| Abstract|| |
Context: Tooth avulsion is one of the most serious dental emergencies in children. Often these injuries occur in school and, therefore, the knowledge of schoolteachers regarding the appropriate measures to be taken immediately after tooth avulsion is crucial to good prognosis.
Aims: The purpose of the present study was to evaluate schoolteachers' knowledge and attitudes regarding immediate management of avulsed teeth in children.
Materials and Methods: A total of 177 teachers from seven schools of Garhshankar town, Hoshiarpur District, Punjab, India, formed the sample of the study. A self-administered questionnaire consisting of 16 questions was used to assess the knowledge and attitudes of schoolteachers about tooth avulsion and its management.
Statistical Analysis: The chi-square test and one-way analysis of variance (ANOVA) were used for analysis. Pair-wise comparison was done using Tukey's honestly significant difference (HSD) test. P≤0.05 was considered to be statistically significant.
Results: Markedly low knowledge levels were noted among the schoolteachers. The mean knowledge score was 5 (of a maximum possible score of 10). Only 0.6% of the teachers answered correctly that they would use milk as a transport medium. The number of correct responses was not affected by previous experience with tooth avulsion, sex, educational level, teaching experience, or teacher training. Overall, 85.9% of teachers showed a positive attitude towards this campaign.
Conclusions: Knowledge regarding emergency management of dental trauma is poor amongst schoolteachers. Therefore, we suggest that orientation to management of avulsed tooth be part of the teacher training education.
Keywords: Attitude, avulsion, knowledge, schoolteachers, tooth
|How to cite this article:|
Kaur H, Kaur S, Kaur H. Prehospital emergency management of avulsed permanent teeth: Knowledge and attitude of schoolteachers. Indian J Dent Res 2012;23:556
The importance of anterior permanent teeth in esthetics and function cannot be underestimated. Anterior permanent teeth have significant effect on an individual's facial profile. Lost teeth can have significant negative functional, esthetic, and psychological effect on children. ,, Epidemiological studies have revealed that children from 8 to 12 years are especially prone to dental injury. ,,,,, Traumatic tooth avulsion comprises 0.5%-16% of traumatic injuries in the permanent dentition and 7%-13% in the primary dentition. ,,,,, The tooth most commonly avulsed in both the primary and the permanent dentition is the maxillary central incisor. The lower jaw is seldom affected.  Tooth avulsion is more frequent in boys than in girls because of the active participation of the former in physical sports and games. ,, Andreasen et al. have suggested that the loosely structured periodontal ligament surrounding the erupting teeth and the elasticity of alveolar bone favor complete avulsion.
|How to cite this URL:|
Kaur H, Kaur S, Kaur H. Prehospital emergency management of avulsed permanent teeth: Knowledge and attitude of schoolteachers. Indian J Dent Res [serial online] 2012 [cited 2019 Oct 23];23:556. Available from: http://www.ijdr.in/text.asp?2012/23/4/556/104974
For the management of an avulsed permanent tooth, immediate replantation is generally accepted as the treatment of choice. ,,, However, in the primary dentition replantation is contraindicated because such a procedure may damage the permanent successor.  The most important factor determining the prognosis of a replanted tooth is the viability of the periodontal ligament remaining on the root at the time of replantation. To prevent dehydration of the root surface during transportation, the storage medium must be of the correct osmolarity and pH. Milk fulfils this requirement and, hence, is considered an effective storage medium. 
Dental traumatic injuries are common, and many occur at school. According to a study over 16% of such injuries occur in the school environment. ,,, Therefore, the ultimate prognosis of an avulsed tooth occurring in a child may depend on the teacher's knowledge of emergency management. Thus, the purpose of this study was to evaluate, by means of a questionnaire, schoolteachers' knowledge and attitudes regarding the emergency management of avulsed teeth.
| Materials and Methods|| |
Source of data
This study was conducted among teachers of seven public schools in Tehsil Garhshankar, Hoshiarpur District, Punjab, India. A total of 177 teachers participated in this study conducted in April 2011.
Method of collection of data
The survey was conducted over a 4-week period. The nature and purpose of the study was first explained to the teachers in the local language. The survey's voluntary nature was emphasized and strict confidentiality assured. Following this, the teachers were asked to complete a 16-stemmed questionnaire in English. The respondents were asked to tick the most appropriate answer from the given list of answers. We also collected information about general demographics, e.g., age, sex, educational level, and teaching experience of the participants. Filled-out questionnaires were collected on the same day. During grading, correct responses to a question were awarded a score of '1' and incorrect responses were awarded a score of '0.'
After the questionnaires had been collected the teachers were given pamphlets containing educational material regarding tooth avulsion and its immediate management.
The responses obtained were tabulated and expressed as frequency distributions and percentages. The teachers were categorized into different groups on the basis of their age, gender, education levels, and teaching experience to find out the influence of these factors, if any, on knowledge and attitudes.
Data were analyzed using SPSS ® (Statistical Package for the Social Sciences) for Windows ® , version 17.0. The mean knowledge scores of different groups were compared using one-way analysis of variance (ANOVA) and pair-wise comparison was done using Tukey's honestly significant difference (HSD) test. The chi-square test was applied for proportions. A significant difference was inferred at P<.05.
| Results|| |
A total of 177 teachers participated in this study. The general characteristics of the participants are summarized in [Table 1].
About half (51.4%) of the teachers were from the 20-30 years age-group. The majority of the teachers (69.0%) had undergone some type of teacher training, and about 41.3% had teaching experience of more than 4 years. [Table 2] shows the mean knowledge scores of participants, along with the distribution of correct responses by participants. Among the teachers, about one-third (34.5%) reported that they had previously witnessed a tooth avulsion injury, while 64.4% reported that they had not witnessed a tooth avulsion before. Most of the teachers (95.5%) considered emergency management of avulsed tooth as important.
|Table 2: Mean knowledge scores and distribution of correct responses by participants|
Click here to view
The majority of the teachers (74%) would remove an avulsed tooth from the child's mouth, while 4.3% would leave the tooth in the mouth. Only 15.3% of teachers said that they would attempt replantation.
When asked if they would throw away an avulsed permanent tooth, almost half (49.7%) answered in the affirmative, while 45.2% said they would not to throw away an avulsed tooth. This shows that a large proportion of teachers lack basic knowledge regarding the management of traumatic tooth avulsion.
When questioned about what would they do with the avulsed tooth, the majority (55.9%) of the teachers preferred taking it immediately to the doctor; however, 23.2% answered they would throw the tooth on to the rooftop as this is the common belief in Punjab that the avulsed tooth if thrown on the roof top is taken by the tooth fairy and in return it blesses with a new tooth., and 8.5% would leave the tooth lying on the ground [Figure 1].
|Figure 1: Participants' choice regarding how to deal with an avulsed tooth|
Click here to view
Participants were also asked about the cleaning strategy they would adopt for an avulsed tooth. The majority (66.1%) of the participants answered that they would clean the avulsed tooth, but the method of cleaning they opted for was wrong. The answers included cleaning with antiseptic solution, soap and water, or tooth brush and paste [Figure 2]. Among the participants, 42.9% said that they would hold the tooth by the crown while cleaning or washing the avulsed tooth; however, 57.1% gave wrong answers regarding the method of handling an avulsed tooth [Figure 3].
|Figure 3: Participants' choice regarding mode of handling an avulsed tooth|
Click here to view
More than half of the participants (61%) said that they would not store the tooth in any storage media during transportation. When asked to opt for a storage media, only 0.6% chose the correct option, i.e., milk. The majority (24.3%) would prefer to store the tooth in an antiseptic solution, followed by dry storage in a plastic bag or wrapped in paper or gauze [Figure 4].
For further management, 91% of teachers said they would immediately seek professional help; 84.2% would go to the dentist for treatment.
As perhaps a testament to the lack of emphasis on dental trauma, the majority of the teachers (79.7%) said that they had never attended any orientation course on dental trauma.
The attitude of almost all the teachers regarding the survey was positive, and 85.9% agreed to read the pamphlets entitled Saving a Knocked-Out Tooth that were distributed to them after the study [Figure 5]. Most teachers (92.1%) felt that this campaign had improved their knowledge about tooth avulsion and its management.
|Figure 5: Response regarding reading the folder entitled Saving a Knocked-Out Tooth|
Click here to view
The mean knowledge scores of participants was also compared within the groups based on age, gender, educational level and teaching experience. [Table 3] shows the mean knowledge scores of teachers according to educational level. Age, gender, educational level, and teaching experience had no significant effect on knowledge score.
| Discussion|| |
The purpose of this campaign was to assess the knowledge and attitude of schoolteachers about tooth avulsion and to alert those working with children on the importance of immediate treatment procedures in cases of tooth avulsion. We also instructed them on the correct way to handle these situations.
Children between 8 and 12 years of age are the ones most commonly affected by dental trauma. Because of increase in the incidence of dental trauma episodes, it is almost certain that more children will suffer from avulsion injuries in their permanent teeth in future. , The single most important factor in the success of replantation is the speed with which the tooth is positioned back in its socket. Every effort should be made to replant the tooth within first 15-20 min.  Reports show that more than half of all children suffer traumatic dental injuries in school. ,, Therefore, professionals who work with children must be aware of the importance of emergency treatment and of how to proceed in cases of tooth avulsion. This study has demonstrated the lack of knowledge among schoolteachers regarding correct handling, transportation, and storage of an avulsed tooth.
The mean knowledge score in this population was 5 (of a maximum possible score of 10). Rather than consulting the dentist, 23.2% teachers said they would throw an avulsed tooth on to the rooftop, demonstrating that the superstitious belief that a broken tooth or an exfoliated tooth should be thrown on to the rooftop so that another tooth can replace it, is still extant in the country. Persistence of such beliefs in schoolteachers is not desirable and is a matter of concern.
The most popular choice of storage medium during transportation was antiseptic solution. Only 0.6% of teachers correctly opted for milk as a storage medium. This is regrettable because the simple measure of storing an avulsed tooth in milk will enhance the prognosis of the tooth when implanted. ,,, Milk has a favorable osmolarity and composition for maintaining the viability of periodontal ligament cells and has been recommended for temporary storage of avulsed teeth before replantation. In addition to being readily available, it preserves cell viability for up to 3 hours. 
Storing the tooth in an antiseptic solution is not recommended because it will compromise the periodontal ligament cells, and thus adversely affect the prognosis of the replanted tooth. Many teachers also opted for 'dry storage.' They are not aware that dry storage during transportation would seriously prejudice survival of the replanted tooth; the prognosis being dependant on avoidance of injury to the periodontal membrane during the time the tooth is out of its socket. ,
Tap water as storage medium was opted for by some teachers. This is not recommended as tap water is of low osmolarity; a hypotonic solution would cause the periodontal ligament cells to swell and rupture.  Thus, dry storage of the tooth or storage in water are not recommended as both methods will lead to injury to the periodontal membrane, with the result that the replanted tooth will be lost over time. 
Many teachers would clean a tooth with toothpaste and brush, unaware that they would be severely decreasing the chances of successful replantation. A large number of teachers said that they would remove an avulsed tooth from the child's mouth immediately after the injury. This action should be encouraged as it will prevent the risk of the tooth being swallowed by the child. 
Most teachers said that they would not attempt replantation of the tooth by themselves. The reasons for the reluctance to replant an avulsed tooth could be related to lack of knowledge, fear of hurting the child, or the greater priority given to stopping the bleeding which is perceived by most people as life threatening. 
The knowledge of teachers regarding tooth cleaning methods before replantation was poor. The use of antiseptics and brushing was preferred by many teachers. Washing in tap water, which is the ideal cleaning method, was chosen by a relatively small number of teachers. A large proportion of teachers correctly said that they would hold the avulsed tooth by the crown when cleaning it and only a relatively small number said they would hold it by the root or the middle of tooth. However, a considerable number of them were not sure about the correct method of holding an avulsed tooth, and a few teachers did not give any answer at all. Thus, our study shows that a large number of teachers will not hold the tooth by the crown and, consequently, will disturb the periodontal ligament. There was a general lack of awareness that one of the most important factors for success of tooth replantation is the integrity and viability of the periodontal ligaments of the avulsed tooth. 
A matter of interest in this study was that the majority of the participants (79.7%) reported that they had never attended any orientation program on dental trauma or tooth avulsion. This shows the need for awareness campaigns targeting teachers. The attitude of teachers regarding emergency management of avulsed teeth was impressive. The majority (85.9%) of teachers were enthusiastic for learning about the emergency management of avulsed tooth.
This study shows the urgent need for dental health education to be stepped up among schoolteachers. The information needs of schoolteachers are important because improved knowledge in this group has possible implications for future pattern of seeking dental care. Although the study subjects were well educated, and more than half of them had undergone teacher training, it was apparent that the level of education had no noticeable influence on knowledge of dental trauma management [Table 3]. This is probably because very little or no information about tooth avulsion and replantation had been given to most of them. Many avulsed teeth in children can be replanted and saved if schoolteachers are aware of the immediate action to be taken after an avulsion injury. By increasing knowledge on how avulsed teeth are to be dealt with at the site of the accident, the risk of permanent tooth loss is minimized . The prognosis of an avulsed tooth is good if it is replanted under ideal conditions, and the tooth can often be retained for life.
| Conclusion|| |
To conclude, this study showed that teachers in Garhshankar town, Hoshiarpur District, Punjab, India, have poor knowledge regarding the emergency management of avulsed teeth. Children and teenagers are especially sensitive about the cosmetic impact of missing anterior teeth. Educational programs should be developed for teachers to encourage them to seek treatment immediately when a dental injury occurs to a child in school. Educational material, posters, and lectures can be used during teacher training programs to increase the knowledge of these professionals regarding tooth avulsion. Thus, information presented in a clear and simple manner can be one of the best ways for improving treatment outcomes of avulsed permanent teeth.
Towards the completion of this study, I would like to acknowledge the principals and teachers of various schools of Garhshankar town for their support and cooperation during my study.
| Acknowledgements|| |
| References|| |
|1.||Cortes MI, Marcenes W, Sheiham A. Impact of traumatic injuries to their permanent teeth on the oral health related quality of life in 2-14 year old children. Community Dent Oral Epidemiol 2002;30:193-8. |
|2.||Mc Donald RE, Avery DR. Dentistry for child and adolescent. 7 th ed. St Louis: The C.V Mosby Co.; 1999. p. 485-542. |
|3.||Tandon S. Textbook of Pedodontics. 2 nd Ed. Hyderabad: Paras medical publisher; 2008. p. 559-600. |
|4.||Abdellatif AM, Hegazy SA. Knowledge of emergency management of avulsed teeth among a sample of Egyptian parents. J Adv Res 2011;2:157-62. |
|5.||Mohandas U, Chandan GD. Knowledge, attitude and practice in emergency management of dental injury among physical education teachers: A survey in Bangalore urban schools. J Indian Soc Pedod Prev Dent 2009;27:242-8. |
|6.||Andreasen JO, Andreasen FM. Textbook and color atlas of traumatic injuries to the teeth. 3 rd ed. Copenhagen: Munksgaard; 1994. |
|7.||Andreasen JO. Effects of extra-alveolar period and storage media upon periodontal and pulpal healing after replantation of mature permanent incisor in monkeys. Int J Oral Surg 1981;10:43-53. |
|8.||Rai SB, Munshi AK. Traumatic injuries to the anterior teeth among South Kanara school children: A prevalence study. J Indian Soc Pedod Prev Dent 1998;10:44-51. |
|9.||Gelbier S. Injured anterior teeth in children: A preliminary discussion. Br Dent J 1967;123:331-5. |
|10.||Shashikiran ND, Reddy VVS, Nagaveni NB. Knowledge and attitude of 2,000 parents (urban and rural - 1,000 each) with regard to avulsed permanent incisors and their emergency management, in and around Davangere. J Indian Soc Pedod Prev Dent 2006;24:116-21. |
|11.||Ravn JJ. Dental injuries in Copenhagen School children, school years 1967-1972. Community Dent Oral Epidemiol 1974;2:231-45. |
|12.||Andreasen JO. Traumatic injuries of the teeth. St. Louis: The CV Mosby Co; 1972. |
|13.||Andreasen JO. Traumatic injuries of the teeth. 2 nd ed. Copenhagen: Munksgaard; 1981. p. 203-42. |
|14.||Blomlof L, Lindskog S, Andersson L. Storage of experimentally avulsed teeth in milk prior to replantation. J Dent Res 1983;62:912-6. |
|15.||Gracia Godoy FM. Prevalence and distribution of traumatic dental injuries in a sample of Dominican school children. J Am Dent Assoc 1981;9:193-7. |
|16.||Sarkar S, Basu PK. Incidence of anterior tooth fracture in children. J Indian Dent Assoc 1981;53:371-3. |
|17.||Marino TG, West LA, Liewehr FR, Mailhot JM, Buxton TB, McPherson JC, et al. Determination of periodontal ligament cell viability in long shelf-life milk. J Endod 2000;26:699-702. |
|18.||Oswald RJ, Harrington GW, Van Hassel HJ. A post-replantation evaluation of air-dried and saliva stored avulsed teeth. J Endod 1980;6:546-51. |
|19.||Pearson RM, Liewehr FR, West LA, Patton WR, McPherson JC 3 rd , Runner RR. Human periodontal ligament cell viability in milk and milk substitutes. J Endod 2003;29:184-6. |
|20.||Trope M. Clinical management of the avulsed tooth. Dent Clin North Am 1995;39:93-112. |
|21.||Holan G, Ram D. Aspiration of an avulsed primary incisor. A case report. Int J Paediatr Dent 2000;10:150-2. |
|22.||Mori GG, Castilho LR, Nunes DC, Turcio KH, Molina RO. Avulsion of permanent teeth: Analysis of the efficacy of an informative campaign for professionals from elementary schools. J Appl Oral Sci 2007;15:534-8. |
Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, Punjab
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]