ANALYSIS ARTICLE Medical Science - Discovery Journals · regarding emergency management of traumatic dental injuries among nursing interns in various institutions of Saudi Arabia

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Awareness about emergency management ofdental trauma among nursing interns in SaudiArabia

Rawan A Saddah1, Shahad H Alhassani2, Rafi A Togoo3, Zakirulla M4☼

1.Student, College of Dentistry King Khalid University, Abha, KSA2.Intern, College of Nursing King Khalid University, Abha, KSA3.Professor, Department of POS, College of Dentistry King Khalid University, Abha, KSA4.Assistant Professor, Department of POS, College of Dentistry King Khalid University, Abha, KSA

☼Corresponding author:Dr.Zakirulla MAssistant Professor,Department of Pediatric Dentistry and Orthodontic Sciences (POS),College of Dentistry King Khalid University,Abha, Aseer region, Kingdom of Saudi Arabia.P.O. BOX – 3263, Zip Pin- 61471.Mobile No: +966530518766Telephone: +96617-2418028E-mail: [email protected]

Author Contribution:Rawan A Saddah: Concepts; Design; Literature search; Data acquisition; Data analysis; Manuscript preparation; GuarantorShahad H Alhassani: Concepts; Design; Literature search; Data acquisition; Data analysis; Statistical analysis; Manuscript preparation;GuarantorRafi A Togoo: Concepts; Design; Literature search; Data acquisition; Data analysis; Statistical analysis; Manuscript preparation;GuarantorM Zakirulla: Concepts; Design; Literature search; Data acquisition; Data analysis; Manuscript preparation; Guarantor

Article HistoryReceived: 09 January 2018Accepted: 28 February 2018Published: May-June 2018

CitationRawan A Saddah, Shahad H Alhassani, Rafi A Togoo, Zakirulla M. Awareness about emergency management of dental traumaamong nursing interns in Saudi Arabia. Medical Science, 2018, 22(91), 279-287

ANALYSIS 22(91), May - June, 2018

Medical ScienceISSN2321–7359

EISSN2321–7367


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ABSTRACTNurses play important role in the emergency department are often the first line of qualified health-care providers immediatelyfollowing the dental trauma. Prompt action by them becomes the decisive factor in survival and prognosis of the tooth. Although afew researchers have evaluated knowledge of nurses, hence this study was conducted to evaluate the knowledge and awarenessregarding emergency management of traumatic dental injuries among nursing interns in various institutions of Saudi Arabia. A 10-

item questionnaire regarding clinical situation and knowledge of dental trauma and tooth avulsion were collected from 440 internnurses. The findings of the study showed that, 62.5% of the participants gave a positive response to questions related to theknowledge emergency management of dental trauma. Approximately, 90.9% of participants agreed that nurses play a major role inthe emergency management of dental trauma. Majority of participants (91%) agreed that emergency management of dental traumashould be taught in the nursing program at their university level. Though nursing interns have a good attitude toward themanagement of dental injuries but they lack knowledge regarding the storage media and time management for avulsed tooth.Nurses should be made aware of their possible role in cases of avulsion of permanent teeth, in order to minimize late complicationsassociated with such injuries, which demands need for appropriate training for delivering treatment with more predictability andbetter prognosis.

Keywords: Nurses, Dental trauma, Knowledge, Avulsion, Storage medium.

1. INTRODUCTIONDental trauma in children is a significant oral health issue worldwide. Dental traumatic injuries[TDI] ranging from simple enamel chipto an extensive maxillofacial trauma are usually the result of sports activity, fights, road traffic accidents and other intentionalassaults.1 The consequences of dental trauma can range from simple tooth fracture to tooth avulsion.2 A large number of studiesreveal that dental trauma mainly affects the upper central incisors and can lead to a loss of function as well as a negative impact onquality of life, producing psychological and social discomfort, with lowered self-esteem, embarrassment upon smiling and difficultyin relating with others.3 A study from Brazil showed that adolescents with severe untreated TDI were 2.4 times more likely to reportworse oral-health-related quality of life than adolescents without untreated TDI.4 Post-traumatic complications may occur, includingcrown discoloration, cervical root fracture, ankylosis, root resorption and tooth loss.5 Among the different types of dental trauma,avulsion results in the greatest functional and esthetic impairment due to its worse prognosis.6

International Association of Dental Traumatology in 2012, published guidelines for management of avulsed teeth, highlights theevidence-based approach to emergency care and is of great help for a dentist, health-care professionals, and parent in decision-

making.7 Many surveys show that neither parents, teachers, children, nor even emergency unit staff are prepared to deal with suchinjuries.1,8-10 Glendor, having reviewed the recently published epidemiological studies, concluded that a large part of the educationalprocess of caregivers and lay people has failed.11 It seems to be very important to transfer sufficient information about emergencyaid in the event of dental injuries to all kind of medical professionals: nurses, paramedics, physicians, general practitioners anddentists.

Physicians and nurses of emergency department are often the first line of qualified health-care providers attending the patient inperson or parent’s query over phone reporting immediately following the dental avulsion. Prompt action by them becomes thedecisive factor in survival and prognosis of the tooth. Still, emergency department personnel lack knowledge regarding traumaticdental injuries.1 Literature lacks any data regarding knowledge and awareness among nurses in Saudi Arabia; hence, this study was


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planned to evaluate the knowledge and awareness regarding emergency management of traumatic dental injuries among nursinginterns in various institutions of Saudi Arabia.

2. MATERIALS AND METHODSThe present study was a cross sectional questionnaire study conducted among nursing interns of various Nursing Institutions inSaudi Arabia (Institutions included: King Khalid University, King Saud University, King Abdulaziz University, King Faisal University,Princess Nora University and others). Convenience sampling method was followed in this study. All the nursing interns were includedas the sample; hence a total 440 subjects completed the survey. The study was approved by the Research Committee at College ofDentistry King Khalid University (Ref No: SRC/REG/2017-18/7). The questionnaires were obtained from different published articlesand the questions were condensed to 10 items covering the important aspects required (Table 1). Experts reviewed thequestionnaire to ensure content validity. Permission to conduct the study was obtained from the nursing institutes. Written informedconsent was obtained and the questionnaire was distributed to the subjects after giving instructions. Sufficient time was given to thenursing interns for completing the forms. Later the forms were collected and the surveys were kept anonymous. The completedforms were compiled and the data was entered into MS excel sheet (Microsoft Corp.) and percentages were calculated using SPSS17. Descriptive statistics were generated for all questions. The results were tabulated and expressed as both number and percentage.

Table1 Questionnaire

1. Knowledge about emergency management of dental trauma No Yes, taught during the nursing program Yes, from external sources like workshops , Conferences, first aid training Yes, Self-study from internet, books , Journals, Television Yes, from dentistry sources Other ……………. ( Please state)

2. Nurses have a role in the emergency management of dental trauma Strongly agree Agree Don’t know Disagree Strongly Disagree

3. Nursing program at your university should teach about emergency managementdental trauma Strongly agree Agree Don’t know Disagree Strongly Disagree

4. In a situation where you face a person with Oral/dental trauma, you would? Do nothing Just give good advice Mange confidently Manage with doubts Call emergency services Other ………………………..

5. After dental trauma what is the best time to visit the Dentist? Immediately After a day when the child feels better


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Within 4 hours Any time when the patient feels relaxed and wants to have treatment Within 24 hours When the parent or guardian is free to bring the patient for examination andtreatment Within 1–2 hours Do not know

6. Immediate management of fractured part of permanent teeth The fractured part is useless, ignore it Find the fractured part wrap it with gauze or tissue, take for examination andtreatment Put it in liquid medium ( saline milk water ), take for examination and treatment Do not know

7. Are you updated on Tetanus Toxoid immunization and prophylaxis in an acute dentalinjury? Yes No

8. An avulsed permanent tooth should only be held by its Root Crown Any part Don’t know

9. Cleaning a unclean avulsed tooth prior to replantation or visit to dentist Brush Wash Rinse gently in water/saline Don’t know Other

10. How would you keep the Avulsed tooth till you reach the dentist? Patients saliva Water Saline Milk Don’t know

3. RESULTSIn the present study, total of 453 filled questionnaires were collected, giving a response rate of 97.1%. After excluding questionnaireswith missing entries, there were 440 for analysis. The study included all the participants are female nursing interns, which could berelated to the interest among the female population towards nursing profession.

Table 2: When the question related to the knowledge emergency management of dental trauma was asked, 62.5% of theparticipants gave a positive response. Approximately, 90.9% of participants agreed that nurses play a major role in the emergencymanagement of dental trauma. Majority of participants (91%) agreed that emergency management of dental trauma should betaught in the nursing program at their university level. About 71.8% of surveyed group knew that they should inquire about previousdosage of tetanus vaccination immediately after trauma. In case of referring the patient to dentist, about 69.5% of the participantswould like to visit the dentist immediately after dental trauma; 2% would visit after a day when the child feels better; 3.2% preferredwithin 4 hours; 5.5% of the participants preferred anytime when the patient feels relaxed; 7% preferred within 24 hours; 0.5%preferred to visit dentist when their parents or guardian is free to take them for treatment; 6.6% preferred within 1 to 2 hours afterdental trauma and 5.7% did not know the time period within which the patient has to be referred.


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Table 2 Participants’ answers to questions regarding emergency management of dental trauma

Questionnaire No. %1. Knowledge about emergency management of dental trauma

No 165 37.5Yes, taught during the nursing program 102 23.2Yes, from external sources like workshops , Conferences, first aid training 57 13.0Yes, Self-study from internet, books , Journals, Television 76 17.3Yes, from dentistry sources 34 7.7Other ……………. ( Please state) 6 1.42. Nurses have a role in the emergency management of dental traumaStrongly agree 142 52.3Agree 200 38.6Don’t know 65 2.5Disagree 30 4.8Strongly Disagree 6 1.83. Nursing program at your university should teach about emergencymanagement dental traumaStrongly agree 230 52.6Agree 170 38.4Don’t know 11 2.5Disagree 21 4.7Strongly Disagree 8 1.84. In a situation where you face a person with Oral/dental trauma, youwould?Do nothing 12 2.7Just give good advice 32 7.3Mange confidently 165 37.5Manage with doubts 132 30.0Call emergency services 95 21.6Other ……………………….. 4 0.95. After dental trauma what is the best time to visit the Dentist?Immediately 306 69.5After a day when the child feels better 9 2Within 4 hours 14 3.2Any time when the patient feels relaxed and wants to have treatment 24 5.5Within 24 hours 31 7

When the parent or guardian is free to bring the patient for examination andtreatment

2 0.5

Within 1–2 hours 29 6.6Do not know 25 5.76. Immediate management of fractured part of permanent teethThe fractured part is useless, ignore it 84 19.1Find the fractured part wrap it with gauze or tissue, take for examination andtreatment

97 22

Put it in liquid medium ( saline milk water ), take for examination and treatment 150 34.1Do not know 109 24.87. Are you updated on Tetanus Toxoid immunization and prophylaxis in anacute dental injury?Yes 316 71.8No 124 28.2

In case of immediate management of fractured part of permanent tooth after dental trauma, 34.1% prefer to carry the fracturedtooth part in the liquid medium before examination and treatment; 22% would prefer to carry the fractured part wrap it with gauze


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2 0.5


97 22




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2 0.5


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or tissue; 19.1% would like to ignore the fractured part as its useless and 24.8% of participants did not know what to do withfractured part of tooth.

For question 4 (Table 2): when they encounter a person with dental trauma, only 37.5% will manage the situation confidently,7.3% would like to give good advice, 30% of participants had doubts regarding the management of dental trauma, 21.6% would callthe emergency services and 2.7% of the participants would not do anything,.

About 51.6% of the participants would prefer water or saline to rinse avulsed tooth before replantation or visit to dentist; 4.3%would clean the whole tooth with a brush; 16.6% would wash the whole tooth under tap water; 26.6% of the participants did notknow what to do if they find the avulsed tooth dirty (Fig. 1).

Figure 1 Response of the participants on cleaning an avulsed tooth prior to replantation or visit to dentist.

When question related to the choice of storage medium after avulsion was asked, 38.4% of the participants would advise tokeep the tooth in normal saline, 32% would prefer patient saliva, 10.9% would prefer water, 7% would use milk and 11.7% were notsure what to do (Fig. 2).

Figure 2 Response of the participants on storage medium for avulsed tooth


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When the tooth is completely out of the mouth, 12.3% of the participants would carry by holding the root part of the crown,45.7% would like to hold the crown part, 4.8% would carry by holding any part of the avulsed tooth and 37.3% said that they don’thave knowledge regarding this (Fig. 3).

Figure 3 Response of the participants on holding an avulsed permanent tooth after dental trauma.

4. DISCUSSIONIn the present study, 440 female participants returned the completely filled questionnaire. In our study, all the participants werefemales because majority of female population was interested towards nursing professions. All the participants were nursing internsin different universities of Saudi Arabia.

In this study, we covered the basic knowledge of nursing interns about emergency management of dental trauma. The importantfields like optimal storage media, critical extra alveolar time after tooth avulsion about replantation of tooth, about how to handleavulsed tooth, knowledge regarding tetanus toxoid immunization after dental trauma and awareness about management offractured part of permanent tooth were evaluated. In the present study, majority of the participants (62.5%) accepted that they hadknowledge about emergency management of dental trauma. 90.9% of participants agreed that nurses play a major role in theemergency management of dental trauma, which is in agreement with the findings of Yunus et al.12 A study conducted by Pani etal,13 in Saudi Arabia, concluded that nurses had most positive attitude towards the management of dental trauma. Majority ofparticipants (91%) agreed that emergency management of dental trauma should be taught in the nursing program at their universitylevel. A study conducted among nursing students, they recommended that there is need for incorporation of emergencymanagement of dental injuries in their curriculum and recommended to all dental traumatic emergency management in first aidpublications.12

In this study, less than half of the majority (37.5%) said that they would manage confidently with emergency management ofdental trauma when encountered. Regarding the important questions, like the best time to visit the dentist after dental trauma,69.5% participants said immediately should visit dentist after dental trauma because they believe that a dentist should ideallymanage the dental trauma. Similar results were reported Hugar et al.14 Good prognosis for avulsed tooth depends on immediatereplantation.15,16 Andersson et al. found that 90% of teeth replanted within 30 min did not develop root resorption and prognosiswould be better.7

The most popular choice of the storage medium during transportation was the saline solution (38%). About 32% of nursinginterns in the present study felt that saliva is a desirable storage media for avulsed tooth, which is similar to the knowledge of dentalassistants of Riyadh.17 Only 7% of nursing students opted for milk as a storage medium, this finding was similar to as reported by


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Raphael and Gregory.18 In similar study conducted by Subhashraj,19 showed that only 5% and 6% of respondents knew that “milk”was the medium of choice for both washing and transporting avulsed teeth, whereas Hugar et al,14 revealed that only 2.2% nursesknew about the storage medium used for storing avulsed tooth. In our study, knowledge regarding type of liquid transport mediumis not satisfactory and indicates that there is a lack of knowledge in this group on how avulsed teeth should be handled after anaccident. This is regrettable because the simple measure of storing an avulsed tooth in milk will enhance the prognosis of the toothwhen implanted.20 Milk has a favorable osmolarity and composition for maintaining the viability of periodontal ligament cells andhas been recommended for temporary storage of avulsed teeth before replantation. In addition to being readily available, itpreserves cell viability for up to 3 h. In a similar survey conducted by Choi et al. showed that 62% of the school nurse in publicschools and 56% of the school nurse in private schools knew that liquid was the appropriate method of transporting avulsed tooth.21

About 71.8% of surveyed group knew that they should inquire about previous dosage of tetanus vaccination immediately aftertrauma; this was similar to the knowledge of dental interns of Nepal22, nursing students in India12 and dental students of Japan.23Thisshows that nursing students in Saudi Arabia have a good appreciable knowledge regarding the significance of tetanus vaccination. Athorough attempt must be made to determine whether a patient has completed primary immunization.12

About the action to be taken when a tooth was broken, 34.1% respondents answered correctly by choosing option, “put it inliquid medium and take for examination and treatment.” Which was in agreement with the findings of Subhashraj.19 In this study,most of the respondents believe that permanent tooth avulsed should be replanted back in its original position compared todeciduous tooth, indicating general knowledge of nursing students regarding the emergency management of permanent tooth wasadequate, which is in agreement with the findings of Hugar et al14 and Yunus.12 In this study, most of the respondents recognizedthat the avulsed tooth should be held with crown part (45.7%), indicating knowledge of nursing interns regarding handling ofavulsed tooth was adequate, which is in agreement with the findings of Hugar et al.14 A study (Baginska and Wilczynska-Borawska,2012) done among the school nurses of Poland showed that 94% of participant nurses knew that an avulsed tooth should be heldby the crown.24

As nurses stand on the front lines of responding to an emergency, it is essential that they also possess adequate knowledgeabout dental traumatic injuries and its emergency management.25 In the present study, though nursing students have a goodattitude toward management of dental injuries, but lack of knowledge in regarding the storage media and time management foravulsed tooth leads to undesirable practice in the management of TDIs. Generally, during emergencies, nurses are more concernedabout the neurological condition, bleeding and pain present in the child and consider tooth avulsion as a permanent and irreversibleloss. A high level of awareness programs and training courses on the immediate management of tooth avulsion is obviouslydesirable among nurses, which should emphasize the possible consequences following trauma so that they can at least provide theprimary management at the earliest possible time before referring to the dentist.

LIMITATIONSThe limitations of the present study are smaller sample size, which could limit its possibility to generalization of the otherpopulation. One of the major limitation of our study that we included only female nursing interns, future research are indicated toinclude both the gender for the comparison of knowledge. Reinforcement of knowledge in the form of repeated intervention wouldbe desirable and possible directions for future research were indicated considering these limitations.

5. CONCLUSIONMany of the participants showed a fair knowledge on the emergency management of an avulsed tooth and their dilemma pertainingto some aspects of this procedure can be solved by providing required awareness and knowledge. Nurses should enrolled in thetraining programs with clinical guidelines for the management of traumatic dental injuries. Academic curriculum of nursing studentsshould be updated by incorporation of emergency management of dental injuries. The nurses should actively participate in all thedental training programs including interdisciplinary seminars, discussions and clinically posted in oral and maxillofacial departments.

DISCLOSURE STATEMENTThere is no financial support for the proposed research work.

CONFLICT OF INTERESTThe authors have declared that there was no conflict of interest.


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ANALYSIS ARTICLE Medical Science - Discovery Journals · regarding emergency management of traumatic dental injuries among nursing interns in various institutions of Saudi Arabia