Knowledge levels and attitudes of teachers towards traumatic dental injuries - A systematic review of literature.

Transcription

1 Knowledge levels and attitudes of teachers towards traumatic dental injuries - A systematic review of literature. Group- C Authors: Ambili Sandeep, Elena Marcarian, Magdalena Iacob, Parviz Roshanzamir Tabary, Rania Salih, Sayeh Jabehdar Wasan Al-saadi. 1

2 ABSTRACT Aim: The objective of this systematic review is to evaluate the knowledge levels and attitudes of schoolteachers towards dental trauma as well as to identify the factors that influence their responses when attending to a traumatized tooth. Methodology: A comprehensive search was conducted on Pub Med using a predetermined search strategy. Inclusion and exclusion of articles were based on specific criteria and limits. The articles retrieved this way, were critically appraised by at least two members of the group independently and scores assigned. Articles with a score above a set base value were selected for the evidence based review. Results: A total of 69 articles were screened and reviewed in a structured manner. Eight articles relevant to the study objective were included in the evidence based report. The review is based on individual cross-sectional studies conducted outside Canada. Recommendations/Conclusion: All the studies reviewed in this assignment described a gross lack of knowledge of the teachers regarding TDI management Strategies to enhance the teachers' knowledge about TDI should take into consideration the results of this review Key Words: Knowledge, Health Knowledge, Attitudes, Practice, Dental Education, First Aid, Questionnaires, Traumatology/Education Tooth Avulsion, Tooth Fractures, Tooth Injuries, Accidental Falls, Athletic Injuries, Dental Trauma, Child, Faculty, Caregivers, Teaching, and Teachers. 2

3 Introduction Traumatic dental injuries(tdi)are highly prevalent from infancy to adolescence and are becoming an important public health concern. Injuries to dentition are overtaking caries and periodontal disease as the most encountered dental problems in children. 1, 2 Dental trauma - due to the high sensitivity of oral tissues- is a painful injury and affects one s wellbeing regardless of age, gender or other factors. According to the Medical Encyclopedia, it is classified as an injury to the mouth, including teeth, lips, gums, tongue and jaws. Dental trauma may be inflicted by sports, accidents, fights, falls, hard food or hot liquids. Classification of TDI according to the National Guideline Clearinghouse (www. guideline.gov) and based on the information provided by the American Academy of Pediatric Dentistry (2007, p14) includes: infraction, crown fracture (complicated/ uncomplicated), crown/root fracture, root fracture, concussion, subluxation, lateral luxation, intrusion, extrusion and avulsion. According to the World Health Organization (WHO) dental injuries- modified by Dr. Andreasen to clarify variations of luxation and intrusion classification- were reduced to 6 classes only, excluding intrusion, extrusion, infraction and concussion. A traumatic dental injury is an event with many consequences; physiological, psychological, financial and can significantly affect the quality of life of parents and child alike 3. All articles reviewed expressed a common concern: traumatic dental injuries are on the rise and there is an urgent call to address TDI occurrences and deal with them systematically, according to a plan. Prevalence rates in a number of studies worldwide revealed that TDI s are very common in children with some studies reporting a rate of up to 35% 4. Locker, (2005) reported a prevalence of 18.5% to permanent incisors of grade 8 children from 6 Ontario communities 5. Lawrence and Locker, (2008) also reported a mean age of the occurrence of TDIs to be 9.5 years. 6 Previous literatures identifies that a significant number of school aged children experience trauma of some sort to primary or permanent dentition 7. Most incidences happen during school time where the primary care giver is a teacher, or other non-medical personnel 8. Reports also show, in some instances that more than half of the children interviewed are affected by TDI s in school 9. Andersen and Mercenes (2007), report that TDI s affect one in five school aged children. 10. Literature has evidenced that up to 25% of these injuries are serious in nature 11. Marcenes and Ryda, (2007), reported that the consequences of a TDI in relation to a child s oral health are much greater in nature and they can leave a permanent imprint on one s well-being and quality of life 3. Alongside the functional, physiological and psychological factors that affect a child with a TDI the financial burden a mismanaged TDI can bear on the future of a child is also worth noting. Costs to improve the quality of life after a TDI can be significant and can influence the decision making process of a parent or child 13. These are the most encountered reasons why previous research suggests the need for a formal TDI management model. Since most TDI s occur during school time 14, it follows that suitable and timely action is imperative to the long-term prognosis of an affected child by a teacher or school staff member 15. All previous research focuses on prevalence rates in schools or at home 3

4 suggesting that schools are the prime locations where preventative management strategies should be implemented. It follows that teachers would require a well thought TDI management model, perhaps similar to or in conjunction with a first aid program. That model should include timely emergency procedures as well as suitable storage methods, all in an effort to secure a better result clinically. The purpose of the present systematic review is to assess the knowledge levels and attitudes of schoolteachers toward dental trauma and to identify the factors that influence responses of teachers to an emergency call of a traumatized tooth. Knowledge levels in teachers and their attitudes toward treating a TDI stand at the base of the development of an accurate management model. Materials and Methods The present review followed a structured approach and the steps were as follows: Stage 0 Development of a review protocol Level I Defining the scope of the review Level II Method of gathering and screening articles Level III Selection of Checklist Stage 1 A Strategy for Literature search. Stage 2 Stage of Screening. Stage 3. Critical appraisal of the articles. Stage 4 Creating the Evidence Table. Stage 5 Evaluation of the Outcome. Stage 0. Development of a review protocol A master plan was drawn to establish the scope of the review, the methods of gathering and screening articles and to develop a checklist for critical appraisal. This was achieved in three phases namely Level I, II and III with group consensus. Level I - Scope of the Review Our research objective was set to evaluate the knowledge and attitude of schoolteachers towards dental trauma and to identify the factors that influence the competency based response of teachers to emergency management of traumatized teeth. Since traumatic injuries are quite common in active young children*, the preferred target population for the review was determined as preschool teachers, elementary school teachers, physical education teachers, teachers with or without formal training in dental first aid. Following this, the variables that we were trying to measure through the review were grouped as knowledge, attitude and experience of teachers with regards to TDI as well as the factors that influence the dental knowledge of 4

5 teachers regarding dental trauma. Level II - Method of gathering and Screening articles Electronic search was chosen as the medium for gathering articles and a set of predetermined written inclusion and exclusion criteria was developed to screen the articles. The inclusion and exclusion criteria are as follows: Inclusion criteria: i. Cross sectional studies that meet our research objective. ii. Surveys with best accepted data collection instrument and methods iii. Articles with a representative sample and a high response rate from the study participants. Exclusion criteria. i. Unethical studies ii. Studies that target the knowledge of parents and layperson with regards to TDI. iii. Studies that target dental injuries outside school environment. iv. Studies that lacked internal validity. Level III- The checklist The most suitable checklist for our study was selected and obtained from the Evidence Based Manual compiled by the Faculty of Community Dentistry, University of Toronto. We chose the Checklist to Assess Evidence of Prevalence and Incidence (Descriptive or Longitudinal Studies for our review. The checklist was slightly modified by omitting 2 questions that were not applicable to our review. The checklist comprised of 10 questions and cut off point for critical appraisal was set at 8.The checklist used is affixed to the report as Appendix A. Stage 1: A strategy for Literature search The literature search commenced with an electronic search of the database MEDLINE (PubMed). We don t defer the fact that other databases may also contain information of interest but we chose to limit our search to single database as it is well known that PubMed is the first choice when publishing articles in dental traumatology. So the quality of the review could be considered as sufficient. The key words used in this review are Knowledge, Health Knowledge, Attitudes, Practice, Dental Education, First Aid, Questionnaires, Traumatology/Education Tooth Avulsion, Tooth Fractures, Tooth Injuries, Accidental Falls, Athletic Injuries, Dental Trauma, Child, Faculty, Caregivers, Teaching, and Teachers. The search ensued with the use of MESH and non-mesh terms as detailed in the following table. 5

6 Search History and Criteria Keywords: "Knowledge"[Mesh] OR "Health Knowledge, Attitudes, Practice"[Mesh] OR "Comprehension"[Mesh] OR "Awareness"[Mesh] OR "child, preschool"[all Fields] OR "Education, Dental"[Mesh] OR "First Aid"[Mesh] OR "Aptitude"[Mesh] OR "Questionnaires"[Mesh] OR "Traumatology/education"[All fields] OR "Understanding"[TITLE]) AND ("Tooth Avulsion"[Mesh] OR "Tooth Fractures"[Mesh]OR "Tooth Injuries"[Mesh] OR "Accidental Falls"[Mesh] OR "Athletic Injuries"[Mesh]OR "Athletic injuries/epidemiology"[all fields] OR "Dental Trauma"[All Fields])AND ("Faculty"[Mesh] OR "Caregivers"[Mesh] OR "Teaching"[Mesh]OR "Teachers"[All fields]) Number of Articles 71 Search limited to English 64 Search limited to Humans 62 Relevant articles at Title stage 21 Relevant articles at abstract stage 8 Relevant articles at fullcopy stage 8 Articles selected for critical appraisal 8 Stage 2: Screening. We chose a three tier screening process to retrieve relevant articles for the review. At least two independent reviewers screened the results of the search at each step. Firstly, the articles were screened at the Title level. Secondly, the articles were screened after reviewing the abstract. Lastly, a full text reading of the relevant articles was done to evaluate if they meet the preframed selection criteria. The number of articles retrieved in each phase of screening is detailed in the above table Stage 3: Critical appraisal of articles The final selections of the articles were made on the basis of critical appraisal. We chose the Checklist to Assess Evidence of Prevalence and Incidence (Descriptive or Longitudinal Studies as described in the stage I of the methodology. Two independent reviewers critically appraised each article and the scores were assessed. It was decided that a third person reviews 6

7 the article if there is any disparity among the individual scores of an article so that an agreement is reached on the score between at least two reviewers. In our study, there was 100% consensus among the reviewers regarding the critical appraisal score. Each article met the cut off score and none of the articles were excluded at this level. Stage 4: Creating the evidence table. An independent assessment tool was created to the grade the level of evidence from each individual study in this review. Group consensus was obtained to rate each articles as good, fair and poor on the basis of critical appraisal score. The following grading criteria were established: A score in the range of 8 to 10 A score in the range of 5 to 7 Any score below 5 Good level of evidence. Fair level of evidence. Poor level of evidence. Evidence table was created for eight articles in this review. (Appendix Stage 5: Evaluating the Outcome. At this stage, results from each of the studies were recorded in tables. The Outcome of Interest followed by the reviewers were the knowledge levels and attitudes of school teachers towards TDI and experience of teachers with regards to management of dental injuries such as tooth fractures and dental avulsion. Factors that influence the dental knowledge of teachers regarding dental trauma were also considered. Results Having set the cut-off point of 8/10 as the final inclusion criteria, eight articles have been drawn for final review and analysis. All of the studies looked into two frequently encountered dental trauma emergencies and their related management, tooth fracture and tooth avulsion. Some gave 16, 17, 18, and 23. a report on attitudes toward TDI management as well Management of tooth fracture Generally, the knowledge level of school teachers with regard to management of tooth fracture was better as compared to tooth avulsion. Sae-lim et al. (2001) reported that 51% of teachers were assessed knowledgeable; whereas Mohandas U et al (2009) found 81% of those with previous physical education training and 25% of those without the training were correct with regard to questions addressing this issue. Mesgarzadeh et al. (2009) found 52.4% of teachers to be well informed on how to manage a situation involving tooth fracture. Feldens et al (2010) stated that 22.5% of school teachers in their study had completely inadequate knowledge of tooth fracture and avulsion management. 7

8 Management of tooth avulsion Overall knowledge of school teachers was assessed to be grossly deficient in this field. Their awareness shown in Mohandas et al. (2009) was assessed as low as 1.5% and awareness in Al- Jundi et al (2005) was 1%. The other studies found to be 17.5%, (Chan et al., 2001); 71%, (Sea- Lim et al., 2001) and 50.6% (Megarzadeh et al., 2009), to be knowledgeable of tooth avulsion management, although the latter study mentioned that teachers were not informed of correct procedures. C.Blakytny et al. (2001) found 27.7% of teachers were not aware that avulsed teeth can be saved and 74.5 % were not confident to replant an avulsed tooth. McIntyre et al (2008) stated that 87% of teachers were comfortable saving the tooth and taking it to a dentist, whereas initially 44% would not replant the tooth. As in many cases, management of these situations involves storage of the avulsed tooth until the appropriate treatment is ready to be performed and school teacher s knowledge with respect to this issue was assessed in details. There has been wide range of responses to questions addressing this issue. Chan et al. (2001) and Sea-Lim et al. (2001) found 15% of teachers knowledgeable of the appropriate medium. The detailed responses of teachers in various studies are reported in Table 1 below. Table 1: Teachers and responses to TDI management Fist choic e of HBSS First choic e of milk Wate r Replantin g the teeth Norm al saline Handkerchi ef Child s cheek No knowledg e Mohandas _ % et al. % % McIntyre et % 6% 29% al. % Mesgarzade 31.8 _ % h et al. C. Blakytny _ _ Mesgarzadeh et al (2009) found 38% of teachers knowledgeable on the subject of proper washing mediums prior to re-plantation and the results for the study done by C.Blakytny et al (2001) are as follows: 41.6 % rinse under running water 7.7 % get the child to suck the dirt 23% do not clean 22% not sure 2.2% scrub Stage of teeth development of children is determinant of proper dental trauma management and teacher s knowledge with regard to this issue is assessed in some studies. Al-Jundi et al. (2005) and Mohandas et al (2009) found 40% respectively 17-25% of teachers knowledgeable of permanent teeth eruption timing. 8

9 Teacher s knowledge on basic growth pattern of dentition As the stage of dentition development is an important factor in determining the right emergency management, this issue has been addressed in some studies and the teacher s level of knowledge are reported as follows: 40% of teachers knew the timing of permanent teeth eruption. Al-jundi et al % of teachers with formal physical training and 17% of teachers without formal physical knowledge possess tooth identification knowledge. Mohandas U et al.( 2009). Moreover, 47% of teachers recognized the anterior teeth of an eight year old child are permanent. Chan et al. (2001). Previous experience and prior advice on management of TDI In some of the studies these two variants have been assessed and statistical analysis performed to determine if they have any effects on teacher s knowledge and attitude. Al-jundi et al. (2005) stated that 46% of teachers had first aid training. Of these 46%, 10% had received advice on dental trauma emergency management, but this had no effects on their TDI management knowledge. In the study done by Chan et al. almost 100% of teachers received first aid training and of those, less than 10% had received prior advice on TDI management. Again, this had no significant effect on their knowledge. Mohandas u et al. (2009) and C. Blakytny et al. (2001) have not found any meaningful correlation between previous TDI experience and TDI management knowledge, but Sea-Lim et al.(2001) stated that 24% of their study population had previous experience of TDI which had affected positively their knowledge of TDI management. Are ages, sex, and educational profile and experience determinants of teacher s knowledge in emergency management of dental trauma? In some of the studies reviewed here these factors have not been controlled or statistically analyzed to determine if they are influential or not. However Al-jundi et al. (2005) and Chan et al. (2001) found these not are factors affecting teachers awareness and attitude toward dental trauma management. Feldens et al. (2010) stated that the probability of complete inadequate knowledge regarding dental fracture and avulsion is 55% higher in males, 2 times higher in less experienced and 4 times higher in teachers without graduate degree. Mohandas et al. (2009) reported teachers with formal physical education training are more informed of proper management. Sea-Lim et al. (2001) found a positive correlation between duration of teaching and self-assessed knowledge of teachers regarding TDI management. Mesgarzadeh et al. (2009) also found that health teachers and those with higher education and experience were significantly more knowledgeable regarding tooth avulsion management. Total TDI knowledge score: McIntyre et al. (2008) employed this measurement to assess the total knowledge of school staff regarding dental trauma management and the results are as follow: 9

10 100% of teachers and teachers assistants scored 64% or less, whereas 100% of nurses scored 82% or 100%. In real numbers, their findings suggest that if 100 schools were to suffer an avulsion in the school environment, all would likely lose the tooth because of TDI mismanagement. Discussion By evaluating the results of 8 studies the present systematic review assesses the awareness levels and attitudes of school caregivers towards Traumatic Dental Injuries (TDI). While in some studies the aim was to evaluate and measure teacher s levels of understanding, preparedness and response, others simply identified factors associated with teachers knowledge of TDI s. As well, some studies reported well on the attitudes of the school teachers towards TDI management. All eight studies reviewed were cross sectional in method and employed questionnaires. Cross sectional studies offered several strengths to the review such as the wide spread quality of the results and the ease of comparison between variables. All eight studies reviewed showed gross lack of knowledge of teachers and other school staff regarding TDI management Although there are some studies that emphasized dental trauma as a whole, all studies focused on dental fracture and avulsion and their related management. As well, the teachers attitude toward management of dental trauma was reported in 4 out of 8 studies reviewed. Mesgarzadeh et al, (2006) concluded that teachers educational background is significant when related to a kind of outcome level in dental trauma management as did the others and suggest that hiring well educated teaching staff a school board can decrease the number of long term consequences in dental trauma. Future studies should have a more in depth look at education levels of staff and TDI incidence in school settings. If this correlation continues to be significant, it only goes to show that school boards and parents alike should demand teaching staff with the highest level of education possible. Teaching experience 16, 17, 23 along with previous dental trauma experience was also a factor that positively correlated with proper dental trauma response. This finding implies that teaching experience and previous dental trauma experience increases the confidence of a teacher to act immediately. Prompt and effective action on a traumatized tooth significantly increases the likelihood of a positive treatment outcome. While this result is positive, not all studies support those mentioned above. Chan et al. (2001) for instance, reported that he didn t find a meaningful correlation between teachers knowledge and previous TDI experience. The paper also pointed out that one reason why their study did not find significant relationships between experience and dental trauma management is due to the sample selected. The sample was defined inappropriately and it did not allow a fair comparison between groups of teachers with different teaching experience. The probability of having complete inadequate knowledge of TDI management was found to be 55% higher in males 16 and female participants were significantly more knowledgeable when it came to the growth patterns of children s dentition 23. Moreover, educational background and 10

11 formal training in first aid were also positively correlated to knowledge and attitudes toward TDI management. 19,23. These findings go to show that females, thanks to their nurturing ways, may remember more and act better when it comes to a dental trauma in a child. Furthermore, it shows that training can be retrieved and can help manage a TDI properly. School staff knowledge about dental injuries is shown to be inadequate in all studies reviewed. While it is generally accepted that the role of the teacher is extremely important in managing a traumatic dental injury, none of the studies reviewed showed a significant number of teachers were prepared to deal properly with a TDI. Teachers and school managers attitudes toward the management of TDI While all studies reported various correlations between teachers knowledge and various variables such as education level, understanding or previous trauma experience, all studies showed an overwhelming desire for improvement and education on a continued basis. Teachers attitudes toward re-implantation, storage methods, transportation mediums varied, as did the attitude toward having to perform any of the aforementioned tasks. It is important to note that answers are mixed when it comes to desire for more knowledge. In fact, although grossly outnumbered, there are still school managers who believe that it is not the duty of a teacher to offer dental trauma care.there is a significant want among teachers to know more on the topic. Some feel that dental trauma education should be included in a first aid course and some also underline the need for education on a continued basis. Effects of educational interventions on school teacher s knowledge of TDI management Overall TDI knowledge has been demonstrated to be grossly insufficient and several papers have recommended the establishment of educational campaigns to improve this deficiency. Researchers addressed this issue and assessed teachers knowledge prior and after provision of educational measures or they compared them to those who have not received such instructions. These educational means ranged from lectures to pamphlet and have been proven to be a positive measure in increase of teacher s knowledge and awareness of TDI management. As cited in Holan G et al. (2006) the effects of these educational campaigns transcend the population who attended or received the instructions and demonstrated a great contamination effect. The table below lists four articles that present 4 different types of interventions although excluded at various levels and based on various criteria, they are presented with pre and post intervention outcomes and final conclusions and recommendations. 11

12 Author Lieger O et al Type of intervention Educational posters Outcome prior to intervention / in control group 72.1%,84% and 54%knowledgeable regarding dental fractures, luxation and avulsion respectively Outcome Following intervention / in trial group 78.9%,87% and 71%knowledgeable regarding dental fractures, luxation and avulsion respectively Conclusion And recommendations Positive effect of educational campaigns. Should encourage the professionals in this field to embark on similar projects McIntyre JD et al Al-asfour A et al 2008 Holan G et al Pamphlet and lectures short lecture dental seminar presented by dental faculty Average total TDI knowledge of 8.5 to 9 Knowledge level assessed 39% for tooth avulsion general knowledge,8% avulsed teeth,5% how to clean avulsed teeth,1% importance of extra alveolar time,4% suitable medium 16 % correct answers regarding dental avulsion Average total TDI knowledge of 9.5 to 10 Knowledge level assessed 97% for tooth avulsion general knowledge,71% avulsed teeth,93% how to clean avulsed teeth,74% importance of extra alveolar time,86% suitable medium 68% correct answers regarding dental avulsion (regardless of attending seminar) 69% correct answers among those who attended the seminar,66% correct answers among those who did not the seminar Positive and statistically significant change in TDI knowledge score of intervention group A lecture followed by discussion proved to be an effective and efficient method of intervention to enhance the knowledge level of teachers so that proper dental first aid procedures can be achieved. Overall there was an increase in knowledge after the seminar but the result was regardless of attending the seminar which indicates the contamination effect of the educational seminar. Despite the improvement,the level of the knowledge after the campaign remained low and more public health promotion efforts are indicated Conclusions: 12

13 1. While there are studies which identified professional experience, level of education, first aid training as factors associated with the different levels of TDI awareness and management in teachers 16 there are others that found teachers to be reluctant to intervene. It seems they find themselves unprepared and also sometimes unwilling to attend to a traumatized tooth All studies encourage some form of education or proper dental trauma management training and it is unanimously recognized that timely, correct management in the early stages provides the best prognosis for a traumatized tooth While some studies provide evidence that gender positively correlates with levels of one s knowledge towards dental trauma 8, it is still not clear how relevant these correlations become when it comes to willingness to re-plant an avulsed tooth or preparedness to act. It is generally accepted that the gender differences in relationship with actions towards TDI are related to the types of experiences women have as mothers/caregivers. There are many implications of the current review. Perhaps the most relevant, is the need to integrate a program that teaches TDI management in schools. Future studies should look at the consequences of interventions such as lectures, pamphlets or posters on the awareness and attitude levels of teachers. The level of introduction can be studied further as opinions differ. Some may think that a teacher is sufficiently occupied in his/her quest to educate and may not need an increase in his/her responsibilities. Others will continue to believe that it is the duty of a teacher to be involved in TDI management workshops because he/she is the prime care provider after the trauma occurred. Future studies may want to separate teachers knowledge levels from teachers attitudes; nonetheless, all future studies should unanimously encourage partnerships between boards of education and dental practitioners in order to broaden their knowledge on the subject of traumatic dental injury procedures. The present review raises a question at the local level. These studies were performed in all corners of the world yet the present study only interviewed formally 3 teachers from the public and private School Boards in southern Ontario, simply to form an impression. There is sufficient evidence in recent literature that warrants a Canadian study on the subject. While Locker, 2005 evaluated the prevalence rates of TDI s in grade school children, further, more in depth studies are required to investigate the levels of knowledge and attitudes of educators in Canada. It is important to establish a working relationship between dental practitioners, educators and parents to outline a coherent management program. It is important on many levels, as the parent and child s future can be affected physiologically and psychologically. Let us not forget the financial implications of a mismanaged TDI. They should also be discussed as TDI s can place a burden on a family s quality of life in more than one way. As with any reviews, the present one showed weaknesses in some areas and left room for improvement. Accordingly, out of all possible searches the final 8 studies came from PubMed (Medline). It is a good yet unilateral search approach, given that there were other methods 13

14 available, such as unpublished articles, or internet affinity groups or other medical databases. Perhaps a search of conference abstracts could have yielded better, more comprehensive results. The present review did not canvas local experts and did not find a review of a Canadian perspective on the subject. Surely, a Canadian perspective would add new meaning and value to dental practitioners as well as teachers of young children in Canada. Some reviews including the present one also come short on organizational issues. They stem mostly from a lack of experience reviewing critically. One such issue would be the high level of inclusion for the articles retained for review. Because of the lack of experience of the present reviewers, it is possible that too high of a standard may have eliminated articles relevant and worthy of inclusion. As well, an effort was made to find the latest articles on the subject for the single reason to be as up-to-date as possible. While the reviewers were aware that the definition itself is older than the year 2000, perhaps future studies should include older articles as well, as again, relevant articles may have been missed simply because they were too old and considered out of date. 14

15 Checklist to Assess Evidence of Prevalence and Incidence (Descriptive or Longitudinal Studies) Citation: 1. Was the study ethical? 2. was the study internally valid? Sampling: Was the sampling frame complete, or for longitudinal studies, were all members of the cohort entered at the beginning? Did the sampling scheme allow a representative sample? Participation: Was the response rate 80% or higher, or for longitudinal studies, was loss to follow up low less than 20%? Was completion rate on individual items of the assessment instrument high? Measurement: Did the survey use valid questionnaires? Were the data gathered using the best accepted techniques? (e.g., trained telephone interviewers or examiners, mail questionnaire) Were the data tested for accuracy and reliability? 3. Do the findings relate to your population/patients? Are the age/sex distributions similar? 15

16 Author Study Critical outcome apprais Design Population al results conclusion recommendati on Level of evidence Feldens Et al Mesgarz adeh Et la Cross section al Cross section al 405 teachers 14 managers 0f 17 public elementary schools 160 teachers from 40 randomly selected elementary schools 8/10 Question naire not validated. Age and sex distributi on not similar. 9/10 Age and sex distributi on not similar 22.5% completely inadequate knowledge regarding tooth fracture and avulsion management Complete inadequate knowledge 55%more in male 4 times higher in teachers with less experience 2 times higher in teachers without graduate degree 43% correct with regard to basic knowledge on growth pattern of dentition Teaching experience positive effect on general knowledge of dental trauma 52.4 % appropriate answer regarding tooth fracture 50.6 % realized the urgency of avulsion management, but less than fifth know the proper action 38% knew the proper washing medium 18.7 knew the proper storage medium Strategies to improve teacher s knowledge must take this study s result into consideration Substantial lack of knowledge regarding dental trauma management among elementary school teacher Teacher s attitude concerning proper action was less than desirable efficient Communication (message strategies):handou t s & brochures first aid training, action protocols regarding dental trauma Educational campaigns to improve knowledge and awareness of teachers with regard to dental trauma management Good Good 16

17 Mohandas U Et al Cross section al 580 teachers from 700 schools 8/10 Sex and age distributi on not similar Data not tested for Accuracy and reliability 25% and 17% able to identify tooth in those with formal training and without formal training respectively 81% and 27.5% correct management of tooth fracture in those with formal training and without formal training respectively 1.5% correct action in tooth avulsion Storage media:21.5 %milk,15.6% water, 58.3% no knowledge Very low knowledge of dental trauma management No dental management component was included in their physical education curriculum. Incorporation of emergency management of dental injuries in the curriculum of physical education teachers Good 39.3% previous TDI experience 18.4 previous advice on management of tooth avulsion 17

18 McIntyre Et al Cross Section al 175 teachers,teacher assistants and nurses for grade 2-5 of all elementary schools in orange county 9/10 Age and sex distributi on not similar 44% would not replant teeth,28% would not be comfortable,8 7% comfortable saving the tooth and taking it to a dentist Storage media:32% HBSS,29% replant immediately,3 4% milk,6% water Total TDI knowledge score :100% teachers 64% or less,100% nurses 82% 0r 100% Participants had little knowledge. Findings support a pressing need for increasing TTKS. Teachers have great contribution to mismanagement of TDI. Educational programs and trainings are needed to enhance proper management of TDI. From all study's participants 61% never had an advice in TDI management. Good Al-junidi Et al Cross section al 220 teachers of northern Jordan schools 9/10 The sex/age distributi on not similar 10% previous training for TDI management 40% knew the timing of permanent teeth eruption 80.5 % gave wrong and 1% gave correct answers regarding management of avulsed tooth, Gross lack of knowledge of dental trauma management among school teachers regardless of age, sex, previous educational and first aid training Educational programs to improve knowledge and awareness Good 18

19 Chan et al Blakytny Et al Cross section al Cross section al Teachers from 100 randomly selected schools in HongKong 388 teachers of 31 primary schools 8/10 Response rate of less than 80% Age/sex distributi on not similar 8/10 Response rate less than 80% The sex and age distributi on not similar Correct answers to questions regarding fractured tooth management,avulsed tooth and storage medium were 71.1%,17.5 %and 15% respectively 47% could recognize the developmental stage of the tooth 28.3% previous TDI experience 27.7% did not know avulsed tooth can be saved 74.5% not confident to replant an avulsed tooth Storage medium:45.6 % first choice of milk 13.9% fist choice child s cheek First aid training, previous advice on TDI management & personal experience has no effect on teacher s knowledge Regardless of prior first aid training, the level of knowledge on the management of dental trauma appears inadequate The majority of respondents possessed at best rudimentary knowledge of the emergency management of tooth avulsion Incorporation of dental trauma management into the teacher training curriculum Provide simple instruction in dental first aid Good Good 19

20 Sea-lim Et al cross section al 291 teachers of various Singapore preschools who attended a dental education program 9/10 The age and sex distributi on not similar 24% previous TDI experience 65% knew the importance of urgent care 63% assessed themselves knowledgeabl e in management of TDI 71% proper handling and immediate care in case of avulsed tooth 51% knowledgeabl e of fractured tooth management 15% knowledgeabl e of appropriate storage medium Teaching experience has positive effect on selfassessed knowledge Previous TDI experience has positive effect on knowledge Educational programs should be organized to improve and enhance the teacher s awareness of immediate management of traumatized teeth Educational programs should include : problems and consequences,availability of after hour emergency service, storage media for avulsed teeth, critical timing for replantation of avulsed teeth, current concepts of management of fractured teeth Good 20

21 References: 1.Todd Je Childrens Dental Health In England And Wales,London Londo:Social Survey Division And Her Majesty Station Office. 2.Andreasen Jo,Andreasen Fm. Dental Traumatology:Quo Vadis.Endo Dent Traumatol 1990;6: W Marcenes And U Ryda Textbook And Color Atlas Of Traumatic Injuries To The Teeth. By J. O. Andreasen, Frances M. Andreasen, Lars Andersson.(2007) 4. Todd Je Childrens Dental Health In England And Wales,. Londo:Social Survey Division And Her Majesty Station Office : Locker D. Prevelance Of Traumatic Dental Injuries In Grade Children In 6 Ontario Communities.Can J Public Health Jan-Feb;96(1): Ks Fakhruddin,Hp Lawrence,Dj Kenny,D Locker.Etiology And Enviroment Of Dental Injury In Years Old Ontario School Children.Dental Traumatology2008;24: Doi. 7. Mc Tigue Dj.Diagnosis And Management Of Of Dental Injuries In Children.Pediatr Clin North Am2000;47: Jarvinen S. Traumatic Injuries To Perminant Incisor Teeth In Children.An Epidemiological And Clinical Study.Thesis.Proc Finn Dent Soc1977;73:Suppl V. 9. Ravn.Ij.Dental Injuries In Copenhagen Schoolchildren School Years Community Dent Oral Epidemiol1974;2: Andreasen J.O., Andreasen F.M., Andreasen L., Text book and Color atlas of traumatic injuries to the teeth. 4 th edition, 2007, Blackwell Publishing Company 11. Miller T R, Spicer Rs.How Safe Are Our Schools?.A M J Public Health 1998;101: Mctigue dj.diagnosis and management of dental injuries in children.pediatr clin north am 2000; 13. Gutman Jl,Gutman Mse.Cause Incidence And Prevetion Of Trauma To Teeth.Dent Clin North Am 1995;39: Judy D Mcintyre,Jessica Y. Lee,Martin Trop,William F Vann Jr. Elementary School Staff Knowledge About Dental Injuries.Dep Of End,Pedo,And Health Pplicy Analysisand Pediatric Dentistry,Unc School Of Dentistry Chapel Hill Nc,Usa. 21

22 15.Andreasen Jo,Andreasen Fm.Textbook And Color Atlas Of Traumatic Injuries To The Teth 3rd Edition.Copenhagen:Munks Guard; Feldens Eg, Feldens Ca, Kramer Pf, Da Silva Kg, Munari Cc, Brei Va. Understanding Schoolteacher's Knowledge Regarding Dental Trauma: A Basis For Future Interventions. Dent Traumatol Apr;26(2): Sae-Lim V, Lim LP. Dental trauma management awareness of Singapore pre-school teachers. Dent Traumatol Apr;17(2):71-6. PubMed PMID: Chan AW, Wong TK, Cheung GS. Lay knowledge of physical education teachers about the emergency management of dental trauma in Hong Kong. Dent Traumatol.2001 Apr; 17(2): Mohandas U, Chandan GD. 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 Oct-Dec;27(4): Al-Jundi SH, Al-Waeili H, Khairalah K. Knowledge and attitude of Jordanian school health teachers with regards to emergency management of dental trauma. Dent Traumatol Aug; 21(4): Blakytny C, Surbuts C, Thomas A, Hunter ML. Avulsed permanent incisors: knowledge and attitudes of primary school teachers with regard to emergency management. Int J Paediatr Dent Sep; 11(5): McIntyre JD, Lee JY, Trope M, Vann WF Jr. Elementary school staff knowledge about dental injuries. Dent Traumatol Jun; 24(3): Mesgarzadeh AH, Shahamfar M, Hefzollesan A. Evaluating knowledge and attitudesof elementary school teachers on emergency management of traumatic dentalinjuries: a study in an Iranian urban area. Oral Health Prev Dent. 2009;7(3): Al-Asfour, A., Andersson, L., & Al-Jame, Q. (2008). School teachers' knowledge of tooth avulsion and dental first aid before and after receiving information about avulsed teeth and replantation. Dental Traumatology : Official Publication of International Association for Dental Traumatology, 24(1), Holan, G., Cohenca, N., Brin, I., & Sgan-Cohen, H. (2006). An oral health promotion program for the prevention of complications following avulsion: The effect on knowledge of physical education teachers. Dental Traumatology : Official Publication of International Association for Dental Traumatology, 22(6),

23 26.Lieger, O., Graf, C., El-Maaytah, M., & Von Arx, T. (2009). Impact of educational posters on the lay knowledge of school teachers regarding emergency management of dental injuries. Dental Traumatology : Official Publication of International Association for Dental Traumatology, 25(4), American academy of pediatric dentistry- guideline on management of acute dental trauma, page Dental traumatology 2010; 26:211 availability of emergency dental treatment- a question of organization, dr. lars andersson, editor in chief 29. Dental traumatology issue 2; Dental traumatology issue 3; Dental traumatology issue 23; Pediatric dentistry- 23:6,2001, page Pediatric dentistry- a clinical approach by g.koch ; s. poulsen, second edition, page Traumatic dental injuries- a manual, second edition, j.o andreasen; f.m.andreasen; l.k.bakland; m.t. flores 23

24 Appendix: Treatment Guidelines Guidelines provide access to the best research evidence and techniques, give indications how to explore and interpret the patient and parent expectations. While most of the guidelines are similar, there are some differences and personal opinions (Pediatric Dentistry-23). It is well known that prognosis of dental injuries is decided during the time immediately after the accident, especially for avulsions. (Dental Traumatology 2010). INTERNATIONAL ASSOCIATION OF DENTAL TRAUMA, IADT, is the organism involved in producing the guidelines that are worldwide accepted. The last set that we could find are those from 2007, although we are aware that in June 2010, in Verona, Italy was the last IADT international conference where the guidelines were updated. The previous once had been divided into 3 parts: part i : crown fractures and luxations of permanent teeth(dent Traumat- 2) part ii : avulsions of permanent teeth (Dent Traum- 3) part iii :guidelines for management of traumatic injuries in the primary dentition (Dental Traumat-23). Recommendations that will help provide the best care for the traumatized child with primary dentition (Dental Traumat- 23): 1. Keep calm and concentrate on the child well-being 2. Wash the wound carefully with plenty of running water. 3. Stop bleeding by compressing the injured area with a gauze or cotton for 5 min. 4. Seek emergency treatment from a pediatric dentist. same guidelines are shared in other publications(traumatic Dental Injuries a Manual) Avulsion of permanent is the most serious of all dental injuries. The prognosis depends on the measures taken at the place of the accident, replantation beeing the treatment of choice. First aid for avulsed teeth (Dent Traum- 23) : 1. Make sure is a permanent tooth; the primary should not be replanted 2. Keep the patient calm 3. Find the tooth and pick it up by the crown 4. If dirty, wash it briefly 10 sec under mouth. Similar guidelines were found in other publications (Pediatric Dentistry and Traumatic Dental Injuries a Manual). Avoid storage in water. A very strong relationship has been found between healing outcome and storage condition and time (Traumatic Dental Injuries a Manual). 24

25 Prognosis of an avulsed permanent tooth depends upon formation and development of the root and the extra oral dry time. The tooth has the best prognosis if replanted immediately. If the tooth cannot be replanted within 5 min should be stored in a medium that will help maintain PDL fibers. 25

26 Critical Appraisal: CITATION: Judy D. McIntyre, Jessica Y. Lee, Martin Trope, William F. Vann Jr. Elementary school staff knowledge about dental injuries. Dental Traumatology 2008; 24: POPULATION: All public elementary schools in the Orange County School District in North Carolina. estimated population to 175 teachers, teachers assistants and nurses for the grades 2 5. LOSS TO FOLOW UP: 24 teachers out of 135 participants, 111 submitted all required components, the response rate was 82%. OUTCOME: * TDI( TRAUMATIC DENTAL INJURY) practice and experience population witnessed TDI : 69% responded never population witnessed children asking for help with a chipped tooth in the last year: 64% responded never population witnessed a knocked out tooth: 805 responded never management of a avulsed tooth: 44% will not do it, 28% will not be comfortable doing it, 87% would be comfortable to save the tooth and to take it to a dentist * TDI treatment cost knowledge: wide distribution of responses * findings for storage media: 34% said milk, 32% said HBSS (HANK 's BALANCED SALT SOLUTION), 29% will replant the tooth, 6% said water. Also a wide range of responses. *TTKS ( TOTAL TDI KNOWLEDGE SCORE) was calculated foe each individual. Result had a median of 9 with a range of 2 11 (SD +_1.87). The score was 80% ( 8.88 out of 11 possible points). 7 of the participants were nurses whom scored 9/11 2 of them and 11/11 5 of them. 100% of the teachers and teachers assistant scored 64% or less, while 100% of the nurses scored 82% or 100%. SREENING ACCURACY: * the demographic questionnaire included 14 questions about participants, their attitudes, beliefs and experiences regarding TDI *TDI online survey instrument contained questions with a response scale similar to 5 Point Likert Scale which evaluated teachers knowledge about crown fractures, avulsions and related management. * the survey questions were patterned using previous surveys * the questions were evaluated and revised by a professional panel * survey was field tested among lay individuals, dental students and dental trauma experts. Survey reliability was tested by calculating Cronbach"s alpha (35 37), a statistical index associated with variability. Value ranges from 0 to 1, with the survey score of more than Data were entered for analysis using Microsoft Access, performed by Biometrics Laboratory in the UNC CH School of Public Health. 26

27 *TTKS survey had 11 items regarding crown fracture and avulsions( max 11 points) *TTKS was calculated for each subject, assigned 1 point for correct and 0 for incorrect. AUTHORS' CONCLUSIONS: * The participants had little knowledge about the proper management of TDI, their associated cost or proper storage media * The findings were consistent with previous published studies about elementary school staff *61% of participants have not received any advice in TDI *72% of participants would not replant an avulsed tooth *80% of them expressed interest in receiving more information about TDI *69% never witnessed a TDI, while 26% had seen from 1 5 TDI *findings support a pressing need of TDI education for school staff *low average TDI scores of 8.88/11 is significant because is translated in clinical importance and detrimental in TDI management *teachers and their assistants greatly contribute to mismanagement of dental injuries *educational programs and training are needed to enhance proper management of TDI experienced by elementary school children. CRITICAL APPRAISAL: * population restricted only to elementary schools *cross sectional study conducted in one county school district *good sampling population, good level of participation *valid survey method and analysis *TTKS score self reported, should not be generalised LEVEL OF EVIDENCE: Good level of evidence, score 9/10. 27

28 POPULATION: 220 teachers is the total number of teachers that were included in this survey (63.1% were females) and this study was carried out in irbid governate in northern Jordan, where 20% of Jordanian population reside. These teachers have at least 14 years of education and 44% were in their twenties. STUDY SETTING: Public schools in Irbid governate in northern Jordan. POPULATION REPRESENTED: 220 teachers that had at least 14 years of education 44% were in their twenties, in general 87 teachers had first aid training once in teaching career. MATERIALS AND METHODS: the questionnaire was modified from those used in previous similar studies and was divided in 4 parts : part 1 consisted of question on personal and professional profile of the respondents, Part 2 consisted of questions on the immediate management of three imaginary cases of dental injuries, part 3 of the questionnaire was concerned with self assessed knowledge. RESPONSE: The number of teachers who responded to all of the questions in the questionnaire was 190; the response rate was 86.3%. Results: 40%of the respondents knew that the fractured tooth is most likely to be the permanent incisor. With regards to the immediate emergency management of the case 56.3% gave the wrong answer.with regards to the emergency management of the avulsed permanent tooth 80.5% gave the wrong action, only 1% responded ideally by replanting the tooth. the response to part 3 of the questionnaire which investigated self assessed knowledge and attitude to further education on the topic which shows that almost 97% of the respondents thought their knowledge regarding emergency management of dental trauma was not enough,however,only 27 teachers(14.2%)indicated that they were unable to provide suitable action when needed in situation associated with dental trauma. DISCUSSION: This survey included all school health education teachers 28