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| Year : 2022 | Volume
: 33
| Issue : 3 | Page : 247-252 |
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| Knowledge, attitude, and practice of autotransplantation among the practicing pediatric dentists in Chennai – A questionnaire study |
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JA Amilia Elizabeth1, Shankar Paulindraraj2, R Hemalatha2, Trophimus Gnanabagyan Jayakaran2, Senthil Dakshinamurthy2
1 Department of Pediatric and Preventive Dentistry, Meenakshi Ammal Dental College and Hospital, Chennai, Maduravoyal, Tamil Nadu, India
2 Department of Pediatric and Preventive Dentistry, SRM Dental College and Hospital, Ramapuram, Chennai, Tamil Nadu, India
Click here for correspondence address and email
| Date of Submission | 12-Jun-2021 |
| Date of Decision | 08-Sep-2022 |
| Date of Acceptance | 14-Sep-2022 |
| Date of Web Publication | 17-Jan-2023 |
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 Abstract | | |
Background: Autotransplantation is a minor surgical procedure which involves transplantation of teeth within the same oral cavity. For children, autotransplantation may be considered as a provisional measure with good survival probability. It offers a viable biological approach for replacing the missing teeth and also for orthodontic treatments in children. Aim: The aim of this study is to assess the knowledge, attitude, and practice of autotransplantation among pediatric dentists in Chennai, India. Methods: An 18-item questionnaire was developed, piloted, and distributed among 100 practicing pediatric dentists in Chennai, India. Descriptive statistical analysis was done using Chi-square test. Results: Seventy valid responses from the practicing pediatric dentists were obtained. Among them, 39.7% had an experience of 5–10 years, 47.1% practiced less than 5 years, and 13.2% had experience more than 10 years. Analysis of the responses showed that 76.5% of the pediatric dentists were aware of the procedure but have not observed autotransplantation being done. Among the respondents, 95.6% have not performed this technique and 40.6% of them were not sure of the prognosis. Atraumatic extraction of donor tooth was considered to be a major limitation in autotransplantation by 41.8% of the pediatric dentists. From the responses received, 95.6% were interested in gaining more information with majority opting for more hands on workshops on the technique of autotransplantation. Conclusion: Though most of the respondents were aware of autotransplantation procedure, they have not practiced it due to inadequate training.
Keywords: Autotransplantation, awareness, children, pediatric dentists, practice
How to cite this article:
Amilia Elizabeth J A, Paulindraraj S, Hemalatha R, Jayakaran TG, Dakshinamurthy S. Knowledge, attitude, and practice of autotransplantation among the practicing pediatric dentists in Chennai – A questionnaire study. Indian J Dent Res 2022;33:247-52 |
How to cite this URL:
Amilia Elizabeth J A, Paulindraraj S, Hemalatha R, Jayakaran TG, Dakshinamurthy S. Knowledge, attitude, and practice of autotransplantation among the practicing pediatric dentists in Chennai – A questionnaire study. Indian J Dent Res [serial online] 2022 [cited 2023 Apr 2];33:247-52. Available from: https://www.ijdr.in/text.asp?2022/33/3/247/367887 |
| Introduction | |  |
Tooth transplantation is not new to mankind. The earliest reports of tooth transplantation involved the slaves in ancient Egypt who were forced to give their teeth to their Pharaohs.[1] This procedure of allotransplantation was abandoned due to complications of incompatibility and from then on eventually the procedure of autotransplantation was adapted. During the early 1950s, the hurdles encountered in autotransplantation were related to improper root development and root resorption of transplants that resulted in low success rates (50%).[2] Extensive research during the 1990s brought about a better understanding on autotransplantation which dramatically improved its success rates.[3],[4]
Autotransplantation is defined as the surgical movement of a donor tooth to a receptor site in the same individual; it is essentially a controlled extraction and reimplantation in an extraction site or surgically prepared site.[5] The first reports of autotransplantation were reported in 1953 by Fong with 80% success rate.[6] The first surgical protocol of autotransplantation was published in 1974 by Slagsvold and Bjercke.
Tooth autotransplantation (TAT) offers a viable biological approach to tooth replacement in children and adolescents after traumatic dental injuries (TDIs), agenesis, developmental anomalies, or specific orthodontic problems where an appropriate donor tooth can be used without negative effects in maintaining the arch form and integrity. It is a biological way of managing missing teeth and has many advantages over conventional tooth replacement in the growing patients. Studies have demonstrated good long-term survival of these transplants, thus providing a realistic treatment alternative for tooth replacement in young individuals and children.[7],[8]
Rationale
Though autotransplantation has shown high success and survival rates, it includes complex treatment planning and adequate clinical experience is necessary to perform an atraumatic donor tooth extraction, analysis and preparation of the recipient site, careful transplantation of the extracted tooth, and periodontal tissue management. The above-mentioned key factors restrain the practice of autotransplantation in day-to-day pediatric clinical practice. Thus far no study in literature have analyzed the knowledge, attitude, and practice of autotransplantation among pediatric dentists in the regular pediatric curriculum.
Therefore, the aim of this present study is to assess the existing knowledge, attitude, and practice of autotransplantation among practicing pediatric dentists in Chennai, Tamilnadu, India.
| Materials and Methods | | |
Study design: The study design is an epidemiological, observational, cross-sectional survey.
Ethical clearance: Ethical clearance from the Institutional Ethical Committee was obtained prior to the start of the study [SRMU/M and HS/SRMDC/2020/PG/010]. Informed consent was obtained from the pediatric dentists for their willingness to participate in the study.
Study sample: The study was conducted among a group of 100 practicing pediatric dentists in Chennai, Tamilnadu, India. Out of the 100 participants, only 70 practicing pediatric dentists gave their consent to take part in this survey. Therefore, the questionnaires were administered to those 70 subjects who showed their desire to participate in this study.
The items included in the questionnaires were selected according to their relevance to the theme of this study and their references in literature.
The questionnaires were distributed to investigate the knowledge, attitude and practice of autotransplantation being performed in routine dental practice by the practicing pediatric dentists in Chennai [Annexure 1].
Inclusion criterion: The questionnaire was administered only to the practicing pediatric dentists in Chennai.
Exclusion criterion: The only exclusion criterion was the refusal to participate in the survey.
Study period: September 2020.
Collection of data: Data collection was carried out by administering an anonymous 18-question survey-based information found in scientific literature. The questionnaire included general information (age, gender, experience) and details on the participant's level of understanding on autotransplantation.
Questionnaire Language: The language used in the questionnaire was English.
Source of Sample: These questionnaires were sent through Gmail and also via WhatsApp a social media platform to the participants.
Type of questionnaire: The type of questionnaire is a closed ended questionnaire, 3 domains with 18 questions and 4 options each.
Content validation: It was done by five experts in the particular field and duplicates were avoided by registering only one mail id.
Data processing was performed using Microsoft Excel software and Google forms.
Statistical analysis
The Chi-square statistical test was used to determine the association between age, gender, type of practice and years of practice among the participants in the study. From the analysis, it was found that most of the responses were statistically nonsignificant with the Chi-square and P value.
| Results | | |
The sample included 100 pediatric dentists of which 70 responses were obtained, from those only 68 responses were accepted and 2 were rejected as it had incomplete responses.
Most of the pediatric dentists in the study were aged between 30-40 years (63.2%) and (30.9%) of them were aged under 30. Among them, 44.1% of the pediatric dentists were both academic as well as part time clinical practitioners, 42.6% were full time clinical practitioners and 13.2% had work experience in government sector.
Knowledge
Out of 100 participants, 70 participants responded. Just over half of the participants [63.2%] suggested that an interdisciplinary approach of pediatric dentists, oral surgeons and general dentists is necessary to examine and treat the kid subjected to trauma. According to 63.2% of the dentists, luxation injuries were the most commonly encountered dental trauma involving primary teeth and 48.5% suggested that color change due to trauma was the most commonly encountered dental trauma in permanent tooth in their respective practices. Majority of the participants [58.2%] opted for space maintainer followed by implant placement in children if the patient could not find the avulsed permanent tooth.
Awareness
Awareness among responses showed that 76.5% of the pediatric dentists were aware of the autotransplantation procedure but were not practicing the same [Figure 1]. According to 38.1% of participants, lower 2nd premolar can be used as a donor tooth for missing permanent upper central incisor and 75.6% were aware that 3rd molar can be used as a donor tooth for missing permanent first molar. Furthermore, 83.3% believed that the success of autotransplantation is determined by esthetics, preservation of alveolar bone support and periodontal healing. | Figure 1: Are you aware that “Autotransplantation” is a treatment option for avulsed permanent tooth?
Click here to view |
Practice
The survey showed that 76.1% of the dentists have not seen any cases done using autotransplantation, males reported to have observed more cases of autotransplantation than females and it was statistically significant [Table 1]. Among the respondents 95.6% have not performed this technique and 40.6% of them were not sure of the prognosis. Atraumatic extraction of donor tooth was considered to be a major limitation in autotransplantation by 41.8% of the pediatric dentists. From the responses received 95.6% were interested in gaining more information irrespective of the type of practice and it was statistically significant [Table 2] and [Figure 2] with majority [50%] opting for more hands on and workshops on the technique of autotransplantation. The results of this study show that autotransplantation is rarely practiced [Figure 3] that depicts its current scenario. | Table 2: Type of practice and its association with participant's interest in gaining more information/knowledge about Autotransplantation
Click here to view |
 | Figure 2: Are you interested in gaining more information/knowledge about autotransplantation?
Click here to view |
| Discussion | | |
Autotransplantation, provides the possibility of a natural tooth rather than a prosthesis or an osseointegrated implant to replace a missing tooth among the young patients. Although there have been a number of studies in literature that have examined the long-term success rates of the transplanted teeth, our study looked at various aspects of the knowledge, awareness and practice of autotransplantation and its treatment planning among the pediatric dentists in Chennai, South India.
Our study had 100 participants, and the respondents were further divided based on their years of experience and the type of practice they had in the field of pediatric dentistry. Most of the participants preferred that this technique can be used effectively in a wide range of clinical situations within the framework of a multidisciplinary team comprising of Pediatric Dentists, Orthodontists, Oral Surgeons, and Restorative Dentists together contributing to the comprehensive treatment plan with the aim of achieving a successful outcome for the patient.
In our study, 63.2% participants reported luxation injuries as the commonly encountered dental trauma in primary tooth which is in accordance with the finding observed by Andreasen et al.[9] Luxation injuries also show evident healing of the periodontal ligament with better prognosis of the affected teeth.[10] About 48.5% of respondents reported that color change due to trauma was the most commonly encountered dental trauma in permanent tooth whereas crown fractures were also more evident among them.
One of the more complicated TDIs is avulsion, in which one or more teeth are completely knocked out of their alveolar sockets. In general, an avulsed tooth must be immediately replanted in its socket to avoid further damage to the periodontal membrane. If replantation is not possible, the other possible treatment options would be orthodontic space closure, fixed partial dentures, removable partial dentures, space maintainer followed by implant placement and autotransplantation. In our study, Space maintainer followed by implant placement was the most sought treatment option by 58.2% of pediatric dentists for a missing avulsed permanent tooth.
Based on occlusal conditions and patient needs, the dentist indicates the potential donor tooth/teeth for autotransplantation. Upper second premolars are smaller since their roots are often close to each other, making them the preferable donors for maxillary incisors compared to first maxillary premolars. On inspecting the mandibular premolars, both first and second, are usually the smallest and the easiest ones to remove from their alveolar crypt and to accommodate in the recipient site in the anterior maxilla, and for this reason surgically preferred as replacement of maxillary incisors.[11] Moreover, the completion of root development for the first and second premolars occurs between 12 to 14 years of age which is suitable time for autotransplantation as the premolars would have erupted and attained adequate root length with a favorable crown-root ratio.[12] In our study 38.1% of the pediatric dentists preferred lower 2nd premolars as donor tooth for missing permanent upper central incisor.
The success rate of third molar autotransplantation recorded in literature was over 50%.[13] In our study, 76.5% of the participants considered third molar as the donor tooth for missing permanent first molar. Third molar transplantation is useful and indicated in patients with extensively decayed first permanent molar with compromised tooth structure.[14]
The most important element for the success of autogenous tooth transplantation is the vitality of the periodontal ligament attached to the transplanted tooth.[13] Timing of transplanting a tooth also plays a pivotal role. The most desirable time of transplantation is when development of the donor tooth roots iare 3/4th to 4/5th complete. Transplantation should be performed within 1 month after extraction. In our study, 83.3% of participants agreed that the aforementioned factors contribute to the success of autotransplantation.
The literature could not identify any study analyzing the knowledge, attitude and practice of pediatric dentists in performing autotransplantation procedure. Out of the 70 responses received, 51 pediatric dentists have not seen/observed the procedure. In the large majority, 95.6% respondents have not performed autotransplantation whereas only 4.4% [3 respondents] have practiced the same. As with many techniques, operator skill is important and therefore autotransplantation should be performed by a clinician with experience in areas such as donor tooth extraction, preparation of the recipient site, and tissue management.[15]
Indications for autotransplantation are of course the existence of a useful transplant object and a suitable transplant site.[16] TAT is not suitable in all cases. Case selection depends on the need for orthodontic treatment, with availability of a suitable donor tooth and adequate bone in the recipient site.[17] In our study, out of the 70 responses, 25 pediatric dentists considered good case selection as a major indication followed by 21 responses who considered preparation and analysis of recipient site as major indication. In this study, 41.8% of the responses also supported the fact that atraumatic extraction of donor teeth selection is one of the major limitations in making autotransplantation as a day-to-day clinical procedure.
It is evident that the prognosis of autogenous tooth transplantation depends on the level of root development, the formation of the root apex, the condition of the periodontal ligament of the transplanted tooth, the method of tooth fixation, the match between the transplanted tooth and recipient socket, and the time of endodontic treatment.[15] Majority of the respondents [41.8%] in our study were not sure of the prognosis because of these reasons listed in the literature.
There is absolutely no question that the autotransplantation procedure is extremely technique sensitive, with the need of surgeon's skill, experience and careful handling of the transplanted tooth being vital for success.[18] According to this literature fact, it is evident from our study that autotransplantation is rarely practiced [63.2%] and often overlooked dental procedure. Unfortunately, many clinicians to date have not received the requisite experience in performing this procedure. This study highlights the certainty that 95.6% of the responses were interested in gaining more information via hands on/workshops in performing autotransplantation. It is promising that hands on experience of this technique will allow the clinicians to acknowledge, consider, recommend and perform this very worthwhile procedure appropriately for selected growing patients.
| Conclusion | | |
Our study among the practicing pediatric dentists in Chennai, revealed that though most of the respondents were aware of autotransplantation procedure, they have not practiced it due to inadequate training.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| Annexure 1 | | |
Knowledge
- What is the most commonly encountered dental trauma in primary tooth in your practice?
- Avulsion
- Complicated crown rooth fracture
- Luxation injuries
- Others
- What is the most commonly encountered dental trauma in permanent tooth in your practice?
- Color change due to trauma
- Avulsion
- Complicated crown/root fracture
- Luxation injuries
- Others
- If a patient could not find the avulsed tooth, what treatment option do you prefer for children?
- Orthodontic space closure
- Fixed partial dentures
- Removable partial dentures
- Space maintainer followed by implant placement
- Autotransplantation
Awareness
- Are you aware that “AUTOTRANSPLANTATION” is a treatment option for avulsed permanent tooth?
- Which of the following can be used as a donor tooth for missing permanent upper central incisor?
- Lower 2nd premolar
- Lower 1st premolar
- Upper premolar
- Lower incisor
- Which of the following can be used as a donor tooth for missing permanent first molar?
- 3rd molar
- Lower 2nd premolar
- Lower 1st premolar
- 2nd molar
- What do you think will be the success of “AUTOTRANSPLANTATION”?
- Esthetics and benefits of natural tooth
- Preservation of alveolar bone support
- Periodontal healing
- All the above
Practice
- Have you seen any cases using “AUTOTRANSPLANTATION” procedure?
- What do you consider as a Major indication for AUTOTRANSPLANTATION?
- Good case selection
- Patient must be ideal for orthodontic tooth extraction
- Stage of root development
- Analysis of recipient site
- What do you consider as a Major limitation for AUTOTRANSPLANTATION?
- Imaging modalities used for AUTOTRANSPLANTATION
- Orthodontic extraction indicated
- Atraumatic extraction of donor tooth
- Behavioral management of the child during this minor surgical procedure
- What do you think will be the prognosis of AUTOTRANSPLANTATION?
- What is the current scenario of AUTOTRANSPLANTATION ?
- Rarely practiced
- Often overlooked
- Not practiced
- By what way more information on AUTOTRANSPLANTATION can be obtained?
- Continuing dental education (CDE) programmes
- Hands on/workshops
- Articles/journals
| References | | |
| 1. | Cohen AS, Shen TC, Pogrel MA. Transplanting teeth successfully: Autografts and allografts that work. J Am Dent Assoc 1995;126:481-5.  |
| 2. | Apfel H. Autoplasty of enucleated prefunctional third molars. J Oral Surg (Chic) 1950;8:289-96. |
| 3. | Tsukiboshi M. Autotransplantation of teeth: Requirements for predictable success. Dent Traumatol 2002;18:157-80. |
| 4. | Lundberg T, Isaksson S. A clinical follow-up study of 278 autotransplanted teeth. Br J Oral Maxillofac Surg 1996;34:181-5. |
| 5. | Czochrowska EM, Stenvik A, Bjercke B, Zachrisson BU. Outcome of tooth transplantation: Survival and success rates 17-41 years posttreatment. Am J Orthod Dentofacial Orthop 2002;121:110-9; quiz 193. |
| 6. | Agnew RG, Fong CC. Histologic studies on experimental transplantation of teeth. Oral Surg Oral Med Oral Pathol 1956;9:18-39. |
| 7. | Slagsvold O, Bjercke B. Indications for autotransplantation in cases of missing premolars. Am J Orthod 1978;74:241-57. |
| 8. | Vilhjálmsson VH, Knudsen GC, Grung B, Bårdsen A. Dental auto-transplantation to anterior maxillary sites. Dent Traumatol 2011;27:23-9. |
| 9. | Boorum MK, Andreasen JO. Sequelae of trauma to primary maxillary incisors. I. Complications in the primary dentition. Dent Traumatol 1998;14:31-44. |
| 10. | Soporowski NJ, Allred EN, Needleman HL. Luxation injuries of primary anterior teeth--prognosis and related correlates. Pediatr Dent 1994;16:96-101. |
| 11. | Andreasen JO, Andreasen FM. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4 th ed. Oxford: Blackwell Publishing; 2007. p. 444-80. |
| 12. | Apfel H. Transplantation of the unerupted third molar tooth. Oral Surg Oral Med Oral Pathol 1956;9:96-8. |
| 13. | Park JH, Tai K, Hayashi D. Tooth autotransplantation as a treatment option: A review. J Clin Pediatr Dent 2010;35:129-35. |
| 14. | Waldon K, Barber SK, Spencer RJ, Duggal MS. Indications for the use of auto-transplantation of teeth in the child and adolescent. Eur Arch Paediatr Dent 2012;13:210-6. |
| 15. | Schwartz O, Bergmann P, Klausen B. Autotransplantation of human teeth. A life-table analysis of prognostic factors. Int J Oral Surg 1985;14:245-58. |
| 16. | Kahnberg KE. Autotransplantation of teeth (I). Indications for transplantation with a follow-up of 51 cases. Int J Oral Maxillofac Surg 1987;16:577-85. |
| 17. | Andreasen JO, Paulsen HU, Yu Z, Bayer T, Schwartz O. A long-term study of 370 autotransplanted premolars. Part II. Tooth survival and pulp healing subsequent to transplantation. Eur J Orthod 1990;12:14-24. |
| 18. | Ong D, Itskovich Y, Dance G. Autotransplantation: A viable treatment option for adolescent patients with significantly compromised teeth. Aust Dent J 2016;61:396-407. |
Correspondence Address:
Dr. J A Amilia Elizabeth
Department of Pediatric and Preventive Dentistry, Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai - 600 095, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijdr.ijdr_571_21
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2] |
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