The appropriate management of traumatic dental injuries (TDIs) in immature permanent teeth is critical for predicting prognosis and preserving injured teeth. However, providing accurate treatment is always challenging for dental students due to their limited knowledge of TDIs. This study aimed to assess TDIs in immature permanent teeth in terms of knowledge, attitudes, and clinical practice among Chinese dental undergraduates and residents.

Dental undergraduates (in 3rd -, 4th -, and 5th -years) and residents (in 1st -, 2nd -, and 3rd -years) at the School of Stomatology, Wuhan University (763 in total, from May to June 2024), were distributed with a structured electronic questionnaire containing 22 items. The obtained data was statistically analyzed via the Chi-square (χ²) test (p < 0.05) using SPSS.

Participants from various academic levels completed 502 questionnaires, with a response rate of 65.79%. Approximately half of the participants (58.6%) were familiar with TDIs, chiefly through traditional classroom learning (90.0%). Participants had limited knowledge on correct emergency treatment for TDIs, including tooth replantation timing (51.6%), fixation method (43.8%), and time (25.5%), with 3rd -year undergraduates reporting the lowest percentage (10.2%) (p < 0.05). Most participants agreed that vital pulp preservation (95.0%) and additional examination (91.0%) are essential for TDI management. Besides, only 29.9% of participants had ever treated a clinical TDI case independently. The majority of participants expressed a strong desire to gain comprehensive knowledge of TDIs (90.0%) and additional training (96.4%).

Dental students at the undergraduate and postgraduate levels lacked sufficient knowledge and practice with TDIs but had a positive attitude toward TDI management. Thus, it would be enormously beneficial for dental students to gain a better understanding of TDIs through improved dental education, including multiple teaching methodologies and more clinical practice.

Not applicable.

Traumatic dental injuries (TDIs) pose a significant threat to dental and general health in children and adolescents worldwide, with a prevalence of 22.7% in the primary dentition and 15.5% in the permanent dentition [1]. Immature permanent teeth, defined as newly erupted teeth with incomplete root formation, have distinct anatomical features such as an open apex and widened root canal space due to ongoing root development [2]. Preserving pulp vitality in these teeth is critical for continued root maturation. Dental trauma patterns in pediatric populations differ from those in adults, involving complex damage to both dental structures and associated oral/maxillofacial tissues. The immediate functional and aesthetic challenges of injured immature teeth can lead to long-term complications, affecting root development as well as physical and psychological well-being [3, 4]. It is critical to achieve timely and effective management of traumatized immature teeth, as this can result in a positive short- and long-term outcome and is beneficial to the prognosis, recovery, and preservation of these teeth [5].

Several studies have evaluated the understanding of TDIs and management strategies among various groups, including parents, educators, healthcare professionals, dentists, and dental students [6,7,8,9,10]. These surveys consistently show a significant knowledge gap across all demographics. It is important to note that dental students are the future knowledge transmitters and practitioners who will be at the forefront of providing professional care to TDIs-related patients. Their knowledge, attitudes, and practice toward TDIs are therefore critical. Studies from Saudi Arabia, Malaysian, and India [11,12,13], however, has suggested that dental students have insufficient knowledge of TDI management. Because of their limited clinical exposure, preclinical dental students were found to have a lower knowledge of TDIs than clinical students [12]. The knowledge differences between preclinical and clinical dental students indicate that adequate clinical practice can help them improve their understanding and mastery of traumatic teeth treatment [13]. Researchers discovered that the level of knowledge of endodontic and paediatric dentistry students at ten dental schools in ten countries is inconsistent globally, with some areas lacking, highlighting the need to review educational approaches for TDI management [14]. These studies emphasized the importance and necessity of a comprehensive curriculum that not only covers the theoretical aspects of dental trauma but also provides hands-on training to ensure dental students have the necessary skills needed for clinical scenarios.

Given the high treatment needs and specific requirements of TDI management, dental students are expected to have the right knowledge and skills to successfully address such issues. However, a thorough review of the literature reveals a significant gap: no published data specifically investigating the knowledge and clinical practice of Chinese dental undergraduates and residents in the management of traumatized immature teeth. Hence, the aim of the study was to assess TDIs-related knowledge, attitudes, and practice among Chinese dental students. Relevant information would be crucial for evaluating the current state of dental education in China and identifying areas where the dental traumatology curriculum could be improved.

From May to June 2024, dental undergraduates and residents were recruited at the School of Stomatology, Wuhan University. This survey was implemented based on the approval of the Ethics Committee of the School & Hospital of Stomatology, Wuhan University ([WDKQ2024] B42). Participants of undergraduates (in 3rd -, 4th -, and 5th -years) and residents (in 1st -, 2nd -, and 3rd -years) were included in the 2021–2024 academic year. Inclusion criteria: All 3rd -, 4th -, and 5th -year undergraduates, as well as 1st -, 2nd -, and 3rd -year residents currently undergoing standardized training. Exclusion criteria: Students and residents who have graduated, dropped out, or are currently on leave of absence. Participants are limited to actively enrolled students and residents who are pursuing academic or training programs at the time of the study.

The study population included 763 dental students (both undergraduates and residents). Based on Cochran’s formula (with p = 0.5, e = 0.05, and Z = 1.96) [15, 16], the required sample size was calculated as 384. After adjusting for the finite population (N = 763), the minimum required sample size was 256. To improve representativeness and reduce sampling bias, the convenience sampling method was used, and the questionnaire was distributed to all 763 eligible participants (3rd -, 4th -, and 5th -year undergraduates, as well as 1st -, 2nd -, and 3rd -year residents).

Following validation by a panel of senior specialists, a structured electronic questionnaire related to TDIs (shown in Supplemental Information File 1) was developed. To ensure that each participant understood the purpose and content of the survey, a presurvey was carried out after they were given a brief explanation. The questionnaire was delivered and collected through cellphones using the SoJump questionnaire survey platform (Ranxing Group, Changsha, China) and WeChat internet messaging application (Tencent Company, Shenzhen, China). At the beginning of the questionnaire, each participant provided their informed consent, and a reminder was delivered to all participants seven days after the distribution of the questionnaire. Anonymous and voluntary questionnaires were obtained.

The questionnaire was divided to five sections. Section I documented participants’ academic level and gender information (Table 1). Section II documented five questions about participants’ experience and learning situation regarding TDIs (Table 2), including “Have you ever encountered TDIs in everyday life?” and “Are you interested in learning systematic knowledge of TDIs in immature permanent teeth?” Section III documented five questions about participants’ knowledge level regarding TDIs (Table 3), including “Which is the best time for replanting an avulsed tooth?” and “Which is the best way to fix avulsed immature permanent teeth after replantation?” Section IV documented six questions about participants’ attitudes regarding TDIs (Table 4), including “Preserving the vital pulp of avulsed immature permanent teeth is important for root development.” and “Do you agree that more training is needed to improve TDI management skills?” Section V documented four questions about participants’ clinical practice regarding TDIs (Table 5), including “Have you ever treated a TDI case independently?” and “Have you ever educated patients with TDI knowledge for protecting traumatic teeth?” The questionnaire included both single and multiple-choice questions.

SPSS statistical package (IBM, Armonk, USA, version 26.0) was utilized to conduct the statistical analysis. All descriptive data were shown as tables of distribution and frequency. For questionnaire items with multiple answers, each option selected by a respondent was counted as a separate response in the frequency analysis. Percentages were used to present and analyze categorical data. Pearson’s Chi-square (χ²) test was employed to compare distribution and frequency data. Fisher’s exact test, Z-test, or Bonferroni test was further performed as needed. A statistical difference of 0.05 was set for all analyses.

In the survey, a total of 502 questionnaires were received by participants, yielding a response rate of 65.79% (Table 1). Undergraduates and residents accounted for 49.01% and 50.99% of all questionnaires received, respectively.

Table 2 summarizes the experience and learning situation of participants on TDIs. Only 12.5% of participants had encountered TDIs in everyday life, and half of the participants were familiar with TDIs (58.6%), with 3rd ‑year undergraduates significantly lower than other grades (p < 0.05). Most participants (90.0%) were interested in learning comprehensive knowledge of TDIs, and traditional classroom was considered the dominant learning approach. Interestingly, compared to other grades, 4th -year undergraduates (70.4%) reported a significantly higher percentage of PBL classroom learning (p < 0.05). For specific contents, emergency treatment (93.0%), therapy (87.1%), and prognosis (75.1%) of TDIs were identified as the most desired learning.

The knowledge level of participants on TDIs is shown in Table 3. The majority of participants approved that saline (73.5%), milk (73.9%), or human mouth (75.9%) should be used to preserve an avulsed tooth. Nearly half of the participants (51.6%) preferred to replant an avulsed tooth immediately, and most participants (89.2%) agreed that saline is suitable for cleaning a contaminated tooth before replantation. Less than half of the participants (43.8%) tended to apply flexible fixation after tooth replantation. Only 25.5% of participants selected correct fixation time for an avulsed immature tooth, with 3rd -year undergraduates reporting the lowest percentage (10.2%) (p < 0.05).

Participants’ attitudes toward TDIs (Table 4) reveal that 95.0% of participants believed that preserving the vital pulp is critical for further root development, and 91.0% disagreed that no examination is needed. Almost all participants agreed that TDI management grasp is essential for future clinical practice (95.4%) and that more training is required (96.4%). About 50.6% of participants were dissatisfied with traditional classroom for TDI knowledge learning, with 2nd - (68.9%) and 3rd -year (60.6%) residents reporting significantly higher percentages than 3rd - (42.0%) and 5th -year (35.1%) undergraduates (p < 0.05). Only 34.3% of participants were confident in treating traumatized immature teeth correctly, with 3rd -year residents (55.6%) having a significantly higher percentage than other grades (p < 0.05).

Table 5 summarizes the clinical practice of participants on TDIs. Only 11.4% of participants reported frequent experiences of TDI cases in immature permanent teeth. The majority of participants (70.1%) never treated TDI cases independently, and 2nd - (63.5%) and 3rd -year (49.5%) residents had significantly higher percentages than other grades (p < 0.05). Besides, 23.1% of participants routinely educated patients with TDI knowledge on traumatic tooth protection, while 24.9% recommended follow-up visits and home care.

Worldwide dental students are now entering a new era of appropriate management of injured immature teeth in order to maximize the likelihood of favorable outcomes. Their knowledge, attitude, and practice are critical in preventing and treating TDIs as well as promoting children’s oral and psychological health [17]. The survey found that few dental students have ever experienced TDIs, and 3rd ‑year undergraduates were less familiar with it compared to other grades. According to the preclinical training program at the School of Stomatology, Wuhan University, 3rd ‑year undergraduates are not exposed to systematic stomatological courses, such as TDIs. Most participants were interested in learning TDI knowledge, implying that TDI teaching can be advanced at the early undergraduate stage. TDIs are common in children and teenagers since they are experiencing physical growth, such as intense activities, but lack risk protection awareness [18]. As a result, prevention knowledge and appropriate measures are indispensable for dental students in order to effectively reduce the risk of TDI occurrence [19, 20]. It is worth noting that the classification, diagnosis, and treatment of TDIs in immature permanent teeth are largely similar to those in mature permanent teeth, with the main differences being pulp treatment protocols and avulsion management strategies. Accordingly, specific questionnaire items dealing with post-avulsion emergency care and general TDI management approaches made no explicit distinction between mature and immature permanent teeth.

Interestingly, most participants gained TDI information from traditional classroom, with 4th ‑year undergraduates reporting 70.0% from PBL courses. This is due to the establishment of a multidisciplinary PBL curriculum at Wuhan University for preclinical dental education in 2008 [21]. This curriculum was updated in 2022 and includes PBL teaching cases for various disciplines in dentistry, including TDI cases, which are typically carried out for 4th -year undergraduates. They completed their TDI learning in paediatric dentistry before engaging in a relevant PBL course. Students gain a deeper understanding of TDIs through self-study and group discussion, as evidenced by the high correct rate for survey questions. Teachers can fully utilize teaching resources, such as clinical examples and prevention strategies, to further stimulate students’ learning interests and improve their knowledge mastery.

First-aid training is highly crucial because the initial phase of TDI management significantly affects tooth survival, which plays a vital role in treatment decision-making for a good prognosis [22, 23]. It is also conducive to provide the desired care in an effective manner in order to minimize long-term complications caused by injured immature teeth [24]. Dental students can still participate in TDI first-aid training despite their lack of professional knowledge [25]. It is recommended that the early curriculum should include emergency treatment of TDIs for dental undergraduates in lower grades, and adequate theoretical teaching is demanded. Apart from 3rd -year undergraduates, it has been reported that the general public lacks adequate emergency knowledge [26,27,28]. The knowledge areas that were not well understood in this survey should be emphasized when educating the general public about TDI management. These areas include the treatment of avulsed teeth, with a focus on the use of appropriate media to store the tooth and the optimal timing to seek professional care. Identifying these areas can help educators, clinicians, and policymakers develop an effective oral health education and promotion program.

Dental students’ attitudes toward a specific disease can influence their treatment planning and decisions [29]. Most participants demonstrated a positive attitude treating traumatic teeth and anticipated additional knowledge and clinical training. Few participants were confident in providing correct treatment for TDIs, despite 3rd -year residents showing a higher percentage. These findings were consistent with a study conducted by Smith et al. [30]. Third-year residents had completed clinical rotation training in most dental disciplines [31], and these backgrounds boost their confidence in dealing with complex traumatic cases [32]. Hence, multiple teaching methods and resources, such as case- or team-based learning and flipped classrooms, as well as computer-assisted simulation materials, augmented reality devices, and interactive virtual patients, should be used to develop students’ comprehensive abilities [33,34,35]. Applying innovative teaching and learning methodologies can effectively motivate students to improve their academic performance and gain confidence in TDI management.

Learning for contemporary dental practice cannot be accomplished solely through the acquisition of theoretical knowledge and technical skills [36]. Few 3^rd- and 4th -year undergraduates ever treated a TDI case in immature teeth independently. It is mainly because only 5th -year undergraduates and residents are permitted to perform clinical manipulations under teacher’s supervision, whereas clinical probation activities are currently implemented for 3^rd- and 4th -year undergraduates at Wuhan University (Hospital of Stomatology). In addition, an inaccurate understanding of TDI knowledge may result in the low frequency for TDI education for patients, which also explains why some participants were not confident in correctly treating traumatic cases. As a result, training in both basic theory and clinical skills needs be consolidated during dental education for undergraduates and residents.

Based on the results of the tables, it provides valuable insights into the academic and clinical preparedness of dental undergraduates and residents regarding TDIs, with a strong emphasis on the importance of education and training for effective management (Fig. 1). Despite the fact that theoretical knowledge teaching of TDIs is an important component of the paediatric dentistry curriculum in Chinese dental schools, the findings of this study indicate that students lack systematic training in general. More professional guidance and training should be emphasized in future dental education. The limitation of this study includes that the quality of participants may vary over time, despite being exposed to the same curriculum. Thus, the same group of students could be included in future research to determine the effects of curriculum learning on attitudes and clinical behaviors at different stages of study. Although certain measures, such as re-sending a questionnaire reminder and excluding ineligible students, were taken to control potential biases, this study cannot accurately reflect the TDI learning status of all students, including those in other grades and those who have dropped out, retaken courses, or are currently on leave. Because TDIs in immature permanent teeth can take various forms [5, 37], and pulp preservation methods may differ due to pulp exposure and contamination levels, the most representative topics were chosen to meet the study’s objectives. Hence, more comprehensive questionnaires should be designed to focus on the theme of pulp preservation in traumatic immature permanent teeth in future research. A formal pilot test and internal consistency analysis were not performed in this survey, which may have had an impact on the psychometric robustness of the questionnaire; therefore, future studies should account for this limitation. Furthermore, the findings are limited to dental students at Wuhan University, it would be representative if more Chinese dental schools and students from various regions were included in future studies.

Flowchart summarizing the key findings on dental students’ knowledge, attitudes, and practice regarding TDIs in immature permanent teeth

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1. Department of Preventive Dentistry, Hospital of Stomatology, Wuhan University, Wuhan, China

   Chang Liu

Jingjing Yu: Conceptualization; Methodology; Formal analysis; Writing - Original Draft. Chang Liu: Conceptualization; Methodology; Investigation; Writing - Original Draft. Jian Yu: Conceptualization; Validation; Data Curation; Writing - Review & Editing. All authors gave final approval to the submitted manuscript.

Correspondence to Chang Liu or Jian Yu.

This study was approved by the Ethics Committee of the School & Hospital of Stomatology, Wuhan University ([WDKQ2024] B42) under the ethical guidelines of the Helsinki Declaration. All participants provided written informed consent to participate in this study.

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The authors declare no competing interests.

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