Enhancing nursing competencies: An assessment of knowledge and attitudes toward dental trauma management among nursing students—An interventional study

Citation: Carrion-Ruiz, B.E.; Cabrera- Fernandez, A.; Crespo-Gallardo, I.; Cabanillas-Balsera, D.; Segura-Egea, J.J.; Pabón-Carrasco, M.; Martin- Gonzalez, J. Enhancing Nursing Competencies: An Assessment of Knowledge and Attitudes Toward Dental Trauma Management Among Nursing Students—An Interventional Study. Nurs. Rep. 2024,14, 3765–3778. https://doi.org/10.3390/ nursrep14040275 Academic Editor: Richard Gray Received: 26 September 2024 Revised: 17 November 2024 Accepted: 27 November 2024 Published: 29 November 2024 Copyright: © 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). Article Enhancing Nursing Competencies: An Assessment of Knowledge and Attitudes Toward Dental Trauma Management Among Nursing Students—An Interventional Study Beatriz Emilia Carrion-Ruiz 1 , Alberto Cabrera-Fernandez 1 , Isabel Crespo-Gallardo 1 , Daniel Cabanillas-Balsera 1 , Juan J. Segura-Egea 1, Manuel Pabón-Carrasco 2,3,* and Jenifer Martin-Gonzalez 1,* 1Department of Stomatology, Faculty of Dentistry, University of Seville, 41009 Sevilla, Spain; [email protected] (B.E.C.-R.); acabr[email protected] (A.C.-F.); icr[email protected] (I.C.-G.); [email protected] (J.J.S.-E.) 2Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, 41009 Sevilla, Spain 3 Research Group PAIDI-CTS-1050: 7 “Complex Care, Chronicity and Health Outcomes”, University of Seville, 41009 Sevilla, Spain *Correspondence: [email protected] (M.P.-C.); [email protected] (J.M.-G.) Abstract: Introduction: Traumatic dental injuries (TDIs) present a significant challenge for healthcare professionals. Nurses, often the first point of contact for patients, may lack essential knowledge in dental trauma first aid, as noted in the existing literature. Objective: To assess the knowledge of traumatic dental injuries (TDIs) among undergraduate nursing students before and after a targeted educational intervention. Materials and Methods: This quasi-experimental study evaluated the effectiveness of an educational intervention involving 300 nursing students from two universities in Seville. The educational intervention was led by specialist dentists. A pre-test survey was administered to assess students’ baseline knowledge. The session included a lecture on TDI management, followed by a simulation in which students practiced emergency splinting techniques for referral to a dentist. A post-test survey was then conducted to measure changes in students’ knowledge and attitudes towards dental trauma. Results: Only 25.4% of students had prior training in dental trauma. After the intervention, there was a significant improvement in students’ self-assessed knowledge of first aid for TDIs (p< 0.05). A high percentage of students also reported increased confidence in their ability to reimplant a tooth. Statistical analysis of pre- and post-intervention survey results showed a substantial increase in average scores (p< 0.05). Conclusions: Nursing students initially exhibited limited knowledge in managing dental trauma but demonstrated a positive attitude toward learning this new skill. The targeted educational intervention significantly enhanced their understanding, underscoring the need to incorporate such training into nursing curricula. By improving nursing students’ competence in managing dental injuries, this training can help better preserve dental structures and improve the prognosis for dental trauma cases. Keywords: nursing; knowledge; health education; dental education; tooth injuries; first aid; dental trauma; traumatology; emergency care; allied dental personnel 1. Introduction In recent years, the prevalence of traumatic dental injuries (TDIs) has increased significantly [ 1 , 2 ]. Despite the oral cavity representing only 1% of the body, TDIs account for 5% of all bodily injuries [ 3 , 4 ]. According to a recently published systematic review [ 5 ], the prevalence of dental trauma is approximately 15%, with similar findings reported in Spain [6,7]. The avulsion of a permanent tooth accounts for 0.5–3% of TDIs [8]. The prevalence of TDI varies by age, with the highest incidence occurring between the ages of 7 and 12, during school age [ 9 – 11 ]. The upper incisors are the most commonly affected teeth [ 9 , 12 ] due to their prominent position in the mouth. Several predisposing factors for TDIs have been identified in the literature, including protruding upper teeth, Nurs. Rep. 2024,14, 3765–3778. https://doi.org/10.3390/nursrep14040275 https://www.mdpi.com/journal/nursrep Nurs. Rep. 2024,14 3766 overjet (greater than 3 mm), anterior open bite, class II malocclusion, incompetent lips, and mouth breathing [13–17], with increased overjet being one of the primary risk factors [18]. Additionally, the rise of new technologies introduced additional risk factors, particularly the accidental dropping of smartphones onto the face during periods of rest periods. This is linked to the weight of these devices and their widespread use globally [19,20]. The etiology of TDIs is closely linked to age, with different causes and patterns observed in preschoolers, school-age children, and adults. Common causes of TDIs include traffic accidents, sports injuries, assaults, and falls [21–23]. One of the most frequent TDIs is dental avulsion, which involves the complete displacement of a tooth from its socket. Avulsion accounts for 0.5% to 16% of all dental traumas, with the highest incidence for avulsion of permanent anterior teeth occurring between the ages of 7 and 9 years. Several studies have shown that the survival rate of an avulsed permanent tooth significantly improves if first aid and treatment are provided within the first 15 min following the injury [24]. A key factor in the successful reimplantation of a permanent tooth is the preservation of the periodontal ligament on the root. To prevent dehydration of the avulsed tooth, it must be stored in an appropriate medium. Therefore, timely and proper knowledge of emergency management is essential to ensure a favorable prognosis for the tooth [25]. The improper initial management of dental trauma can significantly impact the viability of the affected tooth and lead to psycho-emotional issues for the patient, stemming from both functional and aesthetic consequences. This, in turn, can negatively affect the patient’s overall quality of life [ 26 – 28 ]. While general dental practitioners typically have a moderate understanding of TDI management, specialists such as endodontists and pediatric dentists are more adept at handling these injuries due to their specialized knowledge in dental traumatology [ 29 ]. Moreover, medical doctors often lack sufficient expertise in managing dental trauma [ 30 , 31 ]. Therefore, prompt intervention by trained professionals in the initial management of TDI can significantly improve the prognosis of the affected tooth. Some studies emphasize the importance of increasing awareness among all healthcare providers who may be present at the scene of an accident or in the immediate aftermath, including those on the first line of response [ 32 ]. Coaches, recreational leaders, and first responders should all know the initial management of an avulsed tooth. Additionally, patient and parental education, along with timely medical care, can enhance treatment outcomes. The use of protective mouthguards in high-risk contact sports is also recommended as a preventive measure to reduce the incidence of dental injuries [16]. It is important to highlight that dental injuries are more common in children between the ages of 7 and 12, making it essential that those responsible for their care, such as parents, primary school teachers, and school nurses, are informed about how to manage these injuries. Nurses play a crucial role in emergency preparedness and are often the only healthcare professionals available to handle dental emergencies. Training nurses in this area is logical, as their emergency training makes them potential allies of dentists. Furthermore, many dental avulsions occur at night, when most dental clinics are closed, making hospital emergency departments the primary point of care for such traumas. In both school and hospital settings, nurses play a pivotal role in preserving dental integrity [33,34]. Several studies have also assessed the knowledge levels of various professionals who may serve as first responders, such as teachers, parents, or sports coaches, revealing an insufficient level of knowledge in this area [35–37]. It is crucial to emphasize the importance of healthcare professionals in managing such emergencies. They must possess the necessary qualifications to properly address TDI emergencies, based on scientific evidence [ 38 ]. However, the available literature indicates a deficient level of knowledge among non-dental healthcare professionals, particularly in nursing, regarding the initial management of TDI [36,38–41]. Taking into account the widespread lack of knowledge about first aid procedures in cases of dental trauma and the importance of correctly addressing TDIs, this study is particularly justified due to the significant knowledge gap in the field of nursing regarding Nurs. Rep. 2024,14 3767 TDIs [ 42 , 43 ]. The aim of the present study was to assess the knowledge and attitudes toward dental trauma management among nursing students, evaluating the impact of a training workshop on the management of dental avulsion. The alternative hypothesis suggests that there is a positive inclination toward gaining new competencies in first aid, particularly in managing dental trauma. Additionally, educational interventions that combine lectures with simulation have proven effective in improving the acquisition of these skills. 2. Materials and Methods 2.1. Study Design and Ethics A quasi-experimental pre-test–post-test study was designed to evaluate the knowledge and attitudes of nursing students regarding the management of dental trauma by surveys. A total of 300 nursing students were recruited from the Red Cross School of Nursing (Seville) and the University School of Osuna (University of Seville) over three academic years (2022–2023, 2023–2024, and 2024–2025). Accordingly, a multicenter, non-randomized experimental study was conducted, with pre- and post-intervention assessments carried out via a survey following an educational intervention. The study was approved by the ethics committee (code 1485-N-23). The MINORS tool (Methodological Index for Non-Randomized Studies) was used to evaluate the methodological quality of non-randomized studies [44] (Table S1). 2.2. Criteria The inclusion criteria required participants to be enrolled in a nursing degree program at a Spanish university and to have completed at least 75% of their studies (fourth year). In addition, it was verified that all participants had completed courses related to first aid, primary care, or trauma management, to ensure homogeneity in the sample regarding prior competencies. All nursing students who were not in the last year of their degree or who did not have courses related to first aid, primary care, or trauma management were excluded. Nursing students who had completed a degree in dentistry or maxillofacial medical specialty were also excluded. During the study, there were no participant dropouts as the post-test data collection was conducted immediately. Additionally, 100% of the students contacted provided consent to participate, likely because the educational intervention was not part of any academic evaluation and had no impact on their grades. Students were motivated by the opportunity to acquire new practical skills, and the professors leading the sessions were external to the institutions where the students were enrolled, which helped mitigate any perception of coercion. 2.3. Questionnaire A descriptive questionnaire consisting of 20 closed-end questions was used for data collection. These questions were based on surveys from previous studies [ 36 ] and were reviewed by researchers and professors from the Postgraduate Program in Clinical Endodontics at the University of Seville. The questionnaire was divided into four sections: sociodemographic data, previous training on the subject, attitudes towards the topic, and 11 questions related to knowledge on dental trauma management (Table S2). Following the initial evaluation using the questionnaire, a training workshop was conducted. Two licensed dentists with a master’s degree in Endodontics and over 10 years of professional experience were previously trained to deliver the workshop. The workshop consisted of two sections: a 40 min theoretical session, followed by a 30 min practical session using an anatomical model simulating a dental avulsion case (Figure 1). A total of eight sessions were held between 2022 and 2024. Nurs. Rep. 2024,14 3768 Nurs. Rep. 2024, 14 3768 session using an anatomical model simulating a dental avulsion case (Figure 1). A total of eight sessions were held between 2022 and 2024. Figure 1. Anatomical model and instruments during practical session. Data were collected digitally, with students completing anonymous online questionnaires using their smartphones. All surveys were evaluated by two endodontics specialists, who assigned scores ranging from 0 to 11 based on the correctness of the responses. Each correct answer was awarded one point, with a maximum score of eleven points. 2.4. Statistical Analysis The sample size was determined to ensure a statistical power of 0.95, with an alpha level of 0.05 and a medium effect size (calculated using the Chi-square test method, G*Power 3.0.10, Franz Faul, University of Kiel, Germany). A total of 298 participants were required [45]. Data analysis was performed using SPSS Statistics Version 29.0 (IBM Corporation; Armonk, NY, USA). Initially, a descriptive analysis was conducted using frequency tables, providing a numerical representation in percentages based on the total number of responses for each question. An inferential analysis followed, using the Chi-square test to determine whether significant differences existed between pre-intervention and post-in- tervention results. Additionally, a paired sample t-test was performed to analyze the scores obtained by the pre- and post-intervention groups. Statistical significance was set at p < 0.05. 3. Results Eighty-six percent (257 participants) were females, while 14.3% (43 participants) were males. Nineteen participants (6.3%) had previous experience in the dental field, specifying that 5% of participants held a degree in dental hygiene or were a clinical assistant (Table 1). Table 1. Socio-demographic variables and previous education of participants. Socio-Demographic Variables N = 300 Frequency (n) Percent (%) Sex Men 43 14.3 Women 257 85.7 Centre Red Cross Centre 163 54.2 Figure 1. Anatomical model and instruments during practical session. Data were collected digitally, with students completing anonymous online questionnaires using their smartphones. All surveys were evaluated by two endodontics specialists, who assigned scores ranging from 0 to 11 based on the correctness of the responses. Each correct answer was awarded one point, with a maximum score of eleven points. 2.4. Statistical Analysis The sample size was determined to ensure a statistical power of 0.95, with an alpha level of 0.05 and a medium effect size (calculated using the Chi-square test method, G*Power 3.0.10, Franz Faul, University of Kiel, Germany). A total of 298 participants were required [45]. Data analysis was performed using SPSS Statistics Version 29.0 (IBM Corporation; Armonk, NY, USA). Initially, a descriptive analysis was conducted using frequency tables, providing a numerical representation in percentages based on the total number of responses for each question. An inferential analysis followed, using the Chi-square test to determine whether significant differences existed between pre-intervention and post-intervention results. Additionally, a paired sample t-test was performed to analyze the scores obtained by the pre- and post-intervention groups. Statistical significance was set at p< 0.05. 3. Results Eighty-six percent (257 participants) were females, while 14.3% (43 participants) were males. Nineteen participants (6.3%) had previous experience in the dental field, specifying that 5% of participants held a degree in dental hygiene or were a clinical assistant (Table 1). In response to the previous questionnaire, 45.3% (136 participants) were able to distinguish between primary and permanent teeth. Additionally, 90% (270 participants) indicated they would attempt to preserve the tooth fragment, and 81.7% (196 participants) stated they would keep it in a moist environment. Regarding the clinical scenario of an avulsed tooth, 68.3% (205 participants) believed the tooth could be re-implanted, while 23.3% (70 participants) felt capable of performing the re-implantation themselves. When asked about the proper management of an avulsed tooth, 48.3% (145 participants) reported they would rinse the tooth under running water for 10 s. Finally, 82% (245 participants) confirmed they would refer the patient to a dentist (Table 2). Nurs. Rep. 2024,14 3769 Table 1. Socio-demographic variables and previous education of participants. Socio-Demographic Variables N = 300 Frequency (n) Percent (%) Sex Men 43 14.3 Women 257 85.7 Centre Red Cross Centre 163 54.2 University School of Osuna 137 45.8 Previous training Previous dental experience Yes 19 6.3 No 281 93.8 Previous dental trauma training Yes No 76 224 25.4 74.6 Previous avulsion experience Yes No 68 232 22.5 77.5 Mean (SD) 95% IC Max/Min Age (years) 22.28(3.21) 21.93–22.81 45/19 Notes: 95% IC = 95% Confidence Interval; Max/Min = Maximum/Minimum; N = Total sample size; n = Absolute frequency; SD = Standard Deviation. Table 2. Inferential analysis of the correct response rate between the pre- and post-educational intervention groups. ASK PRE GROUP N = 300 POST GROUP N = 300 STATISTICAL SIGNIFICANCE Self-concept (Do you think you have the knowledge necessary to manage a traumatic dental injury?) Yes 19.6% (n = 59) Not 80.4% (n = 241) Yes 87.4% (n = 262) Not 12.6% (n = 38) *p< 0.0001 Cramer’s V 0.679 Predisposition (Do you think you need more knowledge/training regarding dental traumatology?) Yes 85.8% (n = 257) Not 14.2% (n = 43) Yes 83.5% (n = 250) Not 16.5% (n = 50) p= 0.479 Distinction (Are you able to distinguish be-tween a temporary tooth and a permanent one) Yes 45.4% (n = 136) Not 54.6% (n = 164) Yes 99.1% (n = 297) Not 0.9% (n = 3) *p< 0.0001 Cramer’s V 0.596 Case 1A (Is this a temporary or perma-nent tooth?) Temporary 17.1% (n = 51) Permanent 82.9% (n = 249) Temporary 6.1% (n = 18) Permanent 93.9% (n = 282) *p< 0.0001 Cramer’s V 0.171 Case 1B (Would you keep the frag-ments?) Yes 90% (n = 270) Not 10% (n = 30) Yes 98.3% (n = 295) No 1.7% (n = 5) *p< 0.0001 Cramer’s V 0.174 Case 1C (What type of medium would you preserve it on?) Wet 81.7% (n = 245) Dry 16.7% (n = 55) Wet 99.6% (n = 299) Dry 0.4% (n = 1) *p< 0.0001 Cramer’s V 0.304 Case 2A (Do you think it is possible to relocate the avulsed tooth?) Yes 68.3% (n = 205) Not 31.7% (n = 95) Yes 94.8% (284) Not 5.2% (16) *p< 0.0001 Cramer’s V 0.339 Case 2B (Would you be able to reimplant it?) Yes 23.3% (n = 71) Not 76.3% (n = 229) Yes 92.6% (n = 278) Not 7.4% (n = 22) *p< 0.0001 Cramer’s V 0.702 Nurs. Rep. 2024,14 3770 Table 2. Cont. ASK PRE GROUP N = 300 POST GROUP N = 300 STATISTICAL SIGNIFICANCE Case 2C (In what time limit do you think it should be relocated?) Any time 2.1% (n = 6) First 5 h 14.2% (n = 43) After two hours to rehydrate 15.8% (n = 47) As soon as possible, without limit 48.8% (n = 146) In the first 24 h 19.2% (n = 58) Any time 0.4% (n = 1) First 5 h 8.3% (n = 25) After two hours to rehydrate 3.9% (n = 12) As soon as possible, without limit 83.5% (n = 250) In the first 24 h 3.9% (n = 12) *p< 0.0001 Cramer’s V 0.380 Driving (Given that the tooth is dirty, how would you handle it?) I would replace without washing 0.8% (n = 2) Wash with saliva 3.8% (n = 11) Wash 10 sec. Under water 48.3% (n = 145) Wash with milk 8.3% (n = 25) Wash with soap 7.5% (n = 23) Rub with brush 31.3% (n = 94) I would replace without washing 0.4% (n = 1) Wash with saliva 0.4% (n = 1) Wash 10 sec. Under water 82.2% (n = 247) Wash with milk 16.5% (n = 50) Wash with soap 0.4% (n = 1) Rub with brush 0% (n = 0) *p< 0.0001 Cramer’s V 0.505 Transport (What type of transportation do you consider most appropriate?) Liquid medium 64.6% (n = 194) Cold compress 15.8% (n = 47) Child’s mouth 4.6% (n = 14) Adult mouth 0.4% (n = 1) Wrapped in paper 5.4% (n = 16) Plastic container 9.2% (n = 28) Liquid medium 94.3% (n = 283) Cold compress 1.3% (n = 4) Child’s mouth 0.9% (n = 3) Adult mouth 3.5% (n = 6) Wrapped in paper 0% (n = 0) Plastic container 0 (n = 0) *p< 0.0001 Cramer’s V 0.430 Medium type (What type of medium do you consider most appropriate?) Fresh water 15.8% (n = 47) Milk 25% (n = 75) Alcohol 1.7% (n = 5) Serum 36.7% (n = 110) Ice water 2.9% (n = 9) Antiseptic solution 17.9% (n = 54) Fresh water 3.5% (n = 10) Milk 93.5% (n = 281) Alcohol 3% (n = 9) Serum 0% (n = 0) Ice water 0% (n = 0) Antiseptic solution 0% (n = 0) *p< 0.0001 Cramer’s V 0.699 Derivation (Which professional do you con-sider to be your choice?) Pediatrician 2.9% (n = 9) Dentist 81.7% (n = 245) Family doctor 0.8% (n = 2) Maxillofacial 14.6% (n = 44) Pediatrician 0% (n = 0) Dentist 97.4% (n = 292) Family doctor 0% (n = 0) Maxillofacial 2.6% (n = 8) *p< 0.0001 Cramer’s V 0.258 Score mean ±SD IC 95% 5.85 ±1.99 5.59–6.10 10.35 ±0.95 10.22–10.47 *p< 0.0001 Cohen’s d = 0.620 Notes: IC 95% = 95% confidence interval; N = Total sample size; n = Absolute frequency; Sec: Seconds; SD = standard deviation. Effect size = Cohen’s d = 0.2: Small effect size; 0.5: Moderate effect size; 0.8: Large effect size; Cramer’s V = 0–0.1: Very weak association; 0.1–0.3: Weak association; 0.3–0.5: Moderate association; 0.5–1: Strong association. Statistical significance = * p< 0.05. The analysis by center revealed statistically significant differences in the pre-test assessment of seven knowledge items between nursing schools. These differences may be attributed to the fact that students at the Red Cross Centre had more prior experience with avulsion (76.3% (n = 58) vs. 23.6% (n = 18)) and previous training in dental traumatology (69.2% (n = 47) vs. 30.8% (n = 21)). However, no significant differences were observed between the centers after the educational intervention (Table 3). Following the intervention, there was a notable improvement in the rate of correct answers across all questions assessing knowledge of first aid in dental trauma. The mean scores increased from 5.85 ±1.91 to 10.35 ±0.95 (Table 3). Nurs. Rep. 2024,14 3771 Table 3. Inferential analysis of the rate of correct answers between the pre- and post-educational intervention groups taking into account the educational center. ASK PRE-GROUP POST GROUP Cruz Roja n = 167 Osuna n = 137 Cruz Roja n = 167 Osuna n = 137 Self-concept (Do you think you have the knowledge necessary to manage a traumatic dental injury?) Yes 23.1% (n = 39) No 76.9% (n = 128) Yes 15.5% [17] No 84.5% (n = 116) Yes 89.7% (n = 150) No 10.3% (n = 17) Yes 85.1% (n = 117) No 14.9% (n = 20) Statistical significance p= 0.138 Cramer’s V 0.096 p= 0.297 Cramer’s V 0.069 Predisposition (Do you think you need more knowledge/ training regarding dental traumatology?) Yes 90% (n = 150) No 10% (n = 17) Yes 80.9% (n = 111) No 19.1% (n = 26) Yes 79.3% (n = 132) No 20.7% (n = 35) Yes 87.7% (n = 120) No 12.3% (n = 17) Statistical significance p= 0.044 * Cramer’s V 0.130 p= 0.086 Cramer’s V 0.113 Distinction (Are you able to distinguish between a temporary tooth and a permanent one) Yes 55.4% (n = 93) No 44.6% (n = 74) Yes 33.6% (n = 46) No 66.4% (n = 91) Yes 99.1% (n = 166) No 0.9% (n = 1) Yes 99.1%(n = 136) No 0.9% (n = 1) Statistical significance p< 0.001 *** Cramer’s V 0.218 p= 0.990 Cramer’s V 0.001 Case 1A (Is this a temporary or permanent tooth?) Temporary 15.4% (n = 26) Permanent 84.6% (n = 141) Temporary 19.1% (n = 26) Permanent 80.9% (n = 111) Temporary 7.8% (n = 13) Permanent 92.2% (n = 154) Temporary 4.4% (n = 6) Permanent 95.6% (n = 131) Statistical significance p= 0.447 Cramer’s V 0.049 p= 0.285 Cramer’s V 0.071 Case 1B (Would you keep the fragments?) Yes 96.2% (n = 161) No 3.8% (n = 6) Yes 82.7% (n = 113) No 17.3% (n = 24) Yes 100% (n = 167) No 0% (n = 0) Yes 96.5%(n = 132) No 3.5% (n = 5) Statistical significance p< 0.001 *** Cramer’s V 0.223 p= 0.052 Cramer’s V 0.134 Case 1C (What type of medium would you preserve it on?) Wet 80.8% (n = 135) Dry 19.2% (n = 32) Wet 82.7% (n = 113) Dry 13.6% (n = 24) Wet 100% (n = 167) Dry 0% (n = 0) Wet 99.1%(n = 136) Dry 0.9% (n = 1) Statistical significance p= 0.053 Cramer’s V 0.156 p= 0.312 Cramer’s V 0.067 Case 2A (Do you think it is possible to relocate the avulsed tooth?) Yes 83.8%(n = 140) No 16.2% (n = 27) Yes 50.4% (n = 69) No 49.6% (n = 58) Yes 96.6% (n = 161) No 3.4% (n = 6) Yes 93% (n = 127) No 7% (n = 10) Statistical significance p< 0.001 ***Cramer’s V 0.363 p= 0.224 Cramer’s V 0.080 Case 2B (Would you be able to reimplant it?) Yes 35.4% (n = 60) No 63.8% (n = 107) Yes 9.1% (n = 12) No 90.9% (n = 125) Yes 91.4% (n = 153) No 7.8% (n = 14) Yes 93.9% (n = 129) No 43.8% (n = 8) Statistical significance p< 0.001 *** Cramer’s V 0.318 p= 0.539 Cramer’s V 0.073 Case 2C (In what time limit do you think it should be relocated?) Any time 3.1% (n = 5) First 5 h 8.5% (n = 14) After two hours to rehydrate 13.8% (n = 23)As soon as possible, without limit 57.7% (n = 96) In the first 24 h 16.9% (n = 28) Any time 0.9% (n = 1) First 5 h 20.9% (n = 29) After two hours to rehydrate 18.2% (n = 25) As soon as possible, without limit 38.2% (n = 52) In the first 24 h 21.8% (n = 30) Any time 0.9% (n = 1) First 5 h 4.3% (n = 7) After two hours to rehydrate 3.4% (n = 6) As soon as possible, without limit 88.8% (n = 149) In the first 24 h 2.6% (n = 4) First 5 h 12.3% (n = 17) After two hours to rehydrate 4.4% (n = 6) As soon as possible, without limit 78.1% (n = 107) In the first 24 h 5.3% (n = 7) Statistical significance p< 0.001 *** Cramer’s V 0.241 p= 0.117 Cramer’s V 179 Nurs. Rep. 2024,14 3772 Table 3. Cont. ASK PRE-GROUP POST GROUP Driving (Given that the tooth is dirty, how would you handle it?) I would replace without washing 1.5% (n = 2) Wash with saliva 5.4% (n = 9) Wash 10 sec. Under water 50% (n = 84) Wash with milk 8.5% (n = 14) Wash with soap 5.4% (n = 9) Rub with brush 29.2% (n = 49) Wash with saliva 1.8% (n = 2) Wash 10 sec. Under water 46.4% (n = 64) Wash with milk 8.2% (n = 11) Wash with soap 10% (n = 14) Rub with brush 33.6% (n = 46) I would replace without washing 0.9% (n = 1) Wash with saliva 0.9% (n = 1) Wash 10 sec. Under water 75% (n = 126) Wash with milk 23.3% (n = 39) Wash 10 sec. Under water 89.5% (n = 123) Wash with milk 9.6% (n = 13) Wash with soap 0.9% (n = 1) Statistical significance p= 0.312 Cramer’s V 0.157 p< 0.058 Cramer’s V 0.218 Transport (What type of transportation do you consider most appropriate?) Liquid medium 73.8% (n = 123) Cold compress 12.3% (n = 20) Child’s mouth 6.9% (n = 12) Adult mouth 0.8% (n = 1) Wrapped in paper 1.5% (n = 3) Plastic container 4.6% (n = 8) Liquid medium 53.6% (n = 73) Cold compress 20% (n = 28) Child’s mouth 1.8% (n = 2) Wrapped in paper 10% (n = 14) Plastic container 14.5% (n = 20) Liquid medium 94% (n = 158) Cold compress 0.9% (n = 1) Child’s mouth 1.7% (n = 4) Adult mouth 1.7% (n = 4) Liquid medium 94.7% (n = 130) Cold compress 1.8% (n = 2) Adult mouth 1.7% (n = 5) Statistical significance p< 0.001 *** Cramer’s V 0.320 p= 0.509 Cramer’s V 0.100 Medium type (What type of medium do you consider most appropriate?) Fresh water 12.3% (n = 21) Milk 34.6% (n = 58) Alcohol 3.1% (n = 5) Serum 33.1% (n = 55) Ice water 2.3% (n = 4) Antiseptic solution 14.6% (n = 24) Fresh water 22% (n = 30) Milk 13.6% (n = 19) Serum 42.0% (n = 58) Ice water 6.6% (n = 9) Antiseptic solution 15.8% (n = 21) Fresh water 1.7% (n = 3) Milk 96.6% (n = 161) Serum 1.7% (n = 3) Fresh water 3.5% (n = 5) Milk 94.3% (n = 129) Serum 2.2% (n = 3) Statistical significance p< 0.001 *** Cramer’s V 0.283 p= 0.500 Cramer’s V 0.078 Derivation (Which professional do you consider to be your choice?) Pediatrician 1.5% (n = 2) Dentist 86.2% (n = 144) Maxillofacial 12.3% (n = 21) Pediatrician 4.5% (n = 6) Dentist 76.4% (n = 105) Family doctor 1.8% (n = 2) Maxillofacial 17.3% (n = 24) Dentist 97.4% (n = 163) Maxillofacial 2.6% (n = 4) Dentist 97.4% (n = 133) Maxillofacial 2.6% (n = 4) Statistical significance p= 0.116 Cramer’s V 0.157 p= 0.983 Cramer’s V 0.105 Score mean ±sd IC 95% 5.68 ±1.86 5.35 ±1.96 10.37 ±0.95 10.29 ±1.01 Statistical significance p= 0.136 p= 0.593 Notes: IC 95% = 95% confidence interval; n = Absolute frequency; Sec: Seconds; SD = standard deviation. Effect size = Cohen’s d = 0.2: Small effect size; 0.5: Moderate effect size; 0.8: Large effect size; Cramer’s V = 0–0.1: Very weak association; 0.1–0.3: Weak association; 0.3–0.5: Moderate association; 0.5–1: Strong association. Statistical significance = * p< 0.05, *** p< 0.001. 4. Discussion The results indicate an inadequate level of knowledge regarding the proper management of traumatic dental emergencies, although students show a proactive attitude toward acquiring these competencies. Educational intervention demonstrated its ability to reverse this situation, regardless of the educational institution involved. Moreover, prior experience proves to be an asset in acquiring new skills, as it facilitates the better internalization of information. This highlights the value of incorporating clinical cases, as well as both low- and high-fidelity simulators, into educational programs. Currently, no specific training in dental trauma is included in the nursing degree curriculum at Spanish universities, as it is not considered a core or specialized competency of nursing graduates. School nurses, as the first assistance available in trauma situations Nurs. Rep. 2024,14 3773 with school pupils, should have proper knowledge of the emergency early management of traumatic dental injuries to ensure the best possible prognosis for the injured teeth. Studies from different countries around the world demonstrated that school nurses lack proper knowledge of dental injury management and that a pressing need for training and education exists. This also applies to school teachers, another professional group whose knowledge and attitudes toward dental trauma have been assessed. [39,46–54]. It is noteworthy that 22.5% of respondents reported witnessing dental trauma—a figure lower than that found in similar studies among nurse practitioners [ 40 ]. This suggests that professional practice may increase exposure to such events, emphasizing the importance of prior knowledge before entering the workforce. One of the most critical aspects of properly managing a traumatic dental injury is the correct identification of a permanent tooth, distinguishing it from a temporary one, and vice versa. While only 45.4% of respondents considered themselves capable of making this distinction in the pre-intervention phase, this percentage significantly increased to 99.1% following the training session. Dental avulsion is one of the most serious injuries where immediate repositioning can determine the tooth’s prognosis [ 24 ]. This justifies the emphasis placed on avulsion-related questions in our questionnaire, as well as a significant part of the intervention. The goal is not to enable nurses to perform tasks exclusively to dental professionals but rather to ensure that they can manage emergencies, preserving the tooth in an optimal condition until a specialist can assess the extent of the injury. Initially, students were asked about the viability of repositioning an avulsed tooth after the accident. In the pre-intervention questionnaire, 68.3% believed it was possible, and this percentage significantly increased to 94.8% post-intervention. These results contrast with those of Hugar, S.M. and colleagues, where 41% of nurses reported being unaware that a tooth could be replanted in the initial assessment [33]. When asked about their willingness to reposition an avulsed tooth, only 23.3% expressed willingness to do so initially, but this increased significantly to 92.6% following the training. This increase is highly significant, given the importance of timely repositioning for a favorable prognosis. Delays beyond the first 15 min can lead to irreversible damage to the periodontal ligament cells, reducing the chances of successful treatment [ 10 , 22 ]. More pessimistic initial percentages have been observed in analogous studies from other countries [41]. If immediate reimplantation is not possible, and delayed reimplantation by a dental professional is opted for, the storage medium in which the tooth is kept becomes crucial, as it determines the survival of periodontal ligament cells. Prolonged exposure to a dry environment of 20–30 min can cause the loss of normal metabolism and physiology in these essential cells for tooth reattachment [ 24 ]. Prior to the intervention, 64.6% of respondents correctly identified the appropriate transport medium, and this percentage increased to 99.6% afterwards. Although there is a significant difference, the initial 64.6% reflects a reasonable level of knowledge, potentially due to the students’ familiarity with the cytotoxic effects of antiseptics commonly used in healthcare. Not all liquid mediums equally preserve cellular physiology, and although no medium is 100% compatible with the survival of periodontal ligament cells, milk is considered the “gold standard” by the International Association of Dental Traumatology [ 9 ] due to its high compatibility [ 55 ]. In the initial phase of the study, when students were asked about the type of liquid medium, 25% selected fresh milk—a figure that rose to 93.5% following the educational intervention. Additionally, to quantify the improvement in participants’ knowledge of first aid in dental trauma, the pre- and post-intervention questionnaires were scored based on questions that could be evaluated as either correct or incorrect. A statistically significant difference was observed when comparing the pre- and post-intervention scores, consistent with the findings of Al Sari, S. [56].