Dental avulsion management by emergency professionals and efficacy of education

This intervention study evaluated knowledge of first responders regarding the emergency clinical protocol in cases of dental avulsions and impact of an informative campaign. A questionnaire was applied to evaluate effect of provided information on knowledge among emergency service professionals regarding the management of avulsion of teeth: before campaign (T0) and after campaign (T1). Participants were invited to attend the dental trauma awareness campaign that was carried out by the researchers. The campaign addressed main doubts and difficulties regarding emergency dental trauma care. Data were statistically analyzed (p <0.05). There was significant increasing in the knowledge of professionals regarding the possibility (from 74% to 88%) and ability (5% to 32%) of first responders perform tooth replantation; about the ideal time to perform the replantation (from 30% to 59%); about the correct handling (from 52% to 85%) and the need for cleaning (from 60% to 79%) of an avulsed tooth for replantation. It can be concluded there is a lack of knowledge of emergency service professionals about tooth avulsion management. The strong message is the importance not only of identifying the lack of knowledge of the professionals about tooth injuries, but also perform the education that can significantly improve the professional knowledge.


Introduction
Dental trauma is a set of external impact that affects the teeth and surrounding tissues, which can be a simple enamel fracture until the definitive loss of the dental element, being classified into dental injuries, support tissue injuries, tissue injuries, soft and bone tissue lesions (Gonçalves et al., 2017). Recently, Petti et al. (Petti et al., 2018) performed a study to estimate global prevalence and incidence of dental trauma and concluded that more than one billion living people have had dental trauma. In Brazil, the prevalence ranges from 9.4% to 41.6%, with preschool children being the most affected (Gonçalves et al., 2017).
Facial injuries are six times more likely to happen in fast and contact sports compared to workplace accidents and three times more than exposure to violence or traffic accidents, causing orofacial trauma (Petrović et al., 2016).
During sports activities, traffic accidents and fights, adolescents may suffer dental trauma, representing a serious social problem. These traumas affect only a single tooth, or in the most severe cases involve multiple teeth. Fracture of the crown of the dental element of the anterior teeth, especially the central incisors are the most affected, causing pain and discomfort for patients and can significantly affect the quality of life by affecting the smile. And the anterior teeth are not only important for aesthetics, but also for speech, chewing, the health of adjacent tissues and the individual's own psychological health (Azami-Aghdash et al., 2015;Goyal et al., 2017).
In enamel and dentin fractures without pulp exposure, urgent care is not necessary. However, dental care is necessary to evaluate and treat the case (Andersson et al., 2016). Other moderate injuries such as coronary fractures with pulp exposure, intrusive dislocation, concussion, subluxation, and trauma to primary teeth require immediate professional dental care that cannot be performed at the accident site (Andersson et al., 2016). Dental avulsion, although considered a more serious situation, should also receive immediate attention but this management can be performed in the accident site by anyone (Andersson et al., 2016).
Among dental trauma types, greater attention should be paid to dental avulsion when the dental element comes out of the socket completely, as the chances of tooth preservation depend directly on care at the time and place of the accident. In permanent teeth, immediate reimplantation of the tooth in the socket, performed by anyone, even the victim, within the first 5 minutes after trauma is indicate (Andersson et al., 1990;Baginska et al., 2016). Cells in the periodontal ligament can necrosate after 30-60 minutes if stored in a dry medium, which significantly reduces the favorable prognosis of dental replantation. If immediate reimplantation is not possible, to avoid dehydration of the tooth, the best way to store this avulsed tooth is in substances closest to the saliva Ph, like the victim's own saliva or milk Mori et al., 2010). Some natural substances have also been study and demonstrated good storage medium such as propolis (Mori et al., 2010). This storage time have to be only the needed time to take it to the dentist. Some rules must also be followed to prevent crushing of periodontal ligament cells on the root surface: the dirty tooth should be washed with running water or saline solution, not rubbing the tooth or root, always manipulating the tooth by the crown, and routing the fastest possible victim for the dentist .
Avulsed teeth that are stored in the wet environment until replantation can present greater chances of success, but if the tooth is kept stored in dry medium before the replantation, there is no maintenance of the cell viability making the prognosis unfavorable . Post-replantation complications may occur as dental pulp necrosis, dental ankylosis, root resorption, failure of complete root development, and in more severe cases dental loss (Matias et al., 2014).
Twenty-four-hour emergency services are most often referred to dental trauma while dentists rarely provide first aid (Cruz-da-Silva et al., 2016). Therefore, these professionals need to know the protocol of dental trauma, but studies show inadequate professional knowledge on this subject, and after campaigns and lectures contribute significantly to increase knowledge of these professionals (Cruz-da-Silva et al., 2016).
Reliable data related to the prevalence, causes and risk factors of traumatic dental injuries are needed for its prevention. However, many people are unaware of these risk factors and the main ways to prevent these injuries. Moreover, some dentists and health professionals do not attach much importance to prevention but are more concerned with aspects of treatment (Ain et al., 2016). Thus, to increase the chances of a favorable prognosis in cases of dental trauma, it is essential to provide proper guidance to first-aid professionals about the importance of knowing the immediate clinical protocol and thus, it is possible to save more teeth, besides reduce emotional and psychological impacts on individuals affected by dental trauma.
Importance not only identifying the lack of knowledge of the population about the conducts to be performed in case of dental trauma, but also of the education of the emergency professionals about this topic. This intervention study evaluated knowledge of first responders regarding the emergency clinical protocol in cases of dental avulsions and impact of an informative campaign.

Methodology
This study was carried out through a longitudinal analysis of the knowledge of all professionals involved in emergency care (firefighters and professionals of the municipal mobile emergency service) about dental trauma in the city of Presidente Prudente, SP, Brazil.
Inclusion criteria involved professionals who provide first aid in the emergency services in the city of Presidente Prudente (population of 100 professionals). Exclusion criteria involved professionals who did not attend to the lecture about dental traumatism. All participants received information about the objective procedures of the study. A questionnaire was applied twice to evaluate the effect of the information provided on knowledge and changes in attitudes among non-dentists' health care regarding tooth avulsion management: before the lecture (T0) and after the lecture (T1).
The purpose of the first questionnaire application (T0) was to determine a priori knowledge about the subject. The purpose of the second questionnaire application (T1) was to determine improvements in knowledge and to evaluate the influence of the information provided.
The questionnaire (Table 1) contained subjective questions about the definition of tooth avulsion / replantation, postavulsion management, extra-alveolar time, and storage media of tooth. The questions were partly derived from previously published research (Matias et al., 2014;Cruz-da-Silva et al., 2016).
The questionnaire was divided into two sections. The first section comprises items about personal information (gender and age) and the concept of tooth avulsion. The second section consisted of 12 (twelve) multiple choice questions addressing knowledge on dental avulsion, training received on this subject, and management of avulsion cases.
Participants were invited to participate in the information campaign about dental trauma that was carried out by the Dental Trauma Extension Project of the University. The campaign addressed the main doubts and difficulties regarding urgent care. The campaign included lectures and the use of printed materials containing information on the urgent care for dental trauma, especially dental avulsion. Participants were instructed on immediate replantation, on the appropriate way of washing the avulsed tooth, as well as the means of preservation for this tooth and posttraumatic conducts. Participants were encouraged to discuss their questions and collaborate with everyone's knowledge and learning.
For data analysis, chi-square test was used, with a significance level of 5% (R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/.).

Results
One hundred emergency professionals (100% of the emergency professional population) answered the questionnaire at T0. A difficulty in accessing professionals who worked on an hourly scale was observed at T1. So, seventy-tree emergency professionals answered the questionnaire after campaign.
Tables 1 and 2 show percentage of each item answered by the professionals before (T0) ( Table 1) and after (T1) ( Table 2) the campaign. The desired/acceptable answers to each question are highlighted in blue. Figures 1 and 2 show a comparative analysis of the percentages of responses obtained before and after the campaign.
There was a significant increase in the knowledge of professionals regarding the possibility (from 74% to 88%; pvalue = 0.04348) and ability (5% to 32%; p-value = 0.00000797) to replant an avulsed tooth; about the ideal time to perform the replantation (from 30% to 59%; p-value = 0.01488) or the appropriate storage medium until the patient can be in front of a specialized professional (p-value = 0.0001991); about the correct handling (from 52% to 85%; p-value = 0.00001361) and the need for cleaning (from 60% to 79%; p-value = 0.01083) of an avulsed tooth before replantation.

Discussion
Recent literature has shown that first responders have inadequate knowledge about how to act in cases of dental traumatism, including tooth avulsion (Cruz-da-Silva et al., 2016). In fact, the results of the present study showed that professionals involved in emergency care (firefighters and municipal emergency mobile service professionals) provided unsatisfactory answers to the questionnaire applied before the informative campaign. Other professionals strictly related to dental trauma, such as school professionals , physical educators (de Oliveira et al., 2017) and sports participants (Mori et al., 2009), demonstrate faulty knowledge about management conducts.
Most professionals did not know that they could perform the replantation at the time of care or were not able to, did not know the ideal time to perform the replantation, how to properly manipulate the tooth and whether there was need for cleaning before replantation. These results corroborate other findings in the literature in which it was observed that most emergency (Lin et al., 2006;Traebert et al., 2009;Trividy et al., 2012;Ulusoy et al., 2012;Jetro et al., 2013;Needleman et al., 2013;Yigit et al., 2019) or felt little able to perform the replantation (Trividy et al., 2012).
It is known that when replantation is performed right after dental avulsion (up to 15 minutes) or when the tooth is stored in appropriate solutions to provide cell recovery, the prognosis of the tooth is increased . When immediate replantation is not possible, keeping the tooth in a humid environment is obligatory (Andersson et al., 2012). Milk is indicated as a storage medium of choice to avulsed teeth in many countries once it is available immediately, besides to preserve cell viability for up to 6 hours (Blomlöf et al., 1983;Pearson et al., 2003;Arikan et al., 2012;Mori et al., 2016). Lack of knowledge can negatively influence or the primary care of emergency services in case of dental avulsion.
Several studies have shown that there is a need for education of emergency professionals so that appropriate primary care can be provided by the patient in case of dental trauma (Lin et al., 2006;Traebert et al., 2009;Trividy et al., 2012;Ulusoy et al., 2012;Jetro et al., 2013;Needleman et al., 2013;Yigit et al., 2019). Furthermore, these studies reinforce that the lack of training and guidance may be the cause of emergency professionals do not feel safe to perform the replantation at the time of care (Lin et al., 2006;Traebert et al., 2009;Trividy et al., 2012;Needleman et al., 2013). One study also suggested that dental institutions should provide a list of dentists who are available 24 hours a day to provide first-time dental trauma care (Needleman et al., 2013). However, only one of these studies offered campaign or instructions to these professionals after finding that their knowledge was unsatisfactory (Cruz-da-Silva et al., 2016). Thus, the results of the present study corroborate other data from the literature that has demonstrated the importance not only of identifying the lack of knowledge of the population about the conducts to be performed in case of dental trauma, but also of the education of the professionals involved with dental trauma Arikan et al., 2012;Taranath et al., 2017) such as educators, sportsmen, dentists, pediatricians and first responders.
Some authors (Cruz-da-Silva et al., 2016) performed a study similar to the present, evaluating the effects of an educational program on the level of knowledge of emergency medical service professionals in the city of Campina Grande (PB, Brazil). The authors also applied a questionnaire about dental trauma before and after the educational program. The authors observed a significant increase in the number of correct questions about the care to be taken in case of dental trauma.
Results observed by Cruz da Silva et al. (2016) corroborate the findings of the present study, where a significant increase in the knowledge of professionals regarding the possibility (from 74% to 88%) and ability (5% to 32%) of first responder to replace a avulsed tooth was observed; about the ideal time to perform the replantation (from 30% to 59%); about the correct handling (from 52% to 85%) and the need for cleaning (from 60% to 79%) of an avulsed tooth before replantation.
In the present study, no statistically significant difference was observed only regarding to the indication of the appropriate professional to provide emergency care, if it cannot be immediately performed by the first responder. The desirable answer to this question would be to refer you to the dentist closest to the scene of the accident or to the victim's dentist so that the replantation could be performed as quickly as possible. However, most professionals responded that they would refer the victim to a public hospital in the city. In this context, it is important to consider that professionals reported that they are required to refer their patients to hospitals, which certainly influenced these results.
An interesting event observed by evaluating the literature was that most studies that evaluated the knowledge of emergency service professionals about the correct conduct in dental trauma cases addressed doctors and the emergency team offered by hospitals (paramedics, nurses and even dentists). Only one study (Jetro et al., 2013) evaluated the level of knowledge of firefighters in case of dental trauma. Jetro et al. applied questionnaires to firefighters in the city of Caicó (RN, Brazil) and concluded that the knowledge of the professionals was unsatisfactory. The authors reinforced the need for guidance of these professionals but, again, no educational action was taken after the application of the questionnaires.
The limitations of this study include: 1) the number of individuals -which was the majority of emergency professionals in the city but who make up a small sample; 2) the educational campaign was carried out in small groups and not for all participants, due to the work scale of individuals who may have influenced the motivation to seek knowledge; 3) there was a small loss of sample between the first and second application of the questionnaire; 4) little time between the educational campaign and the time for the second application of the questionnaire due to the difficulty of access to the participants and their work scale.

Conclusion
There is a lack of knowledge of emergency service professionals about tooth avulsion management. The strong message is the importance not only of identifying the lack of knowledge of the professionals about tooth injuries, but also perform the education that can significantly improve the professional knowledge.