Introduction
The most beautiful quality of a human being is their smile. Permanent anterior teeth have significant effect on an individual’s facial profile. These are not only important for esthetics but are also essential for speech, mastication, health and growth of supporting tissues and psychological and mental health of children.1
Traumatic injuries to teeth and the associated parts are one of the most common dental problems in children and adolescents all over the world and it is one of the major problems faced by the dental professionals in day to day practice. Among the dental traumatic injuries, anterior teeth involvement is most common. Because of the involvement of the anterior teeth, there is a negative impact on quality of life due to loss of function, social and psychological discomfort, financial burden, lowered self-esteem.2
Among all dental traumatic injuries, avulsion is the most serious one. Avulsion (i.e. exarticulation, knocked-out tooth) is the total displacement of the tooth out of its socket because of traumatic injury. Avulsion of permanent teeth is seen in 0.5–3% of all dental injuries. Numerous studies show that this is one of the most serious dental injuries, and the prognosis is very much dependent on the actions taken at the place of injury, promptly after the avulsion.3
The peak age for avulsion of permanent incisors is found to be between 7 and 9 years. Avulsed permanent teeth can be saved if reimplanted immediately or stored in a physiologic solution, such as saline, milk or even saliva until professional help is obtained. However, in most cases proper first aid procedures are not provided, and the tooth will be lost. The immediate and appropriate management of avulsed teeth within the first 15minutes is critical for the long-term success of the treatment. Primary teeth may not be reimplanted because of the potential risk of damaging the permanent successors.4
The prognosis of tooth reimplantation is dependent on multiple factors; like extra-alveolar period, storage media, time of endodontic intervention, type of immobilization and type of drug prescribed. However, the most critical factor for an excellent prognosis is the preservation of viable periodontal ligament cells (PDL) covering the root and this can be established by storing the tooth in a suitable media such as milk, saliva or saline. Handling tooth with minimal damage to periodontal ligament cells is desirable.5
Maxillary central incisors are the teeth most commonly affected by trauma. Moreover, there is lack of the periodontal ligament’s resiliency and the low mineralization of the surrounding bone so that there is minimal resistance to trauma among children aged 7–9 years.6 Loosing an anterior tooth at this age may have severe psychological and functional consequences. Aesthetic consequences associated with the loss of an anterior tooth should also be considered. Eventhough there are many treatment options for a lost tooth, immediate reimplantation of an avulsed tooth is the best to restore aesthetics and function for the patient.4, 7
Most dental injuries, including avulsion, occur because of sports-related injuries from the school or playground, physical violence and road traffic accidents. Initial emergency management, therefore, may involve individuals such as the school teachers,8 parents, relatives and general medical practitioners9 in the emergency units before any professional dental help obtained. Many avulsed teeth are lost because of lack of knowledge about the proper first aid procedures that need to be provided.4
Immediate and proper emergency management is not only the responsibility of the dental professionals but also parents, school teachers and even common people available at the place of injury.10 Children spend a considerable amount of time at school where they are engaged in physical activities. Since school teachers are mainly in contact with the child soon after the injury, their knowledge of emergency management is critical to give a better prognosis of the clinical treatment.11 At the same time if the situation is occurring at home parents have to take care of the child. In many situations, parents usually take their children to a general physician at the hospital to seek treatment.12, 13
Although numerous studies have been conducted in different countries to evaluate parental knowledge and attitudes regarding avulsed permanent teeth, few studies have been conducted among parents of Kerala. 11 Therefore, this study aimed to investigate parental knowledge and attitudes regarding avulsed permanent teeth and their emergency treatment.
Materials and Methods
The study was conducted in Dept. of Pedodontics, Govt. Dental College, Kozhikode, Kerala and was conducted among 400 parents of children, aged between 6-12 years from rural and urban areas. Study was conducted over a period of 1year. The objectives and nature of the study was explained to the participants, while the voluntary nature of participation was emphasized and strict confidentiality was assured. A written informed consent form according to the ethical guidelines was subsequently obtained from the participants.
The participant’s awareness regarding the avulsed tooth and its management was evaluated based on questionnaire. This was based on modified form of Raphael and Gregory and Tee Jing Loo, Deepa Gurunathan, Sujatha Somasundaram.14
The questionnaire was provided in both simple English and local (Malayalam) language. The questionnaire was essentially be comprised of two parts: First part included the general demographic data and the second part contained closed questions which assessed the knowledge, attitude and previous experience of the participant toward the first-aid management of avulsed permanent tooth. Each question was provided with options which was correct or incorrect answers. Participants were requested to mark the option which they perceive as the most appropriate answer. In the case of parents in some questions the educational qualification, socio-economic status and geographical background were connected. Any enquiries and comments about the questions from the participants were attended. Information regarding the avulsion and its emergency management as a health talk was done on, immediately after the participants had completed their answering.
Data was entered in Microsoft excel sheet and analysis was performed using software statistical package for social science(SPSS). Frequency or percentage of good awareness were calculated. Statistical significance of factors influencing good awareness were calculated using Pearson Chi-Square test.
Results
A total of 400 parents were surveyed to evaluate the knowledge, attitude, and practice regarding emergency management of avulsed permanent tooth. Among that male respondents constituted to 28.3%(113) of the surveyed group, while female respondents were 71.8%(287). 4.8%(19) parents were below 30 year age group and most of the parents 69% (276) were between 30-39 year age group. Considering educational qualification 0.3%(1) was illiterate, 30.3% (121) were coming under both elementary school and above higher secondary school category. 39.3% (157) were educated upto higher secondary school. While considering socio- economic status, 18%(72) were in upper class, 48.3%(193) were included in middle class, 33.8%(135) were come under lower class. Half of the respondents were reported to be coming from urban background 50%(200) and half from rural background.
Previous experience with trauma and avulsion
Among 400 parents 3.3%(13) had given a history of mobility of the tooth to their child by trauma. And 2.8% (11) of them had suffered from dental avulsion.(Figure 1)
Pearson correlation test was performed to correlate the educational background with the knowledge of emergency management of an avulsed tooth, i.e whom will they contact first, which was statistically significant (p<0.05). (Table 1)
Table 1
Correlation of educational qualification with knowledge of emergency management of an avulsed tooth
|
|
Value |
df |
Asymp.Sig. (2-sided) |
|
Pearson Chi-Square |
13.911 |
6 |
.031 |
Pearson correlation test was performed to correlate the socio-economic status with the knowledge of emergency management of an avulsed tooth, which was statistically significant (p<0.05). (Table 2)
Table 2
Correlation of socio-economic status with knowledge of emergency management of an avulsed tooth
|
|
Value |
df |
Asymp.Sig (2-sided) |
|
Pearson Chi-Square |
11.457 |
4 |
.022 |
Pearson correlation test was performed to correlate the geographical background with the knowledge of emergency management of an avulsed tooth, which was statistically not significant (p>0.05). (Table 3)
Table 3
Correlation of geographical background with knowledge of emergency management of an avulsed tooth
|
|
Value |
df |
Asymp.Sig (2-sided) |
|
Pearson Chi-Square |
1.878 |
2 |
.391 |
Data showed that 59%(236) parents will took tooth to dentist immediately, 38.5%(154) will clean child’s mouth with water, keep the tooth in wet atmosphere and took it to dentist and only 2%(8) had a mind to keep the tooth in socket before reaching dentist.(Table 4)
Table 4
Most of the parents are 68.3% (273) unaware about the knowledge of conservation of avulsed tooth (Figure 3). And even 76.8% (307) parents even not know that child can attain normal functions of chewing and smiling after reimplantation of avulsed tooth.(Figure 4).
Pearson correlation test was performed to correlate the educational qualification with the knowledge of protection of an avulsed tooth, which was statistically significant (p<0.05). (Table 5)
Table 5
Correlation of educational qualification with knowledge of protection of an avulsed tooth
|
|
Value |
df |
Asymp. Sig. (2-sided) |
|
Pearson Chi-Square |
13.786 |
3 |
.003 |
Pearson correlation test was performed to correlate the socio-economic status with the knowledge of protection of an avulsed tooth, which was statistically not significant (p>0.05). (Table 6)
Table 6
Correlation of socio-economic status with knowledge of protection of an avulsed tooth
|
|
Value |
df |
Asymp.Sig. (2-sided) |
|
Pearson Chi-Square |
.039 |
2 |
.981 |
Pearson correlation test was performed to correlate the geographical background with the knowledge of protection of an avulsed tooth, which was statistically not significant (p>0.05). (Table 7)
Table 7
Correlation of geographical background with knowledge of protection of an avulsed tooth
|
|
Value |
df |
Asymp.Sig. (2-sided) |
|
Pearson Chi-Square |
3.334 |
1 |
.068 |
Pearson correlation test was performed to correlate the educational qualification with the knowledge of parents regarding reimplantation, which was statistically significant(p<.05).(Table 8)
Table 8
Correlation of the educational qualification with the knowledge of parents regarding reimplantation
|
|
Value |
df |
Asymp.Sig. (2-sided) |
|
Pearson Chi-Square |
9.576 |
3 |
.023 |
Pearson correlation test was performed to correlate the socio-economic status with the knowledge of parents regarding reimplantation, which was statistically not significant. (p>.05). (Table 9)
Table 9
Correlation of socio-economic status with the knowledge of parents regarding reimplantation
|
|
Value |
df |
Asymp.Sig. (2-sided) |
|
Pearson Chi-Square |
4.437 |
2 |
.109 |
Pearson correlation test was performed to correlate the geographical background with the knowledge of parents regarding reimplantation, which was statistically not significant. (p>.05).(Table 10)
Table 10
Correlation of geographical background with the knowledge of parents regarding reimplantation
|
|
Value |
df |
Asymp.Sig. (2-sided) |
|
Pearson Chi-Square |
1.695 |
1 |
.193 |
Pearson correlation test was performed to correlate the educational qualification with the knowledge of parents regarding the transport medium of avulsed tooth, which was statistically not significant. (p>.05).(Table 11)
Table 11
Correlation of educational qualification with the knowledge of parents regarding the transport medium of avulsed tooth
|
|
Value |
df |
Asymp.Sig. (2-sided) |
|
Pearson Chi-Square |
25.194 |
24 |
.395 |
Pearson correlation test was performed to correlate the socio-economic status with the knowledge of parents regarding the transport medium of avulsed tooth, which was statistically not significant. (p>.05).(Table 12)
Table 12
Correlation of socio-economic status with the knowledge of parents regarding the transport medium of avulsed tooth
|
|
Value |
df |
Asymp.Sig. (2-sided) |
|
Pearson Chi-Square |
19.405 |
16 |
.248 |
Pearson correlation test was performed to correlate the geographical background with the knowledge of parents regarding the transport medium of avulsed tooth, which was statistically not significant. (p>.05).(Table 13)
Table 13
Correlation of geographical background with the knowledge of parents regarding the transport medium of avulsed tooth
|
|
Value |
df |
Asymp.Sig. (2-sided) |
|
Pearson Chi-Square |
15.263 |
8 |
.054 |
Pearson correlation test was performed to correlate the educational status with the knowledge of parents regarding the cleaning medium of avulsed tooth, which was statistically not significant. (p>.05).(Table 14)
Table 14
Correlation of educational status with the knowledge of parents regarding the cleaning medium of avulsed tooth
|
|
Value |
df |
Asymp.Sig. (2-sided) |
|
Pearson Chi-Square |
16.807 |
15 |
.331 |
Pearson correlation test was performed to correlate the socio-economic status with the knowledge of parents regarding the cleaning medium of avulsed tooth, which was also statistically not significant. (p>.05).(Table 15 )
Table 15
Correlation of socio-economic status with the knowledge of parents regarding the cleaning medium of avulsed tooth
|
|
Value |
df |
Asymp.Sig. (2-sided) |
|
Pearson Chi-Square |
14.341 |
10 |
.158 |
Pearson correlation test was performed to correlate the geographical background with the knowledge of parents regarding the cleaning medium of avulsed tooth, which was also statistically not significant. (p>.05).(Table 16)
Table 16
Correlation of geographical background with the knowledge of parents regarding the cleaning medium of avulsed tooth
|
|
Value |
df |
Asymp.Sig. (2-sided) |
|
Pearson Chi-Square |
7.605 |
5 |
.179 |
Pearson correlation test was performed to correlate the educational status with the knowledge of parents regarding the handling of avulsed tooth, which was statistically not significant. (p>.05).(Table 17)
Table 17
Correlation of educational status with the knowledge of parents regarding the handling of avulsed tooth
|
|
Value |
df |
Asymp.Sig. (2-sided) |
|
Pearson Chi-Square |
5.184 |
9 |
.818 |
Pearson correlation test was performed to correlate the socio-economic status with the knowledge of parents regarding the handling of avulsed tooth, which was statistically not significant. (p>.05).(Table 18)
Table 18
Correlation of socio-economic status with the knowledge of parents regarding the handling of avulsed tooth
|
|
Value |
df |
Asymp.Sig. (2-sided) |
|
Pearson Chi-Square |
10.066 |
6 |
.122 |
Pearson correlation test was performed to correlate the geographical background with the knowledge of parents regarding the handling of avulsed tooth, which was also statistically not significant. (p>.05).(Table 19)
Table 19
Correlation of geographical background with the knowledge of parents regarding the handling of avulsed tooth
|
|
Value |
df |
Asymp.Sig. (2-sided) |
|
Pearson Chi-Square |
5.142 |
3 |
.162 |
Awareness regarding management of avulsed tooth
Discussion
Avulsion of permanent teeth is seen in 0.5–3% of all dental injuries. This is one of the most serious dental injuries, and the prognosis is very much dependent on the actions taken at the place of injury and the proper management.3
The loss of permanent tooth due to avulsion can be managed by various methods. However, as the injury usually takes place during that period where great amount of growth and development of jaw occurs, permanent replacement of avulsed teeth by means of bridge therapy and implants are, not recommended.15 Immediate reimplantation of the avulsed tooth, followed by endodontic treatment is, considered as the best treatment option.14
Dental traumatic injuries frequently occur at schools and some may occur at home. Therefore, the ultimate prognosis of an avulsed tooth occurring in a child may depend on the actions taken by the teachers and caretakers. Many patients with avulsed tooth visit medical professionals due to lack of awareness or unavailability of a dental surgeon. So that immediate and proper emergency management is not only the responsibility of the dental professionals but also parents, school teachers, medical practitioners and even common people available at the place of injury.
This study provided baseline information about the existing level of knowledge about dental avulsion as well as attitude and awareness towards its management among parents.
When surveyed about previous experience with tooth avulsion among participants, 2.8% of parents had given a history of dental avulsion. Second part of questionnaire was based to determine the knowledge and awareness about the condition. About the emergency management of an avulsed tooth, majority of the parents, (72%) answered that they would consult dental professionals rather than medical practitioners or local hospitals if an injury took place and a tooth got avulsed. Statistically, it was observed that higher educational background and higher socio-economic status was influenced this matter.16 But geographical background was not significant. Knowledge about possibility of reimplantation of an avulsed tooth among participants revealed that 76.8% parents even not know that child can attain normal functions of chewing and smiling after reimplantation of avulsed tooth. Most of the parents are (68.3%) unaware about the conservation of avulsed tooth. But parents with higher educational level showed more awareness. Socio-economic status and geographical background were not significant in this situation. Regarding the method of choice for cleaning the soiled avulsed tooth 42.8% of parents gave the correct answer that they will wash the tooth with tap water. More than half of the parents were unaware of the matter. Hence, we asked about proper handling of avulsed tooth before reimplantation about half of the parents opinion was to hold on crown portion, that was the correct method. 36% don’t know the exact position to hold. The answers were not dependent on educational background, socio-economic status and geographical background. Regarding the storage medium 41.5% of parents did not know what is the exact medium for carrying avulsed tooth. And it was well noted that only 2.3% (9) selected milk as the transport medium which is actually considered as ideal medium.17 When surveyed about previous information regarding management of avulsed permanent tooth, 94% of parents had given a negative response. 96.8% of parents were not satisfied with their current knowledge of management of avulsed tooth. All category parents have generally exhibited a much enthusiastic response in receiving further information about managing an avulsed permanent tooth.
Conclusion
It is well noted children and teenagers are very sensitive about missing anterior teeth. The permanent anterior teeth are not only important for esthetics but are also essential for phonetics, mastication, health of supporting tissues and psychological and mental health of children. Hence, immediate reimplantation of avulsed teeth (Permanent incisors) more often contributes to an improved self-confidence in children. Within the limitation of present study, it is conluded that regardless of educational background, socio-economic status and geographical background, parental awareness regarding the first aid measures to be taken in the case of dental avulsion was inadequate. But at the same time they exhibited positive attitude toward receiving more informations on emergency management of avulsed permanent tooth.
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