|Year : 2016 | Volume
| Issue : 2 | Page : 72-78
Nigerian dental students' permissive tendency to the proposed organized incorporation of stem cells application into dental curriculum: A cross-sectional study
Matthew A Sede1, Ochuwa Audu2, Clement Chinedu Azodo3
1 Department of Restorative Dentistry, University of Benin, Benin City, Nigeria
2 Department of Restorative Dentistry, University of Benin Teaching Hospital, Benin City, Nigeria
3 Department of Periodontics, University of Benin, Benin City, Nigeria
|Date of Web Publication||13-Oct-2016|
Clement Chinedu Azodo
Department of Periodontics, University of Benin Teaching Hospital, Room 21, 2nd Floor, Prof. A. O. Ejide Dental Complex,
Source of Support: None, Conflict of Interest: None
Aim: This study aims to examine the Nigerian dental students' permissive tendency to the proposed organized incorporation of stem cells application into undergraduate and postgraduate dental curriculum.
Materials and Methods: This cross-sectional study of Nigerian final year dental students was conducted between April and June 2014 using the modified Sede et al. questionnaire on stem cell use in dentistry knowledge and attitude questionnaire as the data collection tool.
Results: Of the 110 participants, 63.6% reported awareness of stem cell use in dentistry with their leading information sources as school lecture and internet. Subjective and objective stem cell knowledge assessment revealed inadequate knowledge among the majority of the participants. Subjective knowledge emerged as the significant determinant of objective stem cell knowledge. About a third (32.7%) of the participants reported a positive attitude toward stem cell application and objective stem cell knowledge was the only significant determinant of attitude. The majority (82.7%) of the participants reported a positive permissive tendency to the proposed organized incorporation of stem cells application into undergraduate, and postgraduate dental curriculum and attitude toward stem cell emerged as the only significant determinant.
Conclusion: High positive permissive tendency to the proposed organized incorporation of stem cell application into undergraduate and postgraduate dental curriculum was noted among the participants. Increasing stem cell knowledge will improve attitude toward stem cell use which will ultimately increase positive permissive tendency.
Keywords: Awareness, curriculum, dental students, knowledge attitude, permissive tendency, stem cell
|How to cite this article:|
Sede MA, Audu O, Azodo CC. Nigerian dental students' permissive tendency to the proposed organized incorporation of stem cells application into dental curriculum: A cross-sectional study. J Oral Res Rev 2016;8:72-8
|How to cite this URL:|
Sede MA, Audu O, Azodo CC. Nigerian dental students' permissive tendency to the proposed organized incorporation of stem cells application into dental curriculum: A cross-sectional study. J Oral Res Rev [serial online] 2016 [cited 2019 Feb 15];8:72-8. Available from: http://www.jorr.org/text.asp?2016/8/2/72/192214
| Introduction|| |
Stem cells regarded as the "building blocks" of the body are unspecialized cells with the self-renewal ability and the potential to undergo differentiation in response to appropriate signals. ,,, These differentiations can be into any tissue (totipotent), several types of tissues (pluripotent and multipotent), or one type of tissue (unipotent). 
Stem cells are categorized into embryonic and adult (postnatal, somatic) stem cells.  The embryonic type is the cells contained within the inner cell mass of the blastocyst stage of the embryo which are the most primitive and undifferentiated stem cells with totipotent characteristics, and potential to form ALL somatic tissues. , However, they are not capable of forming all the other "extraembryonic" tissues and by implication cannot give rise to a whole new individual.  The embryonic stem cells can either remain in this "embryonic" state or proceed to differentiate along specific lineages of endoderm, mesoderm, and ectoderm which ultimately gives rise to adult stem cells. The adult stem cells, on the other hand, are the undifferentiated cells that are found in specialized tissues of the fetus and most adult tissues after birth. , The proliferative and differentiation capacity of adult stem cells is thought to become more restricted as specific organ systems are formed.  However, a recent study found adult stem cells displaying unexpected plasticity which is also known as transdifferentiation, the process by which stem cells derived from one type of tissue differentiate into cells related to other tissue types, at least in vitro. 
Stem cell research has increased dramatically in recent years as their potential applications have become better understood.  Consequently, modern therapeutic modalities for some diseases are taking advantage of the regenerative capabilities of stem cells and clinical trials have begun to test the safety and efficacy of embryonic stem cell-derived transplants. , However, hurdles confronting embryonic stem cell research includes the ability of these cells to cause transplant rejection and produce teratomas or malignant carcinomas due to their limitless proliferative capacity. , The others include the objection on philosophical, moral or religious grounds, and expressed concerns about eventual cloning of entire human beings using embryonic stem cells. ,,,, Adult stem cells are not subject to the ethical controversy associated with embryonic stem cells. They can also be isolated from the patient being treated, hence are currently believed to reduce the chances of being rejected after transplantation. 
In dental research and therapeutics, adult stem cells are the preferred cell source. Dental stem cells (DSCs) are therefore adult stem cells which have the capacity to generate arrays of cell and tissue types in vitro, and they include odontoblasts, adipocytes, osteoblasts, cartilage, bone, smooth, and skeletal muscle. ,, In the oral cavity, DSCs have been isolated from different soft tissues such as the apical papilla, dental follicle, periodontal ligament, pulp of third molars, and stem cells from human exfoliated deciduous teeth. ,,,, DSCs are viable and easily accessible sources of stem cells, and current research is exploring their capability to differentiate into dental and nondental tissues. DSC research targets the regeneration of damaged coronal dentin and pulp, regeneration of resorbed root(s), repair of perforations, periodontal regeneration, repair, and replacement of bone in craniofacial defects and whole tooth regeneration. 
Theoretically, stem cell-based therapies in dentistry seem set to be the long-awaited panacea for most dental maladies, including those considered incurable. However, the future of stem cell use in dentistry is still beset with challenges. Several barriers still exist which must be addressed before translating laboratory results to successful clinical applications in dentistry.  Technical difficulties such as limited knowledge of the precise molecular mechanisms that dictate the differentiation and functions of stem cells and how to control these biological mechanisms, coupled with problems obtaining these cells in sufficient quantities in vitro; are some identified issues.  The others are awareness, knowledge, acceptability, and willingness to utilize this form of therapy among dentists. A survey conducted in the United States of America found that dental residents were supportive of using regenerative endodontic procedures (REPs) but indicated the need for more evidence for the effectiveness and safety of regenerative treatments before their recommending such for patients.  Another United States-based survey to determine opinion about the use of regenerative endodontics among endodontists revealed a supportive and optimistic stance toward the future use of REPs as 57.1% of them would recommend stem cell treatments and REPs to their patients.  A similar survey among Indian Dentists found that the 86.6% of the participants had permissive opinion toward the incorporation of regenerative therapy into dentistry.  In Nigeria, a study found that dentists were supportive of stem cell use in dentistry, although their knowledge levels about this emerging field were low.  This study also revealed that undergraduate education constituted the source of information on stem cell use in dentistry in less than a quarter of the participants.  Little is known about the knowledge and attitude of stem cell use in dentistry among dental students in Nigeria and worldwide as available studies were conducted among dentists of generalist, resident, or specialist categories.
The objective of the study was to examine the permissive tendency of Nigerian dental students to the proposed organized incorporation of stem cells application into undergraduate and postgraduate dental curriculum.
| Materials and Methods|| |
Nigeria, which is an English-speaking West African country, is administratively constituted into 36 States and a Federal Capital Territory. It is also divided into 6 geopolitical zones. Dentistry is studied in 8 federal-owned and 1 state-owned universities in Nigeria. Two of Federal-owned dental schools are located in South-South geopolitical zone, 1 Southeast geopolitical zone, 1 Northwest geopolitical zone, 1 Northeast geopolitical zone while 3 federal-owned, and 1 state-owned dental schools are located in the Southwest geopolitical zone.
The protocol was reviewed and approval granted by the Research and Ethics Committee of University of Benin Teaching Hospital in Nigeria. Written informed consent was obtained from participants. Participation in the study was voluntary, and no incentive was offered.
This cross-sectional study of Nigerian final year dental students was conducted using a validated self-administered questionnaire as data collection tool.
Initially, the seven Federal-owned dental schools which have previously graduated dentists and had final year dental students were included in the study. However, one of the dental schools located in the Northeast geopolitical zone was finally excluded from the study because of security challenges posed by terrorism and insurgency in that region of the country. All the final year dental students of the selected dental school were included because of their small numbers. However, students that were unwilling to participate and did not give informed consent or were absent during the study for any reason were excluded from the study.
Data collection tool
The questionnaire was a modification of previously used questionnaire by Sede et al.  to investigate knowledge and attitude in relation to stem cells in dentistry among Nigerian dentists. This modified questionnaire was pretested and validated among ten final year dental students whose set were not included in the study just before their graduation.
The first four questions here dealt with sociodemographic variables which included age, gender, religion, and dental school. The next six questions assessed awareness of stem cell use. The awareness of stem cell use assessment was based on if the participants had ever heard of the stem cell use. Those that had positive answer were further queried on their last exposure to information on stem cell generally and in dentistry, their source(s) of information and self-rating of their extent of knowledge. This subjective knowledge rating as nothing, little, moderate, and a lot was categorized into inadequate (by grouping nothing and little together) and adequate (by group moderate and a lot together) subjective knowledge.
The subsequent eight questions were used to assess the general knowledge of stem cells: Their characteristics, types, differentiation potentials, general sources, dental sources, and potential uses in dentistry. One question was included to elicit the knowledge of ethical and political controversies concerning embryonic stem cell use, and another was used to assess the knowledge of DSCs collection and preservation for future use. All questions in this section were close ended, contained I do not know as one of the response options and had instructions for participants to select answers, as appropriate. The objective knowledge was dichotomized into adequate and inadequate objective knowledge for the purpose of binary regression statistics. The inadequate knowledge was scores 0-10 while adequate knowledge was scores 11-30.
Thirteen items with a four-point Likert scale ("strongly agree," "agree," "disagree," and "strongly disagree") was used to assess the attitude of participants toward stem cells use in dentistry. These items dealt on the controversial and sensitive issues surrounding stem cell collection, utilization, and human cloning. These issues revolved around ethics, morality and the moral status of the embryo, religion, motives, trust, and fear. The negative opinions were intermingled with the positive ones, to give room for a wide range of attitudes to be expressed. Scoring for each question was a maximum score of 4 and minimum score of 1 giving a cumulative minimum score of 13 and maximum score of 52. The cutoff for positive attitude was set at the minimal cumulative score of strongly agree and agree which was 34. A score of 13-33 indicated an overall negative attitude while a score of 34-52 indicated an overall positive attitude to stem cell research and therapy. The last item assessed the permissive tendency of the participants to the proposed organized incorporation of stem cells application into undergraduate and postgraduate dental curriculum on a four-point Likert scale of "strongly disagree" "disagree," "agree," " strongly agree," and "scored from one to four. Scoring for the question on permissive tendency was a maximum score of 4 and minimum score of 1. The cut off for positive permissive tendency was set at the minimal cumulative score of strongly agree and agree which was 3. The scores of 3 and 4 were considered as positive permissive tendency while scores 1 and 2 were considered as negative permissive tendency.
Data collection procedure
The questionnaires were distributed in each of the studied dental school during a regular class session, and the filled questionnaires collected were collected at the end of the class.
Data from questionnaires were manually scored and graded, coded and finally entered into Statistical Package for Social Sciences (SPSS) version 17.0 (Chicago, IL) for data analysis. Age of the participants was categorized into ≥25 years and <25 years while the location of school was categorized into Southwest (Lagos, Ibadan, and Ile-Ife) and non-Southwest (Benin, Port Harcourt, and Enugu) for the purpose of data analysis. A total of thirteen questions measured attitude to stem cell use in the questionnaire. Data collected was subjected to descriptive and inferential statistics to generate frequencies, percentages, and Chi-square values at a significance of P < 0.05. Binary logistic regression was performed on the collated data to ascertain the determinants of the permissive tendency of the participants on the proposed organized incorporation of stem cells application into undergraduate and postgraduate dental curriculum with demographic characteristics, awareness, subjective knowledge, objective knowledge, and attitude toward stem cell application in dentistry as independent variables.
| Results|| |
Of the 140 questionnaires distributed, 122 of them were returned giving an 87.1% retrieval rate. Of these 122 returned questionnaires, 12 of them were incompletely filled and were voided. This left a total of 110 returned usable questionnaires for the final analysis in this study. More than half of the participants were aged 25 years and above. Males constituted 56 (50.9%) of the participants, and 54 (49.1%) were females. The majority of the studied participants were from dental schools in the Southwest geopolitical zone (Ile-Ife [21.8%] Lagos [19.1%], Ibadan [17.3%]), others were from the South-South geopolitical zone (Benin 24.5%, Port Harcourt 10.0%), and Southeast 8 (7.3%). Of the participants, 63.6% reported having heard of stem cell use in dentistry. Male participants (73.2%) reported significantly higher awareness than the female participants (53.7%) (P = 0.032). Male participants significantly reported journals, books, and internet as their sources of information than the female participants [Table 1]. The awareness about stem cell in general (41.4%), dentistry (44.3), and their specific uses in dentistry (34.3%) was mainly more than 1 year but <2 years [Table 2]. Based on subjective knowledge assessment, the majority (75.5%) reported inadequate knowledge about stem cell while 18.2% reported adequate knowledge based on objective knowledge assessment. About a third (32.7%) of the participants reported positive attitude toward stem cell application. The majority (82.7%) of the participants reported positive permissive tendency to the proposed organized incorporation of stem cells application into undergraduate and postgraduate dental curriculum [Table 3]. Participants in Dental School in the Southwest geopolitical zone of Nigeria (P = 0.007) and participants that had an adequate subjective rating of their stem cell knowledge (P = 0.013) significantly exhibited higher objective stem cell knowledge than their counterparts. However, it was only subjective knowledge about stem cell that emerged as the significant determinant of objective knowledge of stem cell [Table 4]. Participants that exhibited adequate objective knowledge about stem cell use in dentistry significantly reported positive attitude to stem cell application in dentistry than their counterparts with inadequate objective knowledge (P = 0.000). In multivariate analysis, the objective knowledge about stem cell still emerged as the significant determinant of attitude toward stem cell application in dentistry [Table 5]. Participants that reported positive attitude toward stem cell application in dentistry exhibited significant permissive tendency to the proposed organized incorporation of stem cells application into undergraduate and postgraduate dental curriculum than their counterparts with negative attitude (P = 0.006). In multivariate analysis, the positive attitude toward stem cell application in dentistry still emerged as the significant determinant of permissive tendency of the participants to the proposed organized incorporation of stem cells application into undergraduate and postgraduate dental curriculum [Table 6].
|Table 3: Stem cell knowledge, attitude, and permissive tendency among the participants|
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|Table 4: Bivariate and multivariate analysis of objective knowledge of stem cell use in dentistry among the participants|
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|Table 5: Bivariate and multivariate analysis of attitude toward stem cell application in dentistry among the participants|
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|Table 6: Bivariate and multivariate analysis of permissive tendency to the proposed organized incorporation of stem cells application into undergraduate and postgraduate dental curriculum among the participants|
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| Discussion|| |
Studying knowledge and attitude in relation to stem cells application in dentistry among dental students will go a long way in discovering the knowledge gaps and negative attitudinal issues that may need to be addressed or incorporated into the curriculum. In this study, about two-third reported awareness of stem cell use in dentistry which is considered high but it was lower than 81.0% reported among Nigerian dentists.  The disparities in the sources of information among these participants and those in the compared study may be the explanation as the leading sources of information on stem cell in this study were school lectures and internet while the leading sources in compared study were conference and postgraduate training.  This indicates the noncomprehensive widespread incorporation of stem cells application in the undergraduate dental curriculum and justifies the call for harmonious undergraduate dental curriculum restructuring by the Nigerian University Commission. , In this study, male participants reported significantly more awareness than females as previously among Nigerian dentists  which however contrasted with findings among Indian dentists  where there was no significant association between gender and awareness of stem cell use in dentistry. This, therefore, reflects a cultural difference in gender variability of stem cell awareness. The increasing availability of a variety of internet connectivity has strategically heightened the scientific knowledge seeking through internet by Nigerian undergraduates thereby making it, the second leading source of information in this study , and such external outsourcing of scientific information has been noted to be higher among males than females.  Although the reported awareness was high, there is an evident lack of in-depth knowledge as a quarter of the participants subjectively rated stem cell knowledge as moderate and above and less than one-fifth (18.2%) of the participants were found to have adequate knowledge on objective assessment. The fact that the awareness was mainly more than a year old but <2-year-old may contribute to the superficiality of the knowledge. The subjective assessment of knowledge of stem cell can obviously be accepted as objective assessment of knowledge of stem cell since subjective assessment of knowledge of stem cell emerged as the only significant determinant of objective assessment of knowledge of stem cell.
In this study, less than one-third of the participants reported positive attitude toward stem cell application in dentistry, and this could have been affected by the lack of in-depth stem cell knowledge among the participants. This is confirmed from the logistic regression analysis that found objectively assessed stem cell knowledge as the only significant predictor of the attitude to stem cell application. The positive permissive tendency to the proposed organized incorporation of stem cell research and therapy in Nigerian undergraduate and postgraduate dental curriculum was quite high (82.7%) among the participants. Evidently, the participants with positive attitude toward stem cell application in dentistry reported significantly higher permissive predisposition of the participants to the proposed organized incorporation of stem cells application into undergraduate and postgraduate dental curriculum. This confirms that understanding the knowledge and attitude in relation to stem cells application in dentistry among dental students is a panacea to the development of success-oriented approach that will eliminate negative any bias and result in wholesome acceptance of this emerging field. It is clear from this study that improvement of stem cell knowledge will improve attitude and ultimately increase permissive tendency of the participants to the proposed organized incorporation of stem cells application into undergraduate and postgraduate dental curriculum.
The exclusion of dental students from the Northeast geopolitical zone of Nigeria may have influenced the outcome of this study. However, the similarity of admission requirements in Nigerian Universities is expected to minimize such effects. The questionnaire used in this study lack longstanding established validity because it has only been previously used in a study among dentists. However, it has proven to be effective study tool among dentists and dental students.
| Conclusion|| |
Data from this study revealed a high positive permissive tendency to the proposed organized incorporation of stem cell application into undergraduate and postgraduate dental curriculum among the participants. Increasing stem cell knowledge will improve attitude toward stem cell use which will ultimately increase permissive predisposition.
The authors wish to thank all the dental students that participated in the study and lecturers that assisted in data collection in the dental schools.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]