Key words:
Crown fracture - dental trauma - lecture - questionnaire - tooth avulsion - undergraduate
students
INTRODUCTION
During the last decade, dental trauma has been reported to occur in an expressive
part of the population around the world (4.5%–17.5%), even interfering in their quality
of life.[1]
[2]
[3] Among the types of dental trauma that can affect the population throughout their
daily practice, especially during sports activities at schools and universities, the
most common and severe types consist of tooth fractures (34.5%–62.2%) and tooth avulsion
(9%–11.7%), respectively.[4]
[5] In these circumstances, it is well known that higher success prognosis rate has
been closely related to the correct management of the traumatized tooth in the local
of the incident, immediately after the dental trauma.[6] However, most of the population in direct contact with these accidents cannot accurately
perform the correct emergency conduct for these cases, including health professionals.[7]
[8]
Taking this into consideration, it is essential that different communities, including
educational and health professionals, should be prepared and well informed to render
the appropriate conduct front a dental trauma situation. Nevertheless, studies have
shown the lack of information and knowhow in dental trauma emergency care of teachers,
athletes, rescue staff, paramedics, educators, sportive coaches, physicians, nurses,
and dental professionals.[9]
[10] These findings characterize an alarming situation that might lead to irreversible
damages to the affected tooth that did not receive the appropriate treatment in the
local of the accident.[7]
[8]
[9]
[10] In addition, health professionals might be frequently requested to help in accidents
involving tooth injury, so they might know the emergency procedures to save traumatized
teeth preventing posttraumatic complications. Thinking in this way, it is important
to start teaching dental trauma emergency protocols to undergraduate health students
so that they can be prepared to act when this situation happens.[11]
[12]
It is also worth to mention that unlike dental caries and periodontal disease, which
may be directly prevented, dental trauma incidents may not be predicted. Therefore,
educational programs aiming to develop the population knowledge regarding the correct
conduct in cases of dental trauma emergency may be the initial pathways to prevent
its complications.[13]
[14]
[15] In Brazil, several studies in different parts of the country (e.g., Minas Gerais,
Paraíba, Pernambuco, Santa Cantarina) have demonstrated high occurrence of traumatic
dental injuries among children; however, no study in the State of Sergipe has focused
its attention to the knowledge of some future health professionals, mainly considering
the high prevalence (40.5%) of dental trauma in Sergipe.[16]
[17]
[18]
[19] Hence, this study investigated the effect of educational intervention among undergraduate
students, from three health courses, of a Federal University in Brazil, including
lecture presentation and question-and-answer sessions, to promote awareness regarding
emergency measures concerning tooth avulsion and tooth crown fractures.
MATERIALS AND METHODS
The present study was approved by the research ethics committee at a Federal University
in Brazil. Educational intervention lecture regarding dental trauma emergency management
was carried out in a Federal University in Brazil to a total of 125 undergraduate
students of three health courses: dentistry (n = 70), nursing (n = 33), and speech therapy (n = 22). All the participants signed written consent form and all of them maintained
their right to withdraw from the study at any time. Besides the lecture, the assessment
was performed using a dual-part questionnaire: The first part contained the participants’
demographic information and the second part was related to the awareness, knowledge,
and attitude toward dental trauma emergency protocol for tooth crown fractures and
tooth avulsion. In this second part, particular focus was presented on storage medium
transportation for crown fractures fragments and tooth avulsion [Table 1]. Briefly, the questionnaire application was divided in three phases: pretest (T0),
intervention, and posttest (T1). The pretest and posttest were carried out through
the application of the mentioned questionnaire which was taken immediately before
and after the lecture. This informative lecture was presented in Portuguese language
during 40 min by one of the authors, regarding general concepts of dental trauma and
how to deal in an emergency situation of crown fracture and avulsion injuries. A computer,
a projector, and a screen were used to perform the lecture. The presentation was finished
with a question-and-answer discussion and an audience to discuss the remaining doubts
of the participants. The results were tabulated and a McNemar’s test with logistic
regression was used to compare the responses between the graduation courses before
and after the intervention, with the significance level set at 5% (P < 0.05).
Table 1:
Questionnaire containing personal information and knowledge of dental trauma
|
Questionnaire about the knowledge of dental trauma
|
|
Graduation course
1. Dentistry
2. Nursing
3. Speech therapy
|
|
Age
1. 18-22 years
2. 23-30 years
3. >30 years
|
|
Gender
1. Male
2. Female
|
|
If you break off a part of your tooth, and find the dental fragment, what would you
do?
1. Take the fragment to the dentist
2. Do not take the fragment to the dentist
3. Another
|
|
How should a “broken” fragment be transported?
1. Wrapped in a napkin
2. Water
3. Inside a dry container
4. Milk
5. Another
|
|
If a friend suffers a blow and his/her tooth completely fall out, what would you do?
1. I would look for the tooth, wash it with soap and take to the dentist
2. I would look for the tooth, replant it and take to the dentist
3. I would not look for the tooth and immediately take to the dentist
4. I would look for the tooth, wrap it in a napkin and take to the dentist
|
|
Considering the anterior situation, if you find the tooth covered by dirt, what would
you do?
1. I would gently wash the tooth with toothbrush
2. I would wash the tooth in tap water
3. I would replant the tooth without pretreatment
4. I would wash the tooth with soap
|
|
Considering the anterior situation, if you did not replant the teeth, how would you
transport it to the dentist?
1. Ice
2. Water
3. Paper
4. Milk
5. In the mouth of the children
6. Saline solution
7. Alcohol
|
RESULTS
The demographic data indicated that most of the participants (56%, n = 70) were dental school students (nursing, n = 33, 26.4%; speech therapy, n = 22, 17.6%) aging from 18 to 22 years (74%) and belonged to the female gender (78.4%).
[Table 2] demonstrates the information related to the answers obtained before and after the
intervention lecture (Part II of the questionnaire). Regarding the storage selection
to transport tooth crown fragment, 78% of the students recognized, before the intervention
lecture (T0), the importance of carrying it to a dentist; however, only 35.2% would
transport the fragment correctly, and 36.8% believed that dry storage selection was
the most appropriated transportation form in this case [Table 2]
[Figure 1]. Pondering each course separately, dentistry students showed higher percentage (54.3%)
of correct answers before the lecture (T0) when compared to nursing (12%) and speech
therapy students (9%), concerning storage medium for tooth fragment transportation
[Table 3]. After educational lecture, a significant improvement of knowledge was observed
from baseline (T0) to postlecture evaluation (T1) (P < 0.001) with almost all the participants understating the importance of carrying
the fractured tooth to dentist (97.6%) in water (75.2%) [Table 3]
[Figure 1].
Table 2:
Distribution of the correct and incorrect answers regarding dental trauma emergency
knowledge before and after the dental trauma lecture (n=125)
|
Questions
|
T0 (%)
|
T1 (%)
|
|
Correct
|
Incorrect
|
Correct
|
Incorrect
|
|
T0: Before, T1: After
|
|
Carry fractured crown fragment to dentist
|
100 (78)
|
25 (22)
|
124 (97.6)
|
124 (97.6)
|
|
Storage medium for fractured fragment
|
44 (35.2)
|
56 (64.8)
|
73 (75.2)
|
73 (75.2)
|
|
Immediate replantation of avulsed tooth
|
26 (20.4)
|
74 (79.6)
|
115 (90.5)
|
115 (90.5)
|
|
Management of messy avulsed tooth
|
107 (84)
|
18 (16)
|
127 (100)
|
127 (100)
|
|
Storage medium for avulsed tooth
|
16 (13)
|
109 (87)
|
127 (100)
|
127 (100)
|
Table 3:
Descriptive analysis of the answers according to the courses before and after the
dental trauma lecture
|
Knowledge
|
Dentistry (n=70)
|
Nursing (n=33)
|
Speech therapy (n=22)
|
|
T0, n(%)
|
T1, n(%)
|
P*
|
T0, n(%)
|
T1, n(%)
|
P*
|
T0, n(%)
|
T1, n(%)
|
P*
|
|
*McNemar’s test. T0: Before, T1: After
|
|
Crown fracture
|
38 (54.3)
|
49 (70.0)
|
0.0009
|
4 (12.1)
|
22 (66.7)
|
<0.001
|
2 (9.1)
|
22 (100.0)
|
<0.001
|
|
Avulsion
|
16 (22.9)
|
70 (100.0)
|
<0.001
|
0 (0.0)
|
31 (93.9)
|
<0.001
|
0 (0.0)
|
22 (100.0)
|
<0.001
|
Figure 1: Crown fracture fragment transportation answers before (T0) and after (T1) lecture
Regarding tooth avulsion, it was observed that before the lecture, the participants
showed unsatisfactory awareness (24%) concerning the correct conduct in cases of tooth
avulsion, which should be replanted in the moment of the trauma [Table 2]. However, the big majority (84%) recognized that a dirty avulsed tooth should be
carefully washed and managed before the replantation [Table 2]. Proceeding on this track, before the lecture, only 13% of all the participants
affirmed that they would store an avulsed tooth in milk; however, after the lecture,
almost all the students (98%) were able to identify the correct storage media to transport
avulsed teeth [Figure 2]. Describing apart each course, it was possible to see that before the lecture, few
dentistry (22.9%) and no nursing and speech therapy students knew about the ideal
storage medium (milk) for avulsed tooth transportation when immediate replantation
was unviable. After educational intervention, a significant improvement was found
between the baseline (T0) and postlecture evaluation (T1) (P < 0.001), for all the evaluated courses, with almost 100% of correct answers [Table 3].
Figure 2: Tooth avulsion storage medium answers before (T0) and after (T1) the lecture
Furthermore, logistic regression after the lecture demonstrated that dentistry students
presented 3.28 times more capability of knowledge absorption when compared to nursing
and speech therapy ones. In addition, nursing and speech therapy students showed 63%
and 71% less knowledge about fracture first-aid knowledge than dentistry students,
respectively.
DISCUSSION
Dental trauma represents an accidental episode usually associated with undesirable
effects (e.g., crown discoloration, pulp necrosis, root resorptions, and partial or
complete loss of the injured teeth).[7]
[20] Some of these consequences, especially the root resorption, may lead to an undesirable
condition, the tooth lost. Thus, situations like this could be largely prevented by
spreading information to the populace regarding the ideal management front an emergency
dental trauma situation, specially tooth avulsion and fractures. Furthermore, health
professionals should be aware of emergence dental trauma conduct since they might
be demanded when it happens.[7]
[13]
[14]
[15]
In this scenario, preventive lectures, mainly to those communities directly connected
to the most susceptible group suffering dental trauma (children), seem to be a pathway
to decrease the possible damages caused by dental injuries. Facing this reality, the
present study applied questionnaires before and after a dental trauma emergency lecture
to compare the preliminary and afterword knowledge of the participants regarding the
correct conduct to be followed in dental trauma situations to 125 undergraduate students
from health courses of Lagarto, a city in the state of Sergipe, Brazil. In general,
before the lecture, the participants showed lack of knowledge regarding dental trauma
first-aid management, where <50% of the undergraduate health students were able to
specify the correct protocol to transport fractured crown fragment and avulsed tooth.
Concerning the transportation of a crown fractured fragment, 46 subjects (36.8%) affirmed
that the best way to carry the fragment would be under dry conditions, demonstrating
lack of knowledge regarding this topic. It is important to mention that dehydration
conditions may interfere in the prospect tooth adaptation and restoration. As a matter
of fact, the dental trauma management guidelines, published by the International Association
for Dental Traumatology (IADT) and the American Academy of Pediatric Dentistry (AAPD),
advocates that the fractured fragment reattachment to the tooth is considered the
first option to achieve better esthetic and functional reestablishment for the traumatized
patient.[6]
Seeking this ideal treatment, it was observed, after the lecture, an expressive increase
in the selection of the correct protocol (take the fragment hydrated to the dentist)
by the students, attaining a correct rate of almost 100%. Previous studies have demonstrated
opposite results about the knowledge on crown fracture transportation with greater
(48.6% and 64.86%) confidence on managing fractured tooth with Hong Kong and London
students, respectively.[11]
[13] Besides the good hydration properties provided to the fragment by water or saline
solution, the literature recently demonstrated an alternative, the egg white, which
may also be suitable as a transportation medium for coronary fragments, contributing
positively to the future adhesion of restorative material during dental attachment.[21]
The design of this study also focused on the knowledge of tooth avulsion management,
and unfortunately, this aspect still remains unknown among most of the participants
since only 20.4% recognized the importance of replantation of an avulsed tooth before
the lecture. This finding corroborates with a previous study, which showed that only
3% of sports and medical university students have been instructed about replantation.[22] Moreover, when replantation is impracticable, IADT and AAPD recommend to store the
avulsed tooth in milk;[23] however, most of the students (33.60%) believed that the saline solution could be
the ideal storage medium for tooth transportation before the lecture. These results
suggests the lack of knowledge concerning saline solution detrimental effects on periodontal
ligament cells, which does not afford good osmolality features for their survival,
a mandatory factor for better prognosis of the replantation, preventing ankylosis
and root resorption.[24] This assumption was similar to international scenario that has examined dentistry
undergraduate students from all over the world, encountering that only 26.9%, 22.3%,
and 20% of Saudi Arabian, Hong Kong, and Japanese undergraduate students, respectively,
have known the proper method to transport an avulsed tooth.[12]
[13]
[25] Although the baseline scores (T0) were low, after the lecture (T1), the correct
conduct increased to 90.5%, demonstrating positive feedback from the students after
the intervention lecture.
To our knowledge, scarce investigations have evaluated the acquaintance of dental
trauma management among undergraduate students from general health courses, so the
present study decided to include nursing and speech therapy students, which constantly
works with urgency situations and oral cavity conditions, respectively.[7]
[22] Based on the results presented in this study, it became clear the critical necessity
to disseminate knowledge regarding dental trauma first-aid management in the university
community. Forthcoming, students awareness regarding dental trauma should not be limited
only to lectures but must also be spread throughout the technology apps and educational
methods based on problem-based learning, to effectively prevent dental trauma complications.
CONCLUSIONS
Within the limitations of this study, it is reasonable to conclude that most of the
undergraduate students did not present previous awareness about first-aid management
of crown fracture and tooth avulsion. However, the dental trauma educational intervention
disclosed a positive impact in the knowledge acquisition regarding the emergency conducts
mainly in cases of tooth avulsion. Hence, educational programs should be developed
for college students in the health area to encourage them to correctly conduct an
emergency dental trauma episode.
Financial support and sponsorship
Nil.
