Primary School Teachers' Knowledge on Tooth Avulsion.

OBJECTIVE: Permanent teeth trauma is most frequent in children aged 7-9 years, and the primary school teachers (PSTs) are often the first to notice it. The aim of this study was to evaluate the competence in tooth avulsion clinical issues and knowledge on dental trauma of PSTs, as they can occasionally take on the role of school nurses.
MATERIAL AND METHODS: Questionnaires were handed to 312 PSTs from 24 randomly selected primary schools in Zagreb, Croatia. An algorithm was designed for PST competence assessment.
RESULTS: Response rate amounted to 81.37% (N=255). Only 3.14% (N=8) of the PSTs would replant the permanent tooth properly and only 43.92% of them (N=112) would immediately take the child to a doctor of dental medicine. Dry tissue, as a transport medium for an avulsed tooth, was chosen by 50.20% (N=128) of the respondents. Altogether, 4.71% (N=12) of PSTs were graded as competent in case of child's tooth avulsion.
CONCLUSION: These results provided significant implications for school health, showed the educators' serious lack of knowledge in cases of dental trauma and stressed a need for continuous education of PSTs on the topic.

Introduction

Tooth injury is the most common trauma of the orofacial region (). Dental trauma can vary from a simple fracture to the avulsion of the tooth (). Studies have shown different incidence rates of dental trauma, from 10.2 to 69.2% (, ), out of which tooth avulsion makes an average of 13.6% (, ).

Tooth avulsion is a complete tooth displacement from the tooth socket and is most frequent with children aged between 7 and 9 years (). It leads to drying, ischemia and bacterial contamination of the tooth pulp and the periodontal ligament which supports the tooth in the alveolus (tooth socket). Even after short extra-alveolar time (outside the tooth socket),a permanent damage of the periodontal ligament and pulp cells appears. This is why a permanent tooth, if knocked out, should be replanted back to the alveolus as soon as possible. If the extra-alveolar time is shorter than an hour, complete or partial reparation of periodontal ligament is possible (, ). If this time is longer, the destruction of periodontal ligament cells takes place. Replantation in this period often results in progressive tooth root resorption (, ). Therefore, the time between the injury and the treatment is the most important factor for the therapy success (, ).

After avulsion, the tooth is contaminated and should be rinsed under running tap water (, , ). Antiseptic solutions should not be used as they lead to destruction of the periodontal ligament cells. Mechanical cleaning of the tooth root removes the periodontal ligament cells and increases the possibility of ankylosis and resorption (, ). Tooth ankylosis is a condition in which the tooth root loses its normal attachment to the bone (periodontal ligament) and fuses directly to the alveolus.

Apart from the extra-alveolar time, the outcome also depends on the transport medium. Tap water, alcohol and dry wipes are the worst choices, as they do not preserve the vitality of the cells (, ). The best way to store and transport the avulsed tooth are specialized media (-).

Since trauma most frequently occurs in pre-schools and primary schools (, ), major role in the intervention can be carried out by educators and teachers, as they could easily be obliged to take on the role of school nurses. Therefore, their knowledge and prompt response can often determine the fate of the traumatized tooth.

Tooth rescue kits can preserve an avulsed tooth up to 24 hours and should be obligatory for every kindergarten and primary school (, ).

The aim of this study is to assess primary school teachers’ (PSTs) knowledge, response and competence to cope with dental trauma. Primary school teachers have completed original competence assessment questionnaires.

Material and Methods

Participants

Questionnaires were personally handed to 312 PSTs from 24 primary schools in Zagreb, Croatia. Systemic sampling randomization technique was used to select primary schools.

Sample size analysis with power of 90% and the alpha level of 0.05 showed a minimum of 140 respondents for conducting this study (, ).

Procedure

Questionnaires were handed only to PSTs who wished to participate in research. All PSTs from one school filled the questionnaire at the same time. While filling the questionnaire, PSTs were monitored by the investigators, thus assuring the accuracy of the data provided.

The survey was conducted between July and September 2014 on weekdays.

With the purpose of raising awareness and educating the respondents, an information leaflet was provided after examining all of the primary school teachers involved in this study, containing the proper procedure in case of tooth avulsion, equivalent to the one released by the International Association of Dental Traumatology (IADT) ().

Questionnaire

The questionnaire consisted of 27 questions and was divided in four parts. The first part was comprised of five questions concerning personal and professional data i.e. gender, age, educational level, years of employment and personal background.

The second part consisted of six questions that revealed PST’s experience with dental trauma and assessed the knowledge on tooth avulsion and primary and secondary dentition.

The third part, i.e. questions 12-20 noted PST opinion and response in tooth avulsion situations.

The fourth part contained questions about tooth replantation, rinsing, storage and transport media of the avulsed tooth and PSTs’ wish to learn more about the topic.

Competence assessment

The assessment of competence was evaluated by questions 15-26 of the survey and was rated individually. Within these questions, there was a possibility of more than one correct answer. The researchers determined a PST as "competent" and "incompetent" through a competence assessment algorithm. In order for a PST to be assessed competent, he/she could either choose to adequately replant a permanent tooth or secure the quickest transportation to the doctor of dental medicine. Both solutions were expressed as separate algorithms (Figures 1 and 2). Proper replantation implied choosing the adequate irrigation media, avoiding the mechanical cleaning of the permanent tooth root surface and its proper handling.

Figure 1

Competence assessment algorithm for tooth replantation / Slika 1. Algoritam za procjenu kompetentnosti za repantaciju trajnog zuba

Figure 2

Competence assessment algorithm for tooth transportation to a doctor of dental medicine / Slika 2. Algoritam za procjenu kompetentnosti za transport doktoru dentalne medicine

This survey was reviewed and approved by the Ethic Committee of the School of Dental Medicine, University of Zagreb, Croatia. The teachers who agreed to take part in the survey were assured of strict confidentiality and signed a written consent for taking part in the survey.

Statistical analysis

All submitted surveys were coded and analyzed. The results were processed in numerical order and expressed in percentages. The data were organized into files (Microsoft Excel, Microsoft Inc., USA) and processed by JMP7 module from the software package SAS (SAS Institute Inc., Cary, NC, USA). Fischer's test was applied to test the hypothesis. The Chi-squared test, where applicable, was used to compare qualitative data. Statistically significant results were found only if p<0.05.

Results

Out of 312 handled questionnaires, 57 (18.3%) PSTs refused to take part in the survey; therefore the response rate was 81.73%. Only completely filled questionnaires met the inclusion criteria. Sample description by age and sex is presented in Table 1. Significantly larger numbers of female respondents were included in this study (96.47% of all respondents).

Table 1

Sample description / Opis uzorka

Age	20-30	31-40	41-50	>51	Total / Ukupno	Statistics / Statistika
Male / Muškarci	1	2	4	2	9	χ2=0.45;
Female / Žene	30	75	85	56	246	P=0.93
Total / Ukupno	31	77	89	58	255

Eighty-four (32.94%), out of 255 primary school teachers, encountered dental trauma during their professional career. More than half (N=163; 63.92%) of PSTs did not know the age at which a child has all the permanent teeth and 108 (42.35%) of them would not seek professional help after the avulsion of a primary tooth. Altogether, 25 (9.80%) PSTs would not seek professional help after the avulsion of a permanent tooth. In case of a tooth avulsion, 43.92% (N=112) of PSTs would seek help from a doctor of dental medicine, while 27.06% of PSTs (N=69) would not seek for the permanent avulsed tooth. Primary school teachers’ selection of professional help in case of permanent tooth avulsion is presented in Table 2.

Table 2

Primary school teachers’ selection of professional help in case of permanent tooth avulsion / Odabir stručne pomoći učitelja u osnovnoj školi u slučaju avulzije trajnog zuba

Professional help /Stručna pomoć	N	%
Doctor of dental medicine / Doktor dentalne medicine	112	43.92
Only the child’s parents / Samo roditelje	95	37.25
Wouldn’t seek for professional help / Ne bih tražio/la stručnu pomoć	25	9.80
Hospital / Bolnica	10	3.92
Other / Ostalo	8	2.92
General practice doctors / Doktor opće prakse	5	1.96

The selection of an irrigation solution and transport medium to the professional care giver are presented in Tables 3 and 4. Replantation of a primary tooth as a treatment option would be considered by 11PSTs (4.31%), while replantation of the permanent avulsed tooth by 15 PSTs (5.88%). From those who considered permanent tooth replantation, only 8 teachers (3.14%) would do it properly.

Table 3

Primary school teachers’ selection of the irrigation solution for an avulsed permanent tooth / Odabir irigacijskog sredstva učitelja za ispiranje avulziranog trajnog zuba

Irrigation solution	N	%
Wouldn’t irrigate / Ne bih ispirao/la	167	65.49
70% alcohol / 70% alcohol	49	19.21
Milk / Mlijeko	16	6.27
Mouthwash / Vodica za usta	21	8.24
Dry tissue / Suha maramica	0	0
Saliva / Slina	0	0
Saline solution / Fiziološka otopinaTap water / Voda iz slavine	00	00
Other / Ostalo	2	0.78

Table 4

Primary school teachers’ transport medium selection for an avulsed permanent tooth / Odabir transportnog medija učitelja u slučaju avulzije trajnog zuba

Transport medium / Transportni medij	N	%
Dry tissue / Suha maramica	128	50.20
Milk / Mlijeko	32	12.54
A plastic bag / Plastična vrećica	26	10.20
Place the avulsed tooth in the hand of a child / Stavio bih avulzirani zub u ruku djeteta	18	7.06
70% alcohol / 70% alcohol	18	7.06
Kitchen foil / Kuhinjska folija	10	1.96
Saliva / Slina	4	1.57
Mouthwash / Vodica za usta	4	1.57
Saline solution / Fiziološka otopinaTap water / Voda iz slavine	00	00
Other / Ostalo	0	0
Would try to reimplant the tooth / Pokušao/la bih replantirati zub	15	5.88

The competence algorithm showed that 12 (4.71%) PSTs were competent, while 36 (14.12%) PSTs considered themselves personally competent in cases of tooth avulsion.

There was no connection between age (Fisher’s test, p=0.5040), educational level (Fischer’s test, p=0.5460), origin (Fischer’s test, p=0.3986) or duration of employment (Fischer’s test, p=0.5860) and level of competence.

Respondents showed interest in the topic and 98.04% (N=250) of them expressed a wish to learn more about dental trauma.

Discussion

Because of an impressive clinical picture, often followed by distress and bleeding in the area of face and mouth, seeking for the avulsed tooth does not present a priority for people in contact with a traumatized child. Firstly, it is essential that life-threatening injuries are excluded. However, afterwards, it is necessary that the permanent tooth is found and properly handled. The fact that 27.06% of PST (N=69) would not seek the permanent tooth when knocked out demonstrates incompetence “a priori”. According to the IADT,an avulsed tooth has the best prognosis if rinsed under running tap water for 10s maximum, without mechanical cleaning and if replanted within 30-60 minutes in the dental alveolus (). Unfortunately, only 5.88% of PSTs (N=15) would replant a permanent tooth, out of which only eight of them would do it properly. This piece of information does not differ from foreign research (, ).

Primary avulsed teeth should not be replanted, nevertheless 4.31% (N= 11) of our respondents would do so. This procedure can damage the bud of the permanent tooth. Even though a systemic review on primary tooth replantation showed outcomes without negative consequences in 15 out of 41 cases, there remains no evidence on its validity ().

If it’s decided not to replant the avulsed permanent tooth, a selection of transport media and quick transportation to the doctor of dental medicine is crucial.

Most of PSTs (50.20%; N=128) in our study would use a dry tissue as a transport medium, which, as well as tap water, distilled water, ice, alcohol and mouthwash leads to dehydration of cells and causes their degradation (, , ). Similar results are noted in other papers (-). Milk has the osmolality and pH value similar to the cells of the periodontal ligament, has valuable nutritional substances and allows the maintenance of cell viability during six hours (, ). Milk as a transport medium was selected by 12.54% (N=32) of our respondents. A solution similar to saline solution is easily prepared by dissolving a teaspoon of salt in two deciliters of water. Milk has obtained acceptance as storage medium. Likewise, a readily accessible saline solution can be used as a transport medium. None of PSTs selected it as a transport medium. Every household with children should own a specialized media kit, not to mention the necessity of it in kindergartens and schools.

Since every avulsed tooth has a good prognosis if replanted within an hour, it is worrisome that 37.25% (N=95) of PSTs would only inform the parents, thus leaving the child's future care to them and wasting precious time, that only 43.92% (N=112) of them would ensure immediate transportation to the doctor of dental medicine, that 80.00% (N=204)of them would not choose the right medium for transporting the avulsed tooth, that most of them would not consider tooth replantation, and that 63.92% (N=163) of them do not even know at what age a child has all of his/her permanent teeth (not including wisdom teeth).

Unfortunately, school policy on dental trauma and healthcare is often not defined at the national level, but varies from school to school. Consequently, school teachers sometimes must completely take on the role of school nurses.

The results of this study have not brought new insights on the level of PST knowledge since the lack of it is reported in other similar studies on the topic (-). However, the novel algorithm proved rigorous, simple and exact. Competence was assessed by questions 15-26 of the questionnaire in which the respondents were able to be assessed competent through two routes. As depicted in Figure 1, PSTs were able to pick a route where he/she was the child’s therapist i.e. the route which included tooth replantation. The second route demanded that the avulsed tooth was properly handled and brought to the doctor of dental medicine as soon as possible (see Figure 2). Questionnaires with clinical cases can be found in the literature, however, to our knowledge, an algorithm as this one, has not yet been used for competence assessment in tooth avulsion issues. A similar algorithm could easily be applicable to other dental trauma cases.

As 32.94% (N=84) of PSTs had previously been in contact with dental trauma, it is needless to justify the need for their obligatory continuous education.

It is satisfying that 98.04% (N=250) of PSTs expressed a wish to find out more about the topic. Since only 14.12% (N=36) of teachers found themselves competent in tooth avulsion cases, their awareness of the lack of knowledge is clear. We expected a connection between the level of education, years of employment, background, experience and the assessed competence. However, we found no statistically significant difference.

A questionnaire, presented as a tool for knowledge and competence assessment, has its already familiar limitations as an indirect measurement tool (, ), since there are difficulties concerning the reproduction of real-time clinical situations, ensuring the truthfulness of the answers and respondents’ recall or the response rate bias. Even though every researcher tends to provide the most accurate data, observer bias cannot be excluded, due to the respondents’ questions during the examination. The answers given to them could not have been credible, but surely any information given was influential.

In order to educate PSTs about tooth avulsion, they were handed an information leaflet that simply describes the methods of managing the avulsed tooth.

A similar study, involving school nurses, would complement the evaluation of dental trauma management in primary schools.

Conclusions

Our results provide significant implications for school health and show the current lack of knowledge on dental trauma among primary school educators. Dental trauma in primary school is not uncommon. Teachers are the first to notice dental trauma, hence they will occasionally have to take on the role of school nurses.

The competence algorithm presents a simple, rigorous and innovative technique to assess knowledge on tooth avulsion and its design could easily be translated for competence assessment in other dental trauma cases and serve for educational purposes. These results are of utmost importance not only for PSTs, but also for doctors of dental medicine since they should instruct educators.

The fact that 95.29% of PSTs were assessed as incompetent for treating an avulsed tooth indicates the need for organizing continuous obligatory courses on dental trauma. This can only be performed by studies like this one,aiming school teachers and school nurses through undergraduate and postgraduate curricula.