|Year : 2015 | Volume
| Issue : 1 | Page : 25-29
General dentists knowledge about the emergency management of dental avulsion in Yemen
Nabil M Al-Zubair
Department of Orthodontics, Faculty of Dentistry, Sana'a University, Sana'a, Yemen
|Date of Web Publication||2-Feb-2015|
Nabil M Al-Zubair
Department of Orthodontics, Faculty of Dentistry, Sana'a University, Sana'a
Source of Support: None, Conflict of Interest: None
Objective: The objective of this research was to investigate the knowledge of general dentists about the emergency management of dental avulsion in Sana'a, Yemen.
Materials and Methods: A questionnaire containing nine questions about emergency management of avulsed teeth was distributed among 416 general dental practitioners working in different private dental hospitals and clinics of Sana'a among them 272 was responded.
Results: Among the studied group, (44%) said that an avulsed permanent tooth cannot be replanted. Sixty-eight percent of the responded informed that they use rigid splint for avulsed tooth and 29% said that semi-rigid splint should be used.
Conclusion: The results suggest that the level of knowledge on the management of dental avulsion of the general practitioners dentists in Sana'a is inadequate. An education program should be conducted to increase the knowledge of general dentists in the management of traumatic injuries to teeth.
Keywords: Avulsion, emergency, general dentists, replantation, yemen
|How to cite this article:|
Al-Zubair NM. General dentists knowledge about the emergency management of dental avulsion in Yemen. Saudi J Oral Sci 2015;2:25-9
|How to cite this URL:|
Al-Zubair NM. General dentists knowledge about the emergency management of dental avulsion in Yemen. Saudi J Oral Sci [serial online] 2015 [cited 2020 Jan 27];2:25-9. Available from: http://www.saudijos.org/text.asp?2015/2/1/25/150588
| Introduction|| |
Dental trauma has become a serious problem of public health due to the increase of violence, traffic accidents, and participation of children in sports with risk for trauma in recent years. Oral injuries are the fourth-most common area of bodily injuries among 7-30-year olds.  Traumatic dental injuries can become an important health problem not only because their prevalence is relatively high they have large impact on individual's daily life. 
Tooth avulsion is one of the most serious of all dental injuries. It is defined as the complete displacement of a tooth out of its socket. Avulsion of a permanent tooth is estimated to represent 0.5-16% of all dental injuries. The most commonly affected teeth are the maxillary central incisors. 
The optimal approach for an avulsed permanent tooth is immediate replantation. Clinical studies have shown that the prognosis is best for teeth replanted within 5 minutes after avulsion which is attempted by the parent or other person at the site of the injury.  Preservation of the viable periodontal cells on the root is critical for long-term success, which is inversely dependent on the time between the accident and final reimplantation by a dentist.  Several storage media have been suggested to preserve the viability of the periodontal ligament cells. It has been suggested to place the tooth under the patient's tongue in cases where immediate replantation was not possible.  Eagle's culture medium had also been used for storing teeth.  Eagle's Minimal Essential Medium contains 4 ml of L-Glutamine; 105 IU/L of Penicillin; 100 μg/ mL of Streptomycin, 10 μg/mL of Nystatin and calf serum (10% v/v).  Many studies demonstrated that the cell culture medium (Eagle's medium at 37°C) can preserve periodontal ligament fibroblasts for extended periods before dental reimplantation.  Also it was suggested to store the avulsed tooth in milk, Hank's balanced salt solution or saline. 
There is a lack of agreement on where to go in the event of an avulsion injury. Most lay persons suggest that a nearby dentist would be contacted and the minority feel that the patient would go to a general hospital directly. Dentists should always be prepared to give appropriate advice to the public about first aid for avulsed teeth. 
Here, the dentist's knowledge in the emergency management of avulsed tooth is very important. There is a lack of published data regarding knowledge of Yemeni dentists in this field. So, this study was designed to evaluate the knowledge of general dentists working in Sana'a about the management of avulsed teeth.
| Materials and Methods|| |
Ethical approval was obtained from both the Ethics Committee of Sana'a University and the Faculty of Dentistry at the University of Sana'a. A brief outline of the study was explained to all participants and consent was obtained prior to participation.
A cross-sectional study was conducted among general dentists working in different private dental hospitals and clinics of Sana'a. The time period of the study was between October 2012 and February 2013.
The target population was general dentists in private practices in the city of Sana'a, Yemen. The dentists were randomly selected from a list of 2746 registered professionals in the Yemeni Dental Association. A total of 416 participants who had completed Bachelor of Dental Surgery degree were randomly selected from those hospitals and clinics; only those who willing to participate were included.
The questionnaire was written in Arabic and English and was composed of two sections. The first section included basic demographic information, including training background. The second part consisted of nine questions related to knowledge of how to treat traumatic avulsion of teeth. Results were expressed as a percentage of respondents for each question.
Data were entered into SPSS 13.0. Descriptive analysis was carried out to assess the frequency.
| Results|| |
Out of 416 participants included in the survey only 272 of them responded, of whom 124 female and 148 male. [Table 1] show the distribution of sample according to gender and age.
One hundred and twenty-four (46%) were self-educated by reading books and scientific articles on dental trauma emergency care; 76 (28%) did continual education courses on their own initiative after graduation in Dentistry; and 72 (26%) have had only information during their education at Dental School as shown in [Table 2].
The existing level of knowledge of general dentists about emergency management of avulsed teeth is depicted in [Table 3].
Considering the factors that may influence outcome of replantation, (53%) considered all three factors (extra-alveolar period, storage medium, injury to the periodontal ligaments); while 47% considered only one factor. The results are summarized in [Table 3].
| Discussion|| |
This study provided baseline information about existing level of knowledge of emergency management of teeth avulsion among the dentists in Yemen.
The present study showed that less than half of dentists in Yemen were unaware of the basic procedures to be followed in case of dental avulsion of deciduous and permanent teeth independently from their professional experience.
A very high percentage of participants (44%) reported that avulsed tooth cannot be replanted. Westphalen et al.,  reported that 100% of participants were in favor of replantation among them (67%) were in favor of replantation after any extra-alveolar time, which also coincide with the finding of other studies showed that most dentists recommended dental replantation. ,
This result was also similar to findings from other international studies. Jyothi et al., reported that 68.5% of the participants had no prior knowledge regarding management of avulsed tooth, while Upadhyay et al.,  reported that almost all of the participants, (96.1%) said that an avulsed permanent tooth cannot be replanted in all cases.
Regarding how the respondents were trained in or informed about management of dental trauma. The present study finds that the majority of professionals (46%) were self-educated by reading books and scientific articles on dental trauma emergency care and have not had continuing education courses in dental traumatology although Sana'a is considered a university city, with four schools of Dentistry. Also, the expressive number of respondents (26%) that reported that they have had only information during their education at Dental School, which reflect the significant result of the present study and may be suggestive of the poor quality of their graduation courses, and the lack of short-duration courses that must be provided by professional associations and universities in this particular field of traumatology.
Westphalen et al.,  reported that the majority of professionals(60%) have had continuing education courses in dental traumatology; (26%) were self-educated by reading books and scientific articles on dental trauma emergency care; and 36 (14%) have had only information during their education at dental school.
Although the best treatment for avulsed teeth is immediate reimplantation, this is often not done for a variety of reasons, such as: The people at the scene of the accident will not do it, the people at the scene of the accident are not dental healthcare workers and, if multiple teeth are avulsed, they will not know which tooth goes into which socket. 
For the question regarding factors that may influence outcome of replantation, (53%) considered all three factors; while 47% considered only one factor, which also reflect the poor quality of their graduation courses and may suggestive for reassessment of their graduation courses and the need for continual education course in this field of traumatology. Research has shown that three factors contribute to the success of reimplanted avulsed teeth: The physiologic status of the remaining periodontal ligament (PDL) cells on the root surface, the storage medium and the length of extraoral time. ,,
Only 24% of the dentists chose milk as the storage media whereas 40% preferred patient's saliva. The use of milk as a storage medium, although appealing and far better than tap water or saliva, is, upon careful examination, a bad choice for the following reasons: It is often not available at accident scenes such as car accidents, hospital operating rooms, schools, and playgrounds, also milk is not the most biologically supportive medium; it has a short supportive time (1-3 hours), and has a poor PDL cell vitality maintenance. ,,,
It was encouraging to know that 29% of the dentists chose Hank's balanced salt solution (HBSS) as the storage media for an avulsed tooth. Guidelines given by International Association for Dental Traumatology also suggest HBSS as storage media. ,
For the question regarding Ideal extra-alveolar period, 62% of the responded chose the correct extra-alveolar period as critical that it was within 30 minutes while 34% suggested a period less than 90 minutes and 4% were in favor of replantation after any extra-alveolar time, which reveals that there is about two out of five of the responded with inadequate knowledge and attitude regarding the most essential factor to be considered in avulsion treatment. An avulsed permanent tooth should be replanted as soon as possible. The risk of ankylosis increases significantly with an extra oral dry time of 20 minutes.  If the tooth cannot be replanted within five minutes it should be stored in a medium that will maintain vitality of periodontal ligament fibers. 
Regarding tooth management before replantation, about half of dentists (47%) chose to wash the teeth with tap water before replanting, while 26% of them preferred physiologic saline solution to wash the teeth. The significant number for those who chose tap water could be explained as these respondents may have been confused with procedures at the site of the accident, where tap water is an acceptable option. 
After replantation, an avulsed permanent tooth should be splinted. The overall knowledge of the respondents about the type of splinting is inadequate and wrong. The result was unsatisfying as 71% of whom 3% answer that splinting is not necessary and 68% informed that they either use rigid splint such as stainless wire (46%) or composite restorative materials (22%) for avulsed tooth, which are in disagreement with Westphalen et al. ,[ who reported the use of semi-rigid splint in 73% of the cases.
The decision regarding type of splinting was not coincident with recently published guidelines, which suggest flexible splinting for 2 weeks. Only 29% said that the semi-rigid splint should be used. The semi-rigid splint allows the traumatized teeth to have some mobility and optimal periodontal ligament healing, and is recommended for teeth with both closed and open apex. 
The decisions of the majority of the respondents (85%) were generally correct regarding the splinting period as 51% of them suggested that splinting period should be 15 days and 34% suggested it to be 30 days. International Association for Dental Traumatology (IADT) suggested up to two weeks splinting for an avulsed tooth decrease the risk for ankylosis. ,,
Authors tend to recommend a shorter period of immobilization.  Otherwise, a 30 day splinting period has been successfully used in cases of replantation, even in cases of unconventional immobilization. 
The decision regarding endodontic treatment are not coincident with recently published guidelines, which suggest an acute approach (endodontic treatment within a few hours) if the tooth is not replanted at the time of injury; otherwise, subacute (within the first 24 hours) and delayed (after the first 24 hours). Calcium hydroxide as an intra-canal medicament during root canal treatment was suggested by 16% of the dentists. Calcium hydroxide is recommended for intra-canal medication for up to 1 month followed by root canal filling, or obturation can be carried out when an intact lamina dura can be visualized radiographically. ,
In this study, a large number of respondents (75%) antibiotics and tetanus prevention suggested in any situation, which agree with the findings by Westphalen et al.,  where the majority of respondents reported a criterious prescription of medication. Tetanus prophylaxis and antibiotic coverage should be considered. Treatment strategies are directed at avoiding inflammation that may occur as a result of the tooth's attachment damage and/or pulpal infection. ,,,
The year of working experience of dentists was not recorded in this study. Knowledge of management of the dentist may be higher in those with greater duration of working experience and low in newly graduated dentists. This may be the limitation of the present study.
Based on the findings of this study, it is possible to suggest that the general dentist knowledge about the emergency management of dental avulsion in Yemen is inadequate. It was surprising to see that 44% of the dentists reported that avulsed tooth cannot be replanted. This explains the reason of insufficient knowledge in this field. The present study finds that the majority of professionals (72%) were either self-educated by reading books and scientific articles on dental trauma emergency care or have had only information during their education at Dental School and have not had continuing education courses in dental traumatology, which reflect the significant result of the present study and may be suggestive of the poor quality of their graduation courses, and the lack of short-duration courses that must be provided by professional associations and universities in this particular field of traumatology.
| Conclusion|| |
Research and clinical studies have demonstrated that the reimplantation of avulsed teeth can be a successful procedure with excellent long-term retention. It is possible to suggest that the level of knowledge of the general practitioners about emergency management of dental avulsion in this sample is inadequate. As management of avulsed teeth is one of the emergency situations in dentistry, they are in need of the education program in this field to improve the quality of life of patients with dental trauma.
| References|| |
Granville-Garcia AF, Ferreira JM, de Menezes VA, Cavalcanti SD, Leonel MT, Cavalcanti AL. Dental avulsion: Experience, attitudes, and perception of dental practitioners of Caruaru, Pernambuco, Brazil. Rev Odonto Ciênc 2009;24:244-8.
Robson F, Ramos-Jorge ML, Bendo CB, Vale MP, Paiva SM, Pordeus IA. Prevalence and determining factors of traumatic injuries to primary teeth in preschool children. Dent Traumatol 2009;25:118-22.
American Academy on Pediatric Dentistry Council on Clinical Affairs. Guideline on management of acute dental trauma. Pediatr Dent 2008-2009;30:175-83.
Andreasen JO. Relationship between cell damage in the periodontal ligament after replantation and subsequent development of root resorption: A time related study in monkeys. Acta Odontol Scan 1981;39:15-25.
Andersen PK, Andreasen FM, Andreasen JO. Prognosis of Traumatic Dental Injuries. In: Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4 th
ed. Oxford: Blackwell 2007. pp. 835-41.
Dumsha TC. Management of avulsion. Dent Clin North Am 1992;36:425-37.
Ashkenazi M, Marouni M, Sarnat H. In vitro
viability, mitogenic and clonogenic capacities of periodontal ligament cells after storage in four media at room temperature. Endod Dent Traumatol 2000;16:63-70.
Hiltz J, Trope M. Vitality of human lip fibroblast in milk, Hank's balanced Salt Solution and ViaSpan storage media. Endod Dent Traumatol 1991;7:69-72.
Patil S, Dumsha TC, Sydiskis RJ. Determining perioidontal ligament cell viability. J Endod 1992;18:189.
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;17:77-85.
Westphalen VP, Martins WD, Deonizio MD, da Silva Neto UX, da Cunha CB, Fariniuk LF. Knowledge of general practitioners dentists about the emergency management of dental avulsion in Curitiba, Brazil. Dental Traumatol 2007;23:6-8.
Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, et al
. Guidelines for the management of traumatic dental injuries II. Avulsion of permanent teeth. Dent Traumatol 2007;23:130-6.
Jyothi KN, Venugopal P, Nanda S, Shah M. Knowledge and attitude of medical doctors towards emergency management of avulsed tooth - a cross sectional survey. J Dent Sci Res 2011;2:156-67.
Upadhyay S, Rokaya D, Upadhyaya C. Knowledge of emergency management of avulsed teeth among general dentists in Kathmandu. Kathmandu Univ Med J (KUMJ) 2012;11:37-40.
Hamilton FA, Hill FJ, Mackie IC. Investigation of lay knowledge of the management of avulsed permanent incisors. Endod Dent Traumatol 1997;13:19-23.
Blömlof L, Otteskog P, Hammarstrom L. Effect of storage in media with different ion strength and osmolalities on human periodontal ligament cells. Scand J Dent Res 1981;89:180-7.
Andersson L, Bodin I. Avulsed human teeth replanted within 15 minutes - a long-term clinical follow-up study. Endod Dent Traumatol 1990;6:37-42.
Andreasen JO, Kristersson L. The effect of limited drying or removal of the periodontal ligament. Periodontal healing after replantation of mature permanent incisors in monkeys. Acta Odontol Scand 1981;39:1-13.
Blomlöf L. Milk and saliva as possible storage media for traumatically exarticulated teeth prior to replantation. Swed Dent J Suppl 1981;8:1-26.
Courts FJ, Meuller WA, Tabeling JH. Milk as an interim storage medium for avulsed teeth. Pediatr Dent 1983;5:183-6.
Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, et al
. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dental Traumatol 2012;28:88-96.
American Academy of Pediatric Dentistry. Guideline on management of Acute Dental trauma. Pediatr Dent 2011;33:222-8.
Sigalas E, Regan JD, Kramer PR, Witherspoon DE, Opperman LA. Survival of human periodontal liament cell in media proposed for transport of avulsed tooth. Dent Traumatol 2004;20:21-8.
Barrett EJ, Kenny DJ. Avulsed permanent teeth: A review of the literature and treatment guidelines. Endod Dent Traumatol 1997;13:153-63.
Martins WD, Westphalen VP, Westphalen FH. Tooth replantation after traumatic avulsion: A 27-year follow up. Dent Traumatol 2004;20:101-5.
Andreasen JO, Andreasen FM, Skeie A, Hjorting-Hansen E, Schwartz O. Effect of treatment delay upon pulp and perdiodontal haling of traumatic dental injuries - a review article. Dent Traumatol 2002;18:116-28.
Turkistani J, Hanno A. Recent trends in the management of dentoalveolar traumatic injuries to primary and young permanent teeth. Dental Traumatol 2011;27:46-54.
Andreasen JO, Andreasen FM. Essentials of Traumatic Injuries to the Teeth. 2 nd
ed. Copenhagen, Denmark: Munksgaard and Mosby; 2000. p. 9-154.
Treatment of the avulsed permanent tooth. Recommended guidelines of the American Association of Endodontists. Dent Clin North Am 1995;39:221-5.
[Table 1], [Table 2], [Table 3]