The Status of Knowledge Related to the Emergency Management of Avulsed Tooth amongst the Medical Practitioners of Nagpur, Central India
Suryakant Kumar1, Arunkumar B. Sajjanar2, Milind Athulkar3, Jayashree Sajjanar4, Akhilesh Shewale5, Milind Wasnik6, Pali Dhongde7, Ankita Moon8
1Reader, Department of Pedodontics and Preventive Dentistry, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra, India.
2Reader, Department of Pedodontics and Preventive Dentistry, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra, India.
3Postgraduate Student, Department of Pedodontics and Preventive Dentistry, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra, India.
4Senior Lecturer, Department of Prosthodontic, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra, India.
5Senior Lecturer, Department of Periodontology, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra, India.
6Postgraduate Student, Department of Pedodontics and Preventive Dentistry, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra, India.
7Postgraduate Student, Department of Pedodontics and Preventive Dentistry, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra, India.
8Postgraduate Student, Department of Pedodontics and Preventive Dentistry, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Akhilesh Shewale, Senior Lecturer, Department of Periodontology, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra, India.
E-mail: akhileshshewale@gmail.com
Introduction
Tooth avulsion is a frequently reported traumatic injury amongst young children and whenever it occurs, the parents or teachers of those children often seek the help of Medical Practitioners to provide the first line of treatment. Therefore, the general physician’s knowledge regarding the same is an important issue to be taken into consideration.
Aim
To assess the knowledge, attitude and practice of general medical practitioners of Nagpur city of Central India regarding emergency management of avulsed tooth and highlight the importance of avulsed tooth education in schools and medical colleges in order to increase the knowledge of the same among teachers, parents and general physicians.
Materials and Methods
A cross-divtional survey was carried out amongst 1045 medical doctors after a comprehensive search made in Google database using the keywords “Medical”, “doctors” “Nagpur”. Data regarding the emergency management of avulsed tooth was collected using a self administered close ended questionnaire.
Results
A total of 1045 medical practitioners (718 males, 327 females) voluntarily participated in this survey. It was observed that 56.8% of the medical practitioners had no prior knowledge of management of an avulsed tooth. A 81.6% of practitioners were unaware of transport medium for an avulsed tooth whereas, more than half practitioners (64.7%) were naive about an ideal time for replantation of an avulsed tooth. A little more than one third of the practitioners (26.5%) were unacquainted about the method of holding an avulsed tooth.
Conclusion
Regardless of the level of education, the general medical practitioners of Nagpur lack most of the knowledge required for the emergency management of an avulsed teeth. Keeping the in mind the present scenario, it was recommended that education regarding avulsed tooth should be incorporated in school and medical curriculum to increase awareness among parents, teachers and medical practitioners. Also, it is the responsibility of the dentist to make the society aware of this situation.
Introduction
Tooth avulsion implies total displacement of an intact tooth out of its socket. The frequency of tooth avulsions following traumatic injuries ranges from 0.5% to 16% in permanent dentition and from 7% to 13% in the primary dentition [1-3]. It has been suggested that the avulsion of the tooth is briefly favoured by the malleability of the alveolar bone and thin structured periodontal ligament.
The permanent anterior teeth apart from being an essential component of the aesthetic zone, is also essential for day to day communication, mastication and psychological and mental health of children. Thus keeping this in mind, immediate replantation of an avulsed permanent tooth is often considered as the treatment of choice which can aid in enhanced self confidence and improved self perception of the children [4].
A moderately high prevalence of dental trauma in 6-11-year-old children (prevalence of avulsion: 5.83 per thousand children) was reported in a South Indian district wide oral health survey [5] as compared with an United Kingdom Children’s Dental Health Survey [6] (prevalence of avulsion: 3.0 per thousand children).
Primary health centers, the basic unit of primary health care in India, do not have the provision for dental care. Owing to which many avulsed teeth are lost only because of lack of knowledge amongst the care takers about the proper first aid procedures that need to be provided. Consequently, dental health education in this field can be very effective in reducing the negative consequences of such injuries.
Whenever the children suffered with an avulsed tooth, the parents or school children are the first one to provide them the attention required and very often the children is taken to a nearby medical practitioners for the primary management. To ensure proper and appropriate treatment of the avulsed tooth, it is essential that medical professionals should have adequate knowledge and sufficient training in the basic principles of the emergency management of traumatic injuries [7,8].
Few studies in literature assessed the knowledge of medical professionals regarding this situation [9-11] including two studies in South India carried out in Puducherry [12] and Telangana states of India [13]. However, no such study was carried out in Central India. Owing to this paucity in literature, the present study was designed to assess the knowledge and attitude of medical professionals in Nagpur city towards emergency management of an avulsed tooth in an attempt to impart the importance of avulsed tooth education in schools and medical colleges to increase the knowledge among teachers, parents and general physicians.
Materials and Methods
The current study was a cross-sectional survey conducted in Swargiya Dadasaheb Kalmegh Smruti Dental college and Hospital, Nagpur amongst the medical practitioners in and around Nagpur city to assess their knowledge, awareness and practice management of avulsed tooth of the children. A nine item English-language questionnaire, which was a modified version of the questionnaire used by Jyothi KN et al., was developed and pretested in a group of Pedodontists [14]. The final questionnaire consisted of nine multiple choice questions regarding the emergency management of an avulsed tooth meant to assess the knowledge regarding its meaning, immediate management, critical extra-alveolar time, optimal storage methods and media, proper cleaning technique of a grossly contaminated avulsed tooth before replantation and its proper handling [Table/Fig-1]. The survey was administered to the medical practitioners in various private and governmental hospitals, clinics, polyclinics in and around Nagpur.
| Sr. No | Questionnaire |
|---|
| I. | Meaning of an avulsed tooth?1)Total dislodgement of intact tooth out of its socket.2)Partial dislodgement of intact tooth out of its socket.3)Dislodgement of fractured segment of the intact tooth.4)Don’t Know. |
| II | Any prior knowledge about management of avulsed tooth:1)Yes2)NoIf “Yes” what is the source of information:a)CDE programme.b)Health talks on TV, radio.c)Conference, convention.d)During tenure of medical course.e)Others. |
| III | Have you ever come across a patient with avulsion?1)Yes2)NoIf “Yes” what did you do?a)Refer to dentist.b)Try for replantation.c)Instruct patient to preserve tooth in saline until appointment.d)Discard the tooth. |
| IV | Do you ever heard about transport medium?1)Yes2)NoIf “Yes” what is the source of informationa)CDE programme.b)Health talks on TV, radio.c)Conference, convention.d)Dentist Friend.e)Others. |
| V. | Best medium to preserve the tooth?a)Waterb)Salinec)Salivad)Milke)Antisepticf)Paperg)Don’t know |
| VI. | Ideal time for replantation of the avulsed tootha)15 minsb)30 minsc)45 minsd)1 Hour e)After few daysf)Don’t know |
| VII. | You encounter a patient with knocked out tooth and it is dirty, will youa)Wipe the tooth with a tissue paper.b)Clean the tooth with a tooth brush.c)Rinse the tooth gently under running tap water for a few seconds without scrubbing it.d)No need to clean the tooth because it is useless. |
| VIII. | How to hold an avulsed tooth?a)From the crown.b)From the root.c)Anywhere (crown or root).d)Don’t know. |
| IX. | Would you care if avulsed tooth were primary tooth?1)Yes2)No |
A comprehensive search in Google database of medical practitioners was made in and around Nagpur city. In addition to this a manual list of doctors working in government hospitals and primary health centres was prepared. The search resulted in total 1125 medical professionals in and around Nagpur city out of which 1045 medical practitioners representing 92.88% of all practitioners took participation in the study over a period of five months starting in February 2016 using convenience sampling methodology. Four of the co-investigators participated in the data collection process and approached each of the prospective participants individually in person. The willingness of the medical practitioners was sought by completing the anonymous questionnaire and informed consent was obtained. No personal information on the practitioners’ identities was required to be disclosed. Practitioners who were willing to participate were given the questionnaire, and after completion, they returned the questionnaire immediately to the co-investigators.
Statistical Analysis
The data obtained from the survey were manually entered into a Statistical Package for the Social Sciences database (IBM, SPSS version 20.0, IL, USA). Chi-Square test was used for data analysis with a significance level established at p< 0.05.
Result
A total of 1045 medical professionals responded positively to the given questionnaire in the present cross-sectional survey. The demographic characteristics of the study population are shown in [Table/Fig-2].
Demographic characteristics of the study population.
| Variables | | Total N=1045, n (%) |
|---|
| Gender /Age (mean) | MaleFemale | 718 (68.71)/34.45±12.36327(31.29)/32.25±11.55 |
| Educational qualification | GraduatePostgraduate | 745 (71.29)300 (28.71) |
| Current employment | GovernmentPrivate | 379 (36.26)666 (63.74) |
The responses of the participants to the questionnaire and their percentage were shown in [Table/Fig-3].
Percentage wise distribution of responses.
| Sr. No | Questionnaire | Total %(n) | X2Value | p-value |
|---|
| I. | Meaning of an avulsed tooth?1. Total dislodgement of intact tooth out of its socket2. Partialdislodgement of intact tooth out of its socket3. Dislodgementof fractured segment of the intact tooth4. Don’tKnow | 67.5 (706)12.76 (133)11.04 (115)8.7 (91) | 7.88 | 0.002* |
| II | Any prior knowledge about management of avulsed tooth1. Yes2. NoIf “Yes” what is the source of informationa)CDE programmeb)Health talks on TV, Radioc)Conference, conventiond)During tenure of medical coursee)Others | 43.2 (451)56.8 (594)6.4 (29)4.4 (20)076.5 (345)12.7 (57) | 10.66 | 0.001* |
| III | Have you ever come across a patient with avulsion?YesNoIf “Yes” what did you do?a)Refer to dentistb)Try for replantationc)Instructpatient to preserve tooth in saline until appointmentd)Discard the tooth | 37.2 (389)62.8 (656)95.4 (371)3.4 (13)01.2 (5) | 12.8 | 0.0017* |
| IV | Do you ever heard about transport medium?1. Yes2. NoIf “Yes” what is the source of informationa)CDE programmeb)Health talks on TV, Radioc)Conference, conventiond)Dentist Friende)others | 18.4 (192)81.6 (853)33 (63)61.6 (118)5.4 (11) | 14.9 | 0.004* |
| V. | Best medium to preserve the tooth?a)Waterb)Salinec)Salivad)Milke)Antisepticf)Paperg)Don’t knw | 3.6 (38)59.7 (624)7.4 (77)5.6(58)4.7(49)1.4 (15)17.6 (184) | 13.8 | 0.001* |
| VI. | Ideal time for replantation of the avulsed tootha)15 minsb)30 minsc)45 minsd)1 Houre)After Few daysf)Don’t know | 4.4(46)6.5(68)2.56 (27)16.4 (171)5.4 (57)64.7 (676) | 9.49 | 0.04* |
| VII. | You encounter a patient with knocked-out tooth and it is dirty, will youa)Wipe the tooth with a tissue paperb)Clean the tooth with a tooth brushc)Rinse the tooth gently under running tap water for a few seconds without scrubbing it.d)No need to clean the tooth because it is useless | 5.2 (54)1.9 (20)86.5 (904)6.4 (67) | 16.3 | 0.0021* |
| VIII. | How to hold an avulsed tooth?a)From the crownb)From the rootc)Anywhere (crown or root)d)Don’t know | 48.7 (509)17.6 (184)7.2 (75)26.5 (277) | 20.3 | 0.01* |
| IX. | Would you care if avulsed tooth were primary tooth?1. Yes2. No | 42.4 (443)57.6 (602) | 22.5 | <0.023* |
Test applied : Chi-square test applied
p<0.05 considered as significant
Discussion
It was seen that more than half of the participants i.e., 56.8% had no prior knowledge regarding the management of an avulsed tooth. These findings were nearly similar to the study by, Abu-Dawoud M et al., Walker A et al., Venkataramana M et al., and Dali M et al., [9,10,13,15]. However, the findings of the present study seem quite lower than reported studies showing a fair knowledge of management of an avulsed tooth amongst the medical professionals in and around Nagpur city.
Almost, 95.4% of the practitioners amongst those who came across patients reported with an avulsed tooth preferred to refer the patient to dentist, which is quite higher with the results of K. Subhashraj K et al., (52%), Venkataramana M et al., (60%), Young C et al., (32.8%) [12,13,16]. These findings show a better rapport between the medical practitioners and dentists in the city.
The available literature regarding the use of storage medium shows a wide array of mediums to be used for an avulsed tooth like saline, milk, saliva. However, there has been no concensus suggested regarding the ideal storage medium. Majority of the participants (81.6%) of the present study lacks the knowledge regarding the transport medium and those who were aware, choose saline (59.7%) as the best storage medium, owing to its availability and known antibacterial action.
“Replantation time” is a critical factor for the good prognosis of an avulsed tooth [17]. Periodontal cells integrity and tooth vitality are the main factors for tooth replantation which depends upon the extraoral time of an avulsed tooth. Andreasen JO et al., suggested that 90% of teeth replanted within 30 minutes did not develop root resorption and prognosis was better [7]. In our study, 64.7% practitioners were unaware regarding the ideal time of tooth replantation whereas, 16.4% participants told that they would replant the tooth into the socket within one hour and only 6.5 % reported that they will replant it within 30 minutes. These findings were much lesser when compared to that obtained by Zhao Y and Gong Y where 88.5% of the participants responded that they replant the tooth within 30 min. The reason might be attributed to lack of knowledge regarding the same during their medical courses [18].
Knowledge of cleaning a knocked out dirty avulsed tooth is an important aspect to be kept in mind while dealing with an avulsion injury. In the present study, 78% participants preferred to clean the avulsed tooth under running tap water for few seconds without scrubbing it, but in the survey [19] conducted, it was reported that 89.5% participants would rinse the tooth under running tap water without scrubbing. This shows that our respondents were unaware that they were minimizing the chances of replantation.
Majority of the participants (57.6%) would not care if the knocked out tooth were primary. These findings were lesser as compared to the findings of Venkatramana M et al., (66.15) [13]. This shows that our participants were unaware that they can damage the permanent successor.
The findings of our survey highlight the present scenario of knowledge, attitude and practice of management of an avulsed tooth amongst them medical professionals. It was observed that there is lack of proper knowledge amongst the practitioners.
Limitation
Validity of the responses could be biased owing to the respondent’s willingness to answer particular questions.
Conclusion
It can be concluded that, regardless of the level of education, the medical professionals in and around Nagpur were quite aware about an avulsed tooth but were lacking most of the knowledge required for emergency management of avulsed teeth and usually they preferred to refer the patient to the dentist for the same. In order to provide a proper management of an avulsed tooth, it is the need of the hour that the dentist should impart education to the parents, school teachers and general medical practitioners through health check up camps, Continuing Dental Educations (CDE) and Continuing Medical Education (CME) programmes. Also, it is suggested that the education regarding the same should be the part of schools and medical curriculum.
Test applied : Chi-square test appliedp<0.05 considered as significant
[1]. Gelbier S, Injured anterior teeth In children. A preliminary discussion Br Dent J 1967 123:331-35. [Google Scholar]
[2]. Hedegard B, Stalhane I, A study of traumatized permanent teeth in children 7-15 years I Sven Tandlak Tidskr 1973 66:431-52. [Google Scholar]
[3]. Ravn JJ, Dental injuries in Copenhagen school children, school years 1967-1972 Community Dent Oral Epidemiol 1974 2:231-45. [Google Scholar]
[4]. Shashikiran ND, Reddy VVS, Nagaveni NB, Knowledge and attitude of 2000 parents (Urban and rural-1000 each) with regard to avulsed permanent incisors and their emergency management and around Davanagere J Indian Soc Pedo Prev Dent 2006 24:116-21. [Google Scholar]
[5]. 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 Traumotol 2013 29:134-38. [Google Scholar]
[6]. O’Brien M, Children’s dental health in the United Kingdom 1993 1994 LondonHMSO [Google Scholar]
[7]. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM, Replantation of 400 avulsed permanent incisors. Diagnosis of healing complications Endod Dent Traumatol 1995 11(2):51-58. [Google Scholar]
[8]. Andreasen JO, Andreasen FM, Andersson L, Textbook and colour atlas of traumatic injuries to the teeth 1994 4th edCopenhagen, DenmarkMunksgaard [Google Scholar]
[9]. Abu-Dawoud M, Al Enezi Andersson L, Knowledge of emergency management of avulsed teeth among young physicians and dentist Dental Traumatology 2007 23:348-55. [Google Scholar]
[10]. Walker A, Brenchley J, It’s a Knock out: Survey of the management of avulsed teeth Accident and Emergency Nursing 2000 8:66-70. [Google Scholar]
[11]. Stokes AN, Anderson HK, Cowan TM, Lay Professional knowledge of method for emergency management of avulsed teeth Dental Traumatology 2008 24:325-29. [Google Scholar]
[12]. Subhashraj K, Awareness of management of dental trauma among medical professionals in Pondicherry India Dental Traumatology 2009 25:92-94. [Google Scholar]
[13]. Venkataramana M, Pratap K, Padma TM, Kalyan VS, Bhargava A, Varma LS, Knowledge and attitude of medical professionals towards emergency management of avulsed tooth in a teaching medical hospital, Khammam Town, South India J Indian Assoc Public Health Dent 2015 13:183-87. [Google Scholar]
[14]. Jyothi KN, Venugopal P, Nanda S, Shah M, Knowledge and attitude of medical doctors towards emergency management of avulsed tooth- A cross sectional survey Journal of Dental Sciences and Research 2011 2(1):156-67. [Google Scholar]
[15]. Dali M, Naulaka D, Rajbanshi L, Knowledge, attitude and practice in emergency management of avulsed tooth among medical doctors in Nobel Medical College, Biratnagar, Nepal: A cross sectional survey Int J Dent Health Sci 2014 1:03-12. [Google Scholar]
[16]. 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. [Google Scholar]
[17]. Ram D, DrOdont Nestor CohencaTherapeutic protocols for avulsed permanent teeth: review and clinical update Pediatr Dent 2004 26:251-55. [Google Scholar]
[18]. Zhao Y, Gong Y, Knowledge of emergency management of avulsed teeth: a survey of dentists in Beijing China Dent Traumatol 2010 26:281-84. [Google Scholar]
[19]. Halawany HS, Al Jazairy YH, Al Hussainan NS, Al Maflehi N, Jacob V, Abraham NB, Knowledge about tooth avulsion and its management among dental assistants in Riyadh, Saudi Arabia BMC Oral Health 2014 14:46 [Google Scholar]