R. Hashim
Ajman University of Science and Technology, Emirate of Ajman, United Arab Emirates e-mail:
[email protected]
Dental trauma management awareness among primary school teachers in the Emirate of Ajman, United Arab Emirates ABSTRACT Aim To assess, by means of self-administered structured questionnaire, the level of knowledge of primary schools teachers in Ajman with regards to the immediate emergency management of dental trauma. Material and methods The questionnaire was sent to teachers in randomly selected primary schools in Ajman. A total of 161 teachers responded (response rate 84.4%). The questionnaire surveyed teachers’ background, knowledge and management of tooth fracture, avulsion, and also investigated teachers’ attitudes and self-assessed knowledge. Results Ninety-one percent of the teachers were females, 51.6% in their thirties and 61.5% had university qualification. Fifty teachers had received formal first aid training, and only thirteen of them recalled that they had received training on the management of dental trauma. Concerning the management of tooth fracture, 138 respondents (85.8%) gave the appropriate management for fractured tooth. One hundred twenty-one (75%) of the respondents indicated that is “very urgent” to seek professional assistance if a permanent tooth is avulsed, but they had little knowledge on the correct media for transporting the avulsed tooth. Most teaches were unsatisfied with their level of knowledge for dental trauma and the majority were interested in having further education on the topic. Conclusion The findings revealed that the level of knowledge of management of dental trauma (especially tooth avulsion) among school teachers in Ajman is inadequate, and education campaigns are necessary to improve their emergency management of dental injuries. Keywords Dental trauma; Emergency; Knowledge; Teachers.
Introduction Dental injuries are common in childhood. It has been EUROPEAN JOURNAL
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shown that when a child reaches school age, accidents in the school environment in the form of falls are very common and are the main cause of traumatic tooth injuries [Carter et al., 1972; O’Neil et al., 1989]. Dental trauma can vary from minor enamel chipping to extensive maxillofacial damage involving the supporting structures and displacement or avulsion of teeth. It is well recognised today that for long-term success, the management or treatment of traumatised teeth optimally should be carried out as soon as possible [Andreasen and Andreasen, 2007]. In this regard, the attitudes and knowledge about dental trauma of children’s parents and their school teachers or those present at the accident, prior to initial dental contact [Andreasen, 1985], would be critical to the ultimate prognosis of traumatised teeth, especially when dealing with avulsed teeth [Andreasen and Andreasen, 2007; SaeLim and Yuen, 1997]. In Ajman, there have not been any studies to ascertain the knowledge of primary school teachers about the management of dental injuries. The objective of this study was to investigate the knowledge of a group of school teachers about the emergency management of dental trauma in Ajman. The outcome of the study could help to refine the curriculum for training of primary school teachers.
Methods The questionnaire was modified from three questionnaires used in previous studies [Sae-Lim and Yuen, 1997; Raphael and Gregory, 1990; Stokes et al.,1992]; the questionnaire was distributed in Arabic. A translated version of the questionnaire is given in Figure 1. The accuracy of the translation was verified by reverse translation. The 3-page questionnaire was divided into three parts (Fig. 1). The first part consisted of 8 questions on personal and professional data including gender, age, level of education, teaching experience and first aid training background. The second part contained five questions; two of them based on two imaginary cases of dental injuries. The first case depicted a mild accident of uncomplicated crown fracture, while the second was a more severe scenario that involved an avulsion. The last part of the questionnaire aimed at assessing both the knowledge and attitude to public education programmes on dental trauma emergency management, and also the importance of seeking immediate care for dental trauma. All questions in the questionnaire were close-ended. To help the respondents make quick decision, they were given alternative choices, which resemble real situation with dental trauma. All returned questionnaires were coded and analysed. Result were expressed as a number and percentage of respondents for each question and were analysed using the SPSS software (Chicago, IL). The chi-square test was performed to test the influence of different variables, such as age, gender, teaching experience and first aid training, on knowledge of management of dental trauma, and the level of significance was set at P=0.05.
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HASHIM R. Part I - Personal and professional information Q.1 Q.2 Q.3 Q.4 Q.5 Q.6 Q.7 Q.8
Gender Age Education Experience Did you receive first aid training? If yes, did it cover dental trauma? Did any kids fall in your class? If yes, how many cases?
Male Female 20-29 30-39 40-49 > 50 Diploma University Higher Ed. < 3 years 3-6 years > 6 years Yes No Yes No Yes No 1-2 3-4 5 or more
Part II - Case study Case I Q.1 A 9-year-old child fell and broke its upper front tooth, is this likely to be:
Q.2 Your immediate emergency management of the case is:
❒ permanent ❒ baby tooth ❒ don't know
❒ send the child to school nurse if available ❒ contact parents and advice them to send child to the dentist immediately ❒ reassure the child and send him/her back to class ❒ not sure what to do
Case II Q.3 A 12-year-old boy was hit on ❒ put the tooth back in its place in the face and his upper front tooth the mouth and send the kid to the fell out. The immediate emergency dentist immediately FIG. 1 - Questionnaire of the survey on primary school teachers’ knowledge and attitude in the management of dental trauma.
Results
Q.4 How urgent do you think that ❒ immediately you should seek professional help if ❒ within 30 minutes a permanent tooth is knocked out? ❒ within a few hours ❒ before next day ❒ not sure Q.5 Suggest transport medium for ❒ water an avulsed permanent tooth: ❒ milk ❒ ice ❒ napkin ❒ plastic bag ❒ disinfectant ❒ others, specify ❒ not sure Part III - Awareness Q.1 Do you think that your knowledge for emergency management is satisfactory?
Yes
No
Q.2 Would you like to receive short training on how to manage dental trauma cases?
Yes
No
Q.3 Do you think it is important to seek emergency management for dental trauma?
Yes
No
Characteristic
Part II: responses The responses to Part-II of the questionnaire, which dealt with the hypothetical dental cases, in addition to the multiple choice questions, were as follows (Table 2). • Case I, broken incisor in a 9-year old girl: 71 (44.1%) of respondents knew that the fractured tooth is most likely a permanent incisor. With regards to the immediate emergency management of the case, 85.8% gave the right response.
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n
(%)
Gender
Male Female
13 148
8.1 91.9
Age
20-29 30-30 40-49 > 50
51 83 25 2
31.7 51.6 15.5 1.2
Education
Diploma University Higher Education
50 99 12
31.1 61.5 7.5
Experience
< 3 years 3-6 years > 6 years
20 39 102
12.4 24.2 63.4
First aid training
Yes No
50 111
31.1 68.3
Training on dental emergencies
Yes No
13 148
8.1 91.9
Trauma cases seen
0 cases 1-2 cases 3-4 cases 5 or more cases
116 40 3 2
72 24.9 1.9 1.2
Part I: response rate and respondent’s profile The number of primary schools teachers who responded was 161; the response rate was 84.4%; 91.9% of respondents were females, and 51.6% were in their thirties; 99 teachers (61.5%) had university qualification (Table 1). In general, 50 teachers (31.1%) had first aid training at least once in their teaching career, but only 13 teachers (8.1%) were trained to deal with dental emergencies as part of their first aid training. With regards to the number of seen trauma cases, Table 1 illustrates that about one quarter of the teachers (24.9%) had seen at least one trauma case throughout their teaching career.
❒ stop oral bleeding then send the kid home ❒ put the tooth in a solution and send the boy home with it straight away ❒ not sure what to do
action you should take is:
TABLE 1 - Responses to Part-I: personal and professional characteristics of respondents. EUROPEAN JOURNAL
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DENTAL TRAUMA MANAGEMENT BY SCHOOL TEACHERS IN THE UAE Case
Incorrect n (%) Correct n (%)
Not sure n (%)
Broken tooth type of tooth management
45 (28.0) 4 ( 2.5)
45 (28.0) 19 (11.8)
Avulsed tooth management urgency transport
99 (61.5) 38 (23.6) 154 (95.7)
71 (44.1) 138 (85.8)
31 (19.3) 121 (75.2) 7 ( 4.3)
31 (19.3) 2 ( 1.2) 0 ( 0.0)
n (%) Self assessed knowledge
enough not enough
20 141
(12.4) (87.6)
Need for further education
yes no
133 28
(82.6) (17.4)
Emergency management of tooth trauma is a priority for teachers yes 158 (98.1) no 3 (1.9)
TABLE 2 - Results of Part II.
• Case II: avulsed permanent tooth in a 12-year-old child: 61.5% of the teachers gave the wrong answer about emergency management, which was to concentrate on stopping oral bleeding and sending the child home. Only 31 (19.3%) responded correctly, by replanting the tooth. When the teachers were asked how urgently professional help was needed for an avulsion injury, 121 teachers (75.2%) responded correctly by seeking professional dental care immediately. Respondents were then asked about the storage medium of the avulsed tooth while taking the child to the dentist and the majority of them, 154 (95.7%), selected the wrong medium; only 7 (4.3%) knew that milk was the medium of choice. The chi-square test indicated that there was a significant difference among respondents in the number of correct responses according to age, level of education, years of teaching experience, first aid training, number of seen trauma cases (P>0.05) but no significant association were found in relation to gender.
Part III: awareness The responses to Part III of the questionnaire, which investigated self assessed knowledge, willingness to get further education on the topic and the importance of seeking immediate care for traumatised teeth show that 141 (87.6%) of the respondents thought that their knowledge regarding emergency management of dental trauma was not enough (Table 3). Interestingly, 133 (82.6%) of the teachers reported that they need further education on the emergency care for dental trauma. With regards to the importance of seeking immediate care for traumatised teeth, the majority of the teachers (98.1%) thought it was very important.
Discussion This survey included teachers from randomly selected schools in the Emirate of Ajman (UAE), and the response rate was high (84.4%). The age of the teachers surveyed was relatively young, 83 (51.6%) being in the 30-39-year group. The percentage of females 148 (91.9%) was much higher than their male counterparts. Most of the teachers, 141 (87.6%), had more than 3 years of teaching experience. A rather disturbing finding in our survey was the fact that only 31.1% of the teachers had first aid training only once in their teaching career, while the others never had any. This EUROPEAN JOURNAL
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TABLE 3 - Responses to Part III; self assessed knowledge, attitude and willingness to receive further education on dental trauma management.
is in contrast to the high percentage of first aid training found among teachers in Hong Kong and England studies [Chan et al., 2001; Al-Jundi, 2004]. However, our result is it close to what previously noted in Jordan [Al-Jundi et al., 2005]. Only 8.1% of the teachers received dental emergency training as a part of their school physical education programmes, indicating the need to properly and periodically train teachers in first aid with focus on dental emergency. Around one quarter of respondents 24.9%, had previous direct or indirect experience of dental trauma cases. This was comparable to other lay groups such as parents and school personnel reported in the studies performed in Jordan [Al-Jundi et al., 2005] and England [Hamilton et al., 1997]. The two imaginary cases in Part II of the questionnaire were designed to test the respondents’ general knowledge of the two different types of dental injuries. The ages of the injured children in the cases were intentionally selected as 9 and 12, respectively, because children between these ages carry the greatest risk of dental injuries [Hareinen-Immonen et al., 1990]. In case I, less than half (44.1%) of the respondents recognised that the maxillary incisors belong to the permanent dentition in a 9-year-old child. This indicates that the general dental knowledge of the respondents was inadequate. It is well known that the prognosis of a fractured incisor depends on the extent of involvement and on the patient’s age [Andreasen and Andreasen, 2007]. It is unreasonable to expect a primary school teacher to make the appropriate diagnosis or make decisions about an injury. Thus, it was felt that the most appropriate response was “B”, i.e. the parents should be contacted and asked to take the child to the dentist immediately. Nonetheless, it is accepted that in reality such contact may not be immediately possible. The author therefore judged that referral to the school nurse was an acceptable alternative. By these criteria, over 85% of the teachers would have acted appropriately and this result is better than what had been reported in similar studies conducted in Hong Kong [Chan et al., 2001] and Norway [Skeie et al., 2010]. For case II, one of the main requisites of dental avulsion treatment is tooth replantation as soon as possible, keeping periodontal cells viable for healing and a possible pulp revascularisation [Blomlof et al., 1983]. Unfortunately, only 31 teachers (19.3%) would put the tooth back into the socket immediately. This finding suggests that most of the
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HASHIM R. teachers were not confident about undertaking this toothsaving procedure or may not know how to do it, or that such decision might be due to accident-associated factors such as a child’s emotional state at the time of injury, and consent issues [Flores, 2007]. Most teachers (75.2%) recognised the urgency of seeking professional assistance for avulsion injuries. A delay in providing emergency dental treatment may jeopardise the prognosis of an avulsed tooth. Ideally, replantation should be carried out within half an hour [Andreasen, 1996]. If the tooth is kept in a suitable medium, the extra-oral time may be extended to up to 6 hours [Blomlof et al., 1983]. For transport for an avulsed tooth, dry storage of the tooth will cause irreversible injury to the periodontal membrane, resulting in loss of the replanted tooth over time. However, storing the tooth in water is not recommended in that the osmolality is too low [Blomlof, 1981; Sigalal, 2004]. Only 7 respondents (4.3%) picked milk as the best storage medium of choice. Milk has a favourable osmolality and composition for the viability of periodontal ligament cells and has therefore been recommended for temporary storage of avulsed teeth before replantation [Blomlof, 1981; Sigalal, 2004]. A large number of respondents (36.6%) suggested using “antiseptic solution” for transporting avulsed tooth (data not presented, probably their intention was to kill the germs on the tooth’s root surface but they did not realize that the viable cells of the tooth would also be damaged severely at the same time). There seems to be an urgent need to educate the public and correct these misconceptions. The results of Part III of the survey indicated that the respondents were not satisfied with their level of knowledge, they were keen to learn more about dental trauma management and the majority of the teachers considered the management of dental trauma a priority for them. The present results indicate that the specific area of weakness in teachers’ knowledge of immediate dental trauma management needs to be emphasised. The general conclusion of many international studies dealing with this topic is that school staff have little knowledge related to handling of dental trauma [McIntyre et al., 2008; Al-Asfour et al., 2008]. However, a growing focus worldwide on the emergency management of dental trauma has emerged, and in some institutions there is now an educational programme. Studies carried out in US [McIntyre et al., 2008] and in England and Wales [Blakytny et al., 2001] report that more than one third of the teachers have received advice regarding dental trauma. According to a Jordanian study, dental emergency training has also been included as part of teachers’ school health education program in Jordan [AlJundi et al., 2005]. Efforts should be made through population-based preventive measures to ensure uniform knowledge about dental trauma. The existing health education curriculum offered in Ajman schools could be modified, incorporating a dental trauma educational program with other dental health education programs. In the United Arab Emirates, young children spend a large proportion of their time in school. Therefore, in addition to parents, teachers assume responsible roles both in their daily activities and in health related issues, including immediate management of traumatised teeth. There is therefore an urgent need to increase the dental awareness
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of teachers as well as that of the parents and to involve both parents and teachers as vital dental health educators of the younger generation.
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