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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 7  |  Issue : 1  |  Page : 39-61

Effectiveness of school-based dental health education on knowledge and practices related to emergency management of dental trauma and tooth avulsion: An educational intervention study


1 Department of Public Health Dentistry, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, JSS Medical Institutions Campus, Mysore, Bengaluru, India
2 Department of Public Health Dentistry, JKK Nattraja Dental College and Hospital, Komarapalayam, Tamil Nadu, India

Date of Submission23-Nov-2019
Date of Acceptance08-Oct-2020
Date of Web Publication25-Mar-2021

Correspondence Address:
Dr. Byalakere Rudraiah Chandra Shekar
Department of Public Health Dentistry, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, JSS Medical Institutions Campus, SS Nagar, Mysore, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_56_19

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  Abstract 


Introduction: Trauma to teeth and jaws are considered major public health problems. The school environment is the most susceptible place for children, to encounter trauma to teeth.
Materials and Methods: This interventional study was conducted to evaluate the effectiveness of school-based dental health education (DHE) on knowledge and practices related to emergency management of dental trauma and tooth avulsion among students and teachers of three government and three private schools each selected from two mandals (Mandal is a sub-district which comprises of a cluster of villages and village is the lowest level of administrative sub-division in rural areas of India) of Guntur district. Baseline information was collected from participants using a validated structured questionnaire. DHE on “Dental Trauma and Emergency Management of Tooth Avulsion” was offered using audiovisual aids (Flip charts, Slideshow) by a qualified Public Health Dentist. Subsequently, trained science teachers in each school were requested to undertake health education sessions at monthly interval for the next 3 months. Postintervention data were collected 1 week after initial DHE by public health dentist and 1 week after last reinforcement session by the teacher. Mean knowledge and practice scores were compared using independent sample t-test and Repeated Measures Analysis of Variance.
Results: A total of 1180 children (570 males and 602 females, age range: 12–16 years) and 54 teachers (24 males and 30 females, age range: 20–56 years) were included. Mean scores for knowledge and practices increased among students and teachers following intervention with no difference between flipchart and slideshow method.
Conclusion: Teachers (preferably science teachers) could be effectively used for DHE provided that they receive proper training and continued education on dental trauma.
The following core competencies are addressed in this article: Medical knowledge, Practice-based learning and improvement, Systems-based practice.

Keywords: Dental health education, dental trauma, knowledge and practice, school dental health, tooth avulsion


How to cite this article:
Srilatha Y, Shekar BR, Krupa N C. Effectiveness of school-based dental health education on knowledge and practices related to emergency management of dental trauma and tooth avulsion: An educational intervention study. Int J Acad Med 2021;7:39-61

How to cite this URL:
Srilatha Y, Shekar BR, Krupa N C. Effectiveness of school-based dental health education on knowledge and practices related to emergency management of dental trauma and tooth avulsion: An educational intervention study. Int J Acad Med [serial online] 2021 [cited 2021 Apr 11];7:39-61. Available from: https://www.ijam-web.org/text.asp?2021/7/1/39/311882




  Introduction Top


The mouth is considered the mirror of body and gateway of good health.[1] Oral health is integral to general health and has a profound impact on the quality of life.[2],[3] Oral health facilitates an individual to speak, eat and socialize without any discomfort or embarrassment.[4] Although dental caries and periodontal diseases have historically been the most significant global oral health burdens,[3] trauma to teeth and jaws are also considered major public health problems in recent times.[5] Some countries in Latin America report prevalence of dental trauma to be 15% among schoolchildren, while it ranged from 5% to 12% among children aged 6–12 years in the Middle East.[6] Traumatic dental injuries are, for the most part, unanticipated events that, if not managed appropriately, can have serious consequences to the patient.[7] Traumatic consequences may range from small tooth fractures to a complete dislocation of the tooth from its alveolus, characterizing a scenario of dental avulsion etc.[8]

The school environment is the most susceptible place for children, to encounter trauma to the teeth.[9] Tooth loss as a result of untreated dental disease and trauma, can affect child's nutritional intake and consequently, has a significant impact on their growth, development and quality of life.[5] Pain, discomfort, sleepless nights and time off school or work are the common problems for many children and adults.[10] Tooth avulsion (Exarticulation) which is defined as the total displacement of the tooth out of its alveolar socket accounts for 0.5%–16% of traumatic injuries in the permanent dentition.[11] Relative to other tooth injuries, avulsion is a more serious assault on the gingiva, periodontal ligament and pulp.[12],[13] Immediate re-implantation is widely accepted as the most appropriate treatment for a traumatically avulsed permanent tooth. Several studies have shown that re-implantation should be done as soon as possible ideally within minutes after tooth avulsion.[11],[14],[15] The International Association of Dental Traumatology and American Academy of Pediatric Dentistry acknowledge that dental injuries could have improved outcomes if the public was aware of first aid measures and the need to seek immediate treatment.[8] Enhancing the levels of knowledge in school children, teachers and parents by educating through various health education modes could be a way to improve awareness of dental trauma management, thereby the oral health-related quality of life. The National Education Policy of India also encourages linkages between education and health. Schools and School children can act as health changing agents in the community.[16],[17] School provides an ideal setting for promoting oral health and to offer preventive services in an efficient and effective way to children worldwide and through them, families and community members.[4],[18] In view of scanty published literature on emergency management of dental trauma and tooth avulsion in India, the present study was undertaken to assess the effectiveness of school based dental health education (DHE) on knowledge and practices related to emergency management of dental trauma and tooth avulsion among students and teachers in Government and Private Schools of Guntur district, Andhra Pradesh, India.


  Materials and Methods Top


This was an interventional study conducted among students and teachers in Government and Private schools of Guntur district, Andhra Pradesh, India over a period of 6 months from September 2016 – February 2017. Ethical Clearance was obtained from the Institutional Ethical Committee (IEC) following the submission of the research protocol (Reference number: JSS/DCH/IEC/MD-24/2015-16).

India comprises 28 states and 7 union territories. These states and union territories are divided into districts. Each district is further subdivided into sub-districts which are known differently in different parts of the country such as tehsil, taluka, community development (CD) block, Mandal, revenue circle, etc.). Each Mandal/Tehsil will have a cluster of villages under them for administrative purposes. The lowest primary administrative units are the villages in rural areas and towns in urban areas. The villages are of different sizes in terms of population, depending upon the geography of the area, availability of land and water, etc. The population in a village may range from 100 to 10,000. The towns include statutory towns (as notified by the government) and census towns as identified by the census organization on the basis of well-defined criteria such as population, land etc., Towns usually will have a population of 10,000–20,000.[19]

Guntur district is an administrative district in the state of Andhra Pradesh, India. It has 57 mandals. Two mandals were selected using the lottery method of simple random sampling. All the mandals in the district were listed, and they were given an identification number. These numbers were written on identical paper slips of uniform size and shape. The paper slips were folded, shuffled and the blindfold selection was made to pick two slips from 57 slips. The two selected mandals were Tadikonda and Amaravathi. The list of Government and private schools in these mandals was obtained from the Department of School Education with prior permission from the concerned Mandal Education Officers. All Government and Private schools in each mandal were given identification numbers. Three government and three private schools each from these mandals were then selected using the lottery method of simple random sampling. Permission was obtained from the District Education Officer (DEO), Guntur to undertake the study. Permissions to carry out the study in selected schools were also obtained from the concerned authorities (Head of the Institution/Principal and Head Masters). A schedule providing information on date and time of various activities to be undertaken in the school during the study was prepared and communicated to concerned headmaster of the school through the mandal education officer. A written informed assent from students who were willing to participate in the study was obtained in English and/or local (Telugu) language. Written informed consent from the school teachers who were willing to participate in the study was also obtained in English and/or local (Telugu) language. [Annexure 1] is the schematic representation of the sequence of activities in the research.



Development and validation of questionnaire

Initial questionnaire containing 34 items was developed using a review of literature and discussion with faculty in the Department of Public Health Dentistry of our institution. The questionnaire was subjected to face validation by two subject experts in public health dentistry, following which two items were removed from the initial questionnaire for lack of relevance. The questionnaire was then subjected to content validation by another two subject experts where the subject experts were asked to grade each item in the questionnaire for its relevance, appropriateness and clarity on a Likert scale of 1-5 (1 being most unfavorable response and 5 being most favorable response). 2 items were removed for lack of appropriateness from the initial questionnaire and 3 items were removed for being irrelevant and 2 for not being clear. The final questionnaire had 25 items. Cognitive interviewing was undertaken on a convenient sample of 20 prospective participants (16 students and 4 teachers). The retrospective verbal probing technique was used for eliciting the response process validity. Wording of two items was modified based on their suggestions to facilitate a correct interpretation of items. Then, the questionnaire was checked for its reliability in both the languages, English and Telugu before being used for data collection in the study on a convenient sample of 16 prospective participants (12 students and 4 teachers). The test-retest reliability assessment was done with an interval of 2 days between the tests. The Cronbach's alpha was 0.77 and 0.79 for English and Telugu versions respectively which demonstrated acceptable reliability of items. The flow diagram on the process of development and validation of the questionnaire is presented as [Annexure 2]. Final questionnaire of 25 items had three sections. Section 1 contained demographic details of study participants, while sections 2 and 3 had questions related to knowledge[15] and practices[10] on emergency management of dental trauma and tooth avulsion, respectively. The final questionnaire in English and Telugu is attached as [Annexure 3] and [Annexure 4].



All available sixth and ninth standard school students along with teachers in selected twelve schools who fulfilled the following eligibility criteria were considered. The age of admission of students into the school system in India is approximately 6 years. We intended to consider 12 and 15 years children into our research as these are two index age groups recommended by the World Health Organization for oral health surveys.[20] Moreover, the headmasters of the schools also informed the investigators not to disturb the academic activities for grade ten children as they were preparing for board examinations. Hence, children in grade 6 and 9 were assumed to be 12 and 15 years, respectively, and they were considered for data collection.

Inclusion criteria

  • Students and teachers who were willing to participate in the study by offering an informed consent
  • The participants should have completed pre- and post-intervention questionnaires (baseline, immediately after, 3 months after).


Exclusion criteria

  1. School children and teachers who were absent during the study period either at baseline or after intervention
  2. Incompletely filled questionnaires.


Collection of baseline data

Baseline knowledge and practices on emergency management of dental trauma and tooth avulsion among sixth and ninth standard school students and teachers were obtained using a self-administered questionnaire in English and/or local (Telugu) language 1 week prior to the date of DHE in their school.

Intervention

DHE on “Dental Trauma and Emergency Management of Tooth Avulsion” was offered to all the school students and teachers using Audio-visual aids (Flip charts, Slideshow) by a qualified Public Health Dentist. DHE for each class in each school was given for 30 min. While giving health education to students, teachers from respective classes had also attended the health education sessions. Two different modes of interventions were used for DHE:

  • Group 1: DHE using Flip charts
  • Group 2: DHE using Slide show (Powerpoint presentation).


DHE material contained the same information in both flipchart and slideshow intervention groups. Health education material on the emergency management of dental trauma and tooth avulsion was given the title “SAVE YOUR TOOTH.” The education material was designed with more of pictures to keep the students focused. It started with a brief introduction of general information on teeth, various oral diseases, dental trauma, most common types of dental trauma, tooth Avulsion, first aid measures for avulsed tooth, Replantation, Storage media, prevention of dental injuries, Do's and Don'ts in case of a dental injury. The content validation of the DHE material was done by two public health dentists. The DHE material in English and Telugu language used in the research is attached as [Annexure 5].



Although the initial DHE session was attended by all teachers in the school along with students, the science teachers in each school were requested to undertake subsequent health education sessions at monthly interval for the next 3 months using the health education material provided. A total of 12 schools (six government and six private schools) were participating in the study. All the government schools were listed first following which the private schools were listed. Identification numbers were given for these schools. All the schools with an odd number as their identification number were assigned to flip chart group and schools with even numbers as identification numbers were assigned to slide show group. The group allocation was done by the coordinator of the research. The flipcharts containing basic information on emergency management of dental trauma and tooth avulsion was handed over to those schools which were given health education through flipchart at the first instance. In the remaining schools, a PowerPoint presentation containing the slide show on emergency management of dental trauma and tooth avulsion was handed over to the teachers. These schools were offered DHE using slide show in the first instance as well. Science teachers who were trained for undertaking reinforcement session in each school were asked to get their doubts (if any) clarified, before undertaking the reinforcement sessions at monthly intervals. They were also given the principal investigator's contact number to resolve any new queries raised by the students during the reinforcement sessions. The science teachers were requested to maintain a diary to document the delivery of DHE and attendance of all participants in each DHE session.

Postintervention data collection

Although, DHE was offered to all school students and interested teachers, the postintervention data related to knowledge and practices on emergency management of dental trauma and tooth avulsion was obtained from sixth and ninth standard students and teachers who completed self-administered questionnaire at baseline. The postintervention questionnaire was self-administered 1 week following initial DHE by qualified Public Health Dentist and 1 week after the last intervention by the teacher concerned. The change in levels of knowledge and practices immediately after DHE by a qualified public health dentist as well as 3 months following intervention (three reinforcement sessions were given by trained teachers at monthly interval during this time duration) were assessed and compared between different groups (schools with different methods of DHE).

Statistical analysis was performed using the Statistical Package for the Social Sciences version 22.0 (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. USA). The correct response for each item in the questionnaire was coded as 1 while incorrect/don't know response was coded zero. Knowledge related 15 items were pooled together to determine knowledge score for each participant and average for the group was computed. In the same manner, the average for 10 practice related items was computed. Mean knowledge and practice-related scores between different groups at each time interval was compared using independent sample t-test and between different time intervals in each group was compared using the Repeated Measures Analysis of Variance.


  Results Top


The baseline evaluation included 1279 students and 55 teachers from three Government and three Private Schools each, selected from two mandals of Guntur district. Among 1279 student participants, 99 participants were excluded. The dropout rate was 7.7% among student participants. The reasons for exclusion of participants were absence during any of the three data collection schedule (29 participants), absence in any of the three DHE sessions which were offered by trained teachers (27 participants), and incompletely filled questionnaires either at baseline (32 participants) or immediately following DHE by Public Health Dentist (8 participants) or 3 months after intervention (3 participants). After making necessary exclusion, a total of 1180 student participants were finally considered for the study. Among them, 570 were males and 602 were female students. The age range of student participants was 12–16 years. Distribution of student participants in relation to the type of school, gender and age is denoted in [Table 1]. Among 55 teachers, 01 participant was excluded from the study due to her absence for data collection in one of follow-up period. A total of 54 teacher participants (24 males and 30 females, age range of 20–56 years) were considered for the study after necessary exclusion [Table 2]. Dropout rate among teachers was 1.8%.
Table 1: Demographic details of student participants in flipchart and slideshow intervention groups

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Table 2: Demographic details of teacher participants in flipchart and slideshow intervention groups

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The mean knowledge score among students at baseline was 7.68 ± 2.43, which increased to 12.45 ± 2.61 immediately after intervention while the mean score decreased to 10.82 ± 3.07 3 months after intervention. The post hoc test showed a statistically significant difference between all these time intervals (P = 0.00). This was true even when a separate comparison was made in flipchart and slideshow intervention groups [Table 3]. Although the mean knowledge score among student participants was significantly higher in Flip chart group (8.19 ± 2.35) compared to slideshow group (7.27 ± 2.42) at baseline, there was no significant difference between the groups during postintervention comparison [Table 3]. The mean knowledge score among teachers at baseline was 8.39 ± 2.59, which increased to 13.79 ± 1.12 immediately after intervention while the mean score increased to 13.87 ± 1.17 3 months after intervention. The post hoc test showed a statistically significant difference between baseline and two postintervention periods (P = 0.00) while it was not significant between immediately and 3 months after intervention (P = 0.42). This was true even when a comparison was made exclusively in flipchart and slideshow intervention groups [Table 4]. There was no significant difference in the mean knowledge score among teachers in flipchart and slideshow intervention groups at baseline as well as two postintervention time intervals [Table 4].
Table 3: Mean knowledge scores among students at baseline, immediately and 3 months after intervention in two different intervention groups

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Table 4: Mean knowledge scores among teachers at baseline, immediately and 3 months after intervention in two different intervention groups

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The mean practices score among students at baseline was 5.76 ± 2.27, which increased to 7.73 ± 2.21 immediately after intervention while the mean score decreased to 7.13 ± 2.44 3 months after intervention. The post hoc test showed a statistically significant difference between all these time intervals (P = 0.00). This was true even when a separate comparison was made in flipchart and slideshow intervention groups [Table 5]. The mean practices score among student participants was significantly higher in Flip chart group (5.98 ± 2.23) compared to slideshow group (5.59 ± 2.29) at baseline. However, 1 week following initial DHE by public health dentist, mean practices score among student participants was significantly higher in slideshow group (7.94 ± 2.03) compared to Flip chart group (7.49 ± 2.39). There was no statistically significant difference between the groups 3 months following the intervention [Table 5]. The mean practices score among teachers at baseline was 5.37 ± 2.61, which increased to 9.57 ± 0.88 immediately after intervention while the mean score increased to 9.59 ± 0.88 3 months after intervention. The post hoc test showed a statistically significant difference between baseline and two postintervention periods (P = 0.00) while it was not significant between immediately and 3 months after intervention (P = 0.32). This was almost true even when an exclusive comparison was made in flipchart and slideshow intervention groups [Table 6]. Although, the mean practices score among teachers was significantly higher in flipchart group (6.03 ± 2.01) compared to slideshow group (4.41 ± 3.09) at baseline, there was no significant difference in the mean practice score between the two intervention groups immediately after (P = 0.6) and 3 months after intervention [P = 0.74, [Table 6]].
Table 5: Mean practices scores among students at baseline, immediately and 3 months after intervention in two different intervention groups

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Table 6: Mean practices scores among teachers at baseline, immediately and 3 months after intervention in two different intervention groups

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  Discussion Top


Health education is one of the most cost-effective interventions. School settings are one of the best-suited locations to initiate DHE interventions. Through the schools with students and teachers as target groups, there could be substantial dissemination of information to their families, communities and future generations. First aid is the preliminary emergency care performed at the site of an accident or during any mishap before taking the victim to a medical professional. First-aid measures can be provided by any individual irrespective of their professional background, if he/she have a basic training. Lay population are much aware of certain first aid measures to be undertaken in case of any animal bites, fire accidents, road traffic accidents, poisonings etc., However, providing first aid during dental trauma and tooth avulsion is something they are not so familiar with. General populations, in fact, are not aware that they could give first aid in case of any dental injury. Tooth avulsion is one such emergency situation in dentistry wherein prompt actions in those critical times before consulting a dentist can markedly enhance the prognosis of treatment. Many studies in the existing literature focused only on assessing their knowledge, attitudes and practices related to emergency management of dental trauma and tooth avulsion[13],[21],[22] with very few studies evaluating the impact of health education interventions aimed at improving their knowledge, attitudes and practices.[8],[23],[24]

DHE by qualified public health dentists to all school-going children, although is an idealistic necessity; it is not a realistic option. Literature indicates that trained school teachers could be effectively utilized to bring about positive, healthy practices and lifestyles among students.[25],[26] This interventional study focused on training the science teachers in government and private schools on emergency management of dental trauma and tooth avulsion and subsequently, evaluated the feasibility and effectiveness of these teachers in undertaking reinforcement sessions using the audiovisual aids provided to them. The study compared two different methods of DHE, namely, the flipchart method and slideshow (PowerPoint presentation) method. The flipcharts method was chosen for comparison with slide show method as some of the remote rural government schools in developing countries like India may not have provision to use computer projections for PowerPoint presentations. This study enabled us to evaluate the effectiveness of flipchart method which can be adopted in such schools which lack computer-based projection facility with that of slide show method which is adoptable in schools having provision for computer-based education. The content for DHE and tool for evaluating the knowledge and practices related to emergency management of dental trauma and tooth avulsion were validated to school settings. These can be applied to all government and private schools.

The mean knowledge score among students improved significantly from 7.68 ± 2.43 at baseline to 12.45 ± 2.61 immediately after health education. However, the score decreased to 10.82 ± 3.07 3 months after intervention. Mean knowledge score among teachers increased from 8.39 ± 2.59 at baseline to 13.79 ± 1.12 immediately after health education and slightly increased to 13.87 ± 1.17 3 months after health education. The possible reason for improvement in their knowledge could be attributed to the content of DHE which was developed in such a way that the students and teachers could easily relate themselves to the scenarios and get prepared to face such situations in their routine life. It was the realization of the fact among participants that such injuries could happen in their life and they should be prepared with adequate knowledge to perform some simple first aid services at the site of injury which plays a substantial role in determining the ultimate success of treatment of an avulsed tooth could have created interest to actively participate in DHE sessions. The active participation could have contributed to improvement in their knowledge on why, when and how to go about performing emergency first aid services before consulting a dental practitioner in the event of dental trauma. This corroborated with the findings of a study by Pujitha et al.[27] who found an improvement in the knowledge levels from 19.2% to 82.4% among rural teachers and from 25.2% to 82.9% among urban teachers following health education. Karande et al.[28] found an increase in the knowledge level of teachers with regard to replantation of permanent teeth. The knowledge score in their study increased from 16% at baseline to 95% 3 months after the lecture. Another study by Andersson et al.[29] in 2006 among school children in Kuwait also found an increase in the knowledge scores following health education. These results were similar to the results of our study.

Mean practices score among students increased from 5.76 ± 2.27 at baseline to 7.73 ± 2.21 immediately after health education which decreased to 7.13 ± 2.44 3 months after intervention. Mean practice score among teachers increased from 5.37 ± 2.61 at baseline to 9.57 ± 0.88 immediately after health education and slightly increased to 9.59 ± 0.88 3 months after health education. The marked improvement in their practice responses following health education could be attributed to enhanced knowledge on various storage media that could be used to store an avulsed tooth if immediate replantation is not possible. Some teachers have expressed that they were totally unaware about storage and transportation media to be used during tooth avulsion before this DHE. Active participation during DHE, the contents of which were based on felt needs of the participants could have resulted in active learning. The results of the present study were comparable with the results of a study by Al-Asfour et al.,[30] who found a substantial improvement in knowledge levels of Kuwaiti intermediate school teachers on suitable storage medium for the avulsed tooth. The decline in student's knowledge 3 months after health education was possibly due to the natural human tendency of forgetting new concepts after a certain period of time. This could happen in the absence of any such events occurring in their real-life during that period where they could have applied this new knowledge. This decline in the scores among students 3 months following the initial DHE highlights the need for reinforcement sessions at regular intervals. We presume that these scores could have dropped down to somewhere very close to baseline scores in the absence of reinforcement sessions by teachers. Among teachers, the knowledge and practices responses remained the same for most of the questions even after 3 months following health education. This could be due to their higher maturity levels and education compared to the students. Further, the active involvement of teachers to reinforce the students at regular intervals could have compelled some of these teachers to frequently go through the reading material provided to them.

The improvement in knowledge and practice responses from baseline to postintervention periods demonstrates the effectiveness of DHE. Sustainment of improved responses even after 3 months could be attributed to reinforcements offered by school teachers. This demonstrates the fact that teachers also could effectively undertake such health education sessions in their regular curriculum. The reaction of the participating students and teachers (evaluation at Kirkpatrick's level 1)[31] was very encouraging and well acknowledged. This could markedly improve their own knowledge and practices toward emergency management of dental trauma and tooth avulsion besides improving student's knowledge and practices. Teachers and students could act as change agents who in turn can spread this knowledge among the general population. We found both methods of reinforcements to be effective in enhancing and sustaining the knowledge and practice related responses among participants (evaluation at Kirkpatrick's level 2).[31]

Novelty

The use of two practically feasible methods of DHE (flipchart method and slideshow method) and the demonstration of the fact that both methods are effective is the novelty of this research. Both methods were effective in enhancing the knowledge and practice related competencies among the participants. One of these methods could be adopted in school systems depending on the availability of digital technology infrastructure. Besides the demonstration on feasibility and effectiveness of these two methods of DHE, this research provides additional evidence to the existing literature that DHE through trained teachers is a practical solution to tackle the issue of lack of knowledge on emergency first aid services in the management of dental trauma and tooth avulsion among school children who are highly prone to traumatic dental injuries. The questionnaire used in this research has 25 items (15 items for eliciting knowledge and 10 items related to practices) which are validated. This new tool could be used in similar studies with further validation to make it suitable for local contexts and scenarios.

Limitation

The participation of students and teachers in both government and private schools was enthusiastic, and the intervention was well accepted. The postintervention results also were similar in both intervention groups. However, a subgroup analysis between government and private schools in each intervention group was not done. This could have highlighted how private schools performed in comparison with government schools. We could have assessed the performance of students in their ability to apply first aid services during tooth avulsion either by using a mannequin or through role plays mimicking the real-life scenarios. This could have given us an opportunity to evaluate performance in a simulated setting (evaluation at Kirkpatrick's level 3).[31] However, we could not undertake this owing to time and financial constraints.


  Conclusion Top


The knowledge and practices response scores improved substantially with school-based DHE through flipchart and slideshow interventions among participating students and teachers. Thus, health education intervention through schools proved to be effective in enhancing existing knowledge and practices among participants. However, the knowledge gained through health education tends to deplete over a period of time if there is no timely reinforcement. Thus, school settings can be used as an ideal platform for the reinforcement of oral health promotion activities by integrating into the regular school curriculum. Health and oral health promotion concepts should be included in teacher training sessions and teachers should be trained in basic emergency services. Dental professionals also should take part voluntarily in school based and community-based oral health promotion activities focusing on prevention and educating the public through all possible means. DHE using flipcharts and slideshow are feasible options to educate the school children on emergency first aid management of dental trauma and tooth avulsion. Teachers (preferably science teachers) could be effectively used for DHE provided that they receive proper training and continued education on dental trauma.

Way forward: The project can be expanded to cover all the districts in the state during the next phase keeping the limitations cited above in mind and subsequently to all schools in the country.

Acknowledgments

We express our sincere thanks to Principal, all teaching faculty in the department, teacher and student participants for their kind support in completing this project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require Institutional Review Board/Ethics Committee review, and the corresponding protocol/approval number is JSS/DCH/IEC/MD-24/2015-16 (2) dated February 12, 2016.



 
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