| |

Received: 14 January 2019    Revised: 20 July 2019    Accepted: 22 July 2019

DOI: 10.1111/edt.12503

ORIGINAL ARTICLE

A questionnaire‐based survey for the evaluation of the

knowledge level of primary school teachers on first‐aid
management of traumatic dental injuries in Athens, Greece

Nestor Tzimpoulas1  | Maria Markou2 | Vasileios Zioutis3 | Giorgos N. Tzanetakis4

1
Private Practice Limited to Endodontics,
The Hague, The Netherlands
2
Private Dental Practice, Athens, Greece
3
Private Dental Practice, The Hague, The
Netherlands
4
Department of Endodontics, Dental
School, University of Athens, Athens,
Greece
Correspondence
Nestor Tzimpoulas, Private Practice Limited
to Endodontics‐Verwijspraktijk Belgisch
Park, Stevinstraat 176, 2587 ET, The Hague,
The Netherlands.
Email: endonestor@gmail.com
Abstract
Background/Aim: School teachers can play an important role in improving the prog‐
nosis of traumatized teeth of school children through immediate onsite management
or on time referral to healthcare providers. In Greece where the research in the field
of dental traumatology is very limited, this issue is of utmost importance. The aim of
this study was to evaluate the knowledge level of Greek primary school teachers and
their attitude with regard to emergency first‐aid management of traumatic dental
injuries (TDI) occurring in schools.
Material and Methods: A cross‐sectional descriptive study among 276 school teach‐
ers was undertaken in Athens, Greece. This was done through a two‐part question‐
naire‐based survey including demographic characteristics, attitude, and knowledge
of first‐aid management of TDI. Data were analyzed using non‐parametric tests for
differences. Log Poisson regression analysis was used to estimate relative risks of low
or high knowledge of first‐aid management.
Results: The risk of lower knowledge score was almost double in teachers with
<10 years of teaching experience and almost threefold higher in those reporting that
they are not interested in being informed about dental trauma. In the case of luxa‐
tion injury, 69.9% of the participants would not take any immediate action and would
refer the child to a dentist. In case of permanent tooth avulsion, 52.2% knew that the
tooth can be replanted in the socket, whereas only 17% believed that this should be
performed within 30 minutes. Most of the participants would send the child to their
own/family dentist, whereas only 4.7% would refer to an Endodontist.
Conclusion: The knowledge of primary school teachers in Greece about first‐aid
management of TDI is limited. However, a clear positive association was found be‐
tween knowledge of first‐aid management and teaching experience. Reliable infor‐
mation about dental trauma may result in improving the knowledge level of Greek
primary school teachers.

KEYWORDS
dental trauma knowledge, first‐aid management, Greece, primary school teachers

Dental Traumatology. 2020;36:41–50. wileyonlinelibrary.com/journal/edt   © 2019 John Wiley & Sons A/S. |  41
Published by John Wiley & Sons Ltd
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42       TZIMPOULAS et al.
1 |  I NTRO D U C TI O N
Traumatic dental injuries (TDI) are considered one of the most im‐
portant oral health problems in childhood and currently ranked fifth
in the list of worlds’ most frequent acute/chronic diseases and in‐
1‒3
juries. A recent major study has shown that approximately one
billion people have suffered from some kind of dental injury and the
worldwide prevalence in permanent dentition is about 15%.1 TDI are
very frequent in the mixed and permanent dentitions with an inci‐
1,2
dence rate ranging between 1.25% and 4%.
In Greece, and despite that official data are limited, the incidence
of dental trauma in children aged between 5 and 12 years has been
reported to be almost 11%.4 According to the most relevant study,
the most prevalent type of traumatic dental injury was crown frac‐
ture with or without pulp exposure (33% and 51%, respectively),
followed by injuries with periodontal involvement such as lateral
luxation (4%), extrusive luxation (4%), crown and root fractures (3%),
4
concussion and subluxation (3%), intrusion (2%), and avulsion (1%).
Most TDI occur during leisure time at home followed by during
school hours.5 It is well known that children spend most of their
daily time in schools and day‐care institutions; therefore, it is not
6,7
surprising that most of the TDI occur during school hours. On such
occasions, school teachers are among the first to see a child imme‐
diately after injury, but their knowledge of emergency management
is considered insufficient to ensure adequate first‐aid handling and
8,9
subsequently an improved prognosis.
Besides pain and distress caused during and after a tooth injury,
the damage to the pulp and periodontal ligament of a traumatized
tooth can compromise its long‐term prognosis, whereas in severe
injuries, it can even lead to tooth loss. It has been shown that ap‐
proximately one third of traumatized teeth develop permanent se‐
quelae such as pulp necrosis and infection, inflammatory resorption,
replacement resorption, or arrested root development in cases of
10
immature teeth. These complications may necessitate multidisci‐
plinary dental treatments11, which beyond discomfort for the pa‐
tient are also time‐ and cost‐consuming for both the child and the
parents.12 Therefore, appropriate action and effective emergency
treatment are crucial for the achievement of a favorable prognosis
of a traumatized tooth and this might prevent further post‐traumatic
complications. Especially in cases where an avulsion has occurred,
prompt and onsite emergency management is very critical for the
13
long‐term outcome. For these reasons, it is important to inform or
educate school teachers that may witness TDI how to properly han‐
dle emergency procedures for different injury scenarios.
In the past 20  years, TDI first‐aid management in schools has
received increasing attention worldwide. A series of previous simi‐
lar studies has revealed inadequate knowledge and management of
TDI by school teachers of other countries. 8,14‒18 A systematic ap‐
proach of the literature showed that so far, a total of 68 studies have
been performed to assess the level of knowledge of school teach‐
ers regarding the first‐aid management following a dental injury.
It is noteworthy that most of these studies (39) are derived from
the geographic origin of Asia and only a small number (11) are from
European countries. Hence, despite this theme having been largely
published, the data relative to this topic in Europe are very limited.
Especially in Greece, no study on this aspect has been previously
conducted showing the need for the dissemination of such findings
worldwide.
The aim of this study was to evaluate the level of knowledge
and attitude of a group of Greek primary school teachers to dental
trauma first aid and to discuss potential means for the improvement
of this knowledge in the future.
2 | M ATE R I A L S A N D M E TH O DS
A cross‐sectional questionnaire‐based study related to TDI in primary
school children was undertaken among a group of Greek school teach‐
ers in the capital of Greece, Athens. The study was approved by the
Human Research Ethics Committee of Dental School Athens, National
and Kapodistrian University of Athens, Greece. Fifteen primary schools
were randomly selected from different districts of Athens. Permission to
carry out this study was requested, and a signed informed consent from
each school administration office was obtained in advance. The ques‐
tionnaire was personally distributed to 300 school teachers after a brief
verbal and written explanation of the scope of the survey and the ques‐
tionnaire itself upon visiting the schools. An informed consent promising
anonymity and voluntary participation was signed and obtained by all
participating school teachers. All questionnaires were distributed, and
data were collected in June 2018. The questionnaire consisted of two
parts: Part I included questions with regard to demographic character‐
istics of participants and their attitude toward dental trauma (Figure 1).
In Part II, three clinical cases which differed according to the severity
and degree of dental trauma were used to assess the level of knowledge
during an emergency TDI at school (Figure 2). These cases were a crown
fracture, a luxation injury and a case of avulsion. An additional question
with regard to first choice of healthcare provider during an emergency
TDI was included in Part II. All questions were set in a multiple‐choice
form. Assessment of the validity of the questionnaire was established
by three independent Endodontists who were not participating in the
study and who made comments about the questions, all of which were
acceptable. The reliability of the questionnaire was determined by
Cronbach's alpha (α = 0.62), indicating acceptable reliability.
Α power calculation was performed, suggesting that with a total
sample size of 276 individuals, there would be sufficient power
to identify “small‐to‐medium” effect sizes (relating to differences
in dental trauma knowledge score between the teacher groups
based on their characteristics), equal to 0.38 of a standard devia‐
tion.19 Descriptive statistics were used for demographic variables.
To evaluate potential differences in dental trauma knowledge score
between the nine demographic variables, non‐parametric testing
was considered. This was done because even after a range of data
transformations were performed with the aim of achieving normal‐
ity, the distribution of the dental trauma knowledge score remained
non‐normal (Shapiro‐Wilk test, P < .001). Therefore, non‐parametric
Mann‐Whitney U tests were performed for demographic variables
TZIMPOULAS et al.
F I G U R E 1   Questionnaire—Part I
with two categories, and Kruskal‐Wallis tests for variables with more
than two categories. For both tests, all assumptions were met, in
particular, the assumption of “homogeneity of variance between the
groups.” Hence, the tests are assumed to be tests of differences in
population medians. 20
To determine the specific factors independently associated (over
and above the potential confounding effects of the other factors)
with risk of a low (or, conversely, high) dental trauma knowledge
score, log Poisson or log‐binomial regression was used, providing rel‐
ative risks (RRs) and their corresponding 95% confidence intervals.
This modeling option was preferred to the use of logistic regression
to estimate odds ratios, since it is known to overestimate the risk in
the case of non‐rare outcomes (incidence >10%, which is the case in
this study). 21 The Akaike information criterion (AIC) and the Bayesian
information criterion (BIC) were used to determine whether Poisson
|
      43
or binomial provided the best model fit. Low and high dental trauma
knowledge scores were defined as scores that were one standard
deviation below or above the mean, respectively. Overall, the aim of
this modeling strategy was to construct a parsimonious model that
would identify and include only variables which have independent
and significant effects on the outcome (in this case, low or high den‐
tal trauma knowledge score).
Results were considered statistically significant at P < .05.
Analyses were performed using SPSS (SPSS® 24.0).
3 | R E S U LT S
A total of 276 school teachers completed the questionnaires. In
the selected schools, the mean teachers’ age was 41.7  years. A
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44       TZIMPOULAS et al.
predominance of female teachers was recorded (75.4%), and most of
the participants (68.8%) had more than 10 years of teaching experi‐
ence. The results demonstrated that 77.2% had no previous dental
trauma training nor information on dental trauma injuries, whereas
19.2% have witnessed a dental trauma injury during school hours.
However, only 23.9% believed in their ability to help during an ur‐
gent situation of TDI at school and 96% of the participants were in‐
terested in getting more information on first‐aid management of TDI.
Responses to participants’ demographic characteristics in Part I of the
questionnaire are summarized in Table 1.
Case 1 concerned a crown fracture, and 67% of the participants
knew that the fractured tooth was a permanent tooth and 48.6%
would keep the fractured pieces. However, only 35.5% would store
the teeth in a moist environment. Of all respondents, 39.1% did not
F I G U R E 2   Questionnaire—Part II
know what to do with the broken parts. Table 2 (Q1‐Q3) summarizes
the responses to questions regarding crown fractures.
Case 2 was a question about the emergency management of a
luxation injury. The responses showed that only 15.9% would control
bleeding before referring the child to a dentist, while 69.9% would
not take any immediate action and would just refer the traumatized
child to a dentist and 14.1% did not know what to do. Responses to
luxation injury question are shown in Table 2 (Q4).
Case 3 concerned an avulsed tooth. Of those surveyed, 52.2%
believed that the tooth can be replanted back into its socket.
However, only 17% responded that this should be performed within
30  minutes. When the teachers were asked about storage media
for avulsed teeth, most of them (37%) did not know where to store
them, whereas 19.9% would immerse the teeth in cold milk. In the
TZIMPOULAS et al. |
      45

TA B L E 1   Responses to Part I: characteristics of study The non‐parametric tests (Mann‐Whitney U test/Kruskal‐Wallis)

population (n = 276) indicated that dental trauma knowledge was greater in teachers

School teachers’ characteristics n % aged over 35 years (P = .041) and with more than 10 years of work‐
ing experience (P < .0001). The same was for those who have their
Gender
own children (P = .009). Previous experience of dental trauma train‐
Female 208 75.4
ing or witnessing previous dental trauma accidents play a significant
Male 68 24.6
role in the knowledge regarding traumatic dental injuries (P < .001
Age, (y) and P = .001, respectively). Significant differences in dental trauma
≤35 88 31.9 knowledge were also found between those who believe in their abil‐
36‐45 80 29.0 ity to help a child with dental trauma or would like to be informed
>45 108 39.1 about it and those who do not (P = .009 and P = .037, respectively).
Teaching experience, (y) No statistically significant differences were observed for gender,
<10 86 31.2 teaching specialization, or number of previous dental trauma events

>10 190 68.8 witnessed. Table 4 summarizes the dental knowledge score by de‐
mographic characteristics.
Teaching specialization
Of the evaluated factors, two were found to be risk factors
Physical education 18 6.5
independently associated with low dental trauma knowledge. Risk
Other 258 93.5
was almost double in teachers with <10  years of teaching expe‐
Have own children
rience (RR: 1.87, 95% CI: 1.11‐3.15, P  =  .019) and almost three‐
Yes 149 54.0
fold higher in those who reported that they are not interested in
No 127 46.0 being informed about dental trauma (RR: 2.91, 95% CI: 1.25‐6.78,
Previous dental trauma training/ information P = .013) (Figure 3).
None 213 77.2 One factor, having had previous dental trauma training/ infor‐
During first‐aid course 25 9.1 mation, was found to be independently associated with high dental
Formal expert training/ 20 7.2 trauma knowledge (RR: 2.73, 95% CI: 1.58‐4.71, P < .001). Further
information exploration of this finding revealed that this was due to two spe‐
Informational leaflets 14 5.1 cific dental trauma information/training methods: being exposed
Internet sources 13 4.7 to such information through a first‐aid course (RR: 3.00, 95% CI:
Incidences of dental trauma witnessed at school 1.58‐5.72, P < .001) or through information leaflets (RR: 3.14, 95%
None 196 71.0 CI: 1.41‐6.96, P = .005) (Figure 1). All RRs were estimated through

1‐2 53 19.2 log Poisson regression since, in all models, the AIC and BIC indicated
that log Poisson regression provided a better model fit compared to
3‐4 23 8.3
log‐binomial regression.
≥5 4 1.4
Believe in their ability to help a child with dental trauma
Yes 66 23.9
4 | D I S CU S S I O N
No 210 76.1
Would like to be informed about dental trauma This is the first questionnaire‐based study conducted in Greece to
Yes 265 96.0 evaluate the degree of knowledge among primary school teachers
No 11 4.0 regarding emergency management of traumatic dental injuries. From
an international perspective, previous similar studies from other
question about cleaning the avulsed tooth before storage, 58.3% re‐ countries have covered the knowledge and attitudes of teachers
sponded “yes,” but 27.5% would rinse them with cold water, whereas either related solely to tooth avulsion11,15,22 or avulsion and crown
52.2% did not know how to do this. Table 2 (Q5‐Q9) summarizes the fractures only.6,10,16,22‒24 The present questionnaire was based on
responses to questions regarding permanent tooth avulsion. pre‐existing models combining questions from previous similar ques‐
All participants were asked an additional question (Part II, Q10) tionnaires, 24,25 and among others, it was structured to investigate
with regard to first choice of healthcare provider to seek in case of the first‐aid management of lateral luxation injuries. The knowledge
an emergency dental trauma situation. Most of the teachers would of school teachers of lateral luxation injuries has not been widely
refer the injured child to their own/family dentist (40.2%), and only investigated so far, and only very limited studies have evaluated the
13% would refer the child to the nearest dentist or hospital. A pe‐ first reaction of school teachers for this type of traumatic injury. 25
diatric dentist was second in the ranking with 23.9%, whereas only The present questionnaire was also enriched with representative
4.7% would refer the child to an Endodontist. A summary of the re‐ figures of traumatic injuries to become more illustrative and to help
sponses is shown in Table 3. teachers to understand the degree of severity of each injury.
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46       TZIMPOULAS et al.

TA B L E 2   Responses to Part II: dental

Question Response n % (95% CI)
trauma knowledge
Crown fracture
1. Dentition knowledge Primary teeth 28 10.1 (6.8‐14.3)
Permanent teeth 185 67.0 (61.1‐72.5)
Don't know 63 22.8 (18.0‐28.2)
2. Use of fractured parts Yes 134 48.6 (42.5‐54.6)
No 34 12.3 (8.7‐16.8)
Don't know 108 39.1 (33.3‐45.2)
3. Storage environment Dry 8 2.9 (1.3‐5.6)
Moist 98 35.5 (29.9‐41.5)
Don't know 170 61.6 (55.6‐67.4)
Luxation injury
4. Emergency management Bleeding control 44 15.9 (11.8‐20.8)
Refer to dentist 193 69.9 (64.1‐75.3)
Don't know 39 14.1 (10.2‐18.8)
Avulsion
5. Replantation Yes 144 52.2 (46.1‐58.2)
No 132 47.8 (41.8‐53.9)
6. Time to replantation 0‐30 min 47 17.0 (12.8‐22.0)
Within 1‐5 h 34 12.3 (8.7‐16.8)
Within 48 h 17 6.2 (3.6‐9.7)
Not important 1 0.4 (0.0‐2.0)
Don't know 177 64.1 (58.2‐69.8)
7. Storage medium Water 19 6.9 (4.2‐10.5)
Saline 41 14.9 (10.9‐19.6)
Cold milk 55 19.9 (15.4‐25.1)
Child's mouth 2 0.7 (0.1‐2.6)
Antimicrobial solution 35 12.7 (9.0‐17.2)
Clean napkin 22 8.0 (5.1‐11.8)
Don't know 102 37.0 (31.2‐42.9)
8. Cleaning tooth before Yes 161 58.3 (52.3‐64.2)
replantation No 115 41.7 (35.8‐47.7)
9. If yes, how Cold water 76 27.5 (22.4‐33.2)
Soft toothbrush 6 2.2 (0.8‐4.7)
Antimicrobial solution 45 16.3 (12.1‐21.2)
Oral mouthwash 5 1.8 (0.6‐4.2)
Don't know 29 10.5 (9.0‐17.2)

Abbreviation: CI, confidence interval.

The results of the present study showed that the level of knowl‐
edge of Greek primary school teachers regarding first‐aid man‐
agement of traumatic dental injuries was limited, which confirmed
22,23,25
similar findings of other previous studies. However, the re‐
sults obtained are very promising considering the very limited in‐
formation on dental trauma and its first‐aid management of all
dentitions in Greece. The limited information is documented in the
present study as 77.2% of the teachers stated that they have never
had any previous training on dental trauma first‐aid management
nor any information about such injuries. Compared to some other
European countries, Greek school teachers seem to be less informed
or trained about dental trauma emergency incidents, 23,26 whereas
a similar level of knowledge has been reported in countries from
South America and Asia. 27‒29 At the same time, 29% of the teachers
had previously witnessed at least one dental trauma injury during
school hours, which corresponds to similar outcomes published pre‐
viously. 25,27 Evaluating the factor of previous training or information
on first‐aid management independently, there was an associated
high knowledge score of the teachers. Based on the present results,
courses about first‐aid management and information leaflets are the
TZIMPOULAS et al. |
      47

TA B L E 3   First choice of healthcare provider TA B L E 4   Median dental knowledge score, by demographic

characteristics
Percentage
Healthcare provider Frequency (%) 95% CI P‐value for
School teachers’ characteristics Median (IQR) differences
General physician 6 2.17 0.6‐4.2
Hospital 36 13.04 8.7‐16.8 Gender

Own/family dentist 111 40.21 33.3‐44.8 Female 4.0 (2.5‐5.5)  

Nearest general dentist 36 13.04 8.7‐16.8 Male 4.1 (2.1‐5.7) .938

Pediatric dentist 66 23.91 19.0‐29.4 Age, (y)

Endodontist 13 4.71 2.5‐7.9 ≤35 3.7 (2.4‐4.8)  

Dental school 4 1.44 0.0‐2.0 36‐45 4.3 (2.5‐6.0)  

Hospital for children 4 1.44 0.4‐3.7 >45 4.3 (2.5‐5.7) .121a

Total 276 100.0   Teaching experience, (y)

<10 3.5 (1.5‐4.7)  
Abbreviation: CI, confidence interval.
>10 4.4 (3.0‐5.9) <.0001

two most important means to educate teachers about how to react Teaching specialization
adequately in such circumstances. These findings dictate the impor‐ Physical education 4.8 (2.4‐6.5)  
tance of informing and training primary school teachers in Greece on Other 4.0 (2.5‐5.5) .272
first‐aid management of TDI. This was also a request of most of the Have own children
teachers who completed the questionnaires, as 96% of them were Yes 4.4 (2.7‐6.3)  
interested in getting more information in the future on first‐aid man‐ No 3.7 (2.5‐4.9) .009
agement of TDI. This result shows a clear positive attitude of Greek
Previous dental trauma training/ information
school teachers to improve their dental trauma management knowl‐
None 3.7 (2.4‐5.0)  
edge, a finding that coincides with the attitude of school teachers
During first‐aid course 6.0 (3.7‐6.5)  
from other countries.10,22,24,25
Formal expert training/ 4.9 (3.6‐6.2)  
The age and the years of working experience of the teach‐
information
ers seem to play an important role in dental trauma knowledge
Informational leaflets 6.5 (4.2‐7.2)  
score, these findings are consistent with previous studies of
Internet sources 5.5 (2.9‐6.7) <.001b
Brazilian school teachers. 30 More specifically, teachers with less
Incidences of dental trauma witnessed at school
than ten years of working experience have almost double the risk
to achieve low knowledge score regarding first‐aid management None 3.9 (2.1‐5.2)  

during a traumatic dental injury. The age and the experience are 1‐2 5.0 (3.5‐6.5)  

directly connected to each other, showing that older teachers with 3‐4 4.5 (2.5‐6.3)  
more working experience seem keener to receive dental trauma ≥5 4.5 (2.3‐6.3) .001c
information than younger teachers with less working experience. Believe in their ability to help a child with dental trauma
A further exploration of this finding revealed that those who re‐ Yes 4.5 (3.5‐6.3)  
ported that they are not interested in being informed about this No 3.8 (2.5‐5.3) .009
issue have a threefold higher risk to achieve a low knowledge Would like to be informed about dental trauma
score. This finding points out the significance of continuous ed‐
Yes 4.1 (2.5‐5.7)  
ucation and training of teaching staff. In addition, teachers who
No 2.0 (1.5‐4.5) .037
have their own children are more willing to be informed since
Abbreviation: IQR: interquartile range.
parenthood might motivate them to seek further information on a
Association is significant (P = .041) if comparison is between “≤ 35” vs
children's health issues. 31 This finding might be a factor associated
“>35” years groups.
with higher knowledge score in the present study. However, it is b
P‐value provided relates to group comparison of “none” vs “any” previ‐
in contrast with previous studies, showing that parenthood is still ous dental trauma training/ information.
c
associated with insufficient knowledge in first‐aid management P‐value provided relates to group comparison of “witnessed” vs “did
32,33 not witness any” dental trauma incidents at school.
of traumatized teeth. Witnessing previous dental trauma in‐
cidents at school was also associated with increased knowledge previous experience could have positively influenced their current
score, a finding that is in contrast with the results of previous sur‐ reaction during a similar incident.
veys of larger sample sizes. 24,25 This result means that previous Surprisingly, no significant differences in dental trauma knowl‐
dental trauma experience has improved the knowledge score of edge were found in terms of teaching specialization. It would be ex‐
approximately one third of school teachers, showing that their pected that teachers of physical education might be more informed
 |
48       TZIMPOULAS et al.
or possibly trained on first‐aid management of dental trauma in‐
juries. However, within this group of teachers no association was
found. This finding is consistent with the results of previous similar
studies.24,32 This suggests the need for lessons in physical education
universities regarding first‐aid management during TDI. Similarly,
gender was not a parameter influencing the dental trauma knowl‐
edge score in the present study. This finding confirms the results
obtained by a previous Iranian study. 24 However, it is in contrast with
the findings of two other similar studies where male school teachers
scored lower levels compared to females.30,34
Interestingly, almost 1 out of 4 teachers started to believe in their
ability to help children during an urgent situation of TDI at school
time. This finding was confirmed by the result that the above group
of teachers had superior dental trauma knowledge compared to
those who did not believe in their ability to offer their help during
emergency TDI.
Three different traumatic dental injury scenarios comprised the
second part of the questionnaire to evaluate the level of knowledge
during a dental trauma emergency incident at school. It was very en‐
couraging that in the first case, 67% of the teachers knew that the
injured tooth was a permanent tooth, a result that can be considered
33
hopeful and similar to a previous study. This knowledge is very sig‐
nificant since it can lead teachers to keep the fractured part of the
tooth for subsequent management by a healthcare professional.
Approximately half of the responders would look for the fractured
piece after a crown fracture, which is higher than the low percentages
found in other studies.24,35 However, only 1 out of 3 teachers would
keep the fractured part in a moist environment. This is where infor‐
mation from dental authorities can make a major difference regarding
first‐aid management in the future.
In the more severe second case, where bleeding was present, it
is obvious that knowledge regarding first‐aid management is lacking
even though the first aid for this case is not considered as special or
particular. Only a small percentage of teachers answered that their
first action would be the control of bleeding. In this case, bleed‐
ing played a significant role based on the answers obtained by the
teachers. Traditionally, bleeding is a clinical consequence of an in‐
jury that, for most people, is considered an uncomfortable situation,
which can lead to ineffective help during an urgent situation. This
result was unexpected because it was initially considered that con‐
trol of bleeding would be an obvious correct answer.
In the third case regarding tooth avulsion, it is very encouraging
that more than half of the teachers answered that the tooth can be
replanted in its socket. However, only few of them (17%) knew that
time of replantation after injury is very important for tooth prog‐
nosis, a result that is lower compared to teachers of another coun‐
try.31 However, this percentage may be used as a baseline for better
and more accurate information in the future. Almost the same per‐
centage (19%) of participants answered that milk is the best stor‐
age medium for the avulsed tooth. This percentage is superior to
that in previous similar studies which ranged between 6.5% and
16.5%. 25,31,33,36,37
With respect to the last general question, about 40% of the
participants answered that their own/family dentist would be the
first choice for referring a child with dental trauma, whereas the
second choice was a pediatric dentist. This finding indicates the
gradually establishing status of pediatric dentistry as a recog‐
nized specialty in Greece. In contrast, it seems that little is known
among the teachers about the management that can be offered
by Endodontists in severe cases of dental trauma. This finding is
certainly disappointing because Endodontists have the ability to
evaluate not only the severity of a traumatic injury but also the
management, if necessary, of potential post‐traumatic complica‐
tions during follow‐up examinations.
F I G U R E 3   Teacher characteristics
independently associated with a low (risk
factors) and high (protective factors)
dental trauma knowledge score. Relative
risks (95% CIs)
TZIMPOULAS et al.
A potential limitation of the present study is the sample size of
participants. The power calculation showed that the 276 teachers
would be sufficient for statistical analysis to identify differences
between the groups studied. However, cautions should be exer‐
cised in generalizing the findings to the whole teacher population of
Greece. The present results are representative of Athens, the capital
of Greece, including teachers and schools from different socioeco‐
nomic districts. However, and to the best of the authors’ knowledge,
this is the first survey in Greece highlighting the level of current pri‐
mary school teachers on dental trauma injuries.
It was very encouraging that all the participants requested to know
the correct answers at the end of the survey. They also requested to
be further informed through a presentation regarding prevention
and first‐aid management of dental trauma. However, the responses
to the questionnaire suggest the need for a series of actions to be
taken to improve the level of knowledge and first‐aid management
among school teachers in Greece. Education campaigns with posters
in schools,38,39 lectures on first‐aid steps followed by discussion with
teachers,40 or the use of an audio‐visual aid41 are effective methods
to improve their level of knowledge regarding the emergency manage‐
ment of dental injuries. The use of the mobile application “ToothSOS,”
developed by the International Association of Dental Traumatology
(IADT) and recently translated to Greek and other languages, can be
a very useful tool providing instant guidelines to school teachers and
other healthcare providers during dental trauma injuries. However,
further research needs to be conducted toward this direction. Besides
the preventive measures taken at schools, more central actions are
required for the information to be more official. The official teaching of
dental trauma first‐aid management in child‐related university depart‐
ments such as primary education or physical education departments
may significantly improve the level of knowledge about traumatic den‐
tal injuries. Finally, the establishment of an official public sector fo‐
cused on prevention, recording, and management of traumatic dental
injuries with the assistance of both Schools of Dentistry in Greece will
change the attitude of the authorities and all the involved individuals
including parents, teachers and healthcare professionals.
5 | CO N C LU S I O N S
1. The level of knowledge of primary school teachers in Greece
about first‐aid management during traumatic dental injuries is
limited.
2. A clear positive connection was found between the level of
knowledge of first‐aid dental trauma management and teaching
experience.
3. Reliable information about dental trauma may result in improving
the knowledge level of primary school teachers in Greece.
AC K N OW L E D G E M E N T S
The authors acknowledge the assistance of the local school adminis‐
trations, as well as all participating school teachers.
|
      49
C O N FL I C T O F I N T E R E S T S
The authors confirm that they have no conflict of interest.
ORCID
Nestor Tzimpoulas  https://orcid.org/0000-0003-0457-4549
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How to cite this article: Tzimpoulas N, Markou M, Zioutis V,
Tzanetakis GN. A questionnaire‐based survey for the
evaluation of the knowledge level of primary school teachers
on first‐aid management of traumatic dental injuries in Athens,
Greece. Dent Traumatol. 2020;36:41–50. https​://doi.
org/10.1111/edt.12503​