Knowledge, awareness, and perception of digital dentistry among Egyptian dentists: a cross-sectional study

Modern dentistry has changed a lot from what was previously taught in dental schools. The recent development of digital dental tools signifies not just a technological innovation but also a fundamental reorganization of healthcare systems, encompassing everything from patient-doctor communication to treatment procedures. Since the introduction of digital dentistry in our practices, there has been a paradigm shift in the way dental treatments are offered to patients [1]. With current equipment, x-ray shifted from 2D to 3D, intra-oral scanning (IOS) is used instead of conventional impression materials, prosthetic and implant software, along with milling machines and 3D printers, are used to create esthetic and precise restorations in a relatively short time [2], which in turn increased the efficacy and the patient’s satisfaction [3]. The main basic phases of the digital workflow are data acquisition, data processing, and the manufacturing phase. Digital photography, cone beam computed tomography (CBCT), and optical scanning are used in the first phase to capture the patient data. While data is processed using different computer-aided design (CAD) softwares, which have different modules for different specialties. The manufacturing phase is divided into subtractive or additive techniques with milling machines or 3D printers, respectively [2].

Almost all dental specialties adopted the digital workflow from the point of diagnosis till the provision of the final treatment [2]. Inlays, onlays, veneers, and crowns can be delivered to the patients on the same day, which increases patient satisfaction [4]. Similarly, in removable prosthodontics, the complete denture workflow is completed with comparable success to conventional approaches [5]. The use of CBCT and 3D printing technology [6], has resulted in a significant improvement in the precision and total control over the quality of treatment in various dental operations through the use of surgical guides. Prior to dental implant surgery, CBCT is used in the initial step of diagnosis to give an accurate estimation of the bone volume and position of the anatomical landmarks [7], while the surgical guides are fabricated to ensure an accurate position of the dental implants in the arch for optimal performance of the prosthetic part [8]. Moreover, surgical guides can be used in endodontics to aid in obliterated canal detection, endodontic microsurgery, and guided auto transplantation which constitutes a major advance in this field [9]. Furthermore, digital technology allows the fabrication of clear aligners, customized appliances, and retainers in orthodontics, which in turn enhances the appliance’s precision, overall treatment time, and predictability [10]. While in maxillofacial surgeries, patient-specific implants, surgical guides, and skeletal reconstruction are among the most important uses of this technology [11]. This increase in precision and patient satisfaction that comes with digital dentistry technology’s infiltration into several dental disciplines requires greater knowledge and awareness of this technology among practicing dentists.

In addition to its clinical advantages in several dental disciplines, a review in 2021 concluded that the digital dental workflow contributed to increased safety and reduced transmission of the COVID-19 virus. This is achieved by reducing the length and the number of dental appointments, less invasive surgical procedures, and reduced contact between the lab and the clinic [12]. However, with all the advantages that come with modern dental technology, the high cost of the equipment, lack of standardized workflow, the size of some intra-oral scanners, and the learning curve are some of the shortcomings of digital technology [13]. Considering the vast advantages and development of digital dental equipment, with relatively few drawbacks. It became necessary to increase awareness and knowledge about its application in our field of practice.

To assess the knowledge and practice of digital dentistry across the globe, surveys were made in some countries. In 2016, a survey was done in the UK, and it concluded that 55.6% of the respondents didn’t use digital dentistry due to the high cost [14], while in the Netherlands the use was much higher, especially among practice owners [15]. In India, a study among dental practitioners found that 96.7% were aware of CAD/CAM technology in dentistry, and 87% believed that lack of knowledge was one of the shortcomings of CAD-CAM rather than its high cost [16], while another study concluded that 74% of undergraduate students were unaware of the materials used to fabricate the CAD-CAM prosthesis [17]. Similarly, studies in Saudi Arabia showed that the majority of the individuals (98.5%) believed that digital dentistry improved the quality of dental procedures and would eventually replace traditional dental services [18, 19].

In Egypt, the market for digital dental technology has grown noticeably, especially in private dental practices, even though the majority of dentists in Egypt work in the governmental sector [20]. This shows that practitioners in various institutions may differ in their utilization patterns and, consequently, in their level of knowledge. When compared to other developed countries, the primary barrier to market expansion in Egypt continues to be the high cost of digital technology [21]. Up to the author’s knowledge, no study was found to assess dental digital technology knowledge among Egyptian dentists. The null hypothesis of the underlying study is that there is no significant difference in Egyptian dentists’ knowledge, awareness, and perception (KAP) of digital dentistry across specializations and institutions. This study aimed to assess (KAP) of digital dentistry among dental practitioners with different specialties and in different institutions (private, governmental, and academic sectors) in Egypt.

As shown in (Table 1), 402 participants responded to this questionnaire. 49.3% of the participants were males and 50.7% were females. Regarding the distribution of participants by their age it was found that 42.8%, 40.8%, 12.9%, and 3.5% were between 20–29, 30–39, 40–49, and 50–59 respectively. The main practice of 25.1% of participants was in private clinics, 27.6% were working mainly in governmental dental clinics, 18.7% were faculty teaching and 28.6% were postgraduate students. 36.1% of participants had less than 5 years of experience, while 28.6% had between 5–10 years and 35.3% had more than 10 years. Concerning governorate of practice, 28.6% of participants were practicing in Great Cairo, 51.7% in Alexandria, 13.4% in Delta and Suez Canal, and 6.2% were practicing in Upper Egypt. Although, it was found that 87.1% were practicing in urban areas and 12.9% in the rural area. It was noticed that 42.3%, 6.0%, 19.4%, 1.0%, 11.4%, 3.7%, 8.0%, 6.0%, and 2.2% were general practitioner dentists, family dentists, prosthodontists, orthodontists, oral surgeons, restorative dentists, pedodontists, periodontists, and preventive dentists respectively.

Figure 1 shows that 47.3% and 64.2% of participants had Moderate knowledge and awareness respectively. While 75.9% of them had a high perception toward practicing digital dentistry.

Multivariate linear regression analysis (Table 2) shows that in comparison to the male gender regarding awareness and perception [5.3(2.1) and 11.0(1.9)], females had significantly lower scores [4.4(2.2) and 10.3(2.3)] (p = 0.001 and 0.042) respectively. Participants who were practicing dentistry mainly in governmental clinics had significantly lower awareness scores [4.1(2.1)], while faculty teaching staff had significantly higher scores [5.7(2.3)] when compared with those who had their main practice in private clinics [4.7(2.3)], (p = 0.003 and 0.029 respectively). In comparison with knowledge score of participants taking Great Cairo as governorate of practice [17.3(4.8)], Alexandria [15.4(5.7)] and Delta/Suez Canal [14.4(4.9)] were significantly lower (p = 0.002 and 0.001) respectively, but in comparison with perception score of Great Cairo participants [10.7(2.2)], only Delta/Suez Canal [9.9(2.3)] showed significant difference (p = 0.029). Participants who were practicing in rural areas had significantly lower knowledge, awareness, and perception [13.4(4.4), 3.9(1.9), and 9.8(1.9)] when compared with those who were practicing in urban areas [ 16.3(5.4), 5.0(2.2) and 10.7(2.1)] (p = 0.004, 0.003 and 0.001) respectively. When comparing knowledge scores with general practitioner dentists [14.9(5.1)], it was found that prosthodontists and periodontists [19.7(4.6) and 17.8(3.5)] were significantly higher (p = 0.000 and 0.007) respectively, however, pedodontists [12.8(3.9)] and preventive dentists [9.7(3.8)] were significantly lower (p = 0.035 and 0.011) respectively. In comparison with the awareness score of general practitioner dentists [4.4(2.0)], it was found that prosthodontists [6.3(2.1)] and restorative dentists [6.9(3.3)] significantly had higher scores (p = 0.000), while preventive dentist showed significantly lower scores [2.1(1.5)] (p = 0.004). Pedodontists [8.2(2.7)] and preventive dentists [7.0(2.5)] had significantly lower perception scores when compared with general practitioner dentists [10.7(1.9)] (p = 0.000). There were no significant differences regarding age and years of experience factors (p > 0.05).

The digital revolution is changing the world, without the exception of the dental field. It is important for dentists to have a better understanding and knowledge about the new trend. This study aimed to address the lack of literature regarding dentists’ knowledge, awareness, and perception of digital dentistry in Egypt, this would give us better information to be able to direct continuous dental education in this important field effectively. The findings of our study revealed a substantial difference among participants across specializations, regions of practice, and institutions, so the null hypothesis can be rejected.

In addition to the increased precision and comfort associated with the use of digital dentistry for practitioners, patient satisfaction has been reported in several studies. A survey conducted in Italy on patients’ and parents’ acceptance of clear orthodontic aligner therapy, showed more improvement in the patient’s social and school lives, increased overall satisfaction, and less painful to wear than traditional interceptive orthodontics [22]. While, according to the finding of a clinical trial conducted in Turkey (2014), the digital impression technique was more efficient, with a shortening of the treatment time, and more accepted from the patient’s point of view than the conventional impression technique [3]. Similar findings were also revealed by a survey conducted in the United States by Saponaro PC et al. [23] among a group of experienced complete denture wearers who confirmed a positive satisfaction rating with their digitally fabricated complete dentures in comparison with traditionally fabricated ones. Increased patient satisfaction with digital dentistry results, direct practicing dentists to be more knowledgeable and start adopting this technology.

In a survey conducted by Ramesh Nayakar et al. [16] in India (2022), 96.7% of the study participants were aware of CAD/CAM technology in dentistry. These findings are in disagreement with the results of the current study where 47.3% and 64.2% of participants had Moderate knowledge and awareness respectively, while 75.9% of them had a high perception of practicing digital dentistry. This may be due to the fact that more than half of the study participants in the Indian study were postgraduate students or the difference in the dental curriculum between the two countries. Furthermore, females had considerably lower awareness and perception scores in the current study as compared to males, which may be due to male practitioners’ preference for fixed prosthodontics as a specialization, according to a study conducted among dental students in Egypt [24]. This is inconsistent with a study conducted in Saudi Arabia which found that females showed higher results with most of the knowledge, awareness, and perception questions about digital dentistry [18]. Mostly, the high level of knowledge among Saudi Arabia’s interns and postgraduate students in India may be attributed to the use of digital education in conjunction with accessibility, collaboration, and communication between instructors and students, which support the transfer of theoretical and practical knowledge.

In Egypt, dental care is provided by three main sectors: governmental, private, and academic healthcare facilities, with most of the dentists practicing in the governmental sector [20]. When comparing dental practitioners in these sectors, the findings of the present study concluded that governmental clinics participants had significantly lower awareness scores, while faculty teaching staff had significantly higher awareness when compared with those who had their main practice in private clinics. Which highlights a significant gap in continued professional training among the participants that may be explained by the more equipped nature of the academic dental facilities and continuous education available to the academic staff. This is consistent with the findings of Ramesh Nayakar et al. [16] study which also revealed that the teaching faculty showed a better understanding of digital technology compared to private practitioners. In comparison with participants taking the Great Cairo region as governorate of practice, Alexandria and Delta/Suez Canal had significantly lower knowledge scores, while regarding perception scores, only Delta/Suez Canal showed a significant difference. This may be related to the knowledge of the more prevalent digital labs and clinics distributed in Cairo than the rest of the governorates, but, the insignificance between Upper Egypt and Great Cairo is not justified. Furthermore, participants who were practicing in rural areas had significantly lower knowledge, awareness, and perception when compared with those who were practicing in urban areas. This may be explained by the finding that there is still a significant urban–rural digital gap in digital practices [25]. Additionally, this difference between rural and urban dentists may be because dentists practicing in rural areas are not interested in digital dentistry because of its biggest obstacle, which is the product’s massive price and the unaffordable cost for patients in these areas.

Hegedus, T et al. [26] conducted an online survey on participants from 20 different countries with the most considerable numbers being from Hungary, the United States, and the United Kingdom, he concluded that the majority of dental practitioners depended on digital dentistry to fabricate their prostheses, casts, surgical guides, and clear aligners. In our study when different specialties were compared with general practitioner dentists, prosthodontists showed the highest level of knowledge and awareness among the participants, which is expected as CAD-CAM technology are mostly studied in the prosthodontics curriculum, with its main application in fabricating crown, veneers, bridges, implant prosthetics, and removable dentures [4, 5]. However, the current uses of digital dentistry are not limited to the prosthodontics field as it infiltrated almost all other specialties and it’s expected for other dental specialists to be also well informed and knowledgeable about this important technology. The lowest scores were related to pedodontists and preventive dentists, respectively. This may be because the use of digital dentistry in their practices is still not as prevalent as in the rest of the specialties. However, it demonstrates a deficiency in digital dental technology education, which needs to be addressed by the incorporation of courses and workshops in pediatric postgraduate studies, as pediatric dentistry can benefit from digital technology in fabricating various types of prostheses or orthodontic appliances. These technologies can provide pediatric patients with the best dental care possible. In addition, it has the power to encourage pediatric patients and foster a cooperative, positive attitude and behavior toward the profession [27]. Contrary to the findings of the study conducted in Switzerland [28] which concluded that younger dentists were more into digitalization, as well as a survey conducted in the United States among AirForce general dentists in 2020 [29], the current study found no differences in the level of knowledge, awareness, or perception based on the participant’s age or level of experience. This may be explained by the insufficient shift in the curriculum to integrate digital dentistry courses in Egyptian dental schools.

The current study revealed that with continuous dental education, availability of equipment, and incorporation of modern digital dental education at both the undergraduate and postgraduate levels, the overall knowledge and awareness of the practicing dentist would be improved, which would positively influence the quality of care and level of satisfaction offered to the patients. This is evident by the higher levels of knowledge and awareness among prosthodontists, academic staff, and dentists practicing in the more equipped regions compared with their colleagues. Additionally, to provide dentists with the skills they need to give their patients the best care possible, it is essential to address the knowledge gaps that exist between dentists with different specializations and work environments. This can be done by creating educational programs that are tailored to the needs of the least knowledgeable groups, whether at dental faculties or government healthcare facilities.

The present study indicates differences in the knowledge, awareness, and perception among dental practitioners in Egypt working in different institutions. Dentists practicing in academia showed a higher level of awareness than their colleagues in other institutions. Prosthodontists showed the highest level of knowledge among the study participants. Furthermore, Participants of Great Cairo and Upper Egypt had high knowledge, awareness, and perception levels, as well as those of urban areas. About half of the dentists in Egypt had moderate knowledge and awareness levels, while most of them had a high level of perception toward practicing digital dentistry. This study demonstrates a deficit in digital dentistry education, which needs to be addressed at both undergraduate and postgraduate levels. The introduction of sufficient theoretical and practical hands-on training programs can assist dentists in gaining the skills and knowledge required for using these technologies efficiently. Therefore, dental education programs in this important field should gain more attention from policymakers by providing adequate funding and resources for implementing these programs, especially for dentists practicing in rural areas, outside the great Cairo region, and in governmental clinics. Courses and workshops will need to be organized in different governmental, and private faculties of dentistry in different governorates.