The Effect of an Educational Intervention in Dental Traumatology on General Dentists' Knowledge: A Study in the Public Dental Service of Western Norway

ABSTRACT

Aim

To assess the effect of a dental traumatology educational intervention on general dentists' knowledge. The study was conducted at Vestland County's Public Dental Service (PDS) in Western Norway.

Materials and Methods

All PDS dental clinics of Vestland County (n = 52) were purposively assigned to a control group receiving no intervention (CC, n = 19), a webinar group (IC1, n = 17), and a combined webinar and in‐person physical course group (IC2, n = 16). To examine the effect of the intervention, participants received a post‐intervention online questionnaire (Q2) with clinical cases. A generalized linear mixed‐effects model (GLMM) was used to compare the individual proportion of correct answers in Q2 between the three groups of educational intervention, where the clinic was set as a random effect factor. Additionally, a GLMM with a binary response variable was used to analyze the answers to individual cases. p < 0.05 was considered statistically significant.

Results

The response rate was 57% (n = 94). The overall proportion of correct answers was 67.7%, 71.0%, and 75.0% for the CC, IC1, and IC2 groups, respectively. There was no statistically significant difference in the overall proportion of correct answers between the groups when accounting for the dependency structure caused by clinics. However, for the individual cases, the IC2 group had a statistically significantly higher proportion of correct answers in complicated crown fracture of the immature tooth (p = 0.02) and first aid after avulsion (p = 0.02) compared to the CC group. Furthermore, the IC2 group had a trend of difference in complicated crown fracture of the mature tooth (p = 0.09) compared to the CC group and in emergency treatment of root fracture (p = 0.08) compared with IC1.

Conclusion

This study demonstrates that an educational intervention combining webinars with in‐person interactive courses has a positive effect on general dentists' knowledge of dental trauma.

1. Introduction

Traumatic dental injuries (TDI) affect nearly one‐quarter of adolescents and adults at least once during their lifetime [1]. In permanent dentition, the global prevalence is 15.25%, and the global incidence rate is 2.75% (events per 100 people per year) [2]. The most affected teeth are the upper central incisors, and enamel fracture is the most frequent injury [3]. Inadequate and delayed TDI treatment may lead to functional and aesthetic problems [4, 5, 6]. To prevent long‐term complications and reduce the need for extensive future treatments, proper diagnosis and early effective TDI management are needed [7]. When the traumatized teeth are promptly and properly examined, and correct emergency treatment is provided, the best patient outcomes can be achieved [8]. Therefore, it is crucial that general dentists have the good knowledge and skills to manage TDI patients.

Several recent studies conducted among general dentists worldwide indicate inadequate knowledge about TDI management [9, 10, 11, 12]. One of the reasons may be the limited exposure of dental students to TDI patients during the undergraduate dental program [13]. In the study conducted among 164 dental schools worldwide by O'Connell et al. [13], the number of contact hours dedicated to dental traumatology teaching activities ranged from 2 to 185 h (median = 10). Furthermore, 1/3 of participating institutions (34%) reported an absolute lack of clinical exposure to TDI patients [13]. Taking into consideration the large variation of TDI and the unique characteristics of each case, together with the restricted exposure of dentists to TDI patients, the importance of continuing professional education in dental traumatology is signified.

During the latest years, changes in the accreditation system of the dental profession around Europe have led to the dynamic growth of continuing professional development (CPD) courses in dentistry [14, 15]. For example, the General Dental Council of the UK has declared that registered dentists must attend CPD courses and that they should be re‐accredited every 5 years [16]. In Norway, members of the Norwegian Dental Association are obliged to complete a minimum of 40 h of continuing education every 3 years [17]. As a result, there has been an increase in the number of theoretical as well as practical courses in dentistry [15].

In the post‐COVID‐19 era, webinars represent an educational approach with increased popularity among healthcare professionals [18]. The advent of webinars brought broad flexibility to education with the main advantage of accessibility, with reduced expenses and cost of delivery [15]. A recent study demonstrated that webinars in oral‐ and maxillofacial surgery were well accepted by the participants regardless of gender, specialty, and work experience and could serve as effective educational formats [19].

To improve continuing education, it is important to understand how to integrate useful interventions into health services and modify practitioners' behavior toward patients [20]. There is scarce information on the effect of educational interventions among dentists, especially in dental traumatology.

A recent study among general dentists in the Public Dental Service (PDS) of Vestland County, Norway, revealed the presence of a knowledge gap in dental traumatology [21]. Furthermore, the same group of dentists experienced TDI management as complex and expressed their need for relevant courses in dental traumatology aimed at combining good theoretical knowledge with clinical skills [22]. The need for a deeper understanding of educational interventions among general dentists generated the idea for the current study. General dentists employed in the PDS of Vestland County were subjected to a specifically designed CPD course in dental traumatology. The present study aimed to evaluate the effect of the educational intervention on general dentists' TDI knowledge.

2. Materials and Methods

2.1. Recruitment

For administrative purposes, the PDS of Vestland County is divided into four geographical districts (North, Southeast, West, and Central districts). Small clinics (up to three dentists) are located in rural areas, whereas large clinics (up to 12 dentists) are located closer to the city of Bergen or other central locations in the county.

All PDS clinics (N = 52) in the county were purposively assigned to three different groups according to the educational intervention: intervention Group 1 (IC1, N = 17 clinics), intervention Group 2 (IC2, N = 16 clinics), and control clinics (CC, N = 19 clinics). The IC1 group included 54 dentists, the IC2 group included 54 dentists, and the CC group included 61 dentists.

The distribution of clinics to the different groups was done by considering the size of the clinic (number of dentists) and geographical location (districts), with the purpose of including a balanced sample of clinics with respect to size and residence place in each intervention group.

2.2. Intervention

The intervention clinics received either a standardized theoretical course in TDI in the form of webinars only (IC1) or the theoretical webinar course combined with a 1‐day in‐person course (IC2). The control clinics (CC) did not receive any educational intervention during the study period, but they were offered webinars and the in‐person course after data collection was concluded.

The webinars were available on a secured internet platform for 3 months (November 2022–February 2023). A link to the platform was distributed through an e‐mail sent by the clinic managers to their staff. The instructions given were to watch the webinars according to their convenience. The clinics were free to choose either to watch the webinars as a group (whole clinic together) or as individuals (when the dentists had available time in their clinic schedules, alternatively after regular working hours). For group IC2, participants were expected to view the webinars prior to attending the physical course, and this pre‐requisite was communicated to the clinics upon scheduling the in‐person course.

The webinars were designed and led by a specialist in endodontics and pediatric dentistry (Athanasia Bletsa) together with a specialist in pediatric dentistry (Georgios Tsilingaridis). Both had long clinical experience in TDI as well as teaching in dental traumatology. Webinars were pre‐recorded video lectures, non‐synchronous, and therefore flexible for participants. There were, in total, nine webinars lasting between 9 and 20 min each, with a total duration of 2 h and 20 min The topics covered were diagnosis, emergency treatment, and prognosis of TDI in the primary and permanent dentition. The official languages of the webinars were two similar languages, Norwegian and Swedish.

The in‐person course was given by the principal investigator (Athanasia Bletsa) to the IC2 group. The course was offered to the whole dental team, including dentists, dental hygienists, dental assistants, and clinical managers, as a 1‐day course (6 h duration) at the respective clinics. The first part (3 h) included general information related to dental trauma and practical advice on the management of TDI. Among the topics covered were how to manage emergency TDI patients as a team, the use of the standardized trauma registration checklist in the County's electronic journal system (OPUS), radiographic examination, and clinical photography related to TDI. The second part (3 h) was an interactive group discussion on various trauma cases, including both emergency treatment and further management and complications. This part was offered only to dentists and dental hygienists. The physical course was given to the selected clinics in the period from early December 2022 to late February 2023.

2.3. Questionnaire

Three months after the completion of the competition of the intervention, a questionnaire was distributed electronically to all PDS dentists in the county (N = 174). Due to new employment in the PDS after the intervention, five additional dentists were invited to participate. Briefly, the questionnaire included two parts. The first part contained questions related to sociodemographic information and attitudinal characteristics of the participants. The second part included eight different clinical cases with a total of 21 questions to answer. The form and content of the questionnaire have been previously described in detail [21] with the additional question, “How easy/difficult did you find the questionnaire?”. The questionnaire was available for 3 months, from May 2023 to July 2023. Data collection was concluded in August 2023.

2.3.1. Statistical Analysis

Statistics and figures were done using R version 4.4.2 (R Core Team, 2024). Based on the three groups (CC, IC1, and IC2), we evaluated background statistics with respect to frequencies of potential predictors. Eventual frequency differences between the three groups with respect to sociodemographic characteristics were evaluated using Fisher's exact tests.

Furthermore, the dataset consisted of answers to 21 questions (eighth TDI case scenarios). Each answer represents binary data, where the values zero and one represent a wrong and correct answer, respectively. To evaluate overall performance, we created two variables; one was called Prop, representing the individual proportion of correct answers, and one was called Total, representing the total number of questions answered for each individual. These variables were used in a generalized linear mixed model (GLMM) for proportions using the glmmTMB library and function [23]. The group was a predictor with three levels: CC, IC1, and IC2 group, and confounder(s) represent one or more background factors that eventually differ between the groups. The random effect factor in the model was the clinic where each individual participant was employed (clustering). If a model showed a statistically significant effect on the Group or if the Group was close to being significant (p < 0.1), we performed an unplanned multiple comparison test (Tukey HSD) to figure out which of the three groups differed (p < 0.05) or showed a trend of difference (p < 0.1).

To explain the variability in Prop, we used the same analyses to evaluate the potential of the following five predictors: (1) gender, (2) age, (3) years since education was finished, (4) Self‐assessed knowledge level, and (5) Continuing education course.

To get an overview of which TDI cases the participants would benefit from the intervention, we analyzed the answers to each question in separate models. Since the response variables in each model represented binary data with only one trial, we used the same type of model as described above but for binary data. Analyses were done using GLMM, and the Tukey HSD test was used to explore pairwise differences between groups. p values were adjusted using the single‐step method.

We also evaluated the association between the perceived difficulty level of the questionnaire and the self‐assessed knowledge level or years since finished education. The two latter variables were used as predictors in two separate analyses. We used Kruskal‐Wallis's test in both analyses, followed by the two‐sided Dunn test for pair‐wise multiple comparisons. Likewise, we looked at the relationship between self‐assessed knowledge level or perceived difficulty level and intervention groups. p < 0.05 was considered statistically significant.

3. Results

3.1. Characteristics of the Participants

Of the 176 dentists invited to participate, 100 dentists responded (response rate 57%). Among the responders, one dentist did not answer the second part of the questionnaire (cases), and five dentists answered less than 15 of the 21 questions. Those six participants were excluded from the analyses. Thus, responses from 94 participants were analyzed. Table 1 presents the socio‐demographic and attitudinal characteristics of the respondents according to the intervention group. Case discussions in the clinic among colleagues and contact with specialists were reported as the most common ways to update their knowledge on TDI, followed by participation in dental traumatology courses and the use of the “Dental Trauma Guide.” The socio‐demographic characteristics of the participants were similar between the intervention groups CC, IC1, and IC2. Significantly more respondents in the IC2 group attended continuing education courses in dental traumatology and had more TDI cases in the last 12 months compared to respondents in the CC group (Table 1). Therefore, the models evaluating overall performance and performance at each individual question included the number of TDI cases in the last 12 months as a covariate.

TABLE 1.

Sociodemographic and attitudinal characteristics of the participants (n = 94).

	Total n (%)	CC n (%)	IC1 n (%)	IC2 n (%)	p value
Gender
Female	79 (84.04)	26 (27.7)	28 (29.8)	25 (26.54)	0.6
Male	15 (15.96)	6 (6.38)	3 (3.19)	6 (6.38)
Age
< 30	17 (17.1)	5 (5.02)	6 (6.03)	6 (6.03)	0.37
30–39	28 (29.8)	11 (11.7)	8 (8.51)	9 (9.57)
40–49	30 (31.9)	8 (8.5)	14 (14.9)	8 (8.5)
50–59	11 (11.7)	3 (3.19)	3 (3.19)	5 (5.31)
≥ 50	8 (9.5)	5 (5.93)	0	3 (3.56)
Country of education
Norway	78 (82.9)	25 (26.6)	28 (29.7)	25 (26.6)	0.65
Other European countries	12 (12.8)	6 (6.4)	2 (2.1)	4 (4.2)
Outside Europe	4 (4.3)	1 (1.1)	1 (1.1)	2 (2.1)
Years since graduation
< 6	27 (27.7)	7 (7.2)	8 (8.2)	11 (11.3)	0.53
6–10	15 (16.0)	7 (7.4)	4 (4.3)	4 (4.3)
11–20	31 (33.0)	9 (9.6)	14 (14.8)	8 (8.5)
> 20	22 (23.3)	9 (9.5)	5 (5.3)	8 (8.5)
Number of patients with TDI last year (follow‐ups included)
0–5	9 (9.6)	7 (7.5)	2 (2.1)	0	0.02
6–15	37 (39.4)	12 (12.9)	15 (15.9)	10 (10.6)
> 15	48 (51.0)	13 (13.8)	14 (14.9)	21 (22.3)
Self‐reported knowledge
Low	0	0	0	0	0.60
Acceptable	36 (38.3)	15 (15.9)	10 (10.6)	11 (11.8)
Good	53 (56.4)	16 (17)	20 (21.3)	17 (18.1)
Very good	5 (5.3)	1 (1.06)	1 (1.06)	3 (3.28)
Clinical work
> 50%	83 (88.3)	27 (28.7)	28 (29.7)	28 (29.9)
21%–50%	2 (2.1)	1 (1.05)	1 (1.05)	0
20%	8 (8.5)	3 (3.2)	2 (2.1)	3 (3.2)
None	1 (1.1)	1 (1.1)	0	0
Continuing education course in TDI
No		16 (17.0)	8 (8.5)	4 (4.3)	0.004
Yes		16 (17.0)	23 (24.5)	27 (28.7)

Note: CC: Control group‐no intervention, IC1: Webinar group, IC2: combined Webinar and in‐person course group. Fisher Exact test for frequency distribution over the CC, IC1, and IC2 groups, p < 0.05 was considered statistically significant. The significance for bold values is 1.

3.2. Participants' Proportion of Correct Answers

The overall proportion of correct answers in the 21 questions (eighth cases) was 67.7%, 71.0%, and 75.0% for the CC, IC1, and IC2 groups, respectively. The GLMM used to analyze the data showed no statistically significant difference between the intervention groups in the proportion of correct answers (Figure 1a). The GLMM controlled for the dependency due to the clinics (random effect factor) and the effect of the number of trauma patients in the last 12 months (potential confounding factors). Using the same statistical model (GLMM), none of the five tested predictors was found to have a statistically significant effect on the individual proportion of correct answers (Figure 1b–f).

FIGURE 1.

The potential of single predictors in relation to the proportion of correct answers (correct number of answers/total number of answers) on clinical TDI cases in the post‐intervention questionnaire. The big data points represent the model predictions of the proportion of correct answers, and the error bars represent corresponding 95% confidence intervals. Predicted values are not corrected for the confounding factor of the number of trauma patients in the last 12 months. The smaller grey points represent the raw data with some random horizontal offset to better separate individual answers. There was no statistically significant effect of the predictors (x‐axis) when controlling for the effect of the number of trauma patients in the last 12 months (covariate) and the cluster effect from the clinic to which each participant belongs (random effect factor). CC, control group; IC1, webinar group; IC2, webinars combined with an interactive in‐person course.

The responses to each case scenario according to the intervention groups are shown in Figure 2. The analysis compared the performances of the three intervention groups across various clinical cases using multiple comparison tests. Statistically significant differences were found in the following clinical cases: complicated crown fracture in immature tooth (p = 0.02) and the best advice on the phone for an avulsed tooth (p = 0.02) with dentists in the IC2 group answering better compared with the CC group. In addition, The IC2 group showed a trend of difference (p < 0.1 in a multiple comparison test) in two more cases: complicated crown fracture in mature tooth and emergency treatment of root fracture. Webinar training had some positive impact on participants' answers in complicated crown fracture of immature tooth.

FIGURE 2.

The proportion with a correct answer on each clinical dental trauma case in the post‐intervention questionnaire. The blue and red points represent the predicted proportions from the models, and the error bars represent corresponding 95% confidence intervals. The smaller grey points represent the binary raw data with some random horizontal and vertical offset to better separate individual answers. A group with a different color from the control (CC) indicates statistical difference, where a dark red color represents a trend of a difference (p < 0.1) and a brighter red color represents a statistically significant difference (p < 0.05) from the control in a multiple comparison test. Panels without error bars (k and f) indicate response variables with very low variability. CC, control group; IC1, webinar group; IC2, webinars combined with an interactive in‐person course.

3.3. Perceived Knowledge and Case Difficulty

The association between the self‐assessed difficulty level of case scenarios and the self‐assessed knowledge level or years since finished education is shown in Figure 3. None of the participants reported a “Low” self‐assessed knowledge level. Participants who assessed themselves as having “Good” knowledge and “Very Good” knowledge found the cases significantly easier (p = 0.03 and p = 0.02, respectively) than participants who assessed their knowledge as “Acceptable” (Figure 3a). Furthermore, participants who finished their education more than 20 years ago found the case scenarios significantly easier (p = 0.015) compared to those with 6–10 years of experience (Figure 3b).

FIGURE 3.

Significant predictors for self‐assessed level of difficulty for the case scenarios. Panel (a) shows the effect of self‐assessed knowledge level and panel (b) shows the effect of years since finished education. The blue points represent the mean level of self‐assessed difficulty for the case scenarios within each x‐axis group. The black points represent individual data with random horizontal and vertical offsets for better visual separation. The x‐axis in panel (a) also contained a category “Low”, but none of the participants answered this. The x‐axis groups in panel (a) that are statistically significantly different about self‐assessed difficulty are Acceptable versus Good and Acceptable versus Very Good. For panel (b), the corresponding groups that differ from each other are 6–10 versus > 20 years since finished education. Kruskal–Wallis's test was used in both analyses, followed by the two‐sided Dunn test for pair‐wise multiple comparisons. p < 0.05 was considered statistically significant.

There was no statistically significant difference between the three intervention groups on self‐assessed knowledge and perceived difficulty level. However, a noticeable trend was observed, with the intervention groups IC1 and IC2 reporting a higher level of knowledge and finding the questionnaire easier compared to the control group (CC) (Figure 4).

FIGURE 4.

The effect of intervention for self‐assessed knowledge level in dental traumatology and self‐assessed difficulty level of the post‐intervention questionnaire. Although the intervention groups IC1 and IC2 reported a higher level of knowledge and found the questionnaire easier compared to the control group, there was no statistically significant difference between the three intervention groups. CC, control group; IC1, webinar group; IC2, webinars combined with an interactive in‐person course.

4. Discussion

The study population had previously expressed the need for CPD in dental traumatology [22]. We designed a course based on the participants' perceived needs and by considering the knowledge gaps [21, 22]. The present study aimed to investigate the effect of this customized educational intervention on general dentists' knowledge. Although there was no statistically significant difference in overall questionnaire performance between the three groups, there was a positive effect of the combined educational package on TDI knowledge. Looking at the individual cases, there were many case scenarios where the dentists exposed to the intervention had a higher proportion of correct answers compared to the dentists in the control group. There were also many cases where the general dentists did well regardless of the intervention group, and there was little variability in the responses due to the relatively low sample size. In general, a large sample size provides more robust statistical power [24]. Detected trends noted that specific clinical cases (e.g., severe intrusion, root fracture) may have reached statistical significance with a larger sample size.

In a recent study conducted among general dentists in the PDS in Western Norway, general knowledge about emergency treatments was reported as good, with identified knowledge gaps in crown fractures with pulp exposure, avulsion, and severe intrusive luxation injuries [21]. It was interesting to see that the IC2 group performed better in the same clinical scenarios, showing a positive effect of the course content and educational format.

The quality of the course content was validated with defined learning objectives related to TDI management based on the International Association of Dental Traumatology (IADT) guidelines [25]. Interaction in educational courses plays an important role in knowledge retention [26]. Webinars were theoretical‐based pre‐recorded lectures and promoted passive learning. According to Bligh, attention drops during so‐called passive learning sessions such as lectures [27]. Although the webinars were delivered by experts and adhered to high standards and the latest IADT guidelines, the group receiving the webinars alone did not achieve better results following the intervention. The online nature of webinars might lead to passive learning, where participants absorb information without much interaction [28]. Additionally, the option of watching the webinars alone or in plenum may have also affected the results. Limited interactivity with the course educator and between colleagues might explain the limited effect of the webinars. The observed trend of improvement in the webinar group for certain cases suggests that webinars have some value but not enough elements for significant improvement. On the other hand, in‐person courses in small groups encourage active engagement. Small group settings promote discussion, questions, and personalized instruction, and they activate the participants more than webinars [29]. It is shown that the educational format's ability to interact enough ensures retention and application of knowledge [30].

Several studies have evaluated the effectiveness of educational interventions in dental traumatology to improve clinical performance and knowledge retention among dental students [31, 32, 33, 34, 35, 36]. On the contrary, educational intervention studies in dental traumatology among general dentists are scarce [37, 38, 39, 40]. When dentists in Brazil attended a 40‐min lecture about avulsion, this short educational intervention improved their knowledge of the topic, as shown by comparing the pre‐ with the post‐intervention questionnaire [38]. This study suggested that the traditional educational format—lecture is an effective way to improve knowledge. On the other hand, in the present study, webinars showed limited effect. Although difficult to compare, webinars in the current intervention resembled the traditional lecture format. However, there was a lack of contact with the educator for questions and answers. Another study among pediatric dentists at Loma Linda University School of Dentistry in the USA showed a positive effect of the use of pamphlets and mobile applications with clinical decision guides as an educational intervention [40]. Using a mobile application required more time but led to a better effect on knowledge. According to these findings, it can be assumed that longer engagement may contribute to deeper learning and understanding [41]. All the above indicates that diversity in the educational format may influence the effectiveness of the intervention as well as course content and structure. Participant engagement was detected in our study during the interactive in‐person course, which can explain the trend toward improvement. Educational interventions through interactive 4‐h didactic workshops on dental emergencies in Australia represent another example of significantly improved knowledge on managing avulsed teeth by medical practitioners, nurses, and medical students [42, 43]. Participants were tested before and after the workshops, and a positive knowledge impact was recorded. Compared to the present study, the similarity lies in interactivity playing an important role in knowledge retention.

General dentists are lifelong learners, and the importance of CPD for every practitioner, particularly in specialized fields like dental traumatology, has been underscored [44]. Although general dentists in this study improved their knowledge in two specific clinical cases after attending the webinar and physical course, it is necessary for learners to engage in the process of reflection and how to apply the new knowledge in practice [44]. However, it is essential to acknowledge that some degree of knowledge declines over time [45, 46]. This means that even after successful educational training, participants may forget over time what they have learned if they do not continually apply the gained knowledge. That is why regular and frequent CPD in dental traumatology is recommended. In support of this, the additional finding in this study that dentists with 6–10 years since completing education find the post‐intervention questionnaire harder to answer compared to colleagues with over 20 years since finishing education indicates the need for repetition and calibration of knowledge in dental traumatology.

Alongside questions that assessed dentists' knowledge on TDI management, participants were also asked to self‐evaluate their knowledge, and most of them self‐reported TDI knowledge as good and very good. Self‐reported questionnaires can be subjective, and various biases may have an impact on the data [47]. Recent experimental investigation suggests that participants often report higher ratings when answering a questionnaire for the first time, so‐called initial elevation bias [48]. Furthermore, participants may give responses they deem to be socially acceptable or have a false sense of confidence [48, 49]. Our findings provided a representation of actual knowledge and helped mitigate potential biases in self‐assessment.

Successful educational interventions have a positive impact on dentists' knowledge. To understand the effect of the educational intervention, there is a need to extend the research and explore the circumstances and conditions under which the intervention is most effective, which means combining quantitative with qualitative approaches [50]. Additionally, future research should also address the assessment of the long‐term impact of acquired knowledge among general dentists, and it would be interesting to compare different educational approaches. From the cost perspective, continuing professional development requires financial investments, and further research should focus on predicting the economic return of the intervention using the education economic model [51].

To understand the wider application of these findings, it is important to put educational activities within the frameworks of preventive measures for dental trauma and available knowledge sources in dental traumatology [52, 53]. The educational activities analyzed in this study can contribute to secondary prevention because they promote the adequacy of TDI treatment [52]. Furthermore, our findings indicate that the combined educational approach aligned with current learning standards [53]. It encouraged interaction between the course facilitator and learners, provided feedback to the learner, and made the content relevant to dentists' learning needs [53]. In addition, it is important to consider the source of knowledge on which dental practitioners base their decisions in TDI management. Educational activities in this study were based on official protocols for TDI management recommended by IADT [54, 55, 56, 57, 58].

4.1. Strengths and Limitations of the Study

A strength of the study was the inclusion of all 52 PDS clinics in the County, and the clinics were representative of the population of clinics in Vestland. Furthermore, assessing the outcomes 3 months after the intervention, knowledge retention was measured, which is important to make decisions for the frequency of the TDI courses. The reliability of the findings was enhanced by using advanced statistical methods such as GLMM for a relatively small sample size to detect differences between the analyzed groups. On the other hand, the good baseline knowledge of the participants in several cases may have limited the intervention's overall effect. This, together with the small sample size, may have affected the main statistical findings. Lastly, this study focused on knowledge outcomes rather than behavioral changes in clinical practice.

5. Conclusion

Despite the limitations of this study, the trend toward improvement points out the value of CPD courses in dental traumatology. Combining several educational formats and encouraging interaction, this study indicates the challenges of designing and assessing CPD in dental traumatology. Further research is needed to understand effective educational methods that can improve knowledge in dental traumatology and change dentists' behavior in clinical practice.

For better patient care and professional growth, it is important to implement mandatory CPD programs in the PDS for all dental professionals. Combining learning approaches, promoting professional interactions, engaging digital tools, and providing financial support for CPD are suggested strategies. Implementation of CPD programs among dentists can be encouraged by the regulatory bodies by offering flexible learning options, providing financial support to participate in CPD, offering free training programs, encouraging peer learning, and establishing monitoring and evaluation to track the impact of CPD programs.

Author Contributions

Andjelka Cvijic contributed to the methodology, statistics, and writing process. Knut Helge Midtbø Jensen contributed to statistics and the writing process. Anne Åstrøm contributed to the methodology and writing process. Monika Kvernenes contributed to the writing process. Georgios Tsilingaridis contributed to conception and study design, and writing process. Athanasia Bletsa contributed to conception and study design, statistics, and writing process.

Ethics Statement

The Regional Ethical Committee for Medical Research accounted for the project as Health Services Research (Case number: 422616), and the Norwegian Centre for Research Data (Norsk Senter for forskningsdata; NSD) approved this project (number 535993).

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.