Impact of Shade Selection on Prosthodontic Outcomes: A Comparative Analysis of Dental Students’ and Practitioners’ Awareness

Abstract

Background: Shade selection is a critical procedure of any esthetic prosthodontic treatment process. Despite its importance, there is a concern regarding the awareness and knowledge of shade selection among dental students and practitioners. Purpose: To evaluate the knowledge of dental students and practitioners regarding shade selection principles and investigate the differences in aesthetic prioritization between fixed and removable prostheses. Additionally, to investigate the emphasis placed on aesthetics in removable prosthetic cases compared to fixed prostheses, and to examine how this emphasis differs between dental students and experienced practitioners. Methods: A cross-sectional questionnaire-based study was conducted involving students and dental practitioners. The questionnaire consisted of multiple-choice questions designed to evaluate participants’ knowledge of shade selection principles and methods used in contemporary dental clinical practice and the perceived impact on treatment outcomes in Saudi Arabia. This study involved 554 participants, divided into three groups: 117 who treated fixed cases, 51 who treated removable cases, and 398 who treated both fixed and removable cases. The collected data was tabulated for data analysis using the Mann–Whitney U test and the Kruskal–Wallis test to generate the significance per category. Results: The study revealed no significant differences in knowledge and practice scores across the demographic factors for participants who exclusively treated either fixed or removable cases, suggesting a uniformity in expertise and application. However, among participants who managed both fixed and removable cases, significant variations emerged based on gender, age, and educational or professional level. Notably, a statistically significant disparity (p < 0.05) was observed in the comprehension of digital shade-matching technology, with practicing dentists exhibiting a higher level of awareness compared to dental students. Conclusions: The study concluded that age, gender, and education level significantly impact the knowledge and practice of shade selection. The findings highlighted a concerning gap in the awareness and knowledge regarding shade selection by dental students compared to practitioners, which emphasizes the need for enhanced educational training programs focusing on shade selection techniques and their implications for prosthodontic outcomes.

1. Introduction

Shade selection is one of the important steps in almost all prosthetic cases [1,2,3]. Patients nowadays demand high aesthetics as much as they care about the function of the prostheses [4,5]. Previous research indicates that variations in shade matching for identical teeth can arise in practitioners over time [3]. Scholars have identified color matching as a subjective process that is influenced by multiple factors [2,3,6] like the type and intensity of the examining light; the patient’s position with respect to the level of the examiner’s eyes, since there should be no eye fatigue; and the color of the surroundings [2,4].

All these factors should be considered for an accurate shade-matching procedure, and the careful attention and application of these precautions greatly affect the esthetic outcome of the prosthodontic treatment [7]. If the shade selected has been agreed on by both the patient and dentist and all the required steps have been carried out correctly, a proper shade that is compatible with the existing teeth will be the outcome, which has a great impact on patients’ satisfaction and acceptance of the prostheses [8].

Multiple methods for shade selection are used; visual assessment is one of the most used methods in which the dentist uses a shade guide [9,10]. A guide tab is one option that depends on the dentist’s experience and judgment [11]. Old photographs and old prostheses (as a reference) could be used to compare the shade and whether the patient likes it or not [12]. Nonetheless, this approach is subjective because it is influenced by factors such as age, gender, the experience level of the observer, visual fatigue, and the surrounding lighting conditions [3,5,10,13].

Digital devices are available to assist in the shade selection step, such as Vita Easy shade, SpectroShade, Olympus Crystaleye, and 3Shape [1,14]. Colorimeters are considered to be more objective than the shade guide [12]. Utilizing instrumental approaches for shade matching significantly diminishes the subjective discrepancies inherent in human perception of color [15]. Consequently, visual tooth color matching is often regarded as an inconsistent and unreliable technique due to a range of both subjective and objective influences [10,13].

To achieve accurate shade matching, dentists must provide detailed written instructions and ensure that impressions and casts are precise [12]. Moreover, mutual communication is emphasized as a cornerstone for successful outcomes in shade matching [2]. Studies indicate that when dental professionals fail to communicate effectively, it can compromise the quality of the shade match, ultimately affecting patient satisfaction [9]. Additionally, the lack of knowledge among dental students and practitioners in shade selection, along with inconsistent lab adherence to instructions, necessitate further studies on new technologies and practitioner awareness to fill this gap in the literature. Therefore, this questionnaire-based study aimed to assess the level of knowledge among dental students and practitioners and point out the areas of deficiencies requiring improvement. We hypothesized that no significant difference exists between students’ and practitioners’ knowledge and practice in shade selection

2. Materials and Methods

2.1. Participants

Eligible participants were dental students (undergraduate and post-graduate), general practitioners and faculty of the prosthodontic division working at the College of Dentistry at Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia.

2.2. Study Design

The questionnaire template used in a previous study was used with some modifications [16]. The content validity was checked by 2 experts in the prosthodontics field reviewing the questionnaire to assess the clarity and relevance of each question among a random sample that reflected our target groups. Feedback from this process led to minor adjustments, ensuring that all questions were accurate and easy to understand. Once the questionnaire’s effectiveness and clarity were confirmed, the prepared proposal was submitted to the research unit, college of Dentistry, IAU, to obtain ethical approval. The ethical approval was secured from the research ethics Committee at Imam Abdulrahman Bin Faisal University (IRB 2022-02-264).

2.3. Data Collection

An electronic survey was created using the QuestionPro survey tool (www.questionpro.com). A brief description was added at the beginning of the questionnaire to include the time needed to complete the questionnaire, and participants were assured of their anonymity and voluntary involvement. To ensure data integrity, each participant was allowed to submit only one electronic questionnaire, with all questions marked as mandatory. The required data was collected using the online questionnaire. For more survey validation, a pilot study was conducted in the beginning, in which 25 responses were collected. Cronbach’s Alpha value was computed for reliability purposes. The obtained coefficient of Cronbach’s Alpha was 0.869 which showed that the questionnaire was reliable for use. After survey validation, an online survey was prepared and distributed to dental students (4^th Year, 5^th Year, 6^th Year, interns, general practitioners (GP), prosthodontics residents, and prosthodontists). Email addresses of all eligible participants were obtained from the college administration and an electronic version of the survey was emailed along with the description of the study purpose. To maximize the response rate, reminder emails were sent weekly to non-respondents. The data collection period spanned one month, after which the survey was closed for analysis.

2.4. Questionnaire Interpretation

The questionnaire was designed to assess both knowledge and practice related to shade selection in dentistry, using a combination of yes/no questions and frequency-based responses (always, sometimes, never). The questionnaire questions were organized into two main categories: knowledge and practice. Knowledge questions (questions 1–12, 15–16, 35–48) assessed understanding of shade selection principles, awareness of tools, and key factors affecting shade matching, practice questions (questions 13–14, 17–34) focused on actual behaviors, such as routine use of second opinions, communication with labs, and addressing patient preferences. This categorization enabled a separate analysis of theoretical understanding versus practical application, highlighting strengths and areas for improvement in both knowledge and practice. Each question related to knowledge and practice had a correct/appropriate response. Hence, after collection of the responses from all study participants, their responses to each question were coded as “good” or “poor”. After that, the total number of “good” responses were counted for knowledge and practice for each participant and a score was generated.

2.5. Statistical Analysis

The Statistical Package for the Social Sciences (SPSS v.23) was employed to analyze data; for the descriptive data analysis, frequency distributions were calculated for the categorical variables. Mean and standard deviation were computed for knowledge and practice scores. The test’s significant results revealed that the data was not normally distributed. Hence, non-parametric tests were used for inferential analysis of the data. Mann–Whitney U test was used to study the difference between the two means. The Kruskal–Wallis test was used to study the difference between more than two means. All p-values less than 0.05 were considered statistically significant.

3. Results

3.1. Participants’ Responses

The study involved 565 participants who started the survey in which 117 started the questions about fixed treatment, 51 started those about removable prosthesis and 398 started questions about both fixed and removable cases. One hundred and six participants completed the fixed-related questions with a response rate of 91.4%, 45 participants completed the removable-related questions and hence the response rate was 88.2% and 354 completed questions related to both fixed and removable with the response rate of 88.9% (

Table 1. Questionnaire Results: Participants’ Knowledge and Practice Answers.

Knowledge and Awareness of Shade Selection		Always	Sometimes	Never
(1)	Do you use a visual method for shade selection?	78.22%	16.55%	5.23%
(2)	Do you use an instrumental method for shade selection?	27%	33.1%	39.9%
(3)	Does a second opinion during shade selection give a better result?	35.54%	59.41%	5.05%
(4)	Do you know the type of the shade guide used in your clinic?	68.64%	24.56%	6.79%
(5)	Does consideration of the patient’s opinion make a difference?	44.08%	52.09%	3.83%
Lighting and surrounding conditions		Always	Sometimes	Never
(6)	Does the use of a unit light during shade selection provide reliable results?	11.32%	28.57%	60.1%
(7)	Does the use of natural light during shade selection provide reliable results?	72.65%	24.22%	3.14%
(8)	Does the patient’s skin tone affect the shade selection?	62.2%	33.97%	3.83%
(9)	Does having patient’s mouth at the operator’s eye level during shade selection contribute to more precise results?	54.36%	41.99%	3.66%
(10)	Is consideration of the patient’s clothing during shade selection important	35.54%	42.33%	22.13%
(11)	Is the removal of lipstick before shade selection important?	69.69%	24.22%	6.10%
(12)	Is cleaning the teeth before shade selection important?	80.49%	16.38%	3.14%
(13)	If patients ask for a whiter color, would you consider the patients’ wishes?	26.66%	63.41%	9.93%
Shade matching after receiving lab work		Always	Sometimes	Never
(14)	Is the selected shade documented in the authorization form?	70.73%	25.44%	3.83%
(15)	Does the shade of the received prosthesis match the pre-selected shade?	37.11%	61.32%	1.57%
(16)	Is the patient satisfied with the selected shade?	62.89%	35.71%	1.39%
Complete denture patients		Yes	No
(17)	Do you select the size and shape of teeth?	57.14%	42.86%
(18)	Do you document the size and shape of teeth?	53.57%	46.43%
(19)	If no, are the received teeth of an improper size and/or shape	53.33%	46.67%
		Always	Sometimes	Never
(20)	If the denture set is not acceptable, do you return it to the lab for teeth set reselection and resetting?	51.85%	37.04%	11.11%
(21)	Do you change labs due to improper shade selection?	27.78%	55.56%	16.67%
(22)	Is there direct contact with the dental lab?	59.26%	35.19%	5.56%
(23)	If yes, does it contribute to better outcomes?	57.41%	37.04%	5.56%
Common teeth setting errors		Yes	No
(24)	Teeth resetting done based on wrong clinical procedures. (JR, mounting)	62.96%	37.04%
(25)	If no, teeth out of the ridge?	5.26%	94.74%
(26)	If yes, deviated midline?	59.38%	40.63%
(27)	If yes, high smile line?	46.88%	53.13%
(28)	If yes, improper occlusal plane?	68.75%	31.25%
(29)	Problems with shade selection are the responsibility of the dentist	75.51%	24.49%
(30)	Unacceptable prostheses shade is the responsibility of the dentist	55.10%	44.90%
(31)	Problems with teeth setting are the responsibility of the dentist	22.45%	77.55%
		Skin tone	Patients’ preference	Old dentures	Trial and error
(32)	What is your reference for shade selection for a complete denture?	46.81%	25.53%	21.28%	6.38%
		Always	Sometimes	Never
(33)	How accurately does the lab follow your requested shade?	48.94%	48.94%	2.13%
		Re-do		Proceed
(34)	What will you do if the teeth set up is perfect but the shade is not following your choice?	66.67%		33.33%
Fixed partial denture patients		Always	Sometimes	Never
(35)	Do you use natural daylight?	71.56%	22.94%	5.50%
(36)	Do you know the type of light in the clinic?	37.61%	41.28%	21.10%
(37)	Do you record the shade for different parts of the tooth?	47.71%	43.12%	9.17%
(38)	Do you ask the dental technician or assistant for a second opinion?	39.45%	50.46%	10.09%
(39)	If the shade is not acceptable, do you ask the dental technician to help?	47.71%	40.37%	11.93%
(40)	If the shade is not acceptable to you, but acceptable to the patient, do you proceed?	37.61%	48.62%	13.76%
(41)	Do you send clinical photos to the lab with the selected shade tab?	49.54%	38.53%	11.93%
(42)	Do you use the neighboring tooth as a guide?	58.72%	36.70%	4.59%
(43)	Do you use the contra-lateral tooth as a guide?	37.61%	51.38%	11.01%
(44)	Do you select the shade at the beginning, before tooth preparation?	68.81%	22.94%	8.26%
(45)	Do you select the shade of the prepared tooth after tooth preparation?	17.43%	33.03%	49.54%
(46)	Do you consider the cement shade in cementing all-ceramic restorations?	47.71%	42.20%	10.09%
(47)	Does sending the patient’s photographs to the lab reduce the common errors?	57.80%	34.86%	7.34%
(48)	Does using a digital shade guide reduce the common shade errors?	36.70%	52.29%	11.01%

). The number of correct responses with percentages for each question under knowledge and practice sections are summarized in the Appendix A,

Table A1. Number of Correct Responses for Each Question Concerning Treatment of Fixed Prosthesis Cases Only (n = 117).

Knowledge	Number	Percent
Do you use the visual method for shade selection?	108	92.3
Do you use the instrumental method for shade selection?	78	66.7
Does a second opinion during shade selection give a better result?	43	36.8
Do you know the type of shade guide used in your clinic?	84	71.8
Does the consideration of the patient’s opinion make a difference?	53	45.3
Does the use of a unit light during shade selection provide reliable results?	71	60.7
Does the use of natural light during shade selection provide reliable results?	85	72.6
Does the patient’s skin tone affect the shade selection?	71	60.7
Does having the patient’s mouth at the operator’s eye level during shade selection contribute to more precise results?	62	53.0
Is the consideration of the patient’s clothing during shade selection important?	32	27.4
Is the removal of lipstick before shade selection important?	70	59.8
Is cleaning the teeth before shade selection important?	92	78.6
Does the shade of the received prosthesis match the pre-selected shade?	55	47.0
Is the patient satisfied with the selected shade?	71	60.7
Practice
Do you use natural daylight?	75	64.1
Do you know the type of light in the clinic?	39	33.3
Do you record the shade for different parts of the tooth?	96	82.1
Do you ask a dental technician or assistant for a second opinion?	55	47.0
If the shade is unacceptable, do you ask the dental technician to help?	44	37.6
If the shade is not acceptable to you, but it is acceptable to the patient, do you proceed?	53	45.3
Do you send clinical photos to the lab using the selected shade tab?	41	35.0
Do you use the neighboring tooth as a guide?	62	53.0
Do you use the contra-lateral tooth as a guide?	38	32.5
Do you select the shade at the beginning before tooth preparation?	72	61.5
Do you select the shade of the prepared tooth after tooth preparation?	17	14.5
Do you consider the cement shade in cementing all-ceramic restorations?	45	38.5
Does sending patients’ photographs to the lab to reduce the common errors?	60	51.3
Does using a digital shade guide to reduce common shade errors?	94	80.3
If patients ask for a whiter color, do you consider the patient’s wishes?	73	62.4
Is the selected shade documented in the authorization form?	85	72.6

,

Table A2. Number of Correct Responses for Each Question for Treatment of Removable Prosthesis Cases Only (n = 51).

Knowledge	Number	Percent
Do you use the visual method for shade selection?	49	96.1
Do you use the instrumental method for shade selection?	44	86.3
Does a second opinion during shade selection give a better result?	13	25.5
Do you know the type of shade guide used in your clinic?	22	43.1
Does the consideration of the patient’s opinion make a difference?	19	37.3
Does the use of a unit light during shade selection provide reliable results?	20	39.2
Does the use of natural light during shade selection provide reliable results?	22	43.1
Does the patient’s skin tone affect the shade selection?	34	66.7
Does having the patient’s mouth at the operator’s eye level during shade selection contribute to more precise results?	21	41.2
Is consideration of the patient’s clothing during shade selection important?	17	33.3
Is the removal of lipstick before shade selection important?	25	49.0
Is cleaning the teeth before shade selection important?	33	64.7
Does the shade of the received prosthesis match the pre-selected shade?	21	41.2
Is the patient satisfied with the selected shade?	33	64.7
Practice	Number	Percent
If patients ask for a whiter color, do you consider the patient’s desire?	27	52.9
Is the selected shade documented in the authorization form?	28	54.9
Do you select the size and shape of teeth?	27	52.9
Do you document the size and shape of teeth?	27	52.9
If no, are the received teeth of improper size and/or shape	15	29.4
If the case is unacceptable, do you return the case to the lab for teeth set selection and resetting?	24	47.1
Do you change labs due to improper shade selection?	11	21.6
Is there direct contact with the dental lab?	18	35.3
If yes, does it contribute to better outcomes?	27	52.9
Was teeth resetting carried out based on the wrong clinical procedures? (JR, mounting)	48	94.1
Teeth out of the ridge?	17	33.3
Deviated midline?	28	54.9
High smile line?	28	54.9
Improper occlusal plane?	28	54.9
Problems with shade selection are the responsibility of the dentist	33	64.7
Unacceptable prosthesis shade is the responsibility of the dentist	19	37.3
Problems with teeth setting are the responsibility of the dentist	36	70.6
What is your reference for shade selection for complete dentures?	32	62.7
How accurately does the lab follow your requested shade?	21	41.2
What will you do if the teeth setup is perfect but the shade is not according to your choice?	28	54.9

and

Table A3. Number of Correct Responses for Each Question for Both Fixed and Removable Treatments (n = 398).

Knowledge	Number	Percent
Do you use the visual method for shade selection?	378	95.0
Do you use the instrumental method for shade selection?	290	72.9
Does a second opinion during shade selection give a better result?	144	36.2
Do you know the type of shade guide used in your clinic?	285	71.6
Does consideration of the patient’s opinion make a difference?	178	44.7
Does the use of a unit light during shade selection provide reliable results?	248	62.3
Does the use of natural light during shade selection provide reliable results?	304	76.4
Does the patient’s skin tone affect the shade selection?	247	62.1
Does having the patient’s mouth at the operator’s eye level during shade selection contribute to more precise results?	226	56.8
Is consideration of the patient’s clothing during shade selection important?	151	37.9
Is the removal of lipstick before shade selection important?	297	74.6
Is cleaning the teeth before shade selection important?	330	82.9
Does the shade of the received prosthesis match the pre-selected shade?	134	33.7
Is the patient satisfied with the selected shade?	252	63.3
Does sending patients’ photographs to the lab reduce common errors?	166	41.7
Does using a digital shade guide reduce common shade errors?	224	56.3
What is your reference for shade selection for complete dentures?	314	78.9
Problems with shade selection are the responsibility of the dentist	123	30.9
Unacceptable prosthesis shade is the responsibility of the dentist	65	16.3
Problems with teeth setting are the responsibility of the dentist	140	35.2
Practice	Number	Percent
If patients ask for a whiter color, do you consider the patient’s wishes?	261	65.6
Is the selected shade documented in the authorization form?	287	72.1
Do you use natural daylight?	189	47.5
Do you know the type of light in the clinic?	152	38.2
Do you record the shades for different parts of the tooth?	330	82.9
Do you ask a dental technician or assistant for a second opinion?	210	52.8
If the shade is not acceptable, do you ask the dental technician to help?	170	42.7
If the shade is not acceptable to you, but it is acceptable to the patient, do you proceed?	228	57.3
Do you send clinical photos to the lab using the selected shade tab?	58	14.6
Do you use the neighboring tooth as a guide?	224	56.3
Do you use the contra-lateral tooth as a guide?	121	30.4
Do you select the shade at the beginning before tooth preparation?	198	49.7
Do you select the shade of the prepared tooth after tooth preparation?	72	18.1
Do you consider the cement shade in cementing all-ceramic restorations?	140	35.2
Do you select the size and shape of teeth?	273	68.6
Do you document the size and shape of teeth?	231	58.0
If no, are the received teeth of improper size and/or shape	91	22.9
If the received prosthesis is not acceptable, do you return it to the lab for teeth set selection and resetting?	253	63.6
Do you change labs due to improper shade selection?	88	22.1
Is there direct contact with the dental lab?	82	20.6
If yes, does it contribute to better outcomes?	259	65.1
Was teeth resetting carried out based on the wrong clinical procedures? (JR, mounting)	221	55.5
Teeth out of the ridge?	68	17.1
Deviated midline?	165	41.5
High smile line?	152	38.2
Improper occlusal plane?	192	48.2
How accurately does the lab follow your requested shade?	105	26.4
What will you do if the teeth setup is perfect but the shade is not according to your choice?	240	60.3

.

3.2. Data of Participants Treated Fixed Prosthetic Cases

Data for participants who treated fixed prosthetic cases are summarized in

Table 2. Analysis of data of participants who treated fixed prosthodontic cases.

Variables		Frequency	Percent
Age	20–24	27	25.5
	25–34	71	67.0
	35–44	7	6.6
	45–54	0	0
	55–64	0	0
	over 64	1	0.9
	Total	106	100.0
Gender	Male	72	67.9
	female	34	32.1
	Total	106	100.0
Level of education	student	13	12.3
	intern	28	26.4
	GP	48	45.3
	postgraduate	11	10.4
	prosthodontist	6	5.7
	total	106	100.0

and

Table 3. Relationship between knowledge and practice scores with the demographic variables for participants treated fixed prosthodontic cases.

Variable	Knowledge Mean (SD)	p-Value	Practice Mean (SD)	p-Value
Age
20–24	8.96 (2.2)	0.148	10.1 (1.94)	0.702
25–34	8.25 (2.67)		9.72 (2.14)
35–44	7.0 (2.0)		9.57 (1.5)
Over 64	3.0 (0)		9.0 (0)
Gender
Male	8.07 (2.56)	0.146	9.76 (2.15)	0.926
Female	8.79 (2.61)		9.88 (1.82)
Level of education/work
Student	7.61 (3.01)	0.094	9.31 (2.3)	0.505
Intern	9.07 (2.2)		10.1 (1.58)
GP	8.1 (2.6)		9.79 (2.4)
Postgraduate	9.18 (2.4)		10.1 (1.3)
Prosthodontist	6.17 (2.2)		9.17.(1.16)

. Table 2 shows the age, gender, and distribution of the participants who treated fixed prosthetic cases. Most of the participants were 25–34 (67%) years old and there were more participant GPs (45.3%). The mean knowledge and practice scores obtained by a respondent 8.2 (±2.6) and 9.8 (±2.0), respectively. Table 3, for participants who treated fixed cases, shows no significant differences in the average knowledge and practice found when compared with age (p = 0.14, p = 0.702), gender (p = 0.146, p = 0.926), and education/work level of the participants (p = 0.094, p = 0.505).

3.3. Data for Participants Treated Removable Prosthetic Cases

The data for participants treated removable denture cases are summarized in

Table 4. Analysis of data of participants treated removable prosthodontic cases.

Variables		Frequency	Percent
Age	20–24	40	80.0
	25–34	2	4.0
	35–44	5	10.0
	45-54	0	0
	55–64	1	2.0
	over 64	2	4.0
	Total	50	100.0
Gender	Male	24	48.0
	female	26	52.0
	Total	50	100.0
Level of education	student	40	80.0
	intern	1	2.0
	GP	1	2.0
	prosthodontist	8	16.0
	total	50	100.0

and

Table 5. Relationship between knowledge and practice scores with the demographic variables for participants treated removable prosthodontic cases.

Variable	Knowledge Mean (SD)	p-Value	Practice Mean (SD)	p-Value
Age
20–24	7.2 (2.78)	0.452	10.35 (3.3)	0.063
25–34	7.5 (0.71)		13.5 (0.71)
35–44	6.4 (1.34)		9.4 (3.6)
55-64	8.0 (0)		4.0 (0)
Over 64	8.0 (0)		13.5 (0.71)
Gender
Male		0.653		0.451
Female	7.42 (2.58)		10.41 (3.78)
Level of education/work
Student		0.734		0.839
Intern	7.2 (2.78)		10.35 (3.3)
GP	7.0 (0)		14.0 (0)
Postgraduate	8.0 (0)		13.0 (0)
Prosthodontist	7.6 (2.26)		9.75 (4.1)

. The highest proportion of the participants (80%) were in the age range of 20–24 years, with an almost equal number of male and female respondents. However, 80% of the participants were students who filled in the removable denture questions. The average knowledge and practice score for a respondent was found to be 7.3 (±2.6) and 10.4 (±3.4), respectively. Table 5 showed no significant differences in the average knowledge and practice found when compared with the age, gender, and education/work level of the participants.

3.4. Fixed and Removable Treat Cases

For participants treated both fixed and removable cases,

Table 6. Analysis of data of participants treated both fixed and removable cases.

Variables		Frequency	Percent
Age	20–24	239	60.1
	25–34	135	33.9
	35–44	20	5.0
	45-54	3	0.8
	55–64	1	0.3
	over 64	0	0
	Total	398	100.0
Gender	Male	226	56.8
	female	172	43.2
	total	398	100.0
Level of education	student	196	49.2
	intern	66	16.6
	GP	78	19.6
	postgraduate	29	7.3
	prosthodontist	29	7.3
	total	398	100.0

summarizes the age, gender, and level of education of the respondents. Most of the participants (60.1%) were 20–24 years old, while the proportion of males was slightly higher than that of females. The mean knowledge and practice scores were 12.2 (±2.9) and 11.9 (±4.3), respectively.

3.5. Knowledge and Practice Scores in Relation to Characteristics

According to

Table 7. Relationship between knowledge and practice scores with the demographic variables for participants treated in both fixed and removable prosthodontic cases.

Variable	Knowledge Mean (SD)	p-Value	Practice Mean (SD)	p-Value
Age
20–24	12.06 (2.9)	0.921	11.54 (4.2) a	0.041 *
25–34	12.24 (2.9)		12.28 (4.4) a
35–44	12.4 (2.5)		12.3 (5.0)
45–54	12.33 (3.5)		12.67 (2.5)
55–64	16.0 (0)		17.0 (0)
Gender
Male	11.91 (2.79)	0.039 *	12.23 (4.3)	0.015 *
Female	12.46 (3.0)		11.36 (4.2)
Level of education/work
Student	11.82 (2.9)a	0.028 *	11.26 (4.3) a,b	0.004 *
Intern	12.94 (2.5)a		12.56 (3.3) a
GP	11.94 (3.0)		12.56 (4.5) b
Postgraduate	12.48 (3.1)		11.93 (4.3)
Prosthodontist	12.86 (2.6)		12.34 (5.0)

* Statistically significant at 0.05 level of significance. Same lowercase alphabets per column showed significant difference.

, the average knowledge scores of the participants were analyzed with their demographic characteristics. It was found that the average knowledge score for the females was significantly high compared to the males (p = 0.039). In addition, education level/work also had a significant effect on the knowledge score, and hence, a significant variation in the score was observed (p = 0.028). The pairwise comparison highlighted that the knowledge scores for students and interns were significantly different, with interns having higher scores (p = 0.028) (p < 0.05). Similarly, the practice score was also analyzed with the demographic variables and a significant association between age, gender, and education level/work (Table 7) was found. The practice score was found to be significantly different between the age groups 20–24 and 25–34 (p < 0.05). In addition, the average practice score was found to be significantly higher for males compared to females (p = 0.015). The variation in the practice score caused by the level of education was also found to be highly significant (p = 0.004). The pairwise comparison provided the pairs (students vs. interns) and (students vs. GPs) had significantly different practice scores (p < 0.05).

4. Discussion

The null hypothesis was partially rejected as participants who treated either fixed or removable cases separately (when investigated separately) showed no significant differences between participants in terms of knowledge and practice of shade selection. Participants who treated both fixed and removable cases showed significant differences in terms of knowledge and practice of shade selection. When comparing age, gender, and education/work level, there were no significant differences observed in knowledge and practice scores between the participants who treated fixed and removable cases (when investigated separately).

However, in the combined part, female participants exhibited higher average knowledge scores than males, while males had higher average practice scores than females. Regarding the education/work level, interns demonstrated a higher average knowledge score compared to students and GPs. At the same time, the GP and interns demonstrated higher average practice scores compared to students. Moreover, the (25–34) age group outperformed the (20–24) age group in practice scores.

The distribution of participants between shade selection in removable and fixed cases separately may be due to the decrease in sample size (n = 106 fixed; n = 50 removable), in addition to the level of education of most participants in both fixed (48 GPs, 28 interns) and removable (40 students) cases. This distribution between participants could be a reason for the non-significance between closed levels in terms of both knowledge and practice of shade selection.

The main drawback for the participants who treated both fixed and removable cases in the knowledge sections was the variation in the educational level of the participants, ranging from undergraduates to specialists. Moreover, in the practice section, some participants might be more experienced in one field of prosthodontics than the other, thus affecting their overall score. So, our recommendation is to have equal numbers of participants in each section to be able to standardize the results.

For participants treated in both fixed and removable cases, there was a variation in results, and there was a correlation between demographic data and knowledge and practice. There was no significance in the knowledge scores for all ages. That means the age of the participants has no significant effect as they gain knowledge and improve this knowledge through continuous education. On the other side, the age group between 20–24 showed the lowest practice score and was significant with the other age groups. This is expected as old age has more expertise and practice than students and freshly graduated students. This finding is in agreement with Habib’s study that practitioners who had more clinical training and work experience had a better understanding of the significance and techniques of the shade-selection process [16]. Clinical experience has not been identified as a significant contributor to the accuracy of shade matching. However, understanding the physical properties of color is considered one of the key factors influencing visual shade selection [7]. The appearance and color of teeth are a common concern for patients across many populations [17]. Some shades yield a more consistent and valid match than others [17]. The significance of color appearance in the aesthetics of dental restorations emphasizes the necessity for precise, high-quality shade matching [18]. Color appearance is a crucial factor in patient acceptance of dental restorations [17]. Additionally, the aesthetic expectations of both patients and dental professionals have heightened the importance of accurate shade selection [18]. The combination of lighting conditions, along with education and training, enhances the quality of shade matching [11]. Furthermore, human color perception is dependent on physiological processes, where emitted electrical signals are processed and interpreted by the brain [19]. These signals are generated by various cells that are sensitive to specific ranges of the light spectrum [19]. However, visual color perception can be influenced by subjective factors, such as eye fatigue and age, as well as environmental elements like surroundings, lighting conditions, and the phenomenon of metamerism, all of which can introduce potential sources of error [19,20]. The implementation of color measurement devices may enhance the quality of shade-matching expertise among dental professionals [6]. Despite meticulous shade selection, challenges with color matching can still arise in definitive restorations [21].

The variations between dental practitioners’ levels of experience require further investigation to overcome errors in clinical outcomes in terms of esthetic concern.

Gender showed some variations in both knowledge and practice between males and females. Females showed high scores in knowledge even with a high number of male participants, and this may be due to more care taken in studying in comparison to males (Table 7). However, a previous study showed that the shade selection of both genders, men and women, did not differ statistically [22]. This discrepancy could be due to utilizing different assessment methods. For instance, our assessment is a questionnaire, while Curd’s study used a practical approach. On the other side, males show higher scores in practice than females, and this may be attributed to the difference in participant numbers, male > female, in addition to more practice for males (Table 7). In agreement with previous studies, males had a smaller number of mistakes, needed significantly less time to complete the final test, and achieved significantly higher scores than females [23].

Based on the findings of the present study, the knowledge and practice regarding shade selection are affected by the level of education. The low knowledge of students is expected due to the early exposure to shade selection and its effect on prosthetic outcomes [24,25]. The increased score for an intern, in terms of knowledge, may be attributed to continuous education and the workshops during the intern program, which resulted in increased scores for Postgraduate and prosthodontists as well. GP knowledge score may be attributed to that acquired after-graduation time with different specialty interests.

Practice, when linked to education level, showed the same behavior as knowledge in the fixed and removable treatment cases separately; while in the combined treatment cases, the level of education had a significant impact on knowledge and practice. A previous study indicated that the experience of participants did not affect the accuracy of shade matching [11]. Another study concluded that skill and knowledge, respectively, were the most essential factors for shade selection [10]. Moreover, it was found that there is a strong correlation between clinical experience and shade-matching accuracy [25].

One of the primary expectations for both dentists and patients is achieving aesthetic restorations that resemble natural teeth [26]. To meet patients’ demands, precise shade selection is essential [7,26]. Choosing the appropriate tooth shade is a challenging task that critically influences the aesthetic outcomes of restorative treatments [15]. According to the current literature, digital techniques demonstrated greater precision than conventional ones [15]. Moreover, digital technology presents a precise method for tooth color matching via enhanced communication with laboratory personnel [14]. Furthermore, long-term aesthetic outcomes are influenced by external factors, such as staining from coffee, as explored in a previous study conducted by Al-Ahmary. This study highlights how coffee staining impacts the physical, optical, and mechanical properties of ceramics, stressing the importance of initial shade selection as well as durability over time. This aligns with our study’s focus on accurate, enduring shade selection [27].

Nevertheless, further refinement of digital methods is necessary to achieve optimal shade-matching outcomes [15]. Instrumental methods demonstrate significant potential for further research and are well-suited for long-term observational studies [14]. Digital shade-matching devices have gained significant prominence in the field of dentistry [3]. Among these, spectrophotometers and colorimeters are the most extensively employed instruments [7]. However, a major drawback of digital shade selection devices is their high cost [26]. Despite certain limitations, the color analysis of digital photographs offers promising applications for shade matching in dentistry [14]. A previous study showed that the recent methods involving intraoral scanners were less reliable than spectrophotometers and visual shade matching [28]. On the other hand, another study proved that the digital shade selection techniques could provide more successful clinical results [26]. This variation might be as a result of using different equipment models such as newer versus older intraoral scanners. All shade selection methods were practical, depending on the individual participant and their experience and level of education [11]. However, digital methods should be considered for shade selection as it might reduce errors [15]. It was found in a previous study that spectrophotometric analysis resulted in a more accurate shade matching compared to traditional methods [7]. The awareness of all participants, in general, about the knowledge and practice of new technology for shade selection was noticeably high. A study showed that the students had high awareness regarding digital shade-matching devices [29]. There were three questions concerning digital shade matching in this survey.

The responses to Q1 and Q2 indicated a strong understanding and practice of digital technology for shade selection among participants. With 72.78% correctly identifying the use of instrumental methods and 92.6% acknowledging that digital shade guides reduce errors, it is clear that most participants are familiar with and supportive of using digital tools for accurate shade selection.

Based on the findings of this study, when comparing age, gender, and education/work level, there were no significant differences observed in the knowledge and practice scores in the fixed and removable parts. However, in the combined part, female participants exhibited higher average knowledge scores than males, while males had higher average practice scores than females. Regarding the education/work level, interns demonstrated a higher average knowledge score compared to students and GPs. At the same time, the GP and interns demonstrated higher average practice scores compared to students. Moreover, the (25–34) age group outperformed the (20–24) age group in practice scores (Table 7).

Clinically, the findings of this study demonstrate a positive correlation between the examiner’s educational level and clinical shade-matching experience, and their knowledge of shade selection principles. Higher levels of education and experience were associated with more effective implementation of fundamental shade-selection principles, resulting in more consistent and accurate shade-matching procedures. Additionally, the study findings emphasize the importance of comprehensive theoretical education and practical training for dental students in shade-matching principles and procedures. Consequently, this enhanced educational focus will translate into clinical practice, leading to the production of more aesthetically satisfying prosthodontic treatments.

One of the primary limitations of this research is its reliance on survey-based data collection, which often depends on self-reported data and can introduce biases such as sampling and response biases. Additionally, surveys may not capture the full depth and complexity of participants’ perspectives. Moreover, the study was conducted with a relatively small sample size, limiting the generalizability of the findings. Furthermore, the distribution of the survey was limited, potentially restricting the diversity of the participants. To increase the scientific strength of future studies, it would be advantageous to include a larger, more representative sample with a broader demographic distribution to capture a wider range of perspectives. Employing a mixed-methods approach, combining surveys with interviews, could provide more comprehensive insights into participant experiences and help avoid potential biases. The students should be exposed to and trained to use contemporary shade-matching techniques. By addressing these gaps, we can assist dental professionals in delivering high-quality shade-matching prostheses.

5. Conclusions

With the limitations of this questionnaire-based study, it could be concluded that:

The age, gender, and level of education have an impact on both the knowledge and practice of shade selection and matching. The higher the examiner’s educational level and shade-matching experience, the more knowledge regarding the shade-selection principles through the implementation of the basic principles and, hence, achieving a more consistent and accurate shade-selection procedure. This is important for achieving high patient satisfaction in prosthodontics treatments. While students have a lower level of consistency and accuracy in the shade-selection procedure, this should be considered in planning the curriculum for teaching the esthetic topic, with more emphasis on the basic principles and modern techniques for shade matching as well as practical training.