doing. The participant also mentioned that should he ever decide to get dental implants, the dentist would play a large role in whether or not he would fear the implant procedure. This included how the dentist spoke to him, how confident the dentist seemed in their decision, and how much information the dentist gave to the patient pertaining to the implant procedure. Another important issue that the participant touched upon was the availability of information regarding implants and its effect on fear. For instance, the participant mentioned that the amount of information he would obtain about dental implants from his dentist would have an effect on how much he feared dental implants. For instance, the participant spoke about the lack of information of dental implants and that it could create more fear for him and other patients. Interview #7: BriefReport Date & Time: Tuesday, Jan. 31,2006.10:30 am Duration: 45 min. Location: Interview room at the Cummings Jewish Centre for seniors. 5700 Westbury, Montreal. Participant: The participant was a 75 year old male. He does not have many problems with his dentures. However, he claims that he is afraid of dental implants and would not receive them under any circumstance. The participant was a very sociable pers on and spoke with me for quite sorne time during recruitment. In fact, l had to stop him from saying too much so that we would have something to talk about during the actual interview. Recruitment: This participant was recruited through the Cummings Seniors Centre. On Monday, Jan. 30, 2006, l set up a table in the main hallway, outside the cafeteria. l sat at this table for several hours, posted up flyers for my research, and gave out business cards. l met with several people passing by my table. l recruited this participant during these hours at my information table. The participant then agreed to meet with me the next day. This interview was very informative, but it was quite difficult to conduct. This was due to the fact that the participant was a big talker and would often begin to talk about the topic at hand, but eventually ended up speaking about an entirely different story. Several times during the interview l had to interrupt the participant to get the conversation back on topic. However, once we were on topic, the participant was very talkative, and informative. The participant did not have too much knowledge of dental implants. An that he knew came from stories told to him by his friend who experienced the procedure. From what his friend told him, the implants were not worth the pain that he experienced. This made the participant quite afraid of the implants. His friend even told him that even though he was satisfied with the implants once they healed, he would not get them again as it was too painful. This also caused quite a bit of fear in the participant. The participant's main fear of dental implants was the pain of the procedure. The participant explained that he was afraid of the pain that he associated with the implant procedure. Sorne of this was due to the fact that his friend who received dental implants told him about his painful experiences. However, another main source of "fear of pain" came from the participant' s past experiences at the dentist. He explained as far back as when he was a child, the dentist was not a fun place to be. He described it as scary. The dentists did not have good bed-side manners. In 1950 when he has his teeth removed, he was initially given no anesthetic or pain medication. He said that the pain was unbearable. Since then, he's always been afraid of the dentist, especially the pain from the procedures. He also stated that this past fear probably affected his fear towards dental implants. Moreover, the participant was even more afraid of the dentist because while receiving these painful treatments, the dentist would not comfort him in any way. The participant explained that the bed-side manners and his confidence in his dentist were very influential in controlling the level of fear in him. The participant also felt that should he ever receive dental implants, how the dentist approached him and spoke to him would influence the level of fear that he experiences. Another main issue that we spoke about was age. The participant could not understand how people at an old age would want to go through so much pain and suffering, only to have the implants for just a few more years of their lives. Furthermore, the participant explained that had he been younger, he would have been more willing to receive dental implants. He also explained that he atiributed part of his fear of implants to his older age. It was also interesting to note that once l showed the participant a picture of the dental implants situated in the lower jaw, he had a petrified look on his face. He responded by saying how he was afraid of having these screws drilled into his gums. He spoke of this as being "not normal", or unnatural. He was afraid of inserting a foreign object into the body, and that it was unnatural. The participant was also somewhat afraid of the recovery time involved after the implant procedure. More specifically, the participant was afraid of suffering during a lengthy recovery period. Moreover, he was afraid of the possibility of complications due to the procedure. For instance, the participant was afraid of the implant surgery being unsuccessful. He was aIso afraid of the possibility of infection. Interview #8: Brier Report Date & Time: Thursday, Feb. 2, 2006. 12:00 pm Duration: 33:30 min. Location: Interview room at the Cummings Jewish Centre for seniors. 5700 Westbury, Montreal. Participant: The participant was a 35 year old male. He is not very happy with his current lower dentures, but is very afraid of dental implants. The participant also works at the Cummings Centre as a caretaker. Recruitment: This participant was recruited through the Cummings Seniors Centre. On Monday, Jan. 30,2006,1 set up a table in the main hallway, outside the cafeteria. 1 sat at this table for several hours, posted up flyers for my research, and gave out business cards. 1 met with several people passing by my table. 1 recruited this participant during these hours at my information table. The participant then agreed to meet with me later in the week. Overall 1 was very happy with the way this interview went. The participant seemed very interested in what 1 was doing. Especially since he claimed he was afraid of dental implants. The participant was very talkative and expressive about his feelings. He seemed very comfortable talking with me. The participant had quite a bit of knowledge about dental implants. He mentioned specific aspects about the implants surgery as well as the recovery time. The implants that the participant was speaking about were the individual tooth implants. Most of his knowledge about dental implants cornes from stories told to him by friends. He also heard about them through a reader's digest magazine. However, what he heard from his friends was not good. He heard several horror stories about dental implants, specifically referring to the pain of the procedure. He was also under the impression that the patients are given no anaesthetic of any kind to freeze the mouth. This made the participant fear the implant procedure even more. Furthermore, when 1 asked the participant what came to his mind when 1 mentioned the word implant, he said- "sorne kind of screw that goes into your mouth. It's something not normal to the body." This was very interesting since several people have also mentioned this "unnatural" theme in their interviews. When 1 asked the participant about his main fear about implants, he responded several times that it was the pain. The source of this "fear of pain" did not seem to be related to past painful experiences at the dentist. Rather, it came directly from the implant horror stories that were told to him by his friends. Furthermore, the participant did admit to having a general fear of the dentist. This was mostly due to the fact that he had one negative root canal experience at the dentist where the dentist accidentally dropped sorne kind of a metal piece down the participant' s mouth. This dentist also happened to be a young dentist. Since then, the participant claims he only goes to more experienced and older dentists and that his confidence in his dentist is extremely important to him, especially in order to alleviate his fears. The participant also mentioned how this negative experience probably affected his fear of dental implants in sorne way. The participant also mentioned how he was always ·afraid of any kind of surgeries, needles, or dental instruments. This only added to his fear of dental implants. The participant said that his second biggest fear of dental implants, second to pain, was the fear of being forced to change eating habits. The participant was afraid that once he got the implants, he would have to change the types of foods that he eats. He thought that he would be more sensitive to hot and cold foods due to the implants, and that he might not be able to eat hard foods with them. The participant also expressed a fear of the recovery time. SpecificaIly, the long time it could take to recover from implant surgery, and the possibility of an unsuccessful surgery. He also mentioned being afraid of the pain during the recovery time. It was also very interesting to see how aIl the participants respond to seeing the pictures of the implants. In this case, the participant seemed very surprised at seeing the implants healed in the gums and bone. He thought it was unnatural that screws could be drilled into the gums in such a manner. He also kept saying the word "pain" over and over when looking at the pictures. Another interesting issue was dental science and technology today vs. several years ago. The participant claimed that he would be much more afraid of implants several years ago since dental science and technology was not as good as it is today. He mentioned that although he his still afraid of implants, he is less fearful of the dentist overall due to advancements in dental science and technology. APPENDIX4 Coding List r Coding List (1) Source of fear of dental implants • Past negative experiences at the dentist • Dental science today vs. past • Horror stories from friends and family • Dentist • TV commercials • Magazine ad • Lack of knowledge • Dentist-patient relationship ~ Bedside manners ~ Confidence in dentist • General Fear (2) Knowledge of dental implants • Pain • Expensive • Non-receptive implants • Successful implants • Lack of knowledge • Source of Knowledge ~ Dentist ~ Friends ~ Family ~ TV Commercials ~ Magazine ad ~ Implant recipients • Type of implant ~ Implant supported dentures ~ Single tooth implants • Drilling • Aesthetics • Permanent Implants • Suitability for implants • Infection • Tooth Extraction • Needles (3) Past experiences at the dentist • Dentures • Pain • Dentist patient relationship • Fear • Negative experiences • Tooth extraction • Anesthetic (4) Fear of dental implants • Fear of dental implant surgery ~ Fear of pain ~ Age • Young • Old ~ Dental drills ~ Duration of dental implant surgery ~ General dental tools ~ Gumpain • Cutting the gums • Inserting dental implants ~ Needles • Anesthetic ~ Suffering • Fear of the recovery period following dental implant surgery ~ Fear of pain ~ Duration of the recovery period ~ Lower jaw pain ~ Suffering ~ Swelling ~ GumPain ~ Fear of infection ~ Disabling effects • Implants removed • Pain ~ Susceptibility ~ Complications ~ Discomfort ~ Non-receptive Implants ~ Not being able to wear dentures • Difficulty eating • Aesthetic appearance ~ Broken Implants ~ Aesthetics (- • Miscellaneous fears ~ Foreign Objects in the body ~ Not normal- unnatural process ~ Assumptions of implants ~ Fear of drug addiction ~ Fear of change in lifestyle ~ Eating habits ~ Fear dental implant pictures ~ F ear of Dentist Environrnent ~ Fear ofwaiting room time (5) Not coded