Avulsed Permanent Teeth Research Articles

Knowledge and attitudes about emergency management of avulsed teeth among primary and secondary school teachers in Malatya, Turkey

Background and Aim: Dental trauma is highly frequent in children during school time and school teachers are often the first witnesses of the incident. This cross-sectional study aimed to assess the knowledge of school teachers about dental avulsion and its management.Methods: This cross-sectional questionnaire study was conducted on 782 primary and secondary school teachers in Malatya, Turkey. The questionnaire included three sections assessing (i) demographic characteristics, (ii), knowledge and attitudes about emergency management of avulsed permanent teeth, and (iii) teachers’ perspective on dental trauma education and selfevaluation of dental trauma knowledge. The correct answer scores were calculated according to section 2 (6 questions-17 items). Data were analyzed using Mann-Whitney U test, Kruskal-Wallis test, and multiple linear regression analysis.Results: The correct answer score was calculated out of 17; the highest score was 13 and the mean score was 8.5. The level of knowledge on emergency management of avulsed teeth was higher among the teachers who had previously been trained on the subject.Conclusion: The knowledge of Turkish school teachers about emergency management of avulsed teeth is limited. The findings obtained in this study indicated that an educational strategy for teachers is strongly required.

An update on management of avulsed teeth

Introduction: Avulsion of permanent teeth is one of the most serious dental injuries, prompt and correct emergency management is essential to achieve the best outcome after this injury.Objective: To analyze the literature on avulsed teeth, particularly its prevalence, storage media, consequences and treatment.Methodology: In order to carry out this literature review, an electronic search was necessary using PubMed and Google Scholar with the words avulsed tooth, and prevalence, storage media, treatment.Results: The prevalence of traumatic dental injuries is greater in male patients of school age. The most common treatment is reimplantation. The main adverse events are dental ankylosis and resorption. When immediate reimplantation is not possible, the most practical means of preservation is cow's milk, currently anti-reabsorption therapy is used to improve the prognosis in addition to the use of a semi-flexible stabilizer.Conclusion: The treatment of choice for dental avulsion will always be reimplantation, whether immediate or delayed, regardless of how long the tooth is kept out of the mouth. Although there is no predictable prognosis, it does not mean that reimplantation should not be attempted, since the tooth will be of great importance in contributing to the mandibular and facial development of the child.

The influence of different dimensions of oral health literacy on parental attitudes and comprehension of an information leaflet about permanent tooth avulsion.

Permanent tooth avulsion requires proper management at the time of the accident and parental oral health literacy (OHL) may influence decision-making with regards to dental trauma. The aim of this study was to investigate the influence of OHL on: (1) self-rated comprehension of an information leaflet (IL), (2) self-rated capacity to execute the tasks proposed on the IL, and (3) attitudes regarding the avulsion of a permanent tooth in children. A longitudinal study was conducted involving the reading of an IL by 466 parents/caregivers. Evaluations were performed prior to the IL (Phase I), immediately after the application of the IL (Phase II) and 60 days after the application of the IL (Phase III). Self-rated comprehension and capacity to execute the proposed tasks were analyzed in Phase II. Attitude was evaluated in all three phases. Functional OHL was measured using the BREALD-30 and interactive OHL was measured using HeLD-14. Correlations were found between self-rated comprehension and both the OHL/BREALD-30 score (rs=0.179; p= .012) and OHL/HeLD-14 score (r= 0.258; p< .001). Correlations were also found between the self-rated capacity to execute the proposed tasks and both the OHL/BREALD-30 score (rs=0.133; p= .047) and the OHL/HeLD-14 score (rs=0.225; p< .001). Higher BREALD-30 and HeLD-14 scores were associated with a better performance regarding parental attitudes toward permanent tooth avulsion comparing Phases I and II and Phases II and III (p< .05). Higher levels of OHL were associated with better parental self-rated comprehension of the IL and the capacity to execute the tasks proposed therein as well as more adequate attitudes regarding the avulsion of a permanent tooth.

Antibiotics at replantation of avulsed permanent teeth? A systematic review.

At present there is no clear consensus whether systemic antibiotics should be administered at replantation of an avulsed permanent tooth. This systematic review and meta-analysis assessed the evidence on effectiveness and harms of the administration of systemic antibiotics at replantation of avulsed permanent teeth. In August 2020 a systematic literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, for systematic reviews, randomized controlled trials (RCT) and observational controlled studies in MEDLINE, PreMedline, Embase, and the Cochrane databases. The population of interest were medically fit patients with a replanted avulsed tooth. Main outcomes were tooth survival, periodontal healing, pulpal revascularization as well as (severe) adverse events. These outcomes were compared in patients who did and who did not receive systemic antibiotics. The GRADE methodology was used to assess the quality of evidence. The search yielded no RCTs, and none of the 7 included observational studies had the prime intent to investigate the effectiveness or harms of antibiotics. According to GRADE, the overall level of evidence was very low. The meta-analyses showed non-significant associations between the administration of systemic antibiotics on the one hand and tooth survival (1 study, RR = 3.70, 95% CI: 0.63-21.69), periodontal healing (meta-analysis of 6 studies RR: 1.07; 95% CI: 0.80-1.45), and pulpal revascularization (meta-analysis of 2 studies, RR: 0.36; 95% CI: 0.05-2.41) on the other hand. Currently there is no high-quality evidence to support the use of systemic antibiotics at replantation of avulsed permanent teeth. Hence, their routine use cannot be recommended in medically fit patients. Well-designed RCTs should be a priority on the research agenda.

Parental and training coaches' knowledge and attitude towards dental trauma management of children.

The aim of this study was to evaluate parental and training coaches' knowledge and attitude towards traumatic dental injuries (TDIs) among children. A 31-item questionnaire was distributed to the parents and training coaches attending local sporting clubs in Brisbane region, Australia. The questionnaire consisted of five parts (i) demographic and professional information; (ii) TDIs in the primary dentition; (iii) fractures and subluxation of permanent teeth (iv) avulsion of permanent teeth, and (v) information and knowledge related to the management of traumatized teeth. The jamovi (Version 1.6.3) and GraphPad Prism were used for data analysis. A total of 233 participants were surveyed, 211 parents and 22 coaches. Of all types of injuries, parental knowledge of managing avulsion to permanent teeth was poorest (9.5%), followed by management of injuries of primary teeth (17.5%) and management of fractures or subluxation of permanent teeth (29.4%). Parents in health care occupations had higher satisfaction on self-knowledge in managing TDIs however there was no significant difference in knowledge levels between health care personnel and other professions (P = 0.128). There was a discrepancy between the lack of knowledge and willingness to further self-educate with online platforms being the preferred medium. The study showed a gap in parents' and training coaches' knowledge regarding the management of TDIs among children.

Management of External Root Resorption Associated with a Replanted Maxillary Central Incisor in an 11-Year-Old Patient: A Rare Case Report

Avulsion of permanent teeth is one of the serious injuries that require immediate attention in a dental setup and immediate replantation and splinting is the treatment of choice. The replantation of avulsed tooth improves aesthetics, occlusion, and function. Most common complication of tooth replantation is inflammatory external root resorption. Mineral trioxide aggregate is a calcium silicate-based material that maintains high alkaline pH for a longer duration and it helps in preventing inflammatory external root resorption. The purpose of this article is to report the successful management of inflammatory external root resorption associated with a replanted maxillary right central incisor using MTA in an 11-year-old girl with one-year follow-up.

Knowledge and Attitude of Guardians in Management of Avulsion of Primary and Permanent Teeth of Children: A Questionnaire-Based Study

Aims: This study aims to assess knowledge and attitude of guardians in management of dental avulsion of the children.&#x0D; Materials and Methods: This cross-sectional study was carried out at Altamash Institute of Dental Medicine, Pakistan, from April to May 2021. A total of 400 parents were recruited. An online self-administered questionnaire was circulated to the parents after taking the informed consent. 17 questions regarding demographics, knowledge and attitude were included. Chi-square test was used for association between demographics and responses of the participants.&#x0D; Results: Of the 400 participants, there were 140 (35%) males and 260 (65%) females. Most of the 180 (45%) participants belonged to 18-30 years age bracket. About 63% of the children did not have past dental trauma history. Predominantly, 80% chose dentists being most appropriate of emergency treatment. 33% believed to visit the dentist within 30minutes for treatment. About 50% participants agreed avulsed teeth can be placed back into its original position. More than half knew different transport mediums, with milk (21%) and Hanks Balanced Salt Solution (19%) being commonly selected. Younger age group and females were more knowledgeable regarding emergency management.&#x0D; Conclusion: Dental avulsion is a common finding in childhood, which mandates proper knowledge for the guardians. There is still a gap present in adequate knowledge for management of such emergencies which mandates organizations of education and awareness programs for both children and adults.

The Influence of Dental Trauma Education on Undergraduate Students at Ajman University, United Arab Emirates: An Interventional Study.

Background and ObjectivesThe main objective of this study was to assess the impact of a lecture on dental trauma on the knowledge of undergraduate dental students at Ajman University in the United Arab Emirates (UAE).MethodsFourth-year dental students were asked to attend a lecture on dental trauma and then respond to an online questionnaire containing 10 close-ended questions related to their approach to managing dental trauma cases and tooth avulsion before (T0) and directly after (T1) the lecture. They were given 5 min for filling the questionnaire either time. McNemars test was used to compare the accuracy of their answers based on the correct or incorrect response for each question. The level of significance was set at p < 0.05.ResultsThe questionnaire was sent to 164 students, out of which 157 responded, giving a response rate of 95.7%. After receiving the educational intervention, the students showed a significant improvement in their knowledge on managing permanent tooth avulsion, especially regarding the handling of an avulsed tooth before replantation, extra-alveolar time, and media used for the storage and transportation of avulsed teeth (< 0.001).ConclusionThe study reveals that the lecture on dental trauma had an excellent outcome on the knowledge of the students. Therefore, it is essential to emphasize the importance of this information among undergraduate dental students in order to save teeth exposed to trauma and to reduce the social burden of such cases. This study contributes to better understanding of the effect of dental trauma education on undergraduate dental students’ knowledge of the subject.

Infraposition or infraocclusion– Is it time to rename?

AbstractDental infraposition and dental infraocclusion, hereinafter referred to as infraposition and infraocclusion respectively, are terms that are often used interchangeably. This can be noted in the International Association of Dental Traumatology guidelines for the management of traumatic dental injuries, where infraocclusion is listed as an injury‐specific outcome following avulsion of permanent teeth. Infraposition and infraocclusion are terms that have been used in the dental literature to describe teeth that interfere with the normal eruption and development of the permanent dentition. While teeth described in this manner share certain clinical characteristics that give rise to these terms being used interchangeably within the dental traumatology field, this may not necessarily be correct and may be confusing. The aim of this short communication is to start a discussion in the dental trauma community regarding the need for a more adequate term, particularly in relation to replanted teeth.

A new approach of permanent tooth avulsion in a growing patient

Objectives Dental traumas frequently occur in young children and young adults. The maxillary incisors are the most commonly damaged teeth with a greater risk for central maxillary in­cisors, especially in children with increased overbite and overjet. In avulsions’ treatment of perma­nent teeth, the reimplantation of the same element is the first choice of treatment in most … Continued

Effect of tetracyclines on pulpal and periodontal healing after tooth replantation: a systematic review of human and animal studies

BackgroundPulpal and periodontal healing are two main concerns of delayed replantation of avulsed teeth. The objective of this review was to evaluate the effectiveness of topical and systemic application of tetracyclines on pulpal and periodontal healing after tooth replantation.MethodsA comprehensive electronic search was conducted in six databases. This systematic review was carried out according to Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.ResultsAfter exclusion of 246 irrelevant papers, 14 animal studies and one human study were included in this review. The human study showed that avulsed permanent teeth treated with doxycycline did not show a better clinical outcome for pulp and periodontal healing compared with treatment with normal saline. As for animal studies, significant more pulpal healing was observed in immature teeth treated with topical doxycycline in two researches, while another one study showed that there is no difference between teeth treated with normal saline and teeth treated with doxycycline. Systemic doxycycline exerted no significant effect on pulpal revascularization illustrated by one research. Only one out of four articles illustrated the positive effect of systemic tetracyclines on periodontal healing. One paper reported that intracanal application of demeclocycline promoted favorable periodontal healing. Two articles showed topical doxycycline contributed to favorable periodontal healing, while five studies showed no significant effect of topical tetracyclines on periodontal healing.ConclusionsAs a result of data heterogeneity and limitations of the studies, the effect of topical or systemic application of tetracyclines on pulpal and periodontal healing is inconclusive. More studies are required to get more clinically significant conclusions.

REIMPLANTATION: BOON TO DENTISTRY - A CASE REPORT

Avulsion of permanent teeth is the most common dental injuries in a road traffic accident. It’s a boon that the patient’s original teeth can be replanted provided the fracture of the tooth and socket are within limits. Educating the community plays a major role in reimplantation. In this case report, the patient’s avulsed maxillary central incisors (11,21) were replanted by simple composite splinting technique. KEY WORDS: Avulsed tooth, Composite splinting, Reimplantation, Golden hour.

Tooth Avulsion Replantation Management: A Review Article

Avulsion of teeth is defined as total displacement of the tooth out of its socket. Incidence of avulsion constitutes 0.5 to 16 % of all traumatic injuries in the permanent dentition. Avulsion is more commonly seen in children and young adults, at an age when the alveolar bone is resilient and provides only minimal resistance to extrusive forces The maxillary central incisors are the teeth most commonly affected. Teeth can be avulsed in many trauma situations. Sports and automobile accidents are the most frequent causes. The incidence of avulsion is reported to be less than 3% of all dental injuries. Tooth avulsion is a true dental emergency since timely attention to replantation could save many teeth. Unfortunately, avulsed teeth are usually lost at the accident scene, and both accident victims and those attending them may neglect to consider the value of finding and saving the teeth. This may gradually change as the public continues to become aware of the possibilities that avulsed teeth can be saved. Discussion: Avulsion of permanent teeth is serious problems of dental injuries. The prognosis depends on the measures taken at the place of accident or the time immediately after the avulsions. Treatment for the avulsion teeth is replantation, but it’s not suggested for primary teeth avulsion. It will give a high risk for underlying permanent tooth germs. Replantation is directed at avoiding or minimizing the resultant inflammation which occurs as a direct result of the two main consequences, attachment damage and pulpal infection. Attachment damage may cause by drying, can additionally occur to the periodontal membrane when tooth is out of the mouth. Drying can cause loss of normal physiologic metabolism and morphology of the periodontal ligament cells. The treatment should minimize this damage so that the fewest possible complication result. Conclusion: Clinical success rate of replanted avulsed teeth based on media and time for replantation. Careful examination regardless including radiographs and clinical examination are necessary to help detect possible alveolar fractures or complication. Such fractures of the tooth socket may reduce the prognosis but are not always a contraindication.

An educational intervention for improving knowledge of Syrian school children about avulsion using the "save your tooth" poster

BackgroundThe prognosis of replantation of an avulsed tooth is affected by the first aid management in the first 15 min after traumatic incident. Knowledge of the optimal management is crucial to successful replantation. The objective of this study was to investigate the effectiveness of educational intervention using the Arabic version of the "save your tooth" poster designed by the International Association of Dental Traumatology IADT, in improving the knowledge of schoolchildren about first aid management of avulsion of permanent teeth.MethodsAn interventional educational study was undertaken. A total of 550 schoolchildren aged 9–12 years participated in this study. Thirteen public primary schools in Damascus city were selected. A questionnaire was developed to measure the knowledge of schoolchildren about avulsion of permanent teeth. The translated IADT education poster about avulsion management was adopted.The content of this poster was explained to the children. Two months later, the subjects were re-evaluated using the same questionnaire. Paired sample t-test was used to test the differences existed between the two assessments.ResultA total of 537 schoolchildren completed the questionnaires in which (n = 305) 57% were females and (n = 232) 43% were males. The findings demonstrated significant improvement in the participants’ responses after interventional education (P < 0.05). The mean score of knowledge increased significantly from 3.71 at the baseline to 4.03 after the intervention (P < 0.003).ConclusionThe findings of the present study showed that the level of knowledge of Syrian schoolchildren regarding first-aid management of avulsion of permanent teeth was limited at the baseline. The follow-up results showed that the educational intervention based on the “save your tooth” poster was significantly effective in improving the knowledge of schoolchildren. Further interventions to educate all Syrian schoolchildren about avulsion could be of great value to prevent its negative aesthetic, functional, psychological, economic impacts.

Knowledge of Avulsion of Permanent Teeth Emergency Management Among Undergraduate in Brazilian Health Care Students

Objective: To assess the knowledge of undergraduate health care students, about avulsion of permanent teeth. Material and Methods: It is a cross-sectional study. The sample consisted of Brazilian undergraduate students of the nursing, medicine, and dentistry degree programs. A structured questionnaire developed by the researchers, containing 18 objective questions about avulsion of permanent teeth was used as the data collection. Data analysis included Pearson's Chi-square and Fisher's Exact. Results: A total of 82.7% dental students, 22.9% nursing students, and 23% medical students had previously received some information about dental trauma. Students in the second half of the dentistry program had a higher percentage of correct answers in all questions (p<0.05). Being in the first or second half of the nursing program had no relation to the percentage of correct answers by students for any questions (p>0.05). Students in the first half of the medical program had a higher percentage of correct answers for six of these questions (p<0.05). Dentistry students had the highest percentage of correct answers in all the questions (p<0.001). Conclusion: Although students from the dentistry degree program report having information on avulsion of permanent teeth, their practical experience was considered low. Upon comparing students from the dentistry, nursing, and medical degree programs regarding their learning about avulsion of permanent teeth, dentistry students had greater knowledge on the subject.

Avulzija stalnih zuba kod dece i odraslih - terapijske mogućnosti za duži opstanak

Introduction: Permanent tooth avulsions (traumatic extraction; total luxation) are one ofthe most severe permanent tooth injuries and can occur as single injuries or associated with other dental injuries or injuries to the face and jaws region. They are defined as the luxation of teeth from the alveoli with complete rupture of periodontal fibres, or with one part attached to the rootcementum and the other to the alveolar bone, thus compromising the dental pulp, root cementum,and alveolar bone. The high prevalence and numerous negative consequences on the stomatognathic systems they have suggest permanent tooth avulsions should be regarded as an important public health problem. The aim: is to point out the therapeutic possibilities of permanent tooth avulsion that can ensure their longer survival in the oral cavity. Conclusion: The treatment strategy for avulsed permanent teeth is always based on limiting root canal infection and periradicular inflammation, shifting the balance from unfavourable (replacement resorption) to favourable (periodontal) healing. The success of therapy and periodontal healing depend on the duration and conditions of extraoral tooth preservation, the degree of damage to the periodontal ligament, and the condition of the pulp.

Awareness and Preferred Mode of Getting Information on First Aid Management of Avulsed Permanent Teeth: Survey of Nigerian Mothers

Objective: To determine the awareness and sources of information on first aid management of avulsed permanent teeth in a group of South-western Nigerian mothers. Material and Methods: An 18-item interviewer-administered questionnaire was used to survey 385 mothers attending the antenatal and immunization clinics on their perception towards dental avulsion, its management, sources, and preferred mode of receiving information on first aid. The effect of all significant factors was inferred at p<0.05. Results: Mothers who had previous information on the first aid management of dental avulsion had significantly higher knowledge (p=0.000). Majority (80.8%) of the mothers did not know that an avulsed permanent tooth could be replanted, though mothers whose children had not experienced dental trauma had significantly higher knowledge (p=0.003). The knowledge of first aid management of avulsed permanent tooth was low, regardless of age, education and employment status of the respondents. Conclusion: There was low knowledge among mothers regarding the first aid measures in the management of avulsed permanent teeth. Their main preference for receiving information was through social media and television. There is a need to increase oral health educational campaigns targeted towards mothers.

Population Knowledge and Attitude Toward Emergency Management of Avulsed Permanent Teeth

Objective: To evaluate the knowledge of patients treated in a public University concerning dental avulsion and its emergency first-aid management. Material and Methods: Three hundred patients were invited to answer a questionnaire about demographic characteristics, attitude and knowledge of first-aid management of dental avulsion. Chi-square test was used to assess the association between knowledge about dental replantation and education level. Results: Female gender (66.7%) aged from 31 to 40 years (31.3%) with high school education (50.3%) predominated among all the participants. It was not found a difference between education level and management of avulsed permanent teeth (p=0.076), and 66% of the respondents were not able to do the replantation. In relation to the management of avulsed tooth, 42.7% of the respondents would brush the tooth and if the replantation was not possible, most of them would choose inappropriate media for storage. The association between the storage medium and educational level showed to be statistically significant (p=0.043). Conclusion: It was possible to notice the lack of knowledge about this subject, and it could result in the worst prognosis. In avulsion cases, the subsequent root resorptions may lead to the loss of the child's tooth. It is important to implement educational campaigns to spread knowledge and improve success rates of permanent avulsed teeth

Management of Dental Avulsion Injuries: A Survey of Dental Support Staff in Cairns, Australia.

Background/Aim: The aim of this study was to assess the knowledge of dental support staff in providing appropriate first-aid advice regarding dental avulsion emergencies. Methods: This study was reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies. Dental support staff (includes dental assistants, administrative staff and other non-clinical staff) were contacted and data were collected from 50 private dental clinics across the Greater Cairns Area, Queensland, Australia. These data were collected through an online survey throughout 2020. Descriptive statistics and Pearson’s Chi-squared test was used to analyze the data and any associations between categorical outcomes. Results: This survey yielded a response rate of 34.1% with a margin of error of 10.3%. More than four-tenths of participants (42%) reported that they had received some form of dental avulsion management training previously. All but five participants (92%) denoted that they would immediately replant an avulsed permanent tooth. More than half of all participants would choose to rinse a soiled avulsed tooth with fresh milk (55%) and transport that tooth in fresh milk (65%) should they not be able to replant the tooth at the site. Almost nine in every ten participants (85%) expressed willingness to further their training in this area. Knowledge in replanting avulsed permanent teeth was found to be significantly impacted by gender, age, years of experience and participation in formal avulsion training. Male participants were found to be significantly more likely (p = 0.025) to replant a permanent avulsed tooth than their female counterparts. Participants who were 40 years of age and above were found to be significantly more likely to choose fresh milk to transport avulsed teeth (p = 0.0478). Older participants (p = 0.0021), alongside those who had greater years of experience (p = 0.0112) and those who had undertaken formal avulsion training (p = 0.0106) were all significantly more likely to express greater confidence in their ability to manage dental avulsion injuries. Participants who had previously received some form of education regarding avulsion injury management were also most likely to warrant further education and training in this area (p < 0.0001). Conclusion: This study demonstrated that dental support staff in the Greater Cairns Area seem to have a fair grasp of first-aid knowledge regarding the management of dental avulsion injuries. This result indicates that this knowledge has been picked up through years of experience, rather than a formal education. Despite this, one would expect people who work in the dental industry to be able to provide accurate and appropriate assistance during dental emergencies, hence, further training is warranted to ensure optimum patient outcomes.

Knowledge of Iranian Parents of Elementary School Children about Traumatic Dental Injuries and its Management.

Statement of the Probelm: Traumatic dental injuries (TDIs) are frequent events during childhood, and emergency management of these injuries has positive outcomes.Purpose: The aim of this study was to evaluate the knowledge of parents of school-aged children about dental trauma and to identify the effect of demographic variables such as age, gender, and education on their responses.Materials and Method: 300 parents of elementary school children were selected through cluster sampling from July 2012 to January 2013 in Yazd, Iran. A questionnaire was designed to collect the data on parents’ knowledge about emergency management of dental trauma, and their demographic characteristics and previous experiences. Statistical analysis of data was performed by SPSS software version 11 using T-test and ANOVA. P-values less than 0.05 were considered significant.Results: 296 out of 300 participants returned their questionnaires (mean age 33.8± QUOTE ± 5). The parents’ knowledge about TDI managements was inadequate (average score = 7.03). According to T-test and ANOVA statistical tests, there was no significant relationship between knowledge and age (p= 0.155), gender of parents (p= 0.113), gender of children (p= 0.776), occupation (p= 0.112), and the information source (p= 0.160). The relationship between parents’ knowledge and parental educational level was statistically significant (p= 0.010), and least significant difference (LSD) test showed that knowledge score of parents with Bachelor’s degree or higher educational levels (7.83±4) was significantly more than other parents who were not educated (6.97±4), or had high school diploma (6.70±4).Conclusion: Majority of parents had little knowledge about TDI and emergency management of avulsed permanent teeth in children. Therefore, it seems that educational programs are necessary to improve parents’ knowledge.