Knowledge, Attitude and Practices of Dental Adhesives use among Dental Practitioners of Chitwan

Introduction: Denture adhesive (DA) is defined as a material used to adhere a denture to the oral mucosa. It plays an important role in the retention and the functional comfort among denture wearers. There are conflicting views in dentistry regarding the use of denture adhesives in clinical practice. Therefore, the main purpose of the study is to reveal the knowledge, attitude and practices regarding denture adhesives among the dental practitioners of Chitwan district, Nepal. Materials and Methods: A 20 item questionnaire was distributed among the registered dental practitioners of Chitwan districts using online google forms and the printed questionnaires were distributed personally to the practitioners who were accessible. Data were entered into Microsoft 2007 excel sheet and descriptive statistical analysis was done using SPSS version 20. Results: The results showed that 69.1% of General dental practitioners and 50% of other specialists had average knowledge while all the prosthodontics had good knowledge regarding denture adhesives. About 96.80% of General dental practitioners, 60% of other specialists frequently use denture adhesive in their practice. Only 20.2% of general dental practitioners and 20% of other specialists knew the adverse effects of zinc-containing denture adhesives. Most of the dental practitioners (93%) used powder form of denture adhesives. Conclusion: Most of the dental practitioners of Chitwan had fair knowledge, attitude and practice regarding denture adhesives.


Introduction
D enture adhesives (DAs) are defi ned as the material used to adhere a denture to the oral mucosa. 1 The American College of Prosthodontists published evidence-based guidelines regarding the use of denture adhesives and concluded that DAs improve the retention, stability, masticatory function, sealing out of food particles, and overall function of dentures. [2][3][4][5] DAs enhance the quality of life of edentulous patients. However, less research is available regarding the long term eff ects of the use of DAs on oral tissue health. 3,5 Despite of this fact DAs have been accepted by denture wearers worldwide, but most of the Prosthodontics, educators & dental professionals have been reluctant to use these over the counter products. 6,7 The use of DAs is still a controversial topic in clinical practice and academia. The confl icting aspects of DAs are classifi ed into two approaches; traditional historical and advocate approaches. The traditional historical approach specifi ed that the use of DAs refl ects the inadequate clinical skills & lack of prosthetic expertise but the advocated approach considers that DAs facilitate fabrication & post insertion phases in denture prosthesis service. 7,8 Several questionnaire-based studies have been performed in various countries, the results showed several diversifi cations regarding the knowledge, attitude & practices of DAs among the dental practitioners. [9][10][11][12] The purpose of this study was to reveal the viewpoints and approaches of dentists regarding denture adhesive use through questionnaires. Such information could serve to disclose both the range and distribution of professional opinions and beliefs of dentists on the topic of denture adhesives.

Materials & Methods
The descriptive, cross-sectional study was conducted among the registered dental practitioners of Chitwan district from 26 th Janauary 2020 to 26 th Feburary 2020. Before data collection, the study was approved by the Institutional Review Committee of The data collection tool was a structured questionnaire, which was adopted from the previous study 12 & modifi ed after the consultation with experts related to the fi eld. The pretesting of the questionnaire was conducted among 30 dental practitioners outside of Chitwan. Based on pretest results, modifi cations were made and the fi nal questionnaire was prepared.
The questionnaire consisted of 20 items & divided into four parts. The fi rst part constituted of sociodemographic details of participants (age, gender, educational qualifi cations, and years of experience. The second part constituted of nine questions related to knowledge regarding denture adhesives (composition, mechanism, indications and contraindications). The modifi ed Bloom's cut-off points, 80%-100%, 50%-79%, and <50.0%, were adapted and were considered good knowledge, average knowledge, and poor knowledge respectively The third part of the questionnaire contained six questions related to attitudes. The options for attitudes were based on a 5 point Likert Scale. It requires the dentists to decide on their level of agreement along this scale (Strongly disagree, disagree, don't know, agree & strongly agree). The fourth part of the questionnaire contained fi ve practice questions (clinical practice, patient recall & evaluation) were included.
The convenience sampling method was used to collect the data. The two methods were adopted to send the questionnaire to participants using google forms through the mail and printed questionnaires personally who were accessible. All fi lled forms & those who consented were included in the study.
All returned questionnaires were checked for completeness, inconsistencies of response manually coded & entered into Microsoft excel sheet & descriptive statistical analysis (frequency and percentage) was done using SPSS version 20.0 (IBM Corporation, Armonk, NY, USA).

Results
The questionnaires were distributed among 140 dental practitioners but only 120 fi lled questionnaires were received in this study with a response rate of 85.71%. The Sociodemographic individualities of the study subjects are shown in (Table 1). The majority of the dentists were females (73.3%) and most of the study population belonged to general dental practitioners (78.3%).
Dentist's knowledge status associated with the use of denture adhesive in denture therapy is presented in Table 2. As presented in this table, when participants were questioned regarding knowledge related questions 69.1% of general dental practitioners had average knowledge but 50% of the other specialists had average and 50% had poor knowledge regarding denture adhesives.
When participants were asked to identify the wrong mechanism of action among the given options, 53.2% of general dental practitioners, 100% Prosthodontics, and 40% of other specialists successfully identifi ed the wrong answer ( Figure 1). A mixed response was elicited when the dental practitioners were asked about the use of denture adhesives among patients with Xerostomia ( Figure 2). Among the participants, only 20.2% general dental practitioners, 20% other specialists & 100% prosthodontics were aware of neurological disease due to prolonged use of Zinc containing denture adhesives.
When participants were asked the questions related to attitude regarding the use of denture adhesive, denture adhesives were means to improve retention in improperly fabricated dentures according to 8.5% of general dental practitioners & 20% of other specialists strongly agreed. Only 30.9% of general dental practitioners & 20% of other specialists agreed that prescribing denture adhesives indicates inadequate skills of the clinician to fabricate dentures. Among the participants, 28.7% of general dental practitioners & 70% of other specialists were not aware that denture adhesives improve mastication effi cacy in denture wearers (Table 3).

Discussion
The knowledge regarding denture adhesives is very important for its proper prescription among edentulous patients to increase the acceptance of removable prosthesis. 7,13,14 About 53.2% of general dental practitioners responded with the right mechanism of action, so it may cause less misuse of these products.
Denture hygiene is very important & this study showed that 78.7% of general dental practitioners were aware that incomplete removal of denture adhesives before reapplication was not good for tissue health. Staff ord et.al established that denture adhesives could infl uence oral fl ora by causing an imbalance in the fl ora. 15 Several past research established that the chronic & excessive use of zinc-containing denture adhesive results in several neuropathies like paraesthesia, muscle weakness & ataxic gait. [16][17][18] Unfortunately, only 20.2% of general practitioners and 20% of other specialists were aware of the adverse eff ects of zinc-containing denture adhesives in our research. Nations et.al & Hedera et.al 19,20 identifi ed that the chronic uses of zinc-containing denture adhesives as a main cause of neuropathy in patients using them. One of the studies established that the overuse of zinc-containing denture adhesives as the main culprit of copper defi ciency myelopathy. 21,22 However, no clinical evidence will be established that zinc-containing denture adhesives result in neuropathy when used according to manufactures instructions. 23 Zinc free denture adhesives are readily available in the market. 23 So proper knowledge about zinc-containing denture adhesives among dental practitioners is a must. Patients should be encouraged to take professional advice as well as follow instructions cautiously before using them. The proper use of hydrated denture adhesives provides a cushioning eff ect on underlying supporting tissues and preventing tissue ulcerations in inpatient with Xerostomia. 24 In this study 43.6% of general dental practitioners, 30% of other specialists contraindicated the use of denture adhesives in patients with Xerostomia.
Most of the previous studies showed that clinical use of denture adhesives has not yet gained worldwide acceptance due to reasons either less contained of denture adhesives in the undergraduate curriculum or continuing dental education programmes. 9,25 This study showed that 69.1% of General dental practitioners & 50% of other specialists had average knowledge regarding denture adhesives.so modifi cation of curriculum in undergraduate level & in continuing dental education programmes are the way to increase the knowledge regarding dental adhesives among dental practitioners.
Attitude is the refl ection of knowledge. The result section of this study showed that nearly half of general dental practitioners inconclusive about the indication of denture adhesives for patients wearing improperly fabricated or illfi tting dentures. In the above statement, 11.7% of general dental practitioners & 20% of other specialists agreed in contrast to none of the Prosthodontics. The diff erence in attitude regarding denture adhesive prescription may be due to a diff erence in curriculum.
In this study, 90.83% of dental practitioners were using denture adhesives in their clinical practice, this percentage is far above the percentage recorded by Temel 26 (56.3%).
In this study, most of the dental practitioners (62.80% General dental practitioners, 30% other specialists, and 100% Prosthodontists) were using denture adhesives for stabilizing trial bases during jaw relations. This fi nding was coherent with the consensus which was established by the panel of Prosthodontists (88%) in the study by Slaughter et al, 8 the reason being a stable record base is a prerequisite for recording accurate jaw relations.
The periodic recall appointments are very much crucial for the evaluation of denture as well as the supporting structure of the edentulous foundation so these guidelines are extremely important for a patient using denture adhesives. 19,27 90.4% of general dental practitioners and 80% of other specialists recall their patients using denture adhesives. The timedependent changes in denture bearing foundation occur so every dentist must periodically recall denture wearing patients for evaluation of residual ridge resorption, prosthetic tooth wear, condition of denture bearing tissues as well as systemic health, oral cancer screening. 16 Several studies established that the periodic professional cleaning of old dentures is one of the techniques to minimize the microbial colonization indenture as well as reduce the chance of respiratory illness in denture wearer patients. [28][29][30][31] In this study 63.8% of General dental practitioners, 40% of other specialists cleaned the old dentures whenever the patients reported to their clinic.
The main limitation of the study is that the numbers of participants are limited so the anticipation of the results is restricted and cannot be generalized to other region. Another limitation of the study is the information bias too. Further studies should address this gap by covering a wider geography and an increased number of dentists.

Conclusions
It can be concluded that denture adhesives are frequently used by dental practitioners. Knowledge about proper indication, contraindications, instructions guidelines to patients and periodic follow up are essential attributes for better management of denture wearing patients. So continuing education courses are essential to get updated knowledge about using denture adhesives in clinical practice and provide the standard care for prosthodontics patients.