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Abstract
Objectives This study aimed to assess the knowledge, attitudes and practices (KAP) of patients with impacted wisdom teeth towards tooth extraction, with the intention of identifying both gaps and opportunities for improved dental health education and practices.
Design A cross-sectional study using a web-based questionnaire.
Setting The study was conducted at the Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University, and Jinan Stomatological Hospital.
Participants This study included responses from 3467 individuals presenting with impacted wisdom teeth at the study settings between March and May 2023.
Primary and secondary outcome measures The primary outcomes measured were the levels of KAP towards wisdom teeth extraction among participants. Knowledge was assessed on a scale of 0–11, attitudes on a scale of 10–50 and practices on a scale of 11–55. Secondary outcomes included the exploration of associations between knowledge, attitudes and practices using structural equation modelling.
Results Participants demonstrated a mean knowledge score of 9.1±1.4, mean attitude score of 38.0±2.7 and mean practice score of 41.7±8.2. The analysis using a structural equation model revealed a direct effect of knowledge on attitudes (path coefficient=2.042, p<0.001) and a direct effect of attitudes on practices (path coefficient=1.460, p<0.001).
Conclusions The findings suggest that patients with impacted wisdom teeth possess adequate knowledge and favourable attitudes towards teeth extraction, which positively influences their practices. However, tailored interventions are still needed to further enhance KAP regarding this procedure in this population.
- Knowledge
- Attitude
- Awareness
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
Large sample size enhances the representativeness of findings.
Structural equation modelling strengthens analysis of relationships between knowledge, attitudes and practices factors.
The online survey method enables convenient, large-scale data collection.
Reliance on self-reported data may introduce reporting bias.
Exclusive use of online surveys could result in non-response bias.
Introduction
Impacted wisdom teeth constitute a significant public health issue due to their high prevalence and the associated complications.1 Epidemiological evidence indicates that a substantial proportion of the adult population will develop at least one impacted wisdom teeth, necessitating extraction to mitigate potential risks such as infection, crowding, and other dental pathologies.1 2
Nevertheless, the extraction procedure for impacted wisdom teeth poses numerous challenges. It is well documented that these procedures can elicit significant psychological stress in patients, resulting in dental anxiety or phobia.3 This stress is exacerbated by the complexity and invasiveness inherent in the extraction of impacted teeth, which can amplify patients' apprehensions and uncertainties concerning dental care.4 5 Such anxiety and uncertainty may negatively influence patients’ attitudes towards dental health and treatment, potentially leading to suboptimal dental health behaviours, delayed care-seeking and, consequently, poorer dental and overall health outcomes.6 7
The knowledge, attitude and practices (KAP) model suggests that an individual’s knowledge significantly influences their attitudes towards health and illness, which, in turn, shapes their health-related behaviors.8 9 Despite the recognition of dental anxiety among patients with impacted wisdom teeth, there exists a notable gap in the research literature regarding the application of the KAP model to better understand and address this issue. Previous research efforts have been directed towards delineating the prevalence of dental anxiety and its determinants within this demographic,3 10 11 with insufficient focus on elucidating how knowledge and attitudes concerning wisdom teeth impaction and extraction affect health behaviours.
Thus, this study aims to address this gap by leveraging the KAP framework to investigate the KAP towards wisdom teeth extraction among patients with impacted wisdom tooth.
Materials and methods
Study design and participants
This cross-sectional study was conducted between March and May 2023 at the Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University and Jinan Stomatological Hospital.
The inclusion criteria were as follows: (1) patients diagnosed with impacted wisdom tooth either at the Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University and (2) patients proficient in Chinese to ensure effective communication during the data collection. Conversely, those who reported prior participation in similar studies were excluded from this study.
Questionnaire introduction and data collection
The questionnaire was designed with reference to relevant guidelines and previous literature12 13 and revised by two chief physicians and one vice-chief physician. A pilot test was conducted (n=34) and the Cronbach’s α coefficient value was 0.819, indicating good internal consistency.
The final questionnaire contains four dimensions: demographic characteristics, knowledge, attitudes and practices. The knowledge dimension consists of 13 questions, with 1 point for a correct answer and 0 points for the rest. Given that the necessity of wisdom teeth extraction is a common misconception among patients, often due to a lack of understanding of guideline recommendations, question K8 was designed to address this issue. Questions K5 and K10 were designed as trap questions, presenting exactly opposite meanings.14 15 Patients who selected ‘right’ or ‘wrong’ for both the questions were deemed to have a logical conflict and were excluded from the survey. Consequently, the knowledge scores ranged from 0 to 11 points. The attitudes dimension consists of 13 questions, wherein questions A11–A13 are designated exclusively for descriptive analysis purposes. The remaining questions used a 5-point Likert scale, ranging from ‘very positive’ (5 points) to ‘very negative’ (1 point), yielding a possible score range of 10–50 points. The practices dimension consists of 11 questions using a 5-point Likert scale as well, ranging between ‘very conforming’ (5 points) to ‘very non-conforming’ (1 point), with a possible score range of 11–55 points.
Both electronic and printed versions of the questionnaire wer used in this study. The electronic questionnaire was hosted on the Sojump platform (http://www.sojump.com), an online survey platform. At the onset of the survey, patients were required to indicate their consent by clicking the option ‘I agree to participate in this study’ before proceeding to respond to the questions. The data-collection process ensured participant anonymity. Additionally, an IP restriction was implemented to prevent duplication of responses, restricting participants to a single submission from each unique IP address. To accommodate individuals who may be less acquainted with electronic devices, such as elderly patients, printed questionnaires were made available during their clinic visit, and they were requested to complete the printed forms. Five trained research assistants first introduced the study face-to-face to patients before distributing the questionnaires. They also provided assistance when necessary, reviewed questionnaire completeness and asked the patients to complete any missing information.
Statistical analysis
STATA 17.0 (STATA, College Station, TX, USA) was used for statistical analyses. Continuous variables were presented as mean±SD and were compared using the student’s t-test or one-way analysis of variance (ANOVA). Categorical variables were presented as numbers (percentages). In this study, 70% of the total score was used as the cut-off value, that is, the threshold for sufficient knowledge, favourable attitudes and proactive practices was 7.7, 35 and 38.5 points, respectively.16 Pearson correlation was used to analyse the correlation between knowledge, attitudes and practices. Variables with p<0.02 in the single-factor logistic regression analysis are included in the multivariate logistic regression analysis. AMOS 24.0 (IBM, NY, USA) was used to construct a structural equation model (SEM) examining the KAP of patients with impacted wisdom teeth towards wisdom teeth extraction. This SEM tested the main hypotheses as follows: (1) knowledge had direct effects on attitudes, (2) knowledge had direct effects on practices and (3) attitudes had direct effects on practices. Model fit was evaluated using χ-square goodness-of-fit test/df (CMIN/df), Root Mean Square Error of Approximation (RMSEA), Incremental Fixation Index (IFI), Tucker–Lewis Index (TLI) and Comparative Fixation Index (CFI). A two-sided p value <0.05 was considered statistically significant.
Patient and public involvement
Patients were not directly involved in the design, conduct, or reporting of this study. However, the study results are planned to be disseminated to participants and relevant patient communities, ensuring accessible formats and timings based on public interest.
Results
A total of 3467 patients participated in this study. Among them, 1092 (31.50%) were aged 30 or below, 2259 (65.16%) were women, 2927 (84.42%) lived in urban areas and 2391 (68.96%) brushed their teeth two times per day. In addition, 1790 (51.63%) had undergone wisdom teeth extraction. The mean scores for KAP were 9.1±1.4 (possible range: 0–11), 38.0±2.7 (possible range: 10–50) and 41.7±8.2 (possible range: 11–55), respectively (online supplemental table S1).
Supplemental material
The three knowledge items with the highest correctness rates were ‘The primary issues associated with wisdom teeth are insufficient space and misalignment’. (K2), with a correctness rate of 89.59%, ‘Wisdom teeth are unlikely to cause damage to neighbouring teeth, even if left untreated promptly’. (K5), with a correctness rate of 88.78% and ‘Delaying the treatment of wisdom teeth may result in harm to neighbouring teeth.’ (K10), with a correctness rate of 88.78%. The three items with the lowest correctness rates were ‘In cases where the growth of wisdom teeth leads to a severe infection, fever may not necessarily be present.’ (K4), with a correctness rate of 74.53%, ‘Various treatment options exist for wisdom teeth, including medications (antibiotics, traditional Chinese medicine, etc) and surgical procedures (incision and drainage, wisdom teeth extraction, etc).’ (K9), with a correctness rate of 78.40% and ‘Wisdom teeth, also known as third molars, are the last and farthest-back teeth to emerge in the mouth. They typically surface in adults between the ages of 18 and 25 years.’ (K1), with a correctness rate of 80.93% (table 1).
Knowledge
A significant majority of the patients (93.86%) reported that they are willing to proactively engage in discussions with their doctor about their condition and receive professional medical support (A1). Similarly, a high percentage (92.70%) claimed that they believe in actively seeking medical treatment if they experience any visible symptoms in their wisdom teeth (A5). Additionally, an overwhelming 90.51% of the patients expressed trust in the treatment plan proposed by an oral surgeon and demonstrated willingness to heed the professional advice given by the oral surgeon (A7). However, it is worth noting that a considerable portion (58.23%) of the patients admitted to experiencing fear and anxiety regarding procedures related to wisdom teeth (A6). Additionally, 58.96% of the patients expressed fear concerning potential hazards associated with wisdom teeth (A4). In addition, 25.12% of the patients strongly agreed or agreed that the daily care or wisdom teeth extraction requires a significant amount of time and energy, leading to a lack of willingness to prioritise it (A8). The decision-making process for undergoing wisdom teeth extraction is influenced by the reimbursement rates provided by medical insurance, as mentioned by 46.47% of the patients (A13). Additionally, 47.6% of the patients preferred medication as an intervention for wisdom teeth rather than opting for surgical procedures (A12). Notably, a substantial 80.3% of the patients expressed their willingness to undergo prophylactic wisdom teeth extraction if recommended by their doctor (A11) (table 2).
Attitudes
Moreover, 83.89% of patients indicated that they are highly capable of evaluating the risks and benefits associated with wisdom teeth extraction, and they readily accept their dentist’s treatment recommendations (P9). Additionally, 79.23% reported using dental floss to clean the crevices that a toothbrush cannot effectively reach during oral cleaning (P5). Moreover, 74.70% of patients asserted their ability to evaluate issues and make incremental adjustments concerning their experiences with wisdom teeth prevention or treatment (P11). However, the proportion of patients who confirmed their intention to inform their family or friends about the potential hazards of wisdom teeth and remind them to seek prompt medical attention or have their wisdom teeth extracted was only 33.89% (P8). Similarly, only 47.76% of the patients reported being consciously vigilant about their oral health by regularly attending the dental clinic (P3) (table 3).
Practices
The correlation analysis showed that the knowledge score and the attitude score were positively correlated (r=0.288, p<0.001), and the knowledge score and the practice score were also positively correlated (r=0.348, p<0.001). Additionally, there was a positive correlation between attitude and practice scores (r=0.452, p<0.001) (table 4).
Correlation analysis
The SEM was established to further investigate whether patients with impacted wisdom teeth knowledge and attitude towards wisdom teeth extraction affect their practice, whether attitude plays an intermediary role between knowledge and practice and whether knowledge can directly affect their practice according to the KAP theory. It also investigated the effect of other factors including residence and monthly per capita household income on the three dimensions mentioned above (online supplemental table S2). The fitting index of the structural model (CMIN/DF=13.905; RMSEA=0.061; IFI=0.847; TLI=0.834; CFI=0.847) outperformed the respective threshold value, signifying that the data fit the structural model satisfactorily (online supplemental table S3). The SEM revealed that knowledge had a direct effect on attitudes, as evidenced by a path coefficient of 2.042 (p < 0.001), and that attitudes had a direct effect on practices, with a path coefficient of 1.460 (p < 0.001).(figure 1).
The knowledge, attitudes and practices (KAP) structural equation model.
Discussion
Patients with impacted wisdom teeth had sufficient knowledge, favourable attitudes and proactive practices towards wisdom teeth extraction.
However, this study still identified deficiencies of certain aspects. Additionally, variances in KAP levels were observed across different demographic characteristics within the patients. These findings underscore the importance of considering these factors in the development of subsequent health education programmes. The present study found that male and younger patients (<30 years) tend to have higher KAP scores. This finding is different from previous studies, which reported higher oral health knowledge and behaviours among females and partipants older than 30 years.17 18 Nonetheless, the previous studies were not conducted in a Chinese population, and characteristics of their participants were distinctively different from participants in our study. Further education and tailored interventions should be designed for female and older patients in China. Furthermore, the present study identified that urban residents, those with higher education levels, non-smokers, non-drinkers, those who had not undergone dental treatment other than wisdom teeth removal and those who were not informed and educated about wisdom teeth during their dental treatment had lower KAP scores; future programmes should also consider the knowledge needs of these patients to enhance the dental care quality and the KAP towards wisdom teeth.
The present study found sufficient knowledge of wisdom teeth and that most patients would accept being educated about wisdom teeth during other oral therapies. Patients had good knowledge about potential complications associated with wisdom teeth and the importance of treating wisdom teeth in a timely manner. This finding is consistent with previous knowledge and awareness studies conducted on medical students: a large percentage of the study population was aware of wisdom teeth impaction and its consequences.19 20 Patients in the present study had less knowledge about infection related to wisdom teeth and different treatment options. Hanna et al have found that patients used the internet to seek information related to wisdom teeth, but internet use was not associated with better wisdom teeth knowledge.21 Therefore, it is important for healthcare professionals to provide patients with accurate information and internet guidance to improve wisdom teeth knowledge. Zincir et al reported that patients found educational videos related to wisdom teeth surgical removal were excellent for their education, and educational videos in Chinese should be made available to improve patients’ knowledge.22 Increased awareness of hazards and removal of wisdom teeth among patients with impacted wisdom teeth will help in the management of wisdom teeth.23
In the present study, most patients had a positive attitude towards seeking professional advice and medical treatments, and they also trusted the treatment plan formulated by their oral surgeon. This result reflected a high level of patient trust in dentists, and the level of trust is higher than previously reported.24 25 This discrepancy can be explained by the larger proportion of patients with higher education in the present study.26 Similar to previous findings, patients in the present study reported a high level of anxiety about the potential hazards of wisdom teeth and extraction surgery.27–29 Lack of knowledge about the procedure is one of the possible contributors to anxiety related to oral surgery.29 Effective education towards wisdom teeth extraction is critical in reducing anxiety in patients and improving the quality of care. Moreover, in the present study, medical insurance reimbursement rates were a decisive factor for wisdom teeth extraction, which is consistent with a previous study conducted in the USA.30 Thus, there is a need to improve insurance coverage of wisdom teeth treatments to improve adherence to dentists’ recommendations.
Most patients claimed that they would weigh the risks and benefits of wisdom teeth extraction to make an informed decision, and around 80% would use dental floss regularly. Zhao et al reported that very few Chinese adults use dental floss, and the patients with impacted wisdom teeth in the present study might have better practice than the general population due to their disease experience and better dental knowledge.31 Liu et al reported that the rate of dental care visits and the use of oral health resources are low in the Chinese general population.32 It is important to enhance patients’ practice by improving their knowledge and attitude towards wisdom teeth extraction. Furthermore, this study found that patients who had prior wisdom teeth extraction demonstrated better knowledge, attitudes and practices compared with those without previous wisdom teeth extraction experience. Similarly, Brasileiro et al also identified that patients with a history of teeth extraction and those without it presented different patterns of knowledge about wisdom teeth extraction.29 Patients who had no experience with wisdom teeth extraction may need more attention to improve their KAP in this area.
The results of correlation analysis and SEM demonstrated that impacted wisdom teeth knowledge had direct effects on attitudes, and attitudes had direct effects on practices. This implies that patients with impacted wisdom teeth with better knowledge about wisdom teeth would have more favourable attitudes, which indirectly results in better practice towards wisdom teeth.33 The finding highlighted the importance of education in patients with impacted wisdom teeth to improve their knowledge, as well as their attitude and practice towards wisdom teeth. It also found that residence had direct effects on knowledge, and monthly per capita household income had direct effects on attitudes. This finding is consistent with previous studies on dental health and dental care use in China.32 34 35 Patients with lower income and those who lived in rural areas tend to have poorer knowledge and health-seeking behaviours, and more clinical and research attention should be paid to these patients. In addition to common complications, patients should also be informed about rare but serious risks associated with wisdom teeth extraction, such as nerve damage. Damage to the inferior alveolar nerve or the lingual nerve, which can occur during extraction of deeply impacted lower wisdom teeth, can result in long-term sensory changes, including numbness, tingling or even pain in the lower lip, chin or tongue. Although such nerve injuries are uncommon, with incidence rates reported between 0.4% and 8.4% depending on the complexity of the extraction, the potential impact on a patient’s quality of life makes it essential for healthcare providers to discuss these risks. Providing patients with clear information about these rare but serious complications can support informed decision-making and reduce postoperative anxiety.
This study has some limitations. The self-reported nature of the data collection may result in deviations between reported and actual practices. Additionally, since over half of the sample has undergone wisdom tooth removal, there might be inherent differences in knowledge and attitudes compared with those who have not experienced the procedure. Future research could consider handling these two groups separately or using a quasi-experimental design to better explore these differences. Moreover, while this study focuses on common outcomes, it may not fully capture rare complications associated with wisdom teeth extraction, such as changes in sensation due to nerve damage. The large sample size enhances representativeness and generalisability of the results. Furthermore, this study provides an in-depth exploration of the knowledge, attitudes, and practices (KAP) of patients with impacted wisdom teeth regarding their perspectives on wisdom teeth extraction. These findings offer valuable insights to inform clinical guidance in this area.
Conclusions
In conclusion, this KAP study demonstrated sufficient knowledge, favourable attitudes and proactive practices towards wisdom teeth extraction among patients with impacted wisdom teeth. Further tailored interventions should be developed and implemented in this population to improve their KAP of wisdom teeth.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
This study was approved by the Ethics Committee of the School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University (Ethical No. 20230361) and the Medical Ethics Committee of Jinan Stomatological Hospital (JNSKQYY-2023-001). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors would like to thank the experts who contributed to this study, the researchers who assisted in the carrying out of the study and all participants for their significant contributions.
Footnotes
JS and JM contributed equally.
Contributors JS, JM, SL and DT conceived and designed the experiments. JS, XW, BW, XL and DT performed the experiments. JS, JM, XW, SL and DT analysed and interpreted the data. JS, JM, XW, BW, XL, SL and DT contributed reagents, materials, analysis tools or data. JS, JM, SL and DT wrote the paper. DT is the guarantor.
Funding This research was supported by the Open Foundation of Shandong Key Laboratory of Oral Tissue Regeneration (SDDX202003) to JS and the Dean’s Reserch Fund of Jinan Stomatological Hospital (2021-01,2019-06).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.