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Dr. Shankar P.R.

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On April 2011

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Important Notice

Original article / research
Year : 2022 | Month : December | Volume : 16 | Issue : 12 | Page : ZC16 - ZC20 Full Version

Knowledge and Attitude about Emergency Management of Avulsed Tooth Amongst Paramedical Students of Visnagar, Gujarat: A Questionnaire-based Cross-sectional Study

Published: December 1, 2022 | DOI:
Shoba Fernandes, Heli Shah, Yash Bafna, Dharati Patel, Harsh Mistry, Kavya Shah

1. Head, Department of Paediatric and Preventive Dentistry, Narsinhbhai Patel Dental College and Hospital, Sankalchand Patel University, Visnagar, Gujarat, India. 2. Postgraduate Student, Department of Paediatric and Preventive Dentistry, Narsinhbhai Patel Dental College and Hospital, Sankalchand Patel University, Visnagar, Gujarat, India. 3. Professor, Department of Paediatric and Preventive Dentistry, Narsinhbhai Patel Dental College and Hospital, Sankalchand Patel University, Visnagar, Gujarat, India. 4. Senior Lecturer, Department of Paediatric and Preventive Dentistry, Narsinhbhai Patel Dental College and Hospital, Sankalchand Patel University, Visnagar, Gujarat, India. 5. Senior Lecturer, Department of Paediatric and Preventive Dentistry, Narsinhbhai Patel Dental College and Hospital, Sankalchand Patel University, Visnagar, Gujarat, India. 6. Postgraduate Student, Department of Paediatric and Preventive Dentistry, Narsinhbhai Patel Dental College and Hospital, Sankalchand Pa

Correspondence Address :
Dr. Shoba Fernandes,
Head, Department of Paediatric and Preventive Dentistry, Sankalchand Patel University, Visnagar, Gujarat, India.


Introduction: Dental trauma has emerged as a significant aspect of dental public health. Traumatised teeth require early and appropriate treatment, which frequently relies on the competence of the dentists, doctors and nurses, who provide the primary care.

Aim: To assess the knowledge and attitude of paramedical students about the emergency management of avulsed tooth.

Materials and Methods: A cross-sectional questionnaire survey consisting of 17 questions was designed and circulated among 365 paramedical students (nursing, pharmacy and physiotherapy) of Sankalchand Patel University, Visnagar, Gujarat, India, to assess their knowledge and attitude about the emergency management of avulsed tooth. Descriptive statistics were applied by Statistical Package for Social Sciences (SPSS) software version 20.0.

Results: Total 260 (71.23%, mean age of 23 years) students responded, with 71 students from Physiotherapy, 106 from Nursing and 83 from Pharmacy. A total of 178 (68.46%) students comprehend the meaning of avulsion. While 193 (74.23%) students had knowledge that tooth re-implantation is possible. Of all the respondents, 192 students (73.84%) were familiar about the benefit of mouth guards for prevention of sports injury and 125 students (48.07%) had the opinion, that it is very important to be acquainted with emergency management of dental trauma.

Conclusion: Though the paramedical students had good understanding about tooth avulsion, they were unaware about the emergency management of the situation. This warrants the need of incorporating training programmes, dedicated to the subject in their curriculum.


Dental trauma, Mouth guards, Questionnaire survey, Re-implantation, Tooth avulsion

Dental avulsion comprises of 0.5-16% of all traumatic dental injuries (1). The International Dental Traumatology Association (2012) guidelines dictates that the correct approach to a case of dental avulsion is extremely important. The choice of treatment for avulsed permanent tooth is by immediate replacement (re-implantation) of the tooth into the socket (2),(3). The success of such replantation is dependent on factors such as extra alveolar dry time, storage media in which the tooth is transported before re-implantation and viability of the Periodontal Ligament (PDL) cells on the root prior to re-implantation (4). The prognosis for avulsed permanent tooth is not favourable if there is improper handling of the emergency situation. Literature show that the first hour forms the critical time frame at the site of accident for successful management of avulsed tooth (1). Thus, it is important that health professionals, to know the measures to be taken in dental avulsion cases.

Emergency medical services, which operate 24 hours a day, receive many patients with dental trauma, such as avulsion. The dentist may not always be the professional who administers first aid at the accident site. Paramedics are healthcare workers, who provide clinical services to patients under the supervision of a physician, they may be the first to offer emergency primary treatment for these injuries (4). Literature has reported that majority of non dental professionals and paramedical technicians are unaware about traumatic dental injury (4). There appears to be paucity of published literature regarding attitude and practice of paramedical students in relation to traumatic tooth avulsion in this part of the world.

Hence, the purpose of the present study was to assess the knowledge and attitude of paramedical students, about the emergency management of avulsed tooth.

Material and Methods

This cross-sectional questionnaire survey was conducted in Department of Paediatric and Preventive Dentistry, Sankalchand Patel University (SPU), Visnagar, Gujarat, India, from 1st November 2021 to 15th December 2021. Ethical approval was obtained from Institutional Ethics Committee (IEC) [No.: NPDCH/IEC/2021/34 dated 28/09/2021]. Permission to collect the relevant data from the students was obtained from the respective college authorities. Informed consent was obtained from the students after explaining the purpose and the procedures involved in the study.

Inclusion criteria: All the undergraduate and postgraduate students from Physiotherapy, Nursing and Pharmacy colleges of SPU, Visnagar, Gujarat, India were included in the study, irrespective of age and gender.

Exclusion criteria: Students who declined to participate in the study were excluded.

Sample size calculation: Based on the pilot study, the sample size was calculated considering confidence interval of 95% and precision of 0.05. The proportion of subjects having knowledge about the topic were considered as 20% and the sample size calculated was 256. To compensate for any missing data entry and considering the missing responses, an extra 30% was added, the sample size of 365 students was finalised.


Based on the aim, a precise self-designed questionnaire was created with reference to previous literature (5),(6) and managed in Google forms. It was circulated among paramedical students via the social media platform. The validation was carried out by a panel of 10 experts in the subjects. Cronbach’s alpha was calculated (α=0.70) and test-retest analysis showed a good reliability.

The Questionnaire was distributed to all the 365 students. It consisted of 17 questions divided into two sections. Section 1 consists of 4 questions for socio-demographic data and professional details of participants. While section 2 consists of eight questions to evaluate knowledge and five questions to assess attitude of the participants. The Questionnaire consisted of multiple-choice questions pertaining to training provided for avulsion, handling of the avulsed tooth and capability to manage the avulsed tooth on their own [Annexure-I]. The prepared questionnaire was circulated among the paramedical students studying in Sankalchand Patel University (SPU).

Statistical Analysis

The data was compiled and tabulated systematically in Microsoft Excel spreadsheet and subjected to statistical analysis using Statistical Package for Social Sciences (SPSS) version 20.0 (IBM Corporation, SPSS Inc., Chicago, IL, USA) Descriptive statistics was employed in terms of percentages. Inferential Statistics were done using Chi-Square Test.


Total 260 students (47 males, 213 females) with the mean age of 23 years (Standard Deviation 1.71) participated in the study (response rate 71.23%). Out of them, 71 students were from Physiotherapy, 106 from Nursing and 83 from Pharmacy (Table/Fig 1). A total of 178 respondents (68.48%) were aware about the correct meaning of ‘avulsion’ and 111 students (42.69%) had knowledge that a dirty avulsed tooth should be handled by the crown. Among them, 41 (15.77%) were Pharmacy students, 39 (15%) were Nursing students and 31 (11.92%) were Physiotherapy students (p=0.008). Only 87 students (33.46%) chose milk as a transport medium for an avulsed tooth (Table/Fig 2).

With regards to respondents’ attitude of handling the tooth at the site of a traumatically avulsed tooth, only 53 students (20.38%) preferred to replant the tooth in its socket immediately, whereas, 101 of them (38.84%) preferred to find the tooth and seek professional help. Awareness regarding time elapsed before seeking professional help for avulsed tooth was elicited in 125 (48.07%) participants and this was highest among Nursing students 62 (23.85%), followed by Pharmacy 40 (15.38%) and Physiotherapy students 23 (8.85%) and this difference was statistically significant (p=0.005) (Table/Fig 3).

Of all the respondents, 125 (48.07%) opined that it is very important to be acquainted with emergency management of dental trauma among which 48 (18.46%) were Pharmacy students, 40 (15.38%) were Nursing students and 37 (14.23%) were Physiotherapy students (Table/Fig 3).


A paramedic is a healthcare personnel who provides rapid response, emergency medical assessment, treatment and care out of the hospital environment. They are often one of the first healthcare professionals at the scene of an accident or emergency. The paramedic is often required to make complex and critical clinical judgment without direct supervision (4). Thus, it is very important that they are acquainted with emergency management of traumatic tooth avulsion. Out of all students that participated in the present study, 196 (75.38%) had received some kind of first aid course covering dental trauma.

In children, sports accidents reportedly account for 10-39% of all dental injuries (7),(8). It is established that wearing of a “properly fitted mouthguard” eliminates mouth injuries during contact sports (9),(10). In the present study, 192 participants (73.84%) of the present study had knowledge about the use of mouth guard for prevention of sports injury. In the present study, most of the students (68.46%) were aware about correct meaning of avulsion. These findings were consistent with other studies conducted among paramedical students of Nigeria and paramedical staff of Uttarakhand, India (4),(11). Similar studies have been tabulated in (Table/Fig 4) (4),(6),(11),(12),(13).

The predominant and widely accepted treatment regimen for an avulsed tooth is to replant immediately. This tends to preserve the attachment apparatus, significantly reducing the occurrence of root resorption and prevents desiccation of the Periodontal Ligament (PDL) cells which leads to their death (14),(15),(16). In this study, 193 students (74.23%) were aware that, it is possible to re-implant an avulsed tooth. Andersson L and Bodin I, stated that the prognosis of an avulsed tooth is mainly determined by its re-implantation time (17). Earlier the tooth is re-implanted into the socket, better the prognosis. There is a chance of cemental/periodontal ligament healing when extra alveolar dry time is less than 30 minutes and extra alveolar total time is less than 90 minutes when stored in an appropriate storage medium (18). In present study, almost 1/2 (48.07%) of them had awareness that professional help should be sought within 30 minutes of tooth avulsion. A total of 30% of the nursing students responded that the critical time for replantation to be within 20 min in a study done by Yunus GY et al., in 2015 (12).

Immediate re-implantation is sometimes not practical; hence, tooth has to be transported in a liquid medium (15),(16). The most suitable transport media is the Hank’s Balanced Salt Solution (HBSS) which provides extraoral time of eight hours (1). Other transport media are viaspan, milk, normal saline, saliva and coconut water (1),(14). If an avulsed tooth is stored in milk, its prognosis would be enhanced after implantation (19),(20),(21). The composition and osmolarity of milk render it favourable for preservation of PDL cells. Hence, it is often recommended for transportation of avulsed tooth, as it is readily available and preserves cell viability for upto two hours (1). Saliva is the last alternative when there is unavailability of other media. Andreasen JO et al., elucidated that due to the shortcomings of saliva like hypotonic nature and bacterial content, the role of saliva as a transport media is limited to a maximum of two hours (1).

In present study, 33.46% of paramedical students knew that milk is one of the suitable transport media for an avulsed tooth whereas Hugar SM et al., in their study concluded that only 2.2% nurses demonstrated this knowledge (22). Other media considered by participants of the current study were isotonic saline (14.61%) and saliva (10.76%). According to the Nursing students at Davangere (30%), saliva is the most preferable storage media for avulsed tooth, which is similar to the knowledge of dental assistants of Riyadh (12),(23). Overall, 125 students (48.07%) believed that it is important to be acquainted with emergency handling of dental trauma. Although the paramedical students had fair knowledge about tooth avulsion, they were untutored regarding the emergency management. Therefore, it is necessary to provide education programs concerning traumatic dental injuries, especially tooth avulsion, for paramedical students and staff.


The convenience sampling methodology adapted, limited the study population to this university, thus, the results of present survey cannot be generalised to the other paramedical students. A state-wide survey, would provide a better overall perspective for implementation of awareness programmes.


Since, the paramedics had good understanding of tooth avulsion but were unaware about the emergency management of the same, hence, training programmes dedicated to dental trauma must be incorporated in the curriculum of paramedics. Additionally, clinical postings in dental teaching set-ups would provide practical exposure to deal with dental trauma.


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DOI and Others

DOI: 10.7860/JCDR/2022/56695.17279

Date of Submission: Apr 20, 2022
Date of Peer Review: Jun 11, 2022
Date of Acceptance: Aug 24, 2022
Date of Publishing: Dec 01, 2022

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Apr 26, 2022
• Manual Googling: Aug 17, 2022
• iThenticate Software: Aug 22, 2022 (18%)

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