Knowledge And Attitude Of Medical Doctors Towards Emergency Management Of Avulsed Tooth- A cross sectional survey.

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1 Knowledge nd ttitude Of Medical Doctors owards Emergency Management Of vulsed ooth- cross sectional survey. Jyothi KN *, Venugopal **, Soumyaranjan Nanda #, Mahaveer kumar Shah #. bstract *rofessor and Head, ** rofessor, # ostgraduate Student. Department of Conservative dentistry and Endodontics, Sri Siddhartha Dental College. im- he purpose of the survey is to assess the knowledge and attitude of medical doctors working in Sri Siddhartha medical college, umkur, towards emergency management of avulsed tooth. Materials and methods Study design cross sectional survey. 70 medical doctors were randomly included in the study and the participation was voluntary. Data regarding the emergency management of avulsed tooth was collected using a self administered questionnaire having questions which were close ended. Results 78.5% of the participants knew the correct meaning of avulsed tooth. Majority of the participants had fair knowledge regarding the handling of avulsed tooth. 51.4% of participants felt that the milk is the best media to preserve the avulsed tooth where as others preferred water or saline. here was divergent openion regarding the critical time for replantation of tooth. 91.4% of the participants preferred to refer the patient to the dentist. Only 5.7% would attempt to replant the tooth confidently. Conclusion he knowledge of medical doctors about avulsion of tooth was although fair none were found to provide first aid. t is the responsibility of the dentists to make them aware of the importance of first aid for avulsed tooth with appropriate measures. Key words vulsed tooth, Replantation, Knowledge and ttitude, Emergency management. Journal of Dental Sciences & Research 2:1: ages

2 ntroduction vulsion is the total dislodgement of an intact tooth from its socket. ccording to ndreasen and ndreasen, avulsion of permanent teeth accounts for approximately 0.5 3% of all dental trauma. he peak age for avulsion is between 7 to 9 years and mainly involves maxillary anteriors. Losing an anterior tooth at an young age may have severe psychological consequences. he immediate replantation of a permanent avulsed tooth is essential to restore the function and esthetics and critical for long term success of the treatment. vulsion presents a challenge with regard to its proper emergency management. he principal challenge is to maintain the vitality of periodontal cells, as prognosis of a replanted tooth is directly proportional to the viable periodontal cells. Use of physiological storage media like milk, saliva or saline is critical to maintain the viability of periodontal cells until professional help is obtained. (1) ooth avulsion mainly occurs during sports, physical violence, road traffic accidents, fall and other physical impacts. Many patients with avulsed tooth visit medical doctors due to lack of awareness or unavailability of a dentist. o ensure proper and appropriate management of the avulsed tooth, it is essential that medical professionals have sufficient knowledge on the emergency management (2). Various surveys conducted on the medical professionals showed lack of adequate knowledge (2,3,4). Our search of the available literature revealed only few studies from other countries (2,4,5) and only one study from ndia (3). So the purpose of this study is to assess the knowledge and attitude of medical doctors working in Sri Siddhartha Medical College, umkur towards emergency management of an avulsed tooth. Materials and Methods he present study is a cross- sectional survey. total of 70 medical doctors were included in the study, of which 26 were staff, 24 were post graduate students and 20 were interns. he participation in the study was voluntary and strict confidentiality was assured to the participants. he data was collected by distributing a self designed questionnaire consisting of 14 questions. he questions were

3 closed ended and were self administered. he questionnaire was divided in to two parts, the first part included information regarding the personal data. he second part was so framed that the knowledge and attitude of medical doctors could be assessed regarding the emergency management of avulsed tooth. QUESONRE 1) Name :- 2) ge :- 3) Sex:- 4) Qualification:- 5) Designation:- 6) Department 1) What is avulsion of tooth? a) otal dislodgement of intact tooth out of its socket, due to any trauma b) Dislodgement of fractured segment of the tooth due to any trauma c) Don t know 2) Do you have any prior knowledge about the management of avulsed tooth? a) Yes b) No 3) f yes what was your source of information? a) CDE program b)health talks on television or radio c)conference/convention d)during the tenure of Medical coarse d)others 4) Have you ever come across a patient with avulsion of tooth? a) Yes b) No 5) What will be your suggestion? a) Contact own dentist b) Wet the tooth

4 c) Dry the tooth d) Discard the tooth saying it is of no use 6) n case if immediate professional care is not available and the tooth needs to be preserved, then what would be the best medium selected to preserve the tooth? a) Water b) Saline c) atients saliva d) Milk 7) How long after the tooth has been knocked out would it be possible to replant the tooth when kept in wet condition? a) < ½ hrs b) < 2hrs c) < 6hrs d) Don t know 8) What will be the ideal time for re implanting the tooth? a) 15 mins b) 30 mins c) 45 mins d) 1 hrs 9) magine you are contacted by the mother of a boy who has knocked out one of his top front teeth playing football. What further information would you request from the mother? a) Loss of consciousness b) Breathing problems c) Other injuries d) ast medical history 10) f you were at a site where someone knocked-out a tooth, you would a) Not take any action b) Not take action because of the medico-legal consequences c) Be confident and replant the tooth

5 d) Refer the patient to dentist 11) You found the knocked-out tooth and it is dirty, will you a) Wipe the tooth with a tissue paper b) Clean the tooth with a tooth brush c) Rinse the tooth gently under running tap water for a few seconds without scrubbing it. d) No need to clean the tooth because it is useless 12) How would you hold the tooth during cleaning? a) From the crown b) From the root c) ny where (crown or root) 13) Can you differentiate if the tooth is primary or permanent? a) Yes b) No 14) Would you care if the tooth that has been knocked-out were a primary tooth? a) Yes b) No RESULS Some important observations are presented with the help of bar graphs. 78.5% of the participants knew the correct meaning of avulsed tooth. 10% of the participants thought avulsion as the dislodgement of fractured segment of the tooth and 11.5% did not know the meaning. 68.5% of the participants did not have the prior knowledge about the management of an avulsed tooth. 17.4% had received information during the medical course. 22.8% of the participants had come across patients with avulsed tooth. 80% of the participants would suggest the patient to consult the dentist in case they come across a patient with avulsed tooth.

6 51.4% of the participants preferred milk to preserve the tooth in case professional care is not possible immediately, where as 25.7% preferred water, 35.7% preferred saline and 7.14% preferred patient s saliva. 25.7% of the participants felt the tooth should be replanted with in half an hour, 27.14% felt replantation possible with in 2 hours, 17.13% thought replantation possible with in 6 hours, where as 30% did not answer. 32.8% felt the ideal time for replantation is 15 minutes, 42.8% felt 30 minutes. nother 15% prefer 45 minutes and 9.4% as one hour. 91.4% of the participants prefer to refer the patients to the dentist even if they are present at the site of injury. Only 5.7% replant the tooth confidently % of the participants felt that the tooth should be rinsed gently under running tap water for few seconds if the tooth is dirty, with out scrubbing. 72.8% prefer to hold the tooth by crown. 74.2% can differentiate the permanent tooth from a deciduous tooth. 62.8% would not care if the tooth is deciduous. DSCUSSON his survey provided baseline information about the existing level of knowledge on the emergency management of avulsed tooth among medical doctors working in S.S.M.C, umkur. majority of the participants knew the correct meaning of avulsed tooth. 68.5% of the participants had no prior knowledge regarding management of avulsed tooth and only 17.4% had received information during their tenure of medical course. 91.4% of the participants preferred to refer the patient to the dentist. his may be because they felt that the dentist can manage the situation better. However prognosis of an avulsed tooth is greatly enhanced by immediate and appropriate measures taken preferably at the site of injury. 25.7% of the participants suggested water as the storage medium for avulsed tooth. Watbecause of it s hypotonicity will adversely affect the vitality of the periodontal ligament cells leading to rapid cell lysis.(6) Some participants preferred saline or milk as storage media. Saline has been shown to be a short term storage media because of its physiologic osmolarity. Cvek

7 etal found that the avulsed teeth that were soaked in saline solution for 30 minutes before replantation showed less root resorption than those stored dry for minutes. (7) Only 7.14% of the participants preferred saliva as storage media. Saliva is found to be more effective than tap water (8) and the tooth can be easily carried by the patient keeping in the buccal vestibule. But saliva has a potential for bacterial contamination. he osmolarity of saliva is m osm/ltr much less than the normal range ( mosm/ltr) required for cell growth.(9) Blomlot et al has shown increased root resorption in avulsed tooth when stored in tap water or saliva.(10) ndreason favours milk as a storage medium as it maintains vitality of periodontal ligament cells upto 3 hours.(1) he osmolarity of milk is 232 mosm/l (11) Gamsen etal has shown that milk is able to maintain the osmotic pressure of periodontal ligament cells, but does not have the ability to reconstitute cell metabolites and restore viability. (12) here was divergent openion among the participants regarding the ideal time for replanting the tooth. ccording to ndreason and Hjorting, teeth that are replanted with in 30 minutes have a better success rate than those that were extra oral for longer periods of time before replantation..(13) Most of the participants were aware that the tooth should be held by crown and cleaned gently by running tap water to avoid damage to the DL cells. 63% of the participants said that they would not care if the deciduous tooth is avulsed. Deciduous teeth should not be replanted as it may injure the developing permanent tooth bud.(1) he over all observation from the survey was that nearly majority of the participants from SSMC, umkur had fair knowledge regarding the management of avulsed tooth, but preferred to refer the patient to the dentist without providing first aid. Only 5.7% would attempt to replant the tooth confidently. n a recent study by Krishnaraj Subhashraj, from podicherry, ndia, it is observed that only 5.5% of the medical professionals would attempt replantation of the avulsed tooth and majority of the participants felt that dental trauma should ideally be managed by a dentist (3). his is much similar to our observation in the present study. One study from Kuwait by Maha bu Dawoud showed

8 that 83.3% of the young physicians had no knowledge on the emergency management of an avulsed tooth (2). nother study by. Walker on medical doctors working in pediatric and accident & emergency department in St. James hospital US showed that 67% of them had no knowledge regarding emergency management of avulsed tooth (4). ll this studies stressed the importance of educating the medical doctors regarding the emergency management of avulsed tooth. Hence Hand outs containing simple guide lines for the emergency management of avulsed tooth were prepared as per the recommendations by nternational cademy of Dental raumatology (14) and distributed to all the medical doctors working in SSMC, umkur. he following recommendations can be suggested to enhance the knowledge of the medical professionals in general. a) Medical doctors who work in hospitals with emergency setting should receive simple instructions about dental first aid. b) Educational campaign should be conducted to broaden the knowledge of medical personnel about emergency management of dental trauma. c) he existing health education system should provide more courses on dental and dentofacial trauma management for medical doctors and interns. d) Medical undergraduates should be engaged in interdisciplinary seminars, case discussions and clinical postings in dental or oral and maxillofacial departments CONCLUSON From the survey conducted many of the participants showed a fair knowledge on the emergency management of an avulsed tooth and their dilemma pertaining to some aspects of this procedure can be solved by providing required awareness and knowledge. s medical doctors form a vital link between the patient and the dentist they need to be educated on emergency management of avulsed teeth.

9 Fig 1. Response of the participants on the ideal transport media R C N S Response of the participants on the ideal time for replantation % 27% Water Saline atient saliva Milk 7% 41% Fig 2. Response of the participants on the ideal time for replantation R C Response 35 of the participants on the course of their action if present at the site N of accident 30 S Response of the participants on the method they would use to clean the tooth Response of 15 the mins participants 30 on mins the method 45 they mins would used 1 to hr clean an avulsed tooth if found dirty

10 Fig 3. Response of the participants on the course of their action if present at the site of accident R C N S % 1% Not take any action 5.7% 91.4% Not take any Be confident and Refer the patient action because of replant the tooth to dentist medico legal consequences Fig 4. Response of the participants on the method they would used to clean an avulsed tooth if found dirty R C N S % Wipe the tooth with a tissue paper Clean the tooth with a tooth brush 77 % Rinse the tooth gently under running tap water for a few seconds without scrubbing it 14 % No need to clean the tooth because it is useless

11 REFERENCES 1. ndreason JO, ndeasonfm. vulsions. n:ext book and tlas of traumatic injuries to the teeth. 4 th ed. Blackwell and Munksgaad; bu Dawoud M, l Enezi, ndersson L, Knowledge of emergency management of avulsed teeth among young physicians and dentist. Dental raumatology 2007; 23: Krishnaraj Subhashraj, wareness of management of dental trauma among medical professionals in ondicherry ndia. Dental raumatology 2009; 25: Walker, J Brenchley, t s a Knock out: Survey of the management of avulsed teeth. ccident and Emergency nursing 2000; 8: lastair N Stokes, Heather K nderson, ony M Cowan, Lay and rofessional Knowledge of method for Emergency management of avulsed teeth. Dental raumatology 2008; 24: rope M, Friedman S. eriodontal healing of replanted dog teethstored in Viaspan, milk and Hank s balanced salt solution. Endod Dent raumatol. 1992;8: Blomlof L, Otteskog, Hammarstorm L. Effect of storage in media with different ion strengths and osmolalities on human periodontal ligament cells. Scand J Dent Res. 1981;89: Van Hassel HJ, Oswald RJ, Harrington GW. Replantation 2: he role of periodontal ligament. J Endod 1989;6: Lindskog S, Blomiof L, Hammerstorm L. Mitosis and microorganismin the periodontal membrane after storage in milk and saliva. Scand J Dent eriodont 1983;91: Blomlof L. Milk and salivaas possible storage media for traumatically exarticulated teeth prior to replantation. Swed Dent J 1981;8: oby homas, Velayutham Gopikrishna, Deivanayagam Kandaswamy. Comparative evaluation of maintainance of cell viabilityof an experimental transport media coconut water with Hank s balanced salt solution and milk, for transportation of an avulsed tooth: n in vitro cell culture

12 study. J Conserv Dent 2008;11: shkenazi M, Saranath H, Keila S. n vitro viability, mitogenicity and clonogenic capability of periodontal ligament cells after storage in six different media. Endod Dent raumatol 1999;15: ndreason JO, Hiorting Hansen E. Replantation of teeth :1, Radiographic and clinical study of 110 human teeth replanted after accidental loss. cts Odontol Scand 1966;24: Flores M, ndreason L, ndreason JO, Bakland LK, Maimgren B, Barnett F et al. Guidelines for management of traumatic dental injuries. vulsion of permanent teeth. Dent raumatol 2007;23:130-6.

Original Article. Introduction. Toby Thomas, Velayutham Gopikrishna, Deivanayagam Kandaswamy

Original Article. Introduction. Toby Thomas, Velayutham Gopikrishna, Deivanayagam Kandaswamy Original Article Comparative evaluation of maintenance of cell viability of an experimental transport media coconut water with Hank s balanced salt solution and milk, for transportation of an avulsed tooth: