|Year : 2015 | Volume
| Issue : 3 | Page : 228-233
Influence of educational intervention on knowledge and attitude toward emergency management of traumatic dental injuries among nursing students in Davangere, India: Pre- and post-design
GY Yunus1, Ambika Nalwar2, GK Divya Priya2, DJ Veeresh2
1 Department of Public Health Dentistry, Rungta College of Dental Sciences and Research, Bhilai, Chhattisgarh, India
2 Department of Public Health Dentistry, Bapuji Dental College and Hospital, Davangere, Karnataka, India
|Date of Web Publication||14-Sep-2015|
G Y Yunus
Department of Public Health Dentistry, Rungt College of Dental Sciences and Research, Bhilai, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Introduction: Dental trauma has become an important attribute of dental public health. The management of traumatized teeth depends on prompt and appropriate treatment, which often relies on knowledge of dentists, doctors, and nurses who render the initial care. Aims: To assess the level of knowledge and attitude toward traumatic dental injuries (TDIs) and their emergency management among nursing students in Davangere city.
Materials and Methods: This study was conducted among the nursing students (240 students) in Davangere city. Pretest knowledge and attitude toward TDIs and its emergency management were assessed using a 21 items structured questionnaire followed by posttest knowledge and attitude assessment after delivering health education on the same day. Wilcoxon signed-rank test was applied to check the pre and post difference in the attitude, knowledge of the nursing students. Results: Post health education, a significant difference in knowledge about immediate emergency management of avulsed tooth and tetanus vaccination was observed (P < 0.005) and also in difference in attitude about need of treating avulsed tooth and emergency management of TDIs as one of their educational priorities was noted.
Conclusions: Though nursing students have a good attitude toward the management of dental injuries but the lack of knowledge regarding the storage media and time management for avulsed tooth leads to undesirable practice in the management of TDIs.
Keywords: Dental trauma, emergency management, health education, nurses
|How to cite this article:|
Yunus G Y, Nalwar A, Divya Priya G K, Veeresh D J. Influence of educational intervention on knowledge and attitude toward emergency management of traumatic dental injuries among nursing students in Davangere, India: Pre- and post-design. J Indian Assoc Public Health Dent 2015;13:228-33
|How to cite this URL:|
Yunus G Y, Nalwar A, Divya Priya G K, Veeresh D J. Influence of educational intervention on knowledge and attitude toward emergency management of traumatic dental injuries among nursing students in Davangere, India: Pre- and post-design. J Indian Assoc Public Health Dent [serial online] 2015 [cited 2019 Jul 22];13:228-33. Available from: http://www.jiaphd.org/text.asp?2015/13/3/228/165212
| Introduction|| |
Traumatic dental injuries (TDIs) can cause esthetic, psychological, and therapeutic problems. "Traumatic" means pertaining to or occurring as a result of or causing trauma. "Injury" refers to damage or an insult sustained by the tissues. It may evoke dystrophic and/or inflammatory response from the affected part. Hence, "traumatic injury" may be defined as damage to a part of the body tissue.  TDIs may be inflicted in a number of ways including contact sports, fights, falls, motor vehicle accidents, eating hard foods.
Studies have affirmed that increased over jet and inadequate lip coverage, violence, traffic accidents, and greater participation in sports and physical leisure activities have contributed to transform dental traumatic injuries into a public health problem. Incidences of these injuries have increased during the last 10-20 years and suggest that the incidence of dental trauma will soon equal to that of dental caries and periodontal diseases. ,,
A review of the literature from 1995 to 2007 shows that the prevalence of TDIs in primary and permanent teeth is high throughout the world. Children in the age group of 1-2½ years sustain injuries to the primary dentition most frequently. School-going children of ages 8-11 years have shown a high prevalence rate for injuries in the permanent dentition. Boys are more susceptible to TDIs than girls, with the ratio being 1.5:1. The teeth most commonly involved are upper central incisors and lower central incisors. As oral tissues are highly sensitive, injuries to the oral cavity are extremely painful, and prompt treatment should be taken after injuries. 
Worldwide epidemiological statistical data indicate that 6-36% of the individuals suffer from TDIs during childhood and adolescence. , In developing countries like India, dental trauma has become a major oral health issue among children and teenagers ,,,,, and the 3 rd largest cause for the mortality of teeth but the treatment of TDIs tends to be neglected. ,,
Avulsion injuries of the tooth due to trauma are common among children. ,,,,,,,,, Untimely and improper management of tooth avulsions can lead not only to physical and mental stress to the children and their parents, but also the emotional and social component of the child's development may be impacted which, in turn, can lead to poor oral health-related quality of life in these children. ,
The prognosis of traumatized teeth depends on prompt and appropriate treatment, which often relies on knowledge of people like dentists, doctors, and nurses who render the initial care. Since in India, as the oral health manpower is limited, nurses need to be equipped with knowledge of TDIs because there is still a majority of people who will visit a medical hospital whenever they sustain traumatic dental injury instead of a dental hospital or clinic. Hence, it would be desirable for nursing students to have a basic knowledge of managing such injuries.
Literature research revealed in India, there have been no studies reported so far to evaluate among nursing students regarding the emergency management of TDIs. Hence, this study has been undertaken with the aim to assess the knowledge, attitude, and practice of nursing students of Davangere city, India. The objectives of this study were to investigate the influence of education on knowledge and attitude toward the emergency management of TDIs among nursing students in Davangere before (pre) and immediately after (post) an educational intervention.
| Materials and methods|| |
The study was conducted in a sample of nursing students in Davangere city, India (pre and post design). The sample size was calculated considering confidence level of 95% and an absolute precision of 0.05. As the population variance was unknown, we adopted P = 50% to allow for the largest possible variance. A sample size of 202 was required and to allow for missing answers, an extra 20% was recruited. The final sample size was therefore 240 students. Ethical approval was obtained from Institutional Review Board. List of nursing colleges located in Davangere city was obtained from the Nursing Council of India. Permission to collect the relevant data from the nursing students was obtained from the respective college authorities. All the available nursing students from 4 nursing colleges were considered to be included the study irrespective of age and sex. Informed consent was obtained from the nursing students after explaining the purpose and the procedures involved in the study.
The questionnaire was prepared in both Kannada and English language for ensuring comprehension by all nursing students and pretested in a group of 10 nursing students and modifications were made accordingly. Moreover, the validation was carried out in a panel expert and among 10 experts in the subjects. Cronbach's alpha was calculated (α = 0.70) and test-retest analysis showed a good reliability of 0.7 of the questionnaire. Those nursing students who were involved in the pilot study were excluded from the final study. The knowledge questions were assigned one point each for the correct answer and zero points for the wrong answer. The partially filled/incomplete questionnaires were excluded.
A self-designed proforma comprised of 3 sections with a total of 21 items regarding knowledge, attitude, and self-assessment toward emergency management of TDIs was administered.
Pretest knowledge and attitude about emergency management of TDIs were assessed using a same questionnaire distributed to 260 nursing students available during the study. Health education about emergency management of traumatic dental was delivered by a trained investigator using power point presentation which included an introduction to dentition, differences between primary and permanent teeth, etiology, classification, and how to manage TDIs on the same day at their college premises. Posttest knowledge and attitude about emergency management of TDIs were assessed on the same day using the same tool.
- Section I - consists of 9 questions to evaluate knowledge of nursing students by giving two imaginary scenarios about broken tooth and avulsed tooth
- Section II - consists of 9 questions to test the attitude of nursing students regarding TDIs
- Section III - consists of 3 questions for self-assessment.
All the obtained data were compiled and tabulated systematically in Microsoft Excel Spreadsheet and subjected to statistical analysis (SPSS version 17.0 (IBM Corporation, SPSS Inc., Chicago, IL, USA) Descriptive statistics was employed in terms of percentages. Wilcoxon signed-rank sum test was applied to check the pre and posttest differences in the knowledge and attitude.
| Results|| |
A total of 253 filled questionnaires were collected, giving a response rate of 97.5%. After excluding questionnaires with missing entries, there were 240 for analysis. Among 240 nursing students, aged 17-24 years (19.8 ± 2.02): 172 (71.66%) were females and 68 (28.33%) were males.
[Figure 1] represents pre and posttest mean knowledge scores of study subjects, among 240 study participants, 84% answered that broken teeth were permanent teeth and regarding the action taken, 38% of them felt they would look for broken tooth piece and send the child to dentist with it. No statistical significant difference found after health education, where 89% identified the tooth correctly, and 44.3% opted for sending the child to dentist (P > 0.005). About 60% of nursing students felt that avulsed tooth requires an emergency management and firstly need to be referred to general medical practitioner (49.2%) or nearby hospital (35.7%), whereas only 12% answered to first contact a dentist.
|Figure 1: Mean knowledge percentage scores (case 1) before and after health education|
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[Figure 2] represents pre and posttest mean knowledge percentage scores of study subjects. There was a significant difference noted in regarding the questions about immediate emergency management of avulsed tooth and tetanus vaccination (P < 0.005). About 60.1% of nursing students were aware to take the history of previous tetanus vaccination in cases reported with dental trauma. There was a significant difference noted in regarding the questions about immediate emergency management of avulsed tooth and tetanus vaccination (P < 0.005). In this study, 54% respondents chose to discard the avulsed tooth whereas only 45% knew that avulsed tooth should be cleaned and brought to the dentist.
|Figure 2: Mean knowledge scores (case 2) before and after health education|
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[Figure 3] represents pre and posttest mean attitude percentage scores of nursing students. There was a statistically significant difference in attitude of nursing students regarding the need of treating avulsed tooth and TDIs as one of their educational priorities (P < 0.005).
|Figure 3: Mean attitude percentage scores before and after health education|
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[Figure 4] represents mean attitude percentage scores of study participants. 50% agreed that their intervention plays a key role in traumatized tooth survival and about 53% felt special training required for nurses in managing traumatized tooth. 58% of nursing students knew that mouth guard should be worn in all contact sport and most of them felt nurses should refrain from such scenarios due to some legal consideration and there was a statistically significant difference found after health education (P < 0.005). Finally, majority of the nursing student assessed that their knowledge level is less, and future education is needed.
|Figure 4: Mean attitude percentage scores before and after health education|
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| Discussion|| |
In the present study, knowledge and attitude toward dental traumatic injury among nursing students were assessed before and after giving health intervention using power-point presentation. An advantage of delivering health education was a possibility to compare their knowledge level and to improve their attitude toward the emergency management of dental traumatic injuries. Interestingly, in this study, knowledge and attitude toward dental traumatic injuries before and after health education remains almost same.
The two imaginary scenarios were given in Part I of the questionnaire was designed with an intention to test the knowledge of the nurses regarding the dental age, along with two most common types of dental injuries. The ages of injured children in cases I and II were intentionally selected as 9 and 13 years, respectively, as children between these ages carry a greater risk of sports-related dental injuries.
In this study, most of the respondents recognized that at the age of 9 years, the broken upper front teeth will be permanent dentition indicating general knowledge of nursing students regarding the time of eruption of permanent teeth was adequate, which is in agreement with the findings of Hugar et al.  No significant difference was noted before and after health education whereas in a study by Mcintyre et al.,  a significant improvement in knowledge among elementary school staff was reported after a dental trauma education. About the action to be taken when a tooth was broken, 44.3% respondents answered correctly by choosing option, "the parent should be contacted and asked to take the child to a dentist." In some instances, this may not be immediately possible. In such cases, they should look for the broken tooth piece and send the child to the dentist with it.
In a scenario of a boy with avulsed upper front tooth, the ideal treatment would be immediate replantation to minimize further insult to the periodontal ligaments cells on the root surface of the avulsed tooth.  Question about the first place of contact revealed that most of the nursing students would consult a doctor (44.2%) or a nearby hospital (35.7%) rather than from dentist (12%). This shows a lack of knowledge among nursing students regarding dental services.
About 60% of surveyed group knew that they should inquire about previous dosage of tetanus vaccination immediately after trauma; this was similar to the knowledge of Dental Interns of Nepal  and dental students of Japan.  There was a statistically significant difference observed after health education (P < 0.005). This shows that nursing students in Davangere have a good appreciable knowledge regarding the significance of tetanus vaccination. A thorough attempt must be made to determine whether a patient has completed primary immunization. Children with unknown or uncertain previous immunization histories should be considered to have no previous tetanus toxoid doses. Children who have not completed a primary series may require tetanus toxoid and passive immunization (tetanus immune globulin - human) at the time of wound cleaning and debridement. Available evidence indicates that complete primary vaccination with tetanus toxoid provides long-lasting protection ≥10 years for most recipients. ,
The knowledge regarding cleaning of the avulsed tooth is very important as most of the avulsed tooth would fall on the ground and get dirty. Most of the study subjects knew that avulsed tooth should not be carried in hand, and the suitable liquid medium is required for carrying the avulsed tooth. In a similar survey conducted by Choi et al. showed that 62% of the school nurse in public schools and 56% of the school nurse in private schools knew that liquid was the appropriate method of transporting avulsed tooth. 
The most popular choice of the storage medium during transportation was the antiseptic solution. Knowledge is not improved even after health education. About 30% of nursing students in the present study felt that saliva is a desirable storage media for avulsed tooth, which is similar to the knowledge of dental assistants of Riyadh.  Only 6% of nursing students opted for milk as a storage medium which was similar to the findings of study by Raphael and Gregory,  where only 5% of respondents knew that "milk" was the medium of choice for both washing and transporting avulsed teeth, whereas Hugar et al. revealed that only 2.2% nurses knew about the storage medium used for storing avulsed tooth. 
In our study, knowledge regarding type of liquid transport medium is not satisfactory and indicates that there is a lack of knowledge in this group on how avulsed teeth should be handled after an accident. This is regrettable because the simple measure of storing an avulsed tooth in milk will enhance the prognosis of the tooth when implanted. ,, Milk has a favorable osmolarity and composition for maintaining the viability of periodontal ligament cells and has been recommended for temporary storage of avulsed teeth before replantation. In addition to being readily available, it preserves cell viability for up to 3 h. 
Saliva should only be indicated when neither milk nor saline solutions are available. Andreasen and Andreasen clarified that when saliva is used as a storage medium, the extra-alveolar period must be limited to a maximum of 2 h due to the slightly hypotonic nature of the medium and the fact that bacteria present in saliva may also have a harmful effect on later healing.  Milk has several favorable characteristics as a storage medium for avulsed teeth, as it is an isotonic liquid with an approximately neutral pH and physiological osmolality, has low or no bacterial content, contains growth factors and essential nutrients for cells, in addition to having a high availability mostly everywhere and low cost.  Water is the least desirable storage medium because the hypotonic environment causes rapid cell lysis and increased inflammation on replantation. 
For the question regarding critical time for the replantation, 30% of the nursing students responded that it was within 20 min while 25.3% suggested 20-60 min. An avulsed permanent tooth should be replanted as soon as possible. The risk of ankylosis increases significantly with an extraoral dry time of 20 min. If the tooth cannot be replanted within 5 min, it should be stored in a medium that will maintain the vitality of periodontal ligament fibers. 
The results of the present study showed that the attitude of nursing students about TDIs was good but no statistically significant difference found after health education.
The majority of nursing students felt that time plays an important role in the emergency management of dental trauma. Dental injuries are mainly caused by hits to the facial area with the hands or elbows or by collisions with another player due to the high speed and physical style of playing. , Otherwise, being hit by the ball at close range may also inflict such injuries. Because of the rapid impulse of the impacting force, the injury mechanism results indirect trauma, this is conducive to a crown fracture. 
In our study, 58.1% participants were familiar with a mouth guard suggesting that they appreciated the significance of mouth protectors during sports but not significantly improved after health education. A few felt that dental trauma emergency management must be included as part of their teaching curriculum and agreed that they have a role in dental trauma management. The majority of the students showed interest in learning about the management of dental trauma.
The limitations of our study include small sample size, a convenience sampling methodology instead of random sampling and the lack of a control group, and finally assessment of knowledge and attitude changes immediately post intervention. The sample size and the response rate indicate that our study included a representative sample of nursing students of Davangere, and the reinforcement of knowledge in the form of repeated intervention would be desirable and possible directions for future research are indicated taking these limitations into consideration.
It has been noticed however that nursing student have a great enthusiasm toward the need for further training in emergency management of dental injuries, but there is a need for incorporating emergency management of dental injuries in their curriculum. An educational campaign dedicated to this topic is recommended for nursing students. Dental trauma emergency management is recommended to be added to first-aid publications. Collaborative actions between dental and nursing professional needed and they should be posted in nearby dental hospitals as part of their routine posting to enable them to detect and proceed correctly in rendering better treatment at the primary levels.
| Conclusion|| |
As nurses stand on the front lines of responding to an emergency, it is essential that they also possess adequate knowledge about dental traumatic injuries and its emergency management. In the present study, though nursing students have a good attitude toward management of dental injuries, but lack of knowledge in regarding the storage media and time management for avulsed tooth leads to undesirable practice in the management of TDIs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Al-Asfour A, Andersson L. The effect of a leaflet given to parents for first aid measures after tooth avulsion. Dent Traumatol 2008;24:515-21.
Hamilton FA, Hill FJ, Holloway PJ. An investigation of dento-alveolar trauma and its treatment in an adolescent population. Part 1: The prevalence and incidence of injuries and the extent and adequacy of treatment received. Br Dent J 1997;182:91-5.
Emerich K, Wyszkowski J. Clinical practice: Dental trauma. Eur J Pediatr 2010;169:1045-50.
Andreason JO, Andreason FM. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 3 rd
ed. Copenhagen: Munksgaard Publishers; 1994. p. 138.
Young C, Wong KY, Cheung LK. Emergency management of dental trauma: Knowledge of Hong Kong primary and secondary school teachers. Hong Kong Med J 2012;18:362-70.
Glendor U. Epidemiology of traumatic dental injuries - A 12 year review of the literature. Dent Traumatol 2008;24:603-11.
Ahlawat B, Kaur A, Thakur G, Mohindroo A. Anterior tooth trauma: A most neglected oral health aspect in adolescents. Indian J Oral Sci 2013;4:31-7.
Ravishankar TL, Kumar MA, Ramesh N, Chaitra TR. Prevalence of traumatic dental injuries to permanent incisors among 12-year-old school children in Davangere, South India. Chin J Dent Res 2010;13:57-60.
Rambharos RR, Kalaskar AR, Wankhade RM, Mehta JD. Evaluation of prevalence, etiological and risk factors of traumatic dental injury in 12-14 years old school going children of Central India. SRM J Res Dent Sci 2014;5:73-7.
Gupta K, Tandon S, Prabhu D. Traumatic injuries to the incisors in children of South Kanara District. A prevalence study. J Indian Soc Pedod Prev Dent 2002;20:107-13.
Baldava P, Anup N. Risk factors for traumatic dental injuries in an adolescent male population in India. J Contemp Dent Pract 2007;8:35-42.
Kumar A, Bansal V, Veeresha KL, Sogi GM. Prevalence of traumatic dental injuries among 12- to 15-year-old schoolchildren in Ambala district, Haryana, India. Oral Health Prev Dent 2011;9:301-5.
Dua R, Sharma S. Prevalence, causes, and correlates of traumatic dental injuries among seven-to-twelve-year-old school children in Dera Bassi. Contemp Clin Dent 2012;3:38-41.
Gupta S, Kumar-Jindal S, Bansal M, Singla A. Prevalence of traumatic dental injuries and role of incisal overjet and inadequate lip coverage as risk factors among 4-15 years old government school children in Baddi-Barotiwala Area, Himachal Pradesh, India. Med Oral Patol Oral Cir Bucal 2011;16:e960-5.
Ramos-Jorge ML, Bosco VL, Peres MA, Nunes AC. The impact of treatment of dental trauma on the quality of life of adolescents: A case-control study in Southern Brazil. Dent Traumatol 2007;23:114-9.
Hugar SM, Suganya M, Kiran K, Vikneshan M, More VP. Knowledge and awareness of dental trauma among Indian nurses. Int Emerg Nurs 2013;21:252-6.
McIntyre JD, Lee JY, Trope M, Vann WF Jr. Effectiveness of dental trauma education for elementary school staff. Dent Traumatol 2008;24:146-50.
Fakhruddin KS, Lawrence HP, Kenny DJ, Locker D. Impact of treated and untreated dental injuries on the quality of life of Ontario school children. Dent Traumatol 2008;24:309-13.
Limbu S, Dikshit P, Bhagat T, Mehata S. Knowledge of dental interns towards emergency management of avulsed tooth in dental colleges in Nepal. J Nepal Health Res Counc 2014;12:1-7.
Fujita Y, Shiono Y, Maki K. Knowledge of emergency management of avulsed tooth among Japanese dental students. BMC Oral Health 2014;14:34.
Recommendations of the Immunization Practices Advisory Committee (ACIP). Diphtheria, Tetanus, and Pertussis: Recommendations for Vaccine Use and Other Preventive Measures. MMWR 40: No. RR-10; 1991.
Cohen S, Burns R. Traumatic Injuries. Pathways of the Pulp. 8 th
ed., Ch. 16. St. Louis: Mosby; 2002. p. 636-7.
Choi D, Badner VM, Yeroshalmi F, Margulis KS, Dougherty NJ, Kreiner-Litt G. Dental trauma management by New York City school nurses. J Dent Child (Chic) 2012;79:74-8.
Halawany HS, AlJazairy YH, Alhussainan NS, AlMaflehi N, Jacob V, Abraham NB. Knowledge about tooth avulsion and its management among dental assistants in Riyadh, Saudi Arabia. BMC Oral Health 2014;14:46.
Raphael SL, Gregory PJ. Parental awareness of the emergency management of avulsed teeth in children. Aust Dent J 1990;35:130-3.
Marino TG, West LA, Liewehr FR, Mailhot JM, Buxton TB, Runner RR, et al.
Determination of periodontal ligament cell viability in long shelf-life milk. J Endod 2000;26:699-702.
Oswald RJ, Harrington GW, Van Hassel HJ. A postreplantation evaluation of air-dried and saliva-stored avulsed teeth. J Endod 1980;6:546-51.
Pearson RM, Liewehr FR, West LA, Patton WR, McPherson JC 3 rd
, Runner RR. Human periodontal ligament cell viability in milk and milk substitutes. J Endod 2003;29:184-6.
Andreasen JO, Andreasen FM. Essentials of Traumatic Injuries to the Teeth. 1 st
ed. Copenhagen: Musksgaard; 1994. p. 113-31.
Blomlöf L. Milk and saliva as possible storage media for traumatically exarticulated teeth prior to replantation. Swed Dent J Suppl 1981;8:1-26.
Trope M. Clinical management of the avulsed tooth: Present strategies and future directions. Dent Traumatol 2002;18:1-11.
Goswami M, Chaitra T, Chaudhary S, Manuja N, Sinha A. Strategies for periodontal ligament cell viability: An overview. J Conserv Dent 2011;14:215-20.
Sane J, Ylipaavalniemi P. Dental trauma in contact team sports. Endod Dent Traumatol 1988;4:164-9.
Sane J. Comparison of maxillofacial and dental injuries in four contact team sports: American football, bandy, basketball, and handball. Am J Sports Med 1988;16:647-51.
Bennett DT. Traumatised anterior teeth. I. Assessing the injury and principles of treatment. Br Dent J 1963;115:309-11.
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