Knowledge, Attitude And Practices (KAP) Survey Of Shade Selection For Indirect Veneers

Keywords

Shade Selection; Veneers; KAP Survey; Anterior Teeth; Restorations.

Introduction

The success of any anterior tooth colored restoration is directly related to the accuracy of chair side shade selection [1-3]. Patients are currently demanding esthetic replacement that must match their existing dentition, and are more concerned about the shade match of their restorations rather than quality of the restoration [4-7]. Consequently, chair side shade selection has become a very important step for experienced dental practitioners, in the overall treatment of the patient [8, 9]. Shade selection can be done by visual and instrumental methods. Both the methods carry merits and demerits over each other. However, due to relative simplicity and low cost, the visual method is still the most commonly used method [10-18].

One of the main concerns in the visual method is its highly subjective nature, different individuals can have different shade presentations for the same object [12, 19-21]. Researchers have explained these differences on the basis of scientific principles and artistic qualities of human vision [13, 22]. Both the factors come into play whenever a shade selection is carried out. To ensure accuracy, various shade selection protocols are important so that visual shade selections can be carried out with accuracy and repeatability [23, 24]. However, those protocols are either not known or are not fully understood by the majority of the dental community including undergraduate students, postgraduate and specialistes [25, 26].

Previously our team has a rich experience in working on various research projects across multiple disciplines [27-41]. Now the growing trend in this area motivated us to pursue this project. The aim of the present study was to determine the knowledge, attitude and practices about the principles and protocols of the shade selection.

Materials And Methods

This cross sectional survey was conducted during April to May 2020 including students and practitioners. Response was obtained from 250 participants. Ethical permission to carry out the study was obtained from Saveetha University Scientific review board. Snowball sampling method was used to distribute the questionnaire among the participants. The questionnaire consisted of 22 questions which included gender, age and specialty. The questionnaire had 22 questions in which 11 questions based on knowledge, 5 based on attitude, 6 questions based on practice were created. 250 responses were assessed and the output was represented in a pie chart for each and every question.

Ethical Approval

Ethical permission and approval for the project was obtained from the institutional review board of Saveetha Institute Of Medical And Technical Sciences, Chennai, India on date 25/04/2020 [SDC/SIHEC/2020/DIASDATA/0619-0320].

Eligibility Criteria

Specialists, general practitioners and dental students from all over India.

Data Collection

This cross sectional survey was conducted during April to May 2020. The questionnaire was shared online via google forms and responses were obtained from 250 participants. The data for 23 questions was compiled and represented in pie charts obtained from the google forms.

Sample Size

Total number of online questionnaires shared was 280. Out of which 23 did not take up the survey and 7 were incomplete forms which were excluded from the study. Hence, the total number of the participants were 250.

Results

We received 250 responses from the participants and among 250 responses, 49.6% consisted of females and 50.4% consisted of male. 65.6% of the participants were under the age group 20-30 years. Majority of the participants were MDS(78.0%).(Table 1).

Responses of participants on what is essential during shade selection, Majority of the participants from MDS responded individual observer (36.80%), majority of the participants from BDS responded with knowledge (11.60%). The association was analysed using Chi square test and was found to be statistically no significant difference. (p>0.05) (Table 2 and Figure 1). Responses of participants on what they think plays a major role in shade selection selection, Majority of the participants from MDS responded hue(38.40%), majority of the participants from BDS responded with hue(11.60%). The association was analysed using Chi square test and was found to be statistically no significant difference. (p>0.05) (Table 3 and Figure 2). Responses of participants on variables affects the perception of color, Majority of the participants from MDS responded tooth, including textures and layers (28.00%), majority of the participants from BDS responded tooth, including textures and layers(9.20%). The association was analysed using Chi square test and was found to be statistically no significant difference. (p>0.05) (Table 4 and Figure 3). Responses of participants on the ideal amount of light that is required for shade selection, Majority of the participants from MDS responded 1500 lux (32.00%), majority of the participants from BDS responded 1500 lux (11.60%). The association was analysed using Chi square test and was found to be statistically no significant difference. (p>0.05) (Table 5 and Figure 4).

Responses of participants on the ideal time required for shade selection, Majority of the participants from MDS responded 5-10 seconds(40.40%), majority of the participants from BDS responded 5-10 seconds(9.20%). The association was analysed using Chi square test and was found to be statistically no significant difference. (p>0.05) (Table 6 and Figure 5). Responses of participants on what they think on shade selection at the beginning of an appointment is better than doing it later, Majority of the participants from MDS responded yes(70.80%), majority of the participants from BDS responded yes(16.80%). The association was analysed using Chi square test and was found to be statistically significant. (p<0.05) (Table 7 and Figure 6). Responses of participants on age and gender of the patients play an important role is shade selection, Majority of the participants from MDS responded yes (73.60%), majority of the participants from BDS responded yes (17.60%). The association was analysed using Chi square test and was found to be statistically significant (p<0.05) (Table 8 and Figure 7). Responses of participants on Who according to you is more concerned about esthetics, Majority of the participants from MDS responded to younger females (72.00%), majority of the participants from BDS responded to young females( 18.80%). The association was analysed using Chi square test and was found to be statistically not significant. (p>0.05) (Table 9 and Figure 8). Responses of participants on what is the most common complaint patients have regarding anterior teeth restoration, Majority of the participants from MDS responded to esthetic correction(42.00%), majority of the participants from BDS responded to esthetic correction(15.20%). The association was analysed using Chi square test and was found to be statistically not significant. (p>0.05) (Table 10 and Figure 9). Responses of participants on whether they take patients' opinion while doing shade selection, Majority of the participants from MDS responded to yes(71.20%), majority of the participants from BDS responded to yes(16.80%). The association was analysed using Chi square test and was found to be statistically not significant. (p>0.05) (Table 11 and Figure 10).

Discussion

Our institution is passionate about high quality evidence based research and has excelled in various fields [42-52].

The present study has provided information on knowledge about the principle of tooth shade selection in dental students, practitioners and specialists. Color is one of the most important determinants of esthetic dentistry considering various factors such as type and intensity of the light source, time of day and year, patients clothes, age and gender [53]. Eye color, skin color and other factors usually influence and make it difficult during shade matching [54]. Even though light is one of the most important factors [55] it is the most commonly overlooked one. Furthermore, color imparted by different skin complexions is another factor that will have an effect on the shades of natural teeth [56, 57].

Among the questions that were asked, the majority of them told age, gender, appointment time and patient opinion plays an important role in shade selection. Tooth shade selection has been regarded as a challenging procedure even for the experienced clinician. Like several previous studies, the present study also showed that the majority of the participants also used visual methods to perform the procedure even knowing the inaccuracies of this method [12, 58-60]. The deficiencies can be controlled by utilizing the instruments method, which provides an objective and scientifically accurate shade reading [26]. However, high tech gadgets such as colorimeters and spectrometers are expensive and difficult to operate in the clinical setting, the reason that the visual method remains the most commonly used for shade selection world wide [61].

Teeth tend to dry out towards the end of dental procedure or when rubber dam is applied. Therefore, it has been recommended to select shades prior tooth preparation [62]. This is especially true for porcelain fused to metal restorations. However, due to the requirement of preparation of a tooth colored die for the newer ceramic systems, shade has to be selected both before and after tooth preparation if all porcelain restorations are being planned. Northern daylight is considered a standard for judging good light [63]. However, in everyday dental practice one cannot rely on sunlight for shade selection, hence color corrected fluorescent light with a CRI of 90 or above are recommended for dental operators [64, 65]. The use of incandescent bulbs and dental unit lights is not recommended because of greater amount of yellow light emittance. Majority of the participants seemed to understand the importance of good lighting. Colored structures or surfaces around the such as adjacent teeth, gingival, lips, face skin, clothing of the patient and operative walls, can influence the perceived tooth color possibly through the phenomenon of contract [66-68]. Therefore, it has been recommended to ask the female patients to remove any lipstick before selecting a tooth shade.

Teeth should be cleaned of all debris and stains before shade selection is carried out. A significant difference was found in participants regarding shade selection. The center field of vision is regarded as most color sensitive and color perception because there is a large collection of color sensitive cones in the center of the retina, surrounded by rods which can perceive only brightness. For this reason, researchers have recommended viewing the patient at the eye level so that the central part of the retina is used in shade selection [69].

Wagenar et al, have stated that whenever an object such as a tooth is viewed for longer than 10 seconds,the color vision capability of the eyes decreases rapidly and the perceived color does not remain stable. In order to overcome any inaccuracies arising from eye fatigue, it has been recommended to get a second operator for the patient whenever shade selections are made [70, 71]. Most of the participants in the current study take 5-10 seconds for the shade selection. Teeth are known to possess a graduation of color from the cervical to the incisal area. According to Schwabacher et al and o’ brien et al, 1994 the cervical color is modified by scattered light from the gingiva whereas the incisal color is most often translucent and is affected by its background [72]. Therefore, shade selected separately for different regions of the tooth surface and recorded on a shade distribution chart. The Vitapan classical shade guide is regarded as the most commonly used and known among the shade guides in dentistry, many other ceramic systems have been based on this guide [73, 74].

Conclusion

Shade determination is more rapidly evolving toward a more objective standard. The clinical importance of a proper shade selection in esthetic dentistry cannot be overlooked until an appropriate shade is selected, all other aspects of the restoration will not produce the best final result. Determining an accurate shade match is one of the most vital steps in esthetic restorative dentistry, it has always possessed a great challenge in esthetic dentistry. Dentists have little or no training in vision physiology or color science as comprehensive color training has continued to be a missing part in the dental school curriculum. In an era of growing interest in cosmetic dentistry, there is a need for adequate training and communication for better and more satisfactory results of shade matching. Based on the result obtained from the current study, we would like to conclude that more attention should be focused on improving the knowledge of color science and its application in esthetic dentistry as the color and appearance of teeth are a complex phenomenon, with many factors. Hence, for a good esthetic outcome to be achieved, the dentist should consider all possible entities which influence shade selection.

Limitations

Within the limitations of this study, this cross sectional descriptive study shows a thorough knowledge and awareness among the specialists about shade selection and inadequate knowledge among general dentists. Therefore, establishing awareness among general dentists regarding shade selection for indirect veneers especially for anterior teeth is compulsory.

Future Scope

This study can be conducted in a larger number of populations. The questions can be focused on the effect of resin cement on final shade, type of instruments for shade selection in future studies.

Acknowledgement

With Sincere gratitude , we acknowledge the staff members of the department of Conservative Dentistry and Endodontics, Saveetha Dental College and study participants for their extended support towards the completion of research.