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Assessing the effectiveness of a school based oral health promotion amongst school teachers with regard to management of tooth avulsion.

INTRODUCTION: Traumatic injuries to permanent teeth between 7 to 10 years commonly results in avulsion and maxillary central incisors are the one commonly affected. (1, 2) This isdue to therelatively resilient alveolar bone, due to the conical tapering anatomy of the root and being the most anteriorly placed tooth in the face. The permanent anterior teeth are not only important for esthetics but are also essential for speech [phonetics], mastication, health of supporting tissues and psychological and mental health of children.

Therefore, apart from implementing preventive strategies for the occurrence of avulsion in children, every possible step should be meticulously planned for successful replantation of avulsed permanent teeth.

Management of avulsion of the permanent dentition often presents a challenge as successful replantation depends upon how early tooth is replanted and, care has been taken to maintain and preserve the vitality of periodontal ligament fibres and storage media used prior to reimplantation.

Clinical studies have shown that the prognosis is best for teeth replanted within 5 minutes after avulsion. (3) Hence, immediate replantation (4-6) or storage of avulsed tooth in solutions compatible with cell viability until it is replanted is very crucial. Milk has been indicated as the preferred storage media as it is readily available and preserves cell viability. Keeping the tooth dry compromises the periodontal ligament cells and prognoses is poor.

Avulsion injuries are very common in schools and home. School teachers should be aware of the protocol and the importance of giving emergency care because of their proximity to children which can save time and doing the correct protocol in helping successful reimplantation. Therefore it is important that school teachers should have the relevant knowledge to handle any such emergency related to dental injuries in school among children.

Many studies done previously amongst school teachers to evaluate their knowledge regarding giving first aid measures after dental injuries showed lack of knowledge. Therefore, the purpose of the study was to assess the knowledge level of school teachers, both urban and rural, with regard to emergency management of tooth avulsion and to check the effectiveness of dental health education to improve the emergency dental care at school premises and elsewhere.

MATERIALS AND METHODOLOGY: This interventional study based on before and after non randomized trial principle was conducted amongst school teachers at Ludhiana, out of which 50% teachers were from the rural areas and rest were from the urban areas.

Total number of school teachers was 200, out of which 100 teachers were from the urban and 100 teachers were from the schools in rural areas of Ludhiana.

A questionnaire containing 11 questions was prepared, about 200 questionnaires written both in English and Hindi languages assessing the knowledge level with regard to emergency management of tooth avulsion were personally distributed to the school teachers by the chief investigator and were collected back with their response.

After one month a lecture was given by the chief investigator to the same teachers on tooth avulsion and its emergency management and discussion on the topic. Followed by this the same questionnaire was given to all the teachers and their responses were reassessed.

Questionnaire used in this Survey:

A Survey of School Teachers Awareness regarding Management of Tooth Avulsion

* Name of the teacher --

* Name of the School --

Q1. Do you know there are two types of dentitions?

* Yes/No

Q2. Have any of your students ever had an accident where a permanent tooth has been knocked out?

* Yes/No

Q3. Do you think the permanent tooth that has been knocked out should be replaced?

* Yes/No

Q4. If your student came to you with one tooth in his/her hand following an accident whom do you contact first?

* Doctors

* Dentists

* Nearby hospital

Q5. How urgent do you think is it essential to seek professional help if a permanent tooth has been knocked out?

* Very urgent--immediately

* Within 30 mins

* Within a couple of hours

* After a few days

Q6. Would your replace a knocked out permanent tooth back to the place from which it came?

* Yes/No

Q7. If you decide to replace the knocked out tooth back to the place, but it had fallen onto the ground and was covered with dirt, what would you do?

* Scrub the tooth gently with a brush

* Wash the tooth in salt water

* Wash in milk

* Wash the tooth in water

* Do nothing

Q8. If you did not replace the tooth back to the place, how would you transport it to the doctors?

* Water

* Milk

* Antiseptic solution

* Child's own mouth

* Paper or cotton roll

Q9. If the permanent tooth that has been knocked out was broken, what would you do?

* Still replace the tooth

* Take it to the dentist

* Do nothing

Q10. Have you received advice/ you are aware on what to do in the event of an accident, where a permanent tooth has been knocked out?

* Yes/No

Q11. Do you know the importance of saving an avulsed tooth?

* Yes/No

RESULTS: Two hundred teachers of both urban and rural schools participated in this study and following were the responses obtained from them after attempting the questionnaire given before and after the educative lecture. After assessing the Table A. for the responses given by school teachers, following key points were noted.

* When asked about the possibility of replanting the avulsed tooth, majority of the school teachers were not aware that permanent tooth should be replanted, however informative lecture improved their knowledge regarding reimplantation.

* Teachers were not aware that in case of avulsion injury the best option is to contact a dental surgeon.

* Very less number of teachers knew the importance of urgency of reimplantation and how it can affect the success of reimplantation.

* After receiving the lecture there was also a significant increase in the number of school teachers who were ready to reimplant tooth themselves.

* Majority of School teachers were not aware of proper handling and cleaning of fallen tooth. Teachers were also not aware about the importance of transport media for an avulsed tooth, majority of them thought that the best transport media was paper or cotton roll. Informative lecture on this issue enlightened their knowledge and their preference of media to be used to clean avulsed tooth was milk or saline.

DISCUSSION: An avulsed tooth demands the most urgent management for its better prognosis and prevention of replacement resorption. Avulsed tooth should be properly handled and cleaned and, immediately replanted back to its socket but for any reason if it cannot be replanted within 5 minutes of the injury then it should be stored in appropriate physiological storage media like Viaspan, Hanks Balanced Salt Solution and cold milk. (7-9)

Tooth avulsion is a very common event in children and emergency care procedure is crucial for case prognosis. Most of the injuries occur at school time and school teachers present at the moment of accident can provide first aid measures.

Previous studies have demonstrated about lack of knowledge of school teachers in handling traumatic dental injuries. Studies also reveal the importance of educating the school professionals regarding this. (10-13)

In this present study, a campaign for providing information about 'Avulsion of the tooth' to the school teachers of both rural and urban school teachers of Ludhiana (India) was done.

The purpose of the campaign was to know their level of knowledge regarding tooth avulsion and to alert school professionals on the importance of immediate treatment procedure and instruct them on how to handle these situations.

The results were positive after school teachers received informative lecture followed by a discussion about how to handle case of avulsion before taking it to dental professional.

School teachers realized how crucial is to reimplant tooth back to its socket in case of an avulsed tooth, as 100 percent of the participants answered positively to this question after the lecture. Milk was the preferred solution for both rural(88%), urban(91%) as compared to the study conducted with the same teachers before this lecture, at that time (58%)rural and((61%) urban wanted to use cotton or paper roll as a transport media without realizing that how 'Dry storage' would jeopardize the chances of an successful reimplantation.

Raphael and Gregory, (14) in Australia, demonstrated the lack of diffusion of information on tooth avulsion. Hamilton et al. (15) in England, showed an unpreparedness of the respondents in cases of tooth avulsion. In 2001, Sae-Lim and Lim (16) highlighted the lack of knowledge of Singapore teachers on the emergency management of tooth avulsion. Chan et al. (12) noted that their results were similar to other authors. These studies demonstrate an unpreparedness of the community in cases of tooth avulsion.

The most encouraging aspect of this survey was the observation that school teachers were keen to learn more about emergency management protocol in cases of avulsed tooth and other traumatic dental injuries.

CONCLUSION: From the present survey, it appeared that educational programmes would be necessary to improve public awareness of the immediate management of traumatized teeth, with emphasis on the following:

1. Availability of after-office-hour emergency services.

2. Storage media for avulsed teeth.

3. Critical timing for reimplantation of avulsed teeth.

4. Current concepts of management of fractured teeth.

DOI: 10.14260/jemds/2014/2547


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(2.) Hedegard B, Stalhone I. A study of traumatized permanent teeth in children aged 7-15 years. Part I. Swed Dent J Suppl1973; 66:431-8.

(3.) Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Reimplantation of 400 avulsed permanent incisors. Diagnosis of healing complications. Endod Dent Traumatol1995; 11(2):518.

(4.) Kinirons MJ, Gregg TA, Welbury RR, Cole BO. Variations in the presenting and treatment features in reimplanted permanent incisors in children and their effect on the prevalence of root resorption. Br Dent J 2000; 189(5):263-6.

(5.) Andersson L, Bodin I. Avulsed human teeth replanted within 15 minutes: a long-term clinical follow-up study. Endod Dent Traumatol. 1990; 6(1):37-42.

(6.) Andreasen JO. Analysis of pathogenesis and topography of replacement root resorption (ankylosis) after reimplantation of mature permanent incisors in monkeys. Sweed Dent J. 1980; 4(6):231-40

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(10.) Al-Jundi SH, Al-Waeili H, Khairalah K. Knowledge and attitude of Jordanian school health teachers with regards to emergency management of dental trauma. Dent Traumatol. 2005; 21(4):183-7.

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Table 1

            A                   B
        QUESTIONS           RESPONSE           lecture

1    TYPES OF          YES                       142
     DENTITION         NO                         58

2    PREVIOUS          YES                        93
     EXPERIENCE        NO                        107

3    POSSIBILTY OF     YES                       127
     REPLANTING        NO                         73

4    FIRST PLACE       DOCTORS                    42
     OF CONTACT        DENTIST                    59
                       HOSPITAL                   99

5    URGENCY OF        IMMEDIATELY               126
     REPLANTATION      WITHIN 30min               34
                       WITHIN HOURS               30
                       FEW DAYS                   10

6    ATTEMTING         YES                       113
     THEMSELVES        NO                         87

7    CLEANING          BRUSH                      13
     EXPERIENCE        SALT WATER                 55
                       MILK                       17
                       WATER                      55
                       DO NOTHING                 60

8    TRANSPORT         WATER                      21
     MEDIA             MILK                       17
                       ANTISEPTIC SOLUTION        31
                       CHILD"MOUTH                12
                       PAPER/COTTON ROLL         119

9    AVULSED WITH      REPLACE                    20
     FRACTURE          DENTISTS                  139
                       NOTHING                    41

10   KNOWLEDGE         YES                        49
     ABOUT EMERGENCY   NO.                       151

11   IMPORTANCE        YES                       193
     OF SAVING         NO.                        7

            A                   B
        QUESTIONS           RESPONSE           lecture

1    TYPES OF          YES                       200
     DENTITION         NO

2    PREVIOUS          YES                        96
     EXPERIENCE        NO                        104

3    POSSIBILTY OF     YES                       194
     REPLANTING        NO                         6

     OF CONTACT        DENTIST                   200

5    URGENCY OF        IMMEDIATELY               200
                       WITHIN HOURS
                       FEW DAYS

6    ATTEMTING         YES                       160
     THEMSELVES        NO                         40

7    CLEANING          BRUSH
     EXPERIENCE        SALT WATER                103
                       MILK                       97
                       DO NOTHING

8    TRANSPORT         WATER                      2
     MEDIA             MILK                      179
                       ANTISEPTIC SOLUTION        0
                       CHILD"MOUTH                19
                       PAPER/COTTON ROLL          0

9    AVULSED WITH      REPLACE                    78
     FRACTURE          DENTISTS                  122
                       NOTHING                    0

10   KNOWLEDGE         YES                       200
     ABOUT EMERGENCY   NO.                        0

11   IMPORTANCE        YES                       200
     OF SAVING         NO.                        0

            A                   B               After

        QUESTIONS           RESPONSE         [chi square]    P value

1    TYPES OF          YES                      67.836      <0.001 ***
     DENTITION         NO

2    PREVIOUS          YES                      0.090       0.764NS
     EXPERIENCE        NO

3    POSSIBILTY OF     YES                      70.807      <0.001 ***
     REPLANTING        NO

4    FIRST PLACE       DOCTORS                 217.761      <0.001 ***

5    URGENCY OF        IMMEDIATELY              90.798      <0.001 ***
                       WITHIN HOURS
                       FEW DAYS

6    ATTEMTING         YES                      25.485      <0.001 ***
     THEMSELVES        NO

7    CLEANING          BRUSH                   198.723      <0.001 ***
                       DO NOTHING

8    TRANSPORT         WATER                   301.174      <0.001 ***
     MEDIA             MILK
                       ANTISEPTIC SOLUTION
                       PAPER/COTTON ROLL

9    AVULSED WITH      REPLACE                  76.434      <0.001 ***

10   KNOWLEDGE         YES                     242.570      <0.001 ***

11   IMPORTANCE        YES                      7.125       0.008 *
     OF SAVING         NO.

NS: p > 0.05 Not Significant; * p < 0.05: Significant at 5% significance level; *** p < 0.001: Highly Significant.


1. Rajesh Kumar

2. Abi M. Thomas


1. Assistant Professor, Pediatric Dentistry, Christian Dental College, CMC Hospital, Ludhiana.

2. Principal and HOD, Pediatric Dentistry, Christian Dental College, CMC Hospital, Ludhiana.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR: Dr. Rajesh Kumar, Department of Pedodontia, Christian Dental College, CMC Hospital, Ludhiana--141008, Punjab.


Date of Submission: 04/04/2014.

Date of Peer Review: 05/04/2014.

Date of Acceptance: 18/04/2014.

Date of Publishing: 05/05/2014.

Rajesh Kumar [1], Abi M. Thomas [2]
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Author:Kumar, Rajesh; Thomas, Abi M.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:May 5, 2014
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