Assessment of Knowledge, Attitude and Practice Regarding Application ofStem Cells in Dentistry Among Dentists: A Cross- Sectional Study

Introduction

The technology of rehabilitative medicine during the recent decades has largely involved different ways to regenerate, replace, or support the function of defective or injured body parts. In general, these approaches can be broadly divided into three categories: (1) biological approach (2) classical engineering and (3) combination approach. The biological approach is based on natural methods and the idea of tissue exchange or organ transplantation.¹

Classical engineering strategies, involve the production of synthetic implantable materials and/or devices, which are placed in patients in order to replace or augment diseased or damaged tissues; implantation of materials in humans has been practiced for more than 3000 years.² Examples are artificial heart, arteries, heart valves, joint replacements, total knee and hip replacements, intraocular lenses, intravascular stents, and dental implants. However, this approach has limitations as these substitutes are generally less functional, durable, and aesthetic.

Hence a combination (biological + engineering) approach that is aimed at regenerating the lost functional tissues rather than mere use of synthetic materials would provide a vital alternative to currently available clinical treatments, and this has developed tissue engineering in the last few decades which aims to enhance repair of damaged tissues as well as to create replacement organs. Tissue engineering involves the use of engineering principles in the development of tissue or organ grafts. It relies on the concept of using cells, biomaterials, and tissue-inducing factors either alone or in different combinations to accomplish tissue regeneration in vivo or in vitro for transplantation.³

Current scope of tissue engineering is rapidly expanding. Along with creating cells and tissues for therapeutic applications, tissue engineering constructs are being developed for useful non-therapeutic purposes. Tissue engineering represents a radical multidisciplinary approach and impinges on a variety of fundamental and applied biomedical technologies such as development biology, genomic and post-genomic technologies, biomaterials, biomedical engineering, biophysics and biomechanics, and transplantation science for clinical and non-clinical applications which plays important role in tissue engineering.⁴

Use of living cells to restore, maintain or enhance the function of tissue and organs is therefore considered a significant therapeutic pillar of healthcare. There are different types of cells, which are commonly categorized as stem (unspecialized) and non-stem (specialized) cells that could be used. This has recently been recognized as a promising alternative to specialized cells, owing to their enormous potential in generating a spectrum of tissues with adequate functions.

Stem cells can be defined as immature or undifferentiated cells that are able to renew by themselves and differentiate into more specialized, tissue-organ-specific cells which qualify them to be a good repair system

Methods

A cross-sectional survey was conducted among 200 dentists, which included PG students and staff of Sri Rajiv Gandhi Dental College from November 2019 to December 2019. Sample size estimation was done using the Statistical Package for Social Sciences [SPSS] for Windows Version 22.0 (Released 2013. Armonk, NY: IBM Corp.,) at 95% confidence interval and 5% allowable error. The ethical clearance was obtained from the Institutional Review Board, and the study was conducted in full accordance with the World Medical

Association Declaration of Helsinki. The purpose of the study was explained to the participants. The self structured questionnaire presented to the participants in the study was devised based on the previous literature review (Table 1). The face validation of the questionnaire for its contents and relevance was performed by the subject experts in the Department of Oral medicine, Endodontics, Community Dentistry and Periodontics.

The collected data were analyzed using Statistical Package for Social Sciences [SPSS] for Windows Version 22.0 (Released 2013. Armonk, NY: IBM Corp.,). Descriptive statistics have been generated in terms of percentages. Chi square goodness of fit test has been used to compare the study participant’s responses based on relevant socio-demographic variables to observe for possible associations between them. The level of significance was set at p <0.05.

Results

This study was conducted to assess the knowledge, attitude and practice regarding application of stem cells in dentistry among dentists. The study consisted of 100 postgraduates and staff of Sri Rajiv Gandhi Dental College. The response rate was 100%.

Regarding knowledge (professional status), all postgraduates and staff (100%) were familiar about stem cell regenerative procedures. Most of the dentists who responded were from Endodontics (25%), Periodontics (23%) and General Dentists (52%). On intergroup comparison, for the responses when asked about how many years they were into dentistry and also how often they read scientific journals, statistically high significant difference was noted with p value ˂0.001*. The p value was 0.69 (p >0.005) which was not statistically significant for dentists receiving CDE programs on stem cells and regenerative treatment (Table 2) (Figure 1).

Regarding attitude (ethical options, beliefs, judgement), on intergroup comparison, p value was ˂0.001 for the responses on regenerative therapy (Table 3) (Figure 2 and 3).

On intergroup comparison for the response towards clinical practice of regenerative therapy, statistically significant p value <0.001 was noted (Table 4) (Figure 4).

Discussion

Dentists are expected to play a major role not only in advancing the field of stem cell research but also in directing and implementing future stem cell therapies in dentistry. Accordingly, a good basic knowledge and a positive attitude towards stem cells and their potential applications is essential for future dentists. Therefore, the current cross- sectional survey was conducted to assess the knowledge, attitude and practice regarding application of stem cells in dentistry among dentists.

The intention of the study was to gather information about stem cells application, knowledge and usage in dentistry. The collected data will aid in planning and implementation of stem cell usage.

Stem cell therapies and regenerative treatments have been under development since human embryonic stem cell lines were first isolated more than a decade ago.⁶

In a living system, there are different types of cells, which are commonly categorized as stem (unspecialized) and non-stem (specialized) cells that could be used for tissue engineering. This is because stem cells are specialized to divide but not differentiate, whereas other cell types are committed to form specific types of cells. This property of stem cells makes them suitable for tissue engineering and regenerative applications. The use of stem cells has recently been recognized as a promising alternative to specialized cells, owing to their enormous potential in generating a spectrum of tissues with adequate functions. Stem cells can be defined as immature or undifferentiated cells that are able to renew by themselves and differentiate into more specialized, tissue-organ-specific cells which qualify them to be a good repair system.⁵

Stem cells also known as “progenitor or precursor” cells are defined as clonogenic cells capable of both self-renewal and multi-lineage differentiation.⁷ In 1868, the term “stem cell” for the first time appeared in the works of German biologist Haeckel.⁸ G. L. Feldman (1932) showed evidence of regeneration of dental pulp under certain optimal biological conditions. This work introduced the biological-aseptic principle of tooth therapy to achieve pulp regeneration using dentine fillings as building material for stimulating pulp regeneration.⁹

In the present study, Chi-square test showed a significant correlation between professional status, ethical opinion, beliefs and clinical practice in relation to the academic qualification of the dental professionals which may be due to more knowledge acquired by highly qualified dental residents. On the contrary, Sede et al., showed non-significant association between attitudes towards the use of stem cells and qualification.¹⁰

Only 48% in the present study received CDE in stem cells / regenerative treatment while the remaining 52% did not receive any CDE in regenerative procedures. Hence there is a need to conduct many CDE programs.

In this study, 89% showed interest to attend CDE programs or conferences in the near future which could be due to increasing research, applications in this field, and also may be due to lack of sufficient in-depth knowledge about dental stem cells. Goyal et al., reported that 73% of the participants were enthusiastic to attend such conferences/workshops/CDE programs because they had never attended the same and when it comes to usage of umbilical cord/ other types of stem cell banking, 80% of the dental professionals and their relatives never used it or were either unaware of it.

About 91% of the dental professionals believed that the main obstacle to seek treatment with the aid of dental stem cells is high cost. Comparable results were reported by Goyal et al., where 63.50% agreed that the high cost was in fact a barrier.¹¹

Dental practitioners had theoretical knowledge regarding the sources of stem cells and also expressed desire for more practical experience through real life training.

Nearly 89% of professional dentists believed that dental professional associations should regulate the use of stem cells and regenerative dentistry. This may be due to the fact that dental pulp stem cells have equivalent potential to differentiate when compared with the stem cells obtained from bone marrow. Similar results (85.3%) were observed in a study conducted by Utneja et al. ¹²

However, 33% did not know about the assessment of regenerative dental treatment outcomes. This study comprised of 100 subjects (dental professionals) and the questionnaire covered aspects like professional status, ethical beliefs, opinions and clinical practice regarding stem cell applications.

Conclusion

In the current study, most of the dental professionals provided positive responses towards ethical opinions, beliefs, judgment towards stem cells. They opinioned that CDE programs have to be held frequently regarding the said topic and also expressed desire for more such informative programs. There is a need to increase knowledge among professionals regarding clinical applications of the same.

Conflicts of Interest

Nil.