Knowledge of dental students of avulsed permanent teeth

The survival of an avulsed permanent tooth depends on the management and the appropriate treatment of the injury by the dental surgeon. The aim of this study was to assess the knowledge of first-year and last-year dental undergraduates on guidelines for management and treatment of tooth avulsion. A 10-item multiple-choice questionnaire was distributed among 65 first-year and 60 last-year dental undergraduates at the School of Dentistry, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Brazil, between 2006 and 2007. Answers were graded 0 to 3. The results revealed a low level of knowledge among first-year and last-year students on the management of permanent avulsed teeth. Knowledge of last-year undergraduates of tooth avulsion was lower than what is required for a future dental surgeon. In conclusion, there is a need to improve the knowledge of dental students in the guidelines for the management of tooth avulsion. Because tooth avulsion is the most prevalent lesion in dentoalveolar traumas, it is of the utmost importance that dental surgeons be prepared to treat it properly, avoiding damage to neighboring teeth and structures, and esthetic, functional, psychosocial and therapeutic implications for the patient.


INTRODUCTION
Dentoalveolar traumas to permanent teeth are among the most serious oral health problems in children and adolescents, compared to the clear reduction of tooth decay and to the low prevalence of periodontal disease in this age group 1 .This type of trauma and its consequences to the teeth and to adjoining structures have remarkable psychosocial effects on patients. 2ooth avulsion is one of the most prevalent lesions caused by dentoalveolar traumas.Factors such as storage, transportation, and time elapsed since the trauma are closely related to the possibility of maintaining the vitality of pulp cells and of the periodontal ligament, a major determining factor for the healing of replanted teeth 3 .The treatment of avulsion is rather complex as it is time-consuming and relatively expensive, and also requires multidisciplinary management, including endodontic, periodontic or orthodontic treatment, surgery, and esthetic restorations 4 .It is of utmost importance that the dental surgeon know how to and be prepared to manage this type of trauma. 5he aim of the present study was to assess the knowledge of first-year and last-year undergraduates attending the School of Dentistry of Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Brazil, on tooth avulsion, to compare the knowledge acquired during the undergraduate course and to verify whether students are prepared to treat and follow up this type of trauma after they leave college and start working as surgeons.

MATERIAL AND METHOD
The study population consisted of 65 first-year and 60 last-year students attending a School of Dentistry in Brazil, between 2006 and 2007.The students were given a hypothetical clinical situation involving avulsion of a permanent tooth and had to answer a questionnaire with 10 multiple choice questions.Each question had only one correct option (CHART 1).The questions assessed students' specific knowledge of avulsed teeth.Each question had five answer options (A, B, C, D, E); the highest the score, the deepest the knowledge on the matter: 0 = poor knowledge, 1 = basic knowledge, 2 = good knowledge and 3 = excellent knowledge; Option E was graded as 0 (zero).
Questionnaire results were expressed as frequency distribution and percentage of right answers for each question.The descriptive statistical analysis was made using the SPSS program, in which the chi-square test was used to establish the significance (p d" 0.05) regarding the percentage of right answers; p d" 0.05 was regarded as statistically significant.

DISCUSSION
All dental surgeons should be scientifically and technically prepared for the treatment and long-term follow-up of tooth avulsion, by carrying out the recommended procedures with proper quality 5,6 they may have to treat a patient with dentoalveolar trauma at any time, regardless of their field of expertise. 7n the United Kingdom, college students and dental surgeons were assessed as to their knowledge on the emergency care of dentoalveolar traumas to permanent incisors and on the difficulties of their management.The answers revealed that respondents had poor knowledge of the emergency care of dentoalveolar traumas. 8n the present study, the first question concerned the most appropriate management in case of tooth avulsion.Sixty percent of first-year undergraduates answered that calming the child and parents down, stopping the bleeding and asking for the avulsed tooth was the most correct option.Only 6.2% did not know what to do.Most last-year students (91.7%) answered that this was the most correct option, showing excellent knowledge on this issue.
The knowledge of first-year and last-year students was poor with regard to the storage of the avulsed tooth.As this is one of the major prognostic factors for the management of avulsion, results showed that first-year undergraduates (15.4%) stated that the replantation of the avulsed tooth was the most appropriate option, but only 35% of last-year students agreed to this statement.The results obtained for the knowledge of first-year students, which show that 53.8% of them do not have enough knowledge of this topic, are similar to those found in a previous study of a lay population, where 54% of respondents did not have sufficient knowledge of the issue 9 .This result was different from that obtained from the study performed in the UK with dental students and dental surgeons, in which the knowledge on the storage and handling of the avulsed tooth was adequate. 8he length of time the tooth is out of the socket was assessed through question 3.In the present study, 23.1% of first-year undergraduates did not know that time is a crucial factor for success after tooth replantation.This result was similar to that of the lay population, in which 25% did not know or did not believe that time plays a key role. 9Fifty-five percent of last-year students chose the correct option.Regarding time, the study undertaken in the UK also yielded a low mean.The management of a patient who arrives at a dental practice without bringing along the avulsed tooth was discussed in question 4, and 72.3% of first-year students and 51.7% of last-year undergraduates answered that the bleeding should be stopped, the socket should be sutured and the patient should be referred to a qualified professional.This demonstrates that general practitioners are not prepared to deal with these patients and that they believe a qualified professional can do that more appropriately. 10uestion 5 asked about the cleaning of the avulsed tooth after it is found.Among first-year undergraduates, 81.5% mentioned that the tooth should be carefully handled by its crown and that it should be washed with delicate jets of water or saline, whereas 90% of lastyear students shared the same opinion.This is an excellent result because when the tooth is minimally handled and treated in a quick and efficient way, the prognosis is better, preventing functional, esthetic and psychological sequelae.
If replantation is done immediately, what type of splint should be used?First-year students (21.5%) were not prepared to carry out this procedure.However, 63.3% of last-year students chose the correct option.Only 38.5% of first-year undergraduates considered giving the patient antibiotics and tetanus vaccine, compared to 81.7% of last-year students.The retention time of a replanted tooth required for the prevention of pulpal necrosis was poorly known by first-year undergraduates (13.8%) and also by last-year students (31.7%).
Dentoalveolar traumas occur quite frequently among children and adolescents.High rates of violence, transit accidents, and sports practice contribute to these traumas 2 .This type of injury and its consequences to adjoining teeth and structures cause esthetic, functional, psychosocial and therapeutic damage and have been regarded as a public health issue, increasingly affecting a large percentage of the population.In countries where prevention of tooth decay is successful, dental injuries are a major oral health problem among young individuals 11,12 .Question 10 assessed the psychosocial impact of dental injury as a public health problem.The mean values for first-year and last-year undergraduates were 49.2% and 53.3%, respectively.
The final results for all the questions showed that first-year undergraduates have poor knowledge of tooth avulsion, with rates of 41.0% for score 3, 18.91% for score 2, 15.7% for score 1 and 23.4% for score 0. This result is similar to those obtained by a previous study performed with parents and surrogates of pediatric patients treated in the same Brazilian setting, who also showed a poor level of knowledge 9 .Last-year undergraduates had low mean values, considering the fact that they are about to go into the job market.The mean values were 62% for score 3, 18.16% for score 2, 5.94% for score 1 and 14.48% for score 0. Another study, which assessed the knowledge of dental surgeons on the immediate treatment of dentoalveolar traumas, revealed a low level of knowledge, and showed that those with a professional experience of less than 10 years answered the questions more accurately than those with greater experience 13 .Knowledge, emergency care and perception of difficulties surrounding tooth injuries were assessed among English dentists.The conclusion is that dental surgeons had insufficient knowledge on the treatment of dentoalveolar traumas. 13n another study, 87 dental surgeons were interviewed about the emergency care of dentoalveolar traumas.Most interviewees were scientifically and technically prepared to treat the patients.It should be a dental surgeon's responsibility to seek knowledge in this field and to convey it to the community, acting as an educational agent in order to prevent these injuries. 14he scores of first-year undergraduates were similar to those of lay persons, considering the results of a previous study 9 .With regard to last-year students, they were expected to have a better performance, since they exercised clinical practice in endodontics, pediatric dental care, surgery and traumatology, which include the management of tooth avulsion both in theory and practice.However, their scores were verybelow expectations and slightly above the results obtained by lay persons, considering the results of a previous study 9 .This finding is indeed worrying as last-year undergraduates should be better prepared to enter the job market.

CONCLUSION
There is a need to improve the knowledge of dental students of the guidelines for the emergency management and treatment of tooth avulsion.

Chart 1 -
Questionnaire : Tooth Avulsion The study protocol was approved by the Research Ethics Committee of the School of Dentistry of PUCRS/ Brazil and Reasearch Ethics Committee of PUCRS/Brazil.

Table 1 -
Percentage distribution of scores per question among first-year undergraduates.

Table 2 -
Percentage distribution of scores per question among last-year undergraduates.