Knowledge and Awareness towards Emergency Management of Dental Trauma among the Teachers in Primary Schools in Syria: A Cross-Sectional Study

Objective The study aimed to assess teachers' knowledge in primary schools about the emergency management of dental trauma. and methods A cross-sectional study. A total of 560 teachers from different 28 primary schools in Damascus, Syria, participated in this study. The scale was adopted, where (1 mark) was given for correct answer, (0 marks) for answer I do not know, and (-1 mark) for wrong answer. Then, three levels of knowledge were considered. The Weak level was taken when the sum is less than one mark, the Intermediate level was taken when the sum is between two and four marks and nally and the Good level was taken when the sum is between 5 and 7.


Introduction
Dental Trauma is one of the most critical health problems in childhood that cause pain, distress, and dysfunction that accompanies injuries (1). Schools and homes are the most common places for hosting dental trauma injuries (2,3). School teachers are likely to be the rst to see a child immediately after an injury, and their sound knowledge about managing traumatic tooth avulsion is essential for effective dental treatment (1,4). Falls, sports, collisions, physical leisure activities, being struck by an object and tra c accidents are the commonly listed causes of traumatic dental injuries (5,6). Andreasen et al. (7) have found that the most traumatic injuries of permanent teeth occur in the age between 9-12 years. The knowledge of dental trauma management is of critical importance to decrease the consequences and improve the prognosis of dental trauma (1,8). The prognosis quite often depends on the child's parents and school teachers present at the accident site prior to referral to a dentist, who has a minor role if the optimal urgent care were not initiated in the location of the injury (9,10). Therefore, this study aimed to assess teachers' knowledge in primary schools about the emergency management of dental trauma.

Material & Methods
This study has a cross-sectional design. It was undertaken to assess the knowledge of teachers in public and private primary schools in Damascus in May 2021.
A total of 560 teachers from 28 primary schools were recruited. A self-administered anonymous, structured questionnaire was developed and distributed to teachers.
It contained 14 questions. The rst seven questions included demographic information (gender, age, years of teaching school type and previous knowledge about dental injuries)-other questions designed to assess knowledge about dental trauma.
A pilot study was conducted and distributed to 68 teachers in ve different schools, which have been selected randomly. The questionnaire was amended by deleting some of the questions following the pilot study results. Based on this pilot study, the sample size calculated for the study was 482 teachers who were considered su cient with 90% power with a two-sided alpha level of 5%.
The data entry and analysis were performed using Statistical Package for Social Sciences software package (SPSS Inc., Chicago, IL, USA) version 23. The survey was tested for reliability by using Cronbach's alpha test. Internal consistency of (0.702) was reported. Chi-square test was used to nd out the association of demographic variables with the level of knowledge regarding rst aid, and P < 0.05 was considered statistically signi cant.

Results
A total of 572 lled questionnaires, giving a response rate of 90.6%. After excluding questionnaires with missing entries in the rst section (demographics and background information), there were 560 for analysis. The statistics of the respondents' background information is shown in Table 1. The results were 87.5% of female and 37.1% males aged between 31 and 40 years. Moreover, 19.5% (109) had received previous medical rst-aid training, but only 3.8% (21) had received previous dental rst-aid training, and only 28.8% (161) had read or heard about dental injury information besides that from rst-aid training.
The distribution of responses to the questions is shown in Table 2. The correct answer(s) for each question were indicated.  The following scale was adopted, where (1 mark) was given for each correct answer, (0 marks) for each answer I do not know, and (-1 mark) for each wrong answer, because the current information is an essential and integrated information and any error in it means that it is hurting the patient rather than helping him. The sum is between -7 for those whose answers were all wrong and 7 for those whose answers were all correct.
Then, three levels of knowledge were considered. The weak level was taken when the sum was less than one mark, the Intermediate level was taken when the sum was between two and four marks, and nally, the Good level was taken when the sum was between 5 and 7. The results were as follows; Weak level 404 (72.2%), Intermediate level: 139 (24.8%) and the Good level: 17 (3%). Total scores are shown in Table  3. The mean and median total scores were positive, with values of 0.4982 and 1, respectively, which showed that the level of knowledge about dental injury treatment among teachers was insu cient. The demographic background (gender, age, number of years of teaching, and school type) did not affect the knowledge of dental injury management. Also, receiving medical and dental rst-aid training and reading or hearing about dental injury information did not affect the total score, and Table 4 shows the pvalue for those independent variables and the test used.

Discussion
The most signi cant age exposed to traumatic dental injuries is between 9 and 12 years (1,7). Teachers are closer to the children of those ages, so processing initial aid of the trauma improves the prognosis of the injury, and because of this, the primary schools were chosen (11,12). The names of public and private primary schools in Damascus were obtained from the Syrian Ministry of Education. Some schools were chosen randomly according to the socio-economic status of the area of schools. The best method was willing to respond to the self-administered anonymous, structured questionnaire.
The concentration was on the effects of gender, age, years of teaching, school type, received medical and dental rst-aid training and if they read or heard about dental injury information about dental trauma with their knowledge.
Many similar studies published in many countries have found, including China(13), Jordan (14), Brazil (15) and some other countries (4), and the results were considered similar to our study, which showed a vast lack of knowledge about how to manage dental trauma.
The ratio of teachers who received medical rst-aid training was only 19.5% (109 teachers). Compared with the studies conducted in China (13) and Jordan (14), their ratios were 50% and 46, respectively. That indicates a lack of guidance teachers in Damascus about a course in the medical rst-aid training.
In this study, the total of teachers who received dental rst-aid training was only 3.8% (21) which was similar to results obtained from other studies (13,14). That indicated the presence of a signi cant lack of awareness of the necessity of dental trauma courses and perhaps because of a lack of its presence. There are several attempts to raise dental trauma awareness in primary schools in Syria, aiming to promote and spread awareness of dental trauma for students and not for teachers (16).
When comparing the changes in the level of knowledge with if they received medical and dental rst-aid training, it did not show any signi cant change in the level of knowledge.
This study revealed that those teachers who have equipped themselves with some information about dental trauma were only 161 (8.28%), and there is no signi cant association with the level of knowledge.
Usually, the dentist is considered responsible for handling dental trauma cases. When the question which referred to the best place to receive appropriate treatment was asked, the percentage of teachers who selected option (c. At the nearest dentist) was 52.5% (294). This percentage has agreed with several previous studies (4,(13)(14)(15).
Preferably, traumatic dental injuries treat immediately to improve the prognosis (1,5), so when we asked about the best time for treatment, the high percentage, 72% (403 teachers), was to the option (a. immediately), and this is a good percentage. It is very close to the ratio of choosing the correct answer at Young, 74.7% (13).
Nevertheless, when exposed to the fractured tooth, the appropriate measure is (c. Put it in a liquid and bring it for examination and treatment.) (5,17), and the percentage of those who chose it was 31.4% (176). The option, which has obtained the highest percentage, was (b. Try to nd the fractured piece, wrap it with gauze or tissue and bring it for examination and treatment) and it was 37.9% (212). This measure is wrong as it inevitably must remain wet (5,17).
Regarding how appropriate dental management is when changing the place of tooth and localization, the correct answer (b. Try to put back to the original position) was 18% (101), and it was a low ratio.
Nonetheless, the answer with the highest percentage was (a. Do not touch, let it remain in its new position), by 44.3% (248); it is the wrong choice.
Temporary teeth cannot be planted if deposed (5,17), so when we asked the question about the possibility to replant the temporary tooth after deposing it, the highest percentage of answers was (b. No) by 75.2% (421); this is correct, and this is consistent with previous studies (13)(14)(15).
However, the permanent teeth can be replanted after deposing them (5,17). The ratio of the option (a. Yes) was 48.6% (272 teachers); this differs from other studies where the percentage of the correct answer were 16.2% (13) and 22.7% (15).
The preferred liquid for putting the deposed tooth in it is HBSS, a commonly used uid in stadiums and the preferred liquid then milk and saline; they save the tooth for a while two hours and then saliva, where he saves the age for half an hour (5,17). The last question was about the importance of placing the tooth in the uid. There were three right choices are (c. put the tooth in saline), and its percentage was 7% (39 teachers), and (d. Put the tooth in milk), its percentage was 2.7% (15 teachers), and (e. Puts the tooth in the patient's saliva), his choice rate is 3.9%. (22 teachers), while those who chose both options (c and d) were 0.4% (2 teachers), and that is not similar to studies (1,8,13,14).
The results of this study showed a low knowledge level in the dental trauma management in Damascus, perhaps due to a low number of teachers who have done the dental rst-aid due to the non-proliferation of such medical courses or because of the absence of this emergency dental information within the paramedics' general courses and lack of attention to matters of dental trauma in their programs.

Conclusion
Primary school teachers' knowledge about dental trauma within Damascus is de cient. This study highlighted on the reality of knowledge of teachers in primary schools and will bene t decision-makers to design an educational course for dental trauma in Syria.

Limitations
The questions focused mainly on the basic information in the management of dental trauma, and we did not address the secondary information, which is less important.