This study explored perceived challenges in the management of traumatic dental injuries (TDI) among general dentists in the public dental service (PDS) of Vestland County in Western Norway and their needs for improving treatment care for TDI patients.

Participants and Methods

This qualitative study conducted three focus group discussions. We recruited a purposive sample of seven general dentists employed in the PDS in Vestland County in Western Norway. The three focus groups consisted of two, two, and three participants, respectively. The focus group discussion took place via the Microsoft electronic platform Teams, and it was visual, and audio recorded. Transcripts of the interviews were analyzed using systematic text condensation.

Results

The general dentists in this study experienced the management of TDI as a set of complex procedures that require good theoretical knowledge, clinical experience, skills, and teamwork. We were able to group these challenges into three results categories: (1) proficiency challenges, (2) the challenge of stress and discomfort during dental procedures, and (3) the challenge of the organization of the PDS. The participants also expressed the need for practical courses, calibration, and refresher courses in dental traumatology. Their needs fell into two categories: (1) regular, clinically relevant continuing professional development and (2) collective efforts in TDI management.

Conclusion

Increasing awareness of the challenges in TDI management and addressing the need for improved dental treatment for TDI patients may lead to targeted programs to enhance dentists' knowledge and skills. There is considerable potential for training dentists in dental traumatology.

1 Introduction

Traumatic dental injuries (TDI) are common among people of all ages, with an estimated prevalence of 58% among adolescents and 15.5% among adults globally [1, 2]. They are considered the fifth most prevalent condition, affecting over a billion people worldwide [3]. To minimize complications and long-term consequences, adequate training in emergency treatment of patients with a TDI is required. The implications of a TDI for the individual are broad ranging, being aesthetic and functional as well as psychological and social, and are thus critical for a person's future quality of life [4].

Studies from several countries on general dental practitioners have observed insufficient levels of knowledge and experience in management of TDI [5-8]. The Marriot-Smith et al.'s study has linked this to the low exposure of dental students to patients with TDI in their training [9].

Two factors that affect TDI treatment most are knowledge and training in the field, and the confidence of the general dental practitioners in their ability to properly treat the patient. Low levels of knowledge lead to inaccurate diagnoses and treatment, with possible complications, functional problems, future tooth loss, and higher costs for treatment to correct what initially may have been avoidable [10, 11]. TDI management is multifaceted, and many factors may affect the outcome. Several identified barriers to the optimal management of TDI include access to the dental care system, difficulties in patient cooperation during treatment, time-consuming treatment, communication with secondary dental care providers, and lack of financial remuneration associated with the long-term management [4, 12, 13].

In Norway, children up to and including 18 years of age are entitled to dental care that is free-of-charge when provided by the public dental service (PDS) [14]. With dental trauma injuries being common in children and adolescents [3], general dentists, and to some extent dental hygienists, in the PDS are the primary care providers of these patients. They are responsible for providing adequate emergency treatment, following up, and referring the patients to dental specialists when needed [14].

Thus, resources for improving and reinforcing the proficiency of general dentists in the field of TDI would be well spent. The recent Iden et al.'s study from Western Norway (Oral Health Centre of Expertise-TkVestland) concluded that general dentists in the Norwegian PDS were uncomfortable with treating young patients with TDI and often preferred to refer these patients to a specialist [15]. Understanding the reason behind this discomfort can highlight the knowledge gap in TDI.

At Norwegian universities, the dental traumatology curriculum is integrated with other dental disciplines such as pedodontics, endodontics, and oral surgery. Given Norway's multicultural landscape, where general dentists come from various countries with different educational backgrounds in dental traumatology, there is a need for curriculum standardization [16, 17].

The above indicates that a greater emphasis on dental traumatology is needed in continuing education programs. Many European countries consider continuing professional development (CPD) to be essential and have made it obligatory [18]. However, there is little evidential knowledge in the literature for guiding the development of CPD activities in dental traumatology. The present study aimed to investigate the perceived challenges associated with TDI management among general dentists, as well as their needs for improving treatment care for TDI patients. For this purpose, the particular sample used was the PDS of Vestland County in Western Norway.

2 Materials and Methods

2.1 Context

This qualitative study explored the experiences of general dentists in managing TDI, including their perceptions for better outcomes in this field.

Recently, all PDS clinics (n = 50) in Vestland County in Western Norway participated in a study where the clinics were divided into two intervention groups (n = 32; 16 clinics in each group) and a control group (n = 18). The intervention clinics were offered dental traumatology training in the form of a webinar alone or a webinar with a half-day practical course at the clinics. The control group received no educational intervention. Since one of our aims was to explore the challenges dentists experience with TDI management, we considered it important to collect data from clinics that had not recently received dental traumatology training. Hence in this project, we recruited participants for the current qualitative study from the control group.

2.2 Study Design

This qualitative, cross-sectional study was based on focus group discussion of the participants. The literature has deemed this approach to be suitable for stimulating reflection and thoughts. The participant interaction that occurs in a group approach makes possible an exchange of experiences as well as reactions to the statements of the other participants [19].

2.3 Sampling and Data Collection

All dentists (n = 59) in the control group clinics (n = 18) were eligible for the present project. An e-mail sent to these dentists described the project and purpose in detail and invited them to participate. The Chief Dental Officer of Vestland County provided the e-mail addresses and allowed the focus group discussions to take place during working hours. Participation, however, was voluntary, and no incentives were offered.

The invitation e-mail also listed contact information (of AC) for queries about the study. Seven dentists agreed to participate in the focus group interviews. All filled out a participation form, which included signed informed consent and queries about work, education, and experience, and returned it to AC before the discussions commenced. Due to busy schedules and the travel time to Bergen, three focus groups of two or three participants were formed and the discussions took place via Microsoft Teams, an electronic meeting platform.

The same moderator (AC) and co-moderator (MK) led all focus group discussions. Neither the moderator nor the co-moderator was acquainted with the participants. The moderator was a dentist with knowledge of TDI and experience in the Norwegian dental health system. The moderator attended a qualitative research methods course as part of the PhD program, which included focus group interviewing. The co-moderator had an Educational Sciences background, with a focus on Medical and Health Professions Education and extensive experience in conducting focus group discussions. Four of the authors (AC, MK, GT, and AB) developed the interview guide through a systematic process using an interview protocol refinement (IPR) [20] theoretical framework and Krueger's suggestions for categorizing, phrasing, and sequencing focus group questions [21]. This theoretical framework provides flexibility, support for change, and openness. Table 1 illustrates the themes for discussion. Furthermore, the interview guide was piloted on a group of three participants, all working in the PDS, and modified according to their comments.

TABLE 1. Topics and questions in the semistructured guide used as a reference when interviewing dentists in the focus group discussions.

Topic	Additional prompts
Experience working with dental trauma	What challenges have you faced in the treatment of patients with TDI? Is your workplace well supplied for treating patients with TDI, that is, with the correct dental materials and equipment? Please describe the conditions necessary for properly treating TDI patients
Aids in an emergency	Do you use the “Dental Trauma Guide” (when a patient has a TDI)?
Interprofessional collaboration	Please describe the collaboration between dentists and dental assistants in dental emergencies Please describe the collaboration between dentists and dental hygienists in dental emergencies. Are responsibilities clearly defined for patients with TDI?
Current knowledge in TDI	In your opinion, is your knowledge on TDI satisfactory, or is there something more you would like to learn? How often would you like to have a refresher course on TDI? Should the PDS offer training on TDI to all dental personnel?
Continuous education in dental traumatology	What form of continuing education (webinar, practical course, case discussions, or other) suits you best? When is the best time (working hours/after work) for you to participate in continuing education courses? In your opinion, as a dentist employed in the PDS, who has is responsible for your professional development? Does your employer (the County municipality) provide financial support for continuing education?

Abbreviations: PDS, public dental service; TDI, traumatic dental injuries.

The electronic platform Teams provided both audio and visual recordings of the discussions. At the beginning of the interview, the participants gave their verbal consent for the session to be video recorded. At this time, they were also reminded that participation was voluntary and that they could withdraw at any time. Discussions took place during working hours between October and December 2022. Each focus group met once, and the discussion lasted 60–90 min.

The recordings were stored on a password-protected research server. Verbatim transcription of the content was made by one researcher (AC) and validated by another researcher (AB). The anonymized transcripts of a total of 36 double-spaced pages were stored on a research server with password-protected access until analysis. Transcripts were not sent to the participants for reading to avoid misinterpretation of the content without proper context.

2.4 Analysis

Three authors (AC, MK, and AB) collaborated on data analysis using systematic text condensation (STC), a cross-case thematic analysis suitable for focus group data [22]. STC is a descriptive approach, which presents the experience of the participants as expressed by themselves. The method is an elaboration of Giorgi's principles, including four comparable steps of analysis [23]. The analysis proceeded through the following stages: (1) Total impression—reading the 36 pages of transcript several times to get the impression of the whole content and looking for preliminary themes related to the research questions without systematization. Preliminary themes are starting points for further organization of data. (2) From themes to codes—identifying text fragments, known as meaning units, that may include the research question. Then start coding manually by identifying, classifying, and sorting meaning units potentially related to the preliminary themes. Identified meaning units were marked with code, a label that connects related meaning units into a code group. (3) Condensation data no longer appears as 36 pages of transcript but is organized into code groups. The new unit of analysis was a subgroup. Reviewing every meaning unit with the subgroup, the content was reduced into condensate—an artificial quotation in the «I» form. Writing the condensate in the first-person format was applied as a reminder to represent every participant who provided information. The artificial quotation represents the amalgamated form from the meaning units of each subgroup. When a condensate was created, we identified an authentic illustrative quotation for each condensate. (4) Synthesizing—putting the pieces together and developing the results categories by synthesizing the contents of the condensates and quotations from each subgroup. Starting with the condensate and quotations from each subgroup, the researcher took the role of a re-narrator, writing in the third-person format [22]. We concluded that the research question was adequately addressed using the data from the interviews with the three focus groups [22]. Stepwise analysis during data collection keeps an overview of empirical data, refines focus and objectives, and prevents the “1000-page problem” of disorganized data [22].

3 Results

The informants comprised five female and two male dentists; six were over 40 years old. All participants had permanent clinical positions at the PDS (>50% of their time). Most had over 10 years of working experience. Three had obtained their dental degree in Norway, two were educated in European countries other than Scandinavia, and two had been educated outside Europe (Table 2).

TABLE 2. Characteristics of the study population (n = 7).

Participant characteristics	n
Gender
Male	2
Female	5
Age (years)
30–39	1
40–49	4
50–59	1
≥60	1
Country of education
Norway	3
Other European country	2
Outside Europe	2
Years since graduation
≤5	1
6–10	1
11–20	3
>20	2
Current clinical work
<50%
>50%	7
Number of TDI patients per year
1–5	0
6–15	0
Over 15	7

Abbreviation: TDI, traumatic dental injuries.

Figure 1 presents the evolution of codes and subcodes during STC analysis. There were five categories divided into two fields regarding the treatment of TDI: challenges (barriers) and needs.

Details are in the caption following the image — **FIGURE 1**
Open in figure viewer PowerPoint

Evaluation of codes and subcodes during the systematic text condensation analysis (TDI, traumatic dental injuries).

3.1 Challenge: Proficiency

Proficiency, as a challenge, represents the attitudes and perceptions of dentists concerning their current knowledge and clinical skills in dental traumatology.

Most participants expected all general dentists in the PDS to have basic knowledge and fundamental skills in handling common dental injuries. At the same time, they admitted that knowledge and skills depend on individual exposure to varying TDI cases and individual experience in dental traumatology. Most informants felt confident in handling common dental traumas, but they also underlined that there may be specific cases where they felt less confident. Many recognized the complex nature of dental traumatology and the importance of staying updated on the latest research, for the benefit of their patients. However, the interviewees stated that TDI is always a challenge, regardless of a clinician's level of knowledge and clinical experience. One participant expressed it like this:

During my work in an emergency dental clinic, I mostly had patients with dental injuries, but I have to say that dental trauma is still a challenge for me, despite my knowledge and experience. (I1)

Severe dental injuries, complicated injuries, or injuries to multiple teeth were considered particularly challenging. In these situations, questions concerning how to prioritize dental trauma injuries, which dental materials to use, when to schedule a new appointment, and how often to schedule controls became pressing. They attributed their lack of knowledge to little clinical experience and the rarity of patients with severe and complicated dental injuries. One dentist described it like this:

I have never actually, come across an alveolar fracture. I don't think
I would have ever managed if it was an alveolar fracture. (I7)

Most dentists felt that managing TDI could be especially challenging for newly graduated dentists. According to some participants, recent graduates had a high level of theoretical knowledge, but their clinical skills were limited. This became apparent when they asked more experienced colleagues for help or advice. In sum, this illustrates the general notion that undergraduate training has not yet been able to compensate for the hands-on work-based experience needed to feel confident managing TDI. One informant put it this way:

I think that newly graduated dentists have good knowledge, they can handle patients with dental injuries but [since they were] recently trained, they need more time [to learn hands-on] treatment. What they need to build is experience, they must practice more. (I4)

3.2 Challenge: Stress and Discomfort During Dental Procedures

The second identified challenge, stress, and discomfort during dental procedures describe the complexity of dental trauma management and how the patient–practitioner relationship and the parent–practitioner relationship affect TDI treatment.

Informants spoke of emergency patients with TDI as infrequent occurrences in daily clinical work. The emergencies were described as very stressful and dramatic for both patients and dentists, in large part because injuries accompanied by bleeding and pain often look more serious than they are. All participants pointed out how treatment becomes highly challenging when patient cooperation is hindered by fear. According to the participants, the difficulties were correlated with the age and cognitive development of the patient. As an example, one practitioner related an experience of treating a very young patient with dental injuries where the crying and lack of cooperation compromised treatment. In addition, several informants experienced how parental behavior can increase the stress level of the practitioners. The dramatic situation is also frightening for the parents, which can make them pressure the dentists, affecting the course of treatment. Some participants reported that parents sometimes did not feel confident about the dentist's competence and wanted a specialist to see their child, which complicated an already dramatic situation. Informant 6 summarized the challenge in this way:

The parents are stressed, and the children are scared, it's true. So, you may know how to treat the patient and what to do, but it can be challenging doing it when everybody around you is stressed.

According to participants, the stress of managing patients with TDI demands teamwork and coordination with knowledgeable and competent dental assistants. Calming the patient, talking to anxious parents, and preparing the workplace for the dentists are the tasks of dental assistants, but several dentists expressed their frustration in often needing to work without chair-side dental assistance. The lack of assistance was attributed to the administrative burden of the dental assistants and dental assistants being on sick leave as informant 5 described:

We currently have only a few assistants at the clinic, so the dental assistants on duty cannot take on any more tasks.

3.3 Challenge: Organization of the PDS

The third challenge, the organization of the PDS, describes how the organization and geographical location of the public dental clinics affect the approach to TDI patients. It also describes how access to hospitals and needed resources in daily clinical practice affect TDI care.

Participants working in rural areas reported more difficulties in the management of TDI compared to their colleagues in urban clinics. According to the participants, emergency dental clinics for after-hours treatment do not exist as an institution in rural areas, as they do in big cities. For after-hours emergencies in rural areas, whether for dental trauma or a toothache, the public dentist who is “on call” and receives a call on the clinic phone opens the public clinic to provide help. One dentist explained it like this:

When we have an emergency patient after working hours, I'd get a call on the phone. So, I go to the clinic and take care of the patient. Sometimes, no dental assistant was able to come with me to the clinic, so, I had to see the patient alone. (I3)

Participants from rural clinics explained their limited options for referring patients with dental injuries to secondary dental care. Specialists are usually settled in the big cities, and for patients, traveling to larger cities for specialist treatment can be difficult in Norway. This limitation can affect treatment choice. One dentist cited the inconvenience of traveling as the reason behind a patient's decision to have the tooth extracted instead of visiting a specialist for a root canal treatment. Severe trauma cases, such as jaw fractures, must be transferred to a hospital located in the “nearest” big city.

We don't always have the opportunity to refer patients, so we must try to solve the patient's problem. Patients don't want to travel far for treatment. (I3)

Usually, participants reported they had most of the special dental equipment needed for TDI cases. The availability of new dental materials (e.g., bioceramics such as Biodentine), however, could be challenging. Few dentists reported a lack of titanium trauma splints for fixation and surgical sutures for soft tissue trauma. One key challenge identified was problems with cameras, which are necessary equipment for clinical images. Participants reported that the clinics do have cameras on hand, but many of the informants struggle to use them. One participant summarized it like this:

You don't always get to do the things you want to do. When you work in the district, you lack equipment and materials … We don't have everything, and we often need to improvise. (I3)

After presenting result categories for the challenges dentists perceived in the workplace, we describe result categories for the dentist's needs in terms of improving the treatment of patients with TDI.

3.4 Need: Accessible and Clinically Relevant CPD

Accessible and clinically relevant CPD is the first category that describes the needs of dentists caring for cases of TDI. This category presents the perceived competency needs of dentists in dental traumatology and their thoughts on being more effective and staying updated on the diagnosis and proper treatment of patients with TDI.

In general, due to busy working schedules, dentists reported having insufficient time to update their knowledge in dental traumatology. Several dentists also reported forgetting protocols for severe dental injuries due to the rarity of these cases in everyday practice. Participants were aware that the international “Dental Trauma Guide” (DTG) could be used as an auxiliary tool in an emergency, but they pointed out the insufficiency of information in the DTG concerning the priority order of injuries, particularly severe dental injuries or complicated injuries. Although they articulated the need for repetition, most dentists expressed the need for specific courses and knowledge updates as a way to calibrate and improve work quality. Their learning needs in dental traumatology were expressed in general terms as potentially useful and that “there is always something new to learn”. As one participant said:

When I have a patient with a dental injury, I take a step back. If I had updated my knowledge in advance, I would have been able to provide correct treatment, and I would feel much more confident. So, I think I need more courses in general. (I6)

According to dentists, all professionals involved with the patient, including dental assistants and dental hygienists, should be trained to work as a team and provide adequate and standardized emergency treatment and follow-ups of patients with TDI. To be able to competently provide treatment, homogenous and consistent information should be provided to all practitioners so that all operate from the same knowledge base.

Most dentists expressed a desire for theoretical courses and lectures delivered by specialists or academic individuals from universities. To refine their diagnostic and treatment skills in dental traumatology, dentists emphasized that discussions on clinical cases are also highly valuable. A clinical case discussion should give a detailed explanation of the TDI treatment from beginning to end, including information about the selection of instruments, dental materials, and follow-ups.

Furthermore, most dentists expressed the need for practical workshops in small groups with knowledge assessment and group assignments. According to the dentists, a knowledge quiz would be useful to evaluate their understanding of the subject. Many participants expressed their wish for online educational material (e.g., recorded videos), for the purpose of repetition. According to dentists, the frequency of CPD should be once a year or every other year. One dentist illustrated educational training like this:

At similar courses, I often think how [the course givers] show pictures of how they went from A to Z, but they don't show all the little things they have done in between. I think it's best if they show and explain which instruments, which materials, etc. they used so that everything comes together, and I understand how it turned out great. Then it's much easier for me to do it and get it right. (I5)

All participants expressed the need for better access to CPD. They complained about the limited funding in the PDS from the County municipality for attending courses in various fields of dentistry and about the difficulties in applying for funding. Informants mentioned so-called professional days, usually organized as pre-recorded video lectures by the County municipality, as useful for the transmission of new knowledge. Several participants suggested that existing professional days could be dedicated to dental traumatology since general dentists are responsible for the patient group with TDI. However, they missed having the opportunity for practical and team-based training. Furthermore, few dentists reported attending dental traumatology courses abroad, as that would usually require private funding in addition to an unpaid leave of absence if they did not wish to use vacation days. One practitioner expressed frustration as follows:

We must find the course we want to attend and then we have to apply for course funding. And then it can be a bit unfair, because if we travel, we only have the course covered, not the travel expenses, while others, who don't travel, would have everything covered. Then I think, no, I can't afford to spend an extra NOK 7,000 to travel to that course. (I7)

3.5 Need: Collective Efforts for TDI Management

The second category under dentist's needs describes the need for developing clinic routines and for communicating better among colleagues to improve the quality of dental care for patients with dental trauma.

Several dentists raised awareness regarding their employer's responsibility to initiate and enable CPD in dental traumatology. The participants called for more accessible, on-the-job, and interprofessional training opportunities organized by the County Municipality.

I think that we should be given more time and more money by our employer to maintain our professionalism. It is very important for our job that we are highly skilled. At the same time, is it we who should use our free time and our own money to travel to courses? It shouldn't be like that when we are employed in the PDS, a position that is not highly paid. (I5)

Most participants reported the need for case discussions and opportunities to exchange knowledge and experience with colleagues on a regular basis. The informants felt that frequent professional meetings with colleagues, including dental assistants and dental hygienists, could build confidence in managing TDI on a team level and serve as an informal way of updating knowledge. Several dentists stated that they initiated contact with specialists employed in the PDS via e-mail and asked for professional assistance in difficult dental trauma cases. However, long response times or unhelpful advice was sometimes considered an issue. Furthermore, a few dentists admitted to not being informed about the status after follow-ups of TDI patients by dental hygienists. The participants concluded that collaborations would work better if conditions were provided for regular professional meetings at the clinics. One participant explained it like this:

I have been working at a few different clinics. A few years ago, we had more available time, and then we had meetings where we could discuss the case, but now in the last year, we haven't had one. I think it would be nice to have it again. (I6)

To avoid unnecessary stress during emergencies, it was considered important to develop well-functioning routines. Part of one routine included being well prepared, for example, by having an emergency cassette (kit) ready for patients with TDI. Furthermore, some also organized rotation schedules that assigned one dentist per day to be in charge of emergencies. Alternatively, taking care of the emergency patients in pairs (two dentists) was also suggested. Participants expressed the need for support from colleagues in emergencies. One practitioner said:

We accept changes in the schedule due to urgent things. We don't have routines regarding who is handling emergencies, but we ask each other for help. So, if we have severe dental injuries, usually two dentists take the patient. In that sense, it's nice to work in a clinic with several dentists, so you can work in teams. (I6)

4 Discussion

This study explored in depth the challenges associated with treating dental injuries and the dentists' needs in terms of improving the treatment and outcomes for TDI patients.

4.1 Challenges

We identified three main result categories of challenges that have an impact on TDI management. These challenges can be defined as those over which the general dentists have direct control, like proficiency, and those over which general dentists do not have control, like those coming from external sources such as patients, parents, or geographic locations of the clinics.

The current study is part of a larger project conducted at the PDS of Vestland County in Western Norway. First, a quantitative study was done to assess the knowledge of general dentists in TDI, and an obvious need for update was revealed [7]. Namely, general knowledge of TDI was rated as good, but analysis of specific case scenarios, such as complicated crown fractures, root fracture, and severe intrusion, revealed a low proportion of correct answers [7]. Participants in the focus group discussions confirmed these findings, expressing difficulties in the management of particular cases. Alignment between the quantitative data and qualitative feedback underscored the need for professional development. The dentists' challenges suggested that while basic knowledge was present, there was a substantial need for training in dental traumatology.

The quantitative study also revealed that participants who perceived their knowledge as very good did not have higher scores on the knowledge test compared to dentists who perceived their knowledge to be less good [7]. This phenomenon is called the “Feeling of knowing” and refers to the subjective illusion of competence in a given field. Clariana et al. found in their pedagogical study that “Feeling of Knowing” increases proportionately with higher academic degrees [24]. This phenomenon defines a discrepancy between actual and perceived knowledge among general dentists. Dentists might feel confident in answering questions about TDI cases but struggle when they must demonstrate their skills with the patients, as highlighted in the group discussions. This has implications for the immediate trustworthiness of their expressed educational needs and urges us to think about how to design specific training programs for this educational gap in dental traumatology.

Furthermore, the external barriers we discussed, such as collaboration difficulties with parents, can also stand in the way of effective TDI treatment. These findings were not surprising, since the unexpected situation can be a source of increased stress for patients, parents, and dental personnel. Several studies report that working with children, collaborating with parents, and managing parental expectations can be difficult situations to navigate [25-27]. Interestingly, while dentists report difficulties in managing distressed patients and parents, they did not view the development of interpersonal skills as a priority, focusing instead on clinical procedures. This discrepancy may be rooted in dental education programs which often emphasize technical competence and procedural knowledge over soft skills. Research supports the idea that interpersonal skills are crucial for healthcare professionals. Studies have shown that strong communication skills can enhance patient trust, reduce anxiety, and improve overall treatment experiences [28]. Given these insights, the integration of interpersonal skills training should be added to dental education and CPD. Dentists should have the ability not only to manage the TDI but also to manage patient and parent distress effectively.

Also, of possible relevance is the overall good oral health in Norway in recent years. Young patients with TDI may never have been subjected to local anesthesia and operative dental procedures before. The Farokh-Gisour et al.'s study among dentists found that the injection of an anesthetic in the mandible of anxious children led to high-stress levels for the child and consequently for the dentists [29]. Interestingly, the dentists in our study did not advocate for stress management training, despite this being identified as a major barrier to optimal treatment.

The third result category under challenges, the geographic location of the clinics, identified difficulties in rural areas in managing dental emergency cases. The participating general dentists highlighted the lack of emergency dental services, which limits the accessibility to dental care for patients who are injured after the official working hours of the PDS clinic. The only organized PDS emergency clinic for after-hours help was in the city of Bergen. Hospitals with maxillofacial surgical units were also located in the cities of Bergen and Førde (the northern region of the County municipality). After-hours help at remote clinics varied, which was a stressor for the general dentists. Other stressors included the lack of certain materials and equipment, the frequent lack of dental assistants, and access to specialists, all identified as barriers to TDI treatment. These challenges may be remedied by implementing mobile dental clinics and telehealth services or developing innovative solutions for rural community conditions. Few scientific studies have investigated the use of teledentistry in PDS services [30]. Some key findings are that teledentistry can be used in the continuing education of dentists, and for exchanging information among health professionals [31]. Teledentistry also increases access to dental care, makes communication and interaction with specialists easier, and reduces consultation waiting time [31].

4.2 Needs

The focus group discussions on the need for better treatment for TDI patients revealed two main result categories: the need for continuing education and the need for a coordinated team effort in order to improve the treatment of patients with TDI.

All members of the Norwegian Dental Association are obliged to complete a minimum of 40 h of continuing education over 3 years [32], including investing in professional education beyond the annual membership fee. This is in accordance with international trends in CPD.

It is well established from the findings of this study that TDI is a clinical field where theoretical knowledge alone is not sufficient. Because general dentists are not often exposed to TDI cases, especially severe injuries, some situations may cause unease or be uncomfortable for the practitioner. Therefore, it is not surprising that dentists emphasize the need for continuous education in dental traumatology with case discussions, practical tips, and updates on new materials. The collective and collegial aspects of educational interventions mirror the collaborative nature of complex TDI treatment.

Highlighting their educational needs, participants also suggested developing clinical routines and internal protocols for emergencies despite the availability of the DTG. One reason could be that dentists need more tailored guidelines for internal organization and workflow, and it is also possible that the existing official protocol (DTG) available in English is not adequately implemented. Having a protocol in the native language ensures understanding of procedure implementation and minimizes the risk of misunderstandings and mistakes. This led us to suspect that general dentists may have difficulty using the official guidelines provided by International Association of Dental traumatology (IADT) and DTG, and often avoid these tools.

Based on these findings, we recommend that, when designing CPD training programs in dental traumatology, attention must be paid to both the perceived challenges and needs of dentists as well as their workplace contexts, actual knowledge, and clinical experience with TDI.

4.3 Strengths and Limitations

The process of recruitment was challenging. Few dentists were unavailable because of sick leave or maternity leave. Most of the invited dentists were unable to participate due to the overbooked schedules. It could be assumed that some dentists choose not to publicly express their opinions. In total, seven of 59 dentists agreed to participate. While this is a small sample, the participants represented variations in age, gender, length of clinical experience, country of education, and location of clinic (rural/urban; Table 2). In the methodological literature on focus groups, we found great variation when it comes to the number of participants [33]. Furthermore, according to Malterud et al., a sample is sufficient when the participants share experiences and thoughts in the way that the aim of the study is obtained, and when the optimal amount of transcribed text pages can establish an overview at the beginning of the analysis [33].

The consensus in qualitative health studies is that researchers should interview as many individuals as necessary to answer the research question [19, 34]. and the provision of sample size justification is limited [35].

The participants in this study had different experiences with TDI patients, and participants who had a shorter or longer experience were included in each group. This may have affected the discussion if younger dentists found it difficult to speak in front of older colleagues about their challenges.

Our experience is that the digital format, Microsoft Teams, works better with smaller groups. Having the interviews on the electronic platform was not perceived as a disadvantage as all participants contributed generously to the conversations. Preliminary evidence on the use of Microsoft Teams for online focus groups demonstrates the efficiency of the method [36].

One-on-one interviews are often used in qualitative research for detailed insights into personal transformation. However, focus groups offer a diversity of opinions, providing a more comprehensive view [37].

The choice of qualitative method should align with the research question. STC is an effective choice for this study, offering structure, clarity, and depth by breaking down complex data into manageable parts. STC is also easier to learn and apply compared to methods like grounded theory or phenomenology, making it ideal for researchers new to qualitative analysis [22].

5 Conclusion

The general dentists in this study experienced the management of TDI as complex on multiple levels. Many of the challenges faced by Norwegian dentists, such as proficiency challenges and stress and discomfort during dental procedures, are common in dental services worldwide. The organizational structure, funding mechanisms, and training programs in Norway may differ from those in other countries, but the core focus on improving dental trauma management is common. To meet this complexity, a combination of good knowledge, clinical experience, interpersonal skills, teamwork, and standardized routines is required.

Key takeaways from the study:

Enhanced training programs: There is a critical need to incorporate more specialized training in dental education to address the knowledge gap in managing TDI cases.
Interpersonal skills: In addition to clinical training, the development of interpersonal skills is essential for enhancing TDI treatment, particularly in dealing with distressed patients and parents.
Support systems: Implementing support systems and promoting teamwork during emergencies can help dentists manage TDIs more effectively and reduce professional stress.

Understanding the challenges and needs in dental traumatology can help dental professionals, researchers, and educators to provide more targeted and effective care for TDI patients, develop dental education curricula based on practical training, and stimulate the development of new technological integrations such as telemedicine.

The current study raised the question of what type of training works for the practitioner and under what conditions. We may assume that practitioners are not aware of their actual needs if they are not aware of their actual skills. To answer these questions and assumptions, further research is needed.

Author Contributions

A.C., M.K., A.N.Å., G.T., and A.B. made contributions to the conception and design of the study. A.C., M.K., and A.B. were responsible for data acquisition, analysis, and data interpretation. A.C., M.K., A.N.Å., G.T., and A.B. drafted and gave final approval of the manuscript.

Acknowledgements

We thank the general dentists in the Vestland County public dental service for their participation in this study.

Ethics Statement

We conducted a qualitative study among dentists employed in the Vestland County PDS in Western Norway. The Norwegian Centre for Research Data (Norsk Senter for forskningsdata; NSD) gave ethical approval for this project (number 535993). The study is part of a PhD project (candidate Andjelka Cvijic) and it has been financed by the Oral Health Centre of Expertise in Western Norway, Bergen, Norway.

Conflicts of Interest

The authors declare no conflicts of interest.

Open Research

Data Availability Statement

The datasets generated and analyzed in the present study are available from the authors on reasonable request.

References

1U. Glendor, “Epidemiology of Traumatic Dental Injuries—A 12 Year Review of the Literature,” Dental Traumatology 24, no. 6 (2008): 603–611, https://doi.org/10.1111/j.1600-9657.2008.00696.x.
10.1111/j.1600-9657.2008.00696.x
CAS PubMed Web of Science® Google Scholar
2D. Locker, “Self-Reported Dental and Oral Injuries in a Population of Adults Aged 18–50 Years,” Dental Traumatology 23, no. 5 (2007): 291–296, https://doi.org/10.1111/j.1600-9657.2006.00457.x.
10.1111/j.1600-9657.2006.00457.x
CAS PubMed Web of Science® Google Scholar
3S. Petti, U. Glendor, and L. Andersson, “World Traumatic Dental Injury Prevalence and Incidence, a Meta-Analysis-One Billion Living People Have had Traumatic Dental Injuries,” Dental Traumatology 34, no. 2 (2018): 71–86, https://doi.org/10.1111/edt.12389.
10.1111/edt.12389
PubMed Web of Science® Google Scholar
4N. G. Jackson, P. J. Waterhouse, and A. Maguire, “Management of Dental Trauma in Primary Care: A Postal Survey of General Dental Practitioners,” British Dental Journal 198, no. 5 (2005): 293–297; discussion 281, https://doi.org/10.1038/sj.bdj.4812127.
10.1038/sj.bdj.4812127
CAS PubMed Web of Science® Google Scholar
5J. Diaz, L. Bustos, S. Herrera, and J. Sepulveda, “Knowledge of the Management of Paediatric Dental Traumas by Non-Dental Professionals in Emergency Rooms in South Araucania, Temuco, Chile,” Dental Traumatology 25, no. 6 (2009): 611–619, https://doi.org/10.1111/j.1600-9657.2009.00835.x.
10.1111/j.1600-9657.2009.00835.x
PubMed Web of Science® Google Scholar
6M. N. Kostopoulou and M. S. Duggal, “A Study Into Dentists' Knowledge of the Treatment of Traumatic Injuries to Young Permanent Incisors,” International Journal of Paediatric Dentistry 15, no. 1 (2005): 10–19, https://doi.org/10.1111/j.1365-263X.2005.00588.x.
10.1111/j.1365-263X.2005.00588.x
CAS PubMed Google Scholar
7A. Cvijic, A. Astrom, M. Kvernenes, G. Tsilingaridis, and A. Bletsa, “Traumatic Dental Injuries: Knowledge Assessment of Dentists in the Norwegian Public Dental Service of Vestland,” Dental Traumatology 40 (2024): 398–409, https://doi.org/10.1111/edt.12945.
10.1111/edt.12945
CAS PubMed Web of Science® Google Scholar
8B. Burak, “Factors Associated With Knowledge and Attitude of Management of Traumatic Dental Injuries: A Cross-Sectional Study Among Turkish Dentists,” Pesquisa Brasileira em Odontopediatria e Clinica Integrada 18, no. 1 (2018): e3948.
Google Scholar
9C. Marriot-Smith, V. Marino, and G. S. Heithersay, “A Preclinical Dental Trauma Teaching Module,” Dental Traumatology 32, no. 3 (2016): 247–250, https://doi.org/10.1111/edt.12251.
10.1111/edt.12251
CAS PubMed Google Scholar
10F. M. Andreasen and J. O. Andreasen, “Treatment of Traumatic Dental Injuries. Shift in Strategy,” International Journal of Technology Assessment in Health Care 6, no. 4 (1990): 588–602, https://doi.org/10.1017/s0266462300004232.
10.1017/S0266462300004232
CAS PubMed Google Scholar
11M. De Rossi, A. De Rossi, A. M. Queiroz, and F. P. Nelson, “Management of a Complex Dentoalveolar Trauma: A Case Report,” Brazilian Dental Journal 20, no. 3 (2009): 259–262, https://doi.org/10.1590/s0103-64402009000300016.
10.1590/S0103-64402009000300016
PubMed Google Scholar
12T. Yeng and P. Parashos, “An Investigation Into Dentists' Perceptions of Barriers to Providing Care of Dental Trauma to Permanent Maxillary Incisors in Children in Victoria, Australia,” Australian Dental Journal 52, no. 3 (2007): 210–215, https://doi.org/10.1111/j.1834-7819.2007.tb00491.x.
10.1111/j.1834-7819.2007.tb00491.x
CAS PubMed Web of Science® Google Scholar
13G. D. Taylor, O. Sumner, R. Holmes, and P. J. Waterhouse, “Primary Care Dentists' Management of Permanent Dentition Traumatic Dental Injuries in 7- to 16-Year-Olds: A Sequential Mixed-Methods Study,” Dental Traumatology 37, no. 4 (2021): 608–616, https://doi.org/10.1111/edt.12676.
10.1111/edt.12676
PubMed Web of Science® Google Scholar
14 Lov om tannhelsetjenester (tannhelsetjenesteloven) [Act on the Dental Health Service (Dental Health Services Act)], 1984, https://lovdata.no/dokument/NL/lov/1983-06-03-54/KAPITTEL_3#KAPITTEL_LOV-2019-06-21-43.
Google Scholar
15O. V. I. Iden, N. Stojkovski, K. H. Midtbø Jensen, and B. Athanasia, “Er et kompetansesenter en konkurrent eller et supplement? Kartlegging av henvisninger til endodontister ved TkV/Hordaland,” Den Norske Tannlaegeforenings Tidende 132 (2022): 232–239.
Google Scholar
16 Statistisk sentralbirå, “Statistics Norway: Dentists With a Foreign Country Background,” 2019, https://www.ssb.no/statbank/table/05680/tableViewLayout1/.
Google Scholar
17M. E. Donaldson, C. C. Gadbury-Amyot, S. S. Khajotia, et al., “Dental Education in a Flat World: Advocating for Increased Global Collaboration and Standardization,” Journal of Dental Education 72, no. 4 (2008): 408–421.
10.1002/j.0022-0337.2008.72.4.tb04506.x
PubMed Web of Science® Google Scholar
18A. Bullock, S. Bailey, J. Cowpe, et al., “Continuing Professional Development Systems and Requirements for Graduate Dentists in the EU: Survey Results From the DentCPD Project,” European Journal of Dental Education 17, no. Suppl 1 (2013): 18–22, https://doi.org/10.1111/eje.12046.
10.1111/eje.12046
PubMed Web of Science® Google Scholar
19K. Malterud, “Qualitative Research: Standards, Challenges, and Guidelines,” Lancet 358, no. 9280 (2001): 483–488, https://doi.org/10.1016/S0140-6736(01)05627-6.
10.1016/S0140-6736(01)05627-6
CAS PubMed Web of Science® Google Scholar
20M. Castillo-Montoya, “Preparing for Interview Research: The Interview Protocol Refinement Framework,” Qualitative Report 21, no. 5 (2016): 811–831.
Web of Science® Google Scholar
21R. A. Krueger, “ The art and Mechanics of Asking Good Questions,” in Developing Questions for Focus Groups, ed. R. A. Krueger (California: Sage Academic Books, 1998), 21–57.
10.4135/9781483328126.n4
Google Scholar
22K. Malterud, “Systematic Text Condensation: A Strategy for Qualitative Analysis,” Scandinavian Journal of Public Health 40, no. 8 (2012): 795–805, https://doi.org/10.1177/1403494812465030.
10.1177/1403494812465030
PubMed Web of Science® Google Scholar
23K. Malterud, “ Systematisk tekstkondensering,” in Kvalitative metoder i medisinsk forskning, ed. K. Malterud (Oslo: Universitetsforlaget, 2019), 97–115.
Google Scholar
24M. Clariana, “Feeling of Knowing and Over-Claiming in Students From Secondary School to University Mercè Clariana,” Learning and Individual Differences 49 (2016): 421–427.
10.1016/j.lindif.2016.05.008
Google Scholar
25R. M. O'Shea, N. L. Corah, and W. A. Ayer, “Sources of Dentists' Stress,” Journal of the American Dental Association (1939) 109, no. 1 (1984): 48–51, https://doi.org/10.14219/jada.archive.1984.0282.
10.14219/jada.archive.1984.0282
CAS PubMed Web of Science® Google Scholar
26E. N. Gale, “Stress in Dentistry,” New York State Dental Journal 64, no. 8 (1998): 30–34.
CAS PubMed Google Scholar
27G. Klingberg, U. Berggren, S. G. Carlsson, and J. G. Noren, “Child Dental Fear: Cause-Related Factors and Clinical Effects,” European Journal of Oral Sciences 103, no. 6 (1995): 405–412, https://doi.org/10.1111/j.1600-0722.1995.tb01865.x.
10.1111/j.1600-0722.1995.tb01865.x
CAS PubMed Web of Science® Google Scholar
28W. Levinson, R. Gorawara-Bhat, and J. Lamb, “A Study of Patient Clues and Physician Responses in Primary Care and Surgical Settings,” Journal of the American Medical Association 284, no. 8 (2000): 1021–1027, https://doi.org/10.1001/jama.284.8.1021.
10.1001/jama.284.8.1021
CAS PubMed Web of Science® Google Scholar
29E. Farokh-Gisour and M. Hatamvand, “Investigation of Stress Level Among Dentistry Students, General Dentists, and Pediatric Dental Specialists During Performing Pediatric Dentistry in Kerman, Iran, in 2017,” Open Dentistry Journal 12 (2018): 631–637, https://doi.org/10.2174/1745017901814010631.
10.2174/1745017901814010631
PubMed Google Scholar
30J. H. Alabdullah and S. J. Daniel, “A Systematic Review on the Validity of Teledentistry,” Telemedicine Journal and E-Health 24, no. 8 (2018): 639–648, https://doi.org/10.1089/tmj.2017.0132.
10.1089/tmj.2017.0132
PubMed Web of Science® Google Scholar
31C. B. da Costa, F. D. S. Peralta, and A. L. S. Ferreira de Mello, “How Has Teledentistry Been Applied in Public Dental Health Services? An Integrative Review,” Telemedicine Journal and E-Health 26, no. 7 (2020): 945–954, https://doi.org/10.1089/tmj.2019.0122.
10.1089/tmj.2019.0122
PubMed Web of Science® Google Scholar
32 Den norske tannlegeforening [The Norwegian Dental Association], “Regler om obligatorisk etterutdanning [Rules on Compulsory Continuing Education],” 2024, https://www.tannlegeforeningen.no/kurs-og-etterutdanning/ntfs-obligatoriske-etterutdanning/regler-om-obligatorisk-etterutdanning.html.
Google Scholar
33K. Malterud, V. D. Siersma, and A. D. Guassora, “Sample Size in Qualitative Interview Studies: Guided by Information Power,” Qualitative Health Research 26, no. 13 (2016): 1753–1760, https://doi.org/10.1177/1049732315617444.
10.1177/1049732315617444
PubMed Web of Science® Google Scholar
34K. Malterud, “ Kappitel 4, Gruppene,” in Fokusgrupper som forskningsmetode for medisin og helsefag, ed. K. Malterud (Oslo: Universitetsforlaget, 2020), 37–46.
Google Scholar
35K. Vasileiou, J. Barnett, S. Thorpe, and T. Young, “Characterising and Justifying Sample Size Sufficiency in Interview-Based Studies: Systematic Analysis of Qualitative Health Research Over a 15-Year Period,” BMC Medical Research Methodology 18, no. 1 (2018): 148, https://doi.org/10.1186/s12874-018-0594-7.
10.1186/s12874-018-0594-7
PubMed Web of Science® Google Scholar
36J. Menary, S. Stetkiewicz, A. Nair, et al., “Going Virtual: Adapting in-Person Interactive Focus Groups to the Online Environment [Version 2; Peer Review: 2 Approved],” Emerald Open Research 3 (2021): 6.
10.1108/EOR-06-2023-0008
Google Scholar
37R. C. Schuster, A. Brewis, A. Wutich, et al., “Individual Interviews Versus Focus Groups for Evaluations of International Development Programs: Systematic Testing of Method Performance to Elicit Sensitive Information in a Justice Study in Haiti,” Evaluation and Program Planning 97 (2023): 102208, https://doi.org/10.1016/j.evalprogplan.2022.102208.
10.1016/j.evalprogplan.2022.102208
PubMed Google Scholar

Citing Literature

Volume41, Issue1

February 2025

Pages 93-103

Treatment of Traumatic Dental Injuries in the Public Dental Services—A Qualitative Exploration of Perceived Challenges and Needs