A Survey on the Problems Faced by Patients Undergoing Dental Implants during Coronavirus Pandemic

Aim: To analyse the problems faced by patients with dental implants during the pandemic. Introduction: Dental implants have been used for a long time in the dental field and continue to dominate the field. Due to this reason, a huge amount of people go for dental implants. However, they have their own drawbacks and this is worsened by the coronavirus pandemic. Patients are unable to reach their dentist in person which sometimes leads to complications. This study hopes to shed more light on the different types of problems faced by patients with dental implants, especially during this pandemic. Materials and Methods: This study had a sample size of 100 and data was collected using an online questionnaire with a total of 11 questions. The statistical method used to analyse data is SPSS software version 23. Results: Some of the responses had significant pvalues (of 0.001 and 0.101) whereas the others did not. Conclusion: By the end of the study, it was concluded that most patients with dental implants underwent a lot of problems during the covid pandemic. Original Research Article Srigopika and Premavathy; JPRI, 33(64A): 273-281, 2021; Article no.JPRI.79151 274


INTRODUCTION
Dental implants, also known as an endosseous implant or fixture, is a surgical component that interfaces with the bone of the jaw or skull to support a dental prosthesis such as a crown, bridge, denture, facial prosthesis or to act as an orthodontic anchor [1,2] Implants are used to replace missing individual teeth (single tooth restorations), multiple teeth, or to restore edentulous dental arches [3,4]. The majority of dental implants are often made of commercially pure titanium, which is available in four grades depending upon the amount of carbon, nitrogen, oxygen and iron contained [5,6]. There is a vast ocean of dental materials and they are successfully used in dentistry. But among them, dental implants are a good example of a fusion of science and technology involved in various disciplines including surface chemistry, physics, biomechanics, and surface engineering. There are different approaches to placement of dental implants after tooth extraction [7,8].
The approaches are: 1. Immediate post-extraction implant placement. 2. Delayed immediate post-extraction implant placement (two weeks to three months after extraction). 3. Late implantation (three months or more after tooth extraction).
The common goal of modern dentistry is to restore normal function, speech, health and aesthetics [9]. The number of dental implants used in the United States increased approximately four fold from 1983 to 1987 [10,11]. It has also seen increasing use of dental implants, with usage skyrocketing from 0.7% of patients missing at least one tooth in 1999 -2000, to 5.7% in 2015 -2016 and was projected to potentially reach 26% in 2026 [12].
Implant dentistry is a field that avoids usage of high speed hand pieces, leading to nongeneration of aerosols [13,14] Thus, treatments can be performed in a sterile environment which is a necessity during the pandemic [15,16] Water coolant is not necessary too [17]. On the contrary, general dentistry was affected because the majority of the treatments use high speed and ultrasonic devices that generate aerosols which increases the risk of respiratory transmission [17,18,19].
This research is specifically necessary to see the effects of COVID in the dental field. It also helps us to analyse the problems faced by patients, if any and all this ultimately leads to improvement of efficiency of dental implants [20,21]. It will keep the patients more prepared in case a crisis occurs similar to this in the near future. It will further lead to improvement of dental technique to minimize errors [22,23].
The aim of this study is to therefore analyses the problems faced by patients with dental implants during the pandemic. The null hypothesis is that there are no problems faced by patients with dental implants during the pandemic and the assumed hypothesis is that there are problems faced by patients with dental implants during the pandemic.

MATERIALS AND METHODS
100 patients with dental implants were chosen for this study from Saveetha Dental College and Hospitals, Poonamallee, Chennai. The Institutional human ethical committee has given ethical clearance for the present study as it does not involve invasive procedures. The numbers of subjects involved were 100. The pros of this study included quick collection of data due to the limited number of participants available and the interest of the participants themselves and the only con being the inability to reach a larger number of people for this study due to current pandemic and consecutive lockdowns. After explaining the experimental procedure and making them aware of their role in the project, informed consent was obtained from them [24]. Patients who had their implants fixed before the lockdown were not included in the study.
The data was collected from the patients from the following questionnaire.

Statistical Analysis
Data were entered in excel spreadsheet and were analysed using descriptive statistics and Chi test. The software used was SPSS version 23. Fig. 1 represents the responses for the question of how long it has been since you had your implant placed. The present observation shows statistical significance (0.001) between the different subjects by using Pearson Chi square test with a confidence level of 95%. Green color denotes "2-3 months", mustard color denotes "5 months", purple color represents "6-8 months ago" and blue color represents "1 year". 22% of the subjects had their implants placed 2-3 months ago, 26% of them had it placed 5 months ago, 33% of the subjects had it placed 6-8 months ago and the rest of them had it placed a year ago. Patients who had their implants placed less than 6 months ago will be affected the most because they still might have to go for regular follow ups which is not possible during the pandemic. Fig. 2 shows the responses recorded for the question, "What type of implant do you have?". The present observation shows statistical significance (0.001) between the different subjects by using Pearson Chi square test with a confidence level of 95%. Green color denotes "endosteal implants" and blue color denotes "subperiosteal implants". 47% of the patients had endosteal implants which means the implants are placed in the jawbone whereas the rest of them had subperiosteal implants, where they are placed under the gum or above the jaw bone. Fig. 3 shows the responses observed for the question of, "How much did your food habits change because of your implant?". The present observation shows statistical significance (0.000) between the participants of the study by using Pearson Chi square test with a confidence level of 95%. Green represents "less change", blue represents "changed alot" and mustard represents "no change". 44% of the subjects had a lot of changes in their food habits post implant, 47% of the habits underwent less change, and 9% of them did not undergo any change. Fig. 4 shows the responses recorded for the question, "Did you have to get any additional dental procedures done to correct the complications?". The present observation shows statistical significance (0.096) between the participants of the study using Pearson Chi square test with a confidence level of 95%. Green represents "no" and blue represents "yes". 33% of the subjects had to get additional dental procedures done to correct the complications whereas 67% of them did not have to go through this long process.  The present observation shows statistical significance (0.096) between the participants of the study using a bar chart with a confidence level of 95%. Blue denotes "yes" and green denotes "no". 58% of the subjects cancelled their appointments due to the fear of the pandemic, while 42% of them did not.

DISCUSSION
From the above results it is very clear that a large number of people with dental implants are affected due to the pandemic. Around 54% of the study population reported extreme pain or bleeding in their gums due to their implants. This is very concerning because these may be symptoms of dental failure. Some signs of infection including hyperplastic soft tissues, suppuration, which means when the gums are under pressure, swelling, fistulation, color changes of the marginal peri-implant tissues, should be noted very earlier on because if not, it might lead to several complications [25,26]. Around 33% of the subjects had to get additional dental procedures done to correct the complications. In a similar study conducted in Ontario, most complications were preventable and the two main causes were poor planning and permanent paraesthesia [27,28].
However in this study, the complications may be attributed to the fact that the patients could not make it to the appointments due to the lockdown. So even if they had symptoms of infection, these couldn't be corrected on time. About 58% of the subjects cancelled their dental appointment due to fear of the pandemic. However during traumatic or emergency situations, treatment cannot be avoided (Figure 1-5). During urgent times like this, patients should be divided into 3 groups -apparently healthy, suspected of COVID 19, confirmed of COVID 19. Waiting rooms must be separated for each group with protective measures with regard to PPE for the dental clinicians and staff [29,30].
Apart from this, other studies found that patients are financially insecure. This leads to postponement of treatments which again will lead to complications or dental implant failures [31,32] What is important to note here is that, not only the patients, but the dentists are also confronted with additional expenses [33]. Lack of sufficient follow ups underestimated the effects of prosthetic loading, additional implant failures and biological and biomechanical complications might be expected over the long term [34,35].
Limitations to this study include the inability to increase the number of sample size which would have ultimately given more credibility due to limited resources because of the pandemic. Since more research has not been done in this exact topic, there were not a lot of references available to compare the results of this study with. One possible alternative for this is a follow up of this study after a few months.
It is necessary to conduct studies like this as it helps us to gain a better perspective of the relation between the pandemic and the field of dentistry. More studies need to be done similar to this so that it will help us to be better equipped in case this situation presents itself again after a specific period of time. Now that such a type of study has been conducted, it gives more awareness and knowledge for dentists on how to treat patients better and will keep them prepared. This helps in improved patient care.

CONCLUSION
The corona pandemic is unexpected all over the world. This pandemic situation affected most people and affects day to day life of individuals including patients also, especially the persons who underwent dental treatments using dental implants. The present study thus concluded that the patients with dental implants were affected by the corona pandemic.

DISCLAIMER
The products used for this research are commonly and predominantly use products in our area of research and country. There is absolutely no conflict of interest between the authors and producers of the products because we do not intend to use these products as an avenue for any litigation but for the advancement of knowledge. Also, the research was not funded by the producing company rather it was funded by personal efforts of the authors.

CONSENT
As per international standard or university standard, patient's written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).

ACKNOWLEDGEMENT
We express our sincere gratitude to Saveetha Institute of Technical and Medical Sciences for their constant support and encouragement.