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Year : 2012  |  Volume : 30  |  Issue : 2  |  Page : 151-157

The prevalence of traumatic dental injuries to permanent anterior teeth and its relation with predisposing risk factors among 8-13 years school children of Vadodara city: An epidemiological study

1 Department of Pedodontics and Preventive Dentistry, Karnavati School of Dentistry, Uvarsad, Gandhinagar, India
2 Department of Pedodontics and Preventive Dentistry, K.M.Shah Dental College and Hospital, Waghodia, Vadodara, Gujarat, India

Date of Web Publication23-Aug-2012

Correspondence Address:
M C Patel
47, Swami Akhandanand Soc., Nr. Ranna Park, Ghatlodia, Amdavad-61, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.99992

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Background and objective: dental trauma is an irreversible pathology that after occurrence is characterized by life-long debilitating effects. The objectives of this study were to measure the prevalence of anterior teeth fracture and their association with predisposing factors such as lip coverage, molar relationship, overjet, and variables such as age, sex, cause, and place of trauma. Materials and Methods: an epidemiological cross-sectional study was carried out among 3708 school children aged 8-13 years in the Vadodara city. All children completed a questionnaire related to history of trauma to their anterior teeth after which they were examined for lip competence, Angle's molar relationship amount of overjet and nature of trauma sustained. The results were statistically analyzed using the prevalence test, Chi-square test, and Mantel-Haenszel Common Odds Ratio. Results: the prevalence of traumatic injuries was 8.79% and the ratio of boys: girl's was 1.28:1. Inadequate lip coverage group sustained about five times more injuries than the adequate lip coverage group (P = 0.000, OR= 5.407). The maximum traumatic injuries were seen in children having Angle Class II Div 1 molar relationship and/or overjet greater than 5.5 mm and was statistically significant (P<0.05). Maximum number of injuries occurred at 9 years of age. The most predominant injuries were enamel fractures, the most common place for occurrence was home and fall against object, the most frequent cause. Conclusion: the prevalence of dental injuries in the Vadodara city is high and it has a great potential to be considered as an emerging public health problem.

Keywords: Predisposing factors, prevalence, trauma.

How to cite this article:
Patel M C, Sujan S G. The prevalence of traumatic dental injuries to permanent anterior teeth and its relation with predisposing risk factors among 8-13 years school children of Vadodara city: An epidemiological study. J Indian Soc Pedod Prev Dent 2012;30:151-7

How to cite this URL:
Patel M C, Sujan S G. The prevalence of traumatic dental injuries to permanent anterior teeth and its relation with predisposing risk factors among 8-13 years school children of Vadodara city: An epidemiological study. J Indian Soc Pedod Prev Dent [serial online] 2012 [cited 2022 Sep 27];30:151-7. Available from: http://www.jisppd.com/text.asp?2012/30/2/151/99992

   Introduction Top

One of the greatest assets a person can have is a "smile" that shows beautiful, natural teeth. An untreated and unsightly fracture of an anterior tooth can affect the behavior of a child, his progress in school, and can have more impact on their daily living. [1] Traumatic dental injury has become the most serious dental public health problem in children since a remarkable decline in the prevalence and severity of dental caries in many countries. [2]

In the Gujarat state, no published literature is available on etiology and the prevalence of traumatic injuries to anterior teeth in mixed dentition period. Hence, this study was carried to determine the prevalence of fractured anterior teeth and its relation with predisposing risk factors among 8-13 years school children of the Vadodara city.

   Materials and Methods Top

A cross-sectional survey was carried out with 3708 school-children aged 8 to 13 years, of both sexes attending primary and secondary schools of the Vadodara city. A prevalence of dental injury of average 10% was presumed for the calculation of the sample size referring to various studies. [3],[4],[5],[6],[7] The minimum sample size to satisfy the requirement was estimated to be 3600 children. The sample size was calculated using following formula. [8]

n = 4pq/l 2 where P = positive character (assumed prevalence) = 10%

q = 100-p = 90, l = allowable error = 10% of P = 1

A multistage sampling technique was adopted to select the children. The map of the Vadodara city was procured and was divided into five zones namely, north, east, west, south, and central zone. The first stage-unit comprised of all private and public primary and secondary schools of Vadodara city. Two schools from each zone were selected at random and an equal probability scheme was adopted by sampling with a probability proportional to the school size. The second stage comprised children within the selected schools. At least 370 children were randomly selected from each school taking care of selecting almost equal or similar number of boys and girls. Before examining the children the consent was obtained from the concerned authorities of education department and principal of respective schools of the Vadodara city.

The children who had entered 8th or 13th year on their last birthday and in whom permanent anteriors had erupted were included in this study. Children who were undergoing or had finished orthodontic treatment or children in whom the permanent anterior teeth had not yet erupted were excluded. Also, the children in whom the permanent anteriors were lost due to caries or cause other than trauma or those having partial/complete anodontia involving permanent anteriors were not included in the said study.

A closed-ended proforma was prepared to collect data. The ADA type-3 technique [9] was used for examination. The age at which injury occurred, type of damage sustained, the size of incisal overjet, lip coverage, and Angle's molar relationship were recorded. CPI probe was used to measure the degree of overjet as described by the 1997 WHO Basic Oral Health Survey Guidelines. [10] Sociodemographic data included age and sex. Other nonclinical data collected were the causes of dental injury and the place where it occurred.

Andreasen's Epidemiological Classification of Traumatic Injuries to Anterior Teeth including WHO codes [11] was used to assess the traumatic dental injuries to anterior teeth.

Code 0 No injury

Code 1 Treated dental injury

Code 2 Enamel fracture only (N 502.50)

Code 3 Enamel/dentin fracture (N 502.51)

Code 4

Pulp injury (N 502.52, N 502.53, N 502.54, N 503.20, N 503.21)

Code 5 Missing tooth due to trauma (N 503.22)

Code 9 Excluded tooth

Root fractures were not considered in the study, since no radiographs were taken.

The survey data were coded and entered onto a PC. All the results were analyzed using "Statistical Package for Social Sciences" (SPSS) 12.0 software. Data analysis included descriptive statistics (frequency distribution and cross tabulation). Chi-square test was employed to compare qualitative data and determine the statistical significance. The level of statistical significance was set at P<0.05. The strength of association between the variable (lip coverage, molar relationship, and incisal overjet) and outcome was calculated using the Mantel-Haenszel Common Odds Ratio.

   Observation and Results Top

On examination of 3708 school children it was seen that 326 (8.79%) children sustained traumatic injuries to anterior teeth and this was statistically significant (P=0.029). The ratio of prevalence between boys and girls was 1.28:1 [Table 1]. Children between 8-10 years of age appeared to be the most prone to injuries, with the peak occurrence at 9 years of age (29.14%) [Figure 1].
Figure 1: Bar diagram showing age in years at which trauma occurred

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Table 1: Prevalence and boys: girl's ratio for anterior teeth fracture

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Children with adequate lip coverage showed less number of injuries (5.32%) as compared to those with inadequate lip coverage (24.19%) [Figure 2]. Also, children having inadequate lip coverage were 5.4 times more prone to injuries as compared to adequate lip coverage (OR=5.407, 95% CI, P=0.000) [Table 2]. Hence, inadequate lip coverage was identified as the most important and an independent risk predictor for traumatic injuries to permanent anterior teeth. The number of children with injured teeth was highest in Class II Div 1 (16.07%) occlusion and least in Class II Div 2 (3.90%) [Figure 3]. Also, in children having Class II Div 1 occlusion , 2.05 times greater chance of experiencing anterior tooth injury was found as compared to those having Class I (OR=2.05 at 95% CI, P=0.001) [Table 2]. The maximum injuries occurred in children with overjet >5.5 mm (22.22%) followed by those having 3.6-5.5 mm (20%) [Figure 4]. With an odds ratio of 3.917 (95% CI, P=0.000) [Table 2], overjet > 5.5 mm was identified as an important risk factor for traumatic dental injury when compared to normal overjet.
Figure 2: Bar diagram showing the frequency distribution of percentage of children with traumatized teeth in relation to lip coverage

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Figure 3: Bar diagram showing the frequency distribution of percentage of children with traumatized teeth in relation to Angle's molar relationship

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Figure 4: Bar diagram showing the frequency distribution of percentage of children with traumatized teeth in relation to degree of overjet

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Table 2: Mantel-Haenszel common odds ratio estimate and statistical significance of lip coverage, Angle's molar relationship and overjet

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It was observed that the highest numbers of injuries (43.87%) occurred at home. Playground and school accounted for the second most common place (16.26%). With P value of 0.338, association of place and occurrence of traumatic injury was statistically insignificant [Table 3]. The most frequent cause of trauma to the teeth was inadvertent fall (43.86%). In boys traumatic injuries due to biting hard food (4.92%), whereas, in girls road traffic accident (4.19%) accounted for the least [Table 4]. While assessing the nature of trauma to the teeth, Enamel fracture were recorded the highest (46.7%) followed by Enamel and dentin (35.45%). Using the Chi-square test, the association was not found to be statistically significant (P=0.73) [Table 5]. Of total 326 children with injured anterior teeth, only eight children (five boys and three girls) had received treatment. Majority of the population studied was devoid of any treatment (97.55%) [Figure 5]. The most affected tooth was maxillary central incisors (83%) followed by maxillary laterals (9.05%) [Table 6].
Figure 5: Pie Diagram showing distribution of children with treated or untreated teeth

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Table 3: Distribution and percentage of children with traumatized anterior teeth according to place of occurrence of trauma

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Table 4: Distribution and percentage of children with traumatized anterior teeth according to etiology of sustaining trauma

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Table 5: Nature of injured teeth in children

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Table 6: Distribution of injured teeth in maxillary and mandibular arch

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   Discussion Top

Traumatic dental injury is not a result of disease but a consequence of several factors that will accumulate throughout life if not properly treated. [12]

For this study, children between 8-13 years of age were chosen, as during this period there is the maximum physiologic growth and development and the children are actively involved in lot of outdoor activities. The prevalence of traumatic injuries in this study was 8.79% that corroborates the results of various recent studies. [12],[13] The prevalence noted is higher as compared to the earlier studies done by Gauba [14] (7.54%), Nick Hussein [15] (4.1%) but lower than Pavan Baldava [3] (14.9%), Tandon S [6] (13.8%). Behavioral and cultural diversity may explain differences in findings between countries and also within a country. [16]

In our study the boys : girls ratio was 1.28:1 that showed that males are more prone to traumatic injuries than females and it was found to be statistically significant. Similar findings were observed by many studies. [6],[14],[17] The higher percentage of traumatic injuries in the boys could be attributed to the fact that boys engage in leisure activities or sports of a generally more aggressive nature or with a greater accident risk than the girls do and that they have delayed maturation rates.

The age at which children are most prone to the traumatic injuries should be identified so that the preventive measures can be directed to protect the risk population to a considerable extent. In this study, the peak age to sustain injury was found to be 9 years, in both boys and girls. This survey identified that children between 8-10 years of age were more prone to traumatic injuries to anterior teeth and this is supported by previous studies. [18] During 8-10 years of age maximum physiologic maxillary growth takes place, at the same time this age group exhibits an increased period of outdoor and reckless activities which increase the liability to injury.

Children with inadequate lip coverage had five times more injuries as compared to the other group. Inadequate lip coverage has been shown as an important risk predictor [3],[16],[17] and was found to be a significant determinant for the occurrence of such injuries in this study also. It is suggested that the protective effect of lip closure, in addition to adequate occlusal contact area of maxillary and mandibular teeth in normal occlusion, tends to decrease the impacting force of trauma. [19]

The maximum number of injuries were seen in Angle's Class II Div 1 molar relationship that is similar to earlier observation by Rai SB. [4] Usually the least injuries can be expected in Class III malocclusion. But this study reported the least injuries in Class II Div 2 malocclusion as compared to Class III. This could be because many of the children having Class III malocclusion were found to have edge to edge overjet that made them more susceptible to injury as compared to the incisors (maxillary) which are retroclined in Class II Div 2 malocclusion.

Also, increased overjet has been found to be associated with increased severity of fractures. [20] This study as well as study by Pavan Baldava [3] considered normal overjet in the range of 0-3.5 mm. The said study showed that as the overjet increased from negative overjet to 5.5 mm and more, the percentage of traumatic injuries also increased. An average of 3.5 fold increased risk to sustain trauma to anterior teeth was found in children having overjet greater than 3.5 mm (OR=3.43 at 95% CI). A very slight difference was observed between those having 3.6-5.5 mm and more of overjet. Thus, children having an overjet of more than 3.5 mm (3-4mm) are definitely more prone to injuries. This is confirmed with many other previous studies. [14],[16]

Careful attention should be given while analyzing the type of injury because it can vary according to the place where the study is conducted. Within the hospital setting Andreasen [11] found luxation and bone injuries were more prominent. In our study that was conducted with randomly examined school children presented the enamel fractures as the most common injuries followed by enamel-dentin fractures. These results are supported by many other studies. [4],[13],[17]

The cause of injury can vary according to age, sex, climate and socioeconomic status of the children. In our study, the most common cause of traumatic injuries was "fall" followed by "impact/collisions." Falls caused due to pushing were categorized in violence category because it represented form of aggression. As school children in India play less contact sports (soccer, Ice-hockey, base-ball etc.), it was not found to be the main cause of trauma to the anterior teeth. Similar results were presented by Tandon et al. [6] The percentage of school children that did not remember the cause of trauma were grouped in "cannot recollect" category which was high (8.89%) and could have resulted in the under-reporting of the various etiologic factors. It was observed that most of the injuries occurred at home followed by at school and playground. Our findings agree with many studies. [6],[16] The majority of injuries which occurred at home could be due to the fact that children (especially girls) spend more time at home rather than at school and playground, or may be the injuries have occurred during the vacation time. It may be concluded that preventive programs for the population studied, should be evolved to educate the parents and children primarily, and then the school authorities and sports coaches.

Our study showed that only 2.45% children had received the treatment for trauma. It was prominently seen that even for complicated fractures involving pulp, discoloration, and avulsion; the children had not received any treatment. There is therefore a high unmet treatment need. Lack of adequate knowledge and proper motivation compounded by limitations imposed due to socioeconomic constraints could explain the high percentage of untreated injuries. It was found that single tooth injuries were more than multiple teeth injuries. This was in agreement with many previous studies conducted. [5],[21] Hospital- and institution-based studies have indicated that traumatic injuries involving two teeth were more prevalent than those limited to a single tooth and that the injuries were more severe. It is likely that less severe injuries, such as enamel injury are under-represented in samples derived from hospital settings. [22]

Our study as many other studies [15],[17] found that the majority of injuries occurred in the maxillary central followed by maxillary lateral incisors. This could be due to early eruption of maxillary central incisors than the maxillary lateral incisors and thus are at risk for a longer period of time. Also, injury to maxillary incisors is more frequent than mandibular incisors because blows to mandibular teeth are dissipated due to nonrigid connection of mandible to the cranial base.

   Conclusion Top

The said study observed the children in mixed dentition period as the population at risk. Hence, prevention through health promotion and correction of predisposing risk factors should be carried out in early mixed dentition period to reduce the prevalence of dental injury and to avoid the financial costs of treatment. An effort can be made to reduce the prevalence of traumatic injuries by taking into consideration the following measures.

  • The use of intraoral and extraoral devices which protects the face and teeth from trauma.
  • Elimination or reduction of predisposing factors in the form of orthodontic treatment.
  • Educational programs where by the children and their parents are given information regarding the preventive and treatment aspects of this commonly occurring condition.
  • Health promotion policies should aim to create an appropriate and safe environment.

   References Top

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2.Petersson HG, Bratthall D. The caries decline: A review of reviews. Eur J Oral Sci 1996;104:436-43.  Back to cited text no. 2
3.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.   Back to cited text no. 3
4.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.  Back to cited text no. 4
5.Marcenes W, al Beiruti N, Tayfour D, Issa S. Epidemiology of traumatic injuries to the permanent incisors of 9 to 12-year-old school childrenin Damascus, Syria. Endod Dent Traumatol 1999;15:117-23.  Back to cited text no. 5
6.Gupta K, Tandon S, Prabhu D. Traumatic injuries to the incisors in children of South Canara District. A prevalence study. J Indian Soc Pedod Prev Dent 2002;20:107-15.  Back to cited text no. 6
7.Traebert J, Almeida IC, Marcenes W. Etiology of traumatic dental injuries in 11 to 13-year-old schoolchildren. Oral Health Prev Dent 2003;1:317-23.  Back to cited text no. 7
8.Mahajan BK. Methods in Biostatistics (For Medical students and research workers) 6 th edn. New Delhi: Jaypee brothers. Medical Publisher Ltd.1997;6:93  Back to cited text no. 8
9.Hiremath SS. Textbook of Preventive and Community dentistry. Amsterdam: Elsevier. 2007;16:173  Back to cited text no. 9
10.World health organization. Oral health survey basic methods. 4 th ed. WHO: Geneva; 1997.  Back to cited text no. 10
11.Andreasen J, Andreasen FM. Textbook and color atlas of traumatic injuries to the teeth. 4 rd ed. Copenhagen: Munskgaard International Publishers; 2004.  Back to cited text no. 11
12.Soriano EP, Caldos Jr AF, Carvalloh MV, Amorium Filho HA. Prevalence and risk factors related to traumatic dental injuries in Brazilian school children. Dent Traumatol 2007;23:232-40.  Back to cited text no. 12
13.Lin H, Naidoo S. Causes and prevalence of traumatic injuries to the permanent incisors of school children aged 10-14 years in Maseru, Lesotho. SADJ 2008;63:152, 154-6.  Back to cited text no. 13
14.Gauba ML. A correction of fractured anterior teeth to their proclination. JIDA 1967;12:105-12.  Back to cited text no. 14
15.Nik-Hussein NN. Traumatic injuries to anterior teeth among school children in Malaysia. Dent Traumatol 2001;17:149-52.  Back to cited text no. 15
16.Bastone Eb, Freer TJ, McNamara JR. Epidemiology of dental trauma-A review of literature. Aust Dent J 2000;45:2-9.  Back to cited text no. 16
17.Ravishankar TL, Kumar MA, Ramesh N, Chaitra TR. Prevalence of traumatic dental injuries to permanent incisors among 12 year old school children in Davangere, South India. Chin J Dent Res 2010;13:57-60.  Back to cited text no. 17
18.Rocha MJ, Cardoso M. Traumatized permanent teeth in children assisted at the Federal University of Santa Catarina, Mariane Cardoso Brazil. Dent Traumatol 2001;17:245-9.  Back to cited text no. 18
19.Jariven S. Incisal overjet and traumatic injuries to upper permanent incisors. A retrospective study. Acta Odontol Scand 1978;36:359-62.  Back to cited text no. 19
20.Nguyen QV, Bezemer PD, Habets L, Prahl-Andersen B. A systematic review of the relationship between overjet size and traumatic dental injuries.. Eur J Orthod 1999;21:503-15.  Back to cited text no. 20
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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