|Year : 2014 | Volume
| Issue : 2 | Page : 73-77
Evaluation of prevalence, etiological and risk factors of traumatic dental injury in 12-14 years old school going children of Central India
Ritesh Rambharos Rambharos1, Ashita Ritesh Kalaskar2, Rucha Manohar Wankhade3, Jinal Dilip Mehta3
1 Departments of Pedodontics, Government Dental College and Hospital, Nagpur, Maharashtra, India
2 Department of Oral Medicine and Radiology, VSPM Dental College and Research Centre, Nagpur, Maharashtra, India
3 BDS Student, Government Dental College and Hospital, Nagpur, Maharashtra, India
|Date of Web Publication||7-May-2014|
Ritesh Rambharos Rambharos
Department of Pedodontics, Government Dental College and Hospital, Nagpur, Maharashtra
Aim: Traumatic dental injury (TDI) in school children has become a serious dental public health problem in developing and developed countries. Worldwide research clearly shows that the prevalence of TDI is increasing. However, hardly any epidemiological data of TDI in central India is available for clinical audit, service management, planning of future services, and effective targeting of preventive measures. The aim of this study was to determine the prevalence and to evaluate the risk and etiological factors associated with TDI. Materials and Methods: A total of randomly selected 2000 boys and girls aged 12-14 years were included from 20 randomly selected schools. Two calibrated examiners examined the school children under day light using the World Health Organization, (1978) classification of tooth fracture. Examination was done for competent and incompetent lip and overjet using community periodontal index probe. Children were interviewed for demographic profile and history of injury. Result: The prevalence of TDI is found to be 10.5%. Boys experience more injury than girls; 11.61% and 9.47%, respectively. The result showed a positive association between risk factors (overjet more than 5 mm and inadequate lip coverage) and TDI. Maxillary central incisors were commonly injured involving enamel fracture. The major cause of TDI was fall, followed by sports and violence. Conclusion: Children with overjet >5 mm and inadequate lip coverage were more likely to have TDI. There is a need to collect local data on TDI to obtain a more comprehensive picture of dental health.
Keywords: Inadequate lip coverage, overjet, tooth fracture, traumatic dental injury
|How to cite this article:|
Rambharos RR, Kalaskar AR, Wankhade RM, Mehta JD. Evaluation of prevalence, etiological and risk factors of traumatic dental injury in 12-14 years old school going children of Central India. SRM J Res Dent Sci 2014;5:73-7
|How to cite this URL:|
Rambharos RR, Kalaskar AR, Wankhade RM, Mehta JD. Evaluation of prevalence, etiological and risk factors of traumatic dental injury in 12-14 years old school going children of Central India. SRM J Res Dent Sci [serial online] 2014 [cited 2019 Nov 13];5:73-7. Available from: http://www.srmjrds.in/text.asp?2014/5/2/73/132074
| Introduction|| |
Traumatic dental injury (TDI) is of everyday occurrence in children and adolescents and has become a serious dental public health problem in developing and developed countries. These dental injuries not only lead to problems with mastication, speech and esthetics but also have an impact on child's personality and quality-of-life.  There is an agreement that traumatic dental injuries occur more often to the maxillary than mandibular incisors and that central incisors are affected more than lateral incisors.  TDI often results in pulpal and periodontal pathology which are of great concern in today's dental practice. , Traumatic dental injuries are often due to falls, collision with people or inanimate objects, road traffic accidents, sports, and violence.  Predisposing factors include inadequate lip coverage and increased incisal overjet of the teeth. 
The prevalence of TDI varies worldwide. In American and European countries the prevalence of TDI ranged from 15-23% to 23-35%, respectively. , In the Asia-Pacific region, the prevalence ranged from 6% to 19%, respectively. , Studies conducted in northern and southern part of India showed high prevalence ranged from 13% to 15%, respectively. ,
Although, traumatic dental injuries being a major worldwide public health problems hardly any epidemiological data of central India is available, addressing etiology, risk factors, and awareness. Therefore, the present study to evaluate the prevalence, etiological and risk factors of TDI in 12-14 years school going children of central India. Secondly, this data can be used for service management, planning of future services, and targeting preventive measures.
| Materials and methods|| |
The cross-sectional study was conducted in the randomly selected schools (Election constituency zone wise - east, west, north, south and south west) of Nagpur city from June 2012 to December 2012. A total of 2000 children in the age of 12-14 years were included in the study. Twenty schools were randomly selected from the list of 60 schools to make up the sample size of 100 per school. The study was approved by the Institutional Ethical Committee.
After training of TDI the oral examinations were conducted by two calibrated examiners under day light using the World Health Organization (WHO) classification of tooth fracture. The criteria and scoring for TDI included, enamel fracture, enamel and dentine fracture, enamel and dentine fracture with pulp involvement, nonvital tooth with discoloration, displacement, avulsion and restored tooth with a positive history of trauma. Root fractures involving cementum were excluded as radiographs were not taken during clinical examination.
Lip coverage was recorded as inadequate and adequate. Adequate, if lip covers the maxillary incisors in rest position and inadequate if 2/3 of the crown height was exposed and visible. Overjet was measured in centric occlusion: The distance from the labioincisal edge of the most prominent maxillary incisor to the labial surface of the corresponding mandibular incisor which was measured using community periodontal index probe as described in the 1997 WHO basic oral health survey guidelines. The overjet observations were divided into two groups: ≤5.0 mm and >5.0 mm. Children included in the study were then interviewed for the demographic profile. Children with clinical evidence of TDI were interviewed for details of the injury event such as cause and place of the injury. Data collected were then analyzed for proportions of damaged tooth, types of tooth damage and risk factors for TDI. Statistical analysis was carried out using Proportion test and Chi-square test. Data were entered in Excel 2007 spreadsheet (Microsoft Corp, Redmond, Wash) and SPSS version 17 software (SPSS Inc, Chicago, Ill., USA) was used for statistical analysis.
| Results|| |
A total of 2000 children (1050 [52.5%] boys and 950 [47.5%] girls) were examined and of these 212 children had TDI. Of the 212 children with TDI, 121 (11.61%) were boys and 90 (9.47%) were girls, giving a prevalence rate of 10.5% in Central India [Table 1]. The boys had a significantly higher incidence of TDI than girls (Proportion test, P-0.007). Children with overjet >5.0 mm were more prone to TDI (1.65 times more); the difference is statistically significant (Chi-square test, P-0.021). Similarly, children with inadequate lip coverage were also at higher risk (1.62 times) for TDI. The difference is statistically significant (Chi-square test, P-0.008), [Table 2].
|Table 2: Distribution of overjet and lip coverage in patients with and without trauma |
Click here to view
Each child was examined for TDI in maxillary and mandibular anterior permanent teeth. Maxillary central incisors (58.59%) were the most common teeth with TDI, followed by maxillary lateral (19.8%), maxillary canines (7.04%), mandibular laterals (7.04%), mandibular canines (3.08%) and mandibular centrals (0.44%). Enamel fractures (68.72%) were the most common type of TDI in both arches, followed by enamel and dentin fractures (18.50%) and only 7.00% involved pulp [Table 3]. Approximately 40% of the TDI were due to fall. Sports (15.7%) accounted for the second most common cause of TDI, followed by violence 13.7%, biting on a hard object 12.8%, road traffic accident 9.9%, and collision 7.1% [Table 4]. Only 7.07% of the children attended the dental clinic compared to 92% who did not attend the dental clinic. The difference is statically significant (Chi-square test, P-0.001), [Table 5].
| Discussion|| |
Dental trauma is an irreversible pathology that may cause life-long debilitating effects ultimately affecting the child's quality-of-life. The prevalence for TDI in Central India is found to be 10.5%.
This data is not in accordance with the prior studies conducted in various parts of India which showed high prevalence ranged from 13% to 15%, respectively. , The study conducted in Brazil  found a similar prevalence (10.2%) to that of our study, whereas the studies conducted in Malaysia, South Africa and London showed high prevalence ranged from 14% to 43%, respectively. ,, The Children's Dental Health Survey in the United Kingdom  showed that one in five children experienced dental injuries to their permanent anterior teeth. Low prevalence of TDI in the current study was supported by the studies conducted in India by Baldava and Anup  and Jose and Joseph  The low prevalence for TDI in the current study may be due to the relative lack of outdoor activities and more emphasis on education. Variable prevalence for TDI in the literature could be attributed to trauma classification, dentition, behavioral and geographical difference between study location and countries.  Majority of the studies conducted worldwide showed an increased trend of TDI ,,,, and probably this trend will continue in the future simply because more individuals will be at risk. This is because inhabitants in countries with growing economies can afford cars, bicycles, sport utilities, etc., but have not yet gained sufficient knowledge regarding safety. The increasing violence among individuals is another alarming factor toward increasing trend of TDI.  In the current study, the prevalence of TDI is higher in boys than in girls. This observation from the current study is in agreement with the studies conducted worldwide ,, Male predominance for TDI could be attributed to the fact that boys are more inclined toward vigorous activities. On the contrary some studies already indicate an increasing trend of dental trauma toward girls because of their increasing participation in activities formerly participated by boys only. ,,
Increased overjet is considered a risk factor for TDI in children. Different authors have argued as to which particular value to be regarded as increased overjet. Some recognize an increased overjet when the value is over 3 mm and others when it is higher than 5 mm. ,,, A study conducted in Brazil found that schoolchildren with an overjet higher than 5 mm had a 50% greater risk of traumatic injuries than those with an overjet of 5 mm or less.  The result of the current study significantly corroborates the assertion that the frequency of dental trauma increases proportionally in relation to an increased overjet. Studies conducted by Hamdan and Rock  and Petti et al.  have reported that children with an overjet size >5.0 mm were 1.37 times more likely to have a dental trauma than children with an overjet size equal or lower. However, in the current study children with an overjet size >5.0 mm were 1.65 times more likely to have a dental trauma.
Literature widely acknowledges the positive relationship between inadequate lip coverage and TDI. , This fact is again reduplicated by this study that children with inadequate lip coverage were 1.62 times more likely to have dental trauma. More recent study found four-fold greater risk of dental trauma among subjects that presented inadequate lip coverage than in those with adequate lip coverage.  On the contrary a study conducted by Haynes have reported that position of upper lip may not be an influencing factor for TDI. 
It is well-documented that maxillary central incisors are the most prone teeth to dental injury and enamel fracture the most common type of fracture. ,, The result of the current study is in agreement with the reported literature which states that maxillary teeth particular maxillary central incisors are the frequently traumatized teeth. However, literature search revealed studies that are in conflict with the observation of present study. Studies conducted in Brazil  and Malaysia  found no significant differences related to the location of the tooth. Enamel fracture is the most common type of fracture. , This result from the current study is also in agreement with the reported literature. However, comprehensive literature review suggests enamel and dentin fracture involving pulp is also the common type of fracture due to TDI. ,
The etiology of traumatic dental injuries observed in the present study is in accordance with the results found in several studies in the literature that have demonstrated that fall is among the main causes of TDI. ,,, In the current study, nearly 40% of the children had dental injury due to fall. However, comprehensive literature review revealed that collision, sports and violence were also the main causes of TDI. Studies conducted in Brazil supports collision as the major etiological factor for TDI. ,, A more recent study result identified play ground or sports related accidents as the most common cause for TDIs.  Similarly, the study that used data from Medline, Cochrane, Social Citation Index and CINAHL from 1995 reported that violence related TDI has increased during the past few decades.  In the current study, sports and violence were the emerging causative factors for TDI accounting approximately 16% and 14%. This may be because there is increase in the intensity and type of sports activity played in the country. Children in this age group neither have in-depth knowledge of the sports nor do they use preventive measures to reduce the severity of injury. Secondly, there is also increase in recorded violence in the peer group.
In the current study, only 7.07% of the children visited the dental clinic compared to 92% who did not attend the dental clinic. This observation from the current study indicates total lack education toward TDI.
In light of these results concerning the considerable number of parents who failed to take their children to dental clinic following a dental injury or had no knowledge about the accident that caused the dental trauma, it is necessary to raise awareness among them. Secondly, the health policy makers seeking prevention of accidents should implement educational and preventive strategies that could reduce the probability of occurrence of TDI. These could include;
- Care takers and educational institutions should provide safe environments and equipment's for children activities;
- Children being encouraged to use helmets, mouth guards or any other protective device during sport activities;
- Sports such as contact sports or the sport which involve aggression to be played under competent supervision on appropriate surfaces;
- National and local campaigns to increase social awareness about TDI;
- Education of the parents and teachers regarding the TDI and its consequences;
- Specific local laws requiring and regulating the use of safety equipment are necessary;
- Furthermore, improving the knowledge of dental practitioners through continuing education will also help in minimizing sequelae of traumatic dental injuries.
Thus, the studies with larger sample are needed in the central Indian school children to better understand the role of risk and causative factors, educational and preventive strategies in the prevalence of TDI.
| Conclusion|| |
The reported prevalence of TDI in the Central Indian population is lower than other Asian countries as well as other parts of the world. This study revealed that, increased overjet and inadequate lip coverage are risk factors for TDI. These findings emphasize the importance of taking these risk factors into account when analyzing the risk for TDI.
| Acknowledgment|| |
The authors would like to thank the Maharashtra University of Health Sciences, Nashik, for their guidance and funding the project under Research Training Fellowship program.
| References|| |
|1.||Alonge OK, Narendran S, Williamson DD. Prevalence of fractured incisal teeth among children in Harris County, Texas. Dent Traumatol 2001;17:218-21. |
|2.||Cavalcanti AL, Bezerra PK, de Alencar CR, Moura C. Traumatic anterior dental injuries in 7-to 12-year-old Brazilian children. Dent Traumatol 2009;25:198-202. |
|3.||Andreasen JO, Andreasen FM. Text Book and Color Atlas of Traumatic Injuries to the Teeth. 4 th ed. Copenhagen: Munksgaard; 1994. |
|4.||Hamilton FA, Hill FJ, Holloway PJ. An investigation of dento-alveolar trauma and its treatment in an adolescent population. Part 1: The prevalence and incidence of injuries and the extent and adequacy of treatment received. Br Dent J 1997;182:91-5. |
|5.||Marcenes W, Alessi ON, Traebert J. Causes and prevalence of traumatic injuries to the permanent incisors of school children aged 12 years in Jaragua do Sul, Brazil. Int Dent J 2000;50:87-92. |
|6.||Soriano EP, Caldas AF Jr, Góes PS. Risk factors related to traumatic dental injuries in Brazilian schoolchildren. Dent Traumatol 2004;20:246-50. |
|7.||Nik-Hussein NN. Traumatic injuries to anterior teeth among schoolchildren in Malaysia. Dent Traumatol 2001;17:149-52. |
|8.||Hargreaves JA, Matejka JM, Cleaton-Jones PE, Williams S. Anterior tooth trauma in eleven-year-old South African children. ASDC J Dent Child 1995;62:353-5. |
|9.||Rai SB, Munshi AK. Traumatic injuries to the anterior teeth among South Kanara school children - A prevalence study. J Indian Soc Pedod Prev Dent 1998;16:44-51. |
|10.||Dua R, Sharma S. Prevalence, causes, and correlates of traumatic dental injuries among seven-to-twelve-year-old school children in Dera Bassi. Contemp Clin Dent 2012;3:38-41. |
|11.||Gupta K, Tandon S, Prabhu D. Traumatic injuries to the incisors in children of South Kanara District. A prevalence study. J Indian Soc Pedod Prev Dent 2002;20:107-13. |
|12.||Naidoo S, Sheiham A, Tsakos G. Traumatic dental injuries of permanent incisors in 11-to 13-year-old South African schoolchildren. Dent Traumatol 2009;25:224-8. |
|13.||Robson F, Ramos-Jorge ML, Bendo CB, Vale MP, Paiva SM, Pordeus IA. Prevalence and determining factors of traumatic injuries to primary teeth in preschool children. Dent Traumatol 2009;25:118-22. |
|14.||Marcenes W, Murray S. Changes in prevalence and treatment need for traumatic dental injuries among 14-year-old children in Newham, London: A deprived area. Community Dent Health 2002;19:104-8. |
|15.||O'Brien M. Children's Dental Health in the United Kingdom 1993. Office of Population Censuses and Surveys. London: Her Majesty's Stationary Office; 1994. |
|16.||Baldava P, Anup N. Risk factors for traumatic dental injuries in an adolescent male population in India. J Contemp Dent Pract 2007;8:35-42. |
|17.||Jose A, Joseph MR. Prevalence of dental health problems among school going children in rural Kerala. J Indian Soc Pedod Prev Dent 2003;21:147-51. |
|18.||Glendor U. Aetiology and risk factors related to traumatic dental injuries - A review of the literature. Dent Traumatol 2009;25:19-31. |
|19.||Todd JE. Children's Dental Health in England and Wales 1973. London: Social Survey Division and Her Majesty's Stationary Office; 1975. |
|20.||Pitts N. Children's Dental Health in the United Kingdom 2003. London: Her Majesty's Stationery Office; 2004. |
|21.||Kontio R, Suuronen R, Ponkkonen H, Lindqvist C, Laine P. Have the causes of maxillofacial fractures changed over the last 16 years in Finland? An epidemiological study of 725 fractures. Dent Traumatol 2005;21:14-9. |
|22.||Rocha MJ, Cardoso M. Traumatized permanent teeth in Brazilian children assisted at the Federal University of Santa Catarina, Brazil. Dent Traumatol 2001;17:245-9. |
|23.||Gutmann JL, Gutmann MS. Cause, incidence, and prevention of trauma to teeth. Dent Clin North Am 1995;39:1-13. |
|24.||Järvinen S. Traumatic injuries to upper permanent incisors related to age and incisal overjet. A retrospective study. Acta Odontol Scand 1979;37:335-8. |
|25.||Otuyemi OD. Traumatic anterior dental injuries related to incisor overjet and lip competence in 12-year-old Nigerian children. Int J Paediatr Dent 1994;4:81-5. |
|26.||Marcenes W, al Beiruti N, Tayfour D, Issa S. Epidemiology of traumatic injuries to the permanent incisors of 9-12-year-old schoolchildren in Damascus, Syria. Endod Dent Traumatol 1999;15:117-23. |
|27.||Cortes MI, Marcenes W, Sheiham A. Prevalence and correlates of traumatic injuries to the permanent teeth of schoolchildren aged 9-14 years in Belo Horizonte, Brazil. Dent Traumatol 2001;17:22-6. |
|28.||Hamdan MA, Rock WP. A study comparing the prevalence and distribution of traumatic dental injuries among 10-12-year-old children in an urban and in a rural area of Jordan. Int J Paediatr Dent 1995;5:237-41. |
|29.||Petti S, Tarsitani G. Traumatic injuries to anterior teeth in Italian schoolchildren: Prevalence and risk factors. Endod Dent Traumatol 1996;12:294-7. |
|30.||Burden DJ. An investigation of the association between over-jet size and lip coverage and traumatic injury to maxillary incisors. Eur J Orthod 2005;17:513-7. |
|31.||O'Mullane DM. Some factors predisposing to injuries of permanent incisors in school children. Br Dent J 1973;134:328-32. |
|32.||Haynes S. Prevalence of upper lip posture and incisor overjet. Community Dent Oral Epidemiol 1977;5:87-90. |
|33.||David J, Astrøm AN, Wang NJ. Factors associated with traumatic dental injuries among 12-year-old schoolchildren in South India. Dent Traumatol 2009;25:500-5. |
|34.||Altun C, Ozen B, Esenlik E, Guven G, Gürbüz T, Acikel C, et al. Traumatic injuries to permanent teeth in Turkish children, Ankara. Dent Traumatol 2009;25:309-13. |
|35.||Ferreira JM, Fernandes de Andrade EM, Katz CR, Rosenblatt A. Prevalence of dental trauma in deciduous teeth of Brazilian children. Dent Traumatol 2009;25:219-23. |
|36.||Cardoso M, de Carvalho Rocha MJ. Traumatized primary teeth in children assisted at the Federal University of Santa Catarina, Brazil. Dent Traumatol 2002;18:129-33. |
|37.||Piovesan C, Abella C, Ardenghi TM. Child oral health-related quality of life and socioeconomic factors associated with traumatic dental injuries in schoolchildren. Oral Health Prev Dent 2011;9:405-11. |
|38.||Malikaew P, Watt RG, Sheiham A. Prevalence and factors associated with traumatic dental injuries (TDI) to anterior teeth of 11-13 year old Thai children. Community Dent Health 2006;23:222-7. |
|39.||Sabuncuoglu O. Traumatic dental injuries and attention-deficit/hyperactivity disorder: Is there a link? Dent Traumatol 2007;23:137-42. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]