|Year : 2009 | Volume
| Issue : 4 | Page : 242-248
Knowledge, attitude and practice in emergency management of dental injury among physical education teachers: A survey in Bangalore urban schools
U Mohandas, GD Chandan
Department of Pedodontics and Preventive Dentistry, VS Dental College and Hospital, Bangalore, Karnataka-560 004, India
|Date of Web Publication||14-Nov-2009|
G D Chandan
VS Dental College and Hospital, Karnataka Road, Bangalore
| Abstract|| |
The purpose of this study was to assess, by means of a self administered structured questionnaire, the level of Knowledge, Attitude and Practice of physical education teachers in Bangalore city with regards to emergency management of dental injuries. The questionnaire surveyed the physical education teacher's background, knowledge of management of tooth fracture, avulsion, luxation injuries, it also investigated physical education teacher's attitude and the way they handle the injuries. The sample consisted 580 teachers from 700 selected schools in Bangalore city. Chi-square test was applied to test the significance between trained and untrained teachers. Among the population 70% were males physical education teachers 30% were females. 95% of the teachers had physical education training and 5% did not have the training. 95% of the population had first aid component and 5% did not have. Only 25% of trained physical education teachers had correct knowledge about tooth identification and 17% among untrained teachers. 81% of trained teachers answered correctly regarding management of fractured anterior teeth against 27.5% of untrained teachers (P<0.0002). The present report indicates that there is lack of knowledge and practice among physical education teachers in Bangalore city regarding emergency management of dental trauma. Educational programs to improve the knowledge and awareness among the teachers have to be implemented.
Keywords: Emergency management, trauma
|How to cite this article:|
Mohandas U, Chandan G D. Knowledge, attitude and practice in emergency management of dental injury among physical education teachers: A survey in Bangalore urban schools. J Indian Soc Pedod Prev Dent 2009;27:242-8
|How to cite this URL:|
Mohandas U, Chandan G D. Knowledge, attitude and practice in emergency management of dental injury among physical education teachers: A survey in Bangalore urban schools. J Indian Soc Pedod Prev Dent [serial online] 2009 [cited 2013 May 23];27:242-8. Available from: http://www.jisppd.com/text.asp?2009/27/4/242/57660
| Introduction|| |
Physical activity is a basic need for the growth of a child. WHO theme for the year 2002 says, 'Move for Health', which emphasizes on the role of physical activity in the healthy living of an individual'. During these physical activities, injuries to the face are one of the risks associated with it. Trauma to both primary and permanent dentition continues as a frequent dental problem. As long as young children remain active, trauma to both primary and permanent dentition continuous to be a frequent dental problem. It is known that majority of dental injuries is seen in children between ages of 8 and 11 years. ,, The prevalence of dental injuries is 60% out of which over 48% involve maxillary teeth. Over 16% was in the school environment and 19% of the injury due to fall. ,,,,,,,,
The prognosis of traumatized teeth depends on prompt and appropriate treatment, which often relies on knowledge of lay people such as the child's parents and their school teachers.  Since sports have been implicated in the etiology of dental trauma , and a high proportion of dental trauma at school occurred during classes in physical education,  it would be desirable for coaches and teachers of physical education to be capable of managing such injuries when they occur.  Studies have revealed that knowledge attitude and practice of physical education teachers have a poor knowledge regarding management of dental trauma. , In India there have been no studies reported so far to evaluate the knowledge, attitude and practice of physical education teachers regarding emergency management of dental injuries. Hence a study has been taken up to assess the knowledge, attitude and practice of physical education teachers of Bangalore schools.
All the available physical education teachers from both government and private schools were considered to the study. Among them a total of 700 teachers were available during the study tenure out of which 580 have responded for the study. A prior permission was obtained from the Directorate of Physical Education Department, Bangalore, to conduct the study. Permission regarding circulation of questionnaires to physical education teachers in various schools was obtained from Principals/School Head Masters of the respective schools. A multistage sampling was done to obtain the sample. The Bangalore city was divided into two parts namely North and South. A total of 100 wards are present in the city. On random sampling a total of 50 wards were taken for the study purpose (1st stage). From these wards, a total of 700 schools selected were taken by random sampling. The data was recorded by investigator personally from the physical education teachers by going to their respective schools.
- Physical education teachers from primary, middle and high schools in Bangalore city are included.
- Teachers who agreed to participate in the study.
- Physical education teachers were included irrespective of specialized game, age, sex and religion.
Questionnaires were distributed to all physical education teachers who agreed to participate in the study. The questionnaires were both in Kannada and English language to ensure comprehension by all physical teachers. The questionnaire was divided into three parts
Part I: - consisted of 11 questions on personal and professional data that recorded sex, age, teaching experience and first-aid training background.
Part II: - consisted of case studies with three imaginary cases of dental trauma in a school environment.
The first case explained of a mild dental trauma involving uncomplicated crown fracture. This was to evaluate the dental knowledge of the teachers and their attitude in rendering dental first-aid.
The second case depicted more serious scenario that involved avulsed tooth. This was to evaluate the knowledge and practice of dental first-aid.
Third case elicited a case of laxative injury.
Part III: - consisted of 11 questions, which were on luxations and avulsed injuries in their experience that evaluated their knowledge and attitude regarding management of dental injuries.
All questions were given alternative choices to help the respondents to make quick decisions.
| Results|| |
Sex: A total of 580 physical education teachers were available for the study. Among them 402 (69.3%) were males and 178 (30.7%) were females.
Age: Among the 580 physical education teachers, 56 (9.6%) were under 25 years of age, 185 (31.8%) were between 25 and 34 years, 244(42%) were between 35 and 44 years of age, 62 (10.6%) were between 45 and 54 years and above age group.33 (5.6%) were above 55 years.
Length of service: Physical education and first-aid training: out of 580 study population 551 (95%) had formal physical education training and 527 (90.8%) had first-aid training, while 29 (5%) had no formal physical education training and 24 (4.11%) of them had no first-aid training [Figure 1].
Dental trauma: - Among 580 study subjects, 228 (39.3%) of them came across dental trauma, out of these 96 (42.1%) found broken teeth without bleeding, 56 (24.5%) saw broken teeth with bleeding. 22 (9.6 %) has found teeth that had fallen off, 44 (19.2%) found mobile teeth (Extrusion), 9(3.9%) saw displaced teeth (Intrusion) and others like soft tissue injuries was (0.43%) [Figure 2]
Among the 580 subjects; only 142 (24.4%) answered that the damaged teeth were permanent, 169 (29.1%) of them as primary teeth, while 269 (46.5%) were not sure which teeth it was. Regarding the action taken 48 (8.2%) of them felt that they would contact the parents of the child and explain to them what happened after the class. About 57(9.8%) of the teachers would give the child warm drink and contact the parents, while 177 (30.7%) would send the child to school nurse, 298 (51.3%) would contact the child's parents and would take her to the nearest dentist [Table 1] and [Table 2].
Out of 580 subjects, 334 (57.5%) felt that they would sideline the injured boy and tell him to bite on a handkerchief, 24 (4.1%) felt that they would look for the teeth, wash it and give it to the boy to take it home. About 9 (1.5%) would look for the tooth and put it back in the socket. While 202 (35.6%) of them felt they would put it in the water, 11 (1.8%) would keep the tooth in milk [Table 3] and [Table 4].
Among 580 study subjects, 170 (29.3%) felt that they would sideline the injured boy and tell him to bite on a handkerchief, while 8 (0.72%) would wash the child's mouth and let him resume the game. 61 (10.5%) checked the degree of injury, and sent him away. About 341 (58.7%) would take him to the nearest dentist [Table 5].
This section will deal with the questions that evaluate the physical education teachers' personal life encounters associated with their knowledge, attitude and practice towards the management of dental injuries. Among 580 teachers, only 103 (17.7%) [Table 6] had come across luxated dental injuries among their spouse/children or students, 51 (8.7%) of teachers had come across avulsion cases. Approximately 130 (22.4%) teachers felt that they would first refer the injured student to a Medical practitioner, while 297 (51.2%) would refer to a dental clinic, 73 (12.5%) to a General Hospital and 75 (12.9%) to a dental hospital and 5 (0.8%) would refer to a school nurse.
Regarding the urgency in seeking professional help for an avulsed permanent tooth among the 580 study subject, 288 (49.6%) thought they should seek professional help immediately, 205 (35.3%) felt that professional help has to be taken within 30 min, 60 (10.3%) within few hours and 27 (4.6%) thought they could seek before next day. All the 580 teachers answered to seek professional help at least before next day; this shows they are not ignorant regarding management of dental injuries like avulsion injury.
Out of 580 study subjects, 128 (22%) knew that an avulsed tooth can be replanted, while 363 (62.5%) of study population felt that the avulsed tooth should be replanted, which shows a positive attitude among these population. While asking their involvement in the procedure to replanted tooth, 162 (27.9%) of physical education teachers agreed to do it by themselves. When questioned regarding cleaning the soiled avulsed tooth, 89 (15.3%) would scrub the tooth gently with a tooth brush, 262 (45.1%) would rinse the tooth under tap water. Approximately 15(2.5%) felt that they would put the tooth straight back into the socket, while 214 (36.8%) did not know what to do. Some teachers have mentioned regarding other procedures as cleaning it in antiseptic solution, soap, warm water.
While answering for the management of intrusion and extrusion injuries, 14 (2.4%) felt that would leave it as it is, 381 (65.6%) of physical education teachers told that they would take the child to a dentist, 16 (2.7%) teachers told that they would correct it by themselves, 169 (29%) accepted that they did not know about the management of luxated injuries. When asked about if they have received any advice regarding first-aid management of dental injuries, 107 (18.4%) answered that they had received advice or information. Finally when asked regarding need for the dental first-aid component in their course, 560 (96.55%) gave a positive answer and only 3.4% answered as negative.
| Discussion|| |
The incidence of dental injuries in children is extremely high. Peak incidence has been shown to be between the age groups of 2-4 and 8-12 years. During these ages, there is a maximum prevalence of anterior teeth injury. ,,,,,,,,,, Physical education teachers are likely to be in contact with the child soon after the injury. It is their knowledge of emergency procedures, which is crucial to ensure a better prognosis of the clinical treatment. In Part I, in the present study, 95% of the physical education teachers had formal teacher training. Among these, 90% had formal first-aid training; remaining 10% did not have any first aid training. A very small number of teachers said they had attended first-aid training courses on their own and only 4% of teachers recalled dental trauma management as being included in their first-aid training. The two imaginary cases in Part II of the questionnaire were designed with an intention to test the general knowledge of the respondents regarding the dental age, along with two commonest type of dental injuries. The ages of injured children in cases I and II were intentionally selected as 8 and 13 years, respectively as children between this ages carry great risk of sports-related dental injuries. ,,,,,,,,,
Case-1, question 1 was regarding 8-year-old girl with a broken upper front teeth less than half only; 24.4% recognized that at the age of 8 years the upper front teeth will be permanent dentition. This indicates the general knowledge of surveyed group regarding the time of eruption of permanent teeth was inadequate. No significant difference was noted between the trained and not trained physical education teachers (p = 0.055). In similar survey carried out on physical education teachers in Hong Kong, 46.8% had identified the tooth correctly.  A good result in Hong Kong may be due to a planned teachers training program focusing on all required topics with regular program/workshops conducted to update their healthcare knowledge. When a question was posed about the action to be taken when a tooth was broken, only 51.3% 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 referral to the school nurse option was an acceptable alternative; 31% of teachers chose this option, and this response is lower than the responses obtained in a similar study by Chan,  where 70% of the teachers answered appropriately. A highly significant difference in the distribution of response between trained and untrained physical education teachers (p < 0.000) was noticed. The reason for the difference in results between the present study and the study conducted by Chang is the presence of school nurse in every school in Hong Kong. This shows that there is a scarcity of school nurses in Bangalore. For case II, presenting a 13-year-old boy with avulsed upper front tooth, the ideal treatment would be immediate replantation  failing when one should ensure minimizing further insult to the periodontal ligaments cells on the root surface of the avulsed tooth. , Approximately 57.5% population chose to answer 'sideline the injured boy asking him to bite on a handkerchief' suggesting that they were concerned with controlling the bleeding first. This would be the most common instinctive reaction by most lay people in such cases, wherein the sight of blood sets off a panicky response focusing on controlling the bleeding first. Similar results were observed in the study done on physical education teachers by Chan.  Unfortunately, the child would not benefit from this maneuver because undue delay in replanting the tooth would jeopardize its prognosis. ,
Only 1.5% of physical education teachers told that they would look for the tooth and put it back in the socket, but this figure was much lower when compared to that obtained in Hong Kong,  where it is 17.5%. However, there was a high statistical significance among the trained and untrained physical education teachers. (p <0.005). Looking through the storage media, 21.5% chose milk, 15.6% chose water and surprisingly 58.3% population did not know about the storage media. This highly significance difference is due to the fact that knowledge, training and practice among the physical education teachers in Hong Kong is higher than the those in Bangalore. As no dental topics covered in the basic teaching and training of physical education programs, physical education teachers in Bangalore have low knowledge and practice ability.
It was revealed in Part III of the questionnaire that only 8.7% physical education teachers had experienced direct or indirect avulsion injury among the children during the tenure. This was lower as compared to physical education teachers covered by Chan (28.3%).  The reasons behind this may be due to the kind of sports that is played in Bangalore, as there is not much contact sport activity compared to Hong Kong.
When confronted with an accident involving an avulsed tooth, a higher proportion of the respondents (51.2%) said that they would go to a dental clinic and 12.9% to a dental hospital. The higher percentage of those seeking help from a dental clinic could be related to accessibility and less knowledge regarding super-specialty dental hospitals, and also lack of interaction with the dental hospitals. The preference of taking the child to a dentist by the physical education teachers may be attributed to the increased availability of private healthcare facilities in Bangalore city. In the Hong Kong study,  a significantly higher proportion (48.8%) of the teachers said that they would take the child to a 'dental clinic'; this may illicit that the dental service being provided in Bangalore is better than Hong Kong.
Most teachers (49.6%) recognized the urgency in seeking professional assistance for avulsive injuries. None of the respondents thought that the treatment was not necessary. This shows that the attitude of the physical education teacher in Bangalore has a good appreciable attitude in providing dental injury treatment.
Regarding the urgency in seeking professional help there was no significant difference of correct response between the trained physical education teachers and untrained physical education teachers (p = 0.54). The general perception, the trained and untrained teacher showed a comparatively same level of awareness regarding the urgency of seeking treatment in the case of an avulsion.
Only 18.4% of teacher had received advice regarding the management of an avulsive injury. A higher number of teachers (39.9%) had received advice on the management of avulsive injury according to studies done by Chan  respectively. There seems to be an urgent need to educate the physical education teachers and correct these misconceptions.
When the responses of the teachers to the questions regarding dental trauma were correlated with their teaching experiences, unexpectedly it was found that there was no significant relationship between the practice conducted and the teaching experience. But according to a study done by Sae-lim,  teaching experience showed a direct correlation with the self-assessed knowledge of physical education teachers regarding the emergency management of dental trauma. In the above results, among trained and untrained physical education teachers there is no difference regarding the knowledge of dental trauma management and the qualification (trained physical education teachers), as the trained teachers have not undergone any special training to handle dental injuries. When the physical education teachers were asked if they thought they needed further training to manage dental trauma cases, a majority of them (560, 96.5%) answered 'yes' and similar response was also observed in a study done by Chan (81.9). 
| Conclusion|| |
Among the physical education teachers, it is clearly elicited that there was significantly very low knowledge of dental trauma emergency management; no dental emergency management component was included in their Physical Education curriculum.
A lack of adequate knowledge was observed among the physical education teachers regarding the suitable medium for transport of an avulsed tooth. There should be more interaction between school teachers and dental professionals along with nearby dental hospitals to enable them to detect and proceed correctly in rendering better treatment at the primary levels. This study shows that all the physical education teachers have good attitude towards management of dental injuries and lack of knowledge is leading to undesirable practice regarding management of dental injuries.
It is been noticed however that the physical education teachers have a great enthusiasm towards the need for further training in emergency management of dental injuries, but there is a need for incorporating emergency management of dental injuries in the curriculum of the physical education teachers as most of them lacked knowledge on management and practiced inappropriate methods, which could lead to disability or loss of tooth.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]