This was a cross-sectional study conducted on the patients aged 20-60 years in the western region (Jeddah and Makkah), who reported to the Dental clinics of Ibn Sina National College for Medical studies, Jeddah seeking replacement of missing teeth from 1^st December, 2018 to 1^st March, 2019, after approval from Ethics Committee of the Institute (Approval No.H-03-12122018).

Inclusion criteria: Patients more than 20 years of age, with partially edentulous dental arch, seeking replacement of missing teeth and also gave consent for participation in the study were included.

Exclusion criteria: Patients more than 60 years of age, with completely edentulous dental arches or those not willing to participate in the study were excluded from the study.

Sample size estimation: The non-probability convenience sampling technique was used for calculating the appropriate sample size. In this current study, authors kept a 95% level of confidence and precision error of 5% and the sample size was selected based on the formula by Charan J and Biswas T [17].

where Z_1-α/2=standard normal variate (at 5% type 1 error (p-value <0.05), it is 1.96 and at 1% type 1 error (p-value <0.01) p=expected proportion in population based on previous studies [10,12,14,15] for pilot studies and d=absolute error or precision. Sample size for this study was calculated as 350.

A literature review was performed by the authors to validate the present cross-sectional study. Based on that, an open ended questionnaire was formulated (in English and Arabic) consisting of 10 questions. The questions were sourced from the previous studies [10,12,14]. Pilot study was conducted on 10 participants seeking replacement of missing teeth. Based on the information received from the pilot study, authors reviewed the content of each questions to make sure that study reflected appropriate phrasing and understanding and validation. The Cronbach’s alpha value has ranged from 0.75-0.85.

The closed-ended questionnaire of 10 questions was constructed by the authors. First part had five questions pertaining to socio-demographic details of participants like age, gender, socio-economic status, education and occupation respectively. Second part of the questionnaire had five questions related to prosthetic status, need of the patient, desired treatments, treatment options explained by the clinician and final treatment opted by the patient respectively. The completed questionnaire was proof read by group of dentists to check for clarity and meanings of the statements.

A total of 350 patients (excluding pilot study) participated in this study. Firstly, the study was explained to the participants and consent was taken from them. Intraoral examination was performed in the dental clinic and the findings were filled by the examiners in the questionnaire with the help of World Health Organisation (WHO) oral health assessment form [18].

The WHO code and criteria were as follows:

The examiners were two dental interns who had been trained and calibrated for inter-examiner variability (kappa value was 0.83) and an average of their scores was considered. A score of 1 was allocated for each correct answer or positive response and score 0 was allocated for wrong, or negative response. Approximately, 10 minutes time was taken for filling the questionnaire. The questionnaire served as a guide to interview the participants and collect data on their perception and to assess the level of trends, attitude and awareness among them towards replacement of missing teeth. Only completely filled questionnaires were selected for final data analysis.

The data were tabulated and analysed using the Statistical Package for the Social Sciences (SPSS) version 21 (SPSS Inc., Chicago, IL). Chi-square test was used to assess the trends, attitude and awareness among the patients in the western region of Saudi Arabia towards replacement of missing teeth. The p-value less than 0.05 was considered statistically significant, and a p-value of less than 0.001 was considered highly significant.

The study included 350 patients, out of which 162 were males (46.3%) and 188 were females (53.7%) [Table/Fig-1]. The mean age of the study participants was 33.76 years in Jeddah population and 37.49 years in Makkah population ranging from 20-60 years [Table/Fig-2].

Socio-economic status of the patients were as follows; 78 (22.3%) of them were of lower class, 245 (70%) of them were from the middle class and 27 (7.7%) of them were from the higher class [Table/Fig-3].

With regard to occupation; the labour class comprised of 73 (20.9%), business class 135 (38.6%), housewives 103 (29.4%) and professionals 39 (11.1%) [Table/Fig-4]. With respect to educational status, the number of Illiterates was 71 (20.3%), educated till Primary School 163 (46.6%), High school graduates were 82 (23.4%) and graduates and postgraduates were 34 (9.7%) [Table/Fig-5].

The distribution of the prosthetic status of the participants across the western region was as follows: Among Jeddah population, 103 (51.5%) of them had crowns, 60 (30%) of them had bridges, 17 (8.5%) of them had porcelain veneers and 20 (10%) of them had removable prosthesis. Among the Makkah population, 65 (43.3%) of them had crowns, 52 (34.7%) of them had bridges, 14 (9.3%) of them had porcelain veneers and 19 (12.7%) of them had removable prosthesis. Chi-square tests showed highly significant differences between both the regions (p-value=0.007).

The patients’ treatment needs across the western region were as follows: among Jeddah population, 91 (45.5%) of them wanted prosthesis for mastication, 107 (53.5%) of them wanted it for aesthetics and only 2 (1%) of them wanted prosthesis for the speech. In the Makkah population, 62 (41.3%) of them wanted prosthesis for mastication, 87 (58%) of them wanted for aesthetics and only 1 (0.7%) of them wanted prosthesis for the speech. Chi-square test showed no significant differences between the 2 regions (p-value=0.68).

Desired treatments by the patients were as follows: Among the Jeddah populations, 128 (64%) of them wanted fixed treatment and 72 (36%) of them wanted removable treatments. Among the Makkah populations, 105 (70%) of them wanted fixed treatment and 45 (30%) of them wanted removable treatment. Chi-square test showed no significant differences between both the regions (p-value=0.28).

The various treatment options explained by clinicians were as follows: Among Jeddah populations, 27 (13.5%) of them were suitable for fixed prosthesis as well as dental implants and 165 (82.5%) of them suitable for removable prosthesis as well as dental implants. Among the Makkah populations, 40 (26.7%) of them were suitable for fixed prosthesis as well as dental implants and 107 (71.3%) of them were suitable for removable prosthesis as well as dental implants. Chi-square tests showed highly significant differences between both regions (p-value=0.006).

And also, final treatments opted by the participants: Among Jeddah population, 30 (15%) of them opted for fixed prosthesis, 70 (35%) of them opted for removable prosthesis and 100 (50%) of them opted for dental implants. Among the Makkah populations, 37 (24.7%) of them opted for fixed prosthesis, 45 (30%) of them opted for removable prosthesis and 68 (45.3%) of them opted for dental implants. Chi-square test showed no significant differences between the 2 regions. (p-value=0. 073) [Table/Fig-6].

Many researchers have indicated that patient needs can enormously influence treatment results in medicine and dentistry [18-20]. Keeping this in mind, this study was conducted to assess the attitude and awareness among the patients in the western region of Saudi Arabia towards replacement of missing teeth.

Distribution of participants in this study was found to be 46.3% males and 53.7% female participants. Most of the participants were in the age group of 20-40 years unlike other study by Alharbi AA et al., conducted survey in Riyadh and age group varied from 15-55 years and 52% and 48% of female and male participants participated, respectively [21]. In addition, Leena SA and Sayegh A et al., reported that most of the participants at the age group of 40-49 years and 50-59 years in their studies respectively [22,23].

Based on the results of this study, 70% belonged to the middle class category and 38.6% participants had small time business and most of the female participants 29.4% were housewives. Study by Mohammed DA et al., reported that 50% of study population was illiterate [24]. Other studies by Wanyonyi KL et al., and Nadeem S et al., reported that replacement of missing teeth was more common among the patients from a high socio-economic status. According to them income and educational status of an individuals were often correlated and prevalence of wearing dentures increased with the increase in the level of literacy [25,26]. In addition, Marcus PA et al., in their study reported that 40.21% of the participants were just primary educated and their knowledge was insufficient with relation to the replacement of missing teeth [27].

In this study, 55.4% of them wanted to replace their missing teeth for aesthetics and 43.7% of them wanted for mastication. However, study by Muteb SA et al., reported that 79.2% of the study population believed that function and aesthetics could be maintained by replacing missing teeth [28]. In addition, study by Manoj S et al., reported that 40% preferred fixed prosthesis for aesthetic purpose [29]. Similar findings were reported by Simhachalam RN in his study that masticatory difficulty was the most frequently voiced complaint [30].

Among the participants of this study, 65.7% of them desired fixed treatment and 32.0% of them desired removable treatment. Mohammed A et al., in their study reported that 86.7% preferred fixed prosthesis [14]. In addition, Firas AMA et al., reported in their study that 40.5% of subjects showed positive attitude towards fixed treatment as mode of replacement of teeth and only 20.1% felt removable prosthesis as a better option [31]. Similar survey was done in Jizan area of Saudi Arabia by Naveen RR et al., reported that around 50% of the sample preferred removable treatment while 25% preferred fixed treatment and the result was opposite to the present study [32].

In this study, 19.1% of the participants were suitable for fixed prosthesis as well as dental implants. A total of 3.1% of them were fit for fixed prosthesis, removable prosthesis as well as dental implants and 77.7% of them were suitable for removable prosthesis as well as dental implants. Final treatment opted by the participants were as follows: 19.1% of them opted for fixed prosthesis, 32.9% of them opted for removable prosthesis and 48.0% of them opted for dental implants. The need for dental prosthesis varies from removable and fixed prosthesis which is in accordance to studies by Mously HA et al., and Suleiman A et al., reported that 76% and 61.5% of the participants in their studies, opted for implant prosthesis respectively [33,34]. In contrast to this, study by Gadeer NM et al., reported that 85% of the participants wanted fixed prosthesis [10]. However, according to Abdulrahman A et al., implant prosthesis was used for the mastication purpose [16].

In addition, Suleiman A et al., reported that 66.4% knew about dental implants as an option in replacing missing teeth [34]. Berge TI, and Tepper G et al., reported that the level of awareness regarding dental implants was 70.1% and 72%, respectively and only 3.3% of the subjects chose removable prosthesis as the best treatment in replacing missing teeth [35,36]. Rastogi I in her study reported that different treatment options were explained to the patients based on the requirements and 62%, 28% and 10% of participants were fit for dental implants, fixed prosthesis and special dentures respectively. However, 56.8%, 28%, 12.4% and 1.6% of the participants opted for complete dentures, acrylic RPD, fixed prosthesis and dental implants respectively [37]. In addition, Amal AS in her study reported that 71.8%, 17.6% and 10.6% of the participants preferred fixed prosthesis, dental implants and removable prosthesis respectively [38]. Study done in Srilanka by Rasika MJ, reported that among the participants of their study, 77.9%, 32.9% and 25.2% were aware of removable prostheses, dental implants and fixed prosthesis respectively [39] [Table/Fig-7].

Fazal G et al., reported that majority of the study population, 83.4% did not know about dental implants [40]. In contrary, Singh SK et al., in their study reported that, 92% of the participants were aware of dental implants for replacing missing teeth [41]. Saeed AQ, in his study concluded that high treatment cost for dental implant therapy was the main reason for patients refraining from implant therapy [42]. In addition, Naveen RR et al., in their study concluded that lack of awareness of various prosthodontic treatment options amongst patients prevented them from utilising available treatment. Dental camps and prosthodontic outreach programmers are possible solution to change the attitude, to raise awareness and knowledge of the patients regarding various methods of replacement of missing teeth [32].

Firstly, small sample size. Secondly, the study was performed in an institutional set-up where prosthetic treatment charges are different as compared to private dental care centers. Thirdly, edentulous patients were not included in this study.

Awareness and attitude of the participants towards prosthodontics treatment were mostly in high level. Majority of the participants wanted to replace missing teeth for mastication and aesthetics. Participants preferred fixed treatment over removable treatment. Most of the participants had favourable knowledge and attitude towards implant as a mode of treatment for replacement of missing teeth. Hence keeping the results of this study in mind, better treatment can be made possible for the patients while taking their desires into consideration.