Evaluation of the Effectiveness of an Educational Intervention Program on Knowledge, Attitude and Practice among School Teachers Regarding Management of Traumatic Dental Injuries in Mangaluru City

Introduction

Dental trauma is any injury to the teeth and/or their supporting structures, including the surrounding soft tissues. The injury can either be direct or indirect,¹ affecting single or multiple anterior teeth during contact sports.² Dental injuries are common amongst children, with a prevalence rate of 35% worldwide and 60% in India.³ While children aged 1-3 years are vulnerable to primary tooth injury due to psycho-motor underdevelopment and poor motor skills, permanent tooth injury is common. among children aged 6-12 years due to vigorous participation in contact games and sports.^4,5

An avulsion is the most frequent form of injury (0.5-16%), followed by enamel fracture (10.5%).³ Tooth avulsion is the complete displacement of a tooth from its socket, comprises 0.5–3% of dentofacial injuries in the permanent dentition and 7–13% in the primary dentition.^6,7 When a tooth is avulsed, the periodontal ligament, alveolar bone, cementum, gingiva, and dental pulp are damaged.⁸ The success of replantation in a permanent tooth is dependent on various factors like extra-alveolar time, storage medium, type of retention employed, time of endodontic intervention, type of drug prescribed, oral hygiene status along with the general health of the individual, and replantation within one hour of avulsion helps in functional healing. It is advisable to place the tooth in saliva, saline, milk, or coconut water to prevent dehydration of the root surface during transportation.⁹

Since anterior teeth are an integral part of a child's endearing smile, loss or injury to these teeth can result to lack of self-esteem, poor aesthetics, and speech defects, affecting a child's psychological and cognitive development.¹⁰ Therefore, ensuring the survival of traumatized teeth is essential, and the same can be achieved by a combined effort of teacher, parent, and dentist. Previous studies have indicated that 16% of dental damages arises at school.^2,11 As children are incompetent to carry out emergency treatment of an avulsed tooth, the immediate caregivers are teachers. So, their knowledge and awareness regarding the immediate management of traumatic injuries is paramount for the favourable prognosis of the treatment.²

A lack of knowledge on the prompt and appropriate emergency management of a traumatic dental injury can result in discoloration, infection, mobility, resorption, and loss of tooth vitality. It can also affect the child's quality of life due to impaired aesthetics, speech difficulties, and psychological trauma.¹² Studies conducted in Singapore¹³ and the northern state of India¹⁴ have reported a lack of knowledge on dental trauma among 63% and 77% of teachers, respectively. However, studies in the southern states of India are limited. Additionally, neither the government's health departments nor dental associations have made any efforts to instruct teachers in the proper way to handle traumatic dental injuries. Thus, in Mangaluru, Karnataka, the present study was conducted to evaluate school teacher's knowledge/ Attitude/Practice (KAP) with regard to emergency management of traumatic dental injury before and after an educational intervention.

Materials and Methods

In this cross-sectional observational study, we included government, state board (aided and unaided) and Central Board of Secondary Education (CBSE) (aided and unaided) school teacher's of Mangaluru city, Karnataka state, India. After obtaining approval from the institutional ethics committee and the concerned school authorities, we collected a list of government, aided, and unaided schools in Mangaluru city from the Block Education Offices (BEO) of Mangaluru north and Mangaluru south divisions.

Using the formula, z2pq÷42 where, Z = 1.96 for 95% confidence interval and 80% power, P = 50%, q = 0.5 and 4 (margin of error) = 5% and an attrition of 10%, a sample size of 300 with 100 participants in each group was estimated. School teachers of the preschool, primary school and high school sections of the respective schools willing to participate were selected by simple random sampling from government (n=100), state board (aided and unaided, n=50 each) and CBSE (aided and unaided, n=50 each) schools. All participants signed informed consent before the study.

The study employed a self-administered, closed-ended structured questionnaire with 20 questions (Knowledge=8, Attitude=4, and Practice=8) written in both English and Kannada. With the help of the Spearman correlation coefficient and Cronbach's alpha, respectively, we examined the validity and internal consistency of the questionnaire. The validity of the survey was evaluated using test-retest by conducting a pilot study on 25 school teachers from government, state board, and CBSE schools in Mangaluru city. We carried out the study in three phases: pre-educational survey, education session with a 30 minute lecture on dental trauma and management, and a post-education survey after six months. The lecture emphasized emergency measures to be taken in case of avulsion before reaching the dentist, possible etiology of dental trauma, stages of tooth development, tooth replantation, and immediate emergency management of dental trauma cases. Following the session, the teachers were encouraged to discuss further and clarify doubts, if any.

The survey responses have been categorized and submitted in MS excel, imported to SPSS software, version 16.0 for statistical analysis. The tests used were the Chi-square test and Mc Nemer's test for pre- and post-education comparison and paired t-test to compare KAP scores. Significance level was set at 0.05.

Results

Responses to the knowledge-based questionnaire are summarized in Table 1. At baseline, there was a significant difference in the knowledge on what instruction to be given in the event of dental trauma between different groups (p=0.015). Lip tear (43%) was considered to be the most common soft tissue injury followed by, tongue (32.67%) and chin (24.3%) (p=0.91). Difference in knowledge on avulsion (p=0.000) and its management (p=0.09) between groups was significant. Nearly half the teachers from all institutions opined that children must seek professional help in case of avulsion of a permanent tooth (p=0.000). Only 26%, 15% and 31% teachers of Government school, state board and CBSE board, respectively, opined that the knocked-out tooth must be placed back in the socket (p=0.02). When asked how to store the avulsed tooth till the child reaches dental clinic, 45.67% responded paper/kerchief, followed by glass of cold water (43.3%), child’s own saliva (8.67%) and child’s hand (2.3%) (p=0.16). In case of dental trauma, consulting the dentist was the first choice amongst 50% teachers (0.38). In the post-education survey, there was a significant growth in all the responses with all the teachers from all schools marking correct responses.

Responses to attitude related questions are summarised in Table 2 and 3. At baseline, the approach to dental trauma among different groups was comparable with each other (p <0.05). Among the study population, only 27.33% preferred consulting a private dentist for dental trauma. Following the health education session, there was a significant growth in the teachers' perspectives on dental trauma and its significance (Table 2). In our study, 63% teachers had come across dental trauma during their teaching career. Trauma involving teeth and soft tissue injuries were noted in 57.6% and 42.3% cases, respectively. Most common management approach of soft tissue injury was applying Dettol and ointment (45%), followed by referral to dentist (30.6%). Around 61% teachers had no idea how to clean the avulsed tooth. In case of broken tooth, 38.3% contacted parents and sent to dentist, and 13.2% teachers sent students to school nurse. Post intervention a significant growth in the answers related to management of soft tissue, avulsed and broken tooth (Table 3) was observed. In the questionnaire, each right answer was scored 1 point. Significant development in the mean knowledge (p=0.000), attitude (p=0.000) and practice (p=0.000) scores was observed after the intervention as compared to knowledge scores at baseline in all the schools (Table 4).

Discussion

Traumatic injuries to the teeth are a neglected condition that could rank fifth if included in the list of the world’s most frequent acute/ chronic diseases and injuries.¹⁵ Traumatic damage of the anterior tooth alter the facial appearance, which negatively affects an individual's self-esteem, especially during childhood and adolescence.. Knowing emergency protocols is essential for school teachers because they are expected to contact the child soon after the injury, which will improve the clinical treatment's prognosis. Literature shows a gross lack of knowledge among teachers worldwide regarding the initial management of traumatic dental injuries.^2,13,16 To our knowledge, this was the first study conducted in Mangalore city to evaluate knowledge of teachers regarding the immediate management of traumatic dental injuries and educate them and prepare for future dental traumatic emergencies. Similar to reports by Panzarni et al.,¹⁷ and Judy et al.,¹⁸ at baseline 36.3% of teachers did not report any dental trauma, and 62% did not know how to manage dental trauma. Lack of knowledge could be due to dearth of dental education in teacher's training curriculum or exposure to insufficient campaigning organized by local dental bodies. Moreover, only 43% of teachers were satisfied with the level of knowledge, and 63% of teachers believed the inclusion of a concept on dental trauma in the school syllabus is essential. These findings are similar to studies by Khan et al.,¹⁹ and Young et al. ²⁰

According to Sandalli et al.,²¹ 84% of teachers had observed teeth injuries while 49% had witnessed lip, gum, face injuries. Similarly, in our study, 42.3% of teachers had witnessed cases of injury to lip, gum, and face in their teaching career, whereas 65.6% had seen injuries to teeth. Furthermore, this study also highlights the frequency of injuries to soft tissues which the teachers encountered throughout the year. It also provides an insight into the prevalence of the injuries and the teachers' response for the same. Interestingly, the frequency of dental trauma in our study was significantly less. Lesser frequency explains the lack of preparedness and awareness to follow a protocol during a traumatic injury on the school campus. Moreover, 58% of teachers had no idea what a knockedout tooth was, 81% of teachers had not received any information regarding the management of knocked-out tooth, 78% of teachers thought knocked-out tooth should not be placed back into the socket. Parallel findings were noted by Prassana et al.,¹² and Vashistha et al. ¹⁴ Interestingly, after the educational intervention, a significant growth in teachers' knowledge regarding avulsion and its management was noted.

Among soft tissue injuries, lip tear is most common.^2,22 Similarly, lip tear (74%) was the most common type of soft tissue injury encountered by teachers in our study. Similar to reports by Mohandas et al.,² and Pujita et al.,¹ half of the teachers in our study preferred referring the child to a physician and cleaning with antiseptics. Only 30% of teachers knew the role of a dentist in managing dental and soft tissue trauma. Although this frequency is higher than the 10% reported by Vashistha et al.,¹⁴ it is significantly less than the frequency reported by Chan et al.,²³ where all the teachers (100%) referred the injured child to a dentist. The lower frequency observed in this study signifies the paucity of knowledge amongst teachers about a dentist’s role in managing dental and soft tissue injuries. The frequency of teachers encountering an injured tooth was also less in our study, and in case of such encounters, 46% of teachers opted to ignore the injury, and only 43% of teachers considered taking the child to a dentist. This highlights the lack of knowledge about dentofacial trauma and its management among the teachers.²⁴ Further efforts should be made to educate the teachers about common dental injuries and their effective first-line management.

Avulsed tooth has higher chances of contamination with environmental particles. Hence, cleaning of an avulsed tooth is paramount to avoid infection post-reimplantation. However, excess scrubbing and cleaning with disinfectants may harm the fibroblasts present on the root surface of the avulsed tooth, which is vital to attach the tooth with the underlying bone. It is recommended to rinse the tooth under tap water holding the crown portion of the tooth without touching the root portion. In the current study, 61% of the teachers had no idea about cleaning avulsed teeth, whereas 3% thought of scrubbing the tooth, which demonstrated the immediate need for teacher’s education. Post-intervention, all the teachers had the same opinion ofusing tap water to rinse the tooth . As per the reports of previous studies by Thabet et al.,²⁵ and Vashista et al.,¹⁴ 41.9% of teachers had no clue how to properly clean an avulsed tooth. and post-intervention it improved to 85%. Urgent replantation of an avulsed tooth is essential for favorable prognosis. However, the reluctance of teachers to replant the tooth could be related to lack of knowledge, fear of hurting the child, or greater priority towards stopping the bleeding.

Type and characteristics of the medium used for storage of avulsed tooth and the time lapse between avulsion to replantation determines the success of replantation. A suitable medium for storage should be accessible at the accident scene and be able to maintain cell viability, adherence, and clonogenic capacity, and accessibility at the accident site. Although Hanks balanced salt solution is the best storage medium, its use is not practical in India because of unavailability and high cost. Propolis is another storage medium that has been recommended in the literature, but it is not readily available. Milk has an excellent capacity of maintaining cell viability. Saliva is the only media that is easily accessible at the site of the incident, therefore is recommended as amedium for storage. Similar to Ozer et al.,²⁶ and Tewari et al.,²⁷ only 8% of teachers in this study considered placing the avulsed tooth in the child’s own saliva. Moreover, similar to the findings of Ahluwalia et al.,²⁸ 75% of the teachers in this study were unaware of the time gap for tooth replantation and only 25% of the teachers considered replanting immediately suggesting the lack of knowledge among teachers.

This study is the first of its kind in Mangaluru city to evaluate teachers' knowledge and further educate them about dental injuries. One of the schools involved in the study procured Hank's balanced salt solution after the educational intervention and it was used for transporting an avulsed tooth; this suggests the success of our educational intervention. Thus, our findings accentuate that training and educational programs are needed to properly manage traumatic dental injuries by school teachers. Certain limitations of this study include a small sample size with a random selection of teachers which limits the generalizability of the results. Our study sample consisted completely of academic teachers instead of a stratified sample including instructors in physical education who are more actively involved with children during outdoor activities. Further, the post-intervention assessment was limited to six months; this could have been followed up to 1-2 years to appreciate the effectiveness and further improvements. Additionally, feedback from teachers regarding the lecture – clarity of presentation, information about traumatic dental injuries, treatment protocol, visual aids used, was not taken to further improve the presentation and get an insight about their understanding of traumatic dental injuries.

Following are a few recommendations to be considered for emergency dental care in a school. Mouthguards/protectors should be made mandatory in schools to decrease or prevent dentoalveolar injuries.²⁹ All schools should have a dental office for emergency management, and Hank's balanced salt solution and a first aid kit must be available. The school's grounds must be decorated with visual aids related to dental trauma management, such as banners and posters.. Guidelines for managing the effects of traumatic dental injuries should be incorporated into the teacher preparation curriculum and made mandatory for physical education teachers, according to the Ministry of Health and Family Welfare and the Ministry of Education. The Dental Association, in collaboration with state and central government authorities should conduct public awareness programs on various aspects of traumatic dental injuries at school level and at community level through pamphlets, banners, audio-visual demonstrations, and lectures to increase awareness among parents and teachers. Another helpful measure would be setting up an emergency helpline for information about traumatic injuries in children.

Conclusion

The basal findings of the current study suggests a lack of proper knowledge on the managing emergency dental trauma in the study participants, which significantly improved post educational intervention. The Indian government and dental organizations have not attempted to train teachers in the treatment of dental trauma. Thus the findings of this study emphasize the importance of an educational intervention program and training to the teachers to increase their understanding since they are the first to react in cases of dental trauma in schools. As dental professionals, we are obligated to educate the general public who have the probability of being at the site of injury like parents, teachers, and physical trainers. Before any long-lasting effect can be seen, the information must be repeated in the form of banners, posters, and awareness campaigns because one educational input to teachers is insufficient to promote the management of traumatic dental injuries.

Conflict of Interest

None