Dental Traumatology 2007; doi: 10.1111/j.1600-9657.2006.00477.

x DENTAL TRAUMATOLOGY

Knowledge of emergency management of

avulsed teeth among young physicians and
dentists
Abu-Dawoud M, Al-Enezi B, Andersson L. Knowledge of Maha Abu-Dawoud1, Basmah Al-Enezi2,
emergency management of avulsed teeth among young physicians Lars Andersson3
and dentists. 1
Ministry of Public Health, Kuwait City; 2Faculty of Dentistry,
Kuwait University, Kuwait City; 3Oral and Maxillofacial
Abstract – This study was designed to investigate the knowledge Surgery, Department of Surgical Sciences, Faculty of
Dentistry, Kuwait University, Kuwait City, Kuwait
and attitude of newly graduated physicians and dentists regarding
emergency management of avulsed teeth. Data were collected
using a self-administered questionnaire. Thirty physicians and 30
dentists who graduated during the period 2000–2004 were
surveyed. They all served in either hospitals or dental centres
with emergency settings. All the participants that were asked
were willing to participate. The majority of the physicians
(83.3%) surveyed had not received information on what to do if a
tooth is knocked-out and 96.6% did not have any dental health
education course during their study. In contrast, nearly all the
dentists (93.3%) had received information on what to do if a
tooth is knocked-out. Regarding knowledge level, eight of the
physicians (26.6%) demonstrated low knowledge while the
remaining 22 (73.3%) had some knowledge; none of the
physicians showed a high knowledge level. In sharp contrast, 22
dentists (78.5%) had high knowledge, six (21.4%) showed some
knowledge and none demonstrated low knowledge. We conclude
that emergency dental treatment is sometimes required to be
provided by a physician before any dental contact. Unfortu-
nately, the findings from this survey clearly suggest that very Key words: replantation; avulsion; tooth; knowledge;
education; first aid
few physicians would provide appropriate emergency treatment.
All medical staff personnel need to receive simple instructions Maha Abu-Dawoud, Ministry of Public Health,
Dental Administration, Behbahani Bldg. – 8th floor,
about management of dental trauma. Most dentists had high Al-Sharq, PO Box 1793, Safat 13018, Kuwait
knowledge regarding this issue; nevertheless, a few dentists, not Tel.: +965 648 9428
graduated in Kuwait, were found to have limited knowledge, e-mail: sweet_dentist@yahoo.com
which needs to be improved. Accepted 15 November, 2005

Traumatic tooth avulsion (i.e. exarticulation, professional help is obtained (1, 2, 5, 6, 10, 11).
knocked-out tooth) is the total displacement of However, if such proper first aid procedures are
the tooth out of its socket because of traumatic not provided, the tooth will be lost. The imme-
injury (1–6). Avulsion of permanent teeth accounts diate and appropriate management of traumatic-
for approximately 0.5–16% of dental trauma (3, ally avulsed teeth provided within the first 15 min
7). The peak age for avulsion of permanent after avulsion is critical for the long-term success
incisors is between 7 and 9 years (1, 3, 8, 9). of the treatment (1, 2, 5, 6, 10, 11). Primary teeth
Avulsed permanent teeth can be saved if replan- should not be replanted because of the potential
ted immediately or stored in a physiologic solu- risk of damaging the permanent successors (1, 2,
tion, such as saline, milk or even saliva until 5, 6).

348 Dental Traumatology 2007; 23: 348–355  2007 The Authors. Journal compilation  Blackwell Munksgaard
 Professionals’ knowledge of management of avulsed teeth

Relative to other dental injuries, avulsion repre- standardized questionnaire forms (Appendix) to
sents a challenge in terms of the proper emergency the target groups. Totally, 30 physicians and 30
management provided at the site of the accident. The dentists who graduated between 2000 and 2004
principal challenge is to keep the cell layer around the were surveyed. They all served in either hospitals
tooth surface vital. During avulsion, the periodontal or dental centres with emergency settings. The
ligament (PDL) cells surrounding the root surface are project was ethically approved by Faculty of
injured (1, 2, 4, 5, 10, 12). The prognosis of avulsion Dentistry (FOD) and permission was given by
injuries is largely dependent on the condition of the the Ministry of Public Health (MOPH) to survey
PDL cells at the time of replantation and is inversely the participants.
related to the period of dry storage (1, 2, 4, 5, 10, 12). The mean age of the dentists at the time of the
Maxillary central incisors are the teeth most study was 26 years (range 22–29 years) and
commonly prone to avulsion (1, 9, 13). Therefore, 26.5 years (range 24–29 years) for the physicians.
functional and aesthetic consequences associated The gender distribution was similar for both groups,
with the loss of an anterior tooth should be with 42 (70%) male and 18 (30%) female partici-
considered. Losing an anterior tooth at this age pants. Table 1 shows the countries of graduation of
may have severe psychological consequences. the 30 physicians and 30 dentists. The majority
Immediate replantation of an avulsed tooth is (73.3%) of the physicians had graduated from
needed to restore aesthetics and function for the Kuwait while half of the dentists had graduated
patient. If the tooth is lost, there are long-term from the USA.
economic consequences as more expensive and All questions were close-ended (multiple-choice
extensive treatment modalities will be needed to questions), except for the questions regarding
restore such impairments. personal data. The survey was voluntary and strict
Most dental injuries, including avulsion, occur confidentiality was assured as no names or phone
because of sport-related injuries in the school or numbers were required.
playground, physical violence, road traffic accidents, The questionnaires were given to the participants
falls and other injuries. Initial emergency manage- under the supervision of the authors. Furthermore,
ment, therefore, may involve such individuals as the the authors were always present at the time the
school nurse, parents, relatives, teachers and general questionnaires were completed and the question-
medical practitioners in the emergency units before naires were collected immediately after the partic-
any professional dental help can be obtained. The ipants answered the questions.
immediate and appropriate management of trau- The questionnaire, containing 20 questions, was
matically avulsed teeth is critical for the long-term divided into three parts. The first part consisted of
success of the treatment. Many avulsed teeth are lost seven questions on personal information. It included
because of lack of knowledge about the proper first information about (age, gender, medical or dental
aid procedures that need to be provided. Conse- graduate, year of graduation, country of graduation,
quently, dental health education in this field can be if first aid training included dental trauma and if the
very effective in reducing the negative consequences medical training involved any dental educational
of such injuries (14). programmes). Parts II and III were composed of 13
Some published surveys (15–22) have investigated questions based on an imaginary case of traumatic
the lay knowledge and awareness of the public avulsion.
regarding this situation. We found only one study in
the literature, however, about the level of knowledge
among medical personnel (13). Dentist should be Table 1. Country of graduation of participating physicians and dentists
well educated in this field, but we found no study
documenting the level of awareness and attitude of Country Physicians Dentists
dentists. Bahrain 4 0
The aim of this study was to investigate the Egypt 0 4
knowledge and attitude of newly graduated physi- India 0 3
cians and dentists in relation to this problem in that Ireland 3 0
Jordan 0 2
these are two important groups involved in the Kuwait 22 0
emergency phase of the management of avulsion Philippines 0 1
injuries. Romania 0 1
Russia 0 1
Syria 0 2
Material and methods UK 1 1
USA 0 15
The present study is a cross-sectional observation Total 30 30
study. The data were collected by distributing

Dental Traumatology 2007; 23: 348–355  2007 The Authors. Journal compilation  2007 Blackwell Munksgaard 349
Abu-Dawoud et al.

The following fields of knowledge were assessed: 80

Physicians
• Importance of immediate management of an
70 Dentists
avulsed permanent tooth on the long-term success
of treatment 60
• Importance of not replanting primary teeth
because of the potential risk of damaging the 50
permanent successors
40
• Critical extra-alveolar time of an avulsed tooth
• Optimal storage methods and media 30
• Proper cleaning technique of a grossly contamin-
ated avulsed tooth before replantation 20
• Proper handling of an avulsed tooth 10
• First place to contact in seeking professional help
The results were analysed and knowledge was 0
assessed by a standardized method with scoring of Low Some High
the participants’ knowledge level. Five questions Fig. 1. Knowledge level of physicians and dentists. For defini-
from part II (questions 1–5) and three questions tion of low, some and high knowledge (see Material and
from part III (questions 1, 2 and 4) were used to methods).
assess the level of knowledge.
A score of eight points represents full know- 100
ledge while a score of zero indicates no knowledge. 90 Physicians
Between these two scores a scale of high knowledge 80 Dentists
(6–8 points), some knowledge (3–5 points) and low
70
knowledge (0–2) was formulated.
60
Descriptive statistics were used to analyse and
present the data. The Mann–Whitney U-test was 50

performed to determine differences in knowledge 40

level between the two groups (i.e. between the 30

dentists and physicians). Statistically significant 20
differences were assumed when P < 0.05. The 10
chi-square test was also used to analyse the data. 0
Water and Milk Contact Saline Pt's mouth Plastic
Salt lens foil
Results solution
(Saline)

All of the participants who were initially approached Fig. 2. Correct answers for suitable storage methods and
gave their consent to participate in the study. medias by physicians and dentists.
Almost all (93.3%) of the physicians but less than
one-third (28.6%) of the dentists reported that the Nine physicians (30.0%) and 20 dentists (66.7%)
‘first aid’ course they had taken did not cover had knowledge about the available dental emer-
management of dental trauma. gency units and their office hours in Kuwait. Seven
The majority of the physicians (83.3%) reported physicians (23.3%) and 14 dentists (46.7%) reported
that they did not receive any information on what to that they or someone they know has been at a site of
do if a tooth is knocked-out; in addition, 96.6% of an accident where somebody had dental trauma.
the physicians did not have any dental health Regarding the type of dental trauma, fractured teeth
education course during their study. In contrast, were the most commonly reported injury by both
nearly all the dentists (93.3%) had received infor- groups. Eleven of 60 (18.3%) participants had
mation on what to do if a tooth is knocked-out. The experienced at least one case of avulsion. Dental
difference in information level between the two trauma caused by sport injuries and falls were more
groups was statistically significant (P < 0.05). commonly seen by dentists. Knowledge of proper
Regarding knowledge level, eight of the physi- storage methods and media was significantly higher
cians (26.6%) had low knowledge, 22 (73.3%) had in the dentist group (Figs 2 and 3).
some knowledge and not one showed high
knowledge. For the dentist group, 22 (78.5%)
Discussion
had high knowledge, six (21.4%) had some
knowledge and none had low knowledge (Fig. 1). This study provided baseline information about the
The difference in knowledge level between the existing level of knowledge of dental avulsion in
groups was significant. newly graduated physicians and dentists. In general,

350 Dental Traumatology 2007; 23: 348–355  2007 The Authors. Journal compilation  2007 Blackwell Munksgaard
 Professionals’ knowledge of management of avulsed teeth

30 lecture or seminar into the curriculum of the Health

Science Centre for training medical students in
25
Physicians Kuwait. Moreover, leaflets, stickers and posters
Dentists
20
about basic first aid treatment can be provided not
only to lay people but also to professional care
15 providers.
Another surprising finding was that only 33% of
10 the physicians and 66% of the dentist had informa-
tion about the location and office hours of dental
5
emergency services. Such information should be
0
available at all emergency settings. Recently, FOD
No need Tap Warm Cold Ice Coke Disinfectant Gauze has distributed guidelines for management of dental
water water water
trauma in which the location of emergency clinics
Fig. 3. Incorrect answers on questions about the storage and their office hours are included (23).
methods and media by physicians and dentists. Although the physicians and dentists in this study
were quite young, 25% of the physicians and 50%
only the dentists showed high knowledge about of the dentists had already gained some experience
dental avulsion. In contrast, the results of the survey about dental trauma and 20% of the participants
reflected the fact that the physicians had received no had already gained experience about avulsed teeth.
advice or had low awareness about the emergency These findings show that professionals in emergency
management of avulsed teeth and the possibility of settings are in fact exposed to patients with tooth
saving them through simple replantation. Physicians avulsions.
who work in hospitals with emergency settings Knowledge of correct measures regarding storage
should receive simple instructions about dental first media was found to vary considerably. Although the
aid. dentists were aware of physiologic media such as
In this survey we preferred to directly supervise saline, milk and saliva, such knowledge was rare in
the questionnaire process. In the survey reported by the physicians. To treat or provide correct profes-
Holan & Shmueli (13) the questionnaire forms were sional advice knowledge about storage media must
mailed to the participants. By using this latter be increased. Professional medical personnel can
method, we feel there is a risk that the participants’ cause serious injury to PDL cells by providing poor
responses may be compromised. advice. For instance, 25% of the physicians thought
It is possible that all 13 questions could have been that there was no need to store an avulsed tooth. In
included in one section rather than dividing the the physician group 25% thought a tooth could be
questionnaire into two sections. However, because stored dry in gauze or tissue paper, but such a
the responses to earlier questions may influence the storage media would rapidly destroy the PDL cells
later responses, we decided to separate the questions (1, 2, 4, 5, 10, 12).
into two parts, making sure that they were given Despite years of research showing that cell
separately to the participants. membranes will be destroyed if stored in water, an
Only 6.7% of the physicians recalled that the first alarming number of dentists thought that a tooth
aid course covered dental trauma. Almost all could be stored in such a medium. Many physicians
(96.7%) of the physicians had no dental health believed that a tooth should be stored on ice. This
education course during their study. The first aid may be recommended for body parts (such as a cut
course given by the authorities in Kuwait is a 4-day finger) but when trying to save a cell layer, a more
course designed to increase the knowledge level so sensitive storage medium is required. When ice
that the physician is able to manage all types of melts during transport to the dentist, it becomes
emergency, (e.g. burns, fractures and poisoning). In water, which, because of a difference in osmolality,
such a comprehensive course it is surprising that will destroy the walls of the cell membrane (1, 2, 4,
dental trauma was not included. Some dental 5, 10, 12).
injuries have a favourable prognosis although this Undergraduate teaching of physicians is carried
will heavily depend on the actions taken during the out in Kuwait since more than 20 years back. The
emergency phase. majority of the physicians interviewed had gradu-
In the light of such results an important impli- ated in Kuwait. There is a need for including an
cation from this study would include the need for an educational course about dental emergency man-
educational campaign to broaden the knowledge of agement in the medical undergraduate curriculum
medical personnel about emergency management in Kuwait. In recent years a FOD has started. This
of dental trauma. This can be done, for instance, new faculty can contribute to teaching in basic
by incorporating a dental trauma management dentistry e.g. management of avulsed teeth in the

Dental Traumatology 2007; 23: 348–355  2007 The Authors. Journal compilation  2007 Blackwell Munksgaard 351
Abu-Dawoud et al.

undergraduate curriculum in Faculty of Medicine. 3. Cho SY, Cheng AC. Replantation of an avulsed incisor
Such discussions have just started. after prolonged dry storage: a case report. J Can Dent Assoc
2002;68:297–300.
At the time of the study no dentist had graduated 4. Donaldson M, Kinirons MJ. Factors affecting the time of
from the FOD in Kuwait. For this reason only onset of resorption in avulsed and replanted incisor teeth in
dentists graduated abroad took part in the study. children. Dent Traumatol 2001;17:205–9.
The quality of teaching emergency dental treatment 5. Peterson L. Oral and Maxillofacial Trauma. In: Peterson L,
Ellis E, Hupp J, Tucker M, editors. Contemporary oral and
may vary between different countries. This may maxillofacial surgery, 3rd edn. St Louis: Mosby; 1998. p.
explain why even some dentists have an insufficient 569–77.
knowledge level of emergency management. The 6. Trope M. Clinical management of the avulsed tooth:
graduating students from the new FOD have been present strategies and future directions. Dent Traumatol
2002;18:1–11.
taught modern principles of tooth avulsion and how 7. Kinoshita S, Kojima R, Taguchi Y, Noda T. Tooth
to act in a situation of emergency. When these replantation after traumatic avulsion: a report of ten cases.
dentists will come out in the society they will Dent Traumatol 2002;18:153–6.
certainly contribute to a rise in knowledge level in 8. Robertson A, Noren JG. Knowledge-based system for
the society of how to act in case of an emergency structured examination, diagnosis and therapy in treatment
of traumatised teeth. Dent Traumatol 2001;17:5–9.
with an avulsed tooth. 9. Caldas AF Jr, Burgos ME. A retrospective study of
There is a need for courses in Dental Trauma- traumatic dental injuries in a Brazilian dental trauma
tology in the society to increase the knowledge level clinic. Dent Traumatol 2001;17:250–3.
among the professionals. Guidelines have recently 10. Andersson L, Bodin I. Avulsed human teeth replanted
within 15 minutes – a long-term clinical follow-up study.
been distributed to all dentists and we feel that this Endod Dent Traumatol 1990;6:37–42.
will contribute to a higher standard of care. In 11. Andreasen JO, Andreasen FM, Skeie A, Hjorting-Hansen
accordance, reaching out to the medical students at E, Schwartz O. Effect of treatment delay upon pulp and
the undergraduate level by a course in dentistry in periodontal healing of traumatic dental injuries – a review
article. Dent Traumatol 2002;18:116–28.
the undergraduate curriculum is presently discussed 12. Barrett EJ, Kenny DJ. Avulsed permanent teeth: a review of
and in such a course the emergency management of the literature and treatment guidelines. Endod Dent
avulsed teeth is an important topic to be covered. Traumatol 1997;13:153–63.
Furthermore courses for staff at emergency clinics 13. Holan G, Shmueli Y. Knowledge of physicians in hospital
emergency rooms in Israel on their role in cases of avulsion
are planned. In addition posters and information of permanent incisors. Inter J Paediatric Dent 2003;13:
brochures will be distributed to emergency clinics in 13–9.
the society. 14. Booth JM. ‘‘It’s a knock-out’’–an avulsed tooth campaign.
J Endod 1980;6:1–7.
15. Blakytny C, Surbuts C, Thomas A, Hunter ML. Avulsed
Conclusion permanent incisors: knowledge and attitudes of primary
school teachers with regard to emergency management. Int
A physician is sometimes required to provide J Paediatr Dent 2001;11:327–32.
emergency dental treatment before professional 16. Chan AWK, Wong TKS, Cheung GSP. Lay knowledge of
dental contact. Unfortunately, the findings from physical education teachers about the emergency manage-
ment of dental trauma in Hong Kong. Dent Traumatol
this survey suggest that few physicians could provide 2001;17:77–85.
appropriate emergency treatment. All members of a 17. Hamilton FA, Hill FJ, Mackie IC. Investigation of lay
medical staff need to receive simple instruction knowledge of the management of avulsed permanent
about management of dental trauma. Most dentists incisors. Endod Dent Traumatol 1997;13:19–23.
18. Pacheco LF, Filho PFG, Letra A. Evaluation of the
had high knowledge regarding this issue; neverthe- knowledge of the treatment of avulsion in elementary
less, a few dentists were found to possess limited school teachers in Rio de Janeiro, Brazil. Dent Traumatol
knowledge of acute dental trauma. 2003;19:76–78.
19. Raphael SL, Gregory PJ. Parental awareness of the
emergency management of avulsed teeth in children. Aust
Acknowledgments – The authors would like to thank all Dent J 1990;35:130–3.
the physicians and dentists from Ministry of Public 20. Sae-Lim V, Lim LP. Dental trauma management aware-
Health for their kind cooperation and participation. ness of Singapore pre-school teachers. Dent Traumatol
We also wish to thank our statistical consultant, 2001;17:71–6.
21. Sae-Lim V, Chulaluk K, Lim LP. Patient and parental
Dr Fleming Scheutz, for statistical advice. awareness of the importance of immediate management
of traumatised teeth. Endod Dent Traumatol 1999;15:
37–41.
References 22. Stokes AN, Anderson HK, Cowan TM. Lay and profes-
1. Andreasen JO, Andreasen FM. Text book and color atlas of sional knowledge of methods for emergency management of
traumatic injuries to the teeth, 3rd edn. Copenhagen: avulsed teeth. Endod Dent Traumatol 1992;8:160–2.
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40–3.

352 Dental Traumatology 2007; 23: 348–355  2007 The Authors. Journal compilation  2007 Blackwell Munksgaard
 Professionals’ knowledge of management of avulsed teeth

Appendix
Case no. uuu
Date (day/month/year) uuuuuu
Dental trauma management awareness
Management of avulsed teeth
Survey of new medical and dental graduates, Kuwait.
Please answer parts I, II & III of the questionnaire.

Part I: Personal information:

1. Date of birth (day/month/year) uuuuuu

2. Gender: u Male u Female

3. Are you a: u New medical graduate u New dental graduate

4. Year of graduation uuuu

5. Country of graduation ——————

6. Did you have any ‘First Aid’ course covering ‘Management of Dental Trauma’ during your study or
training?
u Yes
u No

7. Have you ever received information on what to do if a tooth is knocked-out?

u Yes
u No

8. If you are a medical graduate, have you had any dental health educational course during your study?
u Yes
u No

Part II: You were at the site of an accident where a 14-year-old boy knocked-out* one of his upper front teeth.
*The tooth is totally displaced out of the socket

1. What do you think is the most appropriate action?

u Stop the bleeding
u Stop the bleeding and search for the tooth
u Search for the tooth and seek help
u Search for the tooth and put it back into the socket of the injured person’s mouth
u No need to search for the tooth as it is already knocked-out

2. How urgent do you think it is to seek professional help?

u Immediately
u Within 30 min
u Within a few hours
u Before 24 h has elapsed
u No need to seek professional help

Dental Traumatology 2007; 23: 348–355  2007 The Authors. Journal compilation  2007 Blackwell Munksgaard 353
Abu-Dawoud et al.

3. Would you care if the tooth that has been knocked-out were a primary tooth?
u Yes
u No

4. Can you differentiate if the tooth is primary or permanent?

u Yes
u No

5. Which would be the first place you would contact to seek treatment?
u No need to seek treatment
u General medical practitioner
u Dentist
u School health programme

6. Do you know the dental emergency units and their office hours in Kuwait?
u Yes
u No

7. Have you or someone you know been at the site of an accident where somebody had a dental trauma?
u Yes fi go to questions 8 and 9
u No 8. If yes, what type of dental trauma? (choose all possible alternatives)
u Knocked-out tooth
u Fractured tooth
u Dislocated tooth
u Others, please state.........................

9. What was the cause of the dental trauma? (choose all possible alternatives)
u Road traffic accident
u Sport-related injury
u Fall
u Violence (fight, child abuse…)
u Others, please state ............................

Case no. uuu

Date (day/month/year) uuuuuu

Part III:

1. You found the knocked-out tooth and it is dirty:

u Wipe the tooth with a tissue paper
u Clean the tooth with a tooth brush
u Rinse the tooth gently under running tap water for a few seconds without scrubbing it.
u No need to clean the tooth because it is useless
u Others, please state ........................

2. How would you hold the tooth?

u From the crown
u From the root
u Any where (crown or root)

3. Which of the following storage media are suitable to store a knocked-out tooth? (choose all possible
alternatives)
u No need to store the tooth
u Tap water
u Warm water
u Cold water

354 Dental Traumatology 2007; 23: 348–355  2007 The Authors. Journal compilation  2007 Blackwell Munksgaard
 Professionals’ knowledge of management of avulsed teeth

u Water with a pinch of salt

u Ice
u Coke
u Milk
u Contact lens solution (saline)
u Disinfectant solution
u Physiologic saline solution
u Patient’s mouth
u Wrap it with tissue paper or gauze
u Wrap it with plastic foil

4. If you were at a site where someone knocked-out a tooth, you would

u Not take action because you lack knowledge and training
u Not take action because of the medico-legal consequences
u Be confident and replant the tooth
u Not be confident but you would replant the tooth anyway

Dental Traumatology 2007; 23: 348–355  2007 The Authors. Journal compilation  2007 Blackwell Munksgaard 355