Knowledge and attitude toward dental trauma first aid

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Saudi Journal of Oral Sciences ORIGINAL ARTICLE

Knowledge and attitude toward dental trauma first aid among a sample of emergency room personnel across Saudi Arabia Sharat Chandra Pani, Rayan M Eskandrani1, Khalid Al-Kadhi2, Abdullah Al-Hazmi1 Department of Pediatric and Preventive Dentistry, Riyadh Colleges of Dentistry and Pharmacy, 1Private Dental Practice, 2 General Practitioner, King Saud Medical City, Ministry of Health, Riyadh, Saudi Arabia

Abstract

Background: Traumatic dental injuries (TDIs) have been reported to be a low priority of emergency room (ER) personnel; however there have been increased calls from across the world to train ER personnel in the provision of dental trauma first aid (DTFA). Aim: The aim was to measure the knowledge and attitude of a sample of ER physicians, nurses and emergency medical technicians (EMTs) from across Saudi Arabia regarding DTFA. Materials and Methods: A structured questionnaire was modified from previously existing questionnaires on the topic. A stratified, cluster sample was designed by randomly selecting hospitals across four regions of Saudi Arabia. A total of 150 questionnaires was distributed to all the ER personnel of these hospitals of which 146 completed responses were received. Results: The overall knowledge scores ranged from 0 to 6 out of 7 (mean score 2.88 ± 0.55). Surgeons had the best knowledge about DTFA while EMTs had the lowest knowledge. Nurses had the most positive attitude toward the management of DTFA. Regression models showed that specialty of the personnel and previous education about DTFA significantly influenced knowledge while witnessing a TDI was the only factor that significantly influenced attitude. Conclusion: Overall knowledge of DTFA among ER personnel across the sampled regions of Saudi Arabia is low. Key words: Dental trauma first aid, emergency room personnel, traumatic dental injury

Introduction

The terms dental first aid and dental trauma first aid (DTFA) have been used to refer to the emergency procedures that are implemented immediately after witnessing a TDI.[8] Implementation of proper DTFA can greatly increase the chance of survival of the tooth and reduce the extent of final dental treatment needed.[8,9]

Traumatic dental injuries (TDIs) are often seen in conjunction with trauma to the facial region.[1,2] These could include minor fractures of the enamel, complicated fractures involving the dentin and pulp and even avulsion of the tooth.[3] Patients who have a dental injury that is secondary trauma to the facial region have been widely reported as presenting to emergency rooms (ERs) where there is often no dentist on call.[4-7]

It has been argued that TDI are a low priority for ER physicians and first responders in ERs.[5,10,11] More recent literature shows that there appears to be a shift in this line of thinking, with papers from across the world documenting the need to educate ER physicians on TDI and documenting their acceptance of the importance of early treatment of TDI.[6,7,9]

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Address for correspondence: Dr. Sharat Chandra Pani, Department of Pediatric and Preventive Dentistry, Riyadh Colleges of Dentistry and Pharmacy, PO Box 84891, Riyadh 11681, Saudi Arabia. E-mail: [email protected]

DOI: 10.4103/1658-6816.150591

S J Oral Sci Vol 2 No 1

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Pani, et al.: Dental trauma awareness in ER personnel

The number of road traffic accidents (RTAs) in the Kingdom of Saudi Arabia is considered to be one of the highest in the world with a peak of 283,684 accidents being reported in 2005.[12] Furthermore, RTAs are the greatest cause of traumatic injury to the facial region in Saudi Arabia.[4,13] Given this background it is safe to assume that an emergency medical technician (EMT) or first responder would often be the first to witness the TDI. However, little data exists on the knowledge and attitude of ER physicians, nurses, and EMTs regarding DTFA. This study aimed to assess this gap in the literature through a survey utilizing a structured questionnaire and random, stratified, cluster sampling.

Distribution of the questionnaires

The questionnaires were distributed in person to all personnel of the selected center by three of the investigators (RE, AA, KA). The questionnaires were filled out by the respondents and returned without any assistance from the investigator. Statistical analyses

The emergency management of dental trauma was assessed by scoring one for each correct answer on the seven questions in the knowledge section of the questionnaire. One-way ANOVA was used to compare the knowledge scores among the different groups. The experience of the respondents with dental and maxillofacial trauma was assessed descriptively. The questions regarding the importance placed by the respondents toward DTFA were compared across groups using the Kurskull-Wallis test. Linear regression models were used to compare the influence of different factors on the knowledge and attitude of the respondents. The level of significance for all tests was set at P < 0.05. Analyses were performed using the SPSS version 22 data processing software (IBM corp., Armonk, NY, USA).

Materials and Methods The study was registered with the research center of the Riyadh Colleges of Dentistry and Pharmacy was given the registration number IRP/2013/34. Selection of the sample

A stratified sampling method was used. A list of all hospitals in the Riyadh, Makkah, Northern (AlJouf and Northern Border regions) and Southern regions (Abha + Najran) was obtained from the tertiary referral hospital of the region (King Saud Medical Complex). Two primary and two referral hospitals in each region were chosen by random sampling. All EMT staff and ER doctors in the chosen hospitals were then administered a bilingual (English and Arabic), questionnaire to assess their knowledge and attitude toward TDI. A sample power calculation was done using the G-power sample power calculator (Universtat Kiel, Germany) suggested that the minimum number of respondents to conduct a linear regression with four factors and a beta of 0.95 was 100.

Results A total of 150 questionnaires was distributed of which 146 completed responses were received giving us a response rate of 97.5%. Of these respondents, a total of 89 (61%) were male while 57 (39%) were female. The questionnaires were distributed among Riyadh, Makkah and Southern Region. The sample was roughly evenly distributed between ER Physicians, Surgeons, Nurses and EMTs. Most of the respondents (56% males and 43% Table 1: Demographic distribution of the respondents

Design of the instrument

A three-part questionnaire was designed based on the questionnaire of Holan and Shmueli.[5] The first part of the questionnaire comprised of questions related to the demographic data of the participants. The second part assessed the knowledge of the participants regarding dental trauma, while the third part recorded the experience of the participants with dental trauma and their attitudes toward the importance of emergency management of such injuries. The importance they placed on the emergency management of such injuries was scored on a 5-point Likert-type scale with 0 for “not important at all” to 4 for “extremely important” which was modified from earlier validated questionnaires.[14-16]


Gender Male Female Specialty ER physician Surgeon Nurse EMT Type of hospital Government Private Region Riyadh region Makkah region Abha and Najran regions Northern region

Count

Percentage

89 57

61.0 39.0

70 17 38 21

47.9 11.6 26.0 14.4

137 10

93.2 6.8

67 52 12 15

45.9 35.6 8.2 10.3

ER: Emergency room, EMT: Emergency medical technician

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of the females) had over 4 years of experience and the majority (over 90%) were from government hospitals [Table 1].

influence on the attitude of the respondents toward the management of TDI. The vast majority of the respondents had witnessed a trauma to the teeth or jaws. More respondents had witnessed a trauma to the jaws than had treated trauma to the jaws [Table 3]. Similarly, apart from the surgeons (75%), a minority of the respondents reported having treated trauma to the teeth. Less than 10% of all respondents had received training regarding the management of TDIs. While 35% of the surgeons had received some form of training regarding the management of TDI, none of the EMTs had received any training regarding the management of TDI.

Mean scores ranged from 0 to 6 out of a maximum of 7 with a mean knowledge score of 2.88 (SD ± 1.52). When the mean trauma scores were compared across groups it was seen that, gender and type of hospital significantly influenced the mean knowledge score [Table 1]. Knowledge scores differed significantly among specialties with surgeons (4.06 ± 0.66) having the highest mean knowledge score while EMTs had the lowest mean score (0.86 ± 0.79). The emergency medical responders from the southern (Abha and Najran) regions and those from Riyadh Region had significantly higher mean knowledge score than their counterparts in other regions [Table 2].

The linear regression model with knowledge score as the dependent variable showed that previous training in the management of TDI and the specialty of the ER personnel were the only factors that had a significant positive impact on the knowledge score of the responders [Table 4]. A linear regression model with attitude of the ER personnel was only significantly influenced by whether they had witnessed a dental trauma. Those who had witnessed a dental trauma were found to have a significantly more positive attitude [Table 5] .

When the respondents were asked about how important they felt the management of TDI was, nurses in the ER had a significantly more positive attitude (responded as “important” or “highly important” than other specialties. Responders from the Riyadh region had a significantly more positive attitude than responders from other regions. Gender and years of experience had no

Table 2: Knowledge and attitude of the sample population toward DTFA Knowledge score Gender Male Female Specialty ER physician Surgeon Nurse EMT Type of hospital Government Private Region Riyadh region Makkah region Abha and Najran regions AlJouf and Northern border regions

Attitude score

Mean ± SD

P

Mean ± SD

P

3.06±1.55 2.74±1.34

0.204

11.61±3.87 10.53±3.70

0.091

3.56±1.29 4.06±0.66 2.42±0.95 0.86±0.79

0.000*

10.59±3.65 14.06±2.63 10.89±4.28 11.38±3.50

0.008*

2.96±1.53 2.60±0.70

0.213

11.07±3.93 12.20±1.99

0.135

2.67±1.54 3.15±1.32 3.92±1.51 2.53±1.36

0.02*

11.33±3.96 11.37±3.78 8.25±3.52 12.27±2.60

0.03*

*Differences significant at P < 0.05 (what do you mean?), SD: Standard deviation, EMT: Emergency medical technician, DTFA: Dental trauma first aid

Table 3: Experience of the sample population with dental and facial trauma ER physician Witnessed trauma of the jaws Treated trauma of the jaws Witnessed trauma of the tooth Treated trauma of the teeth Received training in the management of dental trauma

Surgeon

Nurse

EMT

n (%)

n (%)

n (%)

n (%)

53 (75.7) 23 (32.9) 57 (81.4) 22 (31.4) 4 (5.7)

16 (94.1) 10 (58.8) 16 (94.1) 13 (76.5) 6 (35.3)

30 (78.9) 15 (39.5) 30 (78.9) 18 (47.4) 4 (10.5)

14 (66.7) 7 (33.3) 15 (71.4) 10 (47.6) 0 (0.0)

EMT: Emergency medical technician, ER: Emergency room


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Table 4: Linear regression model of knowledge of DTFA as dependent variable Model Constant Witnessed trauma of the tooth Treated trauma of the teeth Have you received any training in the management of dental trauma Years of experience Specialty Region

Unstandardized coefficients

Standardized coefficients

T

Significant

−0.048 −0.142 −0.410

7.776 −0.628 −1.748 −5.556

0.000 0.531 0.083 0.004*

0.009 −0.580 0.046

0.132 −8.267 0.670

0.895 0.000* 0.504

T

Significant

B

SE

Beta

6.096 −0.179 −0.421 −0.550

0.784 0.285 0.241 0.353

0.003 −0.532 0.048

0.021 0.064 0.072

*The condition significantly influences knowledge, SE: Standard error, DTFA: Dental trauma first aid

Table 5: Linear regression model with attitude toward DTFA as dependent variable Model

Unstandardized coefficients

Standardized coefficients

B

SE

Beta

Constant Witnessed trauma of the tooth Treated trauma of the teeth Have you received any training in the management of dental trauma Years of experience Specialty Region

19.264 −4.767 −0.551 0.004

1.896 0.583 0.689 0.855

−0.619 −0.057 0.000

10.162 −8.178 −0.800 0.005

0.000 0.000* 0.425 0.996

0.078 −0.029 −0.163

0.051 0.156 0.174

0.100 −0.012 −0.059

1.534 −0.184 −0.936

0.127 0.855 0.351

*The condition significantly influences knowledge, SE: Standard error, DTFA: Dental trauma first aid

Discussion

the time that it has been left without emergency care. Several studies have shown that in cases avulsion the first ½ h is considered critical to preserve the periodontal ligament fibers while for exposed pulp, earlier initiation of treatment often translates into better prognosis for the tooth.[19,20] The results of our study show that the person with the greatest knowledge to manage TDI is likely to be the last person to see the patient, while the first person to see the patient (EMTs) would have the least knowledge.

The management of TDIs by ER personnel is a factor that has received considerable attention world over in recent years.[6-17] While much emphasis has been placed on the knowledge of ER physicians, little can be found in the literature regarding the role of the EMT. This study is, perhaps one of the first to attempt to assess the knowledge and attitude of EMTs toward the management of TDIs.

The results of this study demonstrate in general ER personnel in the sample studied have a poor knowledge of how to manage TDIs, and this knowledge is poorest among EMTs. Effective education requires the educator not only to identify gaps in knowledge but also identify attitudes so as to design an effective strategy to deliver the education.[21-23] The fact that many ER personnel who had witnessed a TDI had a significantly more positive attitude toward the importance of managing seems to suggest that greater exposure to the types of dental trauma and the significance of dental trauma is needed.

Emergency medical technicians are the first responders at the site of accidents and in case of TDI accompanying other injuries, it is reasonable to assume that the actions of the EMT will determine the final prognosis for the injured tooth. While the results of this study showed the knowledge of ER personnel toward the emergency management of TDI to be low, it is worrying that among EMTs this knowledge was especially low (mean 0.88 out of 7). The best knowledge among all the personnel who participated in this study was among the surgeons. While the relatively high scores seen in this group is heartening, it must be kept in mind that in cases of RTAs, the patients are often seen first by an EMT, then by the ER doctor and ER Nurse and will only reach the surgeon after going through the process of emergency care and triage.[18] The survival of teeth either after avulsion or traumatic exposure of the pulp depends on


Raoof et al. proposed that early education of medical students could improve the overall attitude of these future doctors.[17] The results of this study seem to suggest that such education is required not only for physicians and surgeons but also for nurses and EMTs. The fact that less than 25% of the sample in this study had received any education on the management of TDI

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and that none of the EMTs had received such training suggests that there is an urgent need for such training.

11. Wilson S, Smith GA, Preisch J, Casamassimo PS. Epidemiology of dental trauma treated in an urban pediatric emergency department. Pediatr Emerg Care 1997;13:12-5. 12. Al-Naami MY, Arafah MA, Al-Ibrahim FS. Trauma care systems in Saudi Arabia: An agenda for action. Ann Saudi Med 2010;30:50-8. 13. Abdullah WA, Al-Mutairi K, Al-Ali Y, Al-Soghier A, Al-Shnwani A. Patterns and etiology of maxillofacial fractures in Riyadh City, Saudi Arabia. Saudi Dent J 2013;25:33-8. 14. Al-Obaida M. Knowledge and management of traumatic dental injuries in a group of Saudi primary schools teachers. Dent Traumatol 2010;26:338-41. 15. Díaz J, Bustos L, Herrera S, Sepulveda J. Knowledge of the management of paediatric dental traumas by non-dental professionals in emergency rooms in South Araucanía, Temuco, Chile. Dent Traumatol 2009;25:611-9. 16. Pani SC, Hillis H, Chaballout T, Al Enazi W, AlAttar Y, Aboramadan M. Knowledge and attitude of Saudi teachers of students with attention-deficit hyperactivity disorder towards traumatic dental injuries. Dent Traumatol 2014;30:222-6. 17. Raoof M, Vakilian A, Kakoei S, Manochehrifar H, Mohammadalizadeh S. Should medical students be educated about dental trauma emergency management? A study of physicians and dentists in Kerman Province, Iran. J Dent Educ 2013;77:494-501. 18. Nardi G, Massarutti D, Muzzi R, Kette F, De Monte A, Carnelos GA, et al. Impact of emergency medical helicopter service on mortality for trauma in North-east Italy. A regional prospective audit. Eur J Emerg Med 1994;1:69-77. 19. Rodd HD, Murray AM, Yesudian G, Lewis BR. Decision-making for children with traumatized permanent incisors: A holistic approach. Dent Update 2008;35:439-40, 42. 20. Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, Diangelis AJ, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96. 21. Kahabuka FK, Ntabaye MK, van t’ Hof M, Plasschaert A. Testing a consensus conference method by discussing the management of traumatic dental injuries in Tanzania. East Afr Med J 2000;77:552-7. 22. Arikan V, Sönmez H. Knowledge level of primary school teachers regarding traumatic dental injuries and their emergency management before and after receiving an informative leaflet. Dent Traumatol 2012;28:101-7. 23. Gill P, Chestnutt IG, Channing D. Opportunities and challenges to promoting oral health in primary schools. Community Dent Health 2009;26:188-92.

Conclusions Within the limitations of this study, it can be concluded that the overall knowledge of DTFA among ER personnel across the sampled regions of Saudi Arabia is low. While knowledge of DTFA is the highest among Surgeons, it is lowest among the EMTs who are likely to be the first people to encounter such injuries.

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Cite this article as: Pani SC, Eskandrani RM, Al-Kadhi K, Al-Hazmi A. Knowledge and attitude toward dental trauma first aid among a sample of emergency room personnel across Saudi Arabia. Saudi J Oral Sci 2015;2:30-4. Source of Support: Nil, Conflict of Interest: None declared.

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