ASSESSMENT OF DENTISTS’ KNOWLEDGE IN RABATCONCERNING THE MANAGEMENT OF DENTAL EXPULSION

Abstract

Background

Dental avulsion is an emergency whose prognosis depends on the promptness of the treatment. Adequate management requires the acquisition of correct knowledge, attitude and practice, thus the prognosis of the avulsed tooth should be improved, both in the short and in the long term.

Aim

This study was carried out in order to assess the level of knowledge, attitude and practice of dentists working in the city of Rabat, Morocco regarding their management of avulsed teeth and the factors associated with this level.

Methods

A 14-item questionnaire regarding dental avulsion and its management was administered to dentists working in private practice in Rabat using convenience-sampling methodology. The data obtained were entered into Statistical Package for the Social Sciences database (IBM, SPSS version 13.0, Chicago, USA) and analysed with a significance level established at p<0.05. The knowledge, attitude and practice level was assessed using a scoring system. Chi2 and Fisher's Exact tests were used to compare the groups.

Results

A total of 205 dentists, representing 37% of all dentists working in the private sector in Rabat, completed the questionnaires. The level of knowledge, attitudes and practices of the dentists in this study was moderate with an overall median score of 5 [4;6].

Most of the participants answered the knowledge-based questions correctly, except for those concerning the extra-alveolar period, the timing of endodontic treatment, and the type and duration of retention.

Conclusion

Given the lack of other studies concerning Moroccan dentists, comparison with studies carried out in other countries is difficult, hence the need to carry out more Moroccan studies in order to improve this level.

INTRODUCTION

Avulsion is a trauma during which the tooth is completely moved out of its socket 1. Its prevalence among other traumas varies according to the studies from 0.5 to 3%, 6% or even up to 16% 2. According to the current guidelines of the International Association of Dental Trauma (IADT), established in 2012 3 and recently updated in 2020 4 , the management of an avulsed permanent tooth is replantation whenever possible. Healing then depends on the stage of root development, the complications caused to the periodontal ligament, the management of bacterial infection and the promptness of management 5, 6, 7, 8. Thus, the prognosis is related, among other things, to the time factor 9. Several studies have shown that a favourable prognosis of a replanted avulsed tooth is associated with immediate replantation (at the site of accident), or when the avulsed tooth is adequately preserved for an extra-oral time of less than 15 minutes, or strictly less than 60 minutes 10 or well preserved on appropriate storage medium. In the absence of these conditions, the prognosis would be affected. During bibliographic research, no study that reported the knowledge of dentists in Morocco regarding the management of avulsed mature permanent tooth was found. This study was carried out in order to assess the level of knowledge, attitude and practice of dentists working in the city of Rabat, Morocco regarding their management of avulsed teeth and the factors associated with this level.

METHODS

The ethics committee approved the current study. Each subject (according to the ethical principles of the World Medical Association Declaration) provided informed written consent. A 14-item questionnaire was developed using a cross-sectional survey design and pre-tested online with a group of thirty dentists. Difficulties were identified in respondents' understanding of the questionnaire and the necessary modifications were made based on these results. The final questionnaire consisted of demographic items and multiple-choice questions regarding dental avulsion and its management. The survey was administered to dentists working in private dental offices in the various sectors of the city of Rabat, Morocco.

According to the statistics in Morocco, the total number of dentists working in the private sector in Rabat in 2014 is 554. They were contacted to request their participation in this study over a period of four months starting in February 2019 using convenience-sampling methodology. Dentists who were willing to participate were asked to read an information note explaining the objectives of the study and to sign an informed consent form before completing the anonymous questionnaire distributed directly to dental offices. No personal information on the dentists’ identities was required to be disclosed. The data obtained from the survey were manually entered into Statistical Package for the Social Sciences database (IBM, SPSS version 13.0, Chicago, USA) and analysed with a significance level established at p < 0.05.

Quantitative variables with a symmetric distribution were expressed as mean and standard deviation, while those with a asymmetric distribution were expressed as median and quartiles.

Qualitative variables were expressed as numbers and percentages.

According to the IADT guidelines [3], the nine parameters analysed were:

• Treatment choice: “replantation when it’s possible” was considered the correct answer.

• Optimal extra-alveolar time: answers with “time equal or less than 30 minutes and equal or less than 60 minutes” were considered as correct.

• Physiologic storage medium: “HBSS (Hank’s Balanced Salt Solution)” or “milk” were considered correct answers (if we respect the corresponded allowed time : a maximum of 2h for the milk and 24 h for HSBB)

• Endodontic treatment for permanent mature tooth: “completion of endodontic treatment in all cases” was the correct.

• Time of endodontic treatment: “initiation of root canal treatment 7 -10 days after replantation” was the correct answer.

• Type of splinting : “Flexible splints” was the correct answer.

• Splinting period: “2 weeks” was the correct answer.

• Systemic medication: “Prescribe antibiotics, anti-inflammatory drugs and tetanus prevention” was the correct answer.

• Follow-up: “1 month, 3, 6, 12 months then once a year for 5 years” was the correct answer.

The respondents’ level of knowledge, attitude and practice regarding tooth avulsion and its management was assessed using a scoring system that corresponds to the sum of the correct knowledge, attitudes and practices (correct KAP) and that assigned one point for each correct answer and zero point for a wrong answer, with a maximum possible score of nine points (nine parameters analysed).

The respondents were divided into three groups according to the points:

• 0 to 3 points : group with a low level of KAP.

• 4 to 6 points : group with a moderate level of KAP.

• 7 to 9 points : group with a high level of KAP.

Chi-Square and Fisher's Exact tests were used to analysis the association between the groups of levels KAP and the demographic factors. The univariate analysis was performed with a 95% confidence interval.

RESULTS

A total of 205 dentists, representing 37 % of all dentists working in the private sector in Rabat completed the questionnaires with data that were suitable for statistical analysis.

The median age of the included dentists was 36 [30; 45] years. The number of female participants 115(56.1%). The demographic characteristics of the study population are shown in Table 1 . The percentage distribution of the answers to the questions regarding avulsion and its management is shown in Table 2 .

Table 1. Table 1. Demographic characteristics of the study population.

Variables		Total N=205, n(%)
Age ≤ 35 years 36-45 years ≥ 46 years		97(47,3) 63(30,7) 45(22)
Sex Male Female		90 (43,9) 115 (56,1)
Type of practice General Practitioners Orthodontists Periodontists Pedodontists		151 (73,7) 33 (16,1) 15 (7,3) 6 (2,9)
Years of experience ≤ 10 years 11-20 years ≥ 21 years		112 (54,6) 52 (25,4) 41 (20)
Reception or not of cases of dental avulsion Yes No		130 (63,4) 175 (36,6)

Table 2. Table 2. Distribution of the responses to questions about avulsionand its management.

Questions about the management of avulsed permanent mature tooth	n (%)
Treatment choice Correct Incorrect	194(94,6) 11(5,4)
Optimal Extra-Alveolar Time Correct Incorrect	101(49,3) 104(50,7)
Physiologic storage medium Correct Incorrect	131(63,9) 74(36,1)
Endodontic treatment Correct Incorrect	108(52,7) 97(47,3)
Time of Endodontic treatment Correct Incorrect	53(25,9) 152(74,1)
Type of splinting Correct Incorrect	84(41) 121(59)
Splinting period Correct Incorrect	44(22) 161(78)
Systemic medication Correct Incorrect	23(11,2) 182(88,8)
Follow-up Correct Incorrect	128(62,4) 77(37,6)

The overall median score was 5[4 ;6], which means a moderate level of correct KAP according to this study. The univariate analysis (Table 3 ) showed that age, sex, type of practice and years of experience were significantly associated to this KAP level.

Table 3. Table 3. Level of correct KAP according to demographic variables.

Demographic variables	Levels of correct KAP			p
	Low level	Moderate level	High level
Age ≤ 35 years 36-45 years ≥ 46 years	3 25 4	81 34 36	13 4 5	<0,001
Sex Male Female	17 15	70 81	3 19	0,008
Type of practice General Practitioners Orthodontists Periodontists Pedodontists	29 0 3 0	109 28 8 0	13 5 4 0	0,002
Years of experience ≤ 10 years 11-20 years ≥ 21 years	6 22 4	92 27 32	14 3 5	<0,001
Reception or not of cases of dental avulsion Yes No	19 13	97 54	14 8	0,8

DISCUSSION

The aim of the present study was to assess Moroccan dentists’ knowledge, attitude and practice concerning the emergency management and clinical treatment of avulsed permanent teeth.

The level of KAP

The level of knowledge, attitude and practice of the surveyed sample of dentists was found to be moderate, with an overall median correct KAP score of 5[4 ;6]. In the univariate analysis, the factors associated significantly with this overall median of correct KAP were the age, the sex, the type of practice and the years of experience, whereas reception or not of cases of tooth avulsion had no significant effect (Table 3 ).

These results could be explained by the fact that the highest level of correct KAP score was significantly observed in participants whose age 35 years or less was (p<0.001), so, younger dentists having easier access to academic websites for research such as the IADT used in this study, than older dentists. Similarly, a significantly higher level of correct KAP score was observed for practitioners with up to 10 years of experience compared to other groups (p<0.001). This could be explained by the fact that the group of dentists with the least number of years of experience are recently graduated, reflecting a recent acquisition of information. This association was statistically significant (p<0.001), and it was similar to Duruk et al’s study 11. These findings were not consistent with the results obtained in other studies 12, 13, 14, in which it was confirmed that as the number of years of clinical practice increases, dentists' knowledge of tooth avulsion management improves 15, and most of which have shown a low level of knowledge regarding this subject 16, 17, 18, 12, 19, 20, 21, 13, 14, 22, 11.

Concerning the sex, the highest level of correct KAP score was observed in female participants. This could be explained by the fact that the number of women included in the study is larger than that of men. The same explanation could be given for the type of practice, as the highest level of KAPs was found in the general practitioner category, which could be due to the larger number of general practitioners included in this study compared to the other categories.

The treatment choice of avulsed permanent mature tooth

Replantation when it is possible was suggested by 194(94,6%) of the participants. This observation was in correlation to IADT guidelines 3, 4, 5. Indeed, Replantation of the tooth as soon as possible (while still at the accident site) is the treatment of choice, but when it is difficult to achieve for the accident victim or the person in charge, a dental consultation must be made urgently 3, 4, 5. In cases of severe caries, periodontal disease, and medical conditions, such as immunosuppression or severe cardiac diseases, or in cases in which the patient is not conscious or not cooperative, replantation of the avulsed permanent tooth is not indicated according to the IADT guidelines 3, 4, 5.

The extra-oral time

The ideal extra-oral time reported by 104(50,7%) of the dentists surveyed was more than 60 min, what is not consistent with the IADT guidelines (3-5]. These results demonstrated that Moroccan dentists had poor knowledge regarding the ideal extra-oral time for avulsed teeth. In fact, the longer the time interval between tooth avulsion and its replantation, the greater the risk of replacement resorption and inflammatory root resorption [8, 9]. Treatment guidelines state that if the extra-oral dry time of a tooth exceeds 60min, all periodontal ligament cells become non- viable (8,9). According to Andreason 8, teeth that are replanted within 30 minutes have a better success rate than those that were extra oral for longer periods of time before replantation.

The storage medium

If immediate replantation cannot be performed, a suitable storage medium should be used. Concerning this parameter, the majority of the respondents 131(63,9%) indicated properly that the avulsed tooth should be kept in HBSS or milk while 74(36,1%) of the respondents chose saline solution or saliva as the transport medium.

Trope 10 suggested that the storage medium for avulsed tooth (in order of preference) included Hank's Balanced Salt Solution (HBSS), milk, saline, and saliva (buccal vestibule).

HBSS is a standard saline solution that is widely used in biomedical research to support the growth of many cell types, although it is not yet available in pharmacies or drugstores around the world 20 . It can be used as a conservation medium for avulsed teeth for a period of 24 h. Milk is regarded as a convenient storage medium for an avulsed tooth because it is easy to obtain in the event of an accident and it can maintain periodontal ligament (PDL) cells thanks to its osmolality that is 232 mosm/l  23, 24. Storage of the avulsed tooth in milk at room temperature has been reported to preserve the viability of PDL cells for up to 60 min, whereas refrigerated milk preserves viability for an additional 45 min 23, 24. Saliva should only be indicated when neither milk nor saline solution are available. Andreasen et al. 25 clarified that when saliva is used as a storage medium, the extra-oral time must be limited to a maximum of two hours, due to the hypotonic nature of the medium (the osmolarity of saliva is 60-80 mosm/l much less than the normal range (230-400 mosm/l) required for cell growth), and the fact that bacteria present in saliva may have a negative effect on later healing 25. Saline has been shown to be a short-term storage media because of its physiologic osmolarity. It was found that the avulsed teeth that were soaked in saline solution for 30 minutes before replantation showed less root resorption than those stored dry for 15-40 minutes 26. Water is the least desirable storage medium because the hypotonic environment causes rapid cell lysis and increased inflammation on replantation 27.

Splinting

After replantation, splinting is highly recommended. In the current study, the result was quite unsatisfactory, as 121(59%) of the respondents stated they would use a rigid splint and 161(78%) of the participants recommended a splinting period for more than four weeks what is not consistent with the IADT guidelines. Again, the results demonstrated that Moroccan dentists had low level knowledge, attitude and practice regarding the type and period of splinting for avulsed teeth. The use of a flexible splint is recommended for 7–14 days 3, 28. In fact, this period is sufficient for achieving periodontal support in order to maintain the avulsed tooth in position, except in cases of extra-oral time more than 60 minutes or tooth avulsion associated with alveolar fracture, when splinting must be maintained for a period of 4 weeks or 4–8 weeks respectively 28.

Endodontic treatment

As recommended by the IADT, root canal treatment for a tooth with a closed apex should be performed in all cases. That was stated by 108(52,7%) of the respondents, while about 152(74,1%) of them would perform it only when signs of necrosis appear what is not consistent with the IADT guidelines 3 , thatsuggested to initiate the root canal treatment 7–10 days after replantation of avulsed permanent mature tooth, to control infection and therefore prevent inflammatory root resorption.

Drug prescription

In the current study, the majority of dentists 152(74.1%) favoured prescribing broad-spectrum antibiotic therapy after replantation while only 23(11.2 %) of them suggested prescribing antibiotics, anti-inflammatory drugs and employing tetanus prevention strategies. The American Association of Endodontists(AAE)  29 and the IADT 3 have recommended systemic antibiotics, such as penicillin V four times a day or doxycycline two times a day for seven days, at doses depending on the patient's age and weight. Furthermore, experimental animal studies [30] have also verified a reduction in root resorption with the use of systemic antibiotics following replantation of teeth.In fact, there is no evidence on preferred antibiotic and dosage after replantation of avulsed teeth 28. Hence, further studies are recommended to determine the choice of drug for replantation of avulsed teeth. The IADT 3 recommends also referring the patient to a physician to evaluate the need for a tetanus booster in cases in which the avulsed tooth has contacted soil or the tetanus coverage is uncertain.

Follow-up

The most of participants in this study 128(62.4%) were aware and reported that they would establish a follow-up after 2, 4 weeks, 3 months, 6 months, 1 year and then yearly for 5 years, which are in line with the IADT guidelines. Monitoring replanted teeth by means of clinical and radiographic exams must be performed for a minimum period of five years, aimed at verifying possible treatment complications, such as inflammatory resorption, resorption by substitution, ankylosis and teeth in infraocclusion 1, 3, 10, 29.

Study limitations

A major limitation of this study is the sampling methodology. A convenience sample was adopted in this study for practical reasons of accessibility and time limitation. A convenience sample may not sufficiently represent the entire population of dentists working in Rabat.

Another limitation is the method of administering the questionnaire, where an interview with the dentists to explain the questions was not possible, which may cause a bias of understanding. In addition, a direct comparison of the results with those of other studies was not always possible due to differences in the questions and answers choices.

However, strength of the study is that it is the first one to evaluate the level of knowledge about management of avulsed teeth among Moroccan dentists.

CONCLUSION

Within the limitations of this study, the overall level of Moroccan dentists’ knowledge about the management of avulsed permanent mature teeth was moderate. The present findings highlight the need for further education on traumatic dental injuries.

Studies conducted in others countries, such as Turkey 16, 11, Iran 18, Italy 17, Saudi Arabia 12, 13, Malaysia 21, India 22 and Brazil 20, concluded that there is a need to improve the knowledge of dentists in the current guidelines for emergency treatment of avulsed teeth.

More studies using clinical scenario-based questions related to permanent tooth avulsion and its management should be carried out and dental practitioners should use all means available to improve their knowledge, attitude and practice of the treatment of avulsed tooth.