|Year : 2014 | Volume
| Issue : 2 | Page : 97-107
Knowledge and attitude of parents with regard to avulsed permanent tooth of their children and their emergency management-Chennai
Tee Jing Loo1, Deepa Gurunathan2, Sujatha Somasundaram3
1 UG Student, Department of Pedodontics, Saveetha Dental College, Chennai, India
2 Reader, Department of Pedodontics, Saveetha Dental College, Chennai, India
3 Senior Lecturer, Department of Pedodontics, Saveetha Dental College, Chennai, India
|Date of Web Publication||17-Apr-2014|
Reader, Department of Pedodontics, Saveetha Dental College, Chennai
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Dental avulsion is defined as the complete displacement of tooth out of socket along with severed periodontal ligament with or without fracture of the alveolar bone. Reimplantation of the avulsed tooth is considered as a best treatment modality due to its biological and psychological advantages. The viability of periodontal ligament cell on the root surface determines the prognosis of reimplanted tooth. The knowledge of parents regarding important steps to be taken immediately after dental avulsion is considered crucial for success of the treatment. Aim: The study was conducted to evaluate the knowledge and attitude of parents in Chennai with regard to avulsed permanent tooth of their children and their emergency management using a questionnaire. Materials and Methods: The study included 529 parents who accompanied their children, aged between 6 years and 12 years, to the Department of Pedodontics, Saveetha Dental College and Hospitals. Chi-square test was done to evaluate the association between the results and the genders, educational level, and geographical status of the respondents. Results: The study revealed even though 90.7% of parents knew that saving an avulsed permanent tooth is important, but almost one third of the population thought ice water was the best media to transport an avulsed teeth. Conclusion: There is an imperative need for educating the parents regarding management of avulsed tooth for which 87.9% showed interest.
Keywords: Attitude, avulsion, parents, permanent tooth, practice, knowledge
|How to cite this article:|
Loo TJ, Gurunathan D, Somasundaram S. Knowledge and attitude of parents with regard to avulsed permanent tooth of their children and their emergency management-Chennai. J Indian Soc Pedod Prev Dent 2014;32:97-107
|How to cite this URL:|
Loo TJ, Gurunathan D, Somasundaram S. Knowledge and attitude of parents with regard to avulsed permanent tooth of their children and their emergency management-Chennai. J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2019 Nov 18];32:97-107. Available from: http://www.jisppd.com/text.asp?2014/32/2/97/130781
| Introduction|| |
Dental avulsion is defined as the complete displacement of tooth out of socket along with severed periodontal ligament with or without fracture of the alveolar bone. Being the most serious form of dental trauma, it occurs frequently in the society with an incidence of 0.5%-3% of all traumatic injuries of the permanent dentition. ,,,
Epidemiological studies ,,, reveal that the prevalence of dental avulsion is 3 times more in boys than girls, most probably accredited to their active participation in hostile games and sports of more aggressive nature. It occurs most commonly in the permanent dentition of 8- to 12-year-old children, while the teeth commonly involved are maxillary central incisors and lateral incisors. According to Andreasen et al.,  it is the loosely structured periodontal ligament surrounding the erupting teeth that often exhibit short, incompletely formed roots and the elasticity of alveolar bone which favors the avulsion of these teeth.
Dental avulsion brings aesthetic, functional, and psychological consequences, both on the child and the parents. , The permanent anterior teeth play an important role in good psychological development of the children and teenagers. When the aesthetics harmony is insulted by dental avulsion, there is often a conscious effort of the children and teenagers to avoid smiling. , As the cost of dental treatment following trauma is high, dental avulsion causes a burden to the society's economy. ,,,,, Dental avulsion can be managed by various treatment modalities, such as prosthetic replacement of the avulsed tooth, treatment by minor orthodontic movements, and immediate reimplantation of the avulsed tooth, followed by endodontic treatment. Though dental avulsion can be managed by other treatment modalities, the role of immediate reimplantation can never be overemphasized enough as it carries more psychological benefits than any other treatment modalities. ,
The prognosis of a reimplanted tooth is determined by the viability of periodontal ligament cell on the root surface prior to the reimplantation.  The combination of delayed reimplantation and unphysiological storage is followed by low survival rate of the reimplanted tooth.  Prolonged extraalveolar duration contributed to an uncertain prognosis for most reimplanted teeth.  Functional healing was observed in teeth reimplanted within 1 h after the injury.  In situation where immediate reimplantation of the avulsed tooth is not possible, limited storage of the avulsed tooth in isotonic solution prior to reimplantation gave equal or even better healing results compared with immediate reimplantation. ,
Since majority of dental injuries occur in home environment, the knowledge of parents regarding important steps to be taken immediately after dental avulsion is considered essential in order to achieve more successful outcome of the treatment.  Several studies show that the majority of population, as well as the many professionals who may be involved in the management of dentoalveolar injuries, have little knowledge concerning this subject. ,,,,,,,,,,, In a recent study done in Cairo, Egypt, it was shown that the level of knowledge is markedly low in parents regardless of their educational level.  As no previous study has been conducted in Tamil Nadu to evaluate the knowledge of parents about emergency procedures for tooth avulsion, the present study aims to investigate the level of parental awareness concerning emergency management of avulsed anterior permanent tooth in Chennai. The study also evaluated the most preferred source of information through which further knowledge can be imparted to the population.
| Materials and Methods|| |
The study population consists of 529 parents who accompanied their children, aged between 6 and 12 years, for receiving dental care for the first time in Department Of Pedodontics, Saveetha Dental College and Hospitals, Chennai, between May 2011 and May 2012. The protocol was approved by the Institutional Human Ethical Committee at Saveetha University, Chennai (IHEC No.: B.D.S004/SU114/2011). The objectives and nature of the study were explained to the participants, while the voluntary nature of participation was emphasized and strict confidentiality assured. A written informed consent form according to the ethical guidelines was subsequently obtained from the participating parents.
The participants were asked to complete a 14-stemmed questionnaire [Appendix 1] which was a modified form of questionnaire used by Raphael and Gregory  in their study. The questionnaire was provided in both simple English and regional (Tamil) language. The questionnaire was essentially comprised of two parts: First part contained the general demographic data and the second part includes closed questions which assessed the knowledge, attitude, and previous experience of the participant toward the first-aid management of avulsed permanent tooth (Chart 1). Each question was provided with options which maybe correct or incorrect answers. Participants were requested to mark the option which they perceive as the most appropriate answer.
Collection of completed questionnaire was done on the same day, immediately after the parents had completed the questionnaire. Any enquiries and comments about the questions from the participants were attended to by the authors. This was followed by distribution of information leaflets and health education regarding proper first-aid measures of avulsed young permanent teeth to the participants.
The data obtained from 529 questionnaires were tabulated and statistical analysis was done using SPSS version. While P value ≤0.05 was considered to be significant, the chi-square test was applied to investigate the association between the results and the genders, educational level, and geographical status of the respondents.
| Results|| |
A total of 529 parents who accompanied their children for receiving dental care for the first time in Department of Pedodontics, Saveetha Dental College and Hospitals, Chennai, were surveyed to ascertain the knowledge, attitude, and practice of parents regarding emergency management of avulsed permanent incisors. Male respondents constituted to 45.6% (241) of the surveyed group, while female respondents were 54.4% (288). Around two-third of the respondents were reported to be coming from urban background. While more than half (52.7%) of the respondents have received education of minimum higher secondary level, there were 7.2% of the respondents came from a nonliterate background [Table 1] .
Knowledge about reimplantation
When enquired about the knowledge of reimplantation as an emergency management of an avulsed tooth, almost half of the parents (43.3%) believed in the possibility of reimplanting the avulsed tooth as part of the first-aid treatment modality [Figure 1]. Only 30% of the respondents think that reimplantation should be done immediately [Figure 2], whereas only a quarter (27.6%) of parents had shown tendency in reimplanting the avulsed tooth into socket by themselves [Figure 3]. A total of 59.7% of the parents would consult dentists rather than doctors or local hospitals when the accident took place [Figure 4].
Cleaning media and transport media
Majority of the respondents have selected the inappropriate medium for cleaning and transporting the avulsed tooth. Water (43.8%) and salt water (43.3%) were the two most common mediums that figure prominently when parents were enquired about the medium of choice for cleaning the soiled avulsed tooth [Figure 5]. Disinfecting solution was perceived as the best medium to be used for transporting the avulsed tooth by nearly one-third of the respondents [Figure 6].
Previous knowledge about dental avulsion
Data had also revealed that 74.7% of the respondents had not received advice regarding emergency management of avulsed permanent tooth before [Figure 7]. Among those who had received previous advice on the same, the two main sources were from books (39.5%) and media (24.6%) [Figure 8].
Attitude of parents
As per our survey, majority (90.7%) of parents agreed with the importance of saving an avulsed permanent tooth. High fractions (87.9%) of the respondents have shown interest in receiving more information about the emergency management of avulsed permanent tooth [Figure 9].
Previous experience with dental avulsion
Among 77 parents (14.6%) who have reported with previous experience of dental trauma to their child, 48 (62.3%) of them had suffered from dental avulsion [Figure 10]. Even though 61% of the parents had brought their child to the dentist immediately, there is only a scanty (16.7%) of them who had brought the avulsed tooth with them [Figure 11].
Parents' gender, educational level, and residential locality
The level of knowledge with regards to urgency of reimplantation was observed to be associated with gender of the parents, with female parents exhibiting higher knowledge level. However, male parents seem to have received more information regarding to management of avulsed permanent tooth previously [Table 2]. Statistically, it was observed that parents with higher educational background have shown much positive attitude toward first-aid management of avulsed permanent tooth [Table 3]. The knowledge toward first-aid management of avulsed tooth was not dependent on the educational qualification of the parent except for the source of information which showed statistically significant variation. However, the attitude part of the questionnaire, that is, first place of contact and the interest to receive more information showed a statistically significant difference between the parents. No significant association was noticed between the level of previous experience and all three variables of the interviewed parents [Table 2], [Table 3], [Table 4].
|Table 2: Response of parents of different educational qualifi cation towards fi rst-aid management of avulsed permanent tooth|
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|Table 3: Response of parents of different residential locality towards fi rst-aid management of avulsed|
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|Table 4: Response of parents of different Gender towards fi rst-aid management of avulsed permanent tooth|
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| Discussion|| |
Being considered as the most severe form of dental trauma, dental avulsion is characterized by complete severance of the periodontal apparatus and neurovascular bundles of the tooth, leading to the loss of pulp vitality.
The permanent anterior teeth play an important role in good psychological development of child and adolescent. It was noticed that child often exhibits lower self-esteem when the aesthetic harmony is insulted by dental avulsion. , Furthermore, according to Lee and Divaris,  the combination of experience of pain, emotional distress, shock, and physical impairment during dental trauma has the potential of producing dental anxiety in the future.
The loss of permanent tooth due to avulsion can be managed by various modalities. However, as the accidents usually takes place during the age where great amount of growth and development are observed in the jaw, permanent replacement of avulsed teeth by means of bridge therapy and implant are, therefore, not recommended. , Immediate reimplantation of the avulsed tooth, followed by endodontic treatment is, hence, considered as the best treatment modalities for the reasons that not only it prevents the negative psychological influences to the child, but also it prevents the incurrence of heavy economical burden on the parents which is caused by other complex treatment modalities. ,,,,
The prognosis of a reimplanted tooth is directly correlated to the amount of viable periodontal membrane.  Minimal extraalveolar dry time, adequate storage, and transport medium, along with minimal damage to the root surface and periodontal ligaments are considered by majority authors as the triad of factors which contributes to a desirable prognosis. ,,,
According to Andreasen and Hjorting-Hansen,  teeth that were reimplanted within 30 min are entailed with a success rate of 90%, while only 5 % chances of long-term retention are designated to those that were reimplanted after 2 h.  Andersson and Bodin  have further stated that the prognosis of reimplanted tooth is largely determined in the first 15 min after avulsion. This indicates that immediate reimplantation is of absolute necessity in order to achieve a propitious sequel of the reimplanted tooth. Considering predominance of dental injuries transpires in home environment where professional assistance is not acquirable readily; it is, therefore, cardinal that parents should have adequate knowledge of emergency management of avulsed permanent tooth so that prompt and appropriate action can be taken to save the tooth.
When questioned about the possibility of reimplanting an avulsed tooth, the respondents were split into two almost equal moieties. This finding is in relation to the gender of the participants, with male respondents exhibited slightly higher level of awareness than their counterpart.
Only a quarter of the parents had shown tendency in reimplanting the avulsed tooth into the socket by themselves. Likewise, similar finding has been reported by few previous studies. ,,,,, On the contrary, Raphael and Gregory  had reported that about two-third of respondents in their study were willing for attempting self-reimplantation. Lack of knowledge, fear to hurt the child, and the perceived association between bleeding and death seems to have desisted parents from reimplanting the avulsed tooth. ,,
Regarding the urgency of reimplantation, only one-third of the parents have chosen "immediate reimplantation." Higher fractions of male participants have opted for delayed reimplantation. We have analyzed and suggest that, as governed by cultural and social factors, fathers are usually the bread-winner of the family and have spent less time with the child and hence, mothers whose daily routine is mostly restricted at home, are expected to be responsible for the child.
Lack of knowledge concerning cleaning medium to be used for contaminated tooth has been reported by studies conducted in Kuwait  and Cairo.  In present study, only a scanty of respondents has stated that they would clean a soiled avulsed tooth using milk. A total of 43.8% of the respondents have opted plain water, which is followed closely by salt water (43.3%).
Several studies ,,,,,,,, have demonstrated a generally poor knowledge about transport media of choices. It is worrisome to see "ice water" being chosen the most, followed by dry storage of the avulsed tooth. It was believed that the fact of both options were opted the most was due to their availability and also, lay people's perception of the ability of low temperature in maintaining "freshness" of the items. Lay people should be educated that water should never be used as storage medium due to its hypotonicity. It causes rapid lysis of the periodontal ligament cells, and hence, tremendously jeopardizing the outcome of reimplantation. ,,,,,, Dry storage of the tooth will allow irreversible desiccation of the periodontal membrane, resulting in the loss of the reimplanted tooth over time as well. ,,,
In our study, the options of transporting medium to be used include dry transportation, disinfecting solution, ice water, child's mouth, milk, fruit juice, and saline solution. Though Hank's Balanced Salt Solution (HBSS, Save-A-Tooth® ) has been proven to be the most effective storage media , ever since being introduced by Krasner and Person in year 1992, it was not being mentioned in the questionnaire. This is because the use of HBSS as storage medium in India is not practical due to the cost involved and unavailability of the medium. An ideal storage medium should fit the following criteria: Ability to preserve or replenish cell viability, adherence and clonogenic capacity and accessibility at the site of accident.  Both milk and tender coconut water fulfils both criteria. Thomas et al.,  have shown that tender coconut water is as effective as HBSS during extraoral duration of 15-120 min. This supported the previous studies which were conducted by Gopikrishna et al.,  stating that tender coconut water could be used as a superior transport medium for avulsed tooth. Ice-cold, low-fat milk is an alternative to HBSS which was readily available.  However, the viability of periodontal ligament cells in the milk was demonstrated to be inferior to HBSS after 1 h of storage duration,  this made milk only suitable for short-term storage of avulsed tooth. The use of propolis ,,, and green tea extracts  as storage media for avulsed tooth has been advocated by a number of researchers lately. They were not being discussed in detail here as they were not readily available in the geographical location.
When the respondents were enquired if they have previously received any information about how to deal with an avulsed permanent tooth, only a quarter of them have given positive response. This finding did not have any correlation with the educational background of the participants. Likewise, Shashikiran et al.,  have reported that significant number of the parents (67.2% urban, 95.1% rural) have not received any advice regarding first-aid management of the same. This clearly indicates the lack of programs which create public awareness concerning emergency management of avulsed tooth.
Despite the fact that nearly half of the participants doubted on the possibility of reimplanting an avulsed tooth, significant amount of parents agreed with the necessity to save an avulsed permanent tooth. This showed that the participating parents demonstrated a positive attitude toward the saving an avulsed tooth in spite of having a low level of awareness in how to save it.
In the event of dental avulsion, more than half of the interviewees would seek medical assistance from dentists instead of doctors or local hospitals. There was no statistical correlation observed with the residential locality of the participants. This is in disagreement with a study conducted in Davangere  and Nigeria.  Shashikiran et al.,  have stated that most rural parents would send their child to a doctor or a nearby hospital instead of dentist, due to the lack of access to dental clinic in the vicinity of their residential area. However, it was also noticed that parents' seeking of first help was determined significantly by the educational background of parents as more parents of higher educational background have preferred seeking assistance from dentist.
Parents of higher educational background have generally exhibited a much enthusiastic response in receiving further information about managing an avulsed permanent tooth. Only a minute fraction of parents with above higher secondary school educational qualification has opted "No," whereas more of nonliterate parents have not shown interest when enquired.
Among 77 parents whose child has experienced luxative dental trauma, avulsion injury was observed in 48 (9.1%) child. The incidence of avulsion injury in our study is reported to be higher than those recorded by the recent epidemiological studies conducted in Tamil Nadu (1) and South India (2), which is around 3%-4% It was alarming to know that nearly two-third of the parents did not attempt to retrieve the tooth, while less than a quarter of the parents had carried the avulsed tooth to dentist in moist condition. Parents should be made understand that it is important to retrieve the avulsed tooth not only for reimplanting the tooth but also to be certained of the tooth not being swallowed or aspirated by the child during the accident.  Only 30 parents have brought their child to a dentist immediately. This finding has reflected that most of the parents were not aware of the "time factor" being the most crucial factor in determining a successful prognosis.
Intervention program should be developed targeting parents, so that unnecessary loss of permanent tooth due to avulsion injury can be avoided and the tooth be retained in function for life. Integration of parental awareness can be achieved by different means. A lecture of 30-min duration was found to have significantly increased the knowledge level, yet it is also resource-consuming as the professional is required to visit the audiences personally.  A recent study  has stated healthcare professionals as the most preferred sources of information by all population segments. Elderly preferred television as the source of information the most. On the contrary, younger generation and population with higher educational level have opted for internet as their most preferred source. Al-Asfour and Andersson  have concluded that though it has its limitation in conveying the message for a complete understanding, a simple leaflet is able to raise the knowledge level of parents to 46%-74% by conveying important basic information. Majority of the interviewees were surprised when health educational leaflets were given and explained by the authors. Information about the important steps to be taken by parents as first-aid managements, including the type of transport media which are practically available, was recommended by the authors. Parents have shown great interest and were pleased to grab the opportunity to learn more about their role in saving an avulsed tooth of the child.
Within the limitation of present study, it was concluded that regardless of educational background and geographical locality, parental awareness concerning measures to be taken in the event of dental avulsion was markedly inadequate. Nonetheless, they exhibited positive attitude toward receiving more advice on emergency management of avulsed permanent tooth through television and internet. Enthusiasm and preference of source of knowledge was directly related to the level of education of parents. Further, the authors suggest to the school education department to include avulsion of tooth and its management as a part of curriculum, so that individuals have a knowledge about avulsion at a very young age.
Scoring system may be implemented in the current study to facilitate the comparison of awareness level in the future. Broader perspectives shall be obtained by including more geographic regions in the study.
| Acknowledgement|| |
This project was approved and supported by the Institutional Human Ethical Committee at Saveetha University, Chennai (IHEC No.: B.D.S004/SU114/2011). The research has received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]
[Table 1], [Table 2], [Table 3], [Table 4]