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ORIGINAL ARTICLE Knowledge of Dentists in the Management of Traumatic Dental Injuries in Ankara, Turkey Çaùdaü Çınara/D...

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ORIGINAL ARTICLE

Knowledge of Dentists in the Management of Traumatic Dental Injuries in Ankara, Turkey Çaùdaü Çınara/Didem Atabekb/Alev Alaçamc Purpose: This study was designed to assess dentists’ knowledge of emergency treatment of traumatic dental injuries (TDIs) in Ankara, Turkey. Materials and Methods: A total of 154 questionnaires were evaluated. The first part of the questionnaire consisted of questions regarding personal information. The second part was composed of 12 closed-ended questions related to knowledge of how to manage different types of TDIs in children. The questionnaires were answered by 133 general dental practitioners (GDPs) and 21 specialists. The survey data were statistically analysed using the chi-square test and ttest to assess dentists’ knowledge. Results: The results show that when the answers were compared, lower numbers of correct answers were noted for questions related to splinting time for avulsed teeth and appropriate treatment for complicated crown-fractured deciduous incisors with large pulp exposure. Greater numbers of correct answers were observed for questions related to the storage medium, systemic antibiotic usage for avulsed teeth and appropriate treatment for intruded primary teeth. The mean number of correct answers from specialists was not significantly greater than that from GDPs (P > 0.05). Conclusion: In conclusion, this survey showed a low level of knowledge of TDI management among the participants and highlights the need to improve dentists’ knowledge of TDI treatment protocols. Key words: attitudes, dental trauma, dentists, emergency treatment, knowledge Oral Health Prev Dent 2013; 11: 23-30

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raumatic dental injuries (TDIs) in children and adolescents are a common problem (Westphalen et al, 2007; dos Santos and Souza, 2009). Approximately 50% of schoolchildren experience dental trauma prior to leaving school (Andreasen and Andreasen, 1990). Patients suffering from TDIs are affected both physically and psychologically. Having a TDI is a bad experience for both children and their parents, who are more distressed about the aesthetic aspects than the symptomatic aspects of the problem (Garcia-Godoy and Garcia-Godoy, 1989; Zuhal et al, 2005). Thus, knowledge of the appropri-

a

Assistant Professor, Department of Pediatric Dentistry, Faculty of Dentistry, University of Gazi, Ankara, Turkey.

b

Research Assistant, Department of Pediatric Dentistry, Faculty of Dentistry, University of Gazi, Ankara, Turkey.

c

Professor, Department of Pediatric Dentistry, Faculty of Dentistry, University of Gazi, Ankara, Turkey.

Correspondence: Dr Çaùdaü Çınar, Gazi Üniversitesi, Diühekimliùi Fakültesi, Pedodonti Anabilim Dalı, Biükek Cad. 82. Sok, 06510 Emek-Ankara, Turkey. Tel: +90-312-212-6220/366, Fax: +90-312223-9226. Email: [email protected]

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Submitted for publication: 04.01.12; accepted for publication: 16.05.12

ate treatments of TDIs can reduce stress and anxiety in patients, their parents and dentists as well as improve case prognoses (de Vasconcellos et al, 2009; Pedrini et al, 2011). The general consensus on TDI management is that patients should go directly to a hospital and be evaluated by a local dentist (Westphalen et al, 2007). In Ankara, a full-time dentist is usually available at the dental centre to provide emergency service. As treatment is generally administered by general dental practitioners (GDPs) and specialists in such centres, patients and their parents prefer such centres for emergency treatment. Thus, the knowledge and skills of oral health professionals working in emergency clinics are critical in the management of trauma in young patients (Kostopoulou and Duggal, 2005). Several surveys have been conducted to assess the knowledge of dentists regarding the management of TDIs, and they demonstrated an inadequate knowledge of dental trauma diagnosis and treatment among the surveyed dentists (Hamilton et al, 1997; Kostopoulou and Duggal, 2005; Krastl

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et al, 2009; Zhao and Gong, 2010). However, there are no published data on this subject regarding Turkish dentists. The purpose of this study was to examine dentists’ knowledge of emergency management in dental centres equipped with emergency clinics in Ankara, Turkey.

MATERIALS AND METHODS Participants in this study consisted of 154 dentists who served in dental centres equipped with emergency clinics in Ankara. Questionnaires were administrated to the participants by the authors and then collected. Participation was voluntary, and confidentiality was assured. The questionnaire was divided into two parts. The first part consisted of questions regarding personal information, such as age, gender, year of graduation and educational level (GDP or specialist). The second part was composed of 12 closedended (multiple-choice) questions (Appendix 1) related to knowledge of how to manage different types of TDIs to primary and permanent incisors in children. The questions were associated with the following topics (Kostopoulou and Duggal, 2005): r emergency management of intrusive and extrusive luxation injury r emergency management of complicated crown fractures of permanent incisors in young patients with immature teeth (with pinpoint pulp exposure or large pulp exposure after an elapsed period of 24 h) and mature teeth (with large pulp exposure after an elapsed period of 24 h) r avulsion injuries (best storage media, tooth management prior to re-implantation, duration of the splinting period required for re-implanted incisors, and systemic or local medication usage). The correct answers were determined based on evidence from current dental trauma guidelines and books (Cvek, 1994; Trope, 2002; Flores et al, 2007a; Flores et al, 2007b; Flores et al, 2007c). The data were entered into an SPSS for Windows, version 11.5 (SPSS; Chicago, IL, USA) database and analysed using a chi-square test and t-test for each question. The results of the analyses were expressed as percentages. The level of confidence was set at P < 0.05.

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RESULTS Demographic distribution of participants Questionnaires were completed by 154 dentists, 133 of whom were GDPs and 21 of whom were specialists. The age, gender and year of graduation of the dentists who participated in the study are summarised in Table 1. The age of the dentists varied from 22 to 60 years; the largest age group was 33 to 60 years (54.5%). There were 60 (39%) male and 94 (61%) female participants in the study. There was no statistically significant difference between the mean numbers of correct responses from the male and female participants (P > 0.05). The year of graduation from dental school ranged from 1976 to 2010. Among the study participants, 13.6% were specialists and 86.4% were GDPs. There were no significant differences between the educational levels of GDPs and specialists participating in this study (P > 0.05).

Emergency management of luxation injury The majority of the dentists (76%) responded that they would leave the intruded primary teeth to reerupt (Fig 1), while 55.2% of the dentists responded that they would allow spontaneous re-eruption of an intruded, immature, permanent incisor (Fig 2). For extrusive luxation injury to permanent teeth, half of the dentists (50%) preferred immediate repositioning, treatment with a flexible splint for 2 weeks and root canal treatment if pulp necrosis

Table 1 Demographic characteristics of participants (n = 154) GDPs

Specialists

Number

22–32

66

4

70

33–60

67

17

84

Male

53

7

60

Female

80

14

94

1976–1999

60

10

70

2000–2010

73

11

84

Age

Gender

Year of graduation

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had occurred. Although 48.7% of the dentists preferred a semi-rigid, nylon wire splint, 11.7% preferred a splint with stainless steel wire for extrusive luxation injuries (Fig 3).

80 70 60 50

Emergency management of complicated crown fracture injury More than two-thirds (68.8%) of the dentists in the study responded that they would carry out pulp capping for a complicated crown-fractured incisor with recent, minimal exposure and an open apex. A total of 32.5% preferred to perform partial pulpotomy for a complicated crown-fractured incisor with a large exposure area and open apex after 24 h had elapsed after the trauma. Altogether, 81.2% would perform root canal treatment after 24 h had elapsed between trauma and treatment of a complicated crown-fractured incisor with a large exposure area and closed apex (Table 2).

%

40 30 20 10 0

spontaneous repositioning

extraction

do not know

Fig 1    Percentage distribution of dentists’ answers about emergency management of intruded primary teeth.

80 70 60 50

Emergency management of avulsion injury %

The results of the responses to questions related to avulsion injury are summarised in Table 3. The percentage of dentists who demonstrated knowledge of the best storage medium for avulsed teeth was very high. More than half of the dentists (63%) responded that the tooth should be kept in milk, whereas the remaining 37% chose the patient’s mouth. With regard to the preparation of the root, 39.6% of the dentists preferred to soak the avulsed tooth in doxycycline for 5 min and rinse the debris from it before replantation. Less than half of the dentists (45.5%) believed that the appropriate splint time for replanted incisors should be 2 weeks. Nearly all of the dentists (94.8%) said they would prescribe antibiotics in avulsion cases. With regard to replantation of an avulsed primary tooth, 70.8% correctly responded that dentists should not replant such a tooth, while 29.2% responded that dentists should replant such a tooth. There were no significant differences in the answers to any of questions between the GDPs and the specialists (P > 0.05).

40 30 20 10 0

spontaneous orthodontic surgical repositioning repositioning repositioning

extraction

Fig 2    Percentage distribution of dentists’ answers about emergency management of intruded permanent incisors with open apex.

80 70 60 50 %

40 30 20 10 0

DISCUSSION As TDIs in children can create long-term threats to dental health, it is important that those suffering

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semi-rigid with stainless nylon wire steel wire

composite resin

other

Fig 3    Percentage distribution of dentists’ answers about splint type of extruded permanent incisors.

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Table 2 Distribution of dentists’ answers about emergency management of complicated crown-fractured incisors Open apex, pinpoint exposure

Complicated crown fracture

Open apex, large exposure (>24 h)

Closed apex, large exposure (>24 h)

N

%

N

%

N

%

Do not treat but follow up

10

6.5

8

5.2

5

3.2

Pulp capping

106

68.8

9

5.9

3

2

Partial pulpotomy

19

12.3

50

32.5

1

0.7

Cervical pulpotomy

9

5.9

34

22

15

9.7

Pulpectomy

7

4.5

47

30.5

125

81.2

Do not know

3

2

6

3.9

5

3.2

Correct answers are written in italics.

Table 3 Percentage distribution of dentists’ answers about emergency management of tooth avulsion

Best storage medium

Tooth management before replantation (open apex, 60 min)

Systemic antibiotic usage

Response

%

Ice

0

Tap water

0

Paper tissue

0

Fresh milk

63

Patient’s mouth

37

Rinsed with tap water

9.9

Cleaned with any type of solution

17.5

Left unwashed

9.7

Kept in doxycycline for 5 minutes

39.6

Scrubbed gently

2.6

Kept in fluoride solution for 20 minutes

14.9

Do not know

5.8

No splint

3.9

2 weeks

45.5

4 weeks

31.2

2 months

9.1

24 hours

3.2

Do not know

7.1

Tetracycline (>12 years old)

58.4

Penicillin

36.4

No

5.2

Yes

29.2

No

70.8

Replantation of primary teeth Correct answers are written in italics.

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from dental trauma receive effective emergency and appropriate follow-up treatment. Westphalen et al (2007) stated that the prognosis of traumatised teeth depends on prompt and appropriate treatment, which in turn is influenced by dentists’ knowledge of this field (Zhao and Gong, 2010). Dentists who are familiar with TDIs, know how to handle trauma cases and have knowledge ranging from emergency care to the most suitable clinical protocols according to treatment guidelines are usually associated with favourable prognoses (Pedrini et al, 2011). Intrusive luxation occurs when the tooth is displaced axially into the alveolar bone. The management of traumatic injuries to primary teeth differs from that used for traumatic injuries to permanent teeth. Traumatic injuries to primary teeth must be treated not only for aesthetic and functional reasons but also because they might affect the successors’ developing germs (Carvalho et al, 2010). In the present study, 76% of the dentists said they would leave intrusively luxated primary teeth for spontaneous repositioning if an intruded primary tooth apex was displaced towards the labial bone plate, whereas 11.7% of the dentists stated they would immediately extract traumatised primary teeth. Different approaches have been suggested for the management of intruded permanent incisors, such as spontaneous re-eruption, orthodontic extrusion and surgical repositioning. Spontaneous reeruption has been suggested for immature teeth (Oulis et al, 1996; Flores et al, 2007a; Medeiros and Mucha, 2009). In the present study, 55.2% of the participants agreed that an intruded incisor should be allowed to re-erupt spontaneously. The

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remaining 35% stated they would prefer orthodontic and surgical repositioning for intruded incisors with open apices. There was no significant difference between the responses of GDPs and specialists regarding luxation injuries (P > 0.05). According to these findings, the participants’ knowledge of the emergency treatment of intruded permanent incisor injuries was unsatisfactory. As the extrusive luxation of permanent teeth generally damages both the pulp and periodontal ligament (PDL), appropriate emergency treatment and optimal repositioning of the traumatised tooth is important for PDL healing and pulp revascularisation (Yeng and Parashos, 2008). In the present study, in cases of emergency treatment of extrusive luxation injury to mature permanent incisors, 50% of the dentists stated they would immediately perform corrective repositioning and provide flexible splints. Additionally, dentists stated they would perform endodontic treatment if pulp necrosis was present. Yeng and Parashos (2008) reported that in their survey, 47% of the dentists responded that they would base their decision more frequently on the result of a pulp test for extrusive and lateral injuries. The present study found that dentists’ knowledge of this emergency treatment was insufficient. Complicated crown fracture is a type of dental trauma involving enamel, dentine and pulp exposure (Flores et al, 2007a). The prognosis of complicated crown fracture appears to depend on the extent to which pulp is exposed and the stage of root development at the time of injury (Andreasen and Andreasen, 2000). In mature and immature permanent teeth, if the amount of pulp exposure is small and treated within 24 h, pulp capping has been suggested as the preferred treatment choice. A partial pulpotomy is indicated if the amount of pulp exposure is large, the pulp has been open to bacterial contamination or too much time has elapsed after the injury (Ravn, 1982; Olsburgh et al, 2002; Flores et al, 2007a; Yeng and Parashos, 2008). In the present study, 68.8% of the dentists preferred pulp capping to pinpoint pulp exposure of an immature, complicated crown-fractured incisor. In contrast, 12.3% of the dentists preferred partial pulpotomy, and 32.5% preferred partial pulpotomy as the treatment of choice for immature, complicated, crown-fractured incisors with old, large pulp exposure. Pulpectomy should be the treatment of choice to preserve the tooth if the pulp becomes necrotic in cases of complicated crown-fractured incisors with complete root formation (Flores et al, 2007a).

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In the present study, the majority of dentists (81.2%) stated that they would immediately perform root canal treatment for this type of injury if there were closed apices, large exposures, and if too much time had elapsed between the accident and the treatment. Yeng and Parashos (2008) reported that 48% of the dentists preferred direct pulp capping, while 38% preferred partial pulpotomy; and 54% would perform endodontic treatment. Kostopoulu and Duggal (2005) found that 93% of GDPs would perform pulp capping for a complicated crown fractured incisor with recent, minimal exposure and an open apex, and 78% of the participants would perform pulpotomy for a complicated crown fractured incisor with an old, large exposure and an open apex. Avulsion is the complete displacement of a tooth from its socket (Andreasen and Andreasen, 2007). The prognosis of avulsed teeth depends on whether appropriate emergency management procedures were performed (Andersson and Bodin, 1990). Immediate replantation is the most appropriate treatment for avulsed teeth. When immediate replantation is not possible, the use of an appropriate storage medium, extra-alveolar time and the management of avulsed teeth are important for longterm successful results. Several studies have identified the efficacy of milk in maintaining PDL cell viability, according to which it has been suggested as a suitable medium (Blomlof and Otteskog, 1980; Pearson et al, 2003; Souza et al, 2010). Saliva is not considered as an appropriate storage medium for avulsion injury because of its hypotonicity and presence of bacteria (Blomlof et al, 1981; Malhotra, 2011). More than half (63%) of the study participants preferred milk as a storage medium for an avulsed tooth. In contrast, 37% of the dentists in the present study chose the patient’s mouth as the storage medium. Cohenca et al (2006) reported that 53.6% of their participants identified milk and 30% specified the patient’s mouth as the proper storage medium for avulsed teeth. Similar to the present findings, Kostopoulou and Duggal (2005) reported that 60% of GDPs knew that milk was the best storage medium, while 38% of the respondents preferred the child’s mouth. Doxycycline has anti-bacterial and anti-inflammatory effects. Its use in the replantation procedure could improve the prognosis and enhance revascularisation of avulsed teeth with open apices (Trope, 2002; Flores et al, 2007b). In their report, Shaul et al (2009) stated that the use of root conditioning with doxycycline solution in closed-apex avulsed teeth resulted in

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complete healing at 16 months after tooth replantation. In the present study, 39.6% of the dentists stated they would place the avulsed teeth with open apices in a doxycycline solution. In general, dental splinting is needed to stabilise re-implanted avulsed teeth. The International Association of Dental Traumatology (IADT) recommends flexible splinting (4 weeks) for avulsed teeth with closed apices if the extra-oral dry time is longer than 60 min (Flores et al, 2007b). In the present study, 31.2% of the dentists chose the correct answer. This finding is in agreement with a study by Westphalen et al (2007), who reported that 38% of dentists preferred a 4-week splinting period. These findings may indicate a deficiency in knowledge related to avulsion injuries. In the present study, nearly all dentists (94.8%) prescribed antibiotics in cases of avulsion injury. The IADT recommends the administration of systemic antibiotics, such as penicillin V and doxycycline (Flores et al, 2007b). Systemic antibiotics given at the time of replantation are effective in preventing bacterial invasion of the necrotic pulp and subsequent inflammatory resorption (Hammarstrom et al, 1986; Trope, 2002). Tetracycline has the additional effect of decreasing root resorption by affecting the motility of osteoclasts and reducing the activity of collagenase (Sae-Lim et al, 1998; Trope, 2002). In the present study, a relatively high proportion of answers were correct regarding the appropriate storage medium, systemic antibiotic usage for avulsed teeth and the appropriate treatment of intruded primary teeth. However, the completed questionnaires showed that both specialists and GDPs had insufficient knowledge of appropriate emergency treatment of TDIs. Thus, this study confirmed the low level of knowledge of dentists regarding the management of TDI that was also reported in other studies (Hamilton et al, 1997; Kostopoulou and Duggal, 2005; Hu et al, 2006; Traebert et al, 2009). The correct management of TDIs by dentists would lead to better long-term prognoses. There were several limitations of the present study. One limitation was that the correct answers obtained from specialists were not examined according to the specialists’ areas of expertise. Another limitation was the low sample size of the study. More centralised studies should be conducted to evaluate dentists separately.

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Within the limitations of the study, it was concluded that there is a need to improve the knowledge of current guidelines for the emergency management of TDIs among dentists serving in emergency clinics.

REFERENCES 1. Andersson L, Bodin I. Avulsed human teeth replanted within 15 minutes – a long-term clinical follow-up study. Endod Dent Traumatol 1990;6:37–42. 2. Andreasen JO, Andreasen FM. Dental traumatology: quo vadis. Endod Dent Traumatology 1990;6:78–80. 3. Andreasen JO, Andreasen FM. Essentials of Ttraumatic Injuries to the Teeth, ed 2. Copenhagen, Denmark: Munksgaard and Mosby, 2000. 4. Andreasen JO, Andreasen FM. Textbook and Color Atlas of Traumatic Injuries to the Teeth. Copenhagen: Blackwell Munksgaard, 2007. 5. Blomlof L, Otteskog P. Viability of human periodontal ligament cells after storage in milk or saliva. Scand J Dent Res 1980;88:436–440. 6. Blomlof L, Otteskog P, Hammarstrom L. Effect of storage in media with different ion strengths and osmolalities on human periodontal ligament cells. Scand J Dent Res 1981;89:180–187. 7. Carvalho V, Jacomo DR, Campos V. Frequency of intrusive luxation in deciduous teeth and its effects. Dent Traumatol 2010;26:304–307. 8. Cohenca N, Forrest JL, Rotstein I. Knowledge of oral health professionals of treatment of avulsed teeth. Dent Traumatol 2006;22:296–301. 9. Cvek M. Endodontic management of traumatised teeth. In: Andreasen JO, Andreasen FM (eds). Textbook and Colour Atlas of Traumatic Injuries of the Teeth. Copenhagen: Munksgaard, 1994:517–578. 10. de Vasconcellos LG, Brentel AS, Vanderlei AD, de Vasconcellos LM, Valera MC, de Araujo MA. Knowledge of general dentists in the current guidelines for emergency treatment of avulsed teeth and dental trauma prevention. Dent Traumatol 2009;25:578–583. 11. dos Santos MT, Souza CB. Traumatic dental injuries in individuals with cerebral palsy. Dent Traumatol 2009;25: 290–294. 12. Flores MT, Andersson L, Andreasen JO, et al. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Dent Traumatol 2007a;23:66–71. 13. Flores MT, Andersson L, Andreasen JO, et al. Guidelines for the management of traumatic dental injuries. II. Avulsion of permanent teeth. Dent Traumatol 2007b;23:130–136. 14. Flores MT, Malmgren B, Andersson L, et al. Guidelines for the management of traumatic dental injuries. III. Primary teeth. Dent Traumatol 2007c;23:196–202. 15. Garcia-Godoy F, Garcia-Godoy FM. Reasons for seeking treatment after traumatic dental injuries. Endod Dent Traumatol 1989;5:180–181. 16. Hamilton FA, Hill FJ, Holloway PJ. An investigation of dentoalveolar trauma and its treatment in an adolescent population. Part 2: Dentists’ knowledge of management methods and their perceptions of barriers to providing care. Br Dent J 1997;182:129–133.

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Çınar et al 17. Hammarstrom L, Pierce A, Blomlof L, Feiglin B, Lindskog S. Tooth avulsion and replantation – a review. Endod Dent Traumatol 1986;2:1–8. 18. Hu LW, Prisco CR, Bombana AC. Knowledge of Brazilian general dentists and endodontists about the emergency management of dento-alveolar trauma. Dent Traumatol 2006;22:113–117. 19. Kostopoulou MN, Duggal MS. A study into dentists’ knowledge of the treatment of traumatic injuries to young permanent incisors. Int J Paediatr Dent 2005;15:10–19. 20. Krastl G, Filippi A, Weiger R. German general dentists’ knowledge of dental trauma. Dent Traumatol 2009;25:88–91. 21. Malhotra N. Current developments in interim transport (storage) media in dentistry: an update. Br Dent J 2011;211:29–33. 22. Medeiros RB, Mucha JN. Immediate vs late orthodontic extrusion of traumatically intruded teeth. Dent Traumatol 2009;25:380–385. 23. Olsburgh S, Jacoby T, Krejci I. Crown fractures in the permanent dentition: pulpal and restorative considerations. Dent Traumatol 2002;18:103–115. 24. Oulis C, Vadiakas G, Siskos G. Management of intrusive luxation injuries. Endod Dent Traumatol 1996;12:113–119. 25. Pearson RM, Liewehr FR, West LA, Patton WR, McPherson JC, 3rd, Runner RR. Human periodontal ligament cell viability in milk and milk substitutes. J Endod 2003;29:184–186. 26. Pedrini D, Panzarini SR, Poi WR, Sundefeld ML, Tiveron AR. Dentists’ level of knowledge of the treatment plans for periodontal ligament injuries after dentoalveolar trauma. Braz Oral Res 2011;25:307–313. 27. Ravn JJ. Follow-up study of permanent incisors with complicated crown fractures after acute trauma. Scand J Dent Res 1982;90:363-372. 28. Sae-Lim V, Wang CY, Choi GW, Trope M. The effect of systemic tetracycline on resorption of dried replanted dogs’ teeth. Endod Dent Traumatol 1998;14:127–132. 29. Shaul L, Omri E, Zuckerman O, Imad Ael N. Root surface conditioning in closed apex avulsed teeth: a clinical concept and case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:e125–128. 30. Souza BD, Luckemeyer DD, Felippe WT, Simoes CM, Felippe MC. Effect of temperature and storage media on human periodontal ligament fibroblast viability. Dent Traumatol 2010;26:271–275. 31. Traebert J, Traiano ML, Armenio R, Barbieri DB, de Lacerda JT, Marcenes W. Knowledge of lay people and dentists in emergency management of dental trauma. Dent Traumatol 2009;25:277–283. 32. Trope M. Clinical management of the avulsed tooth: present strategies and future directions. Dent Traumatol 2002;18:1–11. 33. Westphalen VP, Martins WD, Deonizio MD, da Silva Neto UX, da Cunha CB, Fariniuk LF. Knowledge of general practitioners dentists about the emergency management of dental avulsion in Curitiba, Brazil. Dent Traumatol 2007;23:6–8. 34. Yeng T, Parashos P. An investigation into dentists’ management methods of dental trauma to maxillary permanent incisors in Victoria, Australia. Dent Traumatol 2008;24:443–448. 35. Zhao Y, Gong Y. Knowledge of emergency management of avulsed teeth: a survey of dentists in Beijing, China. Dent Traumatol 2010;26:281–284. 36. Zuhal K, Semra OE, Huseyin K. Traumatic injuries of the permanent incisors in children in southern Turkey: a retrospective study. Dent Traumatol 2005;21:20–25.

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APPENDIX 1 Part two of the questionnaire 1. If an intruded primary maxillary anterior tooth has been displaced toward the labial bone plate a. the tooth is left for spontaneous repositioning b. the tooth is immediately extracted c. do not know 2. If an immature permanent maxillary tooth has been intruded, the tooth should be … a. left alone for spontaneous repositioning b. repositioned orthodontically c. repositioned surgically d. extracted immediately e. do not know 3. If a mature permanent maxillary tooth has been extruded, the tooth should be immediately repositioned and stabilised using a … a. rigid splint for 4 weeks b. rigid splint for 2 weeks c. semi-rigid splint for 2 weeks in conjunction with root canal treatment d. semi-rigid splint for 2 weeks in conjunction with root canal treatment if pulp necrosis has occurred 4. What type of splint should be used for extruded permanent incisors? a. semi-rigid with nylon wire b. stainless steel wire c. composite resin d. other 5. If a patient with an immature permanent maxillary tooth injury with pinpoint pulp exposure came to the clinic within 3 hours after the trauma, the treatment procedure would be … a. do not treat but follow up b. pulp capping c. partial pulpotomy d. cervical pulpotomy e. pulpectomy f. do not know Appendix continued on next page.

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6. If a patient with an immature permanent maxillary tooth injury with large pulp exposure came to the clinic more than 24 hours after the trauma, the treatment procedure would be … a. do not treat but follow up b. pulp capping c. partial pulpotomy d. cervical pulpotomy e. pulpectomy f. do not know

9. If the patient comes to the clinic within 60 min after trauma, before replantation, the immature avulsed tooth should be … a. rinsed with tap water b. cleaned with any type of solution c. left unwashed d. kept in doxcycline for 5 min e. scrubbed gently f. kept in fluoride solution for 20 min g. do not know

7. If a patient with a mature permanent maxillary tooth injury with large pulp exposure came to the clinic more than 24 hours after trauma, the treatment procedure would be … a. do not treat but follow up b. pulp capping c. partial pulpotomy d. cervical pulpotomy e. pulpectomy f. do not know

10. If the patient came to the clinic more than 60 min after trauma, for what period do you indicate the use of a splint for a mature avulsed tooth? a. no splint b. 2 weeks c. 4 weeks d. 2 months e. 24 hours f. do not know

8. Which of the following storage media are suitable for the storage of an avulsed tooth? a. ice b. tap water c. paper tissue d. fresh milk e. patient’s mouth

11. After replantation, do you prescribe antibiotic therapy? a. yes, tetracycline (>12 years old) b. yes, penicillin c. no 12. Should avulsed primary teeth be replanted? a. yes b. no Correct answers are written in italics.

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