Parental knowledge and awareness regarding emergency management of permanent avulsed tooth in South Bangalore: A cross-sectional survey

INTRODUCTION

Children’s smile is worth a million dollars for the parents and the people around. Sometimes, unforeseen injuries to face due to sporting and traumatic accidents lead to mental distress for everyone. One of the most serious traumatic dental injuries is avulsion of teeth,¹ which is the dislodgement of an intact tooth from its socket, constituting 0.5%-16% of all traumatic dental injuriesin permanent dentition.^2-7 The peak age for this is between 7 to 9 years, when children tend to indulge in physical activities like playing sports, cycling, skating, running etc. At this age, the loosely structured periodontal ligament surrounding erupting teeth provides least resistance to an extrusive force leading to avulsion¹. The tooth most commonly avulsed in the permanent dentition is the maxillary central incisor.⁴

Avulsion of anteriors leads to pain, later on leading to esthetic and functional impairment in children. It also leads to psychological and mental stress not only for the patient but also for the parents. Ideally, replantation of tooth in the socket immediately is essential to preserve periodontal ligament and long term prognosis of the tooth. This may not always be possible due to fear and lack of awareness among the people around.

Successful replantation later by the dentist depends on the extra oral time of the tooth, media in which it was kept, material used for root cleaning and the way it was carried. It is important for the parents and teachers who are the first contact people at the site of injury be aware of this.

Bangalore as a metropolitan city with various sporting clubs isattracting a number of children after school for coaching in sports. The number of dental related injuries including avulsion has seen a rise. To create awareness about the emergency management of avulsed permanent tooth, it is imperative to know the existing knowledge of the parents. Therefore, this study was conducted among parents visiting sporting clubs of south Bangalore.

MATERIALS AND METHOD

A questionnaire consisting of 14 questions was prepared to assess the knowledge and awareness about emergency management of avulsed permanent tooth. It was prepared in two languages English and Kannada. Each question comprised of multiple choices. A list of various sporting clubs in South Bangalore was made and every alternate club was selected. A list of parents whose children were in the age group of 6 to 10 years was drawn. Every alternate parent totaling 280were selected for the study. The participants were made aware of the purpose and nature of the study. The questions were explained and the doubts were clarified. The completed questionnaires were collected on the same day.

STATISTICAL ANALYSIS

The data was tabulated in Microsoft Excel 2007 software and statistical analysis was performed using SPSS program for Windows, version 22. Frequency distribution of demographic variables and responses to various questions by study participants were expressed in terms of number and percentage. Chi Square Goodness of Fit test was used to compare the distribution of responses to various questions among the study participants. The level of significance [P-Value] was set at P<0.05.

RESULTS

This study comprised of 280 respondents of which 76%were female and 24% were male. A majority of 56% was in the age group of 30-39yrs and 77% were with a qualification of graduation and above (Table 1).

A significant portion (71.4%) of the parents supervised the children during sports activity (p=<0.001). 42.2% parents reported that their children experienced dental trauma (p=0.009) and 37.4% have come across an accident with an avulsed teeth (p<0.001). Approximately 55% of parents would take the child to the dentist with the avulsed tooth (p<0.001) and 36.5% of the respondents would take the child immediately (p<0.001). Further, 46.3% would remove the tooth from the mouth and place it in a medium (p<0.001) while only 19% would put the tooth in the socket. In case the avulsed tooth was dirty, 44.9% of the parents would rinse it with tap water (p<0.001) and 9.5% preferred to scrub the tooth to remove the dirt. 37.4% of the parents prefer carrying the avulsed tooth in a wet handkerchief till they reach the dentist as compared to other ways(p<0.001). About 51% of the parents would hold the avulsed tooth anywhere (p<0.001) while 35.4% would hold it by the crown. The study showed that most of the parents (59.9%) do not have any knowledge on the management of dental trauma (p<0.001). Also, 65.3% respondents had not received any advice about it (p<0.001). Most of the parents (66%) got the advice from hospitals or dental clinics (p<0.001). An overwhelming majority of 76.9% feel that education on dental trauma is necessary (p<0.001) and 27.2% prefer education through mass media (p<0.001) (Table 2).

DISCUSSION

In the present study, it was observed that 42.2% of respondents reported that their children experienced dental trauma and more than one third have come across an accident with avulsed tooth. But some studies have found dental trauma experience to be much higher (90%).⁸

Andreasen JO, Hjorting-Hansen E have shown that the prognosis of replanted teeth is best if the tooth remains out of the socket for less than 20 minutes9.In this study, though 55% of parents would take the child to the dentist with the avulsed tooth, only 36.5% of respondents would take them immediately. This could reduce the success rate of reimplanted avulsed teeth. Our findings are similar to a recent Brazilian study where 33.5% went to the dentist of which 66% went immediately.¹⁰

Further, though it is recommended to immediately replant avulsed permanent teeth, only 19% respondents said they would replant the tooth in the socket. The lack of knowledge and fear of hurting the child may be prompting the parents not to do so. Our finding are in line with previous studies^11-18 which also showed that majority of the population was not ready to reimplant the avulsed tooth. But studies by Raphael SL et. al., Hegde AM et. al., and Qazi SR et. al., showed a higher number of parents would reimplant the avulsed tooth.^19-21

The avulsed tooth needs to be preserved in a medium prior to replantation to maintain the viability of the periodontal ligament cells. Majority of parents in the study said that they would carry the avulsed tooth in a medium till they reach the dentist.

Milk remains one of the most commonly used and recommended storage media because of its high availability, physiologically compatible pH and osmolality with the PDL cells.^22,23 Only 10% of respondents chose milk as the medium and more than one third chose a wet handkerchief to carry the tooth. Our findings are similar to other studies^11,14 where preference of parents was more for dry storage media like cotton or paper tissue. Also, parents preferring milk as a medium was low in other studies.1^{0,11,15,18,19}

One of the most important factors for tooth replantation success is the integrity and viability of the periodontal ligaments of the avulsed tooth.²³ Hence, it is important not to disturb the periodontal ligament as much as possible. In case the avulsed tooth was dirty, half the respondents would rinse it with tap water which is the ideal cleaning method and about 9.5% preferred to scrub the tooth to remove the dirt. This is not in accordance with other studies^14,19 where fewer people preferred tap water. Also, 35% said they would hold it by the crown and about half of the parents would hold the avulsed tooth anywhere greatly reducing the chance of good prognosis due to the manipulation of periodontal ligament.

The study showed that most of the parents have limited knowledge on emergency management of avulsed tooth. Many similar studies conducted in various countries^{10,14,15,17,18,19,21,24,25,26} and also in various parts of India^{8,11,12,13,20,27} have validated this.

Although more than three fourth of the parents were qualified with university degrees, it is apparent that the level of education had no noticeable influence on their knowledge about emergency management of avulsed tooth. This may be because 65.3% respondents had not received any advice about it.

The study also shows that most of the parents (66%) got the advice from hospitals or dental clinics. This emphasizes our role in educating the parents about management of avulsed tooth. It is encouraging to see that an overwhelming majority of 76.9% feel that education on dental trauma is necessary. About a quarter of the respondents prefer education through mass media.

CONCLUSION

It is concluded that, regardless of the level of education, the parents in Bangalore South whose children were training in sports, had insufficient knowledge about emergency management of avulsed teeth. This important epidemiologic finding serves as a warning and can be a useful source of information to support education and prevention strategies and to reduce the overall cost of emergency and rehabilitation treatments. Educational programs should be conducted for parents, coaches, teachers and others who are the first contact people, when children experience tooth avulsion at sporting clubs and schools. Posters and handouts can be prepared and distributed to the target population to effectively convey the message. We believe that information and education programs targeting the parents would improve the management of tooth avulsion.

Acknowledgements: The authors would like to thank Dr. Lavanya, Dr. Sowndarya and Dr. Rekha MC for their valuable help in collecting the data.