Emergency Management of Avulsed Permanent Teeth: National Knowledge Gaps, Clinical Predictors, and a Proposed Intervention Framework

Emergency Management of Avulsed Permanent Teeth: National Knowledge Gaps, Clinical Predictors, and a Proposed Intervention Framework | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Emergency Management of Avulsed Permanent Teeth: National Knowledge Gaps, Clinical Predictors, and a Proposed Intervention Framework Aruna Wimalarathna, Nimna Senerath, Lakshika Nawarathna, Chandra Herath This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8303339/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 19 You are reading this latest preprint version Abstract Background Tooth avulsion is a severe traumatic dental injury where prognosis depends on immediate management and adherence to guidelines. No nationwide assessment of Sri Lankan dentists’ knowledge on tooth avulsion has been reported. Aim To evaluate knowledge, practices, and barriers regarding avulsed tooth management among Sri Lankan dentists, and to identify predictors of knowledge performance. Methods A cross-sectional survey (January 2021–March 2022) was conducted using a validated 21-item questionnaire based on IADT 2020 guidelines. Stratified random sampling identified 750 eligible dentists; 256 participated (response rate 34.1%). Knowledge was assessed in emergency and long-term management domains. Analyses included descriptive statistics, nonparametric tests, Spearman correlation, and multivariable regression with robust errors. Results Participants included 163 females (63.7%) and 93 males (36.3%), mean service 11.6 ± 9.0 years. Correct responses were low for accident-site management (44.9%) and storage media order (44.5%), but higher for tooth handling (99.6%) and splinting time (71.9%). Mean scores: knowledge 2.38 ± 1.0, management 3.00 ± 0.9, grand total 5.38 ± 1.6 (range 0–9). Only 0.8% achieved full scores. Knowledge declined with years of service (ρ = −0.18, p = 0.004). Regression showed statistically significant higher scores among diploma holders, postgraduate trainees, and senior academics compared with dental surgeons (all p < 0.001). Conclusion Significant knowledge gaps exist in avulsion management, especially among experienced practitioners. Targeted continuing education and system-level integration of IADT guideline training are urgently required to improve patient outcomes. Tooth avulsion Emergency management IADT guidelines Knowledge assessment Sri Lanka Figures Figure 1 Figure 2 Figure 3 Introduction Tooth avulsion, the complete displacement of a tooth from its alveolar socket, represents the most severe form of traumatic dental injury, with reported incidence rates ranging from 1.3% to 16.0% across epidemiological studies (Petti et al., 2023 ). The prognosis of avulsed teeth depends critically on two biological factors: the extraoral dry time (optimal < 15 minutes) and the selection of physiologically appropriate storage media (milk, Hank's Balanced Salt Solution, saliva or saline) as outlined in the International Association of Dental Traumatology (IADT) 2020 guidelines (Fouad et al., 2020 ). When managed according to these evidence-based protocols, long-term tooth survival rates exceed 85%, compared to < 10% survival with improper management (Fouad et al. 2020 ). Despite well-established clinical guidelines, recent systematic reviews demonstrate persistent knowledge gaps among dental professionals worldwide. Levin et al. ( 2023 ) analyzed 47 studies across 27 countries, finding that only 28–34% of dentists in high-income countries correctly followed IADT guidelines, with even lower compliance rates (11–23%) in developing nations. Regionally, studies from Brazil (Vasconcellos et al., 2009 ) revealed that 67.3% (112/167) of general dentists were unaware of the critical 60-minute replantation window, while research in Saudi Arabia (AlJazairy et al., 2015 ) showed only 28.1% (42/150) could correctly identify optimal storage media. The Sri Lankan context presents unique challenges and opportunities for dental trauma management (Wimalarathna et al, 2021 ). With an estimated 18.7% (95% CI: 15.2–22.2) prevalence of traumatic dental injuries among school-aged children (Perera et al., 2021 ) and high participation in contact sports contributing to injury risk, the need for competent avulsion management is particularly acute. However, no previous studies have comprehensively evaluated Sri Lankan dentists' knowledge and clinical practices regarding tooth avulsion. This research gap is especially concerning given Sri Lanka's well-developed dental workforce (2.1 dentists per 10,000 population) and universal healthcare system that should theoretically support excellent trauma management. To our knowledge, this is the first nationwide assessment of avulsion management knowledge among Sri Lankan dentists. This study had four primary objectives of establish baseline knowledge levels of avulsion management among Sri Lankan dentists across key IADT guideline domains, identify demographic and institutional factors influencing knowledge accuracy, characterize systemic barriers to guideline implementation in clinical practice, and propose evidence-based interventions tailored to the Sri Lankan context. The findings provide crucial data for policymakers and dental educators to improve trauma management capacity, with potential applications across similar low-resource settings globally. Methods 2.1 Study Design and Ethical Approval We conducted a nationwide cross-sectional analytical study from January 2021 to March 2022, encompassing all nine provinces of Sri Lanka. The study protocol received ethical approval from the University of Peradeniya Faculty of Dental Sciences Ethics Review Committee (ERC/FDS/2020/21) and adhered strictly to STROBE guidelines for observational studies. 2.2 Participant Recruitment and Sampling Through stratified random sampling of Sri Lanka Medical Council registries, we identified 750 eligible dentists meeting the following inclusion criteria: Current registration with practice years between 2010–2019, Active engagement in clinical practice (≥ 20 hours/week), and currently Employment in government, private, or academic dental institutions. After three recruitment rounds via email and professional networks, 256 dentists completed the study, yielding a response rate of 34.1%. Post-hoc power analysis using G*Power 3.1 confirmed this sample provided 99% power to detect medium effect sizes (α = 0.05, two-tailed). 2.3 Data Collection Instrument Development The research team developed a comprehensive 25-item questionnaire (Annexure 1) through a three-stage process including Systematic review of IADT 2020 guidelines and supporting literature, Adaptation of validated instruments from prior studies (Zhao & Gong, 2010 ; AlJazairy et al., 2015 ), and Input from a six-member expert panel (three pediatric dentists, two endodontists, one oral surgeon). The final instrument assessed four critical domains: Emergency protocols (8 items): selection of storage media, cleaning techniques, timing of replantation Long-term management (7 items): Splinting duration, antibiotic use, follow-up intervals Barriers to knowledge updating (5 items): Training access, guideline awareness, institutional support Demographic characteristics (5 items): Age, gender, clinical experience, qualifications, practice setting 2.4 Validation and Reliability Testing The questionnaire underwent rigorous validation: Content validity: Expert review yielded a Content Validity Index of 0.89, Pilot testing: Conducted with 20 dentists not included in the main study, showing excellent internal consistency (Cronbach's α = 0.82), and Test-retest reliability: Subset of 30 participants completed the questionnaire twice (2-week interval), demonstrating strong correlation (r = 0.86, p < 0.001) 2.5 Data Collection Procedures The questionnaire was administered electronically via Google Forms, with three reminder emails sent at 2-week intervals. Participants provided digital informed consent through the platform and could withdraw at any time. Data collection occurred over 14 weeks (January 3 - April 10, 2022), with all responses anonymized prior to analysis. 2.6 Statistical Analysis Data were analyzed using SPSS v26 (IBM Corp, Armonk, NY). Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarize demographic and background characteristics. Bivariate analyses were conducted using chi-square tests for categorical variables and independent-samples t-tests for continuous variables. Spearman’s rank correlation was applied to examine associations between years of professional experience and knowledge scores. Multivariable linear regression with robust standard errors was used to identify independent predictors of overall performance (grand total score). Open-ended responses were analyzed using thematic analysis following Braun and Clarke (2006). Statistical significance was set at p < 0.05 (two-tailed), and effect sizes were reported for significant findings. All percentages are presented with corresponding absolute numbers ( \(\:\frac{n}{N}\) ). Results A total of 256 dentists completed the survey and were included in the analysis (163 female, 63.7%; 93 male, 36.3%). Mean years of professional service was 11.65 ± 8.97 years (median 10.0, range 1–50). The majority were dental surgeons (n = 148, 57.8%), followed by dental surgeons with a diploma (n = 60, 23.4%), postgraduate trainees/lecturers (n = 24, 9.4%), senior lecturers/consultants/professors (n = 19, 7.4%) and general practitioners (n = 5, 2.0%) Fig. 1 . Responses to practice/experience questions (Q5–Q9) indicated that 47.9% (n = 123) reported performing initial management of an avulsed tooth during the prior 6 months, and 47.1% (n = 121) reported managing avulsed teeth as follow-up visits in the previous year. A large proportion reported having updates on avulsion management since their undergraduate/postgraduate training (79.9%, n = 205). The most frequently reported update sources were international guidelines (n = 26; 12.6%), workshops/scientific sessions (n = 26; 12.6%), and the Visual Trauma Guide or internet platforms (various combinations; see Table 1 ). Table 1 Response frequencies and correct answers for knowledge and management questions Question Correct answer n correct % correct Q10 Search for the tooth and put it back into the socket of the injured tooth 115 44.9% Q11 Immediately 169 66.0% Q12 HBSS > Milk > Saline > Saliva 114 44.5% Q13 No 211 82.4% Q14 Rinse the tooth gently under running water for a few seconds without scrubbing 181 70.7% Q15 From the crown 255 99.6% Q16 48 Hours 26 10.2% Q17 2 Weeks 184 71.9% Q18 Within 2 Weeks 122 47.7% Knowledge and management item responses (Q10–Q18) are summarized in Table 1 and Fig. 2 . Item-level correct-response frequencies were: Q10 (first action at the accident site) 115/256 (44.9%); Q11 (urgency to seek professional help) 169/256 (66.0%); Q12 (correct order of storage media) 114/256 (44.5%); Q13 (replanting primary tooth) 211/256 (82.4%). For management items: Q14 (immediate management of tooth from dirty place) 181/256 (70.7%); Q15 (how to hold avulsed tooth) 255/256 (99.6%); Q16 (repositioning window) 26/256 (10.2%); Q17 (recommended splinting time) 184/256 (71.9%); Q18 (timing of endodontic treatment) 122/256 (47.7%). Using the prespecified scoring (knowledge score = sum of Q10–Q13, range 0–4; management score = sum of Q14–Q18, range 0–5; grand total = 0–9), the sample summary was: Knowledge total: mean 2.38 ± 1.00 (median 2, range 0–4), Management total: mean 3.00 ± 0.93 (median 3, range 1–5) and Grand total: mean 5.38 ± 1.57 (median 5, range 1–9). Table 2 Knowledge, management, and total scores by professional role Role Knowledge mean ± SD Management mean ± SD Grand total mean ± SD N Dental Surgeon 2.25 ± 0.95 2.81 ± 0.89 5.06 ± 1.42 148 Dental Surgeon (Diploma Holder) 2.40 ± 1.06 3.12 ± 0.90 5.52 ± 1.64 60 General Practitioner 2.40 ± 1.14 3.00 ± 1.00 5.40 ± 1.34 5 Postgraduate trainee/ Lecturer 2.92 ± 0.97 3.67 ± 0.76 6.58 ± 1.41 24 Senior Lecturer/Consultant / Professor 2.63 ± 1.07 3.26 ± 1.10 5.89 ± 1.82 19 Only 2/256 (0.8%) of participants answered all items correctly (grand total = 9); 9/256 (3.5%) had zero knowledge-item correct answers. Because several outcomes were not normally distributed, nonparametric testing was used for group comparisons. A Spearman rank correlation showed a small but statistically significant negative correlation between years of service and knowledge total (ρ = −0.18; p = 0.0045), indicating a slight tendency toward lower knowledge scores with increasing years in practice. Kruskal–Wallis tests detected statistically significant differences in scores across service-level groups (professional role). For the knowledge total the Kruskal–Wallis statistic was 12.44 (p = 0.014); for management total the Kruskal–Wallis statistic was 22.75 (p < 0.001); and for the grand total the Kruskal–Wallis statistic was 25.24 (p < 0.001). Post-hoc pairwise comparisons indicated that postgraduate trainees/lecturers and diploma-holding dental surgeons had higher mean scores than the reference group (dental surgeons). The summarized regression results is displayed in Table 3 . To estimate adjusted associations with overall performance, we fitted an ordinary least-squares regression for grand total with robust standard errors (HC3), including years of service (continuous), gender, and professional role (categorical; reference category Dental Surgeon) Table 3 Multivariable regression for grand total score Predictor Coef. 95% CI t-value p Intercept 5.58 5.27, 5.88 35.7 < 0.001 Diploma Holder vs Dental Surgeon 1.18 0.65, 1.70 4.39 < 0.001 General Practitioner vs Dental Surgeon 1.73 0.01, 3.46 1.97 0.049 Postgraduate trainee/Lecturer vs Dental Surgeon 1.62 1.04, 2.19 5.47 < 0.001 Senior Lecturer/Consultant/Professor vs Dental Surgeon 1.48 0.54, 2.41 3.09 0.002 Years of service (per year) -0.07 -0.10, -0.04 -4.85 < 0.001 Male vs Female -0.03 -0.44, 0.38 -0.14 0.89 These adjusted estimates indicate that, after accounting for years in service and gender, dentists in diploma, postgraduate training, and senior academic/consultant roles scored on average about 1.2–1.7 points higher on the grand total score than the reference dental surgeon group. Conversely, each additional year of practice was associated with a small decrease in the grand total (≈ 0.07 points per year), consistent with the Spearman result. Model diagnostics showed no indication of influential outliers that materially changed inference; variance-inflation diagnostics did not indicate problematic collinearity for the included predictors. Finally, internal-consistency analysis of the knowledge (4 items) and management (5 items) scales produced low Cronbach’s α coefficients (knowledge α ≈ 0.18; management α ≈ 0.16), suggesting the items measure related but heterogeneous facets of knowledge/management rather than a unidimensional scale. Accordingly, the scales are best interpreted as formative indices rather than reflective measures of a single latent trait. Given the low α values, subscale item-level reporting is retained in tables and interpretation focuses on item- and domain-level performance rather than a single latent construct. Discussion The overall knowledge of avulsed-tooth emergency management among the participating Sri Lankan dentists showed strengths in several practical management items (e.g., correct way to hold an avulsed tooth, splinting time), while gaps remain for specific knowledge items (correct storage media hierarchy, acceptable time windows for repositioning). Longer-serving dentists tended to have slightly lower knowledge/total scores whereas diploma-holders, trainees and senior academics scored higher. These findings identify target groups and topics for continuing education and guideline dissemination, consistent with previous international findings that knowledge decay occurs without structured professional reinforcement (Levin et al., 2023 ; Fouad et al., 2020 ). The findings of this nationwide assessment highlight persistent and clinically significant knowledge deficits among dental practitioners regarding the emergency management of avulsed permanent teeth. Despite widespread awareness of basic handling principles, substantial deficiencies were noted in time-critical decisions—particularly regarding the selection of appropriate storage media and the urgency of replantation—factors most crucial to preserving periodontal ligament cell viability (Fouad et al., 2020 ). The negative correlation between years of service and knowledge scores suggests that continuing experience does not necessarily translate into updated clinical proficiency, echoing similar trends observed in studies from Brazil (Vasconcellos et al., 2009 ) and Saudi Arabia (AlJazairy et al., 2015 ). Collectively, these data underscore the urgent need for systematic continuing professional development (CPD) mechanisms to ensure long-term knowledge retention and adherence to evolving IADT guidelines. Equally important, the results indicate systemic barriers that hinder guideline implementation across practice settings. Participants cited limited training opportunities, lack of institutional support, and restricted access to educational resources as key obstacles. These barriers reflect a broader global pattern where knowledge translation in dental trauma care is inconsistently supported by organizational infrastructure (Levin et al., 2023 ; Petti et al., 2023 ). Addressing these gaps requires a coordinated approach that combines regular CPD activities, digital access to updated guidelines, and institutional reinforcement of trauma protocols through audits and workshops. Such integrated strategies are essential for transforming knowledge into consistent clinical action. Figure 3 : Proposed intervention framework The proposed intervention framework (Fig. 3 ) addresses the principal barriers identified in this study—limited training opportunities, restricted access to facilities, inadequate guideline awareness, and frequent patient referral to other centers. It emphasizes a sequential strategy beginning with the expansion of continuing education and hands-on training programs to enhance practical competence. Ensuring widespread access to updated IADT and national guidelines is positioned as a critical intermediary step to strengthen evidence-based decision-making. Similar multi-level strategies have been successful in improving emergency dental response in other healthcare systems (Fouad et al., 2020 ; Levin et al., 2023 ). Finally, improving institutional facilities and clinical resources is recommended to enable effective implementation of best-practice protocols. Together, these coordinated interventions aim to build a sustainable, system-level improvement in the knowledge, confidence, and clinical performance of dental professionals managing avulsed teeth. Adoption of this framework may therefore contribute not only to national improvements but also offer a replicable model for countries with comparable healthcare contexts and resource limitations. Conclusion This study demonstrates persistent knowledge gaps in the emergency management of avulsed permanent teeth across the dental profession, with deficiencies most evident in storage media selection, accident-site actions, and replantation timing. While some practical aspects such as handling and splinting are well recognized, overall adherence to international guidelines remains suboptimal. These findings emphasize the need for ongoing professional development, systematic integration of evidence-based trauma management into dental curricula, and the dissemination of clear clinical decision-support tools. Strengthening knowledge and practice consistency is essential to improve long-term survival of avulsed teeth and reduce preventable tooth loss. Future research should assess the effectiveness of targeted educational strategies and their translation into clinical outcomes. Future efforts should focus on integrating trauma protocols into national continuing education programs. Declarations Clinical Relevance Effective emergency management of avulsed teeth is critical for long-term survival, yet dentists worldwide continue to demonstrate important knowledge gaps in key guideline-based practices. Targeted education and systematic reinforcement of IADT protocols are essential to standardize care and improve patient outcomes in dental trauma management. Acknowledgment The authors express their sincere gratitude to Prof. Lars Andersson for his invaluable supervision, guidance, and expertise throughout this project. His constructive insights and editorial support significantly strengthened the quality of this manuscript. Funding Declaration: This research received no external funding . Conflict of Interest Statement: The authors declare that they have no conflicts of interest related to this study. References AlJazairy YH, Halawany HS, AlMaflehi N, Alhussainan NS, Abraham NB, Jacob V. Knowledge about permanent tooth avulsion and its management among dentists in Riyadh, Saudi Arabia. BMC Oral Health. 2015;15(1):1–7. Boonsiriseth K, Khanijou M, Jiramongkolchai P, Arunakul P. Implementation of IADT guidelines in Thai dental schools. Dent Traumatol. 2021;37(2):195–202. Fouad AF, Abbott PV, Tsilingaridis G, Cohenca N, Lauridsen E, Flores MT. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries. Dent Traumatol. 2020;36(4):331–42. Levin L, Day P, Hicks L, O'Connell A, Fouad AF, Bourguignon C, Abbott PV. Global status of knowledge for prevention and emergency management of traumatic dental injuries. Dent Traumatol. 2023;39(1):3–18. Nair M, Jain A, Khera A, Gupta S. Community-based dental trauma education programs in India. J Clin Pediatr Dent. 2023;47(2):45–51. Perera PJ, Abeyweera NT, Fernando MP, Warnakulasuriya TD, Ranathunga N. Prevalence of traumatic dental injuries among school children in Sri Lanka. Ceylon Med J. 2021;66(1):12–8. Petti S, Glendor U, Andersson L. Epidemiology of traumatic dental injuries: A global perspective. Dent Traumatol. 2023;39(2):105–18. Vasconcellos M, et al. Knowledge of Brazilian general dentists about the emergency management of avulsed teeth. Dent Traumatol. 2009;25(3):294–8. Wimalarathna AAAK, Herath EMUCK, Senarath NH, Fonseka MCN, Manathunga MMKM, Nawarathna LS, Andersson L. Introduction of an interactive tool (the Dental Trauma Guide) in the undergraduate dental teaching to manage traumatic dental injuries. Dent Traumatol. 2021;37(5):717–24. 10.1111/edt.12687 . Yilmaz Y, Kocogullari ME, Belduz N, Guler N. Evaluation of Turkish dentists' knowledge about managing avulsed teeth. Dent Traumatol. 2020;36(3):221–7. Zhao Y, Gong Y. Knowledge of emergency management of avulsed teeth: a survey of dentists in Beijing, China. Dent Traumatol. 2010;26(3):281–4. Additional Declarations No competing interests reported. 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Framework","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTooth avulsion, the complete displacement of a tooth from its alveolar socket, represents the most severe form of traumatic dental injury, with reported incidence rates ranging from 1.3% to 16.0% across epidemiological studies (Petti et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The prognosis of avulsed teeth depends critically on two biological factors: the extraoral dry time (optimal\u0026thinsp;\u0026lt;\u0026thinsp;15 minutes) and the selection of physiologically appropriate storage media (milk, Hank's Balanced Salt Solution, saliva or saline) as outlined in the International Association of Dental Traumatology (IADT) 2020 guidelines (Fouad et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). When managed according to these evidence-based protocols, long-term tooth survival rates exceed 85%, compared to \u0026lt;\u0026thinsp;10% survival with improper management (Fouad et al. \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e Despite well-established clinical guidelines, recent systematic reviews demonstrate persistent knowledge gaps among dental professionals worldwide. Levin et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) analyzed 47 studies across 27 countries, finding that only 28\u0026ndash;34% of dentists in high-income countries correctly followed IADT guidelines, with even lower compliance rates (11\u0026ndash;23%) in developing nations. Regionally, studies from Brazil (Vasconcellos et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) revealed that 67.3% (112/167) of general dentists were unaware of the critical 60-minute replantation window, while research in Saudi Arabia (AlJazairy et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) showed only 28.1% (42/150) could correctly identify optimal storage media.\u003c/p\u003e \u003cp\u003eThe Sri Lankan context presents unique challenges and opportunities for dental trauma management (Wimalarathna et al, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). With an estimated 18.7% (95% CI: 15.2\u0026ndash;22.2) prevalence of traumatic dental injuries among school-aged children (Perera et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and high participation in contact sports contributing to injury risk, the need for competent avulsion management is particularly acute. However, no previous studies have comprehensively evaluated Sri Lankan dentists' knowledge and clinical practices regarding tooth avulsion. This research gap is especially concerning given Sri Lanka's well-developed dental workforce (2.1 dentists per 10,000 population) and universal healthcare system that should theoretically support excellent trauma management.\u003c/p\u003e \u003cp\u003eTo our knowledge, this is the first nationwide assessment of avulsion management knowledge among Sri Lankan dentists. This study had four primary objectives of establish baseline knowledge levels of avulsion management among Sri Lankan dentists across key IADT guideline domains, identify demographic and institutional factors influencing knowledge accuracy, characterize systemic barriers to guideline implementation in clinical practice, and propose evidence-based interventions tailored to the Sri Lankan context.\u003c/p\u003e \u003cp\u003eThe findings provide crucial data for policymakers and dental educators to improve trauma management capacity, with potential applications across similar low-resource settings globally.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design and Ethical Approval\u003c/h2\u003e \u003cp\u003eWe conducted a nationwide cross-sectional analytical study from January 2021 to March 2022, encompassing all nine provinces of Sri Lanka. The study protocol received ethical approval from the University of Peradeniya Faculty of Dental Sciences Ethics Review Committee (ERC/FDS/2020/21) and adhered strictly to STROBE guidelines for observational studies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Participant Recruitment and Sampling\u003c/h2\u003e \u003cp\u003eThrough stratified random sampling of Sri Lanka Medical Council registries, we identified 750 eligible dentists meeting the following inclusion criteria: Current registration with practice years between 2010\u0026ndash;2019, Active engagement in clinical practice (\u0026ge;\u0026thinsp;20 hours/week), and currently Employment in government, private, or academic dental institutions.\u003c/p\u003e \u003cp\u003eAfter three recruitment rounds via email and professional networks, 256 dentists completed the study, yielding a response rate of 34.1%. Post-hoc power analysis using G*Power 3.1 confirmed this sample provided 99% power to detect medium effect sizes (α\u0026thinsp;=\u0026thinsp;0.05, two-tailed).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data Collection Instrument Development\u003c/h2\u003e \u003cp\u003eThe research team developed a comprehensive 25-item questionnaire (Annexure 1) through a three-stage process including Systematic review of IADT 2020 guidelines and supporting literature, Adaptation of validated instruments from prior studies (Zhao \u0026amp; Gong, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; AlJazairy et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), and Input from a six-member expert panel (three pediatric dentists, two endodontists, one oral surgeon). The final instrument assessed four critical domains:\u003c/p\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eEmergency protocols (8 items): selection of storage media, cleaning techniques, timing of replantation\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eLong-term management (7 items): Splinting duration, antibiotic use, follow-up intervals\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eBarriers to knowledge updating (5 items): Training access, guideline awareness, institutional support\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eDemographic characteristics (5 items): Age, gender, clinical experience, qualifications, practice setting\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Validation and Reliability Testing\u003c/h2\u003e \u003cp\u003eThe questionnaire underwent rigorous validation: Content validity: Expert review yielded a Content Validity Index of 0.89, Pilot testing: Conducted with 20 dentists not included in the main study, showing excellent internal consistency (Cronbach's α\u0026thinsp;=\u0026thinsp;0.82), and Test-retest reliability: Subset of 30 participants completed the questionnaire twice (2-week interval), demonstrating strong correlation (r\u0026thinsp;=\u0026thinsp;0.86, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Data Collection Procedures\u003c/h2\u003e \u003cp\u003eThe questionnaire was administered electronically via Google Forms, with three reminder emails sent at 2-week intervals. Participants provided digital informed consent through the platform and could withdraw at any time. Data collection occurred over 14 weeks (January 3 - April 10, 2022), with all responses anonymized prior to analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Statistical Analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using SPSS v26 (IBM Corp, Armonk, NY). Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarize demographic and background characteristics. Bivariate analyses were conducted using chi-square tests for categorical variables and independent-samples t-tests for continuous variables. Spearman\u0026rsquo;s rank correlation was applied to examine associations between years of professional experience and knowledge scores. Multivariable linear regression with robust standard errors was used to identify independent predictors of overall performance (grand total score). Open-ended responses were analyzed using thematic analysis following Braun and Clarke (2006). Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (two-tailed), and effect sizes were reported for significant findings. All percentages are presented with corresponding absolute numbers (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\frac{n}{N}\\)\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 256 dentists completed the survey and were included in the analysis (163 female, 63.7%; 93 male, 36.3%). Mean years of professional service was 11.65\u0026thinsp;\u0026plusmn;\u0026thinsp;8.97 years (median 10.0, range 1\u0026ndash;50). The majority were dental surgeons (n\u0026thinsp;=\u0026thinsp;148, 57.8%), followed by dental surgeons with a diploma (n\u0026thinsp;=\u0026thinsp;60, 23.4%), postgraduate trainees/lecturers (n\u0026thinsp;=\u0026thinsp;24, 9.4%), senior lecturers/consultants/professors (n\u0026thinsp;=\u0026thinsp;19, 7.4%) and general practitioners (n\u0026thinsp;=\u0026thinsp;5, 2.0%) Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eResponses to practice/experience questions (Q5\u0026ndash;Q9) indicated that 47.9% (n\u0026thinsp;=\u0026thinsp;123) reported performing initial management of an avulsed tooth during the prior 6 months, and 47.1% (n\u0026thinsp;=\u0026thinsp;121) reported managing avulsed teeth as follow-up visits in the previous year. A large proportion reported having updates on avulsion management since their undergraduate/postgraduate training (79.9%, n\u0026thinsp;=\u0026thinsp;205). The most frequently reported update sources were international guidelines (n\u0026thinsp;=\u0026thinsp;26; 12.6%), workshops/scientific sessions (n\u0026thinsp;=\u0026thinsp;26; 12.6%), and the Visual Trauma Guide or internet platforms (various combinations; see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResponse frequencies and correct answers for knowledge and management questions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrect answer\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en correct\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e% correct\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSearch for the tooth and put it back into the socket of the injured tooth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImmediately\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e66.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHBSS\u0026thinsp;\u0026gt;\u0026thinsp;Milk\u0026thinsp;\u0026gt;\u0026thinsp;Saline\u0026thinsp;\u0026gt;\u0026thinsp;Saliva\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e82.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRinse the tooth gently under running water for a few seconds without scrubbing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e70.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrom the crown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e255\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e99.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 Hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 Weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e71.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWithin 2 Weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eKnowledge and management item responses (Q10\u0026ndash;Q18) are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Item-level correct-response frequencies were: Q10 (first action at the accident site) 115/256 (44.9%); Q11 (urgency to seek professional help) 169/256 (66.0%); Q12 (correct order of storage media) 114/256 (44.5%); Q13 (replanting primary tooth) 211/256 (82.4%). For management items: Q14 (immediate management of tooth from dirty place) 181/256 (70.7%); Q15 (how to hold avulsed tooth) 255/256 (99.6%); Q16 (repositioning window) 26/256 (10.2%); Q17 (recommended splinting time) 184/256 (71.9%); Q18 (timing of endodontic treatment) 122/256 (47.7%).\u003c/p\u003e \u003cp\u003eUsing the prespecified scoring (knowledge score\u0026thinsp;=\u0026thinsp;sum of Q10\u0026ndash;Q13, range 0\u0026ndash;4; management score\u0026thinsp;=\u0026thinsp;sum of Q14\u0026ndash;Q18, range 0\u0026ndash;5; grand total\u0026thinsp;=\u0026thinsp;0\u0026ndash;9), the sample summary was: Knowledge total: mean 2.38\u0026thinsp;\u0026plusmn;\u0026thinsp;1.00 (median 2, range 0\u0026ndash;4), Management total: mean 3.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93 (median 3, range 1\u0026ndash;5) and Grand total: mean 5.38\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57 (median 5, range 1\u0026ndash;9).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKnowledge, management, and total scores by professional role\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRole\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eManagement mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGrand total mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDental Surgeon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e5.06\u0026thinsp;\u0026plusmn;\u0026thinsp;1.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDental Surgeon (Diploma Holder)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e5.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral Practitioner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e5.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostgraduate trainee/ Lecturer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e6.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior Lecturer/Consultant / Professor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.63\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.26\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e5.89\u0026thinsp;\u0026plusmn;\u0026thinsp;1.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOnly 2/256 (0.8%) of participants answered all items correctly (grand total\u0026thinsp;=\u0026thinsp;9); 9/256 (3.5%) had zero knowledge-item correct answers. Because several outcomes were not normally distributed, nonparametric testing was used for group comparisons. A Spearman rank correlation showed a small but statistically significant negative correlation between years of service and knowledge total (ρ = \u0026minus;0.18; p\u0026thinsp;=\u0026thinsp;0.0045), indicating a slight tendency toward lower knowledge scores with increasing years in practice.\u003c/p\u003e \u003cp\u003eKruskal\u0026ndash;Wallis tests detected statistically significant differences in scores across service-level groups (professional role). For the knowledge total the Kruskal\u0026ndash;Wallis statistic was 12.44 (p\u0026thinsp;=\u0026thinsp;0.014); for management total the Kruskal\u0026ndash;Wallis statistic was 22.75 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); and for the grand total the Kruskal\u0026ndash;Wallis statistic was 25.24 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Post-hoc pairwise comparisons indicated that postgraduate trainees/lecturers and diploma-holding dental surgeons had higher mean scores than the reference group (dental surgeons). The summarized regression results is displayed in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eTo estimate adjusted associations with overall performance, we fitted an ordinary least-squares regression for grand total with robust standard errors (HC3), including years of service (continuous), gender, and professional role (categorical; reference category Dental Surgeon)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariable regression for grand total score\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCoef.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.27, 5.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiploma Holder vs Dental Surgeon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.65, 1.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral Practitioner vs Dental Surgeon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.01, 3.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.049\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostgraduate trainee/Lecturer vs Dental Surgeon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.04, 2.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior Lecturer/Consultant/Professor vs Dental Surgeon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.54, 2.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of service (per year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.10, -0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-4.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale vs Female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.44, 0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThese adjusted estimates indicate that, after accounting for years in service and gender, dentists in diploma, postgraduate training, and senior academic/consultant roles scored on average about 1.2\u0026ndash;1.7 points higher on the grand total score than the reference dental surgeon group. Conversely, each additional year of practice was associated with a small decrease in the grand total (\u0026asymp;\u0026thinsp;0.07 points per year), consistent with the Spearman result. Model diagnostics showed no indication of influential outliers that materially changed inference; variance-inflation diagnostics did not indicate problematic collinearity for the included predictors.\u003c/p\u003e \u003cp\u003eFinally, internal-consistency analysis of the knowledge (4 items) and management (5 items) scales produced low Cronbach\u0026rsquo;s α coefficients (knowledge α\u0026thinsp;\u0026asymp;\u0026thinsp;0.18; management α\u0026thinsp;\u0026asymp;\u0026thinsp;0.16), suggesting the items measure related but heterogeneous facets of knowledge/management rather than a unidimensional scale. Accordingly, the scales are best interpreted as formative indices rather than reflective measures of a single latent trait. Given the low α values, subscale item-level reporting is retained in tables and interpretation focuses on item- and domain-level performance rather than a single latent construct.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe overall knowledge of avulsed-tooth emergency management among the participating Sri Lankan dentists showed strengths in several practical management items (e.g., correct way to hold an avulsed tooth, splinting time), while gaps remain for specific knowledge items (correct storage media hierarchy, acceptable time windows for repositioning). Longer-serving dentists tended to have slightly lower knowledge/total scores whereas diploma-holders, trainees and senior academics scored higher. These findings identify target groups and topics for continuing education and guideline dissemination, consistent with previous international findings that knowledge decay occurs without structured professional reinforcement (Levin et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Fouad et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe findings of this nationwide assessment highlight persistent and clinically significant knowledge deficits among dental practitioners regarding the emergency management of avulsed permanent teeth. Despite widespread awareness of basic handling principles, substantial deficiencies were noted in time-critical decisions\u0026mdash;particularly regarding the selection of appropriate storage media and the urgency of replantation\u0026mdash;factors most crucial to preserving periodontal ligament cell viability (Fouad et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The negative correlation between years of service and knowledge scores suggests that continuing experience does not necessarily translate into updated clinical proficiency, echoing similar trends observed in studies from Brazil (Vasconcellos et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) and Saudi Arabia (AlJazairy et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Collectively, these data underscore the urgent need for systematic continuing professional development (CPD) mechanisms to ensure long-term knowledge retention and adherence to evolving IADT guidelines.\u003c/p\u003e \u003cp\u003eEqually important, the results indicate systemic barriers that hinder guideline implementation across practice settings. Participants cited limited training opportunities, lack of institutional support, and restricted access to educational resources as key obstacles. These barriers reflect a broader global pattern where knowledge translation in dental trauma care is inconsistently supported by organizational infrastructure (Levin et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Petti et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Addressing these gaps requires a coordinated approach that combines regular CPD activities, digital access to updated guidelines, and institutional reinforcement of trauma protocols through audits and workshops. Such integrated strategies are essential for transforming knowledge into consistent clinical action.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e: Proposed intervention framework\u003c/p\u003e \u003cp\u003eThe proposed intervention framework (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e) addresses the principal barriers identified in this study\u0026mdash;limited training opportunities, restricted access to facilities, inadequate guideline awareness, and frequent patient referral to other centers. It emphasizes a sequential strategy beginning with the expansion of continuing education and hands-on training programs to enhance practical competence. Ensuring widespread access to updated IADT and national guidelines is positioned as a critical intermediary step to strengthen evidence-based decision-making. Similar multi-level strategies have been successful in improving emergency dental response in other healthcare systems (Fouad et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Levin et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Finally, improving institutional facilities and clinical resources is recommended to enable effective implementation of best-practice protocols. Together, these coordinated interventions aim to build a sustainable, system-level improvement in the knowledge, confidence, and clinical performance of dental professionals managing avulsed teeth. Adoption of this framework may therefore contribute not only to national improvements but also offer a replicable model for countries with comparable healthcare contexts and resource limitations.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates persistent knowledge gaps in the emergency management of avulsed permanent teeth across the dental profession, with deficiencies most evident in storage media selection, accident-site actions, and replantation timing. While some practical aspects such as handling and splinting are well recognized, overall adherence to international guidelines remains suboptimal. These findings emphasize the need for ongoing professional development, systematic integration of evidence-based trauma management into dental curricula, and the dissemination of clear clinical decision-support tools. Strengthening knowledge and practice consistency is essential to improve long-term survival of avulsed teeth and reduce preventable tooth loss. Future research should assess the effectiveness of targeted educational strategies and their translation into clinical outcomes. Future efforts should focus on integrating trauma protocols into national continuing education programs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical Relevance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEffective emergency management of avulsed teeth is critical for long-term survival, yet dentists worldwide continue to demonstrate important knowledge gaps in key guideline-based practices. Targeted education and systematic reinforcement of IADT protocols are essential to standardize care and improve patient outcomes in dental trauma management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors express their sincere gratitude to Prof. Lars Andersson for his invaluable supervision, guidance, and expertise throughout this project. His constructive insights and editorial support significantly strengthened the quality of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest related to this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlJazairy YH, Halawany HS, AlMaflehi N, Alhussainan NS, Abraham NB, Jacob V. Knowledge about permanent tooth avulsion and its management among dentists in Riyadh, Saudi Arabia. BMC Oral Health. 2015;15(1):1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoonsiriseth K, Khanijou M, Jiramongkolchai P, Arunakul P. Implementation of IADT guidelines in Thai dental schools. Dent Traumatol. 2021;37(2):195\u0026ndash;202.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFouad AF, Abbott PV, Tsilingaridis G, Cohenca N, Lauridsen E, Flores MT. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries. Dent Traumatol. 2020;36(4):331\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevin L, Day P, Hicks L, O'Connell A, Fouad AF, Bourguignon C, Abbott PV. Global status of knowledge for prevention and emergency management of traumatic dental injuries. Dent Traumatol. 2023;39(1):3\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNair M, Jain A, Khera A, Gupta S. Community-based dental trauma education programs in India. J Clin Pediatr Dent. 2023;47(2):45\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerera PJ, Abeyweera NT, Fernando MP, Warnakulasuriya TD, Ranathunga N. Prevalence of traumatic dental injuries among school children in Sri Lanka. Ceylon Med J. 2021;66(1):12\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePetti S, Glendor U, Andersson L. Epidemiology of traumatic dental injuries: A global perspective. Dent Traumatol. 2023;39(2):105\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVasconcellos M, et al. Knowledge of Brazilian general dentists about the emergency management of avulsed teeth. Dent Traumatol. 2009;25(3):294\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWimalarathna AAAK, Herath EMUCK, Senarath NH, Fonseka MCN, Manathunga MMKM, Nawarathna LS, Andersson L. Introduction of an interactive tool (the Dental Trauma Guide) in the undergraduate dental teaching to manage traumatic dental injuries. Dent Traumatol. 2021;37(5):717\u0026ndash;24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/edt.12687\u003c/span\u003e\u003cspan address=\"10.1111/edt.12687\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYilmaz Y, Kocogullari ME, Belduz N, Guler N. Evaluation of Turkish dentists' knowledge about managing avulsed teeth. Dent Traumatol. 2020;36(3):221\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao Y, Gong Y. Knowledge of emergency management of avulsed teeth: a survey of dentists in Beijing, China. Dent Traumatol. 2010;26(3):281\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Tooth avulsion, Emergency management, IADT guidelines, Knowledge assessment, Sri Lanka","lastPublishedDoi":"10.21203/rs.3.rs-8303339/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8303339/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e Tooth avulsion is a severe traumatic dental injury where prognosis depends on immediate management and adherence to guidelines. No nationwide assessment of Sri Lankan dentists\u0026rsquo; knowledge on tooth avulsion has been reported.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eTo evaluate knowledge, practices, and barriers regarding avulsed tooth management among Sri Lankan dentists, and to identify predictors of knowledge performance.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e A cross-sectional survey (January 2021\u0026ndash;March 2022) was conducted using a validated 21-item questionnaire based on IADT 2020 guidelines. Stratified random sampling identified 750 eligible dentists; 256 participated (response rate 34.1%). Knowledge was assessed in emergency and long-term management domains. Analyses included descriptive statistics, nonparametric tests, Spearman correlation, and multivariable regression with robust errors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eParticipants included 163 females (63.7%) and 93 males (36.3%), mean service 11.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.0 years. Correct responses were low for accident-site management (44.9%) and storage media order (44.5%), but higher for tooth handling (99.6%) and splinting time (71.9%). Mean scores: knowledge 2.38\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0, management 3.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9, grand total 5.38\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 (range 0\u0026ndash;9). Only 0.8% achieved full scores. Knowledge declined with years of service (ρ = \u0026minus;0.18, p\u0026thinsp;=\u0026thinsp;0.004). Regression showed statistically significant higher scores among diploma holders, postgraduate trainees, and senior academics compared with dental surgeons (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eSignificant knowledge gaps exist in avulsion management, especially among experienced practitioners. Targeted continuing education and system-level integration of IADT guideline training are urgently required to improve patient outcomes.\u003c/p\u003e","manuscriptTitle":"Emergency Management of Avulsed Permanent Teeth: National Knowledge Gaps, Clinical Predictors, and a Proposed Intervention Framework","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-11 14:23:20","doi":"10.21203/rs.3.rs-8303339/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-01T09:32:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-26T05:11:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-25T02:52:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-23T01:31:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-19T07:07:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T16:54:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"339478915461972247432450142965532849577","date":"2026-03-18T16:44:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-16T18:08:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"137212583898237466859487426718653285244","date":"2026-03-13T09:09:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"244108575514497199173882939189841690052","date":"2026-03-13T08:53:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"112744858423998682194397284716063173155","date":"2026-03-13T08:50:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"216420124947798292492105139154960520819","date":"2026-03-12T04:47:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"122678576814936407303595119955412104710","date":"2026-03-09T04:53:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"258168313976048424760578573118638922639","date":"2026-03-07T13:49:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-06T09:12:09+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-11T10:05:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-19T01:21:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-19T01:15:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-12-08T04:01:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9ef93701-b50f-4824-9a70-e9e8386ab796","owner":[],"postedDate":"March 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T10:54:05+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-11 14:23:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8303339","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8303339","identity":"rs-8303339","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}