|Year : 2015 | Volume
| Issue : 1 | Page : 16-21
Assessment of knowledge and attitudes of school teachers regarding emergency management of an avulsed permanent tooth
Pooja Ahluwalia1, Parampreet Pannu2, Sanjam Kalra1, Aninditya Kaur1, Dikshit Behl3, Ramandeep Singh Gambhir4
1 Department of Pedodontics and Preventive Dentistry, Gian Sagar Dental College and Hospital, Rajpura, Punjab, India
2 Department of Pedodontics and Preventive Dentistry, BRS Dental College and Hospital, Sultanpur, Panchkula, Punjab, India
3 Department of Oral Surgery, Dasmesh Institute of Research and Dental Sciences, Faridkot, Punjab, India
4 Department of Public Health Dentistry, Rayat and Bahra Dental College and Hospital, Mohali, Punjab, India
|Date of Web Publication||30-Jul-2015|
Dr. Ramandeep Singh Gambhir
Department of Public Health Dentistry, Rayat and Bahra Dental College and Hospital, Mohali - 140 104, Punjab
Source of Support: None, Conflict of Interest: None
Background: Avulsion is defined as complete displacement of a tooth from its socket after trauma. The most accepted treatment for an avulsed permanent tooth is immediate replantation. Children spend a considerable amount of waking hours in school where teachers are the primary caregivers. Hence, this study was carried out to evaluate knowledge and attitudes of school teachers regarding the emergency management of an avulsed tooth in the district of Patiala, Punjab.
Materials and Methods: A two-stage sampling process was used which involved the sampling of schools within the educational district followed by sampling of teachers in the selected schools. A self-structured pretested questionnaire was personally administered to 500 school teachers of district Patiala. Statistical analysis was done using frequency and percentages and descriptive statistics like Student's t-test.
Results : Almost half of respondents were aware of mouth guards. 82.8% felt that treatment should be carried out immediately after injury. Approximately, one-fourth of respondents (25.6%) believed that knocked out tooth cannot be saved so no attempt should be made at cleaning it. There was a statistically significant association of knowledge regarding replantation of tooth with education level and training in first aid.
Conclusion: The present study revealed that overall knowledge regarding the emergency management of avulsed tooth was low in teachers. There is a need of first aid training to all the teachers along with emergency management of dental trauma.
Keywords: Avulsion, first-aid, management, school, teachers
|How to cite this article:|
Ahluwalia P, Pannu P, Kalra S, Kaur A, Behl D, Gambhir RS. Assessment of knowledge and attitudes of school teachers regarding emergency management of an avulsed permanent tooth. Saint Int Dent J 2015;1:16-21
|How to cite this URL:|
Ahluwalia P, Pannu P, Kalra S, Kaur A, Behl D, Gambhir RS. Assessment of knowledge and attitudes of school teachers regarding emergency management of an avulsed permanent tooth. Saint Int Dent J [serial online] 2015 [cited 2020 Feb 20];1:16-21. Available from: http://www.sidj.org/text.asp?2015/1/1/16/161796
Childhood is an active phase of life, when children are involved in various contact sports, indoor games and other physical activities. This makes them vulnerable to dentofacial injuries especially trauma to maxillary anterior teeth.  Since maxillary front teeth form an essential component of a child's endearing smile, loss of these teeth can lead to low self-esteem, poor esthetics, and certain speech defects, hence affecting the psychosocial and cognitive development of a child. 
Tooth avulsion is the complete displacement of a tooth from its socket due to accidental or nonaccidental injuries and may cause loss of healthy teeth. It comprises 0.5-3% of dento-facial injuries in the permanent dentition and 7-13% in the primary dentition. , Because of their effervescent nature and increased participation in physical activities, boys are three times more prone to suffer from dental trauma due to falls and greater involvement in fights.  Maxillary central incisor being the most commonly affected tooth in avulsion injuries in primary as well as permanent dentition. The lower jaw is seldom affected. Children in the age group of 7-9 years are more prone to avulsion injuries as the maxillary permanent incisors are erupting, and the high elasticity of bone also favors complete loss of tooth due to injury.  Tooth avulsion results in detachment of periodontal ligament fibers (PDL) and neurovascular bundles at the apex of tooth. Once outside the socket, the cells of pulp and periodontium begin to deteriorate. This is due to lack of blood supply and environmental factors. The most accepted treatment for an avulsed permanent tooth is immediate replantation.  Furthermore, avulsed primary tooth should not be re-implanted as it can damage developing permanent tooth bud. Functional healing was observed in teeth re-implanted within 1 h after the injury.  The success of replantation in permanent tooth is dependent on various factors like extra-alveolar time, storage medium, type of retention employed, time of endodontic intervention, type of drug prescribed, oral hygiene status as well as general health of the individual.  Hence, longer the time span between avulsion and replantation (extra oral time), poorer is the prognosis.
Children spend a considerable amount of waking hours in school where they are engaged in physical activities. Various studies have revealed that 16% of dental injuries occur in schools. , As children are incompetent to carry out emergency treatment of an avulsed tooth, the immediate caregivers are teachers. Since, school teachers are likely to be in contact with the child soon after the injury, their knowledge of emergency procedure is critical to ensure a better prognosis of the clinical treatment.  Since knowledge of school teachers is critical to the prognosis of avulsed tooth, the present study was undertaken to evaluate knowledge and attitude regarding the management of an avulsed tooth among school teachers of Patiala District, Punjab.
| Materials and Methods|| |
Ethics and informed consent
The present study was conducted on primary and secondary school teachers of tehsil Rajpura, Patiala District. Permission was sought from the block education officer (BEO) of the district to visit the schools. School authorities appraised the study and informed oral consent for completion of the questionnaire was obtained from each teacher prior to the start of the study. Ethical clearance was also obtained from the institutional authorities.
Study sample and sampling procedure
The study was a cross-sectional questionnaire survey of primary and secondary school teachers working in government aided and private schools in Patiala district. The list of the government aided and private schools was obtained from BEO for the survey. A total of 102 schools (both government and private) were there on the list. A two-stage sampling process was used which involved the sampling of schools within the educational district followed by sampling of teachers in the selected schools with an aim to ensure generalization of the results. Principals or Head of all the schools were contacted either telephonically or through E-mails to obtain permission for the study. Consent to participate in the study was given by 76 schools. Finally, 50 schools were included in the study based on the cluster random sampling technique. The calculation of sample size was performed to seek the results at 95% confidence level for which the size of the sample comes out to be 500. Ten teachers from each school who agreed to participate in the study were selected on the basis of simple random sampling to reach the desired sample.
The instrument used in the present study was a pretested self-structured questionnaire. The questionnaire was pretested on a group of school teachers who were not included in the main survey. The questionnaire was framed, and its validity was accredited by experts in the field of dentistry. The questionnaire comprising two parts, with a total of 18 questions was framed in English and Punjabi (regional language) and personally administered to the teachers [Figure 1]. The questionnaire comprised of close-ended questions, with alternate choices to help the respondents make a quick decision. Part-A of the questionnaire comprised of sociodemographic variables like teachers' education, teaching experience, type of education imparted to children, training in first-aid related to sports injuries etc., while part-B consisted of questions analyzing the respondent's knowledge and attitude regarding time of eruption of permanent teeth, knowledge regarding mouth guards, things to be done in case of tooth avulsion, storage and transport of the avulsed tooth. The completed questionnaires were collected on the same day within 15 min after the distribution and responses were later graded as 0 for an incorrect answer and 1 for a correct answer. Incomplete questionnaires were returned to the subjects to complete to ensure fulfillment of the sample. After the questionnaires had been collected, the teachers were given pamphlets and brochures containing educational material regarding tooth avulsion and its immediate management.
The collected data were transferred to a computer and statistically analyzed. Data analysis was done using frequency and percentages. Chi-square test was used for conducting analysis regarding influence of teachers' demographic factors on the management of avulsed tooth. The obtained values were evaluated using SPSS software (Chicago, IL, version 16.0 for Windows). Statistical significance was set at P < 0.05.
| Results|| |
A total of 500 primary and secondary school teachers from 50 schools participated in the study.
[Table 1] depicts the sociodemographic profile of the school teachers. 101 (20.2%) of them were males and 399 (79.8%) were females. The response to part A of questionnaire showed that 59% (295) of these teachers were postgraduates with 51.6% (121) having up to 10 years of working experience. However, only 9.2% (46) teachers were imparting physical education to the pupils. More than 70% (358) of teachers had not received any training in first aid methods in case of sports related injuries, and only 30.2% (151) received advice on emergency management of traumatized tooth.
Knowledge regarding teeth eruption and protective sport equipment
Percentage of subjects having knowledge regarding eruption time of teeth and protective sports equipment is depicted in [Table 2]. A nonsignificant relationship (P = 0.324) was found when education level of the school teachers was compared with awareness regarding mouth guards. However, subjects who received training in first aid were more aware regarding mouth guards as compared to others (P = 0.006) [Table 3].
|Table 2: Knowledge of subjects regarding time of eruption and protective sports equipment |
Click here to view
|Table 3: Comparison of education of teachers and training in first aid with replantation of tooth and awareness of mouth guards |
Click here to view
Managing or referring a case of avulsed tooth
[Table 4] depicts the knowledge of teachers regarding the management of avulsed tooth. The number of respondents having a previous experience of knocked out tooth in their presence in school premises was 17.2% (86). One-tenth (51) of the respondents were confident to manage a case of knocked out tooth. In case of a knocked out tooth, majority of respondents (58.2%, 291) will refer the child to a nearby dentist.
Time of treatment after tooth avulsion
Regarding the timing of treatment of knocked avulsed tooth, a vast majority of teachers (82.8%, 414) felt that treatment should be carried out immediately after injury, 4.8% (24) felt that treatment should be carried out during recess and 3.8% (19) were of the opinion that the treatment should be carried out during first 24 h [Figure 2]. However, knowledge regarding treatment timing was not influenced by subjects' training in first aid, subjects who received advice in dental trauma and who had previous experience with an avulsed tooth.
|Figure 2: Knowledge regarding time of treatment after avulsion among school teachers|
Click here to view
Replantation and cleaning of avulsed tooth
Only 41.8% (184) believed that knocked out permanent tooth should be replanted back into position. More number of post graduates agreed to the fact that tooth should be replanted after avulsion as compared to graduates and results were statistically significant (P = 0.008) [Table 3]. Moreover, statistically significant association was found between subjects who received training in first aid and who opted for replantation (P = 0.003). [Figure 3] depicts the view of the subjects toward cleaning of the avulsed tooth. Cleaning a knocked out tooth under tap water was cited by most of the subjects (30.2%, 151).
Storage of avulsed tooth during transportation
Various answers were given by the respondents when asked about the storage media for avulsed tooth during transportation [Figure 4]. Most common storage media was water which was cited by 24.6% (123) of study subjects. However, only 15.6% (78) of respondents believed that tooth should be stored in child's saliva during transportation. Surprisingly, 23.8% (119) of respondents were of the opinion that avulsed tooth is useless and time should not be spent in looking for it if it gets lost after avulsion. There was no co-relation between teaching experience of subjects and knowledge regarding storage media.
|Figure 4: Choice of respondents regarding transport media used to storing avulsed tooth|
Click here to view
| Discussion|| |
The present study investigated the knowledge of 500 primary and secondary school teachers in Patiala district. Only 9.2% of teachers were imparting physical education, indicating a dearth of physical education teachers in schools. Though primary caregivers in case of trauma in schools are teachers, but very low percentage (28.4%) of teachers in the present study had received any training in first aid which is in contrast to some other study conducted on teachers in Hong Kong.  Among the many accidents that occur at school, dental avulsion is one of the most common and teachers are often witnesses to this trauma.  However, in the present study only 17.2% of school teachers agreed to have previously witnessed a case of avulsed tooth in their teaching career which is dissimilar to some other study findings. 
Sports have been implicated in the etiology of trauma, and a high proportion of dental trauma at school occurred during classes of physical education. , However, findings of the present study revealed respondents were not aware of sports-related orofacial injuries as the majority of them thought that participating in sports is not dangerous. Use and knowledge regarding properly fitted mouth guards during sporting activities is highly recommended by many studies. , However, only half of the teachers were aware of mouth guards in the present study.
There was a significant difference in knowledge of post graduate and graduate respondents' regarding re-implantation of avulsed tooth (P > 0.05) signifying the impact of higher educational qualification on knowledge. Moreover, there was also significant impact of first aid training on respondent's knowledge regarding mouth guards. This could be due to the fact that first aid training covers basic life support as well as some aspects concerning dental trauma management. Hence, appropriate measures should be taken to diffuse information among school teachers regarding the use of mouth guards as a protective measure while engaging in contact sports like cricket, basketball, hockey, football, boxing, etc.
It was encouraging to find out that 58.2% respondents would refer the patient with an avulsed tooth to the local dentist which is in agreement with a study conducted on teachers in Saudi Arabia.  However, this finding was in contrast to findings of some other study conducted in Bangalore.  Only 3.8% of respondents found it acceptable to defer treatment till 24 h. Only 19% of respondents correctly answered regarding eruption time of permanent teeth in the present study which is in contrast to some other study findings.  Furthermore, a statistically significant association was found between knowledge regarding replantation of permanent tooth and level of education in teachers. Thus, signifying that awareness increases with increase in the level of education.
Immediate replantation of avulsed tooth is of absolute necessity in order to achieve a propitious sequel of the replanted tooth.  Hence, it is necessary for either the patient or someone else at the scene to replant the tooth immediately. In the present study, only 36.8% teachers agreed of replanting the tooth into the socket after avulsion. The reluctance on the part of teachers to replant the tooth could be related to lack of knowledge, fear of hurting the child, or the greater priority toward stopping the bleeding which can otherwise prove to be life threatening.  Knowledge of the most appropriate method to clean a dirty, knocked out tooth prior to replantation was investigated using a list of alternatives derived from the study reported by Hamilton et al.  In the present study, 25.6% of respondents believed that avulsed out tooth cannot be saved so no attempt should be made at cleaning it while 7.4% of respondents would clean the tooth with a toothbrush. Such an attitude can completely ruin the chances of a successful replantation of an avulsed tooth.
The success of replantation depends on a number of factors that may contribute to accelerate or minimize the occurrence of root resorption or ankylosis, among which is the type and characteristics of the medium used for temporary storage during the time elapsed between avulsion and replantation.  Hank's balanced salt solution is the best storage media  which was cited by only 15.8% of teachers. However, its use is not practical in India because of unavailability and high cost. An ideal storage medium should fit the following criteria: Ability to preserve or replenish cell viability, adherence and clonogenic capacity, and accessibility at the site of accident.  Propolis is yet another storage media that has been advocated lately by researchers  but it is not readily available in India. Milk has a very good capacity of maintaining the viability of PDL cells, but only 16% of respondents suggested milk as a storage media.  The other appropriate media are physiological saline and saliva. Only 17.4% and 15.6% of teachers chose normal saline and saliva respectively as suitable storage media. Alarmingly, 23.8% of respondents believed that the tooth is useless and time should not be wasted in looking for it. This shows a lack of knowledge among teachers regarding storage media.
| Conclusion and Recommendations|| |
The present study revealed that overall knowledge regarding the emergency management of avulsed tooth was low in school teachers of Patiala district. Very few had correct knowledge regarding proper handling and replantation of avulsed tooth. Loss of permanent tooth in a young child has psychological, functional, and esthetic consequences on the child and the parents. Replacement of avulsed tooth is costly and thus increases the economic burden on the society. The present study entails the need of first aid training to all the teachers along with emergency management of dental trauma. Utilization of pamphlets for education followed by power point presentation or flashcards to increase awareness among lay persons. Educational campaigns can be tailor made according to the geographical and cultural requirements. Further research is required to ascertain the effect of such promotional campaigns and first aid training on teachers.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
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.
Cortes MI, Marcenes W, Sheiham A. Impact of traumatic injuries to the permanent teeth on the oral health-related quality of life in 12-14-year-old children. Community Dent Oral Epidemiol 2002;30:193-8.
Loo TJ, Gurunathan D, Somasundaram S. Knowledge and attitude of parents with regard to avulsed permanent tooth of their children and their emergency management - Chennai. J Indian Soc Pedod Prev Dent 2014;32:97-107.
Shashikiran ND, Reddy VV, 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.
Ankola AV, Hebbal M, Sharma R, Nayak SS. Traumatic dental injuries in primary school children of South India - A report from district-wide oral health survey. Dent Traumatol 2013;29:134-8.
Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors 1. Diagnosis of healing complications. Endod Dent Traumatol 1995;11:51-8.
Blomlöf L, Lindskog S, Andersson L, Hedström KG, Hammarström L. Storage of experimentally avulsed teeth in milk prior to replantation. J Dent Res 1983;62:912-6.
Petrovic B, Markovic D, Peric T, Blagojevic D. Factors related to treatment and outcomes of avulsed teeth. Dent Traumatol 2010;26:52-9.
Karayilmaz H, Kirzioglu Z, Erken Gungor O. Aetiology, treatment patterns and long-term outcomes of tooth avulsion in children and adolescents. Pak J Med Sci 2013;29:464-8.
Abdellatif AM, Hegazy SA. Knowledge of emergency management of avulsed teeth among a sample of Egyptian parents. J Adv Res 2011;2:157-62.
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;16:44-51.
Karande N, Shah P, Bhatia M, Lakade L, Bijle MN, Arora N, et al.
Assessment of awareness amongst school teachers regarding prevention and emergency management of dentoalveolar traumatic injuries in school children in Pune City, before and 3 months after dental educational program. J Contemp Dent Pract 2012;13:873-7.
Young C, Wong KY, Cheung LK. Emergency management of dental trauma: Knowledge of Hong Kong primary and secondary school teachers. Hong Kong Med J 2012;18:362-70.
Al-Jundi SH, Al-Waeili H, Khairalah K. Knowledge and attitude of Jordanian school health teachers with regards to emergency management of dental trauma. Dent Traumatol 2005;21:183-7.
Kaur H, Kaur S, Kaur H. Prehospital emergency management of avulsed permanent teeth: Knowledge and attitude of school teachers. Indian J Dent Res 2012;23:556.
Sarkar S, Basu PK. Incidence of anterior tooth fracture in children. J Indian Dent Assoc 1981;53:371.
American Academy of Pediatric Dentistry. Policy on prevention of sports related oro-facial injuries. Paediatr Dent 2002-2003;24:32.
Trope M. Clinical management of the avulsed tooth: Present strategies and future directions. Dent Traumatol 2002;18:1-11.
Al-Obaida M. Knowledge and management of traumatic dental injuries in a group of Saudi primary schools teachers. Dent Traumatol 2010;26:338-41.
Caglar E, Ferreira LP, Kargul B. Dental trauma management knowledge among a group of teachers in two south European cities. Dent Traumatol 2005;21:258-62.
Andersson L, Bodin I. Avulsed human teeth replanted within 15 minutes - A long-term clinical follow-up study. Endod Dent Traumatol 1990;6:37-42.
Hamilton FA, Hill FJ, Mackie IC. Investigation of lay knowledge of the management of avulsed permanent incisors. Endod Dent Traumatol 1997;13:19-23.
Poi WR, Sonoda CK, Martins CM, Melo ME, Pellizzer EP, de Mendonça MR, et al.
Storage media for avulsed teeth: A literature review. Braz Dent J 2013;24:437-45.
Barrett EJ, Kenny DJ. Avulsed permanent teeth: A review of the literature and treatment guidelines. Endod Dent Traumatol 1997;13:153-63.
Ozer S, Yilmaz EI, Bayrak S, Tunc ES. Parental knowledge and attitudes regarding the emergency treatment of avulsed permanent teeth. Eur J Dent 2012;6:370-5.
Mori GG, Nunes DC, Castilho LR, de Moraes IG, Poi WR. Propolis as storage media for avulsed teeth: Microscopic and morphometric analysis in rats. Dent Traumatol 2010;26:80-5.
Marino TG, West LA, Liewehr FR, Mailhot JM, Buxton TB, Runner RR, et al.
Determination of periodontal ligament cell viability in long shelf-life milk. J Endod 2000;26:699-702.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]