Dental Traumatology 2015; 31: 368–373; doi: 10.1111/edt.12186
Dentists’ self-estimation of their competence to treat avulsion and root fracture injuries Anne B Skaare1, Andrzej Adam Pawlowski1,2, Anne-Lise Maseng Aas1, Ivar Espelid1 1 Department of Paediatric Dentistry and Behavioural Science, Institute of Clinical Dentistry, University of Oslo, Oslo; 2Public Dental Health Service, Rogaland, Norway
Key words: dental trauma; knowledge; management Correspondence to: Anne B. Skaare, Department of Paediatric Dentistry and Behavioural Science, Institute of Clinical Dentistry, University of Oslo, Norway Tel.: +47 22 85 21 86 e-mail: [email protected] Accepted 5 May, 2015
Abstract – Aim: The purpose of this study was to evaluate the knowledge of Norwegian dentists on avulsion and root fracture injuries. Method: An electronic questionnaire (QuestBack) was sent in 2012 to all dentists (n = 255) employed in the Public Dental Service (PDS) in three counties of Norway. The dentists were asked to state whether they felt they had sufficient competence to treat avulsion and root fractures immediately and long term. Based on international guidelines, the authors achieved a consensus for ideal treatment. Based on two cases, the clinicians were to assess their own competence. They were classified into either a ‘sufficient competence’ (SC) group or an ‘insufficient competence’ (ISC) group. The data were evaluated by descriptive statistics and chi-square bivariate analysis. Results: The response rate was 64%, 95 dentists (62%) in the SC group and 58 (38%) in the ISC group. Significantly more young dentists responded (P < 0.001). Correct treatment (reposition and splint) for a oneday-old fracture in the middle third of the root with luxation of the coronal fragment was chosen more often by the SC group compared with the ISC group (P = 0.03), but estimating the long-term prognosis, there was no difference (P = 0.14). In a case with a previous avulsion injury and obvious signs of pulp necrosis and external infection-related root resorption, the majority (n = 97, 63%) would choose root canal treatment with a Ca(OH)₂ dressing which was considered correct treatment, but fewer than half of the clinicians (40%) diagnosed the external infection related to root resorption which was visible on a radiograph. There was no difference between the groups (P = 0.81). Conclusion: The study shows that overall knowledge among Norwegian dentists is good, but more knowledge on detecting and diagnosing external root resorption is needed. Self-estimation of own competence does not reflect level of knowledge.
Dentoalveolar trauma is common (1) and most often occurs in play, sports activities, traffic accidents or violence (2–5). Studies have shown that one-fourth of all schoolchildren have suffered a dental trauma to a permanent tooth before they leave school (6, 7). Although there does not seem to be an increase in the number of dental traumas affecting children (8), dentists and patients may be more concerned and more focused on dental trauma as caries prevalence has declined (9). Dental trauma most often involves the upper central incisors affecting dental appearance, and aesthetics and selfesteem may have an impact on oral health-related quality of life (10–13). To minimize long-term consequences, first-aid treatment is an issue when a child or adolescent has sustained a dental injury. This is most urgent for avulsed permanent incisors; any delay in replantation dramatically reduces their long-term survival (14, 15). Some children receive inadequate treatment, probably because the dentist lacks the necessary knowledge or experience. A limited number of new trauma cases may 368
not provide sufficient experience to develop and maintain clinical skills and knowledge (16, 17). Avulsion and root fracture injuries occur infrequently (1, 8, 18) and are not often encountered by the clinicians (16). Continuous or postgraduate education in the management of dental trauma is important. Practitioners who had participated in postgraduate training have been shown to be significantly more likely to feel confident in the treatment of dento-alveolar trauma (16, 19– 21), whereas practitioners who see relatively few complex dental trauma cases are not confident in its management (16, 17). Several studies have shown that dentists have only moderate (22, 23) or poor knowledge (24) of correct diagnosis and treatment of dentoalveolar injuries. One investigation found that approximately half of the referred patients to a trauma clinic had received unsatisfactory immediate treatment (25). The purpose of this study was to evaluate the knowledge of Norwegian dentists treating the age group 0–18 years on diagnosis and treatment of some selected © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Dentists’ knowledge of dental trauma dental trauma conditions, root fractures and avulsion injuries. The null hypothesis was that the dentists assessing their own competence as satisfactory would not choose correct or proper treatment more often than dentists assessing their competence as inadequate. Material and methods
In May 2012, an electronic questionnaire was sent to all dentists (n = 255) employed in the Public Dental Service (PDS) in the counties of Buskerud, Rogaland and Troms, Norway. Only dentists working in the PDS were included as all children in Norway are offered free comprehensive dental care from birth to 18 years of age in the PDS, and 95% of the children are enrolled in the services. These counties represent different regions of the country – east, west and north – and include dentists from both urban and rural areas and employ 22% of the PDS dentists in Norway. The age distribution of the sample was checked against Statistical Norway’s registry on dentists employed in the PDS in Norway, and there was no statistically significant difference, P = 0.61. There was no power analysis prior to the survey. The questionnaire was distributed using a webbased software program (QuestBack Norge, Oslo) ensuring anonymity of the respondents. Hidden identity ensures that no identifiable information, such as browser type and version, Internet IP address, operating system or email address, is stored with the answer. According to the regulation by the Norwegian Data Protection Authority, anonymous questionnaires do not require specific approval and a data processing agreement exists between QuestBack and University of Oslo to protect the respondents’ identity. The respective Chief Dental Officers provided the email addresses to QuestBack and recommended the dentists to participate to ensure a high response rate, but the participation was voluntary and no incentives were offered. The initial contact with the dentists was by email which contained a unique URL link ensuring that only one answer could be given. QuestBack collects data automatically from web-based questionnaire. The system provides a complete SPSS file representing the responses to the survey. All information is stored securely and can be accessed by authorized QuestBack personnel only. The invitation to participate was sent out in May 2012; one reminder was automatically sent after two weeks by the QuestBack system to nonrespondents. In total, the questionnaire was open six weeks after posting. An expert group (authors ABS, ALMA and IE) developed the survey. The ‘experts’ have much experience with dental traumatology and with the use of selfadministrated questionnaires. Clinical instructors at the Department of Paediatric Dentistry piloted and tested the questionnaire. The information content in each screenshot covered only one specific item in the questionnaire. The respondents could not go back and forth in the questionnaire. The questionnaire was non-adaptive and the respondents could not change their answers. All together 28 items were included in the questionnaire. Four questions dealt with occupational informa© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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tion, and the others were about seven different patient cases focusing on two types of trauma, root fracture and avulsion injuries, in young patients. The participants chose among precoded alternatives and one question allowed to use a text field. In this report, one patient case with four items is not included for analyses. The dentists were, among others, asked to record if they felt they had sufficient competence to treat an avulsion and a root fracture injury on a shortand long-term basis and where they would seek information, if necessary. Based on two questions (patient cases 1a and 2) regarding treatment of an avulsion and a root fracture injury in an acute situation, the respondents were asked to estimate their competence. The two questions (Q1 and Q2) were as follows: Q1: ‘How would you estimate your own competence to give first-aid treatment to a 15-yr-old, tooth 11 mid-root fracture, tooth 21 avulsion with dry time 45 min?’ and question Q2: ‘Do you have sufficient competence to treat a 10-yr-old on a short time basis, tooth 11 mid-root fracture, tooth 21 avulsion with dry time 60 min’ Respondents who in both situations report very good or sufficient competence to treat the patients were selected for a ‘sufficient competence’ (SC) group of clinicians, and the remaining with less confidence in own skills were grouped in an ‘insufficient competence’ (ISC) category. In case 1b, the dentists were asked to rate their competence to treat the 15-yr-old on a long-term basis and/ or where they would seek information. In patient case 3, they were asked about their choice of treatment of a one-day-old root fracture in the middle third of the root with luxation of the coronal fragment and, furthermore, their estimate of the long-term prognosis. Different treatment options were proposed, where more than one choice could be made: (i) refer to another dentist, (ii) reposition, (iii) splint, (iv) extraction of coronal fragment, (v) extraction of both fragments, (vi) root canal treatment of both fragments, (vii) root canal treatment of coronal fragment, (viii) no treatment with observation and (ix) other. Correct treatment was reposition and splint according to international guidelines (26). The choices of treatment were grouped according to the respondents’ self-rated competence. Alternatives for the survival proportion after 10 years were as follows: 1–20%, 21–40%, 41–60%, 61–80% or 81–100%. According to literature, correct treatment has shown long-term survival of mid-root fractures of 78% (CI 64–92%) (27, 28). Patient case 4 (a 9-yr-old child) was presented with a previous avulsion injury, illustrated by a radiograph (Fig. 1). Additional information included was absence of symptoms, absence of tooth discolouration and no reaction to sensitivity testing. The dentists were given the following treatment options, where multiple responses were possible: (i) further observation, (ii) root canal treatment with calcium hydroxide, (iii) single session root canal treatment, (iv) surgical inspection and curettage, (v) other and (vi) I do not know. The dentists were questioned about their choice of treatment before they knew that they later were going to be asked to make a diagnosis with the following
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Skaare et al. 20. The data were evaluated using descriptive statistics and chi-square bivariate analysis. Cronbach’s alpha was used to measure internal consistency. The level of statistical significance was set at P < 0.05. Results
Fig. 1. Radiograph of a 9-yr-old showing tooth 11 with external infection-related root resorption (arrows).
alternatives: (i) infection-related (inflammatory) root resorption, (ii) necrosis of the pulp, (iii) apical periodontitis, (iv) internal resorption, (v) replacement (ankylosis) resorption and (vi) the status of the pulp is not clear. More than one choice could be made. Each alternative was marked with most probable, possible or not probable diagnosis. The main issue of this question was to evaluate whether the clinicians were able to identify external infection-related root resorption, defined as ‘true positive finding’. The dentists were also questioned about the telephone advice they would give to a father of a child (8-year-old, case 5) who has a recently avulsed tooth in his hand, and furthermore, case 6, their assessment of different treatment alternatives to be provided at the clinic if the avulsed tooth had been dry for 45 min and was visibly dirty. Consensus for correct treatment was discussed by the authors, based on international guidelines (26, 29). Statistical analysis was carried out using the SPSS Statistical Package for the Social Science Software version
Of the 255 invited dentists, 164 responded after two reminders, giving a response rate of 64%. Information about how many invited dentists who effectively visited the questionnaire page was not available. Four respondents were dental specialists, and six were not working clinically. Only one did not complete questions 1 and 2 separating the dentists in the ‘sufficient competence’ group or ‘insufficient competence’ group leaving 153 general practitioners for inclusion. Two-thirds (n = 101) had full-time clinical positions at the time of the survey. With respect to years since graduation, 42 dentists (28%) had graduated before 1991, 31 (20%) in the period 1991–2000 and finally 80 (52%) during the period 2001–2012. Significantly more young dentists (educated during the period 2001–2012) responded, P < 0.0001. Based on cases 1a and 2, ninety-five (62%) respondents reported very good or sufficient competence to treat the patients, ‘sufficient competence’ (SC) group of clinicians, whereas the remaining clinicians (n = 58, 38%) reporting less confidence in their own skills were grouped in the ‘insufficient competence’ (ISC) category. The internal consistency between Q1 and Q2 measured by Cronbach’s alpha was 0.57. There were no statistically significant differences between the two groups (SC vs ISC) regarding time of graduation (P = 0.30) or proportion of full clinical position (P = 0.82). Thirty-two respondents (21%) rated their competence to treat an avulsion and a root fracture injury on a long-term basis as sufficient (case 1b). Of the clinicians seeking information or assistance elsewhere (with or without self-reported skills), a majority (45%) would consult an orthodontist and 36% an experienced colleague. The remaining clinicians (19%) would seek internet-based information, textbooks or consult other specialists (prosthetics, oral surgeon). In patient case 3, repositioning and splinting (correct treatment) was chosen more often by the SC group compared with the ISC group. A statistical difference (P = 0.03) between the self-assessed competence and the percentage of correct answers was found. Ninetythree percentage of the SC group answered correctly, while 81% of the ISC group (Table 1). In Table 2, the clinicians’ estimation of the long-term prognosis of the
Table 1. Distribution and treatment suggestions (proportions) for a patient presenting with a one-day-old root fracture. Dentists were grouped according to self-assessed competence Correct treatment of root fracture
Incorrect treatment of root fracture
Total
Self-assessed competence
n
%
n
%
n
%
‘Sufficient competence’ group ‘Insufficient competence’ group Total
88 47 135
93 81 88
7 11 18
7 19 12
95 58 153
100 100 100
P = 0.03; chi-squared test. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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Table 2. The table illustrates the respondents’ estimates of possible 10-yr survival for a mid-root fractured tooth. Proportions (%) are in parentheses. Due to rounding, the proportions do not always sum to 100 Estimation of 10-yr survival of a root fracture (middle third) tooth Self-assessed competence
Do not know
No survival
1–20%
21–40%
41–60%
61–80%
81–100%
Total
‘Sufficient competence’ group ‘Insufficient competence’ group Total
4 (4) 4 (7) 8 (5)
2 (2) 2 (3) 4 (3)
20 (22) 18 (31) 38 (26)
19 (20) 12 (21) 31 (21)
25 (27) 6 (10) 31 (21)
19 (20) 8 (14)** 27 (18)
4 (4) 6 (10) 10 (7)
93 (99) 56 (100)* 149 (101)
*P = 0.14; chi-squared test. **P = 0.91; Dichotomized with «cut-off» >60% survival.
root fracture is shown. There was no statistical difference between the groups (P = 0.14). Only a quarter of the clinicians estimated the survival chance to be more than 60% after 10 years; the proportions in the SC and ISC group were similar (P = 0.93). In patient case 4 with a previous avulsion injury and obvious signs of pulp necrosis (Fig. 1), the majority (n = 97, 63%) would choose root canal treatment with Ca(OH)2 dressing. Forty-two respondents (28%) would continue to observe and three (2%) would recommend surgery. Eleven respondents (7%) did not know what to do or did not answer. No respondents would choose a single session root canal treatment. Fewer than half of the clinicians (40%) diagnosed the external infection-related root resorption which was visible on the radiograph. A true positive finding was more frequent in the SC group compared with the ISC group, but the difference was not statistically significant (P = 0.81) (Table 3). In case 5 where the clinicians were asked about telephone advice to a parent of a child with an avulsed central incisor, a majority (n = 101, 64%) would advise the parent to replant the tooth themselves as soon as possible after the accident, whereas 36% (n = 52) would advise the parent to keep the tooth moist and attend a dentist as soon as possible. None would recommend clean and dry storage of the tooth. Table 4 shows the clinicians’ assessment of treatment alternatives for the avulsed and visibly dirty central incisor of an 8-yr-old (case 6) being stored dry for 45 min before arriving at the clinic. Most dentists (n = 117, 76%) reported as optimal treatment to rinse the tooth with saline before replantation; 22 clinicians (14%) found it acceptable to rinse the tooth with soapy water or ethanol, whereas two found it optimal to tell the patient that the tooth was lost. There was no overTable 3. The dentists’ ability to identify external infectionrelated root resorption on a radiograph (Fig. 1) ‘True positive finding’
‘False negative finding’
Total
Self-assessed competence
n
%
n
%
n
%
‘Sufficient competence’ group ‘Insufficient competence’ group Total
43 18 61
45 31 40
52 40 92
55 69 60
95 58 153
100 100 100
P = 0.81, chi-squared test. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
all statistical difference between the SC and ISC groups. Regarding alternative a) no replantation, the tooth was considered lost, and 84% in the SC group vs only 65% in ISC group considered this alternative as ‘unacceptable’ (P = 0.01). Discussion
This study aimed to evaluate the knowledge of Norwegian dentists working in the PDS regarding the diagnosis, treatment and prognosis of dental avulsion and root fracture injuries. The questions in this web-based survey covered knowledge and treatment options in selected patient cases. A main issue was to study whether there was a relationship between self-estimated competence and choice of treatment. A limitation was that the questionnaire was not subject to test–retest reliability to determine the validity. Furthermore, the web-based questionnaire, which was extensive, may have appealed more to the young dentists. This may have influenced the representativeness of the material. However, the response rate was comparable with other questionnaire-based investigations (19, 21–23, 30–32). As dental trauma in children may have long-term consequences for oral health and is reported to influence the oral health-related quality of life (10–13), it is essential that children suffering from dental trauma receive correct emergency treatment (33) and are scheduled for appropriate follow ups. Almost two-thirds (62%) of the respondents reported they had sufficient competence to treat a patient with a root fracture and an avulsion injury in an emergency situation. This proportion is close to German dentists’ self-assessed knowledge (24), but higher than that of general practitioners in UK where only 51% of the respondents were confident of managing root fractures and 32% were confident of managing an avulsion injury (16). Although 38% evaluated their competence as insufficient, 81% still recorded correct treatment for a midroot fractured tooth with displacement of the coronal fragment and almost all (95%) reported correctly for a visibly dirty avulsed tooth stored dry for 45 min. Experience in dental traumatology or having attended postgraduate dental education increases the probability of providing appropriate first-aid treatment and care (17, 21). In the present study, the SC group of clinicians did not give correct answers more often than the ISC clinicians to treatment and diagnostic options, except in the case of root fracture treatment.
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Skaare et al.
Table 4. Assessment of treatment strategies for an avulsed and visibly dirty tooth stored dry for 45 min. Proportions (%) are in parentheses. Due to rounding, the proportions do not always sum to 100 Treatment assessments
a) No replantation. Tooth is considered lost b) Replant the tooth as it is c) Replantation after rinsing with soapy water d) Replantation after rinsing with ethanol e) Replantation after rinsing with saline
Optimal
Acceptable
Unacceptable
Do not know
Total
2 0 0 0 117
9 29 12 10 32
118 100 113 111 1
24 24 32 32 3
153 153 153 129 153
(1) (0) (0) (0) (76)
There was no difference between the two groups regarding time of graduation or the proportion in a full-time clinical position. It may be speculated that recent education or having attended continuing education courses that influence self-confidence outweigh clinical experience. The finding of no association with graduation year agrees with some (24, 31) but not all previous reports (17, 22, 32). Although there was a trend towards recently graduated dentists having better knowledge in the study by Krastl et al. (24), and a statistically significant association in two recent surveys (17, 32), the latter studies showed an association only related to crown fractures. However, it is difficult to compare studies due to widely different methods and thus a need for more standardized surveys. A limitation of the present study was missing information about how often the respondents were faced with avulsion and root fracture injuries. As the occurrence is low (1, 8), only few patients will present with these traumatic injuries and thus clinical experience may be minimal. Still, a majority of the dentists assessed their knowledge about providing optimal treatment in an emergency situation as good and reported that they themselves would provide all emergency treatment for dental trauma to permanent incisors. One explanation may be the lack of specialists to whom they could refer patients. Dentists have a responsibility to provide initial emergency treatment. In the study from UK (16), general dental practitioners encouraged close collaboration with specialists for the long-term management of complex dental trauma. This is in accordance with the present study, where more dentists would refer to a specialist on a long-term basis than in an acute situation. In another study from UK (25), the establishment and evaluation of a trauma clinic showed that over one-third of the patients were referred when problems had arisen after initial treatment and more than half had received unsatisfactory or inappropriate treatment prior to referral. This is in line with the present study, where fewer than half of the clinicians diagnosed the external infectionrelated root resorption on the radiograph, although the majority would have chosen correct root canal treatment due to the presence of apical periodontitis. To diagnose external infection-related root resorption is particularly important after replantation in children with immature teeth. The resorption process is more aggressive than in mature teeth due to thin dentinal walls and the wide dentinal tubules and the thin covering of protective cement, where the dentinal tubules may be the pathway for diffusion of toxic products from the necrotic pulp (34). Inade-
(8) (18) (8) (7) (21)
(76) (67) (72) (73) (1)
(16) (16) (20) (20) (2)
(101) (101) (100) (100) (100)
quate understanding among dentists of the biological mechanisms of root resorption after avulsion injuries has been documented in an Australian study (23). The overall knowledge of emergency treatment of root fractures injury was adequate and correct in the present study, but only few respondents estimated the long-term prognosis for a tooth with a mid-root fracture to be good, with a survival rate >60% after 10 years. Based on available and published data, this estimate is wrong or knowledge is deficient and may result in treatment options that threaten the long-term prognosis of the tooth. With correct treatment, the success rate may be >80% (27, 28, 35). An avulsion injury is the most severe trauma diagnosis, and minutes count. The prognosis depends on implementing appropriate emergency management procedures, and immediate replantation is the most appropriate treatment. In the present study, approximately two-thirds would advise the parent on the phone to replant the tooth immediately at the time of the accident, whereas about one-third would advise the parent to keep the tooth moist and attend a dentist as soon as possible. Fortunately, no respondent would recommend clean and dry storage, showing that the dentists have proper knowledge about first-aid treatment of avulsed teeth in accordance with current guidelines. The same applied for the clinical situation where most dentists would rinse the dirty tooth with saline prior to replantation in accordance with guidelines. In conclusion, this study has shown that the overall knowledge of treatment of dental trauma among Norwegian dentists is good, with some exceptions. There is a need for more knowledge on detecting and diagnosing external root resorption. There was no overall difference regarding knowledge among the SC group of dentists compared with the ISC group. As the results were inconsistent in regard to the validity of self-assessed skills, the null hypothesis was not rejected. Continuing education courses or education in dental traumatology is required, in particular regarding dental injuries which the clinicians encounter seldom. Self-estimation of own competence does not reflect level of knowledge. Acknowledgements
The authors would like to thank dentists in the Public Dental Health Service in the counties of Buskerud, Rogaland and Troms for participation in the study. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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19. Baginska J, Wilczynska-Borawska M. Continuing dental education in the treatment of dental avulsion: polish dentists’ knowledge of the current IADT guidelines. Eur J Dent Educ 2013;17:88–92. 20. Westphalen VP, Martins WD, Deonizio MD, da Silva Neto UX, da Cunha CB, Fariniuk LF. Knowledge of general practitioners dentists about the emergency management of dental avulsion in Curitiba, Brazil. Dent Traumatol 2007;23:6–8. 21. Hu LW, Prisco CR, Bombana AC. Knowledge of Brazilian general dentists and endodontists about the emergency management of dento-alveolar trauma. Dent Traumatol 2006;22:113–7. 22. Kostopoulou MN, Duggal MS. A study into dentists’ knowledge of the treatment of traumatic injuries to young permanent incisors. Int J Paediatr Dent 2005;15:10–9. 23. Yeng T, Parashos P. An investigation into dentists’ management methods of dental trauma to maxillary permanent incisors in Victoria, Australia. Dent Traumatol 2008;24:443–8. 24. Krastl G, Filippi A, Weiger R. German general dentists’ knowledge of dental trauma. Dent Traumatol 2009;25:88–91. 25. Stewart SM, Mackie IC. Establishment and evaluation of a trauma clinic based in a primary care setting. Int J Paediatr Dent 2004;14:409–16. 26. Diangelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ, Trope M, Sigurdsson A et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol 2012;28:2–12. 27. Andreasen JO, Ahrensburg SS, Tsilingaridis G. Root fractures: the influence of type of healing and location of fracture on tooth survival rates - an analysis of 492 cases. Dent Traumatol 2012;28:404–9. 28. Andreasen JO, Andreasen FM, Mejare I, Cvek M. Healing of 400 intra-alveolar root fractures. 2. Effect of treatment factors such as treatment delay, repositioning, splinting type and period and antibiotics. Dent Traumatol 2004;20:203–11. 29. Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, Diangelis AJ et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2 Avulsion of permanent teeth. Dent Traumatol 2012;28:88–96. 30. Qazi SR, Nasir KS. First-aid knowledge about tooth avulsion among dentists, doctors and lay people. Dent Traumatol 2009;25:295–9. 31. Cohenca N, Forrest JL, Rotstein I. Knowledge of oral health professionals of treatment of avulsed teeth. Dent Traumatol 2006;22:296–301. 32. de Franca RI, Traebert J, de Lacerda JT. Brazilian dentists’ knowledge regarding immediate treatment of traumatic dental injuries. Dent Traumatol 2007;23:287–90. 33. Giannetti L, Murri A, Vecci F, Gatto R. Dental avulsion: therapeutic protocols and oral health-related quality of life. Eur J Paediatr Dent 2007;8:69–75. 34. Andreasen JO. Relationship between surface and inflammatory resorption and changes in the pulp after replantation of permanent incisors in monkeys. J Endod 1981;7:294–301. 35. Cvek M, Tsilingaridis G, Andreasen JO. Survival of 534 incisors after intra-alveolar root fracture in patients aged 7–17 years. Dent Traumatol 2008;24:379–87.
Dentists’ self-estimation of their competence to treat avulsion and root fracture injuries Anne B Skaare1, Andrzej Adam Pawlowski1,2, Anne-Lise Maseng Aas1, Ivar Espelid1 1 Department of Paediatric Dentistry and Behavioural Science, Institute of Clinical Dentistry, University of Oslo, Oslo; 2Public Dental Health Service, Rogaland, Norway
Key words: dental trauma; knowledge; management Correspondence to: Anne B. Skaare, Department of Paediatric Dentistry and Behavioural Science, Institute of Clinical Dentistry, University of Oslo, Norway Tel.: +47 22 85 21 86 e-mail: [email protected] Accepted 5 May, 2015
Abstract – Aim: The purpose of this study was to evaluate the knowledge of Norwegian dentists on avulsion and root fracture injuries. Method: An electronic questionnaire (QuestBack) was sent in 2012 to all dentists (n = 255) employed in the Public Dental Service (PDS) in three counties of Norway. The dentists were asked to state whether they felt they had sufficient competence to treat avulsion and root fractures immediately and long term. Based on international guidelines, the authors achieved a consensus for ideal treatment. Based on two cases, the clinicians were to assess their own competence. They were classified into either a ‘sufficient competence’ (SC) group or an ‘insufficient competence’ (ISC) group. The data were evaluated by descriptive statistics and chi-square bivariate analysis. Results: The response rate was 64%, 95 dentists (62%) in the SC group and 58 (38%) in the ISC group. Significantly more young dentists responded (P < 0.001). Correct treatment (reposition and splint) for a oneday-old fracture in the middle third of the root with luxation of the coronal fragment was chosen more often by the SC group compared with the ISC group (P = 0.03), but estimating the long-term prognosis, there was no difference (P = 0.14). In a case with a previous avulsion injury and obvious signs of pulp necrosis and external infection-related root resorption, the majority (n = 97, 63%) would choose root canal treatment with a Ca(OH)₂ dressing which was considered correct treatment, but fewer than half of the clinicians (40%) diagnosed the external infection related to root resorption which was visible on a radiograph. There was no difference between the groups (P = 0.81). Conclusion: The study shows that overall knowledge among Norwegian dentists is good, but more knowledge on detecting and diagnosing external root resorption is needed. Self-estimation of own competence does not reflect level of knowledge.
Dentoalveolar trauma is common (1) and most often occurs in play, sports activities, traffic accidents or violence (2–5). Studies have shown that one-fourth of all schoolchildren have suffered a dental trauma to a permanent tooth before they leave school (6, 7). Although there does not seem to be an increase in the number of dental traumas affecting children (8), dentists and patients may be more concerned and more focused on dental trauma as caries prevalence has declined (9). Dental trauma most often involves the upper central incisors affecting dental appearance, and aesthetics and selfesteem may have an impact on oral health-related quality of life (10–13). To minimize long-term consequences, first-aid treatment is an issue when a child or adolescent has sustained a dental injury. This is most urgent for avulsed permanent incisors; any delay in replantation dramatically reduces their long-term survival (14, 15). Some children receive inadequate treatment, probably because the dentist lacks the necessary knowledge or experience. A limited number of new trauma cases may 368
not provide sufficient experience to develop and maintain clinical skills and knowledge (16, 17). Avulsion and root fracture injuries occur infrequently (1, 8, 18) and are not often encountered by the clinicians (16). Continuous or postgraduate education in the management of dental trauma is important. Practitioners who had participated in postgraduate training have been shown to be significantly more likely to feel confident in the treatment of dento-alveolar trauma (16, 19– 21), whereas practitioners who see relatively few complex dental trauma cases are not confident in its management (16, 17). Several studies have shown that dentists have only moderate (22, 23) or poor knowledge (24) of correct diagnosis and treatment of dentoalveolar injuries. One investigation found that approximately half of the referred patients to a trauma clinic had received unsatisfactory immediate treatment (25). The purpose of this study was to evaluate the knowledge of Norwegian dentists treating the age group 0–18 years on diagnosis and treatment of some selected © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Dentists’ knowledge of dental trauma dental trauma conditions, root fractures and avulsion injuries. The null hypothesis was that the dentists assessing their own competence as satisfactory would not choose correct or proper treatment more often than dentists assessing their competence as inadequate. Material and methods
In May 2012, an electronic questionnaire was sent to all dentists (n = 255) employed in the Public Dental Service (PDS) in the counties of Buskerud, Rogaland and Troms, Norway. Only dentists working in the PDS were included as all children in Norway are offered free comprehensive dental care from birth to 18 years of age in the PDS, and 95% of the children are enrolled in the services. These counties represent different regions of the country – east, west and north – and include dentists from both urban and rural areas and employ 22% of the PDS dentists in Norway. The age distribution of the sample was checked against Statistical Norway’s registry on dentists employed in the PDS in Norway, and there was no statistically significant difference, P = 0.61. There was no power analysis prior to the survey. The questionnaire was distributed using a webbased software program (QuestBack Norge, Oslo) ensuring anonymity of the respondents. Hidden identity ensures that no identifiable information, such as browser type and version, Internet IP address, operating system or email address, is stored with the answer. According to the regulation by the Norwegian Data Protection Authority, anonymous questionnaires do not require specific approval and a data processing agreement exists between QuestBack and University of Oslo to protect the respondents’ identity. The respective Chief Dental Officers provided the email addresses to QuestBack and recommended the dentists to participate to ensure a high response rate, but the participation was voluntary and no incentives were offered. The initial contact with the dentists was by email which contained a unique URL link ensuring that only one answer could be given. QuestBack collects data automatically from web-based questionnaire. The system provides a complete SPSS file representing the responses to the survey. All information is stored securely and can be accessed by authorized QuestBack personnel only. The invitation to participate was sent out in May 2012; one reminder was automatically sent after two weeks by the QuestBack system to nonrespondents. In total, the questionnaire was open six weeks after posting. An expert group (authors ABS, ALMA and IE) developed the survey. The ‘experts’ have much experience with dental traumatology and with the use of selfadministrated questionnaires. Clinical instructors at the Department of Paediatric Dentistry piloted and tested the questionnaire. The information content in each screenshot covered only one specific item in the questionnaire. The respondents could not go back and forth in the questionnaire. The questionnaire was non-adaptive and the respondents could not change their answers. All together 28 items were included in the questionnaire. Four questions dealt with occupational informa© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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tion, and the others were about seven different patient cases focusing on two types of trauma, root fracture and avulsion injuries, in young patients. The participants chose among precoded alternatives and one question allowed to use a text field. In this report, one patient case with four items is not included for analyses. The dentists were, among others, asked to record if they felt they had sufficient competence to treat an avulsion and a root fracture injury on a shortand long-term basis and where they would seek information, if necessary. Based on two questions (patient cases 1a and 2) regarding treatment of an avulsion and a root fracture injury in an acute situation, the respondents were asked to estimate their competence. The two questions (Q1 and Q2) were as follows: Q1: ‘How would you estimate your own competence to give first-aid treatment to a 15-yr-old, tooth 11 mid-root fracture, tooth 21 avulsion with dry time 45 min?’ and question Q2: ‘Do you have sufficient competence to treat a 10-yr-old on a short time basis, tooth 11 mid-root fracture, tooth 21 avulsion with dry time 60 min’ Respondents who in both situations report very good or sufficient competence to treat the patients were selected for a ‘sufficient competence’ (SC) group of clinicians, and the remaining with less confidence in own skills were grouped in an ‘insufficient competence’ (ISC) category. In case 1b, the dentists were asked to rate their competence to treat the 15-yr-old on a long-term basis and/ or where they would seek information. In patient case 3, they were asked about their choice of treatment of a one-day-old root fracture in the middle third of the root with luxation of the coronal fragment and, furthermore, their estimate of the long-term prognosis. Different treatment options were proposed, where more than one choice could be made: (i) refer to another dentist, (ii) reposition, (iii) splint, (iv) extraction of coronal fragment, (v) extraction of both fragments, (vi) root canal treatment of both fragments, (vii) root canal treatment of coronal fragment, (viii) no treatment with observation and (ix) other. Correct treatment was reposition and splint according to international guidelines (26). The choices of treatment were grouped according to the respondents’ self-rated competence. Alternatives for the survival proportion after 10 years were as follows: 1–20%, 21–40%, 41–60%, 61–80% or 81–100%. According to literature, correct treatment has shown long-term survival of mid-root fractures of 78% (CI 64–92%) (27, 28). Patient case 4 (a 9-yr-old child) was presented with a previous avulsion injury, illustrated by a radiograph (Fig. 1). Additional information included was absence of symptoms, absence of tooth discolouration and no reaction to sensitivity testing. The dentists were given the following treatment options, where multiple responses were possible: (i) further observation, (ii) root canal treatment with calcium hydroxide, (iii) single session root canal treatment, (iv) surgical inspection and curettage, (v) other and (vi) I do not know. The dentists were questioned about their choice of treatment before they knew that they later were going to be asked to make a diagnosis with the following
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Skaare et al. 20. The data were evaluated using descriptive statistics and chi-square bivariate analysis. Cronbach’s alpha was used to measure internal consistency. The level of statistical significance was set at P < 0.05. Results
Fig. 1. Radiograph of a 9-yr-old showing tooth 11 with external infection-related root resorption (arrows).
alternatives: (i) infection-related (inflammatory) root resorption, (ii) necrosis of the pulp, (iii) apical periodontitis, (iv) internal resorption, (v) replacement (ankylosis) resorption and (vi) the status of the pulp is not clear. More than one choice could be made. Each alternative was marked with most probable, possible or not probable diagnosis. The main issue of this question was to evaluate whether the clinicians were able to identify external infection-related root resorption, defined as ‘true positive finding’. The dentists were also questioned about the telephone advice they would give to a father of a child (8-year-old, case 5) who has a recently avulsed tooth in his hand, and furthermore, case 6, their assessment of different treatment alternatives to be provided at the clinic if the avulsed tooth had been dry for 45 min and was visibly dirty. Consensus for correct treatment was discussed by the authors, based on international guidelines (26, 29). Statistical analysis was carried out using the SPSS Statistical Package for the Social Science Software version
Of the 255 invited dentists, 164 responded after two reminders, giving a response rate of 64%. Information about how many invited dentists who effectively visited the questionnaire page was not available. Four respondents were dental specialists, and six were not working clinically. Only one did not complete questions 1 and 2 separating the dentists in the ‘sufficient competence’ group or ‘insufficient competence’ group leaving 153 general practitioners for inclusion. Two-thirds (n = 101) had full-time clinical positions at the time of the survey. With respect to years since graduation, 42 dentists (28%) had graduated before 1991, 31 (20%) in the period 1991–2000 and finally 80 (52%) during the period 2001–2012. Significantly more young dentists (educated during the period 2001–2012) responded, P < 0.0001. Based on cases 1a and 2, ninety-five (62%) respondents reported very good or sufficient competence to treat the patients, ‘sufficient competence’ (SC) group of clinicians, whereas the remaining clinicians (n = 58, 38%) reporting less confidence in their own skills were grouped in the ‘insufficient competence’ (ISC) category. The internal consistency between Q1 and Q2 measured by Cronbach’s alpha was 0.57. There were no statistically significant differences between the two groups (SC vs ISC) regarding time of graduation (P = 0.30) or proportion of full clinical position (P = 0.82). Thirty-two respondents (21%) rated their competence to treat an avulsion and a root fracture injury on a long-term basis as sufficient (case 1b). Of the clinicians seeking information or assistance elsewhere (with or without self-reported skills), a majority (45%) would consult an orthodontist and 36% an experienced colleague. The remaining clinicians (19%) would seek internet-based information, textbooks or consult other specialists (prosthetics, oral surgeon). In patient case 3, repositioning and splinting (correct treatment) was chosen more often by the SC group compared with the ISC group. A statistical difference (P = 0.03) between the self-assessed competence and the percentage of correct answers was found. Ninetythree percentage of the SC group answered correctly, while 81% of the ISC group (Table 1). In Table 2, the clinicians’ estimation of the long-term prognosis of the
Table 1. Distribution and treatment suggestions (proportions) for a patient presenting with a one-day-old root fracture. Dentists were grouped according to self-assessed competence Correct treatment of root fracture
Incorrect treatment of root fracture
Total
Self-assessed competence
n
%
n
%
n
%
‘Sufficient competence’ group ‘Insufficient competence’ group Total
88 47 135
93 81 88
7 11 18
7 19 12
95 58 153
100 100 100
P = 0.03; chi-squared test. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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Table 2. The table illustrates the respondents’ estimates of possible 10-yr survival for a mid-root fractured tooth. Proportions (%) are in parentheses. Due to rounding, the proportions do not always sum to 100 Estimation of 10-yr survival of a root fracture (middle third) tooth Self-assessed competence
Do not know
No survival
1–20%
21–40%
41–60%
61–80%
81–100%
Total
‘Sufficient competence’ group ‘Insufficient competence’ group Total
4 (4) 4 (7) 8 (5)
2 (2) 2 (3) 4 (3)
20 (22) 18 (31) 38 (26)
19 (20) 12 (21) 31 (21)
25 (27) 6 (10) 31 (21)
19 (20) 8 (14)** 27 (18)
4 (4) 6 (10) 10 (7)
93 (99) 56 (100)* 149 (101)
*P = 0.14; chi-squared test. **P = 0.91; Dichotomized with «cut-off» >60% survival.
root fracture is shown. There was no statistical difference between the groups (P = 0.14). Only a quarter of the clinicians estimated the survival chance to be more than 60% after 10 years; the proportions in the SC and ISC group were similar (P = 0.93). In patient case 4 with a previous avulsion injury and obvious signs of pulp necrosis (Fig. 1), the majority (n = 97, 63%) would choose root canal treatment with Ca(OH)2 dressing. Forty-two respondents (28%) would continue to observe and three (2%) would recommend surgery. Eleven respondents (7%) did not know what to do or did not answer. No respondents would choose a single session root canal treatment. Fewer than half of the clinicians (40%) diagnosed the external infection-related root resorption which was visible on the radiograph. A true positive finding was more frequent in the SC group compared with the ISC group, but the difference was not statistically significant (P = 0.81) (Table 3). In case 5 where the clinicians were asked about telephone advice to a parent of a child with an avulsed central incisor, a majority (n = 101, 64%) would advise the parent to replant the tooth themselves as soon as possible after the accident, whereas 36% (n = 52) would advise the parent to keep the tooth moist and attend a dentist as soon as possible. None would recommend clean and dry storage of the tooth. Table 4 shows the clinicians’ assessment of treatment alternatives for the avulsed and visibly dirty central incisor of an 8-yr-old (case 6) being stored dry for 45 min before arriving at the clinic. Most dentists (n = 117, 76%) reported as optimal treatment to rinse the tooth with saline before replantation; 22 clinicians (14%) found it acceptable to rinse the tooth with soapy water or ethanol, whereas two found it optimal to tell the patient that the tooth was lost. There was no overTable 3. The dentists’ ability to identify external infectionrelated root resorption on a radiograph (Fig. 1) ‘True positive finding’
‘False negative finding’
Total
Self-assessed competence
n
%
n
%
n
%
‘Sufficient competence’ group ‘Insufficient competence’ group Total
43 18 61
45 31 40
52 40 92
55 69 60
95 58 153
100 100 100
P = 0.81, chi-squared test. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
all statistical difference between the SC and ISC groups. Regarding alternative a) no replantation, the tooth was considered lost, and 84% in the SC group vs only 65% in ISC group considered this alternative as ‘unacceptable’ (P = 0.01). Discussion
This study aimed to evaluate the knowledge of Norwegian dentists working in the PDS regarding the diagnosis, treatment and prognosis of dental avulsion and root fracture injuries. The questions in this web-based survey covered knowledge and treatment options in selected patient cases. A main issue was to study whether there was a relationship between self-estimated competence and choice of treatment. A limitation was that the questionnaire was not subject to test–retest reliability to determine the validity. Furthermore, the web-based questionnaire, which was extensive, may have appealed more to the young dentists. This may have influenced the representativeness of the material. However, the response rate was comparable with other questionnaire-based investigations (19, 21–23, 30–32). As dental trauma in children may have long-term consequences for oral health and is reported to influence the oral health-related quality of life (10–13), it is essential that children suffering from dental trauma receive correct emergency treatment (33) and are scheduled for appropriate follow ups. Almost two-thirds (62%) of the respondents reported they had sufficient competence to treat a patient with a root fracture and an avulsion injury in an emergency situation. This proportion is close to German dentists’ self-assessed knowledge (24), but higher than that of general practitioners in UK where only 51% of the respondents were confident of managing root fractures and 32% were confident of managing an avulsion injury (16). Although 38% evaluated their competence as insufficient, 81% still recorded correct treatment for a midroot fractured tooth with displacement of the coronal fragment and almost all (95%) reported correctly for a visibly dirty avulsed tooth stored dry for 45 min. Experience in dental traumatology or having attended postgraduate dental education increases the probability of providing appropriate first-aid treatment and care (17, 21). In the present study, the SC group of clinicians did not give correct answers more often than the ISC clinicians to treatment and diagnostic options, except in the case of root fracture treatment.
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Table 4. Assessment of treatment strategies for an avulsed and visibly dirty tooth stored dry for 45 min. Proportions (%) are in parentheses. Due to rounding, the proportions do not always sum to 100 Treatment assessments
a) No replantation. Tooth is considered lost b) Replant the tooth as it is c) Replantation after rinsing with soapy water d) Replantation after rinsing with ethanol e) Replantation after rinsing with saline
Optimal
Acceptable
Unacceptable
Do not know
Total
2 0 0 0 117
9 29 12 10 32
118 100 113 111 1
24 24 32 32 3
153 153 153 129 153
(1) (0) (0) (0) (76)
There was no difference between the two groups regarding time of graduation or the proportion in a full-time clinical position. It may be speculated that recent education or having attended continuing education courses that influence self-confidence outweigh clinical experience. The finding of no association with graduation year agrees with some (24, 31) but not all previous reports (17, 22, 32). Although there was a trend towards recently graduated dentists having better knowledge in the study by Krastl et al. (24), and a statistically significant association in two recent surveys (17, 32), the latter studies showed an association only related to crown fractures. However, it is difficult to compare studies due to widely different methods and thus a need for more standardized surveys. A limitation of the present study was missing information about how often the respondents were faced with avulsion and root fracture injuries. As the occurrence is low (1, 8), only few patients will present with these traumatic injuries and thus clinical experience may be minimal. Still, a majority of the dentists assessed their knowledge about providing optimal treatment in an emergency situation as good and reported that they themselves would provide all emergency treatment for dental trauma to permanent incisors. One explanation may be the lack of specialists to whom they could refer patients. Dentists have a responsibility to provide initial emergency treatment. In the study from UK (16), general dental practitioners encouraged close collaboration with specialists for the long-term management of complex dental trauma. This is in accordance with the present study, where more dentists would refer to a specialist on a long-term basis than in an acute situation. In another study from UK (25), the establishment and evaluation of a trauma clinic showed that over one-third of the patients were referred when problems had arisen after initial treatment and more than half had received unsatisfactory or inappropriate treatment prior to referral. This is in line with the present study, where fewer than half of the clinicians diagnosed the external infectionrelated root resorption on the radiograph, although the majority would have chosen correct root canal treatment due to the presence of apical periodontitis. To diagnose external infection-related root resorption is particularly important after replantation in children with immature teeth. The resorption process is more aggressive than in mature teeth due to thin dentinal walls and the wide dentinal tubules and the thin covering of protective cement, where the dentinal tubules may be the pathway for diffusion of toxic products from the necrotic pulp (34). Inade-
(8) (18) (8) (7) (21)
(76) (67) (72) (73) (1)
(16) (16) (20) (20) (2)
(101) (101) (100) (100) (100)
quate understanding among dentists of the biological mechanisms of root resorption after avulsion injuries has been documented in an Australian study (23). The overall knowledge of emergency treatment of root fractures injury was adequate and correct in the present study, but only few respondents estimated the long-term prognosis for a tooth with a mid-root fracture to be good, with a survival rate >60% after 10 years. Based on available and published data, this estimate is wrong or knowledge is deficient and may result in treatment options that threaten the long-term prognosis of the tooth. With correct treatment, the success rate may be >80% (27, 28, 35). An avulsion injury is the most severe trauma diagnosis, and minutes count. The prognosis depends on implementing appropriate emergency management procedures, and immediate replantation is the most appropriate treatment. In the present study, approximately two-thirds would advise the parent on the phone to replant the tooth immediately at the time of the accident, whereas about one-third would advise the parent to keep the tooth moist and attend a dentist as soon as possible. Fortunately, no respondent would recommend clean and dry storage, showing that the dentists have proper knowledge about first-aid treatment of avulsed teeth in accordance with current guidelines. The same applied for the clinical situation where most dentists would rinse the dirty tooth with saline prior to replantation in accordance with guidelines. In conclusion, this study has shown that the overall knowledge of treatment of dental trauma among Norwegian dentists is good, with some exceptions. There is a need for more knowledge on detecting and diagnosing external root resorption. There was no overall difference regarding knowledge among the SC group of dentists compared with the ISC group. As the results were inconsistent in regard to the validity of self-assessed skills, the null hypothesis was not rejected. Continuing education courses or education in dental traumatology is required, in particular regarding dental injuries which the clinicians encounter seldom. Self-estimation of own competence does not reflect level of knowledge. Acknowledgements
The authors would like to thank dentists in the Public Dental Health Service in the counties of Buskerud, Rogaland and Troms for participation in the study. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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