|Year : 2017 | Volume
| Issue : 3 | Page : 209-215
Prevalence of traumatic dental injuries among visually impaired children attending special schools of Chhattisgarh
Harsha Munot, Alok Avinash, Nilotpol Kashyap, Rashmi Baranwal, Brij Kumar, Maylavarapu Krishna Sagar
Department of Pedodontics and Preventive Dentistry, Rungta College of Dental Sciences, Bhilai, Chhattisgarh, India
|Date of Web Publication||31-Jul-2017|
Department of Pedodontics and Preventive Dentistry, Rungta College of Dental Sciences, Kohka-Kurud Road, Bhilai - 490 024, Chhattisgarh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Studies on dental trauma of the normal population have been carried out in the past; however, limited data are available on dental trauma of the handicapped population, especially visually impaired children in Chhattisgarh, India. Aim: The aim of this study is to determine the prevalence of traumatic dental injuries (TDIs) in visually impaired children in relation to age, cause, and place of injury. Materials and Methods: Epidemiological study was carried out among 400 children from various special schools of visually impaired children of Chhattisgarh followed by school dental checkup camps. All the children completed a questionnaire related history of trauma, cause, and place. The prevalence of TDIs in each special child was recorded based on the Epidemiological classification of TDIs by the WHO and was modified by Andreasen et al. (2007). Statistical Analysis: Statistical analysis was done using SPSS version 17. The level of significance was fixed at P ≤ 0.05. Association between categorical variables was done using Chi-square test. Results: The results showed that out of 400 children, 39% suffered from TDIs. Permanent maxillary central incisors were most commonly injured teeth with injuries involving enamel (53%) being most frequently observed. Increased overjet and inadequate lip coverage were significantly associated with the occurrence of trauma. Conclusion: As blind children are at the risk of multiple TDI, it is necessary to create awareness, health education, and periodic screening for appropriate management.
Keywords: Lip coverage, overjet, traumatic dental injuries, visually impaired
|How to cite this article:|
Munot H, Avinash A, Kashyap N, Baranwal R, Kumar B, Sagar MK. Prevalence of traumatic dental injuries among visually impaired children attending special schools of Chhattisgarh. J Indian Soc Pedod Prev Dent 2017;35:209-15
|How to cite this URL:|
Munot H, Avinash A, Kashyap N, Baranwal R, Kumar B, Sagar MK. Prevalence of traumatic dental injuries among visually impaired children attending special schools of Chhattisgarh. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2019 Jul 18];35:209-15. Available from: http://www.jisppd.com/text.asp?2017/35/3/209/211838
| Introduction|| |
The term disability is defined as any impairment that limits daily activity. Out of the various handicapped condition, blindness is most prevalent worldwide. According to the WHO (2014), 285 million people are visually impaired worldwide. It is estimated that in India, 200,000 children had severe visual impairment, out of which only 15,000 are in schools for blind children. corneal scarring and inadequate sanitation are the main causes of blindness.
Visually impaired children suffer from many health problems which include orofacial trauma, dental caries, and periodontal disease. Out of these, orofacial trauma is the most common health hazards. According to the recent population-based studies, the prevalence of traumatic dental injury (TDI) of permanent anterior teeth is high worldwide ranging from 4.1% to 58.6%. Upper incisors are the most frequently affected teeth by trauma (90%). Incisors play an important role in esthetics, phonation, and psychological impact which affect the behavior of a child on a daily basis. Falls, increased overjet, and inadequate lip coverage are one of the major risk factors for dental trauma. Out of these, falls are frequently reported due to collisions, sports, violence, and traffic accidents.
TDIs are more prevalent in visually impaired children compared to normal children. The prevalence of TDI among visually impaired children ranges from 27.4 to 36.4%. Besides lack of acquisition of movement skills, blind children tend to move and play like healthy children during the 1st year of life. However, as compared to sighted children visually impaired child are more prone to an accident which leads to dental trauma.
Thus, apart from dentists, parents as well as teachers must be aware of emergency management in dental trauma.
There is no available data regarding traumatic injuries to anterior tooth in visually impaired children of Chhattisgarh. Thus, the aim of the present study is to evaluate the prevalence of TDI of anterior tooth in school going visually impaired children of Chhattisgarh and to correlate the prevalence of injury to the cause and place of trauma with the age of child and incisal overjet of traumatized teeth.
| Materials and Methods|| |
A descriptive cross-sectional study was conducted to assess the prevalence of TDIs in children attending various special schools for visually impaired from Chhattisgarh, India. For the present study, a total of 400 children were taken. The pro forma was pilot tested on 60 (15%) children before starting the main study to determine the sample size.
Visually impaired children with a age group of 6–18 years were included in this study while children undergoing orthodontic treatment, traumatized deciduous tooth, lack of institutional approval as well as definitely negative children (Frankel's behavior rating) were excluded from the study.
All examinations were done single-handedly to eliminate intra-examiner variability. With the help of a trained professional, all the children were evaluated using structured questionnaires regarding time, place, and cause of traumatic injuries. The choice of answers to the questions was fixed (close ended). The interviewer read the questions and the relevant options exactly as they appeared in the questionnaire format. The children were asked to select a relevant option and that option was marked by the assistant in the questionnaire format. Clinical examination was done by the examiner which was properly recorded by the trained professional. The recording assistant was allowed to sit close enough while examining so that the instructions and codes could be easily heard and while examining the findings can be recorded correctly.
Clinical examination was carried out in the institute's medical room or classroom under natural light. Children were seated in an ordinary chair in an upright position [Figure 1]. The clinical examination was done using gloves, mouth masks, mouth mirrors, and community periodontal index of treatment need probes.
The examination evaluated that these children and the type of trauma were categorized by using an epidemiological classification of traumatic injuries by the WHO and was modified by Andreasen et al. (2007) [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6].
|Figure 5: Pulp involvement (N 502.52, N 502.53, N 502.54, N503.20, N 503.21)|
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Statistical analysis was done using Statistical Package for Social Sciences version 17, Chicago Inc., USA (IBM Corp). The level of significance was fixed at P ≤ 0.05. Association (correlation) between categorical variables was done using Chi-square test.
| Results|| |
The age of children ranged from 6 to 18 years with mean ± standard deviation 11.76 ± 3.29 years and median 11 years. The children were mostly 10–15 years accounting 60.0% of the total children. Out of total, 152 (38.0%) were female and 248 (62.0%) were male. The study population was male predominance with 1:1.6 male to female ratio [Table 1].
Out of total, the prevalence of TDI was 39.0%.
Most of the children's tooth/teeth fractured were at home (64.1%) and mostly because of fall (64.1%) followed by collision against object (30.8%), accounting together 94.9% of total cause.
The lip coverage of 252 (63.0%) were adequate and 148 (37.0%) were inadequate indicating predominance of adequate lip coverage. Further, the overjet of 240 (60.0%) children were ≤3.5 mm and 160 (40.0%) were >3.5 mm indicating the predominance of normal/increased overjet (overjet ≤3.5) among the children.
Tooth wise, each child were reexamined for TDI (treated dental, enamel fracture, enamel/dentin fracture, pulp injury, missing due to trauma, and excluded tooth) and are depicted in [Graph 1]. Among all children, the most effected tooth was 11, accounting 38% of total injuries followed by 21, accounting 36% injuries and 22, accounting 8% injuries. However, tooth 31 and 43 were the least affected tooth/teeth without injuries [Graph 1].
Overall, 204 (51.0%) different types of TDIs were observed among children with highest being enamel fracture (53%) followed by enamel/dentin fracture (12%), missing due to trauma (12%), pulp injury (11%), treated dental injury (5%) and excluded tooth (0.0%) [Graph 2].
The correlation of fractured tooth with the age of children is summarized in [Graph 3]. Comparing the tooth/teeth fractured (yes/no) frequency between different age groups, Chi-square test showed similar frequency (%) of tooth/teeth fractured among the groups (χ2 = 3.58, P = 0.310), i.e., did not differed significantly. In other words, fractured tooth/teeth frequency is not found to be associated with age.
The correlation of fractured tooth with sex of children is summarized in [Graph 4]. Comparing the tooth/teeth fractured (yes/no) frequency between two genders, Chi-square test showed similar frequency (%) of tooth/teeth fractured between the groups (χ2 = 1.18, P = 0.277), i.e., also not differed significantly. In other words, tooth/teeth fractured frequency is also not found to be associated with sex.
The correlation of fractured tooth with lip coverage of children is summarized in [Table 2]. Comparing the fractured tooth (yes/no) frequency between lip coverage, Chi-squaretest showed significantly different and higher (15.39%) frequency of fractured tooth in inadequate than adequate lip coverage (χ2 = 4.60, P = 0.032). In other words, children with inadequate lip coverage had higher incidence of fractured tooth/teeth.
|Table 2: Association between tooth/teeth fracture and lip coverage of children|
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The correlation of fractured tooth with overjet of children is summarized in [Table 3]. Comparing the fractured tooth (yes/no) frequency with overjet, Chi-square test showed significantly different and higher (14.2%) prevalence of fractured tooth in overjet more than 3.5 mm (overjet >3.5 mm) as compared to overjet <3.5 mm (overjet ≤3.5 mm) (χ2 = 4.05, P = 0.044). In other words, children with overjet more than 3.5 mm had higher incidence of fractured tooth/teeth.
|Table 3: Association between tooth/teeth fracture and overjet of children|
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| Discussion|| |
“Special health care needs” children also known as “disabled child.” According to WHO blindness is defined as “visual acuity of <3/60 or corresponding visual field loss in the better eye with the best possible correction.”
Dental trauma is a serious problem in visually impaired child. Despite its high prevalence, it is a neglected oral condition. A descriptive cross-sectional study was conducted in visually impaired school children which is aimed to assess the prevalence of TDIs in children with age group 6–18 years in Chhattisgarh, India. There is no previously published data regarding Chhattisgarh population.
The present study revealed that age of most of children at the time of TDIs belongs to 13–15 years accounting 35.9% of the total TDIs followed by 10–12 years, 6–9 years and 16–18 years accounting for 25.6%, 23.1% and 15.4% respectively. The reason behind higher incidence of tooth fracture in this age group is that the children are least concerned about their personal safety and involvement in the reckless activity. However reduction in the prevalence of trauma in the 16–18 years age group could be due to increased level of maturity, sense of balance and control over aggression.
Bhardwaj et al. reported 38.3% prevalence of TDIs among blind children of Himachal Pradesh. Agrawal et al. and Varghese et al. of Rajasthan reported 34.95% and 37.8% prevalence of TDIs between 10 and 29 years old visually impaired children. Ramaiah and Maraiah  revealed 37.59% prevalence of dental injuries in South Karnataka state. Reddy and Sharma  revealed 31.2% prevalence of TDIs in visually impaired children of Tamil Nadu.
Studies done by Bhat et al. and Poureslami et al. reported that prevalence of TDIs in visually impaired children was higher than the sighted children. Visual incompatibility is the major reason behind high prevalence of tooth fracture among visually impaired children. There is lack of support or increased chances of collision against an object during fall in a visually impaired children.
In the present study, most of the children's tooth fractured at home (64.1%) followed by classroom (15.4%), field (12.8%) and road traffic accident (7.1%). Dubey et al. (2015) was observed similar result in children suffering from other disabilities like cerebral palsy. In the present study, there was no substantial difference in the prevalence of anterior tooth fracture between male and female. They did not differ significantly. According to Shyama (2001), Sabuncuoglu (2007), Bhat et al., Nayak (2015), Kumar (2016) TDIs in males was 1.2–2.3 times more than females in the sighted population and 4 times more in persons with attention deficit/hyperactivity disorder. This can be attributed to the fact that boys tend to be more energetic and involved in vigorous activities.
In the present study, it was found that the prevalence of TDIs was significantly higher in maxillary arch as compared to mandibular arch due to the increased proclination of maxillary central incisors which tends to receive direct blow. The observation of this study revealed that maxillary central incisors were most commonly affected tooth, which is consistent finding in other studies reported in disabled children as well as sighted children.
The present study revealed that injury involving enamel fracture was the most common type of injury. A similar result was reported in study carried out by Ramaiah and Maraiah  in blind children and by Patel and Sujan (2012) in sighted children.
In present study, 53% fracture was found with enamel only, followed by 12% injury with enamel and dentine, 12% injury missing due to trauma, 7% pulp injury and 5% treated dental injury.
In the present study, out of 400 children, lip coverage of 252 children was adequate, and 148 children were indicating the predominance of adequate lip coverage. On comparing fractured tooth frequency between adequate lip coverage children and inadequate lip coverage children, inadequate lip coverage children (48.64%) had higher incidence of TDIs which is also statistically significant. This result corroborates with the earlier studies done by Bhardwaj et al., Agrawal et al., and Bhat et al. According to Kavia (1966), O'Mullane (1973), and Hunter (1990), there is no association between lip morphology and trauma which could be due to the increased size of interlabial distance, which makes the tooth more vulnerable to TDIs. The absence of effective lip seal suggests deficiency in the natural barrier against trauma to the maxillary teeth. Lips cushion the impact of colliding materials on anterior teeth, thus minimizing the possibility of fracture.
Increased overjet has been considered as one of the predisposing factor for traumatic injuries. In the present study, out of 400 children, 240 had overjet <3.5 mm, and 160 children had overjet >3.5 mm. On comparing the frequency of TDIs between overjet, higher prevalence of TDIs was seen (47.5%) in children with increased overjet which was found to be statistically insignificant. Most of the previous studies have reported a significant correlation between TDIs and increased overjet, which can be explained by the fact that in these studies overjet had been recorded for both children with or without traumatic injuries. Similarly, same results were found in the study done by Bhardwaj et al., Agrawal et al., and Bhat et al. On contrary, a study done by Marcenes et al. reported that children with incisal overjet >5 mm and inadequate lip coverage were less likely to have experienced dental injuries.
Visual incompatibility is one of the most important risk factors contributing higher prevalence of TDIs. Thus, special attention is needed in visually impaired children by the caregivers. It is also important to establish preventive measures for avoiding future injuries. A great improvement is needed in the education of caregiver and parents. Health promotion strategies should aim at providing safer environment as well as awareness toward the health hazards. Appropriate orthodontic treatment is needed in case of increased overjet which is one of the major risk factors. Educational programs focusing on the prevention as well as conservation of the injured tooth should be conducted at community level.
Screening programs are essential for the identification of risk factors so that appropriate preventive measures can be taken. Implementation of early orthodontic treatment and use of mouth guards are the preventive measures which should be undertaken. Development of certain guidelines for the management of TDIs should be done which can be provided to the school teachers. Public oral health-care programs should be conducted for the esthetic as well as functional rehabilitation of the children suffering from TDIs. Social awareness should be spread by conducting local as well as national campaigns.
| Conclusion|| |
Apart from dental caries, TDI is a common feature in children. Visually impaired children suffer from many oral health problems, out of which orofacial trauma consists of main health hazards. Hence, this study is conducted focusing on TDI in visually impaired children. It is seen that the prevalence of traumatic injury to anterior teeth in visually impaired school children of Chhattisgarh was 39%. The most common cause of trauma was fall followed by collision against object and road traffic accident. The most commonly involved tooth with trauma was maxillary central incisors, followed by maxillary lateral incisors, and canines. Increased overjet and inadequate lip coverage were significantly associated with the occurrence of trauma.
Thus, implementation of various educational programs for visually impaired children should be done. Parents as well as caretaker should be educated so as to create awareness among them, regarding prevention and management of TDI. Apart from this, early orthodontic treatment as well as use of mouth guards can be used as a preventive measure.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]