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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 7  |  Page : 885-890

Cultural constraints in the use of dental implants and orthodontic mini-implants in Benin City, Nigeria


1 Department of Preventive Dentistry, University of Benin Teaching Hospital and University of Benin, Benin City, Nigeria
2 Department of Oral and Maxillofacial Surgery, University of Benin Teaching Hospital and University of Benin, Benin City, Nigeria

Date of Acceptance12-Mar-2019
Date of Web Publication11-Jul-2019

Correspondence Address:
Dr. I N Ize-Iyamu
Department of Preventive Dentistry, University of Benin, P.O. Box 7022, Benin City, Edo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_491_18

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   Abstract 


Background: Dental implants and orthodontic mini implants or temporary anchorage devices (TAD) have been used for tooth replacement and as adjuncts to orthodontic treatment in anchorage control and retraction of segments of teeth respectively. They are manufactured from various materials with titanium being the currently used material. The patients in our environment have diverse cultural acceptances and constraints with some prohibiting the use of certain materials in their oral cavity. Aim: The aim of this study therefore was to determine the existence of cultural constraints in the use of dental or orthodontic min-implants and compare them in the management of patients. Materials and Methods: Four groups of dental patients were selected to determine if cultural constraints exist. Groups 1 and 2 were patients with either anterior or posterior missing teeth requiring replacement with dental implants (implant group) or partial dentures (denture group), respectively. Group 3 were orthodontic patients requiring TAD (orthodontic group) and group 4 were patients with other dental problems and served as the control (normal group). Associations between frequencies, gender, educational, and cultural differences were evaluated with the Chi-square test. Significant values of P < 0.05 were applied where applicable. Results: A total number of 192 participants were recruited for the study. Group 1 had the highest number of culturally constrained participants (n = 21, 10.9%). A significantly higher number from the group was seen (n = 11, 52.4%) among the African Traditional worshippers (ATR). Although a total number of 58 (30.2%) patients replaced their missing teeth, 37 (19.3%) utilized partial dentures in group 2 with no cultural constraints. Orthodontic implants were not rejected (n = 0, 0%) by all the four groups. Group 4 demonstrated a low level of constraints (n = 7, 4.2%). Of the four religious groups identified, ATR demonstrated the highest level of constraints with Christians and Muslims showing fewer constraints to the use of implants (n = 7, 33.3%) and (n = 2, 9.5%), respectively. Participants with the highest educational levels and social classes were more culturally constrained in the use of dental implants. Conclusion: Cultural constraints exist in the use of dental implants in our environment among African Traditional religion worshippers. There was, however, no cultural constraint to the use of orthodontic implants by any of the religious groups.

Keywords: Cultural constraints, dental implants, orthodontic mini-implants


How to cite this article:
Ize-Iyamu I N, Saheeb B D. Cultural constraints in the use of dental implants and orthodontic mini-implants in Benin City, Nigeria. Niger J Clin Pract 2019;22:885-90

How to cite this URL:
Ize-Iyamu I N, Saheeb B D. Cultural constraints in the use of dental implants and orthodontic mini-implants in Benin City, Nigeria. Niger J Clin Pract [serial online] 2019 [cited 2019 Jul 22];22:885-90. Available from: http://www.njcponline.com/text.asp?2019/22/7/885/262524




   Introduction Top


Dental implants were introduced as far back as 600 A.D. with evidence from archeological remains of ancient skulls from different cultures exhibiting signs of missing teeth replaced with materials ranging from ivory, carved stones, jade, and sea shell fragments with some of these primitive materials showing evidence of fusing to the bone.[1],[2],[3] The history of materials utilized in the fabrication of modern implants includes work by Greenfield in 1913[2] who utilized iridio-platinum soldered with 24-karat gold; Alvin and Moses Strock (1939),[1] who introduced the first biocompatible material made from vitallium which is a cobalt chromium alloy, was used for the replacement of teeth. A variation in the design of implants was achieved by researchers like Formoginni and Zepponi in the 1940s [1],[3] whereby a spiral implant with stainless steel wire was made. Gershkoff,[4] Zolberg,[3] and other researchers like Weinberg,[2],[3] in the late 1940s, also produced a cobalt chromium–molybdenum implant. Cobalt chromium and surgical grade stainless steel implants were fabricated in the 1960s and 70s by Cherchieve and Roberts,[1],[3],[5] respectively, and vitreous carbon by grenoble, also in the mid 1970s.[1],[2],[4],[5],[6],[7] However, Per-Ingvar Brånemark in 1969 introduced pure titanium implants and Schroeder (1976), the roughened implant surface.[1],[3],[7],[8],[9] Brånemark in 1970 reported the successful osseointegration of implants in bone [2],[3],[7],[9] and this began the exclusion of other materials in humans.

The characteristic property of modern dental implants is osseointegration and this has been identified most recently with titanium or titanium coated with either calcium phosphate derivatives,[4],[5],[10] hydroxyapatite coating, plasma sprayed coatings, and nano-hydroxyapatite coating.[2] Other materials previously used such as metals, ceramic, and polymeric materials,[4],[5] exhibited some form of compact bone formation around these materials.[2],[10] The fundamental basis for implant stability and success was based on the biologic process of either compact bone formation or osseointegration with the bone [1],[2],[3],[4],[5],[10] and studies by Greenfield,[3] Strock,[2] Formiggini,[2],[3] Zepponi,[3],[5] and Brånemark [2],[5],[7],[9] demonstrated these successfully.

This principle was also utilized for orthodontic anchorage with devices temporarily fixed to the bone.[11],[12] Although osseointegration is defined histologically as the direct anchorage of an implant by the formation of bony tissues around the implant without the growth of fibrous tissue at the bone–implant surface,[4],[8],[10],[13] when applied in the field of orthodontics and used as temporary anchorage devices or orthodontic mini-implants, they are removed after 3--6 months so osseointegration is not fully developed [11],[12] and they are useful as an adjunct in orthodontic treatment.

Implants may be rejected by the body as a result of varying factors which include incorrect positioning, overloading, inadequate bone volume and density, or outright rejection by the host's defense mechanism.[13],[14] although other studies have reported psychological rejection of orthodontic implants by patients or parents of patients based on various reasons,[13],[15] there appears to be no studies in our environment on either a rejection or acceptance of orthodontic implants and its role in managing orthodontic patients as a treatment option. Previous studies on the cultural beliefs of oral healthcare [16],[17],[18] are few and there appears to be no studies on cultural or traditional beliefs in the use of implants.

Culture is an important part of people and determines their perceptions and beliefs about certain practices which may influence medical treatment.[16],[17],[18],[19] This study was carried out in Benin City, which is the capital of Edo State and one of the 36 states in Nigeria. It is situated in the south–south of the country and it is a rich cultural multiethnic and multireligious urban city with a large percentage being Christians, fewer practicing African traditional religion, and an even smaller percentage practicing Islam.[19] However, as it is common among African communities irrespective of their religion, there is a general belief in earth gods especially among African traditional religion practitioners who classified them as divine beings.[17],[18],[19] In Edo State, these include olokun, ogivwu, ogun, esu, and oto.[19]

The ogun divinity is the most interesting, in that it is believed to be a god of iron and is the permanent patron god of blacksmiths, hunters, and all who deal with iron, surgical incisions, tattooing, and body scarification. Covenants and oaths are taken before this divinity and is sealed with these traditional adherents kissing a piece of iron.[19] The most significant emblem of ogun is iron, stone, and metal scraps. In modern day Edo, traditional worshippers of ogun still exist and traditional chiefs, drivers, cyclists, and businessmen still worship this divinity as a source of protection against accidents and other injuries which may be inflicted by any form of metal.[19]

The perception and acceptance of the use of implants in Edo State which many believe to be made of metal and a procedure which is relatively new in a culturally diverse environment are the subjects of this study.

The aim of this study therefore was to determine the existence of cultural constraints in the use of dental or orthodontic min-implants and compare them in the management of patients.


   Materials and Methods Top


The clinical setting for this prospective study was a private Dental Clinic in an urban area of Benin City. Patient selection was done by interviewing and examining all patients attending the dental clinic over a 6-month-period in 2015, and entering their data into a register. Demographic data including religion, social class as to the affordability of implants, and cultural constraints to the use of metals in the body if any were included and recorded.

Patients were divided into 4 groups based on their clinical presentation. Group 1 were patients with either anterior or posterior missing teeth requiring replacement with dental implants (implant group); group 2 were patients with either anterior or posterior missing teeth requiring replacement with dentures (denture group), whereas group 3 were orthodontic patients requiring TADS (orthodontic group). The 4th group was patients with other dental problems and served as the control (normal group).

Children below 16 years of age were excluded from the study. Other exclusion criteria included adults with systemic diseases that may prevent the placement of implants, severe periodontitis, and those with inadequate volume of bone. This gave a total number of 192 participants for this study. The method of investigation was patient examination and application of an interviewer-administered structured questionnaire to standardize the collected data which was then recorded. A pilot survey with a small sample (n = 20) was conducted to determine the wording and comprehension of the respondents and to construct the validity.

The social classification of the participants was stratified according to the method described by Brown (2009)[20] as stated below:

  • Upper Professional occupations/wealthy
  • Middle Managerial and technical occupations/skilled workers
  • Lower Partly skilled/Unskilled occupations.


Data obtained were analyzed using the Statistical Package for Social Sciences Software (SPSS) version 20.0. The student t-test and the Chi-square test were used for descriptive and analytical analysis. Significance levels were set at 95% confidence level. Probability values (P values) less than 0.05 were regarded as significant.


   Results Top


A total of 192 patients made up of 92 (47.9%) females and 100 (52.1%) males were studied. Their age groups were 16--20-years (n = 25, 13%), 21--30 years (n = 42, 21.9%), 31--40 year (n = 41, 21.4%), 41--50 years (n = 40, 20.8%), and 51 years and above (n = 44, 22.9%).

[Figure 1] shows the frequency distribution of participants among the four groups with group 3 (the orthodontic group) demonstrating the lowest prevalence (n = 18, 9.4%) and group 4 showing the highest number (n = 95, 49.4%). There was no significant cultural constraint to the use of implants among gender P > 0.05.
Figure 1: Frequency distribution of participants

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Social class was upper (n = 56, 29.2%), middle (n = 130, 67.7%), and lower (n = 6, 3.1%). The level of education was nonformal (n = 15, 7.8%), primary (n = 4, 2.1%), secondary (n = 61, 31.8%), and tertiary (n = 112, 58.3%). Correlation between cultural constraints, social class, and educational level showed that a higher number of participants with a higher educational level and social class were more culturally constrained [Figure 2].
Figure 2: The Relationship between cultural constraints, social class, and educational level

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[Table 1] shows the frequency distribution and relationship between religion and cultural constraints to the use of dental implants. All religions showed various degrees of constraint with highly significant values observed in Hinduism and African Traditional Religion.
Table 1: The relationship between religion and cultural constraints

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A comparative analysis of cultural constraints among religion is shown in [Figure 3]. [Figure 4] shows the orthodontic implant or TAD used for anterior segment retraction, whereas [Figure 5] and [Figure 6] show the dental implant used for an anterior tooth replacement. [Figure 7] represents the radiographic view of osseointegrated implants within the bone and 58 (30.2%) patients replaced their missing teeth with 37 (19.3%) and 21 (10.9%) utilizing partial dentures and dental implants, respectively.
Figure 3: Comparative analysis of cultural constraints to implants among religion

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Figure 4: Orthodontic mini implants or TAD's for correction of severe skeletal class II malocclusion

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Figure 5: Clinical photograph of implant

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Figure 6: Clinical photograph of implant

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Figure 7: Orthopanthomogram showing dental implants within the bone

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A total number of 47 dental implants were placed in 21 (10.9%) patients. Anterior implants were placed in 21 (44.7%) and posterior in 26 (55.3%) patients, respectively. Eighteen (18) orthodontic mini-implants were placed in 9 (50%) patients for retraction of the anterior segment, 3 (16.7%) for correction of occlusal cant, and 6 (33.3%) for intrusion of the posterior teeth.


   Discussion Top


Cultural constraints are an important aspect of patient management and this study demonstrates that culture and religion are an integral aspect of determining procedures and appliances acceptable to patients for their oral care.[1],[17],[18] African traditional religious worshippers in this study exhibited highly significant cultural constraints to the use of dental implants for replacement of missing teeth and preferred partial dentures which are nonmetallic as an alternative.

Orthodontic implants did not exhibit any cultural or religious constraint which is in agreement with results of other studies where aesthetic concerns were not a barrier to treatment.[1],[15],[21],[22] Studies on the psychological impact of malocclusion [21] found that patients were not bothered by the appearance of the appliance or its composition, but rather on correcting the malocclusion.[11],[12],[22] This could explain why there was no cultural constraint in this study to the use of TADS for the correction of malocclusion.

Studies [23],[24] have shown that social class and the educational level of patients may be a barrier to dental attendance and treatment. Although Donaldson et al.[23] and Costa et al.[24] in their studies showed that a poor economic status is associated with poor oral health and also a barrier to dental services,[23],[24] this study showed that higher educational level and social class demonstrated higher level of constraints even though majority of the participants were from a higher socioeconomic class.

Dental implants are a relatively new procedure in our environment with some studies outlining their use.[25],[26] Akeredolu et al.[26] demonstrated a low level of awareness of dental implants among dentists in our environment with 98.7% having no knowledge about it. The clinician's knowledge and attitude to procedures determine the extent to which patients become enlightened.[1],[13],[26],[27] Culture and religion have been identified as an integral part of patient management and with knowledge of new techniques and procedures, determine patient acceptance and compliance.[1],[16],[17] This study identified various religious groups and constraints to the insertion of dental implants and this could probably be as a result of a low level of awareness in our society.[26],[27]

Previous studies have shown that culture and sometimes religion play a major role in medical treatment with some groups rejecting some forms of management as a result of their religious and cultural beliefs.[1],[18],[19] Other studies identified special events where fasting was a religious constraint to medication and blood transfusion, a constraint to surgical intervention.[1],[17],[18] This could explain why some patients refused the use of dental implants for restoration of their missing teeth. Society, community, religion, and rituals remain major and significant barriers to treatment in local communities.[1],[17],[18],[19],[15]

Some studies on African traditional religious worshippers [16],[17],[18],[19] identified the beliefs that the use of metals within the body of some adherents is a taboo. This could also explain the highly significant differences between the religious groups with the ATR worshippers demonstrating the highest constraints.


   Conclusion Top


Cultural constraints exist in the use of dental implants in our environment among African traditional religion worshippers. There was, however, no cultural constraint to the use of orthodontic implants by any of the religious groups. ATR worshippers in our environment believe that implants are composed of metals and therefore frequently decline their use for their oral care based on these beliefs. Awareness programmes should be carried out in the community to educate and eradicate wrong beliefs on the composition and use of dental implants for the replacement of missing teeth.

Abbreviations

TAD = Temporary anchorage devices

ATR = African Traditional Worshippers

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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DeWeert, DJ. The Sick Person and Science: The Role of Religion in Medicine and Modernity. 2011. Honors Projects. Paper 21. Available from: http://digitalcommons.iwu.edu/religion_honproj/21. [Last accessed on 2017 May 26].  Back to cited text no. 17
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
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