The Main Decisional Factors That Influence the Decision of the Patients Suffering from Diabetes to Have Dental Implants Using New Technologies after the COVID-19 Pandemic Period

Abstract

The problems that have arisen in recent years in Romania (the financial crisis, the COVID-19 pandemic, the accelerated growth of inflation and unemployment) have led many people to give less and less importance to dental hygiene, which has led to an increase in the number of people with dental medical problems. In addition, poor information about the need for regular visits to the dentist, the low importance given to this field, and insufficient financial resources led people to turn to dental medical services less often. Moreover, the two-month closure of medical practices during the COVID-19 pandemic made individuals more reluctant to make appointments with dentists for fear of coming into contact with a person infected with the new SARS-CoV-2 virus. All this led to the occurrence of dental complications among patients, which made the number of dental implants increase. Patients suffering from diabetes mellitus present a series of particularities due to a series of risks generated by this condition that may appear in their case. The aim of this research is to identify the main factors that can influence the decision of patients with diabetes mellitus to have a dental implant. The data collection was performed with the help of a questionnaire, and the analysis of the database was performed with the help of IBM SPSS software. Following the analysis, it was noted that this decision is largely influenced by the reputation of the medical practice, the perceived risks, the quality of the materials used, the warranty of the dental implant, the quality of the services provided, and the costs.

1. Introduction

The passing of time, poor nutrition of individuals, stress, and low importance given to dental hygiene have gradually led to the occurrence of more and more serious dental problems. Individuals started to turn to the services provided by dentists only when their medical problems worsened, which often led to the loss of natural teeth and an increase in the number of dental implants performed [1]. In this manner, dental implants have become a necessity in order to fix the patients’ teeth and help them live a normal life [2]. Dental implants were considered by both doctors and patients to be the most effective solution from an aesthetic and functional point of view and seen as a minimally invasive intervention whose durability over time is much higher. This method has also been used many times when patients’ teeth have suffered some problems caused by diseases, such as diabetes [3], a condition that, in many cases, caused the development of periodontitis [4,5] which gradually led to tooth loss.

Considering these aspects, Butera [6] has carried out a study in which he proposed to study the decrease in HbA1c in patients suffering from type 1 diabetes mellitus. The patients were treated using non-surgical periodontal therapy: professional dental hygiene (every 3 months), ozonated water (monthly), and home therapy with mouthwash and “Biorepair Plus” paste. The results of the study illustrated that, the frequent professional oral hygiene, the use of ozonated water, and home therapies can decrease the periodontal indicators, which also determine the reduction in the HbA1c index. While in the past doctors used dental implants mainly for the elderly, nowadays, there has been an increase in the number of younger patients who increasingly request to have such a medical procedure [7] in order to restore their teeth. In many cases, they suffer from diabetes mellitus, which has led to certain problems with their teeth.

The passing of time has illustrated that the dental implants are complex procedures that present some particularities depending on the patient’s state of health, the diseases he or she suffers from, his or her age, the type of the materials and technologies used, and the training and experience of the doctor who performs the intervention. The increase in the number of dental implants automatically led to more complications. If, when this procedure first emerged, implants were performed quite rarely, and the cases solved were much more limited, the increase in their number brought with it the increase in the complications for patients due both to aspects related to each individual, the technologies and materials used (e.g., titanium), and the surgical procedure, as well as some aspects related to the way the intervention was performed. An issue that has been analyzed in recent years regarding dental implants focuses on the success rate and survival rate over time, considering that, on average, more than 90% of the implants placed have a higher survival rate. [8]. Moraschini [9] stated that, in recent years, the average survival rate reached the threshold of 94.6% after 10 years from the time of the intervention; this aspect is considered to be an advantage for patients because very often they fear that the dental implants made will not last very long over time, and then they give up the idea of resorting to such a medical procedure.

1.1. The Influence of Diabetes on the Dental Implant, the Risks of the Dental Implants at Patients That Suffer from Diabetes

Diabetes mellitus is a chronic metabolic disorder characterized by the occurrence of hyperglycemia [10]. This is a disorder that occurs when high blood glucose levels are recorded because the body no longer has the ability to produce enough insulin, or the body is making insulin but does not respond normally. Liu [11] considered that, in many cases, diabetes causes osteoporosis, which, in turn, has a series of implications on the whole body, causing a reduction in alveolar bone mass, problems in bone microstructures, a reduction in bone density, and an increase in bone fragility. Currently, in the specialized literature, we encounter several types of diabetes, such as type I, type II [12], or gestational. Worldwide, type II diabetes has the highest frequency (over 90% of cases registered globally) [13]. The International Diabetes Federation [14] estimates that more than 600 million people will end up suffering from this condition by 2030. The World Health Organization (WHO) stated that diabetes mellitus is currently the sixth leading cause of death in the world [15].

In addition, patients suffering from diabetes mellitus are much more likely to develop periodontitis [16,17,18] and lose their teeth [19,20]. Moreover, wound healing is delayed [21], which can generate a series of complications with the placement of the dental implant [22]. Patients who suffer from this condition also present some particularities regarding the success rate of the implant, its resistance over time, the predisposition to develop peri-implantitis, osseointegration [23], marginal bone loss, etc.

1.2. The Risk of Failure

Regarding the failure of a dental implant in patients with diabetes mellitus as opposed to healthy ones, it has been noted that the risk is higher for the former category. Implant failure can occur at two different times, namely, early (in the early stages of healing, when healing of the implant could not be achieved), or late (this is actually osseointegration failure) [24]. The American Diabetes Association [25] has shown that dental implant failure in patients suffering from this condition is also influenced, to a high extent, by their type of diabetes. The results show that the failure rate of dental implant is higher among patients suffering from type I diabetes. The failure rate is lower for healthy patients and type II diabetes patients [5,26]. Nowadays, the specialists have not reached an unanimously accepted conclusion regarding the type of impact that diabetes mellitus has on dental implant failure rate. Some stated that they did not identify significant differences between individuals with diabetes and those who did not suffer from this condition in the study they carried out [27]. Other authors identified statistically significant differences between the two groups analyzed [28], while others stated that there are a number of differences between healthy patients and those suffering from diabetes mellitus, but this difference is not statistically significant [28,29].

A study carried out by Chrcanovic [30] stated that the failure rate of a dental implant in patients suffering from diabetes mellitus is also influenced to a high extent by the location of the implant (in the maxilla or mandible—the lower jaw). The study showed that in the maxilla, where the bone quality is poorer and there is not adequate bone volume, higher dental implant failure rates can be seen.

1.3. Predisposition to Develop Peri-Implantitis

Patients suffering from diabetes mellitus and who do not control their blood sugar levels are much more likely to develop peri-implantitis after the completion of a dental implant compared to healthy patients or patients who maintain their glycemic level under control. Soh [31] confirms the abovementioned data, emphasizing that there is a significant difference between patients suffering from this condition and healthy ones [32]. Due to this, doctors must be more careful when performing dental implants in patients suffering from diabetes. Al Zahrani [33] noted that there are significant differences between the two groups if analyzed comparatively, depending on the HbA1c level. Patients whose level is lower (below 8%) have a lower risk of developing this complication, while individuals with higher values have a higher risk.

Other authors [34] have studied the existence of significant differences between patients suffering from different types of diabetes (I or II) in terms of peri-implantation complications that may occur. Thus, it was noted that people suffering from type II diabetes have a higher risk of developing a series of peri-implantation problems as opposed to healthy people or even to those suffering from type I diabetes.

1.4. The Survival Rate

From the perspective of the dental implant survival rate in diabetic patients, it was observed that the survival rate is higher in those who suffer from this condition but who permanently control their blood glucose level, compared to those who do not. If individuals maintain an optimal level of blood sugar in the body, the durability of the dental implant over time is much higher, sometimes similar to that of a healthy patient [35].

A study conducted in 2016 [36] emphasized that there are differences between patients who record different HbA1c indicator values. The comparison was made between patients whose value is between 6.1 and 8% and those whose value is between 8.1 and 10%. The results showed that the dental implant survival rate for patients who belong to the first group is higher than that for those who register HbA1c values higher than 8.1%. Even if some specialists believe that there is a significant difference between patients who have this condition and healthy ones, some stated that they did not note clear differences between the two groups in the study they carried out [37], considering the fact that diabetes mellitus does not influence the resistance of a dental implant over time. They were of the opinion that a number of other factors, such as the particularities of each individual patient and the materials or the technology used, have the ability to influence survival over time. Other authors analyzed the survival rate of a dental implant also from the perspective of the type of diabetes the patients suffer from (type I or II). Thus, it was noted that, in individuals who have type II diabetes, the survival rate is maximum [38] or over 80% [36]. In the case of this type of diabetes, it has been noted that there are no major negative implications on the long-term resistance of the dental implant.

1.5. Marginal Bone Loss and Bone Augmentation

Marginal bone loss (MBL) represents one of the most important indicators for a dental implant [39], having a fairly high connection with the degree of resistance of the dental implant over time but also with its resistance duration over time [35]. A study performed in this field [40] has showed that there are significant differences between patients suffering from diabetes mellitus and healthy ones in terms of marginal bone loss. Liebl [41] believes that the effect of this condition on MBL can be seen over time but not immediately, and, for this reason, the dentist must constantly carry out a careful control of the peri-implantation tissues in these patients. In addition, it has been noted that, even in the case of patients with diabetes mellitus, there are significant differences between those who control their blood sugar levels and those who do not. Patients who do not control their blood sugar levels have a much higher rate of marginal bone loss compared to those who keep this condition under control [36]. Important differences were also identified in patients suffering from type II diabetes, noting that marginal bone loss (MBL) is higher in their case than in healthy patients, even if they constantly control their glycemic levels [42]. Another negative effect that diabetes mellitus has on the dental implant is bone augmentation. A study carried out in this field [43] showed that this disease has no influence on maxillary sinus augmentation. In addition, other research that was carried out on patients suffering from diabetes mellitus showed that this condition does not generate bone augmentation or peri-implant bone alteration [44].

1.6. Microvascular Complications

Over time, a fairly close connection between blood sugar levels and the occurrence of micro- and macrovascular complications was observed. However, it was identified that maintaining the glycemic level under control can positively influence the way microvascular complications appear and develop [45]. Farzad [46] stated that microvascular complications have the ability to influence, to a high degree, the failure rate of a dental implant in patients suffering from diabetes mellitus. It was noted that microvascular implications have the ability to influence the resistance of the implant in the first year of implantation, a fact that can lead to subsequent complications.

1.7. Osseointegration

Diabetes mellitus has the ability to greatly influence the clinical effect of implants in terms of osseointegration [47]. Osseointegration is considered to be one of the most important processes in a dental implant. It refers to how the bone healing and bone remodeling took place, which is meant to achieve an interface between the bone tissue and the implant after its placement. Osseointegration is essential in order to be able to benefit from a dental implant over time that does not become inflamed [48]. If, in previous years, the specialists analyzing the success/failure of a dental implant during the osseointegration period stated that there are differences between patients suffering from diabetes mellitus and healthy ones [49], a recent study [50] has shown that there are no such differences between the two categories studied, stating that patients who permanently control their glycemic level do not present significant risks of dental implant failure during the osseointegration period. From the perspective of type II diabetes, the research has shown that this type of diabetes can negatively influence early osseointegration, even if the glycemic level is strictly controlled, a fact that eventually affects the success of the dental implant.

1.8. The Aim of the Study

In recent years, the number of implants in Romania has increased quite a lot because many patients have lost their natural teeth, which led doctors to turn to dental implants to restore their dentition [51]. A special case in terms of dental implants is represented by patients suffering from diabetes mellitus. The success rate, as well as the survival rate, of dental implants in patients with diabetes mellitus may be lower than that recorded among healthy people due to the adverse effects that this condition has on the human body [22]. It has been noted that patients with this condition are more prone to peri-implantitis than healthy ones. Diabetes mellitus automatically leads to delayed wound healing [22,52] and the likelihood of post-operative infections [53,54,55] but also to the occurrence of bone metabolism disorders. Moreover, a series of differences have been identified in patients suffering from this condition in terms of marginal bone loss, osseointegration, and bone augmentation.

Based on all this information, it was considered necessary to carry out a quantitative study. The aim of this research is to identify the main factors that can influence the decision of patients suffering from diabetes mellitus to have a dental implant.

In order to build the conceptual model of the paper and sustain the research hypotheses, various models that were previously created by different authors have been analyzed. Over time, it has been observed that the individuals’ decision to acquire various goods or services (in our case, to make a dental implant) is influenced by many factors. Kusumah [56] mentioned that the risks perceived by individuals have a strong impact on their decisions to act in a certain direction and benefit from a certain service. Grönroos [57] noticed that the quality of the services has the capacity to influence to a risky extent the decision of individuals to acquire a certain good or service, while Parasurman [58] built the SERVQUAL model within which he analyzed the five dimensions of service quality as the following: tangibles, reliability, responsiveness, assurance, and empathy. Venkatesh [59] studied the individuals’ capacity to accept new technologies. It is known that some individuals are more open to accepting the introduction of new technologies, while others are more reticent. Therefore, it has been observed that the individuals’ perception regarding new technologies and the benefits that they bring have the capacity to influence individuals’ decision to utilize them in the future. Moreover, it has been noticed that the human decision to acquire various goods or services is influenced by their perceived cost [60].

The data obtained from this research are very important both for dentists who have their own practice and for managers of dental clinics because they will understand the main elements which are considered by patients when they make the decision to have a dental implant. Based on these data, doctors will understand the main aspects they need to consider when discussing with individuals suffering from such a condition about a possible dental implant.

2. Materials and Methods

2.1. Survey Design and Research Sample

In support of this research approach, a quantitative study was carried out. Data collection was performed with the help of a questionnaire consisting of 20 questions. The questions in the questionnaire were constructed based on the research that was carried out previously on this topic and was analyzed in the literature review part. Data collection was carried out with the help of a questionnaire. The first question in the questionnaire was a filter, with the role of selecting only people who currently suffer from diabetes mellitus. The questions that were considered in the multiple regression model were measured on a 7-point Likert scale. At the end of the questionnaire, there were several questions that had the role of creating the demographic profile of the respondents.

Regarding the way in which the participants were recruited, it should be mentioned that the study was carried out in collaboration with OnDental—Microscope dentistry. In order to collect the data from the patients, the questionnaire was posted on an online platform. The respondents received a link, and they were asked to answer the questions. The patients were informed that, if they have relatives or friends who suffer from diabetes mellitus, they can send them the link of the questionnaire to participate in this research.

The research was carried out between April and September 2022. The sample included 78 people who currently suffered from diabetes mellitus.

To identify the sample dimension, we used the following formula [61]:

$$N=\frac{t²\times p\times \left(1-p\right)}{\Delta w²}$$

N—the required size of the sample.

t—the coefficient associated to the probability of guaranteeing results; in our study, t = 1.96 with a probability of guaranteeing results of 95%.

p—the share of respondents with the required characteristics – > p = 0.5.

ω—maximum admitted error (limit of error)—5%.

2.2. Regression Model

The multiple regression model that was used in this analysis aimed to determine the type and intensity of the existing links between the dependent variable (the decision of patients suffering from diabetes mellitus to have a dental implant) and the independent variables (the reputation of the medical practice, the duration of healing, the perceived risks, the reputation of the dentist, the quality of the materials used (e.g., the use of titanium), the occurrence of further complications, the warranty of the dental implant, the information provided by the dentist, the quality of the services provided, the perceived costs, the increased risk of peri-implantitis, and the technology used).

The regression equation can be written in the following form:

Y = β0 + β1*X1 + β2*X2 + β3*X3 + β4*X4 + … + βn*Xn + ε, where

Y = dependent variable of the proposed conceptual model;

β0—constant;

β1 … βn—coefficients for the independent variables;

X1, X2 … Xn—estimated value of model parameters;

ε—standard error.

The following results by applying this formula to the proposed conceptual model:

The decision of patients suffering from diabetes mellitus to have a dental implant = β0 + β1* Reputation of the medical practice + β2* Duration of healing + β3* Perceived risks + β4* Reputation of the surgeon + β5* Quality of the materials used + β6* Occurrence of further complications + β7* Warranty of the dental implant + β8* Information provided by the dentist + β9* Quality of services provided + β10* Perceived costs + β11* Increased risk of peri-implantitis + β12* Technology used + ε.

2.3. Hypotheses Formulation

The hypotheses underlying the multiple regression model were the following:

H1. 

The increased reputation of the medical practice has a direct and positive effect on the decision of patients suffering from diabetes mellitus to have a dental implant.

H2. 

The healing time of the dental implant directly and negatively influences the decision of patients suffering from diabetes mellitus to have a dental implant.

H3. 

The risks perceived by patients with diabetes mellitus regarding dental implants have a direct and negative effect on the decision of patients to have a dental implant.

H4. 

The reputation of the surgeon has a direct and positive effect on the decision of patients suffering from diabetes mellitus to have a dental implant.

H5. 

The quality of the materials used in a dental implant has a direct and positive effect on the decision of individuals to undergo such a medical procedure.

H6. 

The likelihood of post-implantation complications has a direct and negative effect on the diabetics’ decision to have a dental implant.

H7. 

The warranty offered for the implant has a direct and positive effect on the decision of diabetic patients to have a dental implant.

H8. 

The information provided by the dentist has a direct and positive effect on the decision of diabetic patients to have a dental implant.

H9. 

The quality of the services provided in the medical practice has a direct and positive effect on the respondents’ decision to have a dental implant.

H10. 

The costs perceived by respondents directly and negatively influence the decision of diabetic patients to have a dental implant.

H11. 

The perception of an increased risk of peri-implantitis directly and negatively influences the decision of diabetic patients to have a dental implant.

H12. 

The technology used in the medical practice directly and positively influences the decision of diabetic patients to have a dental implant.

3. Results

Following the analysis, it was noted that 84.6% of the participants in the study were women, and 15.4% were men. The age distribution of the respondents showed that 57.7% of the individuals were between 55 and 65 years old, and 24.4% were between 45 and 54 years old, while only 17.9% were over 65 years old. Thus, younger people have increasingly begun to turn to dental medical services for dental implants due to the loss of natural teeth.

In terms of the last level of education completed by the respondents, in the

Table 1. Respondents’ profiles.

Category		Frequency (%)
Gender	Male	12 (15.4)
	Female	66 (84.6)
Age	45–54	19 (24.4)
	55–65	45 (57.7)
	Over 65	14 (17.9)
Last level of education completed	High school	25 (32.1)
	Bachelor’s degree	40 (51.3)
	Master’s degree	13 (12.4)
Income	<RON 2000	7 (9)
	RON 2000–3000	13 (16.7)
	RON 3001–4000	23 (29.5)
	RON 4001–5000	20 (25.6)
	>RON 5000	15 (19.2)

Source: statistical survey made by the authors.

below, it can be noted that most had completed their bachelor’s degree studies (51.3%), and 32.1% had graduated from high school. A smaller share of those who participated in the study (12.4%) had completed their master’s degree studies. In terms of the income distribution of the interviewees, it can be noted that 29.5% had incomes between RON 3001 and 4000, 25.6% earned between RON 4001 and 5000 monthly, while 19.2% earned more than RON 5000 monthly. Only 16.7% of those interviewed earned between RON 2000 and 3000 monthly, and 9% had incomes lower than RON 2000.

In order to test the reliability of the scale, the Cronbach’s alpha coefficient was calculated. In the

Table 2. Reliability statistics.

Cronbach’s Alpha	Cronbach’s Alpha Based on Standardized Items	No. of Items
0.746	0.770	13

Source: statistical survey made by the authors.

below, it can be noted that, its value is 0.746; a value that exceeds the threshold of 0.7 shows the model is accepted. This aspect also illustrates the viability of the variables which was taken into consideration in the linear model regression.

The data obtained from this quantitative study were analyzed using IBM SPSS software. Following the interpretation of the results, it can be seen that the coefficient of determination R2 (R-square) recorded the value of 0.590, which shows that 59% of the variation in the decisions of patients suffering from diabetes mellitus to have a dental implant placed is explained by the variables which were considered in the regression model developed. Moreover, it should be emphasized that this indicator shows that there is a positive and quite close link between the analyzed variables. The denominator degrees of freedom (df) 1 is 12, the denominator degrees of freedom (df) 2 is 65, and the value of Sig. F change is 0. The standard error of the estimate in this model is 1.083.

In this research, we used an ANOVA (analysis of variance) formula. This is used to compare variances across the means of different groups. Interpreting the data obtained after the analysis carried out in IBM SPSS, it can be seen in

Table 3. Model summary.

Indicators	Validation Criteria
R	0.768
R-square	0.590
Adjusted R-square	0.514
Std. Error of the Estimate	1.083
R-square Change	0.590
F Change	7.799
df1	12
df2	65
Sig. F Change	0.000

Source: statistical survey made by the authors.

that ANOVA, the multiple regression equation proposed in this study, is valid; the value recorded by the Sig. indicator is less than 0.05. The sum of squares is the statistical measure of deviation, and the results obtained for this indicator is 109.857 (for regression) and 76.297 (for residuals). The value of F (variance of the group) is 7.799.

Based on the statistical results that were previously obtained, the next step was to identify how the independent variables considered in the model (reputation of the medical practice, healing time, perceived risks, reputation of the surgeon, quality of the materials used (e.g., the use of titanium for the implant), the occurrence of further complications, the warranty of the dental implant, the information provided by the surgeon, the quality of the services provided, the perceived costs, the increased risk of peri-implantitis, and the technology used) can influence the decision of patients suffering from diabetes mellitus to have a dental implant. In

Table 4. ANOVA.

Model	Sum of Squares	df	Mean Square	F	Sig.
Regression	109.857	12	9.155	7.799	0.000
Residual	76.297	65	1.174
Total	186.154	77

Source: statistical survey made by the authors.

which we obtained from IBM SPSS, we analyzed the beta coefficients (with their standardized and unstandardized values), t-test, and value of Sig. for each variable that we used in our model.

In the

Table 5. Coefficients.

Coefficients a
Model	Unstandardized Coefficients		Standardized Coefficients	t	Sig.	95.0% Confidence Interval for B		Correlations			Collinearity Statistics
	B	Std. Error	Beta			Lower Bound	Upper Bound	Zero−Order	Partial	Part	Tolerance	VIF
(Constant)	3.941	1.125		3.503	0.001	1.694	6.187
Reputation of the medical practice	0.439	0.117	0.460	30.757	0.000	0.206	0.672	0.527	0.422	0.298	0.420	2.381
Healing time	−0.203	0.153	−0.151	−10.325	0.190	−0.508	0.103	−0.002	−0.162	−0.105	0.486	2.056
Perceived risks	−0.337	0.106	−0.333	−30.190	0.002	−0.548	−0.126	−0.094	−0.368	−0.253	0.579	1.728
Reputation of the dentist	−0.238	0.153	−0.185	−10.555	0.125	−0.543	0.068	0.337	−0.189	−0.123	0.446	2.241
Quality of the materials used	0.644	0.219	0.381	20.939	0.005	0.206	10.082	0.220	0.342	0.233	0.375	2.667
Occurrence of further complications	−0.206	0.232	−0.120	−0.888	0.378	−0.669	0.257	0.322	−0.110	−0.071	0.344	2.903
Warranty of the implant	0.344	0.161	0.255	20.136	0.036	0.022	0.666	0.425	0.256	0.170	0.441	2.269
Information provided by the dentist	0.136	0.158	0.106	0.862	0.392	−0.180	0.453	0.308	0.106	0.068	0.417	2.398
Quality of the services provided	0.339	0.148	0.332	20.286	0.025	0.043	0.635	0.612	0.273	0.182	0.298	3.352
Perceived costs	−0.216	0.099	−0.231	−20.171	0.034	−0.415	−0.017	0.039	−0.260	−0.172	0.558	1.793
Increased risk of peri−implantitis	0.082	0.108	0.080	0.760	0.450	−0.134	0.298	−0.226	0.094	0.060	0.564	1.773
Technology used	−0.081	0.124	−0.074	−0.655	0.515	−0.328	0.166	−0.208	−0.081	−0.052	0.496	2.016

^a Dependent variable: the decision of patients suffering from diabetes mellitus to have a dental implant placed. Source: statistical survey made by the authors.

, it can be noted that, some of the independent variables that were considered in the proposed conceptual model recorded Sig. values greater than 0.05, which underlines the fact that they cannot be considered in this analysis. These were the healing time (Sig. = 0.190), the reputation of the surgeon (Sig. = 0.125), the occurrence of further complications (Sig. = 378), the information provided by the surgeon (Sig. = 392), the increased risk of peri-implantitis (Sig. = 0.450), and the technology used (Sig. = 0.515).

If we apply the standardized beta coefficients from the table above to the proposed conceptual model, we obtain the following multiple regression model results:

The decision of patients suffering from diabetes mellitus to have a dental implant placed = 3.941 + 0.460* Reputation of the medical practice − 0.333* Perceived risks + 0.381* Quality of the materials used + 0.255* Warranty of the dental implant + 0.332* Quality of the services provided − 0.231* Perceived costs + 1.087.

4. Discussion

A number of particularities regarding dental implants have been identified in patients suffering from diabetes mellitus. The main factors that can affect a dental implant in patients suffering from such a condition are delayed healing of wounds, the existence of microvascular diseases, and a higher predisposition to develop infections. Over time, it has been noted that patients with diabetes mellitus are more prone to periodontitis and tooth loss. In their case, there is a higher risk of failure of dental implants, unlike healthy patients. In addition, in their case, a series of post-operative complications caused by this condition may occur.

The results obtained in this study have the role of giving us a lot of information regarding the opinion of diabetics regarding the main factors that can influence their decision to have a dental implant. Following the analysis, it was observed that 59% of the variation in the decision of patients suffering from diabetes mellitus to have a dental implant is explained by the variables which were considered in the regression model. From the total of 12 independent variables that were analyzed in the regression model, only 6 of them obtained a value of Sig. < 0.05, and only these variables (6) were taken into consideration in the final regression model. In addition, it was observed that the value of the standardized beta coefficients recorded the highest values among the reputation of the medical practice (0.460), the quality of the materials used (0.381), the perceived risks (0.333), and in the case of the quality of the services provided (0.332). In the case of the perceived costs and the warranty of the dental implant, the value of the standardized beta coefficients was lower—0.231 and 0.255, respectively. The standard error obtained in the case of the multiple regression model was 1.087.

Based on these aspects, it was considered necessary to carry out a quantitative study among patients suffering from diabetes mellitus in order to identify the main factors that can influence their decision to have a dental implant. Following the analysis, it was noted that the decision is directly influenced by the reputation of the medical practice, the risks perceived by the patients, the quality of the materials used, the warranty offered for the dental implant, the quality of the services provided, and the costs perceived by each individual patient. It is thus noted that the decision to resort to such a medical procedure is influenced by a number of factors that have the role of generating patients’ confidence in this procedure (the knowing degree of the practices, the quality of the materials and the services provided, and the warranty offered), as well as some related to its related risks (the occurrence of post-operative infections, higher failure rate, and the likelihood of lasting less over time) or perceived costs.

Analyzing from the limits of the research perspective, it has to be mentioned that the study was carried out on a limited number of respondents (78); this does not provide us the possibility of extrapolating the data over the entire researched community. The restrained value of the sample has also influenced the intensity of the links between the variables. In order to have a better image on the analyzed subject and better observe the intensity between the links of the variables taken into consideration within the regression model, in the future, other studies should be conducted on a larger number of respondents. These should take place both at the level of private clinics from Romania, as well as at the level of specialty hospitals.

Another limit identified at the level of this study refers to the fact that in order to collect data, a questionnaire that was posted on a dedicated online platform was utilized. The respondents had the possibility of completing the questionnaire online, and from this cause, we do not have certainty that only those who were part of the researched community participated at this study. From this cause, it is recommended that other quantitative research should be carried out, both in physical and online formats, that would certify or deny the results obtained at the level of the present paper.

Another limit of this research refers to the variables that were taken into consideration at the level of the regression model. Within this model, only a part of the variables that have the capacity to influence the decision of the patients with diabetes mellitus in the making of a dental implant were examined: the reputation of the medical practice, duration of healing, perceived risks, reputation of the surgeon, quality of the materials used, occurrence of further complications, warranty of the dental implant, information provided by the dentist, quality of services provided, perceived costs, increased risk of periimplantitis, and technology used. The existence of others apart from the ones taken into consideration is possible. In the future, it is recommended that other quantitative research in which more variables that have not been tested within the model of this paper be conducted.

The information obtained through this quantitative study provides us with relevant information regarding the behavior of patients suffering from diabetes mellitus and the factors that can influence their decision to have a dental implant.