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ORIGINAL ARTICLE  
Year : 2011  |  Volume : 1  |  Issue : 1  |  Page : 18-23
Knowledge of upper primary and secondary school physical education instructors in Davangere city, India, about emergency management of dental trauma


1 Department of Community Dentistry, College of Dental Sciences, Davangere, India
2 Department of Pedodontics and Preventive Dentistry, V S Dental College and Hospital, Bangalore, Karnataka, India

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Date of Web Publication6-Mar-2012
 

   Abstract 

Background: Injury to both, primary and the permanent dentitions and their supporting structures is one of the most common dental problems seen in children. Studies on dental trauma have shown that most dental accidents in children occur at home, followed by school. The prognosis of traumatized teeth depends on prompt and appropriate treatment, which often relies on people such as the child's parents and school teachers who are present at the site of accident, prior to the initial dental contact, and who may have only little information about the prompt steps that need to be taken incase such a traumatic injury occurs.
Objective: The objective of this study was to assess the knowledge of upper primary and secondary school Physical Education instructors in Davangere city, India, about emergency management of dental trauma.
Materials and Methods: A total of 109 physical education instructors from 87 upper primary and secondary schools were included in the questionnaire based survey.
Results: Majority of the respondents said that their training included first aid training. Only 10.1% recalled that their course covered management of dental trauma. Although about 70% of the respondents were aware about management of fractured tooth, the knowledge regarding avulsed tooth was poor. Vast majority of the respondents felt that they required further training to manage such trauma cases. Over 70% of teachers indicated that it was urgent to seek professional help for tooth avulsion; however, they had little knowledge regarding correct procedures for replanting and storing avulsed tooth.
Conclusion: Although the upper primary and secondary school physical education teachers in Davangere city had good knowledge of first aid, the knowledge on management of dental trauma remained inadequate.

Keywords: Dental trauma, replantation, tooth avulsion, tooth fracture

How to cite this article:
Subramaniam R, Mittal S, Hiregoudar M, Mohandas U, Sakeenabi B, Prashant G M, Chandu G N. Knowledge of upper primary and secondary school physical education instructors in Davangere city, India, about emergency management of dental trauma. J Educ Ethics Dent 2011;1:18-23

How to cite this URL:
Subramaniam R, Mittal S, Hiregoudar M, Mohandas U, Sakeenabi B, Prashant G M, Chandu G N. Knowledge of upper primary and secondary school physical education instructors in Davangere city, India, about emergency management of dental trauma. J Educ Ethics Dent [serial online] 2011 [cited 2019 Sep 21];1:18-23. Available from: http://www.jeed.in/text.asp?2011/1/1/18/93412



   Introduction Top


Injury to both, primary and the permanent dentitions and their supporting structures is one of the most common dental problems seen in children. Dental trauma may exceed dental caries and periodontal disease as the most significant threat to dental health among young people, and is accompanied by significant economic consequences. It has been shown that when a child reaches school age, accidents in the school environment, in the form of falls are very common and are the main cause of traumatic tooth injuries. [1],[2],[3] Dental trauma can vary from a minor enamel chip to extensive maxillofacial damage involving the supporting structures and displacement or avulsion of teeth. It can result in functional and aesthetic disturbances which concern both the patients and their parents. [1]

Epidemiological studies of dental trauma have shown that most dental accidents in children occur at home, followed by school. It was reported that sport and school injuries accounted for 60% of dental trauma. [1]

Within the dental profession, it is generally accepted that the prompt and appropriate management of traumatic dental injury is an important determinant of prognosis. This is particularly true in relation to avulsed permanent incisors, where the well being of tooth directly depends on the length of time for which it is out of mouth and the medium in which it is stored. [4] The prognosis of traumatized teeth depends on prompt and appropriate treatment, which often relies on people such as the child's parents and school teachers who are present at the site of accident, prior to the initial dental contact, and who may have only little information about the prompt steps that need to be taken incase such a traumatic injury occurs. [2] Studies that have been conducted to assess this knowledge among lay persons, particularly on parents and school teachers have shown the general knowledge regarding management of dental trauma to exist only at a basic level. [4] Since sports have been implicated in the aetiology of dental trauma, and a high proportion of dental injuries at school occur during classes in physical education, it would be desirable for coaches and teachers of physical education to be capable of managing such injuries when they occur. [1],[2]

Objective

The objective of this study is to assess the knowledge of upper primary and secondary school physical education instructors in Davangere city, India, about emergency management of dental trauma.


   Materials and Methods Top


The target population was upper primary and secondary school teachers involved in physical education (PE) classes. The list of schools with PE teachers was obtained from the Block Education Officer of Davangere City. The schools in Davangere city were divided into six clusters. A total of 109 PE teachers from 87 upper primary and secondary schools, from all the six clusters, who gave an informed consent to participate in the study, were included in the questionnaire based survey.The questionaire used in the study was similar to the questionnaire used in a study conducted by Chan AWK et al. in Hong Kong. [1] The questionnaire was divided into three parts. The first part consisted of questions on personal and professional data including age, sex, teaching experience and first aid training background. The second part contained four questions based on two imaginary cases of dental injuries. The first case depicted a mild accident of uncomplicated crown fracture, while the second was a more severe scenario that involved an avulsion. The third part of the questionnaire had eight multiple-choice questions on the knowledge regarding management of avulsed teeth. All questions in the questionnaire were close-ended.

To help the respondents make quick decisions, they were given alternative choices, which resemble real situations with dental trauma. All returned questionnaires were coded and analyzed. Results were expressed as a number and percentage of respondents for each question; and, were analyzed using the Statistical Package for the Social Sciences (SPSS) Version 17 software. Chi-square test was performed and the level of significance was set at P=0.05. Ethical clearance for conducting the study was obtained from the Ethical Committee of the college.


   Results Top


Part I: Respondent's profile

Of the 109 respondents, 68.8% (n=75) were males and 31.24% (n=34) were females. 32.1% (n=38) were aged between 20 and 30 years and 37.6% (n=41) were aged between 31 and 40 years. 32.1% (n=35) of the respondents had less than five years of teaching experience and 7.3% (n=8) had more than 20 years. Majority of the respondents, 87.2% (n=95) said that their teachers training included first aid training while 38.5% (n=42) had formal first aid training on their own. Only 10.1% (n=11) recalled that their course covered management of dental trauma, and 24.7% (n=27) attended course on management of dental trauma on their own after graduation.

Part II: Case study

In this section, teachers were questioned about their knowledge on the emergency management of two imaginary cases of dental trauma. The first case was on fractured teeth and the second one on tooth avulsion.

Case I: Fractured teeth

In the first question, teachers were asked whether the damaged teeth of an 8 year old girl child were primary or permanent teeth. Of the respondents only 45.9% (n=50) gave the correct answer and 15.6% (n=17) were not sure.In the second question, the teachers were asked about their action towards the above case. Among them 38.5% (n=42) would take her to the dentist immediately, and 35.8% (n=39) responded that they would contact her parents and ask them to take her to dentist. There was statistically significant difference among sexes (P=0.04) and age (P=0.002).

Case II: Tooth avulsion

In the first question, teachers were asked to imagine a case in which a 13 year old boy got hit in his mouth by his colleague in a football game and his mouth was bleeding and upper front tooth was found to be missing. The responses were as follows: 54.1% (n=59) of the respondents would ask the boy to hold the tooth carefully in his mouth and take him to a nearby dentist. 42.2% (n=46) would sideline the injured boy and make him bite on a handkerchief to prevent bleeding. There was a statistically significant difference among the teachers who attended and did not attend the course on management of dental trauma (P=0.02). Most of the respondents, 87.2% (n=95) felt that they required further training to manage such trauma cases.

Part III: Knowledge on management of avulsed teeth

The third part of the questionnaire consisted of 8 questions which requested the respondents to select from a list of advice on management for an avulsive injury. 62.4% of the respondents (n=68) had no previous experience on dental trauma management. When the teachers were asked about the first place of contact following dental trauma, 51.3% (n=56) responded that they would take the child to dental hospital and 39.4% (n=43) responded that they would take the child to a dentist. The rest opted to take the child to general hospital (n=8) or medical doctor (n=2). When the teachers were asked regarding the urgency in seeking professional help for a tooth avulsion injury, 73.4% (n=80) considered it necessary to seek professional help immediately. There was a statistically significant difference with teaching experience (P=0.01). Only 22.9% (n=25) of the respondents would themselves replant the tooth into the socket from which it came out.

Of the respondents who would replant the tooth back, 60% (n=15) would rinse the tooth under tap water and 32% (n=8) would scrub the tooth gently with the tooth brush prior to replantation. There was a statistically significant differenceamong the teachers who attended and did not attend the course on management of dental trauma (P=0.05).Respondents were asked about the method of transport of avulsed teeth. 32.1% (n=35) would carry the tooth in a paper tissue or a clean handkerchief, 25.6% (n=28) would use a plastic wrap, 22.9% (n=25) would carry in any liquid media. Only 11.9% (n=13) would place it in a child's mouth. There was a statistically significant difference among the teachers who attended and did not attend the course on management of dental trauma (P<0.001). When the transport medium was narrowed down to liquid, 32.1% (n=35) chose antiseptic solution, 20.18% (n=22) chose ice water, and only 9.1% (n=10) chose either fresh milk or normal saline. There was a statistically significant among the teachers who attended and did not attend the course on management of dental trauma (P<0.001).

[Table 1] shows response by the physical education teachers included in the study to questions related to first aid knowledge.
Table 1: First aid knowledge among physical education teachers included in the study

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[Figure 1] shows response by the physical education teachers included in the study when they were asked whether damaged front teeth in case I were primary or permanent.
Figure 1: Response by the physical education teachers included in the study when they were asked whether damaged front teeth in case I were primary or permanent

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[Figure 2] shows response by the physical education teachers included in the study when they were asked about what actions would they would consider appropriate in case I.
Figure 2: Response by the physical education teachers included in the study when they were asked about what actions would they would consider appropriate in case I

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[Figure 3] shows response by the physical education teachers included in the study when they were asked about what actions they would take in case II.
Figure 3: Response by the physical education teachers included in the study when they were asked about what actions they would take in case II

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[Figure 4] shows response by the physical education teachers included in the study when they were asked if they required any further training to manage dental trauma cases.
Figure 4: Response by the physical education teachers included in the study when they were asked if they required any further training to manage dental trauma cases

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[Table 2] shows knowledge of the physical education teachers included in the study about management of avulsed teeth.
Table 2: Knowledge of the physical education teachers included in the study about management of avulsed teeth

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   Discussion Top


The present survey included 109 physical education teachers from 87 Upper Primary and Secondary schools in Davangere City, India. Most of the physical education instructors were males (68.8%). The results are similar to the results of a study conducted by Mohandas U and Chandan GD in Bangalore in 2009. [5] Majority of the respondents were less than 40 years of age (75.6%) and had more than 5 years of teaching experience (68%). It is a promising finding that majority of the teachers (87.2%) had received first aid training. In similar studies conducted in Hong Kong, [1] United Kingdom [4] and Bangalore, [5] it was seen that the corresponding figures were 99.4%, 57.8% and 95% respectively. Only 38% of the respondents had further first aid training on their own, indicating that many of them did not update their knowledge on first aid training after their graduation.

Very few respondents (10.1%) recollected that the first aid course covered emergency management of dental trauma which indicates that management of dental injuries is not given much importance in the curriculum.The two imaginary cases in Part II of the questionnaire were designed to test the respondent's general knowledge of the two different types of dental injuries. The ages of the injured children were intentionally selected as 8 and 13 years, respectively because children between these ages carry the greatest risk of sports related dental injuries. [1] In Case I, less than half (45.9%) of the respondents recognized that the maxillary incisor is a member of the permanent dentition in an 8 year old. This indicates that the general dental knowledge of the surveyed group was inadequate. The results are comparable to the study conducted in Hong Kong and England [1] and in contrast to the studies conducted in Porto and Istanbul. [6] The prognosis of a fractured incisor depends on the extent of involvement and the patient's age. It is unreasonable to expect a PE teacher to make appropriate diagnosis or make decisions about the injury. Thus, the most appropriate response was to take the child to the dentist or contact her parents and ask them to take their child to dentist. By these criteria, over 71% of the teachers would have acted appropriately and the results are similar to the Hong Kong study [1] and in contrast with the studies conducted in Istanbul and Porto. [6]

For case II, the ideal treatment for avulsed teeth is immediate replantation. Failing that, one should ensure minimal further insult to the periodontal ligament cells on the root surface of an avulsed tooth. [1] Over half of the respondents (54.1%) answered that they would ask the injured boy to hold the tooth in his mouth and take it to the nearby dentist. Majority of the respondents (73%) who had attended a course on management of dental trauma opted for the same answer. About 42.2% of the respondents would sideline the injured boy and make him bite on a handkerchief to prevent bleeding, suggesting that they were more concerned with controlling the bleeding first. In the study conducted in Bangalore by Mohandas U and Chandan GD, [5] the corresponding figure was 57.5%. This may be a reflection of basic life support provided in the first aid training. Unfortunately, the child would not benefit from this maneuver because undue delay in replanting the tooth will jeopardize its prognosis.

Vast majority of the respondents (87.2%) agreed that they needed further training to manage such cases admitting their lack of knowledge regarding management of dental trauma, which was similar to the results obtained in Bangalore study (96.5%). [5] It was revealed in Part III of the questionnaire that over 37% of the respondents had previous direct or indirect experience of an avulsive injury. The results were similar to the Istanbul study. [6] When confronted with an accident involving an avulsed tooth, half of the respondents would contact a dental hospital and about 40% would contact a nearby dentist. Rest of the respondents (9%) preferred to contact a medical doctor or general hospital. These results are in striking contrast with the results obtained in the Bangalore study [5] in which the 34.9% of the respondents preferred to contact a medical doctor or a general hospital. The higher percentage of those seeking help from dental hospital may be related to the inexpensive, however, accessible quality dental care in dental hospitals of Davangere city.

Most teachers (73.4%) recognized the urgency of seeking professional assistance for avulsive injuries. Only 2.6% of respondents considered a one day extraoral period prior to replantationto be acceptable. The observations were similar to studies conducted in United Kingdom, [4] Hong Kong, [1] Istanbul and Porto. [6]

It is noteworthy that 22.9% of teachers would themselves put the tooth back into the socket from which it came. It is similar to the study conducted in Bangalore [5] and in contrast to study conducted in Hong Kong. [1] Of them 60% teachers would rinse the tooth under tap water and 32% would scrub the tooth gently with a toothbrush before replantation. In the Bangalore study, [5] the corresponding figures were 45.1% and 15.3%, respectively. Majority of the respondents who had attended course on management of dental trauma would rinse the tooth under tap water before replantation.

When questioned about the ideal storage media for transport of avulsed tooth, one third of teachers chose paper tissue or handkerchief. One fifth of respondents preferred ice/ice water. This may be related to the popular use of ice for transportation of human organs and accidentally detached limbs. [1] One third of the respondents suggested the use of an antiseptic solution. Their intention was to kill the germs on the root surface; however, they did not realize that the viable cells of the tooth would also be damaged simultaneously. Only teachers who had attended course on management of dental trauma suggested carrying the avulsed tooth in the child's mouth or in milk, highlighting the effectiveness of such programmes. Many such programmes and seminars regarding dental trauma management will definitely have an impact on the teachers as concluded by a study conducted in United Kingdom, [2] Israel [7] and Kuwait. [8]

The loss of permanent teeth is a painful and irreversible injury. Although restoration of the damaged dental tissues can be highly effective in modern dentistry, this is usually very expensive. Most health care providers and educators would agree that prevention of injury is a more desirable course of action than dealing with the consequences, which usually means the treatment of injury. Therefore the best treatment for the dental trauma would be prevention of injury, and as it is very rightly said, " Prevention is better than cure". [1]

Unfortunately, even in the dental field, the prevention of accidental trauma to the teeth is perhaps overshadowed by the tremendous interest worldwide in the prevention and control of other dental diseases. [1]

School teachers should ensure a safe environment during physical education lessons. The identification of causal factors and high-risk groups are important for the design of appropriate preventive measures. The aim would be to reduce incidents such as collisions, fights and falls, which are the main etiological factors for dental trauma. [1]

Many dento-alveolar injuries can be prevented by the use of well-fitted, properly constructed mouthguards in any sport in which there is a risk of sudden impact to the face. It is the responsibility of physical education teachers and sports coaches to identify potentially dangerous sports in their area; and, recommend the use of mouthguards. However, the use of mouthguards is limited due to a lack of perceived need for them, and lack of information provided to parents of children who participate in contact sports. The minor effort to ensure mandatory dental protection for all players involved in contact sports would have major effects in preventing unnecessary dental injuries, and associated lifelong discomfort, as well as reducing the high treatment costs involved. [1] However, dental injury can happen even when proper precautions are taken and emergency treatment usually has to be provided by lay persons prior to the initial dental contact. The recognition of this important role for lay persons has resulted in attempts to educate the public in this respect in many countries. Prevention campaigns can start with the provision of information to the public about the appropriate first aid, and its relationship to improved long-term prognosis in many trauma situations; and, this can improve public awareness of the need for emergency care. [1] Unfortunately, no such campaign has been carried out in India as of now.

Dental injury prevention and management should be recognized as a major public health issue and adequate resources should be allocated for research in this area, and the development of prevention programmes. [1] A proposed dental health education package on management of dental trauma should include and emphasize on the following information:

  1. problems and consequences of dental trauma;
  2. availability of after-office hour emergency services;
  3. specific storage media for avulsed teeth;
  4. critical timing for replantation of permanent avulsed teeth for long term success;
  5. current concepts of management of fractured teeth. [9]


However, in introducing appropriate programs, the necessity to evaluate their effectiveness should not be neglected.


   Conclusion Top


The present study determined the knowledge on the management of dental trauma of a selected group of upper primary and secondary school physical education teachers in Davangere city, India. Although the number of respondents with the knowledge of first aid is high, the knowledge on management of dental trauma remains inadequate.Programs aimed at educating the teachers regarding dental trauma management had a tremendous impact on the knowledge of teachers in Davangere city, India, in our study. The present survey thus indicates that educational programs and campaigns should be organized to improve and/or enhance the school teacher's awareness of the immediate management of traumatized teeth. Hopefully, dental trauma management could also be incorporated into the teacher training curriculum.

 
   References Top

1.Chan AW, Wong TK, Cheung GS. Lay knowledge of physical education teachers about the emergency management of dental trauma in Hong Kong. Dent Traumatol 2001;17:77-85.  Back to cited text no. 1
    
2.Olivier L, Christoph G, Mohammed EM, Thomas VA. Impact of educational posters on the lay knowledge of school teachers regarding emergency management of dental injuries. Dent Traumatol 2009;25:406-12.  Back to cited text no. 2
    
3.Panzarini SR, Pedrini D, Brandini DA, Poi WR, Santos MF, Correa JP, et al. Physical education undergraduates and dental trauma knowledge. Dent Traumatol 2005;21:324-8.  Back to cited text no. 3
    
4.Blakytny C, Surbuts C, Thomas A, Hunter ML. Avulsed permanent incisors: Knowledge and attitudes of primary school teachers with regard to emergency management. Int J Paediatr Dent 2001;11:327-32.  Back to cited text no. 4
    
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 SocPedodPrev Dent 2009;27:242-8.  Back to cited text no. 5
    
6.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.  Back to cited text no. 6
    
7.Holan G, Cohenca N, Brin I. Sgan-Cohen H. An oral health promotion program for the prevention of complications following avulsion: The effect on knowledge of physical education teachers. Dent Traumatol 2006;22:323-7.  Back to cited text no. 7
    
8.Adel AA, Andersson L, Quomasha AJ. School teachers' knowledge of tooth avulsion and dental first aid before and after receiving information about avulsed teeth and replantation. Dent Traumatol 2008;24:43-9.  Back to cited text no. 8
    
9.Sae-Lim V, Lim LP. Dental trauma management awareness of Singapore pre-school teachers. Dent Traumatol 2001;17:71-6.  Back to cited text no. 9
    

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Correspondence Address:
G N Chandu
Professor and Head, Department of Community Dentistry, College of Dental Sciences, Davangere, Karnataka - 577 004
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-7761.93412

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