Knowledge, Attitude, and Practices (Kap) Survey on the Management of Traumatic Dental Injuries (Tdis) among Dental Students in Prince Sattam Bin Abdulaziz University (Psau), Alkharj.

Background: Traumatic dental injury (TDI) is described as a lesion of variable extension, intensity, and severity caused by forces acting on teeth due to falls, fights, traffic accidents, collisions against objects or people, and para-function and/or as a result of an assault. Appropriate treatments of TDIs can improve the outcome chance and reduce stress and anxiety for both patients and the dental team. Despite the importance of this topic, there remains a paucity of evidence on the current situation of TDI management among dental students in Prince Sattam bin Abdulaziz University.
Objectives: To assess the knowledge, attitude, and practice (KAP) of dental students about the management of TDIs and compare the knowledge according to the year of study. Methodology: A KAP survey was conducted on undergraduate dental students at Prince Sattam bin Abdulaziz University dentistry college. All clinical dental students (4th-5th year) and interns enrolled during the 2019-2020 academic year were invited to participate in the study (n = 92). Participants filled out a questionnaire containing 16 items related to KAPs toward the management of TDIs.
Results: The majority of fifth-year students (78.8%) and interns (70.8%) perceived that TDIs have the priority to be seen as an urgent case, compared to only 45.7% of fourth-year students (P = 0.013). Also, more than half of study participants reported not following any protocol for TDIs with no significant differences between study years. Furthermore, 69.7% of fifth-year students and 66.7% of interns considered the Hanks-balanced solution as the best medium for storing an avulsed permanent tooth.
Conclusion: The current results demonstrated a significant shortage in the KAP toward TDI management among dental students in Prince Sattam bin Abdulaziz University. Almost half of the students (45.7%) did not know any guidelines for the treatment of TDIs. The majority of study participants had no exposure to any previous workshops, symposiums, or conferences about managing TDIs, which makes it more difficult for them to understand and manage dental traumatic injuries. Hence, there is a need to assess the reasons behind this issue and develop solutions to improve the current situation. Copyright:

INTRODUCTION

Traumatic dental injury (TDI) is described as a lesion of variable extension, intensity, and severity caused by forces acting on teeth due to falls, fights, traffic accidents, collisions against objects or people, and para-function and/or as a result of an assault.[1]

TDIs can be categorized as childhood injury, which accounts for a significant number of pediatric dentistry patients. Studies show that about 20% of elementary school students have a history of dental trauma. The average rate of TDIs occurrence is 25% to 58%.[2] The majority of TDIs involve anterior teeth, which can negatively affect academic achievement and learning in children if not managed immediately and properly.[3]

Primary school-age children group of 7–12 years indulge in various activities such as sports and risk-taking behaviors. Though these activities are considered to be markers of growth and development, there is an increased possibility of dental injuries. There has been an exponential rise in TDI rates and they account for the third major cause of dental morbidity. Besides these alarming facts, TDIs are still on the verge of neglect.[4] In addition to that, most families cannot afford the cost of dental treatment as it may involve complex procedures and also replacement of teeth, which adds to the financial burden on families. Considering all these facts, TDIs have become an important public health problem. Therefore, health professionals must realize this as their responsibility to evaluate various predisposing factors related to dental trauma to help prevent its occurrence as well as manage it and its complications once happened.[34]

Glendor conducted a literature review on the etiology, reported risk factors for TDIs, and concluded that there has been a tremendous rise in the number of causes of TDIs over the last decades. He suggested understanding the complexity of a TDI by considering oral, environmental, and human etiological factors.[5]

A study done between September 2005 and August 2006 in an armed forces hospital in Jeddah, Saudi Arabia, showed that a high frequency of TDIs was seen in children between 9 and 11 years, and most of these injuries happened in street (57%). Also, most of these injuries were due to falls (68%),[6] and in other studies done by Al-Majed et al.[7] on Saudi schoolboys aged from 12–14 years. The prevalence of TDIs was 34%, whereas it was 31.4% the prevalence of TDIs to maxillary incisors in Saudi schoolgirls aged from 12-15 years Saudi schoolgirls.

Types of dental trauma range from a concussion to an alveolar fracture. The most frequent types of dental trauma, which consist of all diagnosed dental trauma, are the least severe types, which are enamel and dentin fracture, enamel fracture, and tooth discoloration.[5] Although the most common injury in the permanent dentition is a crown fracture, luxation is the most common injury in the primary dentition.[8]

A study done on oral health professionals showed an uneven pattern of knowledge among general dentists who participated regarding the emergency management of an avulsed tooth.[9] And another study among dental students in Saudi Arabia showed insufficient knowledge regarding TDI management, in addition to that, Saudi Arabian participants stressed the importance to receive more educational programs regarding dental trauma.[10] In a literature review, it is shown that professionals and dental students presented, in general, a low-to-moderate level of knowledge about TDI treatment.[1112]

Guidelines for the management of emergency of TDIs are useful for oral healthcare professionals to provide the best possible care in an efficient manner for their patients and take part in the education of their communities and it is expected from them to be familiar with the recommendations of these guidelines. In addition, knowledge of the appropriate treatments and the application of these guidelines can improve the outcomes and reduce stress and anxiety for both patients and the dental team.[9]

Despite the importance of this topic, there remains a paucity of evidence on the current situation of TDI management among dental students in Prince Sattam bin Abdulaziz University.

MATERIALS AND METHODS

This was a cross-sectional study using the knowledge, attitude, and practice (KAP) model that evaluated the KAP of the participants. The study was conducted among undergraduate dental students at Prince Sattam bin Abdulaziz University who are enrolled in the dentistry program at the College of Dentistry, Alkharj, Saudi Arabia. All clinical dental students (4th–5th year) and interns in the 2019–2020 academic year were invited to participate in the study (n = 92).

The study was approved by the Ethical Review Board of the College of Dentistry at Prince Sattam bin Abdulaziz University (IRB ID: PSAU2020012). Study participants were contacted through phone invitation and informed consent was obtained from all participants.

The survey was carried out in December 2019 using a close ended questionnaire containing 16 items, which have been used before in previous studies, with little modification study (Al Shamiri et al. 2015[10] and Fujita et al.,[13]). The research group reframed the study questions to make them easier to understand by the participants. The first six questions investigated the TDI knowledge among dental students. Questions from 7 to 16 investigate both attitude and practices of TDIs in which more importance was given to knowledge and attitude questions. The validity of the questionnaire was measured on 20 subjects who were excluded from the main analysis. The reliability of the questionnaire was measured using the test–retest method.

After collecting and cleaning the data, descriptive statistics were computed using SSPS V23. Categorical data are expressed as percentages, and data were analyzed at 95% confident interval using a Chi-square test and Fischer exact test.

RESULTS

The distribution of study subjects is shown in Table 1. There were a total of 92 subjects, among which 39.13% were fourth-year students, 35.86% were fifth-year students, and 26.08% were interns. The mean age of study subjects was 23.68 ± 0.89.

Table 1

Distribution of study subjects according to the year of study

Year of study	Number (percentage)	Mean age	Standard deviation
Fourth year	36 (39.13)	23.03	0.98
Fifth year	33 (35.86)	23.82	0.77
Interns	24 (26.08)	24.46	0.93
Total	92	23.68	0.89

Table 2 shows responses of study subjects to knowledge and awareness about the guidelines of dental trauma. For the question of how many types of TDIs you know, the majority of study subjects opted for the others option. The result was statistically non-significant with a P value of 0.744. The majority of fifth-year students (78.8%) and interns (70.8%) perceived that TDIs have priority to be seen as an urgent case, compared to only 45.7% of fourth-year students (P = 0.013). In addition, almost half of the students (45.7%) did not know any guidelines for the treatment of TDIs, with no statistically significant differences between the years of study.

Table 2

Responses of study subjects to knowledge and awareness of guidelines of dental trauma

Questions	Responses	Year of study			Total	Statistics
		Fourth year	Fifth year	Interns
How many types of traumatic dental injury do you know?	4	2	4	1	7	Fischer exact=6.060
		5.7%	12.1%	4.2%	7.6%	P=0.646
	7	5	4	2	11	NS
		14.3%	12.1%	8.3%	12.0%
	10	6	2	4	12
		17.1%	6.1%	16.7%	13.0%
	13	0	1	1	2
		0%	3.0%	4.2%	2.2%
	Others	22	22	16	60
		62.9%	66.7%	66.7%	65.2%
Do traumatic dental injury patients have priority to be seen as urgent cases in your clinic?	Yes	16	26	17	59	χ2=8.711
		45.7%	78.8%	70.8%	64.1%	P=0.013 S
	No	19	7	7	33
		54.3%	21.2%	29.2%	35.9%
Do you know any guideline for treatment of traumatic dental injuries?	Yes	18	19	13	50	χ2=0.259
		51.4%	57.6%	54.2%	54.3%	P=0.878 NS
	No	17	14	11	42
		48.6%	42.4%	45.8%	45.7%

As shown in Table 3, more than half of the study participants reported not following any protocol for TDIs, with no statistically significant differences between the year of study; also, the majority of the participants (90.2%) indicated that they do not use any special chart when treating TDIs, which was more prevalent among fourth-year students and interns (48.6% and 45.8%) compared to fifth-year students (42.4%) (P < 0.001). Only 27.2% of study participants had worked outside the PSAU dental school, which was significantly more among fourth and fifth-year students compared to interns (P < 0.001). In addition, a total of 40.2% reported treating TDIs before, out of which fifth-year students were significantly more in number (48.5%) (P > 0.05). Also, the majority of study participants (89.1%) had no exposure to any previous workshops, symposiums, or conferences about managing TDIs.

Table 3

Knowledge and awareness protocols in the management of traumatic dental injuries

Questions	Responses	Year of study			Total	Statistics
		Fourth year	Fifth year	Interns
Do you follow any protocol for traumatic dental injuries record keeping?	Yes	14	15	10	39	χ2=2.130
		40.0%	45.5%	41.7%	42.4%	P=0.144 NS
	No	21	18	14	53
		60.0%	54.5%	58.3%	57.60%
Do you use a special chart form when treating traumatic dental injuries patient?	Yes	3	3	3	9	χ2=59.52
		8.6%	9.1%	12.5%	9.8%	P<0.001 HS
	No	32	30	21	83
		91.4%	90.90%	87.5%	90.2%
Have you worked in any health care center other than PSAU Dental School?	Yes	7	7	11	25	χ2=19.17
		20.0%	21.2%	45.8%	27.2%	P<0.001 HS
	No	28	26	13	67
		80.0%	78.8%	54.2%	72.8%
Have you treated a traumatic dental injury patient before?	Yes	11	16	10	37	χ2=3.522
		31.4%	48.5%	41.7%	40.2%	P=0.061 NS
	No	24	17	14	55
		68.6%	51.5%	58.3%	59.8%
Have you attended any workshops, symposiums, or conferences about managing traumatic dental injuries?	Yes	5	4	1	10	χ2=56.348
		14.3%	12.1%	4.2%	10.9%	P<0.001 HS
	No	30	29	23	82
		85.7%	87.9%	95.8%	89.1%

Table 4 shows the knowledge of study participants in the treatment of an avulsed tooth and its preservation method. In total, 69.7% of fifth-year students and 66.7% of interns considered the Hanks-balanced solution as the best medium for storing an avulsed permanent tooth, whereas 57.1% of fourth-year students considered milk as the best medium (P = 0.001). For the cutting time for re-implantation of the avulsed tooth, 60 min was preferred by fifth-year (60.6%) and interns (50%), and 30 min was preferred by fourth-year students (45.7%) (P < 0.001). Also, 40.0% of fourth year and 54.2% interns responded as 1–2 weeks for splinting time of avulsed tooth, whereas 69.7% fifth-year students as 2–4 weeks (P < 0.001). Furthermore, 58.7% of study participants were of the view that apical root fracture has a good prognosis. According to the total percentage of opinions, the result was found to be statistically significant.

Table 4

Knowledge and awareness of avulsed tooth and its preservation method

Questions	Responses	Year of study			Total	Statistics
		Fourth year	Fifth year	Interns
What is the best medium for storing an avulsed permanent tooth?	hanks-balanced solution	9	23	16	48	χ2=63.21
		25.7%	69.7%	66.7%	52.2%	P<0.001 HS
	saliva	2	2	1	5
		5.7%	6.1%	4.2%	5.4%
	Water	4	0	0	4
		11.4%	0.0%	0.0%	4.3%
	Milk	20	8	7	35
		57.1%	24.2%	29.2%	38.0%
The cutting time for re-implantation of avulsed tooth is	30 min	16	12	4	32	χ2=33.91
		45.7%	36.4%	16.7%	34.8%	P<0.001 HS
	60 min	8	20	12	40
		22.9%	60.6%	50.0%	43.5%
	90 min	7	1	8	16
		20.0%	3.0%	33.3%	17.4%
	Time is not important	4	0	0	4
		11.4%	0.0%	0.0%	4.3%
Splinting time for avulsed teeth	1-2 week	14	8	13	35	χ2=60.87
		40.0%	24.2%	54.2%	38.0%	P<0.001 HS
	2-4 weeks	13	23	11	47
		37.1%	69.7%	45.8%	51.1%
	More than month	7	2	0	9
		20.0%	6.1%	0.0%	9.8%
	It should not be splinted	1	0	0	1
		2.9%	0.0%	0.0%	1.1%
Which location of root fracture has good prognosis?	Apical	24	10	20	54	χ2=36.02
		68.6%	30.3%	83.3%	58.7%	P<0.001 HS
	Middle	5	2	0	7
		14.3%	6.1%	0.0%	7.6%
	Coronal	6	21	4	31
		17.1%	63.6%	16.7%	33.7%

Table 5 shows the responses of study subjects for the better prognosis methods in the management of dental trauma. Sixty-three percent of the participants perceived that traumatized tooth has a better prognosis if the apex of the tooth is closed (P < 0.05). The majority of the respondents in the fourth year, fifth year, and interns reported that all fractured teeth should be treated by root canal treatment (P > 0.05) In total, 77% of study participants thought root canal is necessary, again the result was statistically significant (P < 0.001). Furthermore, 75% of the respondents perceived that antibiotics should not be prescribed for all TDIs, whereas 63.0% of study participants thought that analgesics should be prescribed for all TDI patients. The result according to total responses was statistically significant (P < 0.005).

Table 5

Knowledge and awareness about better prognosis methods in the management of dental trauma

Questions	Responses	Year of study			Total	Statistics
		Fourth year	Fifth year	Interns
The traumatized tooth has better prognosis if the apex of the tooth is	Open	11	9	14	34	χ2=6.261
		31.4%	27.3%	58.3%	37.0%	P=0.012 S
	Closed	24	24	10	58
		68.6%	72.7%	41.7%	63.0%
All fractured teeth should be treated by root canal treatment	Yes	10	6	5	21	χ2=27.17
		28.6%	18.2%	20.8%	22.8%	P<0.001 HS
	No	25	27	19	71
		71.4%	81.8%	79.2%	77.2%
Antibiotic should be prescribed for all traumatic dental injury patients	Yes	12	6	5	23	χ2=23.00
		34.3%	18.2%	20.8%	25.0%	P<0.001 HS
	No	23	27	19	69
		65.7%	81.8%	79.2%	75.0%
Analgesics should be prescribed for all traumatic dental injury patients	Yes	20	20	18	58	χ2=6.26
		57.1%	60.6%	75.0%	63.0%	P=0.012 S
	No	15	13	6	34
		42.9%	39.4%	25.0%	37.0%

DISCUSSION

The crucial factor in the success of TDI includes a correct diagnosis and an appropriate treatment. Many times, patients report to clinics with a delayed time after a traumatic injury and dentists may have to make a decision urgently. Therefore, the level of knowledge during decision-making in dental trauma cases directly affects the prognosis. Thus, the present study was a cross-sectional study, which evaluated KAPs of dental students regarding the management of TDIs in children. All students who participated were within 25 years of age.[91011]

In this study, the majority of study participants (89.1%) had no exposure to any workshops, symposiums, or conferences about managing TDIs. Despite their lack of training, 64.1% of students felt TDI patients have priority to be seen as urgent cases in the clinic.

If tooth avulsion was handled and treated quickly and in an efficient way, then it may have an excellent prognosis regarding function and esthetics and will decrease the physiological effect caused to the child.[12]

Results from the undergraduate dental students showed that they had insufficient information regarding the management of TDIs. Although when interns were compared to fourth- and fifth-year students, they were having slightly more knowledge. Similar results were obtained by a few other authors.[1013] This may be due to their inexperience of trauma in the dental clinic as most of the schools do not provide a trauma emergency department. These results may also be due to the lack of importance given to this topic in elementary schools, high schools, and even in early years of studying dentistry as the course of dental trauma is only taken theoretically in the fourth or fifth year in most dental schools. Moreover, the clinical examination, diagnosis, and treatment of trauma should be included in the curriculum instructions.

The teaching of dental trauma management seems to be lacking although early management of dental trauma, especially tooth avulsion, is critical for a good prognosis. The best transportation media for avulsed teeth include Hank's balanced salt solution (tissue culture medium), saline, and cold milk.[14] In the present study, 69.7% of fifth-year students and 66.7% of interns selected the Hanks-balanced solution as the best media for storage, whereas 57.1% of fourth-year dental students selected milk as the best media for transportation. In contrast, a recent study revealed that long shelf-life ultra-high temperature skim cow milk is not effective in preserving fibroblast viability in vitro.[15] Therefore, it is necessary to educate dental students regarding the type of storage media to be used for preserving the avulsed tooth.

Regarding the knowledge on cutting time for re-implantation of an avulsed tooth, in the present study, 34.8% gave the correct answer, which is within 30 min of trauma meaning more than 65% of students being not aware of the time for re-implantation of avulsed tooth. Previous studies also reported similar kinds of findings including different professionals.[161718]

We evaluated the knowledge of students about the dental trauma through some questions such as splinting time, apex whether it is closed or open to having a good prognosis, the requirement of antibiotics, analgesics, and root canal treatment. Overall, there was an acceptable positive response from students regarding the above points. Unsurprisingly, there was a significant favorable response from students of the higher academic level compared with those of lower academic level. This result is expected and could be attributed to the fact that their knowledge regarding dental trauma is more updated and refreshed than fourth- and fifth-year dental students. Another possible explanation for this finding is the fact that the interns had been exposed to clinical cases as compared to those of lower academic levels but the same was not observed in all questions.

A previous study has shown that 95.7% of dental students from academic levels stressed the importance of receiving dental trauma education, indicating their willingness to receive more educational programs regarding dental trauma.[9]

Similar to previous studies, the results of the present study demonstrate insufficient knowledge regarding dental trauma management among dental students in Saudi Arabia. This highlights the need to improve the knowledge of dental students regarding dental trauma and its management using a variety of educational methods such as problem-based learning and powering the curriculum concerning those topics of dental trauma.[919]

Being a questionnaire-based survey, there might be some elements of underreporting bias in the study. KAP study design and nonrespondent bias may be considered as other drawbacks. Additionally, the sample size for the study was less; hence, further studies with more number of dental students should be considered. Despite these limitations, the study provides some important information about the Saudi dental students' knowledge and attitude regarding dental trauma, which can be utilized to deliver comprehensive guidelines in the management of TDIs among dental students.

CONCLUSION

Suitable emergency management and treatment plan are critical to the success and good prognosis of dental trauma. Treatment guidelines for dental trauma are required to help dentists and other healthcare workers to provide proper and effective care for children in case of trauma. The current results demonstrated a significant shortage in attending courses about dental trauma, among dental students. This makes it more difficult for them to understand and manage DTIs. Hence, dental students should be encouraged and motivated to attend courses about dental trauma and its management. Consequently, it is important to enhance the awareness and upgrade the information about dental trauma for those professionals. If those guidelines were applied immediately after traumatic injury, both short- and long-term outcomes would be improved.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.