Management of traumatic dental injury among otolaryngologists in Southwestern Mainland China: a cross-sectional observational survey

Abstract

Background

This study aimed to examine otolaryngologists’ attitudes and knowledge regarding the management of traumatic dental injury (TDI) encountered when patients present at the emergency department or during procedures such as tonsillectomy, adenoidectomy and suspension laryngoscopic surgery, as well as their motivation for pursuing additional education in this area.

Methods

A cross-sectional observational survey involving otolaryngologists selected from multiple hospitals across Sichuan province was carried out in this study. The questionnaire, consisting of 31 questions, was segmented into three sections: demographic data (10 items), knowledge about the management of TDI (17 items), and attitudes toward acquiring dental trauma education (4 items). Descriptive analysis, the Kruskal–Wallis test, the Mann–Whitney U test and ANOVA were used for statistical analysis.

Results

In the analysis, a total of 214 surveys were included, with over half of the participants (60.3%) having experienced at least one TDI case in their practice, whereas four in ten (39.7%) reported never encountering any cases. Participants who had a longer duration of practice were more likely to have a large caseload on the TDI (χ2 = 29.44, p < 0.001). 71% of participants experienced TDI during the perioperative period; however, only 6/214 participants (2.8%) responded correctly to all three questions about emergency management of TDI, and nearly all participants (98.1%) chose to refer TDI patients to a dentist. The majority of participants (91.1%) stated that they had not received any training on TDI, and 94.4% were willing to receive TDI-related education.

Conclusions

The findings of this study highlight the inadequate knowledge of otolaryngologists in southwestern mainland China regarding the management of TDI. Furthermore, the results indicate a strong interest among otolaryngologists in pursuing further training, which could help meet the educational needs necessary for providing appropriate management of TDI patients. Hence, it is imperative to provide targeted training courses to ensure prompt and appropriate TDI treatment, thereby minimizing the associated medical and societal costs.

Introduction

Traumatic dental injury (TDI) is a broader concept that is classified by the World Health Organization (WHO) as damage to oral tissues, including teeth, periodontal tissues, supporting bone, gingiva and oral mucosa. Encountering these injuries is one of the most common dental health complications and can result in functional, aesthetic, financial, and psychological consequences for patients and their families [1, 2]. In recent decades, TDI has been acknowledged as a significant global public dental health issue, ranking as the 5th most prevalent condition [3, 4] and accounting for 85% of injuries to the oral region [5]. Indeed, reports indicate that as many as 66% of all emergency department visits related to dental problems are specifically for the management of TDI [6]. Because traumatic injuries in permanent dentition peak between the ages of 10 and 12 and existing data show that TDI are more common in permanent dentition than in primary dentition [7, 8], with significant consequences for quality of life, the impact of dental trauma may last a lifetime.

Previous studies have indicated that the most common etiologies of TDI are accidental falls and injury during sports activities [7, 9]. In most cases, dentists and emergency physicians complete the first intervention for patients with TDI. Nevertheless, a small but significant proportion of patients with TDI (between 2.9% and 11%) and accompanying orofacial injuries are referred to the Otorhinolaryngology Department [10, 11]. For orofacial injuries, incorrect and inappropriate trauma treatment will often result in secondary deformities that are extremely difficult to correct [12]. For this reason, treatment planning often involves multidisciplinary specialists [7]. Furthermore, with advancements in medical technology and an increasing number of surgical procedures, iatrogenic trauma has attracted the attention of some scholars. During tonsillectomy, traumatic dental injuries (TDIs) involving rupture, dislocation, or avulsion of dental elements can occur [13, 14]. Jens et al. investigated 339 patients who underwent suspension laryngoscopy in Cologne and Germany and reported that TDI occurred in 6.5% of all patients [15]. Therefore, not only dentists and emergency physicians but also otolaryngologists should have basic knowledge of the emergency management of TDI.

The majority of practicing otolaryngologists do not routinely perform this procedure, for non-dental professionals, identifying the types of TDI that require urgent management is crucial. This includes cases such as avulsion, lateral and extrusive luxations, which necessitate immediate treatment [16], as the timing and methods of management significantly impact the prognosis of traumatized teeth [14]. Less serious cases, such as crown fractures, tooth concussion and subluxation, do not constitute emergencies [16]. Therefore, timely and accurate assessment, diagnosis, and management can help improve the prognosis and reduce adverse outcomes for affected patients, particularly pediatric patients.

Recent studies conducted in several countries have evaluated the level of knowledge regarding the emergency management of TDI among physicians specializing in various fields. Studies investigating the knowledge and management of TDI among otolaryngologists were published in 2021 by Üstün et al. [10]. The findings revealed that 44.38% of the participants answered the questions incorrectly, and 97.7% of the participants indicated that they had not received any education regarding TDI. Similar studies have also demonstrated that medical professionals, such as general practitioners [17], emergency medicine physicians [11, 18, 19], and pediatricians [20], have insufficient knowledge regarding the management of TDI.

To the best of our knowledge, there is limited literature available on the understanding and initial assessment of TDI among otolaryngologists. Furthermore, no studies have been published that specifically focus on the knowledge, practices, and attitudes of otolaryngologists regarding TDI in China. This study aimed to (1) assess the current knowledge level of Chinese otolaryngologists regarding the management of patients with TDI, (2) explore their attitudes toward dental trauma education, and (3) determine potential factors that affect their knowledge.

Materials and methods

This study was a questionnaire-based cross-sectional survey of otolaryngologists from southwestern mainland China. Ethical approval was obtained from the Institutional Review Board of West China Hospital, Sichuan University (2022.1588). All participants voluntarily participated in the study, and their information was kept confidential.

Questionnaire

The original version of the questionnaire was created by an investigation team on the basis of previous counterpart studies and dental trauma guidelines [18, 19]. Prior to data collection, three otolaryngologists and two dentists, each with a minimum of five years of practice and research experience, were asked to review the preliminary questionnaire individually. The questionnaire items were adjusted on the basis of feedback and suggestions from the reviewers. A second questionnaire survey was subsequently distributed to 15 otolaryngologists for completion, with the aim of gathering additional feedback on the clarity of the instructions and wording. The questionnaire was reviewed and finalized by the project team. The questionnaire comprises 31 questions categorized into three sections: demographic data, knowledge about the management of TDI, and attitudes toward acquiring dental trauma education.

Participants

This study specifically targeted certified otolaryngologists from southwestern mainland China. The participants indicated their willingness to participate in the study by answering the first question of the questionnaire, ‘Are you willing to participate in this survey?’. Individuals who were unwilling to participate were not included. During the data screening process, the inclusion criterion included Chinese residents aged 18 years or older who volunteered to participate and were capable of understanding the questionnaire. Those who declined to participate, provided inconsistent or untruthful answers (such as age not matching years of practice, years of practice not aligning with job title, etc.), or completed the questionnaire in less than 180 s were excluded. All participants were practicing in the otolaryngology department between December 20th, 2022, and June 20th, 2023.

Data collection and analysis

The electronic questionnaire was distributed to otolaryngologists online through Wenjuanxing, a widely utilized platform for conducting survey studies. This was accompanied by a brief introduction outlining the study’s nature and objectives, emphasizing its voluntary nature. The principal investigator was in charge of verifying the collected data from Wenjuanxing. The survey collection methods consisted of attending academic conferences focused on otolaryngology, engaging with social media groups for otolaryngology professionals, and conducting one-on-one surveys aimed at this group, all of which helped confirm that the respondents were part of the otolaryngology professional community.

Statistical analysis was performed with IBM SPSS Statistics for Mac (version 26.0) and GraphPad Prism 8 (San Diego, CA, USA). A statistically significant alpha was considered at p < 0.05. Descriptive analysis was conducted, which included calculating the mean, median, standard deviation, minimum, and maximum values. The Mann‒Whitney U test was used to compare two independent groups, whereas the Kruskal‒Wallis test was used for comparisons involving more than two groups. The statistical significance level of alpha was set at p < 0.05.

Results

This study recruited 214 otolaryngologists, mainly from southwestern mainland China (95.40%), comprising 122 males and 92 females aged between 23 and 60 years (mean ± SD = 39.0 ± 8.57). The educational and professional backgrounds revealed that the majority of participants held a bachelor’s degree (68.2%) and were attending physicians (41.6%). They had practiced as otolaryngologists for one to forty years (mean = 15.0 years, SD = 9.38). The majority of the medical institutions in which the participants worked were public hospitals (93.0%), teaching hospitals (70.1%), and tertiary hospitals (77.1%). Moreover, 91.6% of them reported that their hospital had a dental department. Among the surgeries performed in hospitals, supported laryngoscopy, transoral tonsil/adenoidectomy, and oropharyngeal mass removal were performed on more than nine of the ten patients. Only eight otolaryngologists reported that none of them had performed in their hospital (3.7%).

Management of dental trauma

When asked about their knowledge of dental trauma, 75.3% of the participants said they had “heard of it, but do not know about it” or “know a little about it”. Only 3.7% reported knowing a lot about it (n = 8), and 13.1% reported that they had not heard of it (n = 28). Regarding the caseload of TDI they had encountered (Table 1), four in ten participants reported that they had never encountered it (39.7%), and 41.1% reported that they had encountered 1–5 cases of TDI. Furthermore, there were significant differences in the caseload of TDI among the various practiced duration groups (χ2 = 29.44, p < 0.001).

Table 1 The caseload of TDI varied among the different practiced duration groups

Almost all otolaryngologists informed patients about the risk of dental injuries before surgical intervention (98.1%) and checked patients’ teeth conditions before starting a transoral surgical procedure (96.7%). A total of 71.0% of the participants experienced TDI during the perioperative period (n = 152). During the surgical procedure, more than 90% of otolaryngologists provided additional items to protect their teeth (93.9%), with gauze being the most common choice (n = 97, 92.1%). In addition, a suction tube and a rubber tube were used to protect the teeth. A small number of participants also reported that they usually used appropriate items for additional protection, such as customized dental protectors, adhesive pads, suction devices, oxygen tubes, and other plastic cannulas. With respect to knowledge of TDI, 69.6% of otolaryngologists stated their ability to differentiate between permanent and deciduous teeth, whereas only 128 participants (59.8%) could accurately define complete tooth luxation.

A total of 179 participants reported that patients with TDI require emergency treatment (83.6%), and 35 patients had negative responses (16.4%). When asked if a patient presented with a complete luxation of permanent teeth, nearly all participants chose to refer him/her to a dentist (n = 210, 98.1%). During the perioperative period, only 36.9% of participants (n = 135) expressed their willingness to independently reposition the tooth back into the alveolar socket when confronted with a patient experiencing TDI. Further questions and concrete statistics about refusal reasons and knowledge about the management of TDI are shown in Table 2. Figure 1 illustrates the percentage of otolaryngologists who provided accurate responses to three knowledge-based questions. Among these emergency management questions, only 6/214 participants had 3/3 correct answers, whereas 22 participants failed to answer any right one.

Fig. 1

The distribution of correct answers to three questions about the management of TDI (Q25-Q27

Table 2 Questions about the management of TDI

Attitudes toward acquiring knowledge about traumatic dental trauma

Although the majority of participants indicated that they had not received any training or education on TDI (n = 195, 91.1%), they all regarded its necessity as quite important (Fig. 2). Overall, there is a strong willingness to receive continuous education on TDI management. The attitudes of otolaryngologists toward acquiring knowledge about TDI are shown in Table 3. Several participants reported that they would not attend the training because these injuries were beyond their professional scope and lacked time.

Fig. 2

Necessity of acquiring knowledge about TDI among otolaryngologists

Table 3 Emergency management of dental trauma among otolaryngologists

Discussion

As a worldwide public dental health problem, TDI can occur at any age and represents approximately 5% of all injuries among children and young adults. DiPaolo et al. [21] reported that tooth avulsion had an average direct cost of $1619 USD, and patients had an average of 9.5 follow-up visits after the avulsion. The treatment outcome of TDI is strongly related to the timeliness of the intervention and the knowledge and skills of emergency personnel [14]. Therefore, proper and immediate management can improve patient prognosis, minimize undesired consequences and reduce patient costs. The objective of this study was to evaluate the ability of otolaryngologists to handle common traumatic dental injuries in emergency situations.

TDI is primarily managed by dentists and emergency physicians. However, with the increasing use of intraoral examinations and surgeries, as well as referrals for orofacial injuries accompanied by TDI, the probability of encountering TDI has significantly increased for otolaryngologists. In contrast to Üstün et al.’s study [10], where 96.9% of participants had faced at least one case during their clinical experience. In this study, 60.3% of the participants had encountered at least one case. Under these conditions, all otolaryngologists should receive basic training on how to manage TDI.

Otolaryngologists had a low level of knowledge about TDI. In this study, only a small percentage of individuals (8.9%) had received formal education on the relevant knowledge, and the majority of them (97.2%) were unable to answer all three questions correctly regarding the emergency management of TDI. A low level of knowledge is also evident in questions 12 and 16, where 39.7% of the respondents answered “0” to “What caseload of patients with dislocated teeth have you ever met at work?” Moreover, 71% of the respondents answered “yes” to “Did your patient have any traumatic dental injuries during the perioperative period?” This indicates that the respondents were not familiar with the definition of TDI. This is also demonstrated in other similar articles, emergency physicians [11], pediatricians [20], and otolaryngologists [10] exhibit low levels of knowledge with respect to TDI. Even among dentists, there is often a lack of knowledge regarding TDI. A study conducted on Chinese dentists about their knowledge of the traumatic injuries in primary teeth indicated that the correct response rate for questions about treatment of luxation injuries in primary teeth presented a correct-response rate of 66.6% [22]. In the research of Parisay et al. [23] In Mashhad and Iran, compared with residents in emergency medicine and otolaryngology, those in maxillofacial surgery presented the highest level of proficiency in handling traumatic dental injuries.

For surgeons, it is essential to master both preventive and treatment methods for TDI. In this study, almost all participants (98.1%) were aware that TDI is one of the surgical risks and that they would inform patients about this risk. The majority of participants will take a series of measures to prevent TDI, including examining their teeth and using gauze to protect them. Managing luxation injuries in TDI involves repositioning the affected tooth within the alveolar socket and applying gentle pressure [20]. Although participants were aware of the need for immediate intervention when TDI occurred, 63.1% of the otolaryngologists indicated that they would not undertake reimplantation of the avulsed teeth. This is closely related to the high referral rate and the lack of knowledge and confidence among participants in dealing with dental issues. These results are highly consistent with studies conducted by scholars such as Üstün et al. [10] and Nikolic et al. [20]

Among the three issues in scoring, “the correct way to hold an avulsed tooth” and “the most appropriate practice to deal with stained teeth” achieved accuracy rates of more than 50% for these two issues. The condition of periodontal ligament (PDL) cells depends on both the storage medium and the duration that the tooth is out of the mouth, which impacts the selection of treatment. After being allowed to dry for 60 min or longer, all PDL cells became nonviable. In the event of a tooth avulsion, the most effective initial response is to prompt the patient to reinsert the tooth and bite down on a handkerchief to secure it in place. If this is not possible, placing the tooth in a glass of milk or another osmolality-balanced storage medium is necessary [7, 24]. However, with respect to preserving an avulsed tooth, 61.7% of otolaryngologists would place the tooth in saline, 12.6% would wrap it with gauze or a paper towel, and only 3.7% would use milk as a storage medium. These results are unsatisfactory, particularly compared with those of Üstün et al.‘s study [10], in which 12.5% of participants stored their teeth in milk. In Doğan et al.‘s study on anesthesiologists, 11.8% of the participants also indicated that their ideal storage medium for an avulsed tooth was fresh milk [25]. For emergency physician, the awareness rate of this knowledge can be as high as 31.1% [26].

Most of them (99.5%) considered that acquiring knowledge related to TDI is important. However, similar to the research conducted by Abu-Dawoud et al. [27] and Manochehrifar et al. [28] the majority of non-dental healthcare professionals (96.6% and 90.7%, respectively) do not receive specialized education on the management of TDI. However, for emergency physicians, this percentage can drop to between 45.9% and 50% [26, 29]. Consistent with previous research [11, 19, 20, 26, 27, 30], almost all otolaryngologists had positive attitudes and were willing to undergo further education to enhance their professional competence. Bruno et al. [31] and Parisay et al. [23] both studies demonstrated that educational interventions resulted in a notable increase in correct responses concerning the actions to be taken in cases of tooth avulsion. However, Bruno et al. [31] reported that professionals’ knowledge level decreased slightly six months after the lecture but still remained high. However, participants’ confidence in their ability to perform replantation significantly decreased. Therefore, regular education and skill training for nondental medical professionals is needed.

Limitations

The present study shares limitations common to all cross-sectional studies. First, there may be selection bias among participants due to the lack of randomization, which is attributed to limited objective conditions. Individuals interested in TDIs or those with prior experience in such cases were more likely to respond to the questionnaire. Second, the majority of the data were collected from multiple centers in southwestern mainland China, potentially limiting the generalizability of the results to the broader population. Third, in the design of the questionnaire, no questions were included to assess the participants’ knowledge of the periodontal status of the teeth. In addition, the questionnaire addressed traumatic dental injuries, such as tooth crown injury, tooth root injury and periodontal ligament injury, to a lesser extent.

In future studies, we aim to develop more deeply into dental issues that are closely associated with orofacial concerns. Furthermore, we propose stratifying clinicians on the basis of their practice characteristics to ensure that the analysis yields a more objective and representative conclusion.

Conclusions

The results of the present study indicated that more than half of the otolaryngologists in southwestern mainland China had experienced TDI, which is insufficient for managing TDI. Educational campaigns must be undertaken to improve the knowledge of otolaryngologists regarding the emergency management of TDI. A significant proportion of otolaryngologists have expressed a keen interest in receiving education on TDI. Leveraging new multimedia approaches to provide TDI knowledge in a more convenient manner could be a promising strategy for enhancing TDI management practices among otolaryngologists and increasing their awareness of TDI.