Investigation of mothers' knowledge of dental trauma management in United Arab Emirates.
Abstract: AIM: To assess, by means of a structured questionnaire, mothers' level of knowledge with regards to the immediate emergency management of dental trauma in the Emirate of Ajman, United Arab Emirates (UAE). METHODS: A cross-sectional study using anonymous structured questionnaires was employed for mothers chosen at random from child care centres. The questionnaire surveyed mothers' background, knowledge and management of tooth fracture, avulsion, and also investigated mothers' self-assessed knowledge of the availability and priority of emergency services of trauma in UAE. RESULTS: The sample consisted of 676 mothers (response rate 96.6%) who attended mother and child care centres in Ajman over a period of two months (January-February 2011). More than half of the mothers participated in this study were in their twenties and 69.4% had university qualifications. Around 61.5% of the mothers had previous direct or indirect experience of dental trauma. Mother's knowledge of dental trauma seemed to be inadequate. Chi-square test indicated that there was no significant difference in the number of correct responses in relation to age, level of education, or number of observed trauma cases. Most mothers were unaware of the availability of after working-hours emergency services. They were dissatisfied with their level of knowledge of dental trauma and the majority were interested in having further education on the topic. CONCLUSIONS: The level of knowledge of dental trauma management (especially tooth avulsion) among mothers in Ajman was inadequate and education campaigns are necessary to improve the emergency management of dental injuries. Therefore it is important to educate the public of the availability of after hours dental emergency services to overcome any delay in seeking professional help in cases of dental trauma.

Key words: Mothers; dental trauma, knowledge, children, UAE.
Article Type: Report
Subject: Dental emergencies (Demographic aspects)
Dental emergencies (Research)
Health attitudes (Demographic aspects)
Health attitudes (Surveys)
Teeth (Injuries)
Teeth (Care and treatment)
Teeth (Demographic aspects)
Teeth (Research)
Author: Hashim, R.
Pub Date: 04/01/2012
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: April, 2012 Source Volume: 13 Source Issue: 2
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: United Arab Emirates Geographic Code: 7UNIT United Arab Emirates
Accession Number: 290066488
Full Text: Introduction

It is well recognised today that, for long-term success, the management or treatment of traumatised teeth optimally should be carried out as soon as possible [Andreasen and Andreason, 2007]. The attitudes and knowledge of patients and parents of the injured children about dental trauma would thus be critical to the ultimate prognosis of traumatised teeth [Sae-Lim and Yuen, 1997; Andreasen and Andreason, 2007]. Several studies showed that the population at large, as well as many professionals involved in the treatment of dentoalveolar injuries, had little knowledge concerning this subject [Raphael and Gregory, 1990; Hamilton et al., 1997; Caglar et al., 2005; Kostopoulou and Duggal, 2005; Hu et al., 2006]. These studies have encouraged the initiation of educational campaigns intended to inform the public regarding the importance of initial dental trauma management as well as the specific steps that can be taken in the case of traumatic events. As 41% of dental injuries occur at home [Al-Jundi, 2002], mothers are frequently required to provide prompt and proper action. The aim of this study was to assess, by use of a questionnaire, the general knowledge and attitudes of mothers with regards to emergency management of dental trauma and to investigate the effect of some variables on the responses. The results of this study might provide information that can help to design simple instructions to mothers who attend mother and child care centres in Ajman. The provision of this information could be part of the services provided by these centres, which cover large sectors of the society.

Methods

Ethical approval. Informed verbal consent from all mothers and the directors of the health centres were obtained prior to participation. The study was approved by the ethical committee in Ajman University of Science & Technology.

In the United Arab Emirates (UAE), all mothers are required to attend child and mother care centres to receive their follow-up reviews during pregnancy, and also to receive medical check-ups and vaccination for their newborn infants until they reach school age. The importance of these centres in providing advice to a large sector of mothers made them the target of the current study. The study objective was to assess the general knowledge of mothers with regards to the immediate dental trauma management, and their attitude to public education on this topic, as well as knowledge of availability and priority of emergency services for dental trauma. It was also to assess the influence of a mother's education and other related variables on their responses.

In this cross-sectional survey, structured questionnaires were used. Seven hundred mothers were chosen at random through a computer-generated program from attendants of all (five) mother and child health care centres in the Emirates of Ajman in UAE. The questionnaire was modified from those used in similar studies in the literature [Raphael and Gregory, 1990; Sae-Lim and Yuen, 1997; Hashim, 2011] and was divided into three parts. Part one consisted of three questions on personal and educational background in addition to a number of trauma cases encountered previously, while part two consisted of four questions based on three imaginary cases of dental trauma (Table 1). The third part consisted of five questions investigating self assessed knowledge, attitude to public education program on dental trauma emergency management, and the knowledge of availability and priority of emergency services of dental trauma (Table 4).

All women entered the study voluntarily, following an explanation of its purpose and objectives. A research assistant interviewed the participating mothers and completed the questionnaires. The participants were assured of the strict confidentiality of the data. All questionnaires were coded and analysed using SPSS version 13.0 (Chicago, IL). Results were expressed as a number and percentage of respondents for each question. Chi-square test was used to evaluate the differences between the different variables such as age, mother's level of education on knowledge and attitudes of the mothers, and the level of significance was set at p<0.05.

Results

In the current study, 676 of the 700 approached mothers who attended all mother and child care centres in Ajman over a period of two months (January-February 2011) agreed to participate in the study. Therefore the study sample consisted of 676 mothers (response rate 96.6%).

The results of part I of the questionnaires is shown in (Table 2). The majority (440, 65.1%) of the mothers were aged 20-29 years; 469 (69.4%) of the mothers were university educated. A previous experience of dental trauma was recalled by 416 (61.5%).

The responses to part II of the questionnaire which dealt with the case studies were as described in (Table 3). Mothers' knowledge of the fractured incisor of a 9-year-old girl seemed to be inadequate, 241 mothers (35.7%) knew that the fractured tooth was most likely to be a permanent incisor. Chi-square test indicated that there was no significant difference in the number of correct responses in relation to age, level of education, or number of observed trauma cases (p values: 0.18, 0.12 and 0.11 respectively). With regards to the immediate emergency management of the case, 56.5% gave the wrong answer.

For the management of an avulsed permanent tooth in a 12-year-old girl, 83.4% of the mothers gave a wrong response which was to concentrate on stopping oral bleeding. Chi-square test indicated that there was no significant difference in the number or correct responses among the participants according to age, level of education, or number of observed trauma cases (p values: 0.16, 0.11 and 0.07 respectively). More than three quarters (76.4%) of the respondents were either "not sure" or gave "incorrect answer" to the management of loss consciousness associated with a fall.

The responses to part III of the questionnaire is presented in (Table 4). Whilst 418 (61.8%) of the mothers admitted to having poor knowledge on the management of traumatised teeth, most of them (86.2%) were enthusiastic about being educated further. When the mothers were asked how urgently professional help was needed for dental injury, 349 mothers (51.6%) responded correctly by seeking professional care immediately; 66% of the participated mothers had correct knowledge on the availability of the emergency services during working hours. The knowledge on the after working-hours services seemed to be inadequate.

Discussion

To our knowledge, this is the first published study conducted in the UAE assessing the level of awareness among mothers on dental trauma management. The questionnaire used in the current study was short with simple, direct and closed-end questions. Similar studies in the literature have surveyed the knowledge of mothers and teachers concerning the management of dental trauma [Stokes et al., 1992; Hamilton et al., 1997; Hedge et al., 2010; Skeie et al., 2010]. The study included all mother and child care centres in the Emirate of Ajman and the response rate was very high (96.6%). These centres were considered as an excellent source of information for a large proportion of the community in the Emirate. The majority of the mothers 65.1% were aged 20-29 years. Interestingly 69.4% of the mothers were university graduates. Around 61.5% of the mothers had previous direct or indirect experience of dental trauma. This was much higher than reported in studies performed in England [Hamilton et al., 1997] and in Singapore [Sae-Lim et al., 1999].

The three imaginary cases in Part II of the questionnaire were designed to test the respondents' general knowledge of the two different types of dental injuries and emergency management of lost consciousness as a result of dental trauma. The ages of the injured children in the cases were intentionally selected to be between 9-12 years because children between these ages carry the greatest risk of dental injuries [Hayrinen-Immonen et al., 1990]. In case I, only (35.7%) of the respondents recognised that the maxillary incisor is a member of the permanent dentition in a 9-year-old girl. This response was lower than that reported by school teachers in Ajman [Hashim, 2011] indicating that the general dental knowledge of the mothers was inadequate. However, only 40.4% of the mothers in the current study responded correctly by choosing to take the child to the dentist to treat the fractured incisor. Similar findings had been reported by Al-Jundi (2006) in Jordan.

A favouable prognosis of avulsed teeth significantly depends on the minimal extra-alveolar time outside of the socket, adequate storage and transportation medium and minimal handlining of the root surface and the periodontal ligament. Knowledge concerning the management is very important and was assessed in lay populations [Boyd et al., 2000; Panzarini et al., 2005; Pohl et al., 2005] with regard to the emergency management of an avulsed permanent tooth in a 12-year-old girl, 564 mothers (83.4%) responded incorrectly and only 11.7 % gave the correct response by replanting the tooth, or putting it in a solution and going immediately to the dentist. Similarly, Al-Jundi (2006) reported that 89% of the mothers answered they would not replant the tooth. However, in the current study, the percentage of mothers responding appropriately was less when compared with other studies where it was 39% [Oliveria et al., 2007]. In an Australian survey by Raphael and Gregory [1990] reported that two-thirds of the parents would attempt replantation. If the tooth is not replanted, it should be stored in milk, saline solution or saliva, and a dentist should then be seen as soon as possible. In the current study, the educational background of the respondents did not reflect or correlate with other aspects of dental trauma knowledge. It is therefore recommended that the educational programs on dental trauma be directed at the public at all educational levels.

The response to part III (self-assessed knowledge and attitudes) was the most encouraging aspect of this study because the majority of mothers were not satisfied with their level of knowledge, and they were interested in getting further information to handle dental trauma cases. It would be alarming if, on the contrary, the respondents were content with their lack of knowledge and expressed no enthusiasm to be educated. Similar findings were reported by school teachers in Ajman [Hashim, 2011] reflecting the general need of the Ajman society to have a population-based preventive program to ensure uniform knowledge about dental trauma. It was less than desirable that only 51.6% of the mothers indicated priority for the urgency in seeking dental trauma management. It should hence be reasonable to assume that, while the educational programs on dental trauma should be directed at the public at all educational levels, those with lower educational background may need further reinforcement.

With regards to the knowledge of availability of dental emergency services, most of the respondents were aware of the "during working hours" services, however after-hour services were only known by the minority. The basic knowledge on where to seek emergency services is crucial for the timely management of dental trauma, especially for avulsed teeth where a prolonged extra-alveolar period would be detrimental to the long term success rate [Andreasen and Andreason, 2007]. Hence, this information needs to be more widely publicised in the UAE.

Conclusion

The general knowledge of mothers in Ajman with regard to the emergency management of dental trauma was lacking regardless of their age, education level, or previous experience of dental trauma. The lack of experience and knowledge expressed by the mothers reflects the need of more effective communication between dental professionals and mothers in order to enable them to act correctly when facing a case of dental trauma.

Acknowledgement

I would like to thank Miss Shatha Zuhir for her contribution in data collection.

References

Al-Jundi SH. Dental emergencies presenting to a dental teaching hospital due to complications from traumatic dental injuries. Dent Traumatol 2002; 18:1-5.

Al-Jundi SH. Knowledge of Jordanian mothers with regards to emergency management of dental trauma. Dent Traumatol 2006; 22:291-295.

Andreasen JO, Andreason FM. Textbook and colour atlas of traumatic injuries to the teeth. 4th edn. Oxford: Blackwell Munksgaard; 2007.

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Caglar E, Ferreira JP, Kargul B. Dental trauma management knowledge among a group of teachers in two south European cities. Dent Traumatol 2005; 21:258-262.

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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: 10-19.

Oliveria TM, Sakai VT, Moretti AB et al. Knowledge and attitude of mothers with regards to emergency management of dental avulsion. J Dent Child 2007; 74:200-202.

Panzarini SR, Pedrini D, Brandini DA et al. Physical education undergraduates and dental trauma knowledge. Dent Traumatol 2005; 21:324-328.

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R. Hashim

Department of Growth and Development, College of Dentistry, Ajman University of Science and Technology, Emirate of Ajman, United Arab Emirates.

Postal address: Dr. R. Hashim, Growth and Development Department, Ajman University of Science & Technology, PO. Box 346 Ajman, UAE.

Email: raghad69@yahoo.co.nz
Table 1. Part II: Knowledge questionnaire (case scenarios).

Case I:      A 9-year-old girl fell and broke her upper front tooth

  Q1:        The broken tooth is likely to be

             a: Permanent tooth *

             b: Baby tooth

             c: Do not know

  Q2:        Your immediate emergency management of the case is

             a: Send child to the dentist immediately *

             b: Reassure the child and put her to rest

             c: Not sure what to do

Case II:     A 12-year-old girl was hit on the face & her upper front
             tooth fell out of her mouth

  Q1:        The immediate emergency action you would take is

             a: Put the tooth back in its place in the mouth, or in
             a solution and send the girl to the dentist immediately *

             b: Stop oral bleeding then put the child to rest

             c: Put the tooth in a solution and send the child to
             the dentist immediately *

             d: Not sure what to do

Case III:    A 10-year-old child fell down while playing and lost
             consciousness

  Q1:        The immediate emergency action you would take is

             a: Awaken the child and put him to rest

             b: Send the child to hospital immediately *

             c: Not sure what to do

* Correct responses.

Table 2. Responses to part I: Characteristics of mothers in UAE.

Characteristics                    n       (%)

Age (years)
<20                               28      (4.1)
20-29                             440    (65.1)
30-39                             137    (20.3)
40-49                             56      (8.3)
[greater than or equal to] 50     15      (2.2)

Mother's education
High-school                       116    (17.2)
Diploma                           80     (11.8)
University                        469    (69.4)
Higher education                  11      (1.6)

Number of previous trauma encounters
0                                 260    (38.5)
1-2                               300    (44.4)
3-4                               104    (15.4)
[greater than or equal to] 5      12      (1.8)

Table 3. Results of Part-II: Knowledge of case scenarios involving
trauma by mothers in the UAE.

                        Incorrect     Correct      Not sure
Case                      n (%)        n (%)        n (%)

Broken tooth
Type of tooth           368 (57.1)   241 (35.7)    49 (7.2)

Management              382 (56.5)   273 (40.4)    21 (3.1)

Avulsed tooth
Management              564 (83.4)   79 (11.7)     33 (4.9)

Loss of consciousness
Management              172 (25.4)   194 (28.7)   310 (51.0)

Table 4. Responses to part III: Self-assessed knowledge, attitudes
and emergency services for dental trauma in UAE.
                                                           n      (%)
Self assessed knowledge
Enough                                                    258    (38.2)
Not enough                                                418    (61.8)

Need for further education
Yes                                                       583    (86.2)
No                                                         93    (13.8)

Priority for the urgency of dental trauma management
Yes                                                       349    (51.6)
No                                                        327    (48.4)

Availability of emergency services during working hours
Correct                                                   446    (66.0)
Incorrect                                                 230    (34.0)

Availability of emergency services after working hours
Correct                                                   208    (30.8)
Incorrect                                                 468    (69.2)
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