Knowledge of Emergency Management of Avulsed Tooth among Dental Surgeons of Chitwan Knowledge of Emergency Management of Avulsed Tooth among Dental Surgeons of Chitwan

Avulsion injury has a significant physical, esthetic, functional and psychological impact and affects the patients ‘quality of Introduction: Prognosis of an avulsed tooth depends on timely and correct management. Therefore, knowledge about the emergency management of an avulsed tooth among dentists is very important. The study was aimed to access the knowledge of emergency management of avulsed tooth among the dental surgeons of Chitwan.

life. [4][5][6] Prognosis of an avulsed tooth depends on multiple factors such as; time duration between injury and replantation (extra-oral dry time (EODT), storage medium and stage of root development. 2,7 Therefore, Avulsed tooth should be replanted as soon as possible. Therefore, knowledge of dentists in the emergency management of an avulsed tooth is vital for a favorable prognosis of injured tooth. 8 Studies have shown inadequate knowledge of management of an avulsed tooth among dentists. [9][10][11] This study was aimed to access knowledge among dentists of Chitwan regarding the emergency management of an avulsed tooth.

METHODS
This was a descriptive cross-sectional study conducted among the dental surgeons in Chitwan, from February 2020 to April 2020. A convenience sampling method was utilized to collect the data from all the dental surgeons of Chitwan. The questionnaire was adopted from previous studies. [10][11][12][13] Face validity of the questionnaire was done by getting all the questions reviewed by experts in the field and was pretested among 30 dental surgeons in another district. The questionnaire was typed in Google form and the link was sent to the dental surgeons through emails and Facebook messenger. Few questionnaire sets were printed out and also distributed among dental surgeons who were accessible.
Participation in the study was voluntary, free and anonymous. Clear objective was placed in the front page and all the participants were allowed to answer the questionnaire after consenting. The questionnaire contained demographic details followed by 12 questions related to the knowledge management of tooth avulsion. The response was collected in the google forms till three months. During this period, google form link was sent twice again and then disabled. For printed version, a countable number were distributed as the study period was COVID pandemic period.
All the dental surgeons from Chitwan those who consented to participate, were included in the study. Regarding the printed forms only fully filled forms with consent signed were included in study. The study was approved by the institutional review committee of Chitwan Medical College (CMC-IRC/076/077-147). Data was entered into Statistical Package of Social Science (SPSS) version 16 and was analyzed using descriptive statistics.

RESULTS
The study was conducted among dental surgeons of Chitwan. A total of 140 dental surgeons were contacted out of which only 105 participated in the study. It was observed that female respondents (n=77, 73.3%) were more than the male respondents (n=123, 54.4%) ( Table 1). The mean age of the respondents was 28.84±5.10 years.     tooth have also been demonstrated in few studies. 12,16 Immediate and proper management of avulsion injury significantly improves the prognosis of an avulsed tooth. Avulsion injury requires immediate treatment to ensure a favorable outcome. 17 In the absence of proper and timely treatment it may lead to increased risk of complication and loss of tooth. Root resorption and ankylosis are important complications related to avulsion injury. Timely and correct management of TDIs can help to significantly improve the outcome. 1 The response rate in the present study was 75%, which is less than (89%) the study by Zhao et al.11 but more than (47.5%) reported by Bajinksa et al. 9 Various studies have demonstrated that most of the dentists are in favor of replantation of an avulsed tooth. However, a very high percentage of dentists (96.1%) did not agree with replantation of an avulsed tooth in all cases, in a study by Upadhyay et al. 10 However, in another study 50% of dentists were against replantation of avulsed tooth. 18 A similar study also reported that most of the dentists 87% did not agree with replantation of avulsed tooth. 11 However, in the present study all of the dentists 100% agreed on replantation of avulsed tooth. All of the dentists were willing to save an avulsed tooth. This was similar to a study by Westphalen et al. 16 An avulsed tooth should always be handled from the crown and must be cleaned before replantation. The prognosis for the replanted tooth depends on careful handling of the root surface. Correct management of the tooth before replantation is very important, and hence it is recommended to rinse with physiologic solution (sterile saline) to clean the debris on the root surface, and then replant the tooth in its socket and splint. The root surface of an avulsed tooth should not be scraped brushed or removed in order to preserve the vitality of the cells of the root surface. With questions related to this, most of the dentists 71.4% correctly responded by choosing to wash the teeth with saline before replantation. However, few of them 18.1% choose to wash with tap water which is not the preferred way. This shows that, there are still some lack of knowledge among dentists. The root surface should be rinsed and cleaned if it is dirty, else it can be replanted immediately.
Immediate replantation into its socket is the proper treatment of an avulsed tooth. However, this is not always possible and the avulsed tooth has to be transported to a suitable place before replantation can be performed. Therefore, a transport/storage medium is also required to preserve the vitality of the periodontal ligament cells, until replantation can be done. Different types of storage mediums, including saliva, normal saline, tap water, milk and culture media are available. According to IADT Hanks balanced salt solution (HBSS) is considered the ideal storage medium. 2 However, it is expensive and is not easily available. An excellent alternative is considered to be milk and is readily available. 19 Regarding storage medium, most of the dentist 44.4% correctly choose HBSS, while 21.9% choose saliva as the best storage medium for an avulsed tooth, in this study (Table 3). This was in accordance to the guidelines by the IADT. 2 In an earlier study by Upadhyay et al HBSS was considered by most 59.8% of the dentist to be the ideal storage medium. In the same study 31.4 % choose patients saliva and very few 4.9 % of the dentists chose milk as the storage media. 10 However, in other studies milk was mentioned as the best storage medium for an avulsed tooth by dentists. 12 Only few 11.8% selected milk as the best storage medium. Although milk is considered a better option over tap water or saliva, it is not a very good biological supportive medium. It has short duration of support time, and does not maintain cell vitality. 2 However storing in the patient's saliva can be an alternative. Saliva was mentioned as the most suitable storage medium for an avulsed tooth by majority of dentists in several studies. 11,13,16,20 Knowledge of Emergency Management of Avulsed Tooth among Dental Surgeons of Chitwan Prognosis of an avulsed tooth depends on timely and correct management. Therefore, an avulsed tooth should be replanted into the socket as soon as possible. 2 Proper management of an avulsed tooth within the first 15 minutes after avulsion injury is considered critical for the long-term prognosis of treatment. The EODT should not be more than 60 minutes. Periodontal ligament cells become non-vital, when the extra-oral dry time EODT is more than an hour. 2 Time duration from injury to replantation is the most essential factor to be considered in management of avulsion injury. According to IADT an avulsed tooth should be replanted as soon as possible.
The risk of ankylosis is significantly increased along with an increase in the duration of EODT. 2 It is accepted that shorter the extra-oral dry time better the prognosis for replanted tooth. Regarding the critical time for the replantation of an avulsed tooth (EODT), 47.6% of the dentist choose that less than 30 minutes was the extra alveolar critical time while 35.2 % suggested that the critical time was within an hour. However, few 11.4% selected more than 90 minutes as the critical time. This shows that there is still some deficiency in the knowledge regarding critical time for replantation. Results from this study demonstrated that most of dentists were aware of that fact that EODT is a very significant factor. In a separate study 61.8% suggested that the avulsed tooth should be replanted within 20 minutes, while 37.3 % suggested within an hour. 10 Regarding knowledge about important factors influencing the outcome of an avulsed and replanted tooth, a high no of dentists (90.5%) mentioned all the factors including storage medium, extra-alveolar time period, and amount of the loss of periodontal ligaments to influence the outcome of avulsion injury. This rate was more than the study by Al-Zubair (50%). 13 Healing of an avulsed tooth can be improved when it is replanted as soon as possible and stabilized by splinting. A flexible splinting technique is used for a favorable healing. 2 In the present study more than half of the dentists 51.4% preferred stainless steel to be the method of splinting after replantation, while only 21.9% of dentists choose semi rigid splinting method. The result of this study does not match with the study by Westphalen et al., in which 73% of the respondents opted for the use of semi-rigid splinting method. 16 Similarly, almost half of the 51.6% dentists incorrectly chose rigid splinting technique in a study by Abdullah et al. 20  All of the participants in this study agreed that they had information regarding management of an avulsed tooth. Regarding the source of information about the management of an avulsed tooth, the present study found that most of the dentist 72.4%, had received such information from school dental program, during their education at dental school. This may be the reason for the better knowledge among the dentists found in the result of this study. About 27.6% informed that they had received their knowledge from dental clinics and hospital. In a study by Al-Zubair nearly half of the dentists had received their knowledge about avulsion from books and articles. 13 In another study by Westphalen

CONCLUSIONS
It can be concluded that the dentists of Chitwan have knowledge regarding emergency management of an avulsed tooth, however, with time, the dentists should regularly update their knowledge of dental traumatology. Recently introduced compulsory continuous professional development programs may also be useful for this purpose. Proper knowledge about the treatment of dental injuries among dentists has an important role in the outcome of such injuries.

LIMITATION Of THE STUDY
This study is not without limitation. The first limitation of this study was that it was conducted in the local population and hence the results cannot be generalized to all dentists of Nepal. We used questionnaire in this study due to which we cannot ignore information bias and response bias. Other shortcoming of the study was that only a particular type of TDI was evaluated. Similarly, duration of working experience of dentists was also not evaluated in this study.