Knowledge, attitude, and practice of Chennai school teachers on traumatic dental injuries management - A cross-sectional study.

Aim: To assess the knowledge, attitude, and practice of traumatic dental injury (TDI) management among school teachers of Chennai. Materials and
Methods: Forty-seven schools were selected from various parts of Chennai for the cross-sectional survey by simple random sampling. Four hundred school teachers who participated were from 26 regular schools and 21 special schools. Questionnaire with 32 close-ended questions assessing knowledge, attitude, and practice of TDI management was devised, face validated by experts, and pilot tested. Link to the online survey questions was provided after obtaining the informed consent. Responses were analyzed using Microsoft Excel.
Results: Twenty-two percent reported to have undergone first aid training and among them, 4% were trained on TDIs management. 27% had a false sense of knowledge and practice of TDIs management. 12% were confident in replanting an avulsed tooth by themselves. Ten percent were aware of using milk as a storage media. 86% were willing to learn about TDIs management. Conclusions: Within the limitations of the present study, it can be concluded that despite the lack of knowledge and practice regarding TDI management, school teachers of Chennai had a good attitude towards TDI education. Emergency management training is by itself a necessity in schools and it should be inclusive of TDI management. Copyright:

INTRODUCTION

Traumatic dental injury (TDI) is a trauma to the teeth and/or their supporting structures in the oral cavity. It manifests as dislodgment, crush injury, or a combination of both. Dental trauma is a significant public health problem due to its frequency and impact on quality of life. It takes longer durations to treat and is more expensive than many other bodily injuries treated on an outpatient basis.[1] Epidemiological studies indicate the annual incidence of dental trauma globally is about 4.5%, and that in the near future, the incidence of trauma will exceed that of dental caries and periodontal disease in the young population.[23]

The currently accepted system to classify dental injuries is based on the World Health Organization's Application of International Classification of Diseases to Dentistry and Stomatology and modified by Andreasen. They are mainly grouped as traumatic injuries to teeth, soft tissues, and supporting bone.[3] Among these avulsion of permanent teeth is seen in is considered one of the most serious dental injuries requiring prompt and correct emergency management.[4] The maxillary anteriors are the most commonly avulsed teeth in the primary and permanent dentition.[5] The anterior teeth not only contribute to esthetics but also are vital for phonetics, mastication, the integrity of supporting tissues, as well as psychological and mental wellbeing of children.[6]

TDIs in primary dentition ranges between 11% and 30%, and in permanent dentition range between 5% and 29%.[3] Most of a child's time is spent at school which is about 40% of their awake time. Since the children aged 8–11 years are prone to trauma, the schools are the place where one can find a noticeable risk of TDIs following home.[7] Since sports and school injuries account for 60% of the overall cause of TDIs, teachers are generally present at the time when a dental trauma occurs during school hours.[7] The prognosis of traumatized teeth depends on prompt action and appropriate treatment, which often relies on the knowledge of people such as the child's caretakers.[4] Conjuring upon the importance of this issue, knowledge, attitude, and practice by school teachers about dental injuries caused by trauma was deliberated.

Special health care needs are defined by the American Academy of Paediatric Dentistry as “any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, healthcare intervention, and/or use of specialized services or programs.” These individuals are at higher risk for TDIs, which may be related to the nature of the medical condition or to the side effects of medications they are taking.[5] A study in India reported 12.1% prevalence of TDIs in Children with special health care needs compared with 6.9% in healthy children.[8] There is the prevalence of an under-treatment scenario for TDI in special children mainly due to economics, numbers of trained and willing practitioners, parent and caregiver awareness, problems in transportation, and negative thoughts related to oral health care.[5] This illustrates the fundamental importance for school teachers to be duly informed about the correct first-aid measures.

In recent years the role of school teachers in the prevention of TDIs has received a great deal of attention.[9] However, there are not any studies reported from this region of the country assessing the knowledge, attitude and practice of regular and special school teachers regarding emergency management of TDIs. Hence, a forward step was needed to be taken in this particular area. Thus, the aim of the present study was to assess the knowledge, attitude, and practice of TDIs management among school teachers in Chennai.

MATERIALS AND METHODS

The study was designed as a cross-sectional survey which included regular and special school teachers of Chennai, India. After obtaining approval certificate to conduct research from the Institute ethics committee, the study was initiated. Forty-seven schools were selected from various parts of Chennai by employing simple random sampling, of which 21 were special schools and the rest were regular schools. Special schools taught children with special health care needs and regular school trained children with no special health care needs. Approval to survey the selected schools was obtained by taking permission from the head of the institution of the respective schools.

Sample size calculation was done, to obtain results at 95% confidence interval using G power analysis sample size calculator software, from previous study sample sizes.[5610] The appropriate sample size required was found to be 390 and was rounded off to 400. Two hundred special school teachers and 200 regular school teachers were selected from those 47 schools, to ensure equal random samples from each type of school. The school teachers who taught students aged 6–20 years were selected for the current study. The study was executed for 3 months, from June 2019 to August 2019.

A close-ended questionnaire containing 32 questions was devised for the current study. The questionnaire was face validated by experts and pilot tested among 25 teachers, other than those who participated in the study. It consisted of three parts: Part 1 contained questions pertaining to demographic characters of the respondents, including first-aid training background. Part 2 comprised of questions assessing participants' knowledge and practice concerning TDIs management. This part was further divided into the following sections: Basic knowledge on the growth patterns of children's dentition, general knowledge of dental trauma and knowledge of avulsed, fractured, luxated teeth as well as its emergency management. It also consisted of two imaginary case scenarios to assess the participants' knowledge and practice on TDI management. Part 3 comprised of questions aimed to assess the level of the teachers' satisfaction with their knowledge on the management of TDIs and their willingness to attend an educational program on management of dental trauma.

The nature and purpose of the study were first explained to the teachers in English and the local language. Its voluntary nature was emphasized. Online survey link using Google forms was provided after obtaining informed consent individually. One pretrained investigator was available throughout to make any required clarifications and rectify any difficulty in comprehension by the participants. The responses obtained were tabulated and then analyzed using Microsoft Excel.

RESULTS

All the participating teachers filled the entire questionnaire with a 100% response rate. This can be attributed to the presence of one pretrained investigator who was available throughout to help the participants in filling the online survey. Out of the 400 participants, 200 were special school teachers and 200 were regular school teachers. The majority of the respondents (83%) were women. The participants' age distribution is presented in Table 1. Among the participants, only 22% had undergone formal first aid training, among them only 4% were trained on TDIs management. Of those who had undergone first aid training, 84% of the teachers belonged to special schools.

Table 1

Participiants age distribution

Participants age (years)	Percentage response
Under 20	4
21-30	24
31-40	25
41-50	30
51 and above	17

Fifty-two percent of the overall participants had proper basic knowledge on the growth patterns of children's dentition-of which 76% belonged to special school and the rest to regular school. Twenty-one percent admitted to have no knowledge regarding it and the rest 27% were found to have false knowledge. Sixty-eight percent of those who had false knowledge belonged to the special school. It was observed that only 51% were able to identify the damaged front tooth in a 9-year-old child will be a permanent tooth, of which 68% were special school teachers and 32% were regular school teachers. In the case of a simple crown fracture, 50% of the respondents would contact the child's parent after class hours and explain the incident, 29% would give the child water to drink and continue with the class and only 19% would search for the broken piece.

In the scenario of avulsion during school hours the action they would take, 10% would look for the tooth, wash it and give it to the child to take home, 43% would get the child to bite on a handkerchief and send the child home once the bleeding is controlled, 7% would look for the tooth and put it back in place in the child's mouth and leave it, 40% would get the child to hold the tooth carefully in their mouth/carry the teeth in a container with liquid and seek for professional help immediately.

Eighty-one percnt of the participants were aware of seeking professional help immediately during the intrusion, extrusion, luxation, and soft-tissue injuries with bleeding, while the rest 19% would manage the situation by controlling the bleeding and leaving it as it is. Regarding professional help, 86% would visit a dentist nearby, 9% would visit a general hospital, and 5% would visit a Pediatrician.

A significant number of school teachers (76%) were not satisfied with their knowledge regarding TDIs management and most of them (86%) were willing to receive training to manage TDIs, with almost equal responses from special and regular school teachers. Only 12% of the participants taught their students on how to manage when TDI occurs. Tables 2 and 3 present the participants response to manage an avulsed teeth.

Table 2

Knowledge on replantation

	Percentage response
Knowledge on replantation
Avulsed permanent tooth can be replanted	56 (R: 36, S: 64)
Avulsed milk tooth can be replanted	12 (R: 44, S: 56)
Involvement in the procedure to replant the avulsed permanent tooth
Agreed to do it by themselves	12 (R: 28, S: 72)
Duration for replantation
Acquainted with the urgent need for action	43 (R: 48, S: 52)
Felt that professional help has to be taken within 12 h	23 (R: 54, S: 46)
Felt that professional help has to be taken within 24 h	10 (R: 58, S: 42)
Thought time is not a significant factor	14 (R: 47, S: 53)
Thought time is not a significant factor	14 (R: 47, S: 53)

R: Regular school, S: Special school

Table 3

Knowledge on avulsed tooth management

	Percentage response
Knowledge on avulsed tooth handling
Hold the root	51 (R: 48, S: 52)
Hold the crown	38 (R: 43, S: 57)
Not a significant factor	11 (R: 51, S: 49)
Cleaning method of soiled avulsed tooth
Scrub and rinse	21 (R: 43, S: 57)
Gently rinse	51 (R: 47, S: 53)
Did not know what to do	28 (R: 45, S: 55)
Cleaning/rinsing solution
Tap water	18 (R: 53, S: 47)
Antiseptic solution	27 (R: 44, S: 56)
Saline	9 (R: 54, S: 46)
Milk	7 (R: 57, S: 43)
Did not know what to do	39 (R: 52, S: 48)
Knowledge on transportation method of avulsed tooth
Unaware of the transport method for avulsed tooth	20 (R: 51, S: 49)
Wrap in tissue paper	9 (R: 58, S: 42)
Soft cloth	17 (R: 53, S: 47)
Plastic cover	13 (R: 48, S: 52)
Container with liquid	40 (R: 51, S: 49)
Storage medium
Milk	10 (R: 38, S: 62)
Saline	17 (R: 48, S: 52)
Antiseptic solution	34 (R: 53, S: 47)
Tap water	24 (R: 63, S: 37)
Did not know what to do	15 (R: 47, S: 53)
Ask the student to spit saliva into a container and put the tooth into it for transportation	26 (R: 46, S: 54)

R: Regular school, S: Special school

DISCUSSION

Knowledge of TDIs management is fundamental for the provision of spot-on care to an injured child for the future prognosis of affected teeth. Teachers who participated in the present survey were questioned about their knowledge on emergency management, with two imaginary cases of TDIs. Case scenario 1, regarding a 9-year-old girl with a broken upper front teeth-less than one-third of the teachers, recognized that the upper front teeth were permanent. This indicates a lack of general dental knowledge of the surveyed group regarding the time of the eruption.

Case scenario 2, regarding a 16-year-old boy with a knocked out front tooth and bleeding-the ideal treatment, would be immediate replantation or to look out for the tooth ensuring minimal further insult to the cells of page description language (PDL) on the root surface of the avulsed tooth and seek for professional help immediately. But <1/3rd of the teachers were aware of it. Almost 2/3rd of the teachers as a common instinctive reaction by most people, wherein the sight of blood sets off a panicky response focusing on controlling the bleeding first-side-lined the injured boy asking him to bite on a handkerchief. Avulsion is common in children because the bone is not completely mineralized and more resilient. Thus, any injury or trauma to the tooth at this stage leads to ex-articulation of the teeth rather than fracture. The first line of treatment for it is immediate replantation.[11] When immediate replantation is not possible, the avulsed tooth must be transported or stored before replantation to preserve the vitality of the PDL cells. Specially developed storage media such as Hank's balanced salt solution can sustain the vitality of the PDL for several hours. However, the ease of immediate availability of the media is a problem and milk has been demonstrated to be a suitable alternative storage solution for several hours, which is easily accessible. The avulsed tooth can also be transported in saliva, but not for several hours as it lacks the nutrients required to maintain the vitality of PDL cells. Tap water or dry storage of the avulsed teeth will result in the destruction of the PDL and its cells.[12] Functional healing was observed in teeth re-implanted within 1 h after the injury.[13] Longer the time elapsed between avulsion and replantation, poorer is the prognosis.

In the present study, the knowledge and management of avulsed tooth among special and regular school teachers of Chennai was poor. Although the teachers knew that knocked out (avulsed) teeth come under emergency treatment but the management of it has not been fully understood by them. Small percentage of teachers considered replantation of knocked-out permanent teeth immediately. This can be attributed to the fact that among the school teachers surveyed in the present study only 22% of the teachers had attended a formal first-aid training and of which <5% recalled dental trauma management being a part of it.

On comparing the overall knowledge, practice, and attitude of TDI management between both school teachers there was no significant difference. Most of the teachers were unsatisfied with their knowledge and practice in managing TDIs but they had a very good attitude towards the same. This indicates that educational promotion programs on dental trauma management must be organized. The study by Pujita et al. stated a significant improvement in trauma knowledge among school teachers post TDI management informative promotion.[7] The education system and teachers in India, besides imparting education, are becoming increasingly aware and are taking an active part in the proper health care of a child. Educational programs and dental camps can prove to be beneficial in this regard.

More than a quarter of the participated teachers had a false sense of knowledge and practice on TDIs management. Those teachers indicated that they were able to give suitable action when needed in cases of TDIs but their responses were incorrect. Among those teachers with false knowledge, 78% of them reported to have undergone an emergency first aid training and a higher percentage of them belonged to special schools. This sense of false knowledge could actually worsen the prognosis of the treatment outcome due to improper management and also partly attribute to the prevailing scenario of under treatment among the special health needs children. Although the overall numbers are not large enough to draw wide conclusions, it still emphasizes that the programs designed to train teachers on the management of TDI should be well planned and executed, utilizing visual aids to make sure the correct information is being retained. The need for these programs should be provided to all school teachers with no regard to their age, experience, or gender. Some steps that can be considered to improve the knowledge and practice regarding TDIs management among school teachers:

First-aid emergency management inclusive of dental trauma management should be included in the teacher training curriculum which would help the teachers to act in a better way when faced with such situations. Creating awareness about preventive measures and use of safety equipment such as wellfitted mouthguards, face cages, helmets during sport/recreational activities in which there is a risk of sudden impact to the face. Developing interaction between dentists and school teachers during dental education promotion programs enables the teachers in rendering the appropriate management of traumatized teeth thereby improving its prognosis. Dental camps should be held regularly every year in schools, implementing awareness lectures, informative handouts highlighting emergency management of TDIs for reinforcing knowledge.

While this study fulfilled the desired goals, the findings are that of a limited population. Further studies to assess and compare the knowledge, practice, and attitude regarding emergency management of dental trauma in other regions would give a broader perspective. The present study was also limited by the fact that it included only the school teachers, further studies to assess the knowledge regarding TDI management involving the general public, parents and medical personnel would help in the identification of areas of lacunae in the society.

CONCLUSIONS

Within the limitations of the present study, it can be concluded that despite the lack of knowledge and practice regarding TDI management, school teachers of Chennai had a good attitude towards TDI education. Emergency management training is by itself a necessity in schools and it should be inclusive of Traumatic Dental Injuries management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.