Dental Professionals Management of Avulsed Teeth and Implementation of COVID-19 Related Safety Precautions
Aim: One of the most common dental problems is oral trauma, which is a great threat to the dental health of children and adolescents. This study aims to improve Saudi dentists’ knowledge of the management of avulsed teeth and the safety precautions necessitated by the coronavirus disease 2019 (COVID-19) pandemic. Materials and methods: A cross-sectional study was conducted. The 403 participants, who were from Saudi Arabia, were recruited through social media. The data were collected by a questionnaire that assessed their knowledge about managing avulsed teeth. Significance was set at p=0.05. Results: The mean score for the correct answers to 22 questions to assess clinical knowledge about avulsed teeth was 15.26 (SD=3.48). According to the responses, 93.3% knew that an avulsed permanent tooth can be replanted, 72.2% indicated that an avulsed primary tooth can be replanted, 63.8% were aware of the best splinting materials, and 58.3% knew the optimal splinting duration. Only 29.8% indicated knowledge about the most recent (2020) International Association for Dental Traumatology guidelines for avulsed permanent teeth. The mean score for the correct answers to the four questions about the management of avulsed teeth during the COVID-19 pandemic was 3.27 (SD=1.02). Conclusion: Saudi dental professionals were found to have moderate levels of knowledge about the management of tooth avulsion. The answers to the COVID-19-related questions revealed good knowledge about managing avulsed teeth during the pandemic. Health campaigns or online lectures would be helpful in improving dentists’ knowledge about managing avulsed teeth.
One of the most common dental problems, oral trauma poses a great threat to the dental health of children and adolescents . The avulsion of permanent teeth accounts for 0.5 to 3% of all dental injuries . Avulsion (exarticulation) is the complete displacement of the tooth from its alveolus; thus, it is a complex injury that affects the tissues . The maxillary central incisors are most prone to avulsion , and this can cause severe functional and psychological problems . The important factors in the prognosis of avulsed teeth are extra-alveolar time and immediate treatment upon injury because of their role in the prevention of pulp necrosis and the degeneration of the periodontal ligament (PDL). These conditions result in inflammatory root resorption and even tooth ankylosis, which can subsequently lead to tooth loss [3,6].
The International Association of Dental Traumatology (IADT) published new guidelines for managing luxated and avulsed primary and permanent teeth [7-10]. According to the guidelines, the best approach is the immediate replantation of the avulsed permanent tooth. If this is not possible, the tooth should be transferred to a dentist as soon as possible, preferably within 30 to 60 minutes, in an appropriate storage medium. The best storage media are Hank’s balanced salt solution, milk, normal saline, and the patient’s saliva. If the tooth is visibly contaminated, the root surface should be rinsed gently with a saline stream. For patients who have not been immunized within the previous 5 years, tetanus prophylaxis should be administered if the tooth has come into contact with dirt. Antibiotics are recommended to prevent infection and to decrease the possibility of inflammatory root resorption. The splinting time should be 2 weeks, depending on the stage of root development, and endodontic treatment should be performed within 2 weeks of replantation. Because of the possibility of pulp revascularization, root canal treatment in immature open-apex teeth should be delayed unless there is clinical or radiographic evidence of pulp necrosis or infection. The IADT advises against the replantation of primary teeth because of the high risk of harming the permanent tooth germs [7-10].
Public awareness of avulsed permanent teeth has been investigated. Studies have focused on teachers, parents, and children [11,12]. Similar studies have been conducted in Saudi Arabia [13-15]. Studies around the world have assessed dental professionals’ knowledge of the management of avulsed teeth to determine their ability to provide optimal treatment and to raise community awareness. The countries include Japan , Malaysia , Brazil , Turkey , Pakistan , and Sudan .
Such studies were also conducted in Saudi Arabia in Riyadh [2,22], Jazan , and Qassim . The questionnaires varied. One study focused on students.22 Others assessed dental graduates [2,23,24]. Most dental students (95.7%) were aware of the importance of dental avulsion  however, their knowledge about its management varied. For example, 77% were aware of the transportation media; however, only 26.9% were aware of suitable transportation methods, which include appropriate prereimplantation storage . Dentists in Riyadh and Al-Qassim were found to have medium levels of awareness, given that the mean of the correct answers was approximately half of the number of questions [2,24]. However, they had low levels of knowledge about the best storage medium, follow-up duration , and critical time for replantation.22 Women,24 public dentists  and more experienced dentists, such as specialists [23,24], exhibited higher knowledge levels. However, such studies were not conducted in major cities, such as Jeddah and Makkah, which have the highest number of dentists in Saudi Arabia. External validity data were not available for the Saudi Arabian studies because of the differences in the questionnaires that were used.
These studies are important, however, because of the 34% prevalence of dental trauma in young Saudis . The coronavirus disease 2019 (COVID-19) pandemic, which started in September 2019 , necessitated many changes and the adoption of new safety precautions in the healthcare system . These changes have affected clinical dental care , and dental emergency treatment around the world . The effects on the management of avulsed teeth during the lockdown and social distancing periods in Saudi Arabia have not been addressed. Thus, the aim of this study was to assess Saudi dentists’ knowledge about the management of avulsed teeth and the safety precautions necessitated by the COVID-19 pandemic.
The aim of this study was to increase Saudi dentists’ knowledge of the management of avulsed teeth and the safety precautions necessitated by the COVID-19 pandemic.
This cross-sectional study used a questionnaire to assess Saudi dentists’ and dental students’ knowledge about the management of avulsed teeth and the necessary safety precautions during the COVID-19 pandemic. The participants were recruited nationwide on social media platforms (Instagram, Twitter, Snapchat, WhatsApp, ResearchGate, and Facebook) through convenience sampling because of the implementation of social distancing during the data collection period. The inclusion criteria were dentists or dental students currently living and working in Saudi Arabia. Failure to provide written consent resulted in exclusion from the study. Data collection occurred in October and November 2020.
The questionnaire was adapted from two previous studies.2,19 It consisted of 30 items in four main sections. The first section comprised nine sociodemographic questions (age, nationality, current hospital, education level, region of residence, number of dental avulsion cases encountered per year, participation in continuing dental education in the management of tooth avulsion, and familiarity with the most recent IADT guidelines for avulsed permanent teeth [7-10]. The second section contained seven multiple-choice questions on the management of avulsed teeth in the pre-clinical phase: the possibility of primary and permanent tooth replantation, correct handling of a tooth, best cleaning method for a dirty tooth, storage medium for a permanent tooth, critical time frame for determining the treatment procedures, and ideal extra-alveolar period for a permanent tooth. The third section comprised nine multiplechoice questions on clinical management. The fourth section consisted of five multiple-choice questions on the procedures for managing avulsed permanent central incisors during the COVID-19 pandemic. The questions addressed patient consultations, treatment and infection control precautions, management of waste from COVID-19-infected patients, and dentists’ anxiety about treating avulsed teeth during the pandemic.
The questionnaire was validated by a pilot study of 20 dentists. The data were collected, tabulated, and subsequently analyzed in IBM SPSS Statistics, Version 23.0 (IBM Corp., Armonk, NY, USA). The mean, standard deviation, frequency, and percentages were determined through descriptive analysis. The significance level was 0.05. Chi-square tests and t-tests facilitated the comparisons of the participants’ responses. The data were anonymized and stored in a private computer accessible to only the research team at Umm Al-Qura University. The study received ethical approval from the Umm Al-Qura University institutional review board.
Data were collected from 403 respondents to 600 invitations (response rate, 67.16%). The mean age was 30.27 (SD=7.18). Table 1 presents the participants’ demographic data. The participants were asked about the number of dental avulsion cases treated annually. The mean number was 17.61 (SD=35.07).
|Current hospital||Private clinic||85||21.1|
|Education level||Dental intern||54||13.4|
|General dental practitioner||190||47.1|
|Participation in continuing dental education in the management of tooth avulsion||Yes||197||48.9|
|Knowledge of the most recent (2020) International Association for Dental Traumatology guidelines for avulsed permanent teeth||Yes||120||29.8|
Table 1: Participant demographics (N=403).
The participants were asked 22 questions about their clinical knowledge about avulsed teeth. Table 2 summarizes the answers. The mean score was 15.26 (score range, 0–22, SD=3.48). The Cronbach’s alpha was 0.732.
|Can an avulsed permanent tooth be replanted?||Yes||376||93.3|
|Can an avulsed primary tooth be replanted?||No||291||72.2|
|The correct part of an avulsed permanent tooth to be held||Crown||344||85.4|
|The best cleaning method for a dirty avulsed tooth (before the end of the critical timeframe)||Saline or osmolality-balanced media||342||84.9|
|Appropriate transportation medium|
|Sponge, cotton wool, or napkin||No||395||98|
|Patient’s mouth or saliva||Yes||307||76.2|
|Any aseptic solution||No||386||95.8|
|The critical time for determining dental avulsion treatment||First 30–60 minutes||328||81.4|
|The ideal extra-alveolar period for an avulsed permanent tooth||Less than 30 minutes||220||54.6|
|Does an open or a closed apex affect treatment?||Yes||360||89.3|
|If the tooth has been out of the socket for less than 60 minutes, what would be the best procedure?||Continue treatment and avoid touching the root surface||332||82.4|
|If the tooth has been out of the socket for more than 60 minutes, what would be the best procedure?||Remove PDLs from the root surface before continuing treatment||219||54.3|
|Does the critical period affect the splinting time?||No||103||25.6|
|Optimal splinting materials||Flexible splints||257||63.8|
|Optimal splinting duration||2 weeks||235||58.3|
|Should antibiotic prophylaxis be provided?||Yes||198||49.1|
|Should tetanus prophylaxis be provided?||Yes||188||46.7|
|How long would you follow up with clinical and radiographic examinations?||5 years||96||23.8|
Table 2: Clinical knowledge about avulsed teeth.
The participants were asked four questions about their management of avulsed teeth during the COVID-19 pandemic (Table 3). The mean of the correct answers was 3.27 (SD=1.02, score range, 0–4). Analysis of variance (Tukey’s post hoc tests) and t-tests were used to assess the scores for the management of avulsed teeth during the pandemic by demographics (Table 4).
|If a patient consulted you for an avulsed permanent tooth during the COVID-19 pandemic, what would you do?||325||80.6|
|Ask them to come to the clinic immediately and provide the appropriate instructions.|
|Before treating a patient with an avulsed permanent tooth during COVID-19, what would you do?||Ask whether the patient has COVID- or has been exposed to it so that the necessary safety precautions can be taken.||325||80.6|
|If a patient came to the clinic with an avulsed permanent tooth during COVID-19, what type of infection control precautions would you take?||Take additional precautions.||326||80.9|
|How would you manage the waste from a COVID-19-infected patient who presented with an avulsed tooth?||Dispose as biomedical waste in a yellow bag.||343||85.1|
|How do you rate your anxiety about treating a patient with an avulsed tooth during the COVID-19 pandemic?||High||130||32.3|
|No anxiety at all||43||10.7|
Table 3: Management of avulsed teeth during the COVID-19 pandemic.
|Item||Total knowledge scores||COVID-19-related knowledge scores|
|M (SD)||M (SD)|
|1. Gender||Male||14.73 (3.91)||3.23 (1.05)|
|Female||15.46 (3.3)||3.29 (1.01)|
|2. Nationality||Saudi||15.34 (3.47)||3.29 (1.05)|
|Non-Saudi||14.49 (3.59)||3.11 (0.74)|
|3- Region||Central||15.24 (3.8)||3.17 (1.05)|
|West||15.82 (3.18)||3.41 (0.91)|
|East||14.84 (2.55)||3.29 (0.92)|
|South||11.96 (4.73)||2.68 (1.41)|
|North||13.59 (3.65)†||2.64 (1.43)‡|
|4 Current hospital||Private clinic||14.96 (3.22)||3.12 (0.99)|
|Governmental hospital||15.37 (3.68)||3.38 (0.99)|
|Not employed||15.29 (3.25)||3.15 (1.11)|
|5. Education||Dental intern||15.74 (2.73)||3.22 (0.84)|
|General dental practitioner||15.03 (3.17)||3.36 (0.93)|
|Postgraduate student||15.32 (3.91)||3.26 (1.07)|
|Specialist/consultant||15.45 (4.15)||3.13 (1.25)|
|6. Did you participate in continuing dental education in the management of tooth avulsion?||Yes||15.82 (3.52)||3.25 (1.02)|
|No||14.74 (3.38)*||3.3 (1.02)|
|7. Do you know about the newest (2020) International Association for Dental Traumatology guidelines for managing avulsed permanent teeth?||Yes||16.05 (3.97)||3.07 (1.1)|
|No||14.93 (3.21)*||3.36 (0.98)*|
|*p < 0.05|
‡The ANOVA and Tukey’s post hoc test results indicated that participants in the Western region had significantly higher knowledge levels than those in the Southern and Northern regions.
Table 4: Total and COVID-19-related knowledge scores by demographics.
The linear regression results indicated a direct relationship between age and the scores for the management of avulsed teeth during the COVID-19 pandemic (p=0.009, R2=0.017). There was an inverse relationship with the number of avulsed teeth treated per year (p=0.001, R2=0.027).
The aim of this study was to assess Saudi dentists’ knowledge about the management of avulsed teeth and the safety precautions necessitated by the COVID-19 pandemic. Knowledge of avulsion and its management as a dental emergency is very important in reducing stress and anxiety for the doctor and the patient . The immediate post-traumatic management protocols have been found to improve the prognosis for avulsed teeth .
The participants had moderate knowledge levels (M=15.26, SD=3.48). The responses to the COVID-19-related questions indicated good knowledge levels about the management of avulsed teeth during the pandemic. Only about 30% of the participants indicated knowledge about the most recent IADT guidelines for managing avulsed permanent teeth, thus the moderate knowledge levels [7-10].
The knowledge levels in this study were similar to those in a Turkish study . The results indicated that 51.1% of the respondents had not participated in continuing dental education in the management of tooth avulsion. These results were similar to those of a Riyadh study in which 58.3% of the results had not participated.2 Most of the participants in the present study were aware that an avulsed permanent tooth could be replanted. This was much higher than the percentage (35.37%) reported by Alharbi et al. . The reason might be differences in the public’s and dentists’ knowledge. The participants in the present study (72.2%) indicated that a primary tooth cannot be replanted. This was similar to the results of previous studies [32,33].
In the present study, 85.4% of the participants indicated correctly that an avulsed permanent tooth should be held by the crown. This is a lower percentage than that (97.3%) reported in a study conducted in Turkey19 but higher than that (71%) in a study in Riyadh . Most of the participants in the present study indicated that sponges, cotton wool, or aseptic solutions were not good storage media for an avulsed tooth. They indicated that normal saline (49.4%), the patient’s mouth or saliva (76.2), cold milk (81.1%), and Hank’s solution (65.5) were appropriate, and that percentage is considered moderate. In contrast, a previous study18 found lower percentages, the reason might be that the participants were general dentists.
The most recent IADT guidelines recommend the use of a flexible splint for up to 14 days . Approximately 63.8% of the dentists in the present study used flexible splinting materials after the replantation of an avulsed tooth. This was slightly higher than the results of a previous study2 in which almost half of the dentists used flexible splinting materials. Slightly more than half of the respondents in the present study indicated a 2-week splinting duration. Approximately 23.8% stated that they would conduct five years of clinical and radiographic follow-up, as recommended in the most recent IADT guidelines [7-10]. The knowledge levels about avulsed permanent teeth indicated the need for dentists’ and dental students’ participation in continuing education to create awareness of the most recent IADT guidelines.
Almost 80% of the dentists gave the correct answers about the management of tooth avulsion during the COVID-19 pandemic. This reflects acceptable knowledge levels. However, when asked to rate their anxiety about treating patients during the pandemic, 32 to 45.4% indicated moderate to high anxiety levels, and 10 to 11.7% indicated low anxiety levels.
This study of dentists’ awareness of the management of dental avulsion is different from previous studies because it was conducted during the COVID-19 pandemic. The study has strengths, such as the investigation of dentists in multiple Saudi Arabian regions. Previous studies have tended to focus on one region. However, the use of a self-report online questionnaire requires the consideration of self-reporting bias.
Saudi dental professionals were found to have moderate levels of knowledge about the management of tooth avulsion. The answers to the COVID-19-related questions revealed good knowledge about managing avulsed teeth during the pandemic. Health campaigns or online lectures would be helpful in improving dentists’ knowledge about managing avulsed teeth.
The authors would like to extend their appreciation to Dr. Faizah Kurdi, Dr. Hidayah Beresaly, Dr. Maryam Al Harqani and Dr. Shaimaa Kadi for helping with the data collection. The authors would also thank all participants for their invaluable contribution to this study.
- Nikam AP, Kathariya MD, Chopra K, et al. Knowledge and attitude of parents/caretakers toward management of avulsed tooth in Maharashtrian population: A questionnaire method. J Int Oral Health 2014; 6:1.
- AlJazairy YH, Halawany HS, AlMaflehi N, et al. Knowledge about permanent tooth avulsion and its management among dentists in Riyadh, Saudi Arabia. BMC Oral Health 2015; 15:135.
- Andersson L, Andreasen JO, Day P, et al. International association of dental traumatology guidelines for the management of traumatic dental injuries: Avulsion of permanent teeth. Dent Traumatol 2012; 28:88–96.
- Holan G, Shmueli, Y. Knowledge of physicians in hospital emergency rooms in Israel on their role in cases of avulsion of permanent incisors. Int J Paediatr Dent 2003; 13:13–19.
- Lee JY, Divaris, K. Hidden consequences of dental trauma: the social and psychological effects. Pediatr Dent 2009; 31:96–101.
- Soares ADJ, Gomes BPFDA, Zaia AA, et al. Relationship between clinical–radiographic evaluation and outcome of teeth replantation. Dent Traumatol 2008; 24:183–188.
- Bourguignon C, Cohenca N, Lauridsen E, et al. International association of dental traumatology guidelines for the management of traumatic dental injuries: Fractures and luxations. Dent Traumatol 2020; 36:343–359.
- Day P, Flores MT, O'Connell A, et al. International Association of dental traumatology guidelines for the management of traumatic dental injuries: Injuries in the primary dentition. Dent Traumatol 2020; 36:314–330.
- Fouad AF, Abbott PV, Tsilingaridis G, et al. International association of dental traumatology guidelines for the management of traumatic dental injuries: Avulsion of permanent teeth. Dent Traumatol 2020; 36:331–342.
- Levin L, Day P, Hicks L, et al. International association of dental traumatology guidelines for the management of traumatic dental injuries: General introduction. Dent Traumatol 2020; 36:309–313.
- Cosme-Silva L, Moretti ABS, Lima DC, et al. Knowledge of parents from public and private school students on emergency management of avulsed permanent teeth. J Public Health 2017; 25:167–71.
- Ningthoujam S, Gurunathan D, Singh WR, et al. Parental self-perceived knowledge and attitudes toward emergency management of avulsed permanent teeth in Imphal: A cross-sectional study. Natl J Maxillofac Surg 2019; 10:33.
- AlGhamdi NMS, Alothman SA, Assiri AM, et al. Knowledge of Saudi parents toward the emergency management of avulsed permanent teeth: A cross-sectional survey. J Dent Res Rev 2016; 3:85.
- Alzahrani MS, Almaqboul FA. Parents’ awareness and attitude toward urgent management of avulsed permanent tooth in AL-Baha city. Saudi Endod J 2019; 9:82.
- Alharbi R, Aboalshamat K, Alrabghi K, et al. Assessment of parents’ knowledge and attitudes on emergency management of permanent avulsed teeth in Western Saudi Arabia. Open Dent J 2020; 14:396–402.
- Fujita Y, Shiono Y, Maki K. Knowledge of emergency management of avulsed tooth among Japanese dental students. BMC Oral Health 2014; 14:34.
- Abdullah D, Soo SY, Kanagasingam S. Knowledge of managing avulsed tooth among general dental practitioners in Malaysia. Singapore Dent J 2016; 37:21–26.
- Westphalen VPD, Martins WD, Deonizio MDA, et al. Knowledge of general practitioners dentists about the emergency management of dental avulsion in Curitiba, Brazil Dent Traumatol 2007; 23:6–8.
- Duruk G, Erel ZB. Assessment of Turkish dentists’ knowledge about managing avulsed teeth. Dent Traumatol 2020; 36:371-381.
- Jain N, Srilatha A, Doshi D, et al. Knowledge of emergency management of avulsed tooth among intern dental students: A questionnaire based study. Int J Adolesc Medi Health 2018; 32:1-7.
- Azmi MA, Awooda EM. Knowledge of emergency management of avulsed tooth among undergraduate preclinical and clinical dental students: questionnaire-based study. J Dent Res Rev 2016; 3:140.
- Al-Shamiri HM, Alaizar, NA, Al-Maweri SA, et al. Knowledge and attitude of dental trauma among dental students in Saudi Arabia. Eur J Dent 2015; 9:518.
- Alaslam RA, Elshamy FM, Maamar EM, et al. Awareness about management of tooth avulsion among dentists in Jazan, Saudi Arabia. Open access Maced J Med Sci 2018; 6:1712.
- Al-Haj Ali SN, Algarawi SA, Alrubaian AM, et al. Knowledge of general dental practitioners and specialists about emergency management of traumatic dental injuries in Qassim, Saudi Arabia. Int J Pediatr 2020; 6059346:1-7.
- Al-Majed I, Murray JJ, Maguire A. Prevalence of dental trauma in 5–6-and 12–14-year-old boys in Riyadh, Saudi Arabia. Dent Traumatol 2001; 17:153–158.
- Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395:497–506.
- Tanne JH, Hayasaki E, Zastrow M, et al. Covid-19: How doctors and healthcare systems are tackling coronavirus worldwide. BMJ 2020; 368:1090.
- Ather A, Patel B, Ruparel NB, et al. Coronavirus disease 19 (COVID-19): implications for clinical dental care. J Endod 2020; 46:584-595.
- Guo H, Zhou Y, Liu X, et al. The impact of the COVID–19 epidemic on the utilization of emergency dental services. J Dent Sci 2020; 15: 564-567.
- Robertson A, Norén JG. Knowledge-based system for structured examination, diagnosis and therapy in treatment of traumatised teeth. Dent Traumatol 2001; 17:5–9.
- Flores MT, Andreasen JO, Bakland LK. Guidelines for the evaluation and management of traumatic dental injuries. Dent Traumatol 2001; 17:193-198.
- Halawany HS, AlJazairy YH, Alhussainan NS, et al. Knowledge about tooth avulsion and its management among dental assistants in Riyadh, Saudi Arabia. BMC Oral Health 2014; 14:46.
- 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.
Citation: Somaya Abdulrahman, Khalid Aboalshamat, Arwa Dewedar, Nada Gazzaz, Alaa Almabdi, Dental Professionals Management of Avulsed Teeth and Implementation of COVID-19 Related Safety Precautions, J Res Med Dent Sci, 2021, 9 (2): 1-7.
Received: 27-Dec-2020 Accepted: 18-Jan-2021