ORIGINAL ARTICLE
Prevalence of Traumatic Dental Injuries and Associated Factors Among Brazilian Schoolchildren Simone Scandiuzzi Franciscoa/Francisco Jóse de Souza Filhob/Éricka Tavares Pinheiroc/Rodrigo Dutra Murrera/Adriana de Jesus Soaresd
Purpose: To assess the prevalence of traumatic dental injuries to permanent anterior teeth in 9- to 14-year-old schoolchildren attending public schools in Anápolis, Brazil, and to investigate the association between the occurrence of these injuries and the size of incisal overjet and type of lip coverage. Materials and Methods: A cross-sectional survey and a two-stage cluster sampling technique were used. The sample size included 765 9- to 14-year-old schoolchildren. Data were collected through clinical examinations and interviews carried out by a trained, calibrated dentist. Oral examinations dealt with the type of traumatic dental injury (TDI), the treatment received, the size of incisal overjet and the type of lip coverage. The teeth examined were maxillary and mandibular incisors. Results: A 16.5% prevalence of dental trauma was found. Boys experienced double the number of girls’ injuries. The maxillary central incisors were the teeth most affected, totaling 84.8%. The most frequent type of injury found was enamel fracture (66%), followed by enamel-dentin fracture (27%) and enamel cracks (5%). Only 26% of traumatised teeth were restored. Children with an overjet size > 3 mm were 1.78 times (CI = 1.18 – 2.69) more likely to have a dental injury than children with an overjet size ≤ 3 mm. Children with inadequate lip coverage were 2.18 times (CI = 1.27 – 3.76) more likely to experience dental trauma than children whose lip coverage was adequate. Conclusion: This study shows that the prevalence of traumatic dental injuries among schoolchildren in Anápolis, Brazil is similar to that of other regions in Brazil. The teeth most affected by dental trauma are the maxillary central incisors. Boys run a 2.03-times higher risk of crown fracture than girls, and children with an overjet size > 3 mm are 1.78 times more likely to have dental injuries. In addition, children with inadequate lip coverage are 2.18 times more likely to present traumatic dental injuries than children with adequate lip coverage. Key words: aetiology, permanent dentition, prevalence, trauma Oral Health Prev Dent 2013; 11: 31-38
T
raumatic dental injuries are a public health problem and one of the main reasons for dental
a
Professor, School of Dentistry, Faculdade Leão Sampaio, Juazeiro do Norte-CE, Brazil.
b
Professor, Faculdade São Leopoldo Mandic, Curso de Odontologia, Programa de Pós-Graduação, Mestrado em Endodontia, CampinasSP and State University of Campinas-UNICAMP, Piracicaba, SP, Brazil.
c
Assistant Professor, Department of Microbiology, Institute of Biomaterial Sciences, University of São Paulo, SP, Brazil.
d
Assistant Professor, Faculdade São Leopoldo Mandic, Curso de Odontologia, Programa de Pós-Graduação, Mestrado em Endodontia, Campinas-SP and State University of Campinas-UNICAMP, Piracicaba, SP, Brazil.
Correspondence: Prof. Simone Scandiuzzi Francisco, UniEvangélica, Centro Universitário de Anápolis, Curso de Odontologia, Av. Universitária Km. 3,5 - Cidade Universitária, Anápolis, Goiás, Brazil 75083515. Email:
[email protected]
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Submitted for publication: 16.01.12; accepted for publication: 16.05.12
emergencies in children and adolescents (Andreasen, 1989; Alonge et al, 2001; Tapias et al, 2003; Glendor, 2008). Such injuries can have serious physical and psychological consequences for patients and cause great emotional stress for parents as well (Andreasen and Andreasen, 1994; Cortes et al, 2002). The severity of traumatic injuries can vary from simple fractures in enamel to even more serious damage, such as intrusion and avulsion, which cause irreversible damage to the pulp and periodontal tissue and lead to tooth loss (Andreasen and Andreasen, 1994). Evidence suggests that traumatic injuries can have a negative impact on a child’s quality of life, due to difficulties in eating, interacting and socialising (Marcenes et al, 1999; Cortes et al, 2002).
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Epidemiological studies of dental trauma have shown various levels of prevalence around the world (Marcenes et al, 2000; Cortes et al, 2001; Malikaew et al, 2006; Adekoya-Sofowora et al, 2009; David et al, 2009). Variation in prevalence has been related to many factors, such as type of study, classification of dental trauma, sample size, diagnostic criteria, age group, environmental and behavioural factors, population type and culture (Andreasen and Andreasen, 1994). Earlier studies reported that the prevalence of TDI in schoolchildren ranged from 2.6% to 58.6% in Brazil and from 12.2% to 28.4% in Latin America (Garcia-Godoy et al, 1985; Sanchez and Garcia-Godoy, 1990; Grimm et al, 2004). The majority of TDIs affect the permanent anterior teeth and the risk of such injuries increases when predisposing or risk factors are present, such as increased overjet with protrusion and inadequate lip coverage (Nguyen et al, 1999; Cortes et al, 2001; Artun et al, 2005; Soriano et al, 2007). TDI risk factors are well defined and involve oral and environmental factors, as well as human behaviour, all of which highlights the complexity of the aetiology of dental trauma (Andreasen and Andreasen, 1994; Marcenes et al, 2000; Traebert et al, 2003b; Glendor, 2009). In order to introduce appropriate preventive measures for traumatic injuries, the association between their prevalence and the risk factors involved must be better understood (Marcenes et al, 2000; Glendor, 2008; Glendor, 2009). Prevalence rates of TDI have been reported in different parts of Brazil: 10.7% to 58.6% in the south (Marcenes et al, 2001; Nicolau et al, 2001; Traebert et al, 2003a; Traebert et al, 2006), 2.6% to 14.4% in the southeast (Cortes et al, 2001; Cortes et al, 2002; Grimm et al, 2004) and 10.5% to 36.8% in the northeast (Soriano et al, 2007; Cavalcanti et al, 2009). Despite the increasing number of publications on TDI in permanent dentition in Brazil, there is no data about its prevalence and associated risk factors in individual States in the country’s central region. Thus, the aim of this study was to assess the prevalence of traumatic dental injuries to permanent anterior teeth in 9- to 14-year-old schoolchildren attending public schools in Anápolis, a city in central Brazil, and to investigate the association between the occurrence of these injuries and the size of incisal overjet and the type of lip coverage.
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MATERIALS AND METHODS This study was conducted in compliance with the ethics guidelines issued by Resolution 196/96 of the Brazilian National Health Council, Ministry of Health on research involving human subjects. The research project was reviewed independently and approved by the Ethics Research Committee of the University Center of Anápolis, Brazil. A cross-sectional survey was performed with a sample universe population comprising 9- to 14-year-old schoolchildren of both genders regularly attending public schools in Anápolis, Goiás, located in the central region of Brazil. The city has an estimated population of 325,544 inhabitants and according to the data provided by the Municipal Education Office, there were 28,114 students enrolled in elementary schools, of which 10,887 were in municipal schools. Local authorities (Health Council and Education Council) provided the necessary information for the construction of a sample frame. For sample calculation, a prevalence of 50% was adopted considering an unknown prevalence in the State, a sample error of 5% and a confidence interval of 95%. In addition, a correction factor of 1.5 was applied because a multistage sampling technique was used. The minimum sample size to satisfy the requirements was estimated to be 612 students. The sample involved the municipal schools and, using a multistage sampling method, the children were randomly selected from such schools in the five geographic regions of Anápolis. The first unit included all municipal schools of Anápolis. The second unit included all students enrolled in the selected schools. A total of 850 children were randomly selected and invited to participate. Prior to data collection, a letter was sent to parents requesting permission for their children’s participation and explaining the aim, characteristics and importance of the study as well as the benefits which could ensue. Negative consent was adopted, without any prejudice toward the children who had opted not to participate. In order to test interview administration and dental examination procedures, a pilot study was carried out on a sample of 185 children from two schools. The results confirmed that the protocol was feasible. All dental examinations were carried out by one dentist (SSF) who had participated in a training and calibration exercise on the criteria used to identify dental injuries. During this phase, the results were found to be reliable (kappa = 0.82). Children were examined according to a predetermined
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order during school hours. During the dental examination, the children were interviewed to identify their history of dental trauma and the location and activity being carried out when the incident occurred. The children were visually examined using a wooden spatula in a room with good natural lighting after having their teeth and soft tissue dried with gauze to minimise variables. Strict cross-infection control measures were adopted. The examiner used disposable gloves and examined maxillary and mandibular incisors and adjacent soft tissues. The type of damage, treatment received because of TDI, the size of incisal overjet and lip coverage were recorded. The questionnaire provided information about the children’s sex, age and details of the injury event, which included the location and nature of the activity being performed when the incident occurred. The types of damage included treated and untreated crown fractures at all levels, and enamel cracks, discolouration, sinus/fistulous tract and teeth missing as a result of trauma. A tooth crown was scored as fractured when some of its surface was missing as a result of trauma and there was no evidence of caries. An enamel crack was diagnosed when an incomplete fracture of the enamel was present without loss of tooth substance. Teeth with dark discolouration, the presence of swelling or a fistulous tract adjacent to an otherwise healthy tooth and teeth missing due to trauma were also recorded as traumatised (Cortes et al, 2001; Malikaew et al, 2006). Teeth were examined by direct vision. Neither vitality tests nor radiographs were used to assess the extent of the fractured teeth. In addition, traumatic injuries were categorised using a classification adapted from O’Brien (O’Brien, 1994). The codes used were: 1: discolouration; 2: enamel cracks; 3: fracture involving enamel; 4: fracture involving enamel and dentin; 5: fracture involving enamel, dentin and pulp; 6: tooth missing due to trauma; 7: composite restoration (incl. acid etching step); 8: bonded dental fragment; 9: permanent crown; 10: temporary restorations or crowns; 11: denture or bridge pontic provided; 12: fistulous tract or swelling without evidence of caries; 99: impossible to assess. Children with no anterior tooth trauma received a code 0. Overjet (OJ) was recorded using a straight-edged wooden spatula. To acquire this information, the child was placed in centric occlusion and the size of overjet was recorded by pencil from the incisal edge of the most labial maxillary central incisor to the most labial mandibular central incisor. The reading of the size of overjet was performed by a caliper
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and was considered a risk factor when it presented values > 3 mm. Lip coverage was classified as adequate when the lips completely covered the anterior teeth in the at-rest position and as inadequate when they did not (O‘Mullane, 1972). Data analysis included descriptive statistics (frequency distribution and cross-tabulation). The data were analysed using SPSS version 14.0 (SPSS; Chicago, IL, USA). A chi-square test was used for bivariate analyses and an entry method of multivariate logistic regression was performed. Statistical significance for the association between the occurrence of dental injuries and gender, age, incisal overjet size and lip coverage was determined using simple and multiple logistic regression. The level of significance set was P < 0.05.
RESULTS A total of 765 children were examined and interviewed. There was an 89% response rate and the sample size satisfied the requirements. The main reason for this level of response was the lack of parents’ agreement for their child’s participation and the absence of children on the day the dental examination was conducted. The group consisted of 418 girls (54.6%) and 347 boys (45.4%). The prevalence of traumatic dental injuries of permanent anterior teeth was 16.5%, affecting 126 9- to 14-year-old schoolchildren of both genders. A statistically significant difference between genders was found: boys were 2.03 times (95% CI = 1.35 – 3.04) more likely to have dental injuries than girls (P < 0.001; Table 4). The main types of accident which resulted in dental injuries were falls (47.6%) and collisions with objects or people (26.9%). The majority of accidents occurred at home (46.8%) followed by accidents on the street (23%) and in school (15.1%) (Table 1). Most of the children (73%) who had experienced traumatic dental injuries had only one damaged tooth, 23.8% had two damaged teeth and only 3.2% had three or more damaged teeth. The most common type of teeth affected were the maxillary central incisors, with almost no difference being noticed between the right (44%) and left (41%) incisors (Table 2). The most frequent type of injury was enamel fracture (66%), followed by enamel-dentin fracture (27%) and enamel cracks (5%) (Table 3). Only 26% of traumatised teeth were restored. Composite restoration including an acid-etching step
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Table 1 Frequency distribution of aspects related to traumatic dental injuries in 126 schoolchildren Anápolis, Brazil, who experienced injuries to the permanent incisors Injury characteristics
Frequency, n (%)
Table 2 Frequency distribution of traumatic dental injuries according to affected teeth in schoolchildren (n = 765), Anápolis, Brazil Types of tooth*
Number
%
Maxilla
Knowledge about injury Yes
114 (90.5)
Right lateral (12)
6
4
No
12 (9.5)
Right central (11)
73
44
Type of accident that resulted in dental injury
Left central (21)
67
41
Fall (all reasons)
60 (47.6)
Left lateral (22)
4
2
Collision against objects or people
34 (26.9)
Mandible Left lateral (42)
3
2
Bicycling
11 (8.7)
Left central (41)
6
4
Right central (31)
4
2
Right lateral (32)
2
1
Total
165
100
Sports
2 (1.6)
Traffic accident
1 (0.8)
Unknown
18 (14.3)
Place of dental injury
* Tooth numbering according to FDI system.
Home
59 (46.8)
Outside, in the street
29 (23.0)
School
19 (15.1)
Public leisure areas Unknown
Types of injury
n
Frequency (%)
Enamel cracks
9
5
Enamel fracture
109
66
Enamel / dentin fracture
44
27
Fracture with pulp involvement
3
2
Missing tooth
0
0
Treatment
Composite restoration
41
25
Bonded fragment
1
1
Permanent crown
0
0
Temporary restoration
0
0
Denture or bridge
0
0
Sequelae
Discolouration
8
5
Fistulous tract
0
0
5 (4.0) 14 (11.1)
was the most common type of treatment, while other types of treatment were uncommon. A low incidence of sequelae was registered either due to treatment or lack of it. Discolouration of the tooth accounted for 5% of injured teeth. No fistulous tract was observed in the population examined (Table 3). The results of simple logistic regression showed a significant association between dental injuries and gender (P < 0.001), size of the overjet (P < 0.001) and type of lip coverage (P < 0.001) (Table 4). The results of multiple logistic regression confirmed the statistically significant associations found after adjusting for the other variables studied (Table 4). There was a tendency for children whose incisal overjet was > 3 mm and who had inadequate lip coverage to have experienced dental injuries; the differences were statistically significant (P < 0.001). The results of multiple logistic regression showed that children with an overjet size > 3 mm were 1.78 times (95% CI = 1.18 – 2.69) more likely to present with a dental injury than chil-
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Table 3 Frequency distribution of types of traumatic dental injuries in schoolchildren in Anápolis, Brazil
dren with an overjet size ≤ 3 mm. In addition, children with inadequate lip coverage were 2.18 times (95% CI = 1.27 – 3.76) more likely to present dental trauma than children with adequate lip coverage.
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Table 4 Results of multiple logistic regression of gender, size of the incisal overjet and type of lip coverage for traumatic dental injuries in 765 schoolchildren in Anápolis, Brazil Traumatic dental injury No
Girls
OR and CI‡ , 95%
3 mm were 1.78 times most likely to have dental injuries. Furthermore, children with inadequate lip coverage were 2.18 times more likely to suffer traumatic dental injuries than were children whose lip coverage was adequate. Although the majority of traumas found were relatively minor, it is still recommended that people be educated in the prevention of dental injuries in children. Further investigations of the factors associated with this kind of injury are also required.
ACKNOWLEDGEMENTS The authors would like to thank São Leopoldo Mandic Dental School, Unievangélica University Center of Anápolis and the Anápolis Education Office for their contributions to the success of this project.
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