Informative promotional outcome on school teachers' knowledge about emergency management of dental trauma.

AIM: To assess awareness of school teachers concerning the emergency management of traumatized teeth.
MATERIALS AND METHODS: This is a prospective intervention study conducted with 1000 teachers (500 urban, 500 rural) randomly selected from the entire government and private, primary (elementary) as well as secondary (high) schools of Nellore district of Andhra Pradesh, India. Study was carried out in three phases; the first phase being an initial survey conducted to assess the existing knowledge of teachers on management of traumatic injuries by using self-administered questionnaire. This was followed by a comprehensive informative promotion regarding the initial management of the traumatic dental injuries for the teachers. A post-promotion follow-up review was conducted 3 months later to evaluate the effect of the informative promotion, using the same set of questionnaires. Study was completed over a period of 9 months. STATISTICAL METHODS: Data analysis was done using SPSS software version 14.0, and Chi-square test was used to compare the knowledge of teachers prior to and after the informative promotion. The level of significance was set at P ≤ 0.05.
RESULTS: The teachers' overall knowledge with respect to the emergency management of the traumatic injuries was deficient and significant differences were found in the knowledge of teachers before and after the informative promotion.
CONCLUSION: Informative promotion programs to improve the knowledge and awareness of this group of community, who are generally the first line of assistance in case of dental trauma in schools, are mandatory.

INTRODUCTION

Dental trauma remains one of the important oral health problems in childhood occurring mostly between the ages of 8 and 11 years.[1] There is perhaps no single dental disturbance that has greater psychological impact on both parent and the child than the loss or fracture of a child's anterior teeth. Primary and permanent anterior teeth are not only important for aesthetics but also are essential for phonetics, mastication, integrity of supporting tissues, psychological and mental well-being of children. Sports account for 60% of traumatic dental injuries (TDIs),[2] and schools are the place where one can find a noticeable risk of TDI.[3] Prompt and pertinent emergency management is not only the responsibility of the dentist but of lay people, such as the parents and the school teachers available at the site of accident. From the available data, it is clear that a high percentage of the parents, school teachers, healthcare professionals, including general dentists have insufficient information on management of TDI.[4-7]

As noted above several studies conducted all over the world reveal scarce knowledge regarding emergency measures for traumatized teeth. Hence, a forward step is needed to be taken by the dental professionals in this particular area. The prime objective of this study was to assess the knowledge and attitudes of school teachers (primary and secondary school teachers) on the management of TDI and to update their information with informative promotion on initial management of TDI wherever necessary.

MATERIALS AND METHODS

This prospective intervention study was conducted in both the private and government primary (elementary) and secondary (high) schools that were randomly selected with 1000 teachers (500 urban; 500 rural) who volunteered to participate. All participants were promised anonymity and the participation was voluntary with informed permission obtained from their respective school administration. The study was carried out in three phases–initially (preliminary survey) to assess the existing knowledge of teachers on management of TDI using self-administered questionnaire prepared both in English and Telugu (local language), delivered directly by hand to the respondents at their respective schools. The questionnaire was divided into three sections as follows:

Section A: General questions pertaining to TDI [Figure 1]

Figure 1

Sections A and B of questionnaire used in the study

Section B: Specific questions dealing with soft tissue injuries [Figure 1]

Section C: Subdivided into three parts with each part containing three to ten questions related to avulsion injuries, fractured teeth and luxation injuries [Figure 2]

Figure 2

Section C of questionnaire used in the study

The initial survey was followed by a comprehensive informative promotion regarding the initial management of the TDI in schools, which included an informative 30-min lecture on the management of TDI, and general oral hygiene practice methods was conducted in the schools using MS Power Point presentation (Microsoft Corporation, Redmond, Washington, USA) or with the help of a self-prepared manual (flipchart) containing pictures, in places without projector facility as used by Al-Asfour et al.[8] The lecture was delivered using simple language with emphasis on important information like; short introduction to dental tissues, different types of TDI, emergency measures to be taken in case of avulsion before reaching dentist, treatment options for different injuries of anterior teeth and jaws, briefing of different dental treatment procedures done in children. After the lecture a short time was allotted for discussions and clarification of doubts encouraging interaction and participation.

After the informative promotion, a 3-month follow-up survey was conducted to evaluate the outcome of the informative promotion on the school teachers’ knowledge using the same set of questionnaires. The study was completed over a period of 9 months.

Statistical methods

The returned questionnaires were coded and entered on computer, using SPSS (Statistical Package for Social Sciences) software, Version 14.0 (SPSS Inc., Chicago, IL, USA). Chi-square test was used to compare the knowledge of teachers (both urban and rural teachers) before and after the informative promotion. The level of significance was set at P ≤ 0.05 (equivalent to 5%).

RESULTS

In the present study, during the 3-month post-promotion follow-up survey, there was an attrition of four teachers in the sample (loss of 0.8%) of the urban area. In spite of best efforts, a certain percentage of attrition in follow-up surveys is inevitable. This attrition may bias the results. The safest course recommended is to achieve as close to 95% follow-up as possible.[9]

The present study showed that 438 (87.6%) teachers in rural and 474 (94.8%) teachers in urban area had first-aid component in their teacher training curriculum (P = 0.000), and 40 (8.0%) teachers in rural and 47 (9.4%) in the urban area had dental first-aid component in their teacher training curriculum (P = 0.432).

Largely the results [Tables 1–5] suggested that the knowledge of teachers on management of soft tissue injuries and avulsed and fractured teeth was poor. After the informative promotion, improvement was observed in the knowledge of teachers, but not to the expected levels, suggesting the need for frequent updating of information to teachers through promotion programs.

Table 1

The responses of teachers for “General questions on management of TDI”

Table 5b

The responses of teachers for the questions on “fractured teeth”

DISCUSSION

Teachers’ knowledge of emergency management of TDI was measured using self-administered standardized questionnaire. An advantage of this method is the possibility to compare knowledge level over a time period (e.g. before and after a specific group has been given information). The results of the initial survey were analyzed and for those teachers with negative results, a short lecture followed by discussion was chosen as a method for educating the teachers. This is because, lecture provides a good opportunity for a direct interaction between the lecturer and the receiving group, with a possibility to raise questions and discuss issues. In addition, lecture can get immediate feedback whether the message was understood or not and also the kind of information that should be further developed, but a recent study done in Kuwait noted that, lecture is source demanding and therefore costly. Hence, they concluded that leaflet (pamphlet) followed up by an informative lecture would be the best method of delivering the information.[81011]

In the present study, response of teachers was checked on the general aspects of TDI in children [Table 1] and it was found that teachers in rural area came across a greater incidence of TDI during their teaching experience than the urban teachers, which could be due to the over-protective nature of the urban parents that indirectly reflected on the TDI. In spite of the reported greater incidence of observing TDI by rural teachers, urban teachers managed more number of such injuries. This could be correlated with the better dental first-aid knowledge of the urban teachers. Most of the teachers in the urban and rural area were unsatisfied initially with the knowledge they had in managing TDI, which was also shown in other studies,[4712] and indicates that educational promotion and preventive programs on dental trauma must be organized. The severe and often serious infection of tetanus and the importance of tetanus prophylaxis were known to many people; unfortunately this has been quite neglected in case of TDI. In the present study, initially majority of the teachers (slightly higher percentage of urban teachers) showed a positive response for tetanus prophylaxis during traumatic injuries and after the informative promotion, the response showed further increase.

The present study found that teachers knew the importance of emergency management of soft tissue injuries [Table 2]. However, when it came to the management of the same, rural teachers initially preferred managing themselves with traditional household remedies i.e. application of turmeric rather than consulting a dentist, and in the urban teachers there was divided opinion in the choice of management of such injuries. None of them preferred to manage such injuries using antiseptics, spirit or ointment and it was surprising to know that urban teachers preferred the traditional method of managing injuries like application of turmeric in spite of readily available modern medicaments. Informative promotion was effective in teaching the management of soft tissue injuries for these teachers.

Table 2

The responses of teachers for the questions on “Soft tissue injuries”

Though many teachers knew that knocked out (avulsed) teeth come under emergency treatment [Table 3a], the concept of management of avulsed teeth has not been fully understood. From the teachers interviewed, it was disappointing to find very less percentage of teachers considering the replantation of knocked out permanent teeth [Table 3b]. A controversial issue was the replantation of avulsed primary teeth, due to the potential risk of damaging the permanent successor. This is supported by a study done in Singapore, which stated that people have poor knowledge regarding the replantation of permanent and primary teeth.[12] Time is one of the most important factors for the avulsed tooth to preserve their vitality after replantation, but in the present study most of the teachers cited that they would take the child to a dentist within few hours, with a few teachers stating that they would consult the dentist immediately and within 30 minutes [Table 3c], which is analogous with the findings noted by a study conducted in Saudi[1] and in contrast to the findings of Chan[4] and Ηaglar et al.,[13] that 60% of the teachers in Hong Kong and all the teachers from two European cities stating correct time for replantation respectively. 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.[14] In the present study, considerably fewer teachers wanted to keep the teeth under running water and most of the teachers volunteered that they would gently scrub the tooth prior to replantation. After the informative promotion, adequate levels of improvement has been achieved in terms of managing knocked out teeth [Table 4a]. The appropriate storage/transport media to permit periodontal and pulpal healing are milk, physiological saline and saliva. The composition and osmolality of milk are more compatible for survival of cells over the root and easy access to milk in the moment of accident makes it the best short-term storage/transport media. The options mentioned in the questionnaire included ice, child's mouth, child's hand and paper/tissue/clean handkerchief. Urban teachers suggested child's hand can be used as the storage/transport media which shows us the lack of knowledge among urban teachers about the storage medium as also noted by Skele,[15] and majority of teachers had preferred "ice" as better storage/transport medium [Table 4b] which can be related to the popular use of ice for transportation of meat, fish or human organs and accidentally detached limbs.

Table 3a

Responses of teachers regarding questions on “Avulsion injuries”

Table 3b

Responses of teachers regarding questions on “Avulsion injuries”

Table 3c

Responses of teachers regarding “importance of time in Avulsion injuries”

Table 4a

The responses of teachers for the questions on “Cleaning of avulsed tooth”

Table 4b

Responses of teachers on the preferred medium for the “transport of knocked out teeth”

Most of teachers in the present study were of divided opinion with a higher percentage of urban teachers; about seeking an immediate care in cases of fractured teeth. Only a few teachers had managed such injuries in their teaching experience, with slightly higher percentage of urban teachers [Table 5a]. There has been a difference of opinion of urban and rural teachers on the point that, fractured teeth can really have an impact on the aesthetics and the possibility of reattachment of the fractured crown part. As mentioned earlier, poor dental first-aid knowledge among the teachers can be one of the reasons for this. Regarding the concept of management of fractured teeth, both rural and urban teachers were with a divided opinion between sending the child to a school nurse if available, calling the parent and telling them to take the child to a dentist and some of the teachers were enthusiastic to know what can be done in such case [Table 5b].

Table 5a

The responses of teachers for the questions on “fractured teeth”

Our survey also showed that majority of teachers personally think that mobile teeth come under an emergency treatment, which is probably because the teachers knew that the mobile teeth may interfere with mastication frequently and is often painful. Regarding the management, findings suggest scattered and varied opinions of teachers with majority of the teachers comfortably saying that they would call the parent and ask them to take the child to a dentist, while one-third of the teachers were not able to decide what to do and the remaining teachers were ready to send the child to school nurse if any available.

Ideally after an informative promotion it would have been ideal to observe the percentage of improvement in all areas at 90% or above, but in most of the areas the results came short of this which is in accordance with a study done in Kuwait, though they observed improvement in school teachers’ knowledge on management of tooth avulsion after an informative 30-min lecture.[8] According to Kahabuka et al.,[16] a single educational input to school teachers is not enough to promote childhood self care. This is in parallel with the study conducted in Iran where knowledge level of participants who had formal first-aid training at least once in their career and those who did not have.[3] Most likely the information has to be repeated before any long-standing effect can be noted and such repetition can be performed in other ways such as brochures and posters. Feldens et al.,[17] had suggested the inclusion of management of TDI in the teachers’ curricular training and pedagogical education in a continuous manner as a basis for future interventions [Tables 6a and b]

Table 6a

Teachers who thought that mobile tooth is an emergency condition

Table 6b

The responses of teachers for the question on encountering mobile teeth

CONCLUSION

Our findings emphasize that educational programs and training are needed to enhance proper management of traumatic injuries by school teachers apart from information on dental caries and brushing methods. The Ministry of Health and Family Welfare and Ministries of Primary and Secondary Education should be advised to look into this matter and make it mandatory for all the teachers to have the guidelines on the management of TDI in their teachers training curriculum. As dental professionals we are obligated to educate the lay people who have the probability to be at the site of injury like parents, teachers, physical trainers and traffic police etc.