This study intended to evaluate the attitude and knowledge on traumatic dental injuries among family physicians who provide the most far-reaching and rapidly accessible healthcare services to Turkish population. Since it is not possible for people residing in the rural parts of our country to have access to dental care services in emergency situations, medical doctors are expected to take action in the event of a TDI (19).
It has been previously reported that education provided in medical schools in Turkey does not specifically cover TDI (17). Based on our findings, 20.9% of the family physicians received education on TDI in medical schools but 86% stated that their knowledge of TDI was insufficient. The percentage of family physicians who received education on TDI is higher than those reported in literature but low in terms of overall education level (3.4-9.8%) (22, 23). The low rates of education and personal competence regarding TDI may be related to insufficient coverage of dental practices in medical education and the belief that dentists are totally responsible for dental problems.
Outside the working hours of dental professionals or when access to dental care is not possible, individuals experiencing a TDI present to family health centers which are the healthcare facilities that can be accessed quickly. Some investigators have stated that hospitals and emergency departments do not have a written protocol for TDI or attend to specific cases only (14, 24). As mentioned earlier, the low level of education on TDI coupled with the absence of treatment and referral protocols in place in medical facilities poses problems in terms of TDI treatment and management.
In the present study, family physicians were shown photos of 2 cases (Figure 1, 2) involving an avulsed tooth and an enamel-dentin fracture which are among the most prevalent TDIs occurring in our region and their responses were reviewed (25). 53.5% of the physicians stated that they have come across a TDI patient at least once in their practice. While Kumar et al. and Subhashraj reported that 37.2% and 24% of physicians had come across avulsion cases respectively (18, 26), Bahammam et al. and Aren et al. reported that 59% and 55.6% of emergency care physicians had seen patients with TDI (19, 20). Nikoliç et al. and Chanchala et al. found that 95% and 65% of pediatricians had come across a case of TDI at least once in their practices (15, 21). Emergency departments are the first places to go in the case of a trauma or an accident and this may explain why emergency care physicians encounter with TDI patients more frequently than family physicians. The reason behind higher rate of encounter with TDI among pediatricians than in surveyed family physicians might be that pediatricians take care for children only and come across with a larger number of cases.
Several studies published in literature reported that a vast majority of physicians (86%-100%) thought that undergraduate or postgraduate courses about TDI should be provided in medical schools and were willing to receive training in the management of TDI (15, 18, 21). In line with these data, 74.4% of surveyed family physicians considered that medical schools should provide educational courses on TDI.
In our study, 46.5% of the family physicians have previously heard about the term avulsion and its management. The corresponding figures were 88% among pediatricians (21), 43.2% in medical doctors (26) and 52.5% among emergency care physicians (20). The findings that 53.5% of the family physicians encountered with at least one patient presenting with a traumatic dental injury and only 46% of them have previously heard about the term avulsion suggest that TDI patients may be exposed to incorrect treatment or instructions.
Nikoliç et al. found that 81% of the pediatricians surveyed would replant avulsed permanent teeth (21). When emergency care physicians were asked whether it is possible to replant permanent teeth, correct response rates varied between 12.7% and 79.5% (19, 20). In our study, 16.3% of the family physicians said they would replant avulsed teeth into their sockets. Higher rates of reimplantation as reported among pediatricians and emergency care physicians may be related to the fact that they are more likely to attend to such cases due to aforementioned reasons and thus, they may have greater experience in managing traumatic dental injuries.
For the case of avulsed permanent tooth in an 11-year-old child presented in Figure 1, 67.4% of the physicians correctly identified it as a permanent tooth. However, 9.3% of the physicians thought that the avulsed tooth was a primary tooth and 23.3% had no idea. In Turkey, tooth anatomy is covered in medical school curriculum. The finding that 32.6% of the physicians failed to give the correct answer suggests that the issues of tooth development and anatomy in medical school are not considered sufficiently.
The use of a correct transport medium for the transfer process is important to preserve viability of the tooth and periodontal tissues if immediate reimplantation of the tooth is not possible (27, 28). In the question where we asked the family physicians about the storage medium of avulsed tooth before referral to a dentist, 44.4% of the responses were among recommended storage media (milk, saline solution and child’s saliva) (13). This percentage is similar to those reported by Bahammam et al. and Subhashraj from their studies involving medical doctors (52.4% and 40%, respectively) but lower than that reported by Nikoliç et al. (74%) (18, 20, 21).
Another factor that is critical for the treatment and prognosis in avulsion cases is the extra-oral dry time (28, 29). Bahammam et al. reported that 48.4% of the physicians were not aware of the importance of extra-oral time. Similarly, 55.8% of the physicians did not have correct information about extra-oral dry time. Periodontal ligament cells cannot survive if avulsed teeth are not replanted within the first 60 minutes after injury and the prognosis will be poor even if they had been replanted (13). Therefore, avulsed teeth should be replanted as soon as possible to maintain viability of the periodontal cells and for a better prognosis. If the tooth cannot be replanted immediately, it should be placed in a suitable transport medium and replanted without further delay (20, 23).
When encountered with an avulsed permanent tooth such as the one shown in Figure 1, 7.5% of the physicians said they did not know what to do in that case. Only 5.7% of them stated that they would replant the tooth into its socket and refer the patient to a dental professional immediately. Our findings are consistent with those in former studies where most of the physicians said they would refer the patient to a dentist without any immediate intervention (20, 30). The low rate of correct responses suggest that physicians have a poor knowledge of reimplantation and thus, low self-confidence in this area.
In our study, 79.1% of the family physicians said they would advise the patient to bring fragments of fractured tooth to a dentist (Figure 2). Today’s adhesives and composite materials can be used successfully in the treatment of crown fractures caused by trauma. Preservation of fragments both facilitates dentist’s work and provides improved aesthetic outcomes after treatment (31–33).
Our cross-sectional questionnaire study was conducted with family physicians working in only one of 81 cities in Turkey. This precludes extrapolation of the study findings to the population of family physicians all over Turkey. Further studies involving a larger sample of physicians from various districts can improve comprehensiveness of the research.