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ORIGINAL ARTICLE
Year : 2021  |  Volume : 11  |  Issue : 3  |  Page : 375-382

Assessment of knowledge of traumatic tooth fracture management among endodontists and general practitioners in two different countries: A cross-sectional survey


Department of Clinical Dental Sciences, College of Dentistry, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia

Date of Submission18-Sep-2020
Date of Decision20-Oct-2020
Date of Acceptance27-Nov-2020
Date of Web Publication3-Sep-2021

Correspondence Address:
Dr. Reem MZ Barakat
Department of Clinical Dental Sciences, College of Dentistry, Princess Nourah Bint Abdulrahman University, P.O. Box 84428, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sej.sej_246_20

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  Abstract 

Introduction: Knowledgeable and timely management of traumatic dental injuries (TDIs) plays a decisive role in their long-term prognosis. The aim of this study was to assess knowledge of managing traumatic tooth fracture of permanent teeth among endodontists and general practitioners (GPs) set in two different countries.
Materials and Methods: A two-part self-administered questionnaire assessing knowledge of traumatic tooth fracture management was distributed among 400 professionals in Saudi Arabia and the United Kingdom. The first part contained seven questions related to the participants' demographic data, and the second part included ten questions related to the management of trauma case scenarios focused on crown and root fracture. Data were statistically analyzed.
Results: One hundred and eighty-two individuals participated in this survey. Endodontists managed TDIs more frequently, and the mean number of their correct answers was significantly higher when compared with GPs (P = 0.004). Specialty was the constant predictor of level of knowledge (P = 0.001) excluding geographic location and frequency of treating TDIs.
Conclusion: The level of knowledge of the participants in both countries in managing traumatic tooth fracture was moderate. Correct answer score was influenced by having a specialty in endodontics. Dental professionals' perception of their knowledge did not reflect their objectively measured level.

Keywords: Crown fracture, crown-root fracture, knowledge, management, root fracture, traumatic dental injury


How to cite this article:
Almohareb RA, Barakat RM, Alrabiah AM, Alyabis AH, Bin Humeed AH, AlJurayyan HN, Alhefdhi MA, Kheir SA. Assessment of knowledge of traumatic tooth fracture management among endodontists and general practitioners in two different countries: A cross-sectional survey. Saudi Endod J 2021;11:375-82

How to cite this URL:
Almohareb RA, Barakat RM, Alrabiah AM, Alyabis AH, Bin Humeed AH, AlJurayyan HN, Alhefdhi MA, Kheir SA. Assessment of knowledge of traumatic tooth fracture management among endodontists and general practitioners in two different countries: A cross-sectional survey. Saudi Endod J [serial online] 2021 [cited 2021 Dec 4];11:375-82. Available from: https://www.saudiendodj.com/text.asp?2021/11/3/375/325402


  Introduction Top


Traumatic dental injuries (TDIs) are prevalent worldwide, ranking as the second most frequent oral disease after dental caries;[1] afflicting all too often the esthetic anterior teeth.[2],[3] Failure to provide appropriate treatment may result in undesirable esthetic and functional consequences along with financial implications, should advance restorative procedures be required.[4] Negative consequences may also extend to mental health, as untreated TDIs are associated with severe difficulty in chewing, making social contacts, and smiling, especially among juveniles, who are the most likely to suffer from dental trauma.[5]

This array of undesirable consequences can be prevented or minimized by providing knowledgeable and timely management. The International Association of Dental Traumatology (IADT) has proposed guidelines to assist dental professionals in that effect.[6]

TDI prevalence studies reported that crown fracture is the most common injury as far as permanent dentition is concerned.[6],[7],[8]

Managing tooth fracture resulting from dental trauma varies in complexity according to which tissue or group of tissues have been injured: enamel, dentin, pulp, and cementum. This highlights the importance of multidisciplinary knowledge in managing such cases.[9],[10] Although the majority of the general practitioners (GPs) express confidence in managing crown fractures and perceive themselves responsible for providing some form of emergency care before referring complicated cases, this treatment was reported to be poor,[11] unsatisfactory, or inappropriate in half the cases.[4]

Several studies have demonstrated inadequate knowledge among dental professionals in managing TDIs in general and traumatic tooth fracture injuries in particular.[9],[12],[13] They were always conducted within the limits of one geographical location.[2],[13],[14],[15],[16],[17],[18],[19] Some of these studies[18],[20],[21] showed that having a specialty, especially endodontics, has a positive influence on the level of knowledge of TDI management.[2],[22] Hence, the aim of this study was to assess knowledge of managing traumatic tooth fracture among endodontists and GPs set in Saudi Arabia and the United Kingdom (UK). It is hypothesized that having an endodontic specialty will influence the level of knowledge in managing tooth fractures, whereas the geographic location of the dental professional will not.


  Materials and Methods Top


A cross-sectional survey assessing knowledge of traumatic tooth fracture management among dental professionals was conducted in Saudi Arabia and the UK. Ethical approval had been obtained from Princess Nourah Bint Abdulrahman University (PNU) Institutional Review Board (#18-0189).

Sample size calculation was carried out by taking the total number of registered dentists in the UK General Dental Council[23] located in both England and Scotland, as well as those registered in the Saudi Commission for Health Specialties,[24] which totaled 53,000 dentists, a population variance of 50%, confidence level 0.05, and margin of error 7.5. The result was 171. However, due to the unpredictable response rate in such studies, the sample size was set at an achievable 400.

In the UK, randomly selected dental professionals were approached during two dental conferences held in London, England, and Edinburgh, Scotland, during July 2018, as well as during a dental meeting in one of London's dental colleges. After explaining the survey objective, those who expressed interest in participating were asked to provide their E-mail contact information, to which the online survey link was sent accordingly. The survey was also sent to dental professionals in randomly selected dental clinics in both cities.

The survey's self-administered questionnaire was first pilot tested on dental professionals at PNU, College of Dentistry, dental clinics. It consisted of two parts: the first part contained seven questions relating to the participants' demographic data, self-assessment of their dental trauma knowledge, and how frequently they treat trauma in permanent dentition. The second part included ten questions related to the management of trauma case scenarios focused on crown and root fracture.

Dental professionals were asked to choose one correct answer for each scenario. The correct answers were based on the IADT guidelines.[17],[19] A scale of knowledge was designed based on a score equal to the total number of correct answers. Scores that range from 0 to 3 were considered “poor knowledge,” while scores ranging from 4 to 7 and 8–10 were “moderate knowledge” and “excellent knowledge,” respectively.[17],[19]

Using SPSS software (IBM Corp., version 27.0, Chicago, IL, USA), descriptive data analysis was carried out to determine the distribution of demographic and professional characteristics. Participants were categorized based on specialty into endodontists and GPs. The mean difference of correct responses between the two categories was determined using independent t-test. Stepwise multiple regression analysis was used to determine the association between demographic and professional characteristics and the number of correct answers. Frequency of treating dental trauma according to specialty was analyzed using Chi-square test. Statistical significance was set at P < 0.05.


  Results Top


One hundred eighty-two individuals participated in this survey, setting the response rate at 45.5%. The ratio of endodontists to GPs was 1:4. Analysis of demographic and professional characteristics [Table 1] showed that the majority (70%) of the participants were below the age of 30 years and working in the governmental sector. There were a slightly higher number of male participants compared to females. The majority of the GPs were Saudi, while the majority of the participating endodontists were from the UK.
Table 1: Demographic and professional characteristics among endodontists and general practitioners

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The assessment of participants' knowledge in managing traumatic tooth fracture using different scenarios is summarized in [Table 2]. No participant was able to answer all the questions correctly. Endodontists arrived at the maximum number of correct answers of 8 out of 10. Although the mean scores for both endodontists and GPs were in the moderate range, knowledge of traumatic tooth fracture management was influenced by the participant having an endodontic specialty (P = 0.001). The distribution of correct answers according to specialty for each clinical scenario is shown in [Figure 1]. The mean number of correct answers among endodontists (5.46) was significantly higher than that among GPs (4.54) (P = 0.004).
Figure 1: Distribution of correct answers by endodontists and general practitioners for each clinical scenario about management of traumatic tooth fracture

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Table 2: Assessment of knowledge in managing traumatic tooth fracture using different scenarios, n (%)

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Regardless of the participants' specialty, the majority reported that they rarely treat TDIs. However, there was a statistically significant association between the frequency of TDI management and participants' specialty: management of TDIs was more frequent among endodontists (P = 0.009).

Although the majority of the endodontists had self-evaluated their knowledge as comprehensive, whereas GPs self-evaluated their knowledge as sufficient but incomplete, there was no significant association between the level of participants' knowledge based on self-evaluation and their actual knowledge as measured by the number of correct answers (P = 0.610) [Table 3].
Table 3: Univariate analysis of variance according to the number of correct answers out of 10

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Factors that had a significant association with objectively measured level of knowledge were: specialty, geographic location, and frequency of treating TDIs [Table 3]. Although the correlation between the score of correct answers and each of these factors was weakly positive (Pearson correlation coefficient: 0.254, 0.237, and 0.030, respectively), multiple regression placed specialty as the constant predictor excluding the other two factors [Table 4].
Table 4: Stepwise multiple regression model

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  Discussion Top


A unique element of this study is the diversity of participants, whether in nationality or geographic location, which translates into different dental training and working experiences and environments. However, the present findings showed that being located in the UK, having an endodontic specialty, and treating dental trauma more frequently were associated with better knowledge in managing tooth fracture due to trauma. The majority of the UK participants were endodontists, and the majority of those who reported frequently treating dental trauma were also endodontics, which explains that multiple regression placed specialty as the constant predictor of knowledge of management, excluding geographic location and frequency of treating dental trauma. The results thus support the hypothesis that having an endodontic specialty and not geographic location influences knowledge of traumatic tooth fracture management. However, future studies to corroborate these findings need to compare knowledge of dental trauma management between endodontists in different geographical locations.

Although no studies comparing different countries are currently available, the influence of having an endodontic specialty on knowledge of trauma management is in accordance with similar studies conducted in a single geographical area.[2],[22] A recent study, however, found that Turkish pediatric dentists had more knowledge than endodontists in management of avulsion.[21] While results from another study surveying dental professionals from Al Qassim area in Saudi Arabia showed that having a specialty (not necessarily in endodontics) influenced the level of knowledge in managing TDIs, this was not found in relation to questions on crown fractures.[18] Unlike the latter study, the scenarios related to crown fracture in the present study focused on management of mature teeth.

Endodontists in the present study reported more exposure to managing TDI cases compared to GPs. Lack of experience in treating dental trauma has been highlighted as an important determinant in acquisition of knowledge and self-confidence.[14],[19] Many studies had attributed poor knowledge to the infrequent exposure to treating TDIs,[14],[25],[26] while others reported that dental professionals who frequently managed TDIs showed higher levels of knowledge.[2],[17],[18],[22],[27] The present study initially found that frequent management of TDIs influenced the correct answer score, however, when other factors such as specialty were taken into consideration, frequent management was excluded as a factor associated with a higher level of knowledge. This is in accordance with other studies.[15],[20],[21]

The mean number of correct answers for endodontists and GPs corresponded to a moderate level of knowledge. Most studies evaluating knowledge of TDI management among dental professionals conducted in different parts of the world have also reported a similar level.[14],[17],[18],[21],[22]

In this study, participants were asked to self-evaluate their knowledge in managing TDIs. No association was found with objectively measured knowledge, which is in accordance with several studies,[19],[20],[28] but in contrast to other recent studies conducted among GPs and specialists, which found that those who evaluated their knowledge as comprehensive achieved the highest score.[21],[22] Unlike this study, however, the majority of the participants were either specialists or had a clinical postgraduate degree. Other studies found that self-evaluation of knowledge was related to the number of years since graduation[14],[25] or age.[17]

Some studies found that age or number of years since graduation also influenced the objectively measured level of knowledge. Young professionals who graduated <20 years ago or were <50 years old had better knowledge of managing TDIs.[19],[21],[22],[25],[29] This was not to be the case in the present study, which found that level of knowledge was not influenced by the age of participants. An explanation could be that 90% of the participants were below the age of 40. A previous study conducted in Brazil comparing endodontists and nonendodontists reported similar findings.[2]

The IADT guidelines concerning complicated crown fractures recommended preserving pulp vitality through pulp capping or partial pulpotomy, in the case of young patients with mature teeth. Although complete root canal treatment was the treatment of choice for older patients, the IADT guidelines did not rule out the possibility of using pulp vitality-preserving techniques.[6] Almost one-third of the endodontists in the present study and 80% of the GPs recommended the more invasive complete root canal treatment in the large complicated crown fracture scenario involving a young patient with a mature tooth. For the scenario concerning an older patient, with pinpoint exposure, 18.6% of the endodontists and almost a quarter of the GPs did not realize that pulp vitality-preserving procedures were applicable. Previous studies reported that GPs were unaware that pulp vitality-preserving procedures, especially partial pulpotomy, were an option for mature as well as immature teeth in case of complicated crown fractures.[14],[25]

At the time the survey was administered, the IADT guidelines' material of choice for pulp vitality-preserving procedures was calcium hydroxide.[6] This was revised in the 2020 guidelines which recommend using either calcium hydroxide or nonstaining calcium silicate cement.[30] Yet, the majority of the endodontists 74% and GPs 67% in this study had opted for using bioactive calcium silicate cement such as mineral trioxide aggregate (MTA) or Biodentine to preserve pulp vitality after complicated crown fracture. This tendency was corroborated in the answers to question no. 10, where most endodontists and GPs chose Biodentine over calcium hydroxide as the ideal material for direct pulp capping. Using MTA or Biodentine for direct pulp capping and pulpotomy procedures has achieved high success rates.[31],[32],[33],[34] Several studies found that these materials were superior to calcium hydroxide in preserving pulp vitality in young and older patients where pulp exposure was due to caries.[32],[35]

In the current study, the majority of the endodontists and GPs correctly managed uncomplicated crown fracture, which is in accordance with other studies.[9] The majority of the endodontists also managed crown-root fractures correctly in contrast to only half the GPs. This is in accordance with Hartmann et al.'s study.[22] Other studies, however, found that management of complicated and uncomplicated crown-root fractures is challenging for specialists or GPs.[9],[12],[20]

According to the IADT guidelines, the preferred treatment for horizontal root fractures is repositioning and splitting of fractured segments.[6] Participants in the present study performed poorly on questions related to root fracture. More than half of the GPs and 30% of the endodontists believed that the tooth must be extracted. Many studies have reported similar results,[14],[19],[22],[27] whereas Norwegian dental professionals showed good knowledge in this area of TDIs.[28] It is worth noting that a comparison between different studies may be difficult due to differences in their methodology.

The low response rate in this study may be comparable to response rates reported in studies of a similar nature,[4],[22] yet it poses as a limitation, as participants may be different from the nonrespondents. Unlike studies where questionnaires were distributed, filled, and collected on the spot during dental meetings, yielding a high response rate,[14],[17],[25] this study relied on participants replying at their own leisure to the survey link sent via E-mail. Procrastination or forgetfulness could easily compromise the efficacy of such a distribution methodology. Perhaps, using paper questionnaires that are later collected from the participants on an agreed-upon date may have yielded a higher response rate.[18] Other studies had also made a point of sending reminders,[4] which could have perhaps improved the response rate.

Another limitation is the study's focus on the most common of TDIs (fracture) without addressing the equally challenging avulsion and luxation injuries. More multigeographical location studies that address these matters need to be conducted. Future studies should also focus on exploring strategies to improve dental professionals' trauma management, for example, smartphone applications that provide evidence-based information to guide management of dental trauma emergencies that may present with little or no warning.


  Conclusion Top


Within the limitation of this study, endodontists and GPs in both Saudi Arabia and the UK revealed a moderate level of knowledge in managing traumatic tooth fracture. This highlights the need to improve dental training and education in management of traumatic tooth fracture, along with providing continuous educational courses that utilize the advancement in simulation to create structured hands-on training in dental trauma management targeting dental professionals. The number of correct answers was influenced by having a specialty in endodontics. Dental professionals' perception of their knowledge did not reflect their objectively measured level.

Financial support and sponsorship

This research was funded by the Deanship of Scientific Research at Princess Nourah Bint Abdulrahman University through the Fast-Track Research Funding Program.

Conflicts of interest

There are no conflicts of interest.

 
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