KNOWLEDGE OF DENTAL PROFESSIONALS ABOUT THE MANAGEMENT OF FOOD IMPACTION ASSOCIATED WITH FIXED PARTIAL DENTURE PROSTHESIS
Ammar Muslih AlShamrani1, Khalid Muslih AlShamrani1, Hisham Mohammed AlShamrani1, Ali Mohammed AlMudawi1, Yazid Khalid AlKhathlan1, Shahzeb Hasan Ansari2*
1 Internship Training Program, Faculy of Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia.
2 Department of Preventive Dentistry, Faculty of Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia. [email protected]
ABSTRACT
One of the most common complaints about fixed partial denture (FPD) prostheses is food impaction. However, these complaints are often neglected by the dental practitioner leading to pain for the patient in the long term. This cross-sectional study was carried out among the dental professionals in Riyadh using an online survey. Dental clinics and hospitals in Riyadh were contacted and participants were asked to fill up the survey. This cross-sectional study was carried out among the dental professionals in Riyadh using an online survey. Dental clinics and hospitals in Riyadh were contacted and participants were asked to fill up the survey. Online questionnaire was constructed consisting of questions about demographic and personal data followed by questions about food impaction and its management. 410 dental professionals responded to the survey, which included 61% males and 39% females. Regarding their qualifications, 72% were BDS and 28% had done master’s or Saudi board post-graduation. The attitudes of dentists when fabricating or giving instructions to lab technicians needs to be improved.
Key words: Food impaction, Fixed dental prosthesis, Complications, Dental professionals.
Introduction
Fixed Partial Dentures (FPD) are commonly used for prosthodontic rehabilitation [1]. However, the maintenance of it is of equal importance. Prosthesis dislodgement and food impaction are the most common complaints of the patients regarding FDP. Therefore, the practitioner must be aware of the factors of food impaction that lead to failures of FDP and that could help in minimization such incidences and meeting the patient’s expectations [2, 3].
For the benefits of the patients, the dentist should be involved at the time of selection of pontic designs and its awareness should be improved on the pontic design selection for different situations, as it can reduce the harmful impacts of any food impaction [4].
One of the most common complaints about fixed partial denture (FPD) prostheses is food impaction. However, these complaints are often neglected by the dental practitioner leading to pain for the patient in the long term. The practitioner, therefore, must be able to evaluate the factors contributing towards the food impaction and then carry out the treatment. Generally, a patient is treated with a symptomatic treatment rather than a root cause elimination. Patients mostly complain about halitosis, bleeding gums, and pain. If the FI is not treated properly, it in future gives rise to secondary caries, periodontal pocket, gingival abscess formation, and interdental bone loss [5]. For temporary relief in pain patients usually use dental floss, proximal brush, or toothpick. However, if the frequency of such use is increased it leads to increased frustration for the patients and worsens the inflammation [6, 7].
Eosinophilic Esophagitis (EoE) is the most widespread fundamental etiology in cases of food impaction. It is also seen that there is an increased incidence of the complicated EoE. Whereas it is also noted that EoE is not properly identified and addressed with patients by the medical practitioner [8].
In a similar study conducted, it was seen that the knowledge was good, however, there were some lacking. It was also seen that the knowledge and practice enhanced with increasing levels of education [9]. Another study showed that there was a lack of knowledge of interdental cleaning and practice. Therefore, mass educative programs should be introduced to increase awareness, knowledge, and its practice [10].
Another study in India indicated that dental professionals possess sufficient knowledge to make an appropriate diagnosis but there are knowledge gaps that warrant a need for more teaching such subjects in the dental undergraduate curriculum [11].
Study hypotheses
Knowledge of dental professionals about the management and effect of food impaction in FPDs is low.
Aims
Materials and Methods
Study design
This cross-sectional study was carried out among the dental professionals in Riyadh using an online survey.
Sample
Dental clinics and hospitals in Riyadh were contacted and participants were asked to fill up the survey.
Instrument
Online questionnaire was constructed consisting of questions about demographic and personal data followed by questions about food impaction and its management.
Instrument validity and reliability
A pilot study was performed by sending the survey to twenty participants and the data reliability was assessed using Chronbach’s coefficient alpha. The validity of the questionnaire was evaluated by sending it to experts in REU, but no change was made.
Statistical analysis
Collected data were analyzed using SPSS22, where inferential and descriptive statistics were carried out. The significance level was considered below 0.05 using the Chi-square test.
Results and Discussion
A total of 410 dental professionals responded to the survey, which included 61% males and 39% females (Figure 1). Regarding their qualifications, 72% were BDS and 28% had done master’s or Saudi board post-graduation (Figure 2). As far as their work experience is concerned, 33% had more than 5 years of experience and 67% had less than 5 years (Figure 3). Table 1 shows the frequencies of responses to questions asked in the questionnaire. 51.8% of the participants had received less than 5 patients with food impaction complaint in the last 6 months, most common complaint was pain on biting, 68.7% of patients were sometimes aware of any food impaction, most common site of FI was the posterior mandibular region (41%), 50.6% responded with food being impacted in interproximal spaces, 48.2% reported caries as a consequence of FI, 51.8% mentioned faulty prosthesis design as the cause of FI, the majority were in the favor of redoing the FPD (53%) as a treatment of FI, 28.9% reported that patients mostly responded positively to the treatment and 37.3% revealed symptoms mostly subsided once treatment was provided.
Table 2 shows the comparison of survey responses based on qualification, with a majority of the differences being statistically significant. 30% of specialists had received more than 10 cases during 6 months as compared to 17% general practitioners (p-value: .007), 43% reported caries being the major consequence of FI as compared to 61% of specialists (p-value: .009), most common contributory factor for faulty FPD reported by GPs was poor margin adaptation and improper contour of the crown by the specialists (p-value: .009), specialists were more strict about giving necessary information to the lab technician as compared to general practitioners (p-value: .000) and 35% of specialists reported symptoms being fully subsided after treatment as compared to 10% of GPs (p-value: .000).
Table 3 demonstrates the comparison of survey responses based on work experience, with a majority of the differences being statistically significant as well. 41% of experienced dentists had received more than 10 cases during 6 months as compared to 17% of less experienced practitioners (p-value: .000), 22% of less-experienced practitioners reported FI being occurred in maxillary posteriors as compared to 32% of more experienced dentists (p-value: .000), most common contributory factor for faulty FPD reported by less experienced practitioners was poor margin adaptation and improper contour of the crown by more experienced dentists (p-value: .009).
|
|
|
Figure 1. Gender ratio of study participants |
|
|
|
Figure 2. Qualifications of study participants |
|
|
|
Figure 3. Work experience of study participants |
Table 1. Response frequencies of the study participants
|
Survey Questions |
Response Frequencies |
|
Number of patients reporting complaints of food impaction in last 6 months |
Less than 5: 51.8% 5 to 10: 27.7% More than 10: 20.5% |
|
Presenting complaint along with food impaction |
Pain: 41% Bleeding gums: 24.1% Halitosis: 24.1% Any other: 10.8% |
|
Were the patients aware of the occurrence of food impaction? |
Never: 7.2% Sometimes: 68.7% Mostly: 15.7% Always: 8.4% |
|
Time elapsed after fabrication of prosthesis when food impaction occurred |
less than 6 months: 50.6% 6 months to 1 year: 34.9% more than 1 year: 14.5% |
|
Common site of food impaction about FPD/crown |
Anterior maxillary region: 6% Posterior maxillary region: 28.9% Anterior mandibular region: 9.6% Posterior mandibular region: 41% No particular region: 14.5% |
|
Surfaces most commonly involved in food impaction |
labial/buccal: 16.9% lingual/palatal: 14.5% interproximal: 50.6% area beneath pontic: 18.1% |
|
Consequences of food impaction observed |
Proximal caries of teeth adjacent to abutment teeth: 48.2% Secondary caries beneath the crown in relation to abutment: 21.7% Pocket formation in relation to abutment teeth and adjacent abutment teeth: 20.5% Interproximal bone loss between the abutment and adjacent teeth: 9.6% |
|
Presence of use of interdental aids |
Never: 31.3% Sometimes: 57.8% Mostly: 7.2% Always: 3.6% |
|
If yes, interdental aids used by the patient |
Dental floss: 37.3% Interproximal toothbrush: 13.3% Toothpicks: 15.7% Anything else: 13.3% Not applicable: 20.5% |
|
Most likely reason for food lodgment |
Faulty FPD/crown design: 51.8% Improperly restored adjacent teeth: 33.7% Improper alignment of opposing teeth: 3.6% Others: 10.8% |
|
Contributory factors for faulty FPD design |
Improper contact relation of the crown with the adjacent tooth or crown: 30.1% Improper contour of the crown: 30.1% Improper pontic design: 12% Poor margin adaptation of the crown: 27.7% |
|
Treatment options considered |
Redoing the FPD: 53% Refilling of the adjacent tooth: 12% Altering the existing restoration of the adjacent tooth: 15.7% Blocking the interproximal contact area: 6% Prescribing interdental aids: 8.4% Others: 4.8% |
|
Was the necessary information related to the new FPD design communicated to the lab technician? |
Never: 8.4% Sometimes: 59% Mostly: 20.5% Always: 12% |
|
Did the patients respond to prescribed treatment satisfactorily? |
Never: 7.2% Sometimes: 51.8% Mostly: 28.9% Always: 12% |
|
Specialists/Consultants to whom these patients can be referred |
Prosthodontist: 62.7% Periodontist: 26.5% Any other: 10.8% |
|
Did the symptoms of food impaction subside after final treatment? |
Never: 8.4% Sometimes: 37.3% Mostly: 37.3% Always: 16.9% |
|
Recall was done after how long |
Once every month: 20.5% Once a year: 55.4% Once every 2 years: 13.3% No recall appointment was made: 10.8% |
Table 2. Survey response comparisons on the basis of qualification
|
Survey Questions |
BDS |
Masters/Board |
p-value |
|
Number of patients reporting with complaints of food impaction in last 6 months |
Less than 5: 55% 5 to 10: 28% More than 10: 17% |
Less than 5: 43% 5 to 10: 26% More than 10: 30% |
.007 |
|
Presenting complaint along with food impaction |
Pain: 45% Bleeding gums: 23% Halitosis: 23% Any other: 8% |
Pain: 30% Bleeding gums: 26% Halitosis: 26% Any other: 17% |
.011 |
|
Were the patients aware of the occurrence of food impaction? |
Never: 5% Sometimes: 72% Mostly: 17% Always: 7% |
Never: 13% Sometimes: 61% Mostly: 13% Always: 13% |
.004 |
|
Time elapsed after fabrication of prosthesis when food impaction occurred |
less than 6 months: 53% 6 months to 1 year: 37% more than 1 year: 10% |
less than 6 months: 43% 6 months to 1 year: 30% more than 1 year: 26% |
.000 |
|
Common site of food impaction about FPD/crown |
Anterior maxillary region: 7% Posterior maxillary region: 33% Anterior mandibular region: 7% Posterior mandibular region: 38% No particular region: 15% |
Anterior maxillary region: 4% Posterior maxillary region: 17% Anterior mandibular region: 17% Posterior mandibular region: 48% No particular region: 13% |
.000 |
|
Surfaces most commonly involved in food impaction |
labial/buccal: 20% lingual/palatal: 12% interproximal: 50% area beneath pontic: 18% |
labial/buccal: 9% lingual/palatal: 22% interproximal: 52% area beneath pontic: 17% |
.007 |
|
Consequences of food impaction observed |
Proximal caries of teeth adjacent to abutment teeth: 43% Secondary caries beneath the crown in relation to abutment: 25% Pocket formation in relation to abutment teeth and adjacent abutment teeth: 22% Interproximal bone loss between the abutment and adjacent teeth: 10% |
Proximal caries of teeth adjacent to abutment teeth: 61% Secondary caries beneath the crown in relation to abutment: 13% Pocket formation in relation to abutment teeth and adjacent abutment teeth: 17% Interproximal bone loss between the abutment and adjacent teeth: 9% |
.009 |
|
Presence of use of interdental aids |
Never: 30% Sometimes: 62% Mostly: 7% Always: 2% |
Never: 35% Sometimes: 48% Mostly: 9% Always: 9% |
.002 |
|
If yes, interdental aids used by the patient |
Dental floss: 37% Interproximal toothbrush: 13% Toothpicks: 13% Anything else: 17% Not applicable: 20% |
Dental floss: 39% Interproximal toothbrush: 13% Toothpicks: 22% Anything else: 4% Not applicable: 22% |
.009 |
|
Most likely reason for food lodgment |
Faulty FPD/crown design: 53% Improperly restored adjacent teeth: 35% Improper alignment of opposing teeth: 5% Others: 7% |
Faulty FPD/crown design: 48% Improperly restored adjacent teeth: 30% Improper alignment of opposing teeth: 0% Others: 22% |
.000 |
|
Contributory factors for faulty FPD design |
Improper contact relation of the crown with the adjacent tooth or crown: 28% Improper contour of the crown: 27% Improper pontic design: 15% Poor margin adaptation of the crown: 30% |
Improper contact relation of the crown with the adjacent tooth or crown: 35% Improper contour of the crown: 39% Improper pontic design: 4% Poor margin adaptation of the crown: 22% |
.002 |
|
Treatment options considered |
Redoing the FPD: 50% Refilling of the adjacent tooth: 5% Altering the existing restoration of the adjacent tooth: 20% Blocking the interproximal contact area: 8% Prescribing interdental aids: 12% Others: 5% |
Redoing the FPD: 61% Refilling of the adjacent tooth: 30% Altering the existing restoration of the adjacent tooth: 4% Blocking the interproximal contact area: 0% Prescribing interdental aids: 0% Others: 4% |
.000 |
|
Was the necessary information related to the new FPD design communicated to the lab technician? |
Never: 10% Sometimes: 58% Mostly: 23% Always: 8% |
Never: 4% Sometimes: 61% Mostly: 13% Always: 22% |
.000 |
|
Did the patients respond to prescribed treatment satisfactorily? |
Never: 10% Sometimes: 52% Mostly: 30% Always: 8% |
Never: 0% Sometimes: 52% Mostly: 26% Always: 22% |
.000 |
|
Specialists/Consultants to whom these patients can be referred |
No Statistically Significant Association |
.670 |
|
|
Did the symptoms of food impaction subside after final treatment? |
Never: 8% Sometimes: 40% Mostly: 42% Always: 10% |
Never: 9% Sometimes: 30% Mostly: 26% Always: 35% |
.000 |
|
Recall was done after how long |
No Statistically Significant Association |
.331 |
|
Table 3. Survey response comparisons on the basis of work experience
|
Survey Questions |
Less than 5 years |
More than 5 years |
p-value |
|
Number of patients reporting complaints of food impaction in last 6 months |
Less than 5: 61% 5 to 10: 29% More than 10: 11% |
Less than 5: 33% 5 to 10: 26% More than 10: 41% |
.000 |
|
Presenting complaint along with food impaction |
Pain: 41% Bleeding gums: 20% Halitosis: 30% Any other: 9% |
Pain: 41% Bleeding gums: 33% Halitosis: 11% Any other: 15% |
.000 |
|
Were the patients aware of the occurrence of food impaction? |
No Statistically Significant Association |
.082 |
|
|
Time elapsed after fabrication of prosthesis when food impaction occurred |
less than 6 months: 59% 6 months to 1 year: 32% more than 1 year: 9% |
less than 6 months: 33% 6 months to 1 year: 41% more than 1 year: 26% |
.000 |
|
Common site of food impaction in relation to FPD/crown |
Anterior maxillary region: 5% Posterior maxillary region: 32% Anterior mandibular region: 7% Posterior mandibular region: 45% No particular region: 11% |
Anterior maxillary region: 7% Posterior maxillary region: 22% Anterior mandibular region: 15% Posterior mandibular region: 33% No particular region: 22% |
.000 |
|
Surfaces most commonly involved in food impaction |
No Statistically Significant Association |
.098 |
|
|
Consequences of food impaction observed |
No Statistically Significant Association |
.205 |
|
|
Presence of use of interdental aids |
Never: 32% Sometimes: 52% Mostly: 7% Always: 2% |
Never: 30% Sometimes: 56% Mostly: 7% Always: 7% |
.040 |
|
If yes, interdental aids used by the patient |
Dental floss: 39% Interproximal toothbrush: 14% Toothpicks: 13% Anything else: 18% Not applicable: 16% |
Dental floss: 33% Interproximal toothbrush: 11% Toothpicks: 22% Anything else: 4% Not applicable: 30% |
.000 |
|
Most likely reason for food lodgment |
Faulty FPD/crown design: 50% Improperly restored adjacent teeth: 38% Improper alignment of opposing teeth: 5% Others: 7% |
Faulty FPD/crown design: 56% Improperly restored adjacent teeth:26% Improper alignment of opposing teeth: 0% Others: 19% |
.000 |
|
Contributory factors for faulty FPD design |
Improper contact relation of the crown with the adjacent tooth or crown: 27% Improper contour of the crown: 27% Improper pontic design: 16% Poor margin adaptation of the crown: 30% |
Improper contact relation of the crown with the adjacent tooth or crown: 37% Improper contour of the crown: 37% Improper pontic design: 4% Poor margin adaptation of the crown: 22% |
.000 |
|
Treatment options considered |
Redoing the FPD: 46% Refilling of the adjacent tooth: 9% Altering the existing restoration of the adjacent tooth: 21% Blocking the interproximal contact area: 9% Prescribing interdental aids: 13% Others: 2% |
Redoing the FPD: 67% Refilling of the adjacent tooth: 19% Altering the existing restoration of the adjacent tooth: 4% Blocking the interproximal contact area: 0% Prescribing interdental aids: 0% Others: 11% |
.000 |
|
Was the necessary information related to the new FPD design communicated to the lab technician? |
No Statistically Significant Association |
.000 |
|
|
Did the patients respond to prescribed treatment satisfactorily? |
Never: 11% Sometimes: 52% Mostly: 30% Always: 7% |
Never: 0% Sometimes: 52% Mostly: 26% Always: 22% |
.000 |
|
Specialists/Consultants to whom these patients can be referred |
No Statistically Significant Association |
.572 |
|
|
Did the symptoms of food impaction subside after final treatment? |
Never: 11% Sometimes: 36% Mostly: 39% Always: 14% |
Never: 4% Sometimes: 41% Mostly: 33% Always: 22% |
.017 |
|
Recall was done after how long |
Once every month: 21% Once a year: 57% Once every 2 years: 9% No recall appointment was made: 13% |
Once every month: 19% Once a year: 52% Once every 2 years: 22% No recall appointment was made: 7% |
.002 |
The present study aimed at determining the experience and practice of dental practitioners towards the problems related to food impaction associated with fixed partial dentures. Untreated and chronic food impaction around a fixed prosthesis is accountable for inflammation that causes pain, bleeding, and edema around the mucosa. It also contributes to the onset of tooth mobility, loss of bone, pocket formation, papillary loss, and halitosis. It is important to comprehend the differences between food impaction and food lodgment. Unlike food impaction that is a more chronic condition, food lodgment is the mere lodgment of food particles and debris in mucosa around the fixed prosthesis that can be removed by natural self-cleansing mechanisms. So, to prevent the onset of food impaction around the prosthesis, clinicians should recall and monitor patients every 3-6 months for the development of faulty or open proximal contacts and occlusion [12]. However, the practice of recall was frequently maintained by merely 20.5% of our study participants on monthly basis.
Food impaction is caused mainly due to the faulty design of FPD or crown, which is reported by the study participants. Food impaction caused by faulty constructed restoration could be best prevented if appropriate precautions are taken while designing the prosthesis. In recent years, heat-pressed glass-ceramic material is extensively used for restoration. It can decrease the occurrence of food impact in those who preserved the adjacency relationship between the proximal and distal middle surfaces of teeth. For the reconstruction of the adjacent area, compared to the traditional whole-crown restoration, they did not show better results in a good edge close and preventing food impaction [13].
It was observed in our findings that the most common problem related to the prosthesis and food impaction was pain, followed by bleeding gums and halitosis. Another similar study conducted in Chennai, India by Ashok & Sangeetha (2016) listed the common problems associated with fixed prostheses and disclosed that 40% of patients had complained of food impaction, due to which they faced pain and halitosis [14]. Most of the FPD failures are a result of poor patient care after insertion while the others occur due to defective design and inadequate execution of laboratory and clinical procedures. Regarding the latter issue, it was noticed that 59% of our study sample rarely communicated necessary information related to the new FPD design with the lab technician.
When comparing the responses from our participants with another similar study by [6], it was noted that bleeding gums was the most common complaint reported by their dentists among their patients. However, a similar question in our study revealed that pain was the most common presenting complaint. Moreover, when inquired about the common site of food impaction, the posterior mandibular region was found to be reported by the majority of dentists, which was similar to what we observed among our study participants. Furthermore, when inquired about the treatment options for food impaction, the Indian study reported redoing the FPD, which was similar to what we retrieved from our study participants. Finally, recall time was observed to be once a year among the majority of dentists in their study, which was also similar to our study observations.
Conclusion
Acknowledgments: Authors of this study would like to acknowledge the support and cooperation of the research center of Riyadh Elm University.
Conflict of interest: None
Financial support: None
Ethics statement: None
1. Alshammari GK, Alreshide AN, Alshammar LS, Abdulwahed SF, Alotaib AS, Altuwalah SM, et al. Prosthodontics: An Overview Prosthodontics indications, differences, Prognosis and Complications. J Biochem Technol. 2020;11(4):32-5.
2. Ramaswamy S, Taware SS, Kore AR, Sawant SA, Sanyal PK, Tayade PN. Awareness of Hygiene Practices and Satisfaction Level among Patients Wearing Fixed Dental Prosthesis: A Cross-Sectional Survey. J Clin Diagn Res. 2020;14(5):18-21.
3. Amurdhavani BS, Ganapathy D. Failures in fixed partial denture. Drug Invent Today. 2020;13(3):473-5.
4. Udhayaraja P, Ariga P, Jain AR. Awareness on pontic design among general dental practitioners: A knowledge, attitude, and practice survey. Drug Invent Today. 2018;10(6):860-3.
5. Yamany IA. The Employment of CBCT in Assessing Bone Loss around Dental Implants in Patients Receiving Mandibular Implant Supported over dentures. Int J Pharm Res Allied Sci. 2019;8(3):9-16.
6. Nagarsekar A, Gaunkar R, Aras M. Knowledge, attitude, and practice of dental professionals regarding the effect and management of food impaction associated with fixed partial denture prostheses: A survey. J Indian Prosthodont Soc. 2016;16(4):372.
7. Radafshar G, Khaghani F, Rahimpoor S, Shad A. Long-term stability of retreated defective restorations in patients with vertical food impaction. J Indian Soc Periodontol. 2020;24(4):329.
8. Senatore F, Bhurwal A, Brant S. 427 Admission Trends for Food Impaction and Foreign Body Associated With Eosinophilic Esophagitis. Off J Am Coll Gastroenterol| ACG. 2019;114:S251.
9. Bennadi D, Halappa M, Kshetrimayum N. Self reported knowledge and practice of inter dental aids among group of dental students, Tumkur, India. J Interdiscip Dent. 2013;3(3):159-62.
10. Kamil MA, Bashir RO. Interdental cleaning aids knowledge, awareness and practices among jazan university students, Saudi Arabia. Int J Dent Health Sci. 2017;4(1):85-93.
11. Aggarwal VR, Joughin A, Zakrzewska JM, Crawford FJ, Tickle M. Dentists’ and specialists’ knowledge of chronic orofacial pain: results from a continuing professional development survey. Prim Dent Care. 2011;18(1):41-4.
12. Chopra A, Sivaraman K, Narayan AI, Balakrishnan D. Etiology and classification of food impaction around implants and implant‐retained prosthesis. Clin Implant Dent Relat Res. 2019;21(2):391-7.
13. Lu Q, Wang L. The reduction of vertical food impact using adjacent surface retaining zirconium crowns preparation technique: a 1-year follow-up prospective clinical study. Ann Transl Med. 2020;8(16):1019.
14. Ashok NG, Sangeetha S. Evaluation of post operative complaints in fixed partial denture wearers and those with crowns: A questionnaire based study. Int J Cur Res Rev. 2016;8(16):30-4.
