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  Table of Contents    
ORIGINAL ARTICLE
Year : 2021  |  Volume : 39  |  Issue : 2  |  Page : 138-146
 

Educational approaches for assessing knowledge about and actions of educators in response to dental avulsion


1 Department of Dentistry, Positivo University, Curitiba, Paraná, Brazil
2 Department of Dentistry, Pontifical Catholic Universisty of Paraná, Curitiba, Paraná, Brazil
3 Department of Dentistry, Tuiuti University of Paraná, Curitiba, Paraná, Brazil
4 Department of Dentistry, University of the Region of Joinville, Joinville, Santa Catarina, Brazil

Date of Submission24-Apr-2020
Date of Decision07-May-2021
Date of Acceptance02-Jun-2021
Date of Web Publication29-Jul-2021

Correspondence Address:
Prof. Marilisa Carneiro Leão Gabardo
Rua Prof. Pedro Viriato Parigot de Souza, 5300, 81280-330 Curitiba, Parana
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_186_20

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   Abstract 


Background: Dental trauma affects especially schoolchildren and adolescents. Educators, the responsible for the first appointment, have a fundamental role in the prognosis of dental avulsion that occurred in this environment. Aim: To evaluate the educational approaches for assessing knowledge and actions in response to dental avulsion among educators. Settings and Design: This cross-sectional and quanti–qualitative study included 197 teachers and 24 pedagogical coordinators (PCs), from the public schools of Pato Branco, Paraná, Brazil. Methods: A questionnaire was initially administered regarding the knowledge about avulsion to all participants. Teachers just read a manual and answered the questionnaire after 30 days. PCs were divided into (n = 12): G1 – manual + fictitious scenario of avulsion and G2 – active methodology + fictitious scenario. The questionnaire was re-administered to all. Statistical Analysis: Quantitative data were analyzed statistically. For the qualitative stage, two questions were proposed and the Bardin's analysis was performed. Results: For teachers, knowledge about avulsion increased after the intervention (P < 0.001), except as related to cleaning the tooth (P = 0.21). Activities involving G1 and G2 also led to an increase in knowledge, but no difference occurred in this increase between the approaches (P = 0.14). Qualitative analysis highlighted the need for calm and for performing actions that could favor a good prognosis in cases of avulsion. Conclusions: The level of knowledge increased after interventions, but no significant differences between the educational approaches were found.


Keywords: Education, knowledge, school teachers, tooth injuries, training


How to cite this article:
Lima J, Caldarelli PG, Rocha JS, Fagundes Tomazinho FS, Fariniuk LF, Baratto-Filho F, Leão Gabardo MC. Educational approaches for assessing knowledge about and actions of educators in response to dental avulsion. J Indian Soc Pedod Prev Dent 2021;39:138-46

How to cite this URL:
Lima J, Caldarelli PG, Rocha JS, Fagundes Tomazinho FS, Fariniuk LF, Baratto-Filho F, Leão Gabardo MC. Educational approaches for assessing knowledge about and actions of educators in response to dental avulsion. J Indian Soc Pedod Prev Dent [serial online] 2021 [cited 2022 Jun 27];39:138-46. Available from: https://www.jisppd.com/text.asp?2021/39/2/138/322495





   Introduction Top


Tooth avulsion is a trauma that occurs frequently in schoolchildren.[1] It has been reported that 0.5%–16% of dental trauma incidents result in tooth avulsion,[2],[3] with the majority of these cases caused by falls, sport activities, collisions, and violence.[4],[5],[6],[7] Tooth avulsion is considered a dental emergency,[8],[9] and the best treatment is reimplantation, as it allows preservation of function and esthetics, postpones the need for prosthesis, and reduces the psychological impact.[9] For this reason, it should always be considered in permanent teeth, even when the prognosis is not favorable.[1] In this context, the time elapsed between the accident and dental assistance is crucial,[1],[10] along with knowledge and resourcefulness in those who provide first-aid.[4],[9]

Schools are reported to be one of the places where most of these accidents occur,[11],[12] and teachers are responsible for first-aid in most cases. However, it has been reported that the level of knowledge of them regarding this topic is insufficient.[11],[13],[14],[15],[16],[17] Given the importance of preparing teachers to perform the correct procedures about traumatic dental injuries, the literature has emphasized the relevance of evaluating their knowledge on the subject and has demonstrated the need to educate them to improve the prognosis of patients.[14],[15],[16],[17],[18],[19],[20] In this context, the knowledge about the subject is not synonymous with knowing how to put it into practice. Different educational approaches can be used, such as lectures followed by discussions.[18],[19] However, active methodologies based on problematization, involving meaningful discovery and valuing the process of “learning to learn,” can generate more positive results.[21] These strategies promote reaching and motivating the individuals because when they are faced with a problem, after stopping, examining, reflecting, and relating it to their history, their discoveries are more meaningful.[21]

Thus, using different educational approaches, the present study sought to assess the knowledge and actions related to dental avulsion by educators from municipal public schools in Pato Branco, Paraná, Brazil.


   Methods Top


This study was approved by the Human Research Ethics Committee (No. 3.047.164) at Universidade Positivo and by the Municipal Education Secretariat of Pato Branco. Individuals who agreed to participate signed informed consent form.

This was an exploratory intervention study with a quanti–qualitative approach. Pato Branco has been chosen because it is a municipality in the southwest of the state of Paraná with approximately 82,000 inhabitants and with a Human Development Index (IDH) of 0.782, a high value ( Atlas More Detailsbrasil.org.br/2013/pt/perfil_m/pato%20branco_pr">http://atlasbrasil.org.br/2013/pt/perfil_m/pato%20branco_pr). It is a regional education center and is considered to rank first in terms of performance among medium-sized cities (50,000–100,000 inhabitants) in the municipal education network of the state.

Overall, 286 teachers from elementary schools and 24 pedagogical coordinators (PCs) were eligible to participate. Teachers at municipal centers for early childhood education were excluded, given that avulsed primary teeth (the dentition prevalent in the age group of children attending these centers) should not be reimplanted.

For sample calculation, a confidence level of 95% and an error of 5% were considered, with an increase of 20% for possible losses; hence, the final sample consisted of 197 teachers, who were reached by saturation sampling. All PCs participated in the research.

Interventions based on reading a manual (“conventional education”) as well as reading manual versus the problematizing approach (“problematizing education”) were considered in this study. A previously calibrated researcher with expertise on the subject conducted all stages of the intervention in loco.

Initially, a questionnaire (16 objective questions), elaborated based on the instruments applied to Brazilian populations,[22],[23] was administered to all participants (n = 221). It was structured in two parts: the first (3 questions) recorded data from participants, such as age, gender, and experience time as a teacher; and the second (13 questions) specifically addressed knowledge related to and actions that would be performed in case of avulsion. Respondents were given 12 min to complete the questionnaire.

Thirty days after, the educational approach termed “conventional education” began. A manual was distributed to the teachers (n = 197) to read it within 10 min. This manual had been developed by researchers specialized in endodontics and containing text and illustrations related to optimal conduct in cases of dental avulsion. Thereafter, the second part of the questionnaire, specific to the theme, was re-administered to the group of teachers, who were then given 10 min to complete it.

PCs (n = 24) who had already answered the initial questionnaire proposed a health education activity involving different educational approaches and lasting approximately 1½ h. After a brief introduction (10 min), participants were simply and randomly divided into two groups (n = 12): G1 used “conventional education” and G2 used an educational approach based on problematization (active methodology – “problematizing education”).

The members of G2 were randomly subdivided into smaller groups (n = 4) to each of which a questionnaire with 12 multiple-choice questions and two open questions about avulsion and the first appointments for dealing with the trauma was administered. For the multiple-choice questions, numbered templates were made with the alternatives; for the open questions, white cards and colored pens were distributed. The questions were projected using multimedia equipment, and 3 min was given for each team to discuss and present their answers using the material provided. Thereafter, the researcher discussed the answers with the participants to make the learning meaningful and pointed out the correct answer. Here, it was identified whether or not the participants had the correct knowledge. Eventually, all participants should be able to identify possible risk factors within the school environment and develop strategies to prevent and also deal with avulsion.

Both subgroups (G1 and G2) had their knowledge assessed after using the assigned educational approaches. The PCs were then invited to analyze a fictitious scenario of a tooth avulsion case. Images were distributed depicting different stages and procedures for the case, based on the manual. Participants were asked to choose and order the images correctly, during 5 min. Then, they answered two reflective questions: “What feelings did you experience when faced with the situation of avulsion presented?” and “Do you feel empowered/prepared to provide the first care in a case of avulsion?” The responses were audio-recorded. The researcher established a dialog to make this phase more dynamic, and participants were given freedom to express themselves. Impartiality was maintained, and the speech saturation was used to finalize data collection.

Finally, the second part of the questionnaire was reapplied to all PCs, with 10 min for responses. The flowchart of the study is shown in [Figure 1].
Figure 1: Flowchart of the study process

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The data were analyzed in a descriptive way, and a binomial test was used to compare the two assessments (pre- and post-educational intervention). To compare the number of correct answers, Wilcoxon's nonparametric t-test was used. Fisher's exact test and the Mann–Whitney nonparametric test were used to compare the two groups of PCs. The data were analyzed using the SPSS program version v. 20.0 (IBM® SPSS® Statistics, Armonk, NY, USA).

For qualitative analysis, the speeches were transcribed manually by the researcher. A researcher with experience in qualitative methodologies and trained in interview transcripts was asked to review this stage of the work. The recordings were destroyed after the transcription, guaranteeing the confidentiality of the respondents' identity. Preanalysis of the material was performed by the researcher, a guest researcher, and another member of the research team so that the point of redundancy of the data was identified. Care was taken to keep data and interviewees confidential. Participants were coded in an alphanumeric manner according to the position held: teachers (T1, T2, T3…) and PC (PC1, PC2, PC3…).

Thematic content analysis, proposed by Bardin,[24] was adopted, using the following steps: reading, determining the registration units and meanings, coding, and classification. By fluctuating reading, the registration units were marked; they were organized by themes and by means of approximations and distance to construct categories of analysis.


   Results Top


In total, 221 educators participated in the research: 197 teachers in the “conventional education” and 24 PCs in the “problematizing education.”

The age of the teachers varied between 19 and 71 years, with a mean of 39 years (standard deviation [SD] = 10.6), and a predominance of females (91.4%; n = 180) occurred. The mean time teaching experience was 14 years (SD = 9.7). The age of G1 ranged between 31 and 62 years (mean = 46.5; SD = 8.1), with a mean time experience of 20.3 years (SD = 8). The age of those in G2 ranged from 31 to 53 years, with a mean of 39.6 (SD = 5.9), and the mean time experience was 17 years (SD = 5.3). In both groups of PCs, all were women.

For the teachers, 64.8% had not received any information on the theme of “dental avulsion,” which was reduced significantly, to 14.9% (P < 0.001), after the re-administration of the questionnaire. These results were not statistically different for G1 and G2 (P = 0.06). Furthermore, knowledge about what avulsion is increased significantly from 10.7% to 85.6% (P < 0.001) after “conventional education.” This finding was similar for PC, with P values of 0.04 and 0.004 for G1 and G2, respectively.

In sequence, [Table 1] shows the results of absolute and relative frequencies of the pre- and post-educational interventions, with questions aimed at understanding what dental avulsion is, and its etiological factors; [Table 2] exposes the procedures through tooth avulsion; [Table 3] exposes the conducts with the tooth in avulsion; and [Table 4] exposes the issues related to tooth reimplantation.
Table 1: Absolute and relative frequencies of the pre- and post-educational interventions applied to teachers and pedagogical coordinators regarding issues related to understanding the tooth avulsion

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Table 2: Absolute and relative frequencies of the pre- and post-educational interventions applied to teachers and pedagogical coordinators regarding issues related to the procedures through tooth avulsion

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Table 3: Absolute and relative frequencies of the pre- and post-educational interventions applied to teachers and pedagogical coordinators regarding issues related to conducts with the tooth in avulsion

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Table 4: Absolute and relative frequencies of the pre- and post-educational interventions applied to teachers and pedagogical coordinators regarding issues related to reimplantation in tooth avulsion

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When comparing the two assessments (pre- and post-reading intervention) concerning the correctness of each question, significant results (P < 0.05) were found for teachers, G1, and G2, showing an increase in 10, 7, and 5 correct answers to the 11 questions, respectively. The only question that did not follow this pattern for teachers was related to tooth-washing (P = 0.21) [Table 3]. For the G1, the questions that did not show significant increases in correct answers after the intervention (P > 0.05) were related to the definition of avulsion, etiology [Table 1], important procedures for good outcome of cases, professional referral, storage of the tooth, and possibility of reimplantation. In G2, the questions that did not show a significant increase were related to etiology, procedures favorable to prognosis, professional referral [Table 2], storage of the tooth [Table 3], transport [Table 3], and possibility of reimplantation [Table 4].

When comparing the evolution of responses (increase in correct answers) between groups of PC, no significant differences were found in any of the responses analyzed individually. Nevertheless, in relation to the number of correct answers before and after interventions, educational strategies did not significantly influence the results (P = 0.14).

For qualitative analysis, the core nuclei most often present in the dialogs were identified as security (feeling safe to provide care), acquired knowledge, transmission of knowledge, emotional control (keeping calm), following protocols, and raising parents' awareness. The educators' speeches were then grouped into thematic categories [Figure 2].
Figure 2: Nuclei of meaning present in the analyzed speeches and the representative speeches of each nucleus

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   Discussion Top


In the present study, it was hypothesized that different educational approaches would result in different levels of educators' knowledge regarding dental avulsion. Although an increase in knowledge has occurred, no significant differences between the strategies were found.

Avulsion is the complete displacement of a tooth out of its alveolus and is more common in young permanent teeth in which root formation is incomplete and for which the periodontium is very resilient.[25] Under these circumstances, even slight impacts can lead to tooth avulsion.[6] In this context, many traumatized teeth are lost or have an unfavorable prognosis due to the lack of information and unpreparedness of those who provide the primary care.[26]

Negative consequences can be minimized by increasing the knowledge about how avulsed teeth should be handled at the accident site.[27] Thus, it is important to investigate not only this variable and the actions but also to ascertain the influence that different educational approaches can have in this process. The results found in a study by Alves et al.[28] in elementary school teachers indicated that the majority of the interviewees did not have enough knowledge on how to proceed in cases of dental trauma.

In terms of the situations in which participants considered that tooth avulsion may occur, after reading the manual, an expressive increase occurred with the teachers. Conversely, in PC groups, a mix of answers was identified. It is noteworthy that the etiological factors involved in injuries include falls, traffic accidents, sports, and violence[5],[6],[7] and are common in young people.[2]

Concerning the approach required for obtaining a good result when treating avulsion, while teachers and G1 answered “calming the child” was the most important procedure in both pre-and post-educational phases, in the G2, in the pre-educational intervention phase, 33.3% considered that hemorrhage was containment. However, after the educational activity, this group showed the highest correct response rate, which is to find the avulsed tooth [Table 2]. The answer given to this question may have a bias, given that the manual used suggested a step-by-step process for reimplantation, and the first step indicated was to calm the child. This action is important, but not decisive for the success of reimplantation.

When asked about referral of cases to a professional, in all groups, the most responded “the dentist.” In a study by Berti et al.,[29] 81.57% of 76 respondents replied that they would take the patient to the dentist immediately after the trauma, in accordance with the present findings. The correct referral to a dentist is an important factor for the prognosis of avulsion, and in this context, a recent survey showed a lack of knowledge on this topic among medical students.[30]

In addition, other procedures, such as handling and preserving the avulsed tooth, are essential to preserve the cells of the periodontal ligament and the fibers inserted into the root surface.[6],[25],[31] It is recommended that the tooth is reimplanted as soon as possible by the patient or by a person.[6],[26] Thus, cleaning procedures before the reimplantation should aim to remove dirt, debris, and bacteria, without rubbing the root.[1],[9] In the present study, the results showed that reading the manual was not enough to establish correct procedures. Alves et al.[28] conducted an analysis with 138 teachers, and about 44% of them indicated that they would brush the tooth before going to the dentist.

Regarding the tooth storage medium during transport to the dentist, before the intervention phase, prevailed the answer “empty container/wrapped in paper or cloth” in all groups. However, the most correct approach, i.e. to keep the tooth in milk, increased after the intervention. These answers revealed that, initially, the worst action, which promoted dehydration and consequent necrosis of the periodontal ligament was elected. These findings corroborate other studies with teachers who point out these same inadequate conducts.[32],[33] The literature points out that the most important thing is to maintain humidity.[31],[33] The use of saliva, reported by a few individuals in the present study, is not indicated, since the placement of a tooth in the mouth, by the patient or by the parents, poses a risk for swallowing and cross-contamination.[31] Saline solution (0.9% NaCl) has an appropriate physiological pH and osmolarity but does not provide essential ions or glucose to the cell.[3] Thus, milk is considered the most suitable, because it is easily available and can maintain the vitality of the periodontal ligament as it has a basic pH and adequate osmolarity.[31],[34] Furthermore, in a school environment, milk is often part of the menu, which makes it an affordable choice for professionals.

Most teachers and PCs considered the possibility of reimplanting avulsed teeth at both time-points. When asked about the extra-alveolar duration, both had a low frequency of “I don't know” responses and considered “the shortest time possible” as correct. In the study by Alves et al.,[28] the majority (77.5%) of the educators answered that the ideal would be immediately after the trauma. Similar results were here found after interventions, when the participants pointed out that emergency care was essential in cases of avulsion.

As mentioned, the period between avulsion and reimplantation is considered extremely important for the prognosis.[1],[9] The appropriate care should ideally occur within the first 30 min.[1],[35] When the extra-alveolar period exceeds 60 min, the cells of the periodontal ligament undergo necrosis, which increases the probability of root resorption and failure of reimplantation.[9]

When asked about the positioning of the tooth in the case of replantation, 41.3% of the teachers replied that they did not feel capable of carrying out this task. After the intervention, this response was reduced to 26.9%. However, in the present study, after reading the manual, 66.0% of the teachers stated that they would place the tooth aligned with the flanking teeth. Repositioning the tooth in the correct way was confirmed by 100% and 83.3% in G1 and G2, respectively, after the intervention.

According to Hamilton et al.,[36] teachers do not reimplant an avulsed tooth because they do not have the knowledge or training for doing that, or because they fear of becoming infected or of hurting the child et al.,[27] in which teachers would not perform reimplantation because they had not received training, and they fear the risk of causing pain or frightening the child and of legal implications.

In the qualitative analysis, positive impacts of the educational activity were found when observing the representative speech nuclei that emerged from the analysis [Figure 2]. Although rare, some findings have been identified in the literature in terms of the qualitative analyses for assessing perceptions about dental trauma, but without involvement of the school environment and teachers, as in the present study. Kenny et al.[37] performed a study with semi-structured qualitative interviews to determine how parents had access to emergency care for their children after avulsion of a permanent tooth. The authors concluded that the qualitative approach provided a source of information on how parents perceived this type of care. Kayıllıoğlu Zencircioğlu et al.,[38] in a qualitative analysis of parents of children who had tooth avulsion, identified feelings of sadness and anguish after the event, as well as frustration and disappointment in relation to the service provided, in addition to self-perceived lack of knowledge about how to deal with tooth avulsion.

According to Chan et al.,[11] it is necessary to develop campaigns aimed at teachers, which promote an increase in knowledge regarding emergency care in cases of dental trauma. The authors even suggested that training should be incorporated into the teaching curriculum. The more comprehensive the curriculum related to promoting health at school, the lower the likelihood of dental trauma.[39]

Despite the lack of statistical differences between the educational approaches adopted in this research, it is important to emphasize the positive aspects of active teaching methodologies, which allow for more critical, motivating, and reflective analysis, which is a requirement for promoting meaningful learning.[40]

The potentialities related to this study derive from the interaction between theory and practice achieved here through the proposed activities. However, a prospective follow-up, with a longer interval after the interventions, could generate other evaluations with other outcomes, based not only on recent memory but also on the fixation of contents over time. Future studies may be carried out precisely in this perspective of temporal analysis. Finally, the development of protocols and more educational activities are positive strategies consistent with the subject presented and can be done in the future.


   Conclusions Top


The present study revealed that the level of knowledge of the education professionals surveyed regarding tooth avulsion is insufficient. From the perspective of professional qualification, both “conventional” and “problematizing” educational approaches promoted an increase in the correct answers to the questions in the research tool used. Thus, improving the knowledge and actions regarding dental avulsion in schools is necessary and should be encouraged.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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[Pubmed] | [DOI]



 

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