Abstract
Objectives
The aim of this study was to evaluate the knowledge of first aid measures for a permanent tooth avulsion among parents in Kuwait and to assess the effect of different sociodemographic characteristics.
Materials and Methods
A cross-sectional study was conducted among 554 parents who visited 5 dental specialty centers in Kuwait. Parent sociodemographic data and responses to avulsion management questions were collected through a self-administered questionnaire. Descriptive and binary logistic regression analyses were used for data analysis.
Results
In the 554 responses from patients, gaps were identified in the following areas: replantation (199, 35.9%), cleaning of the tooth (182, 32.9%), and transport media (84, 15.2%). Most parents demonstrated satisfactory knowledge levels regarding the urgency to seek professional help (391, 70.6%) and the first place of contact after the injury (525, 94.8%). Having previous information on emergency management of dental avulsion was a significant predictor of good knowledge (OR 2.138, 95% CI 1.347–3.395, p = 0.001). Of the 544 parents, 99 (17.8%) had received information on dental avulsion management: 30 (30.3%) from the Internet, 19 (19.2%) from books, 12 (12.1%) from television, 6 (6%) from smart phone applications, 2 (2%) from newspapers, and 30 (30.3%) from other sources.
Conclusion
In this study, parents in Kuwait did not have adequate knowledge of emergency management for dental avulsion. Future educational campaigns on dental avulsion are urgently needed to educate parents.
Keywords: Parents' knowledge, Dental avulsion, Dental emergency
Significance of the Study
• This study revealed poor parental knowledge regarding the management of dental avulsion. This could substantially affect the prognosis of an avulsed permanent tooth and could also pose economic and psychological burdens on the child and the parents.
Introduction
Dental avulsion is one of the most serious traumatic dental injuries that result in ischemic damage to the pulp and periodontal ligament tissues [1]. Tooth avulsion poses economic and psychological burdens, both on the child and the parents [2, 3]. It also affects the psychological development of children and teenagers, which can be demonstrated by their conscious effort to avoid smiling [4]. In addition, the cost of dental treatment after tooth avulsion is high [2, 5, 6].
It was reported that recommended treatment for ensuring the viability of periodontal ligament cells was immediate replantation and minimizing the extraoral dry time of an avulsed tooth [7]. In many instances, an avulsed tooth cannot be replanted immediately; therefore, it should be stored in a suitable medium [7].
Previous epidemiological studies showed that the majority of dental injuries occur at home, and therefore the parents' knowledge of the emergency management of an avulsed tooth is essential for achieving a successful outcome [8]. However, poor parental knowledge of first aid measures for avulsed teeth were reported previously [1, 9, 10, 11, 12, 13], and a major weakness was detected in certain areas, such as appropriate storage media and storage time [9, 10, 11, 12, 13]. This is unfortunate because prompt and appropriate management at the site of the injury can significantly improve the prognosis of an avulsed permanent tooth [14].
Despite the crucial role played by the parents in the emergency management of dental avulsion, only one study was conducted in Kuwait in 2007 [1]. The International Association of Dental Traumatology (IADT), which is the professional organization in the field of traumatic dental injuries, released the IADR guidelines for the management of avulsed permanent teeth in 2012 [7]. Therefore, it is necessary to develop a questionnaire based on the current guidelines to include all the relevant items. The aim of this multicenter cross-sectional study were to assess the parental knowledge of first aid measures for permanent tooth avulsion among parents in Kuwait and to investigate the influence of different sociodemographic characteristics on the emergency management of dental avulsion.
Subjects and Methods
Study Design and Population
This population-based, multicenter cross-sectional study was conducted from August 2015 to February 2016. The Ministry of Health Ethics Clearance Committee approved the protocol of this study.
G*Power version 3.1.9.2 software was used to calculate the sample size. The effect size was calculated based on the study by Al-Jame et al. [1], in which 30% of parents could not demonstrate any knowledge of the emergency management of dental avulsion. Based on 80% power and a significance level of α = 0.05, a minimum sample size of 501 subjects was needed to detect a change in proportion from 30 to 25% (effect size = −0.05). An additional 20% was added to the calculated sample size to compensate for possible drop out. Thus, a total sample size of 600 was selected. A total of 554 parents agreed to take part in the study. The age of the parents ranged from 20 to 75 years.
Parents in this study were recruited randomly from Kuwait's largest dental specialty centers: Bneid Al-Gar, Al-Amiri, Al-Farwaniya, Al-Jahra, and Al-Adan. Kuwait is divided into 6 administrative units (governorates): Capital, Hawalli, Ahmadi, Mubarak Al-Kabeer, Farwaniya, and Jahra. Every selected dental specialty center covers the dental needs of 1 administrative unit, with the exception of Al-Adan Dental Specialty Center, which receives patients from both Ahmadi and Mubarak Al-Kabeer administrative units.
One hundred questionnaires were given to each of the following dental specialty centers: Bneid Al-Gar, Al-Amiri, Al-Farwaniya, and Al-Jahra, while 200 questionnaires went to Al-Adan dental specialty center because it includes patients from 2 governorates. The inclusion criteria were: parents >18 years of age, competence in both spoken and written Arabic language, and agreement to participate in the study. Before distributing the questionnaires, the inclusion criteria were announced in each center. All potential parents in the waiting room and at the reception area of each center were approached directly by the authors (L.A., S.A.A., and S.A.) and were invited to participate in the study.
The information that would be gathered from the questionnaire and its importance in promoting awareness of the proper and urgent management of avulsion were explained to all eligible parents. Participation was voluntary and free of constraint or pressure. Written informed consent was obtained from the parents before proceeding with the study. To maintain the confidentiality of patient information, each questionnaire was given an identification number.
Study Questionnaire Content and Face Validity
A list of potential items was constructed based on a literature review of previously used questionnaires relating to the same topic [1, 4, 9, 10, 11, 12, 13, 15, 16, 17]. The included items, namely the replantation and proper handling of an avulsed permanent tooth, cleaning and transport media, and seeking professional help, were evaluated for their relevance to the study objectives by reviewing the current guidelines for first aid management of avulsed permanent teeth [7].
The questionnaire was pretested on 25 literate parents to evaluate comprehension, syntax, organization, grammar, appropriateness, and the logical sequence of the draft questionnaire. Based on this, some questions were rephrased and 2 pictures were added: an intraoral frontal picture showing the missing tooth and another showing the knocked-out tooth with labels that demonstrated the tooth parts, i.e., the crown and the root. Information gathered from this pilot study was excluded from the main study sample.
Data Collection Instrument
Data were collected through a self-administered questionnaire that was developed in Arabic, which is the official language of Kuwait. This was achieved through forward translation by L.A., who is a general dental practitioner familiar with the medical terms used and conversant in written Arabic. The developed questionnaire consisted of 3 distinct sections. First there was information about the parent's sociodemographic characteristics, such as gender, age, residence, and educational level. Parent age was categorized into “20–30,” “31–40,” and “≥41” years. Residence was categorized into “Capital,” “Hawalli,” “Ahmadi,” “Mubarak Al-Kabeer,” “Farwaniya,” and “Jahra.” Educational level was categorized into “primary” (compulsory schooling/below high school diploma), “secondary” (high school diploma), and “tertiary” (university degree or higher education). The next section assessed parental knowledge of the emergency management of dental avulsion, including questions covering the following areas: replantation, cleaning, transport media, and seeking professional help. To obtain this information, the parents were provided with an imaginary clinical scenario that stated: “You are in a football field and an 8-year-old boy fell down and knocked out his upper permanent front tooth.” They were also shown an intraoral frontal picture with the missing tooth and another with a knocked-out tooth with labels demonstrating the tooth parts, i.e., the crown and the root. The final section covered previous knowledge of first aid measures for avulsed teeth and the source of information.
A simple scoring system was used to predict knowledge among parents in Kuwait. The questionnaire was graded based on answers to the second section. The questions were in multiple-choice format except for items 2, 3, and 8, which were binary questions. Parents were informed to respond to each question with 1 answer only. One point was earned for each correct answer, while wrong answers earned no points; the maximum possible score was 8 points. The total knowledge score of each parent was calculated by summing the number of correct answers.
Test-Retest Reliability
To examine the questionnaire reliability, a sample of 40 parents, i.e., 31 mothers and 9 fathers, completed the final format of the questionnaire twice with a 1-week interval. These questionnaires were excluded from the main study sample.
Statistical Analysis
Data analysis was performed using Statistical Package for Social Science software version 21.0 (SPSS Inc., Chicago, IL, USA). Test results of p < 0.05 were regarded as statistically significant. Data were descriptively analyzed using frequencies and percentages. Test-retest reliability was assessed using the kappa coefficient (as a measure of agreement between the responses of parents at times 1 and 2). The Landis and Koch criteria for interpreting agreement for categorical variables was used: ≥0.75, excellent; 0.4–0.75, fair to good; and <0.4, moderate or poor [18].
The dependent variable (total knowledge score) was divided into 2 groups (high or low) depending on the 50th centile value, i.e., the median, of the total knowledge score, i.e., “high” was above the median and “low” was below the median. All independent variables were included in the binary logistic regression model. The results of the binary logistic analysis were reported using adjusted odds ratios (OR) and 95% confidence intervals (CI).
Results
Participation Rate
The response rate was 91.5% (554/605). The median age of the parents was 38 years (IQR 14). Of the 554 parents, 330 (59.6%) were female, 262 (47.3%) had a university degree or higher education, and 135 (24.4%) resided in Ahmadi. The detailed sociodemographic characteristics of the parents are shown in Table 1.
Table 1.
Sociodemographic characteristics of the parents (n = 554)
| n (%) | |
|---|---|
| Gender | |
| Male | 224 (40.4) |
| Female | 330 (59.6) |
| Age | |
| 20–30 years | 150 (27.1) |
| 31–40 years | 212 (38.3) |
| ≥41 years | 192 (34.7) |
| Residence | |
| Capital | 108 (19.5) |
| Hawalli | 66 (11.9) |
| Ahmadi | 135 (24.4) |
| Mubarak Al-Kabeer | 45 (8.1) |
| Farwaniya | 104 (18.8) |
| Jahra | 96 (17.3) |
| Educational level | |
| Primary | 89 (16.1) |
| Secondary | 203 (36.6) |
| Tertiary | 262 (47.3) |
Test-Retest Reliability
The test-retest reliability over a period of 1 week was fair to good for the overall score of the 8 items included in the second section (0.499; p < 0.001). Kappa values for items in the second section ranged from 0.721 (p < 0.001; item 2: “Attempt for self-replantation”) to 0.356 (p < 0.001; item 7: “Urgency to seek professional help”; Table 2). Based on the values cited by Landis and Koch [19], the kappa coefficients obtained for individual items showed a fair-to-good (0.4–0.75) or moderate (<0.4) degree of agreement. Hence, the questionnaire developed was a valid, reliable, and reproducible instrument, and was readily understood and accepted by the parents.
Table 2.
Kappa coefficient (κ) for items assessing parental knowledge
| Questions evaluating the knowledge of emergency management of dental avulsion | κ | p value | |
|---|---|---|---|
| Q1 | Possibility of replantation | 0.662 | <0.001 |
| Q2 | Attempt for self-replantation | 0.721 | <0.001 |
| Q3 | Avulsed permanent tooth handling | 0.479 | 0.001 |
| Q4 | Urgency of replantation | 0.558 | <0.001 |
| Q5 | Appropriate cleaning media | 0.621 | <0.001 |
| Q6 | Appropriate transport media | 0.511 | <0.001 |
| Q7 | Urgency to seek professional help | 0.356 | <0.001 |
| Q8 | First place of contact following the injury | 0.481 | <0.001 |
Knowledge of Emergency Management of Dental Avulsion
Of the 554 parents, 199 (35.9%) were aware that an avulsed permanent tooth could be repositioned back into its socket. About a third of parents (n = 154, 27.8%) responded that they would reposition the avulsed tooth by themselves, and 382 (69%) would pick up the avulsed permanent tooth by its crown. The awareness that an avulsed permanent tooth should be replanted immediately into its socket was present in 162 (29.2%) of the parents (Table 3, Q1–Q4). Only 182 (32.9%) identified correctly how to clean an avulsed permanent tooth prior to replantation, and 84 (15.2%) of them correctly identified the appropriate storage media for an avulsed tooth (Table 3, Q5-Q6). More than two-thirds of the parents (n = 391; 70.6%) would seek professional help immediately after dental avulsion, and the majority of them (n = 525; 94.8%) stated that they would seek dental attention following tooth avulsion, while 29 (5.2%) would seek medical help (Table 3, Q7-Q8).
Table 3.
Knowledge of emergency management of dental avulsion
| n (%) | ||
|---|---|---|
| Q1 | Possibility of replantation | |
| – Yes (correct answer) | 199 (35.9) | |
| – No | 266 (48) | |
| – Don't know | 89 (16.1) | |
| Q2 | Attempt for self-replantation | |
| – Yes (correct answer) | 154 (27.8) | |
| – No | 400 (72.2) | |
| Q3 | Avulsed permanent tooth handling | |
| – By its crown (correct answer) | 382 (69) | |
| – By its root | 172 (31) | |
| Q4 | Urgency of replantation | |
| – Immediately (correct answer) | 162 (29.2) | |
| – Within 30 min | 44 (7.9) | |
| – Within a few hours | 88 (15.9) | |
| – Before the next day | 66 (11.9) | |
| – It is not urgent to put it back | 194 (35) | |
| Q5 | Appropriate cleaning media | |
| – Scrub the tooth with toothbrush | 40 (7.2) | |
| – Cold tap water (correct answer) | 182 (32.9) | |
| – Wipe the tooth with alcohol wipe | 57 (10.3) | |
| – No need to clean it | 95 (17.1) | |
| – Don't know | 180 (32.5) | |
| Q6 | Appropriate transport media | |
| – Milk or child's mouth if the child if not very young (correct answer) | 84 (15.2) | |
| – Paper tissue/plastic wrap | 176 (31.8) | |
| – Disinfecting solution (e.g., alcohol) | 106 (19.1) | |
| – Ice water | 188 (33.9) | |
| Q7 | Urgency to seek professional help | |
| – Immediately (correct answer) | 391 (70.6) | |
| – Within 30 min | 27 (4.9) | |
| – Within a few hours | 40 (7.2) | |
| – Before the next day | 48 (8.7) | |
| – It is not urgent to seek professional help | 48 (8.7) | |
| Q8 | First place of contact following the injury | |
| – Doctors | 29 (5.2) | |
| – Dentists (correct answer) | 525 (94.8) | |
The median total knowledge score of the parents was 3 (IQR 2) out of a maximum score of 8. A total of 267 (48.2%) of the parents demonstrated a high level of knowledge, while 287 (51.8%) demonstrated a low level of knowledge.
Logistic regression analysis revealed that previous exposure to information about the emergency management of dental avulsion was the only significant predictor for high knowledge (OR 2.138, 95% CI 1.347–3.395, p = 0.001; Table 4).
Table 4.
Association between total knowledge score and independent variables: binary logistic regression
| Independent variable | OR | 95% CI | p value |
|---|---|---|---|
| Gender | |||
| Male | 0.837 | 0.585–1.199 | 0.333 |
| Female | Ref. | ||
| Age | |||
| 20–30 years | 0.749 | 0.474–1.184 | 0.749 |
| 31–40 years | 0.925 | 0.612–1.398 | 0.712 |
| ≥41 years | Ref. | ||
| Residence | |||
| Capital | 1.028 | 0.505–2.096 | 0.938 |
| Hawalli | 1.554 | 0.711–3.398 | 0.270 |
| Ahmadi | 1.045 | 0.524–2.085 | 0.901 |
| Mubarak Al-Kabeer | 0.727 | 0.354–1.491 | 0.384 |
| Farwaniya | 0.619 | 0.296–1.295 | 0.203 |
| Jahra | Ref. | ||
| Educational level | |||
| Primary | 0.642 | 0.383–1.074 | 0.092 |
| Secondary | 0.791 | 0.538–1.162 | 0.232 |
| Tertiary | Ref. | ||
| Previous information | |||
| Yes | 2.138 | 1.347–3.395 | 0.001 |
| No | Ref. |
OR, adjusted odds ratio; CI, confidence interval.
Assessment of prior knowledge of dental avulsion management revealed that 99 (17.8%) of the parents had received previous information on the emergency management of tooth avulsion: 30 (30.3%) gained the information from the internet, 19 (19.2%) from books, 12 (12.1%) from television, 6 (6%) from smart phone applications, 2 (2%) from newspapers, and 30 (30.3%) from other sources.
Discussion
In this study, responses indicated that parents in Kuwait lacked adequate knowledge for the emergency management of dental avulsion in the following areas: possibility of replantation, attempt at self-replantation, and urgency of replantation. A poor level of knowledge was revealed in identifying suitable cleansing and transport media. Previous information on dental avulsion was the only significant predictor for adequate knowledge. No correlation was found between the participants' overall knowledge and educational level, probably due to noninclusion of the management of acute dental trauma in school curricula. Hence, parents did not have the necessary knowledge required for handling dental emergencies.
The finding of a low overall knowledge of dental avulsion management among parents in Kuwait was similar to findings from other countries, such as Brazil, Jordan, and the UAE [13, 17, 19], in which a low level of knowledge was reported. This is unfortunate because prompt and appropriate management at the site of the injury could significantly alleviate the distress and improve the prognosis of an avulsed permanent tooth [14]. The percentage of participants who recommended immediately replanting an avulsed permanent tooth (29.2%) was lower than the 74.1% reported from a study in England [15]. This difference could be due to the participants included in the study by Addo et al. [15] being personnel working at emergency clinics, and therefore having a higher knowledge than the general population surveyed from Kuwait.
The finding that only 27.8% of the parents would reposition the avulsed permanent tooth by themselves is similar to rates reported previously: 27.6% in Chennai (India) [9], 31.8% in Haryana (India) [10], and 9.3% in Samsun (Turkey) [12]. However, a high level of knowledge regarding self-replantation was observed in a previous survey of parents and caretakers in India [11]. This might be attributed to the fact that the majority of participants had experienced previous dental trauma, and therefore might have received appropriate advice from the treating dentist. The majority of parents would pick up the avulsed permanent tooth by its crown [7], which is consistent with the current guidelines of the International Association of Dental Traumatology (IADT) and was also reported in a previous study [16]. The inability of almost two-thirds of parents in this study to identify suitable cleansing and transport media confirmed the findings of previous studies [9, 10, 12, 13]. The findings that most parents had satisfactory knowledge regarding the urgency to seek professional help, and would make an appropriate choice of first point of contact following the injury, were similar to those reported by Namdev et al. [10] and Santos et al. [13]. These findings might be explained by the fact that emergency dental services in Kuwait are organized in such a way that they can be provided at any time.
In the present study, the majority of parents received health information from the Internet. The Internet has become a powerful platform for accelerating the flow of health information. However, many researchers have highlighted inadequate skills of the public in evaluating the quality of information on the Internet and in the ability to comprehend complex health-related information [20, 21]. The dental trauma smartphone application that is endorsed by and follows the current guidelines of the International Association of Dental Traumatology is a valuable educational tool. It is designed to provide parents, teachers, sport coaches, and others with effective first aid training in case of dental trauma. A recent study showed that the dental trauma app alone is an effective tool for providing knowledge to guide the public in managing dental avulsion, and it can be superior to the other educational interventions used [22]. Therefore, disseminating information on the emergency management of dental avulsion using the dental trauma app would be a valuable educational tool for parents, especially due to the immediate availability of such a tool at the place of injury.
Conclusion
This study showed that parents in Kuwait did not have adequate knowledge of the emergency management of dental avulsion because less than a third of the study participants had previously been exposed to information on dental avulsion management. Hence, multidisciplinary approaches are needed to improve parent knowledge of the emergency management of dental avulsion. The management of acute dental trauma should therefore be incorporated early in school curricula.
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