Libyan general dentists knowledge of dental trauma management

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1 International Dental & Medical Journal of Advanced Research (2015), 1, 1 6 ORIGINAL ARTICLE Libyan general dentists knowledge of dental trauma management Marwa Hatem, Elsanousi M. Taher Department of Oral Diagnosis, Oral Radiology and Oral Maxillofacial Surgery, Libyan International Medical University, Benghazi, Libya Keywords Dental trauma, dentists, knowledge, traumatic dental injuries Correspondence Marwa Hatem, Department of Oral Diagnosis, Oral Radiology and Oral Maxillofacial Surgery, Faculty of Dentistry, Libyan International Medical University, Benghazi, Libya. Tel.: +(0) cousinmemo@ gmail.com Received 25 August 2015; Accepted 25 September 2015 doi: /ins.idmjar.28 Abstract Objectives: The aim of the present study was to evaluate the level of Libyan general dental practitioners knowledge about the current guidelines of dental trauma management. In addition, association between knowledge of recommended treatment modalities and demographic data of participants was evaluated. Materials and Methods: A two-part questionnaire containing questions on demographic data and 12 multiple choice questions on dental trauma management was distributed among a total of 233 dentists in Benghazi and Tripoli. The survey data were analyzed using the Pearson Chi-square test at P < 0.05 level of confi dence. In addition, mean knowledge scores were calculated, and one-way ANOVA was used to determine the association between knowledge scores and demographic data of participants. Results: Questionnaires were returned by 157 dentists. However, this study only reports on the 144 general dental practitioners who comprised (91.7%) of participants. Dentists who had previous experience in dental trauma had signifi cantly higher mean knowledge scores (P = 0.000).in contrast, there was a poor correlation between mean knowledge scores and dentists gender, years since graduation or postgraduate dental trauma courses. Conclusion: There is a need to improve the knowledge base of general dental practitioners in the current guidelines for the emergency management of traumatic dental injuries. Introduction It is recognized today that traumatic dental injuries are frequent and widespread, and represents a serious public health problem, especially among young people. [1] Published studies have shown that a high number of schoolchildren have experienced dental trauma in the permanent dentition. [2-4] Nevertheless, some studies indicate that the number of dental trauma cases will exceed dental caries or periodontal disease. [5] Dental trauma could be attributed to various factors such as falls, collision with objects or persons, automobile accidents, violence and the high participation of children in sport activities. [4-7] Overjet, exposure of maxillary incisors and interlabial gaps are predisposing factors that could attribute to the increased risk of traumatic dental injuries. [8] Oral healthcare professionals are expected to be familiar with the various types of dental trauma and the current guidelines of management for each type, in order to ensure effective treatment for their patients. Several studies, mainly from Australia, Brazil, China, Germany, and the UK were published in an attempt to assess the knowledge of dentists regarding the emergency management of traumatic dental injuries. [9-18] Most of these surveys demonstrated generally poor knowledge and highlighted the need for continuing education for dental professionals in this fi eld. To date, there are no similar published data for Libyan dentists. The aim of the present study was to investigate by means of the questionnaire the knowledge of Libyan dentists on different case scenarios of dental trauma, which might refl ect the standard of care and treatment provided to trauma patients. Furthermore, the association between knowledge of recommended treatment modalities and participants years of experience, dental trauma experience, and previous dental trauma education were also evaluated. Materials and Methods A 12 item questionnaire [10] was distributed to a total of 233 general dentists and specialists who were randomly selected International Dental & Medical Journal of Advanced Research Vol

2 A questionnaire based assessment of Libyan dentists perception of dental trauma management Hatem and Taher from different parts of Tripoli and Benghazi. The survey was carried out between February and April Questionnaires were given to participants under supervision of the main author and were immediately collected after completion. In addition, confi dentiality was maintained as participates were not requested to give their names or other identifying information. The fi rst part of the questionnaire requested demographic and professional data related to participants age, gender, years of professional experience, practice experience with trauma patients and postgraduate dental trauma courses. The second part consisted of 7 case scenarios on dental trauma. The questions asked about the following: 1. The indication of pulpotomy after traumatic pulp exposure (complicated fracture) in a tooth with open apex 2. The procedure, including type of splint used to stabilize a replanted tooth 3. Management of crown fracture involving enamel and dentin (uncomplicated fracture) 4. Decision making and management of intra-alveolar root fracture 5. Procedure for delayed replantation of an avulsed tooth with complete root formation 6. Treatment of internal resorption in a previously traumatized tooth 7. Procedure for replantation of an avulsed tooth with complete root formation performed 30 min following the injury. Participants were asked to select the most appropriate response to each question out of three to fi ve alternatives, and correct answers were determined by evidence in the accepted literature. Data from the returned questionnaires were entered into an SPSS database and statistically analyzed using the Pearson Chisquare test at P < 0.05 level of confi dence. In addition, mean knowledge scores were calculated, and one-way ANOVA was used to determine the association between knowledge scores and participants gender, years of professional experience, practice experience with trauma patients and postgraduate trauma courses. Results Of the 233 questionnaires, 157 were completed and returned. Of these, 144 participants (92%) were general dental practitioners and 13 (8%) were specialists. Due to the small sample size of specialists group, analysis is presented only for the 144 general dental practitioners. The results show that (36.8%) of participants have previous trauma experiences in practice while only (10%) responded that they attended postgraduate courses on dental trauma management [Table 1]. Of maximum of 12 correct answers to questions given, respondents scores ranged from 2 to 11 (mean: 6.59, standard deviation: 1.68). The mean knowledge scores in relation to the demographic data of participants are shown in Table 2. A signifi cant association was found between the mean knowledge scores and Table 1: Demographic data of participants Demographic data Number (%) Age Age range years Mean±SD 28.9±5.72 Gender Males 60 (41.6) Females 84 (58.4) Years since graduation <5 years 89 (61.8) Graduation 5-15 years 48 (33.3) >15 years 7 (4.9) Trauma experience Yes 53 (36.8) No 91 (63.2%) Postgraduate trauma courses Yes 10 (7) No 134 (93) SD: Standard deviation Table 2: Mean knowledge scores in relation to demographic data of respondents Participants information Mean score±sd P value Gender Male 6.26± Female 6.82±1.57 Years since graduation <5 years 6.48± years 6.66±1.69 >15 years 7.42±1.39 Trauma experience Yes 7.54± * No 6.03±1.58 Postgraduate trauma courses Yes 6.5± No 7.5±1.5 *Significant association, SD: Standard deviation previous trauma experience (P = 0.000), as dentists with trauma experience appeared to have better knowledge (86.23% correct answers) than dentists with no trauma experience (50.72% correct answers). In contrast, practitioners gender had no effect on the mean knowledge scores (P = 0.051). Furthermore, there was a poor correlation between knowledge scores and postgraduate trauma experience (P = 0.077) or years since graduation (P = 0.337). 2 International Dental & Medical Journal of Advanced Research Vol

3 Hatem and Taher A questionnaire based assessment of Libyan dentists perception of dental trauma management The frequency of answers to the questionnaire is summarized in Table 3. Overall, the correct answer response was 55%. When asked about how to instruct a parent over the phone when informed of a knocked-off tooth, the majority of participants (85.4%) correctly recommended replanting the tooth back in the socket and seeking dental care as soon as possible. In addition, over half of the respondents (56%) correctly indicated milk as the preferred extra-alveolar storage medium for an avulsed tooth. After positioning the avulsed tooth in the socket, (88.8%) correctly responded that they would perform radiographic examination, splinting and provide plaque and diet instruction instead of undergoing an immediate root canal treatment, while (49.3%) identifi ed the correct type of splint (semi-rigid) to be used. Cross tabulations were then examined between knowledge of dental trauma management and participants years of experience and previous dental trauma experience. Three signifi cant associations were found between knowledge scores and dental trauma experience of participants. The fi rst one regarding the emergency management of an avulsed tooth on the site of injury, given over the phone. (Q3) (χ 2 = 9.469, df = 1, P = 0.002) [Table 4]. The second signifi cant association was between dental trauma experience of participants and the type and duration of splint used in stabilizing a replanted tooth (Q5) (χ 2 = , df = 1, P = 0.000) [Table 5]. The last signifi cant association was found between dental trauma experience of participants and the recommended extraalveolar storage medium of an avulsed tooth (Q12) (χ 2 = , df = 1, P = 0.000) [Table 6]. Discussion Treatment guidelines of traumatic dental injuries have been published in order to promote optimal prevention and treatment for patients [19,20] and appropriate clinical application of these techniques immediately after an injury can improve both short and long-term outcomes. Nevertheless, knowledge of the appropriate treatment plan will reduce stress and anxiety among patients and the entire dental team. [21] It is therefore expected that oral healthcare professionals be familiar with the up-todate protocols regarding prevention and emergency treatment modalities. Our results showed an uneven pattern of knowledge among participants regarding the emergency management of traumatic dental injuries, which is in agreement with previous published studies. [15,22] The level of knowledge of participants was quite extensive on some cases while on the others it was not as satisfactory. For example, in the case of emergency management of an avulsed tooth, 123 (85.4%) dentists knew that replanting the tooth back into the socket if possible- is the best fi rst line treatment, while 128 (88.8%) dentists knew the correct procedures to perform following replantation. However, only 33 (22.9%) dentists correctly identifi ed the appropriate Table 3: Frequency and percentage distribution of answers in the questionnaire Question Number (%) Case 1: A patients presents with fracture involving enamel and dentine with pulp exposure in tooth with incomplete root formation arrives one hour after the accident Q1: The immediate treatment is A. Pulpectomy B. Pulpotomy C. Endodontic treatment in one session Q2: Medication used in treatment of this case is A. Aramon chloroform B. Calcium hydroxide C. Formalin D. No medicament needs to be employed Case 2: A mother called to the dental office explaining that her daughter have knocked out her tooth at this moment Q3: What instructions should be given to the mother A. Store the tooth in water and go to the dental office immediately B. Store the tooth in ice and go to the dental office immediately C. Replant the tooth or if not possible, store the tooth in saline and go to the dental office immediately Q4: What is the next procedure to be done at the dental office A. Thermal test, radiographic examination, endodontic treatment B. Radiographic examination, splint and diet and hygiene instructions C. Do not know Q5: What type of splint and how long should it be used in this case A. Rigid, for 2 weeks or until tooth mobility has reduced B. Semi-rigid or rigid, a month C. Semi-rigid, for 2 weeks or until tooth mobility has reduced D. No splint should be used Q6: Would you prescribe any medications A. No B. Yes, antibiotic of narrow spectrum, anti-inflammatory, analgesics C. Yes, anti-inflammatory, analgesics D. Yes, antibiotic of extended spectrum, anti-inflammatory, analgesics Case 3: A patient who suffered an accident a day ago came complaining of little pain in tooth no. 41, clinically it showed fracture involving enamel and dentin but not exposing the pulp Q7: The immediate treatment is: A. Endodontic treatment B. Calcium hydroxide liner applied on exposed dentin, and then its decided whether or not to place immediate restoration C. Immediate restoration with composite resin 50 (34.7) 80 (55.5) 14 (9.8) 10 (7) 92 (63.9) 24 (16.6) 18 (12.5) 14 (9.8) 123 (85.4) 11 (7.6) 128 (88.9) 5 (3.5) 60 (41.7) 6 (4.2) 71 (49.3) 12 (8.3) 41 (28.5) 22 (15.3) 69 (47.9) 112 (77.8) 25 (17.4) Cond... International Dental & Medical Journal of Advanced Research Vol

4 A questionnaire based assessment of Libyan dentists perception of dental trauma management Hatem and Taher Table 3: (Continued...) Question Number (%) Case 4: A patient came to the office explaining an accident that she suffered the day before, after radiographic examination, tooth no. 21 showed a middle root fracture Q8: The immediate management is A. Extraction of the tooth B. Endodontic treatment C. Thermal test, rigid splint D. Thermal test, semi-rigid splint Case 5: A patient came to the office with an avulsed tooth which has been dry for 7 h Q9: The immediate treatment is A. Cleanse tooth and socket with saline solution, replant the tooth, splint, and antibiotic therapy B. Place the tooth in 2.4% fluoride solution, cleanse the alveolar socket with saline, replant, endodontic treatment, splint, and antibiotic therapy C. Place the tooth in 2.4% fluoride solution, cleanse the alveolar socket with saline, endodontic treatment, replant, splint and antibiotic therapy D. Replacement of missing teeth by prosthesis Case 6: A patient came to the office complaining of change of color of tooth no. 12. He explained that the tooth has been traumatized 4 years ago. Radiographic examination revealed internal resorption Q10: The treatment is A. Extraction B. Pulpectomy C. Endodontic treatment in one session D. Endodontic treatment by means of replacing filling with calcium hydroxide before the canal is obturated definitely Case 7: A patient presented with An avulsed tooth with completed root formation, which had already been replanted within 30 min Q.11: The next step is: A. Must be root canal treated immediately B. Requires apical resection and transdental fixation C. Should not be root canal treated in the first month after the trauma D. Should be root canal treated within 7-14 days E. Should never be root canal treated Q12: If a specialized cell culture medium is not available, the most adequate possibility for the storage of avulsed teeth would be A. Tap water B. Saline C. A clean handkerchief D. Cold milk The correct answers are printed in italics 80 (55.5) 20 (13.9) 25 (17.4) 19 (13.2) 20 (13.9) 25 (17.4) 33 (22.9) 66 (45.8) 43 (29.9) 18 (12.6) 75 (52.7) 27 (18.7) 6 (4.2) 29 (20.1) 59 (41) 24 (16) 8 (5.6) 49 (34) 6 (4.2) 81 (56.2) management of an avulsed tooth that was kept dry for long periods (7 h). Complicated crown fracture is a fracture that involves enamel, dentine with exposure of the pulp. [23] Treatment protocol in this case depends on the size of the exposure and time elapsed since the injury. Literature demonstrated high success rates of partial pulpotomy following traumatic pulp exposure both in mature and immature teeth, [24] however, the recommended treatment for complicated crown fracture in teeth with mature roots is endodontic treatment. [25] When asked about the preferred treatment option, 80 (55.5%) dentist correctly recommended pulpotomy, while 50 (34.7%) and 14 (9.8%) dentist chose pulpectomy and endodontic treatment in one session, respectively. These results showed that a large number of dentists would perform a non-vital pulp therapy. In comparison, Yeng and Parashos [9] reported that 86% of dentists would carry out vital pulp therapy for teeth with an open apex. Furthermore, Kostopoulou and Duggal [26] reported that 78% of general dental practitioners would carry out pulpotomy for large exposures with an open apex and 81% would perform root canal treatment for teeth presenting with large exposures and closed apices. Tooth avulsion occurs when the tooth is displaced completely out of the socket which clinically appears either empty of fi lled with coagulum. [23] Some authors believe that the best emergency treatment of an avulsed tooth is replantation, even if it is carried out at the site of injury. This procedure is performed in an attempt to preserve the functional and aesthetic characteristics of the buccal cavity. [27] About 85.5% of respondents in this survey believed that immediate replantation for avulsed teeth is preferred over delayed replantation carried out at the dental offi ce. If immediate replantation is not possible, the use of an appropriate extra-alveolar storage medium is required to promote the success of the intervention. [27] More than half of the respondents (56.2%) properly indicated that the avulsed tooth should be kept in cold milk and saline should be used only when cold milk is not available. Tap water is the least desirable storage medium due to its hypotonic environment which results in rapid cell lysis and increased infl ammation of periodontal ligaments. [28] Fortunately, only few dentists (5.6%) recommended placing the tooth in tap water, which is in agreement with another study where oral health professionals identifi ed water as an inadequate storage medium. [22] Although the use of specialized storage medium like Dentosafe (Medice, Iserlohn, Germany) has shown an improved prognosis of replanted teeth, [29] it was not offered as a possible choice in this survey. In the event of avulsion, the use of fl exible (semi-rigid) splint for a period of 7-14 days is recommended. [20] This allows physiological movement of the tooth during healing and application of the splint for a maximum period of 2 weeks reduces chances of ankylosis. However, if avulsion is associated with alveolar fracture, the splint must be maintained for longer periods (4-8 weeks). [30] In this study, the majority of participants (95.2%) reported that replanted teeth need to be splinted, but only (49.3%) choose the correct type of splint. This is higher than a previous study that reported only 20-30% [26] correct response among Brazilian dentists. If root canal treatment is indicated following avulsion (replanted teeth with closed apex), the ideal time to begin the treatment is 7-10 days following replantation. Current protocols 4 International Dental & Medical Journal of Advanced Research Vol

5 Hatem and Taher A questionnaire based assessment of Libyan dentists perception of dental trauma management Table 4: Association between dental trauma experience of participants and the emergency management of an avulsed tooth on site of injury, given over the phone Trauma Place in water Place in ice Replant in socket experience Yes No χ 2 =9.469, df=1, P=0.002 Table 5: Association between dental trauma experience of participants and the type and duration of splint used following replantation of an avulsed tooth Trauma experience Rigid splint, 2 weeks Semi-rigid or rigid, a month Semi-rigid, 2 weeks No splint Yes No χ 2 =45.175, df=1, P=0.000 Table 6: Association between dental trauma experience of participants and the recommended extra-alveolar storage medium for an avulsed tooth Trauma experience Tap water A clean handkerchief Saline Cold milk Yes No χ 2 =38.241, df=1, P=0.000 involve the use of calcium hydroxide as an intra-canal medicament for up to 1 month, followed by permanent root fi lling material. Alternatively, intra-canal medicament with anti-infl ammatory or anticlastic properties might be indicated. However, if the tooth was kept dry for more than 1 h (delayed replantation) root canal treatment might be performed extra-orally prior to replantation. [19] This approach was selected by only 33 (22.9%) respondents while 66 (45.8%) respondents chose not to attempt replantation of a tooth which was kept dry for long periods. Enamel and dentine fractures not involving the pulp can be treated by bonding the fractured fragment (if available) to the tooth. Otherwise, fractured tooth could be restored provisionally with glass-ionomer cement to cover the exposed dentin, or permanently using a bonding agent and composite resin, or other accepted dental restorative materials. [19,27] If the exposed dentine is within 0.5 mm from the pulp with no evidence of bleeding, it is recommended to place a calcium hydroxide base on the deep exposed layers of the dentine. [19] In this study, the majority of participants (88.9%) would place a calcium hydroxide layer and then decide whether an immediate permanent restoration should be made, while only (3.5%) would attempt an immediate restoration with composite resin. Horizontal root fractures are fractures that involve dentine, cementum, and the pulp. [23] In this study, participants were asked about the emergency treatment of horizontal root fracture only. Surprisingly, only 25 (17.4%) correctly recommended rigid splint as a preliminary line of treatment, while over half (55.5%) recommended extraction of the involved tooth. A study by Krastl et al. [15] reported that almost half of the general dental practitioners in his survey would carry out rigid splinting as an emergency treatment of horizontal root fractures. Literature indicates that horizontal root fractures should be splinted for a period of 3-4 weeks, to ensure stability and improved prognosis with closed reduction of root segments. [25] Moreover, endodontic treatment may not be indicated for every root fracture case. A study of 400 root fractures revealed good prognosis for mid root fractures as the overall healing rate was approximately 80%, of which 30% healed with hard tissue formation. [31] There were several limitations to this survey. These include the use of small sample size, which could be attributed to the low return rate of completed questionnaires and the lack of comparison of respondents level of knowledge with a control group. Although the questionnaire comprised 12 multiple choice questions, it involved only certain dental trauma scenarios because of the several variations possible with each case. In addition, level of knowledge was not assessed among specialists who made <9% of respondents. Finally, no pre-pilot or pilot studies were conducted prior to distributing the questionnaires to the target group. Conclusion The present survey revealed defi ciencies in the knowledge base of general dental practitioners on different case scenarios regarding dental trauma. This highlights the need to improve International Dental & Medical Journal of Advanced Research Vol

6 A questionnaire based assessment of Libyan dentists perception of dental trauma management Hatem and Taher the undergraduate and postgraduate education of oral health professionals on the current guidelines for preventing and treating traumatic dental injuries, to ensure a high standard treatment for patients presenting with tooth injuries. Continuing dental education is one of several possible approaches that could be implemented to increase the knowledge level of dentists Which will be of great value in keeping up with the up-to-date theoretical and management issues of the various aspects of dental trauma. References 1. Glendor U, Marcenes W, Andreasen JO. Classification, epidemiology and aetiology. In: Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and Colour Atlas of Traumatic Injuries to the Teeth. 4 th ed. Oxford: Blackwell Publishing; Cortes MI, Marcenes W, Sheiham A. 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Dent Traumatol 2002;18: Andreasen JO, Andreasen FM, Mejàre I, Cvek M. Healing of 400 intra-alveolar root fractures 1. Effect of pre-injury and injury factors such as sex, age, stage of root development, fracture type, location of fracture and severity of dislocation. Dent Traumatol 2004;20: How to cite this article: Hatem M, Taher EM. Libyan general dentists knowledge of dental trauma management. Int Dent Med J Adv Res 2015;1: International Dental & Medical Journal of Advanced Research Vol