Dental Traumatology 2017; 33: 13–18; doi: 10.1111/edt.

12298

Smartphone App as an aid in the

emergency management of avulsed teeth

Ala Al-Musawi1, Mona Al-Sane2,
Lars Andersson1
1
Department of Surgical Sciences, Faculty of
Dentistry, Health Sciences Center, Kuwait
University; 2Department of Developmental and
Preventive Sciences, Faculty of Dentistry,
Health Sciences Center, Kuwait University,
Kuwait City, Kuwait
Key words: tooth avulsion; dental trauma;
replantation; emergency management; App
Correspondence to: Ala Al-Musawi,
Department of Surgical Sciences, Faculty of
Dentistry, Health Sciences Center, Kuwait
University, P.O. Box 24923, Safat, Kuwait City
13110, Kuwait
Tel.: +965 2498 6695
Fax: +965 2498 6732
e-mail: jaw@hsc.edu.kw
Accepted 29 June, 2016
Abstract – Background/Aim: The initial response by bystanders to an
avulsed tooth is a significant factor that can affect its survival and long-term
outcome. This study was to assess the knowledge of emergency management
of tooth avulsion in a group of schoolteachers and to compare the effects of
three different educational interventions. Methods: Baseline knowledge
was assessed using a questionnaire developed for this study. The same
questionnaire was used to test changes in the knowledge level following each
educational intervention. A convenience sample of elementary and interme-
diate school teachers (n = 87) participated in this study. Teachers were
divided into three groups: Group 1 (Lecture only) was given a 30-min lecture
on the emergency management of tooth avulsion. Their knowledge was
assessed immediately after the lecture. Group 2 (Lecture and App), the same
lecture was given, but participants also had access to a smartphone App,
Dental Trauma App (Dental Trauma AB, Link€ oping, Sweden), when
assessed on their knowledge after the lecture. Group 3 (App), this group was
only given the smartphone App to explore and had access to that when being
assessed. Results: All three interventions increased the knowledge of tooth
avulsion management. A marked increase in the knowledge, regardless of
the type of intervention, was observed in the following areas: handling the
tooth on the ground (16–96.8%); holding the tooth while being cleansed
(19.1–62.5%); and on the best storage medium (10.1–59.3%). Participants
using the App only had a significantly higher mean score than participants
receiving the lecture only (group 3; P = 0.019) and participants subjected to
both Lecture and App (group 1; P = 0.000). Conclusion: The Dental
Trauma App alone is an effective means of providing accessible knowledge
to guide laypeople in managing tooth avulsion, and it can be superior to a
lecture-based delivery of information.

The prognosis of dento-alveolar injuries is largely proper emergency management is to be provided to

dependent on their management at the accident site
(1–9). With school aged children being among the high-
est risk groups for injuries, and with many accidents
occurring at school (10), knowledge of school teachers
in the correct management of dento-alveolar injuries is
a key factor in determining the prognosis of injured
teeth. Several studies have, however, shown that teach-
ers’ knowledge is weak in this area (11–21). Multiple
assessments have been made of the effectiveness of dif-
ferent educational interventions, such as lectures, pos-
ters and brochures, in raising teachers’ awareness of
optimal emergency management procedures (17–22).
Lectures and discussions, either alone, or combined
with other reading material, have been shown to be
more effective than reading material alone (19). This
has been attributed to the direct face-to-face interaction
with the trauma expert delivering the information (23).
Delivering lectures, however, is costly when targeting
wide sectors of the population. It requires a significant
resource investment (23, 24). A more practical, cost-
effective alternative is a necessity if knowledge of the
teachers and the general community (23). Currently,
smartphones and their software applications (Apps) are
accessible by the majority of people. With approxi-
mately five billion mobile phone users globally, oppor-
tunities for mobile technology use in health information
dissemination are being increasingly recognized (25–28).
Recently, a smartphone App, Dental Trauma App
(Dental Trauma AB, Link€ oping, Sweden), has been
introduced as a means of disseminating information on
the management of traumatic dental injuries (Fig. 1).
This App has been translated into over 20 different
languages and presents the information in simple, easy
to understand terms for users with no or limited dental
backgrounds. It is available for Apple and Android
phones and can be downloaded from the Internet from
iTunes AppleÒ https://itunes.Apple.com/us/App/dental-
trauma/id527527459?mt=8) and for Android from
Google App store Òhttps://play.google.com/store/Apps/
details?id=com.dentaltrauma&hl=en.
The effectiveness of the Dental Trauma App in pro-
viding information has not yet been tested in the

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 13
14 Al-Musawi et al.
Fig. 1. Example of a page in the smartphone App ‘Dental
Trauma’.
general community, nor has its relative effectiveness in
comparison with other methods of disseminating infor-
mation.
The purpose of this study was twofold: to assess the
effectiveness of the Dental Trauma App in delivering
information to schoolteachers on the optimal emer-
gency management of traumatic dental injuries, namely
tooth avulsion, at an accident site; and to compare the
effectiveness of the Dental Trauma App to that of a tra-
ditional lecture-based method to deliver information, in
this case to school teachers.
Materials and methods
Subjects
The target population was a convenience sample of ele-
mentary and intermediate schoolteachers (n = 87) who
taught 6- to 14-year-old students in Kuwait. All partici-
pating teachers were females, and they were teaching
female elementary students. The group represented
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
teachers active with multiple educational disciplines
including mathematics, sciences, language and physical
education. The target population was selected from
three different schools located at similar socioeconomic
areas of Kuwait. Permission to carry out the study
was obtained from the Ministry of Education, State of
Kuwait. Only teachers familiar with using smartphone
were asked to participate. The registration was carried
out during one visit per school and was not announced
to the participants in advance. Only the leadership of
the school was informed and gave their approval.
Testing of knowledge prior to applying different learning
methods
To establish the baseline knowledge of tooth avulsion
and replantation first aid, a questionnaire with 17 mul-
tiple-choice questions was presented to all participants.
All questions were translated into Arabic, the mother
tongue of the participants. The questions were in
accordance with a questionnaire of a previous study by
Al Asfour and Andersson (21) which covered dental
first aid with particular focus on the following areas:
1 Replantation of primary and permanent teeth
2 Cleaning of an avulsed tooth before replantation
3 Importance of extra-oral time
4 Storage methods and media for an avulsed tooth
Testing of knowledge after applying different learning
methods
Participants were assigned into three groups, ranging
between 27 and 32 in number.
Three learning methods were applied, one for each
group.
Group 1 – Lecture only: A 30-min PowerPoint lec-
ture was given in Arabic at layman level to the par-
ticipants on how to manage an emergency situation
involving an avulsed tooth.
Group 2 – Lecture and App: This group received the
same lecture as Group 1, but also had access to the
Dental Trauma App (Fig. 1) when being tested on
their knowledge after the lecture.
Group 3 – App only: This group received no formal
instruction. Participants had access to the Dental
Trauma App when tested on their knowledge.
Copies of the Dental Trauma App (Fig. 1) were
installed on a handheld device smartphone (Samsung,
Seoul, South Korea) and made available to participants
in groups 2 and 3. The language setting was Arabic.
Testing was carried out at the end of each interven-
tion using the same test as the baseline test according
to Al Asfour and Andersson (21). In addition to testing
the knowledge, the time it took for each individual to
answer the questions and complete the test was regis-
tered in all groups. Two of the authors (AM, MS) were
present during all testing procedures.
Statistics
The results for each test were recorded on a spread-
sheet, and the means and standard errors for the

pretest and post-test scores within each learning
method were calculated. The adjusted means were cal-
culated by IBM SPSS statistics for Windows, version
22.0 (IMBM Corp, Armont, NY, USA). They were
reported as the mean of the covariate. Associations
were analyzed using an analysis of covariance (ANCO-
VA). Pretest scores served as the covariate; the indepen-
dent variable was type of learning method. The
dependent variable was the post-test scores. The differ-
ences in testing times between the groups were tested
by Student’s t-test. A significance level was set at
P < 0.05.
Results
The time to answer all questions ranged from 1 to
11 min. The pretest results showed there were some
areas where the knowledge was low in all groups, and
other areas where the knowledge was higher. Sixteen
percent (n = 14) of the participants had knowledge on
how to handle a situation when a tooth had fallen to
the ground. Knowledge on how to clean a tooth was
correct in 19.1% (n = 17) of the participants and
10.1% (n = 9) knew how to store an avulsed tooth.
Knowledge was higher in all groups in knowing that
permanent teeth need to be repositioned (70%)
(n = 61), primary teeth need not be repositioned
(71.9%) (n = 63), and the urgency to replant an
avulsed tooth in a timely fashion (52.8%) (n = 48).
The means for the pretest and post-test scores within
each group are shown in Table 1. The time to complete
the test ranged from 1 to 11 min. There was no signifi-
cant difference in time to complete the questions
between the different learning methods. One person
reported difficulties in reading the font on the App,
mentioning it was too small.
The adjusted means and their standard errors for
the post-test increase in knowledge across the three
learning groups are shown in Table 2. All three learn-
ing methods applied in the study generally increased
the knowledge. Post-test scores were generally higher
than pretest scores within each of the learning methods.
Table 1. Means and standard errors for pretest and post-test
knowledge scores
Pretest Post-test
Educational intervention N M SE M SE
Lecture only 32 6.28 0.40 11.06
Lecture and APP 27 4.52 0.43 10.26
APP only 28 6.57 0.42 12.50
Table 2. Adjusted means and standard errors for post-test
knowledge scores
Adjusted post-test
Learning method N M
Lecture only 32 11.20
Lecture and APP 27 9.87
APP only 28 12.72
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Smartphone in emergency management 15
Table 3. ANCOVA results for post-test knowledge scores as a
function of type of learning method (N = 87)
Source df MS F Sig.
Pretest scores 1 37.13 6.15 0.015
Type of learning method 2 49.57 8.23 0.001
Error 83 6.04
The mean post-test results varied from 12.7 for the
App only group to 9.9 for the App plus lecture group,
out of a possible 17.
The highest rise in score from pre- to post-test scores
was found in questions on storage media, how to hold
the tooth and how to clean the tooth before replanta-
tion. When the App only was used as an aid to answer,
it was possible to raise the knowledge level from 16%
to 96.8% in handling the tooth on the ground. A rise
in knowledge level was seen from 19.1% to 62.5% in
how to hold the tooth when cleaning it and from
10.1% to 59.3% in how to store the avulsed tooth.
As shown in Table 3, after controlling for pretest
scores, the type of learning method had a significant
effect on post-test knowledge scores, F(2, 83) = 8.23,
P = 0.001. The findings indicated that participants in
the APP only group had a significantly higher mean
score (M = 12.72, SE = 0.47) than participants in the
Lecture Only group (M = 11.20, SE = 0.44, P = 0.019)
and participants in the Lecture and APP group
(M = 9.87, SE = 0.50, P = 0.000).
Discussion
To the authors’ knowledge, this is the first study that
has compared the effectiveness of the Dental Trauma
smartphone App, the standard lecture-based delivery of
information, and a combination of the two methods in
delivering knowledge on tooth avulsion. The design of
this study facilitated direct comparison between the
learning methods, but also enabled changes in learning
effect by comparing pre- and post-testing. The results
show that acting with the help of such a smartphone
App for managing a situation of tooth avulsion and
replantation is possibly even better than acting
after only being instructed by a lecture given by profes-
sionals.
A number of studies have shown that lay knowledge
is low in society regarding how to manage tooth avul-
sion and replantation (11–22). The results of this study
0.45 confirmed this. In the study by Al-Asfour et al. (18)
0.49 using the same questionnaire model, the baseline
0.48 knowledge in society was also low, especially on how
to clean an avulsed tooth and how to store it. How-
ever, there appeared to be recent changes in baseline
knowledge when compared to 2008. The baseline
knowledge was higher in this study regarding the
urgency of replanting the tooth and that primary teeth
should not be replanted. This is probably an effect of
SE evolution of knowledge in society due to campaigns
and other information. Apparently, people know better
0.44
today that teeth can be replanted, and that it is urgent
0.50
0.47 to act, but knowledge on the technical procedure of
how to do it practically is still missing.
16 Al-Musawi et al.
As in many previous studies, it was possible to gen-
erally raise the knowledge level to a higher level by giv-
ing information (18–24, 29). This was especially noted
for procedure knowledge on how to hold the tooth and
how to clean the tooth before replantation and for
knowledge on storage media, which was very low prior
to applying the different learning methods. The results
of this study showed that it was possible to increase
such knowledge regardless of the learning method
applied.
Using the App alone gave somewhat better results
than the other learning methods. This is perhaps due to
the active learning component involved with the use of
the App. Active learning is defined, in education litera-
ture, as an instructional method that engages students in
the learning process (30). The step-by-step instructions
involved in using the App are therefore likely to actively
engage users. This can enhance both short- and long-
term information retention.
There is empirical support in the education literature
of the positive impact of active learning on education
outcomes compared to that of traditional ways of
delivering information in educational settings, for
example, lectures (30–34). Active learning proponents
agree that good activities that actively engage learners
tend to develop deeper understanding of important
ideas to be learnt (30–34). In this study, the immediate
postintervention knowledge was higher among those
who used the App alone, compared to the other educa-
tional interventions used.
In this study, there were some examples of reduction
in knowledge for some questions where the lecture had
been given. This is difficult to explain but possibly
parts of the lecture may have been confusing, and the
participants may not have fully understood the message
given in the lecture, or not given it full attention. Other
distracting factors (e.g., various human related factors)
could be introduced with a lecturer present. Teachers
also may be eager to emphasize the importance of cer-
tain information at the expense of other information.
Content and accuracy of information, appropriateness
of language, and presentation quality can all impact
the audience’s recall of material. Moreover, giving lec-
tures in layman’s language to audiences of different
backgrounds and knowledge is not always easy. Such
reduction in knowledge was not seen when only the
App was used, so working alone with this App may
even be advantageous. There is a perceived risk of
using the App by following step-by-step instruction
rather than having a holistic view of tooth avulsion
and replantation. However, it seems as if this can be
an advantage in the emergency situation where the aim
is not to make individuals understand everything, but
for them to be able to do a few correct measures in the
emergency situation. Even if not understanding why, it
is important to perform the correct procedures in an
emergency situation.
Emergency management is carried out under stress-
ful conditions. It may be difficult in such a situation to
recall what has been learnt, and there is always a risk
that information given earlier in lectures can be forgot-
ten over time. However, a step-by-step action can be
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
presented in an App. Moreover, brochures and other
instruction manuals are generally not available at the
place of an accident, but an App on a smartphone will
usually be available in the pocket or handbag. This
requires that smartphones are allowed to be used by
teachers at school, which may not always the case.
The term ‘mHealth’ is emerging in the literature to
describe the use of portable electronic devices with
software applications (Apps) for health services and
information. A recent overview of smartphones and the
many Apps available demonstrated that there was a
range in quality and many were not evidence based
(28). The field of mHealth has seen smartphone tech-
nologies used to disseminate health information (26,
35), and they have also been used as a monitoring
device testing for compliance of prescribed self-manage-
ment programs (36). A number of studies have moved
toward electronic means of obtaining information with
the Internet being a preferred source of health-related
information among many population sectors, particu-
larly young educated adults (23).
One of the major pitfalls in mHealth utilization is
the credibility of the information. It has been shown
that for optimal utilization of technology in health
information dissemination, information must be scruti-
nized by health authorities and preferably be provided
by a professional (23). The Dental TraumaÒ Smart-
phone App used in this study has been endorsed by the
International Association of Dental Traumatology
(IADT), and the information in the App is based on
the IADT guidelines for emergency treatment. It con-
tains information on what to do with a patient who
has suffered a traumatic dental injury suggesting guide-
lines and options for the emergency management. Due
to the immediate availability at the place of the acci-
dent, a smartphone application would be an ideal
method of providing information to a teacher or other
lay person who is confronted by a person with an
injury that requires immediate treatment.
The three groups came from three different schools
and one can speculate whether this could have any
influence on the results. However, all three schools
were located in similar socioeconomic areas and the
teachers were teaching at similar levels so they can be
regarded as similar. The registration was carried out at
only one visit per school, which is important. The rea-
son for not visiting the same school several times was
that this could have influenced the results. If teachers
had heard that colleagues at a school had already been
tested, they could then have prepared themselves before
their own test.
The participants were tested under controlled condi-
tions in a quiet environment whereas an emergency sit-
uation is more stressful. A study like this cannot
measure if the participants are familiar with the use of
smartphones. This may be an important factor in an
emergency situation. This research did not test which
presentation format participants were more comfort-
able with and there may have been age difference pref-
erences. However, those who had access to a mobile
phone, and who were comfortable with downloading
and using an App, would probably be better equipped

in dealing with traumatic dental emergencies by follow-
ing the App instructions.
There may be practical difficulties in using the
devices and reading texts (screen with no expansion
abilities). One person had difficulties in reading the
font of the App. Hence, ideally the font should be
slightly larger in the next version of the App. In the
present study, the participants were given devices to be
used. When using their own devices, the font can often
be adapted to the individual and they are more familiar
with their own device.
In conclusion, the use of the Dental Trauma App
alone is superior to a lecture-based delivery of informa-
tion and is an effective means of providing an accessi-
ble knowledge base to guide laypeople in managing
tooth avulsion.
Acknowledgements
This study was funded by a grant from Research Sec-
tor Kuwait University DS02/13. We also want to thank
statistical consultant Victoria Briones Chiongbian,
Ph.D. for statistical analysis. Moreover, we also thank
the ministry of education, for providing access to
schools and all-participating teachers. We also thank
Dr. Alex Moule for contributing by giving comments
on the manuscript.
Conflict of interest
The authors confirm that they have no conflict of
interest.
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