Dental Traumatology 2015; 31: 471–476; doi: 10.1111/edt.12184
Dental trauma in Brazilian children and adolescents with cerebral palsy Andreia Medeiros Rodrigues Cardoso1, Clara Regina Duarte brega Gomes2, Silva2, Lays No brega Cesarino Monalisa da No Gomes1, Wilton Wilney Nascimento Padilha2, Alessandro Leite Cavalcanti1 1 Department of Dentistry, Faculty of Dentistry, State University of Paraiba, Campina Grande, PB, Brazil; 2Department of Dentistry, Faculty of Dentistry, Federal University of Paraiba, Cidade ria, Joa ~o Pessoa, PB, Brazil Universita
Key words: Dental trauma; Cerebral palsy; Epidemiology; Prevalence Correspondence to: Alessandro Leite Cavalcanti, Department of Dentistry, Faculty of Dentistry, State University of Paraiba, Avenida das Baraunas, S/N, Bodocongo, 58429-500 Campina Grande, PB, Brazil Tel.: +55 83 33153326 Fax: +55 83 331153355 e-mail: [email protected] Accepted 9 December, 2014
Abstract – Background: Assessing the frequency and factors associated with dental trauma in pediatric populations with cerebral palsy is important for the planning and implementation of prevention and health promotion programs. The aim of this study was to determine the prevalence and factors associated with dental trauma in children and adolescents with cerebral palsy. Material and methods: Cross-sectional study with a nonprobabilistic sample of 80 patients aged 2–18 years was treated in a rehabilitation institution in northeastern Brazil. Caregivers completed a socioeconomic questionnaire, while oral exams were performed by a calibrated investigator (K = 0.75–1.00), with record of the Dental Trauma Index, DMFT and dmft, and Dental Aesthetics and malocclusion indices. Bivariate and multivariate Poisson regression analyses (a = 0.05) were performed with the Statistical Package for Social Sciences, version 17. Results: The prevalence of dental trauma was 36.3%, enamel fracture was the most common trauma (89.1%), and the upper central incisors were the most affected dental elements (63.0%). Patients with dental trauma were male, aged 7–18 years, with family income more than one minimum wage, caregiver’s education over 4 years, increased overjet, lip hypotonia, quadriplegia, epilepsy, oral breathing, and severe communication skills. The presence of dental trauma was not associated with socioeconomic characteristics (gender, age, family income, and caregiver’s educational level), oral health perception, and systemic and oral conditions (dental caries, malocclusion, and lip hypotonia) were evaluated (P > 0.05). Conclusion: The prevalence of dental trauma was high, but not associated with clinical variables and evaluated socioeconomic indicators.
Cerebral palsy (CP) is a neurological disorder with an overall prevalence of 2.11 per 1000 live births (1). It is defined as a set of non-progressive developmental disorders of movement and posture caused by a damage that occurred during the formation of fetal or infant brain (2). These motor disorders are often accompanied by sensation, cognition, communication, behavior, and convulsive alterations (2, 3), which represent constraints for the performance of daily living activities such as eating, mobility, and general hygiene (4, 5). Epidemiological studies have shown that the more severe the neurological damage in individuals with CP, the greater the risk of dental trauma (6–8). The high prevalence of dental trauma found is due to physical and mental disabilities that reduce their defensive reflexes (7, 9), although children and adolescents with CP participate less often in sports activities (7, 9). This oral problem, in addition to causing pain and loss of function in teeth and periodontal tissues (10), can influence the lives of these individuals, bringing functional, esthetic, psychological, and social damage (11, 12). There are several studies with individuals with CP in literature evaluating aspects related to dental caries (6, 8, 13–15), periodontal tissue status (13, 16), and oral © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
hygiene (13, 16). With regard to dental trauma, few studies have analyzed its prevalence (5, 7, 17, 18) and association with demographic (7, 17, 18) and systemic factors (7, 17, 18), referring to dental malocclusion (7, 18), and there are no studies assessing factors such as socioeconomic status, perception, communication, dental caries, and open bite. Given the high frequency of dental trauma and the negative impact that this injury has on the population with CP, there is the need to determine its prevalence and possible associated social, oral, and systemic factors to plan and develop preventive actions. Therefore, the aim of this study was to determine the prevalence and factors associated with dental trauma in children and adolescents with CP. Material and methods Study population
This cross-sectional study was conducted in the city of Campina Grande, state of Paraıba, Brazil. The city has approximately 385 213 inhabitants and Human Development Index of 0.72 (19). 471
472
Cardoso et al.
Inclusion criteria were as follows: children and adolescents aged 2–18 years diagnosed with CP enrolled at APAE; primary caregivers, aged >18 years, defined as responsible for making decisions and carrying out the daily activities of people with CP (14). Exclusion criteria were children with history of orthodontic intervention and primary caregivers who were performing this activity for 4 years of school Family income ≤1 minimum wage >1 minimum wage Total
n
(%)
42 38
52.5 47.5
22 37 21
27.5 46.3 26.2
45 23 12
56.2 28.8 15.0
60 18 2
75.0 22.5 2.5
18 62
22.5 77.5
27 53 80
33.8 66.3 100.0
Table 2. Distribution of children and adolescents with CP according to the presence of dental trauma, affected teeth, and type of trauma Frequency Variables Dental trauma (n = 80) Present Absent Number of affected teeth (n = 29) One Two or more Affected teeth (n = 46) Upper central incisors Upper lateral incisors Lower central incisors Lower lateral incisors Type of injury (per tooth; n = 46) Enamel fracture Enamel and dentin fracture Crown fracture Extrusive luxation Lateral luxation Intrusive luxation Avulsion More than one trauma
n
(%)
29 51
36.3 63.7
15 14
51.7 48.3
29 11 2 4
63.0 23.9 4.4 8.7
41 3 2 0 0 0 0 0
89.1 6.5 4.5 0.0 0.0 0.0 0.0 0.0
In the bivariate analysis, none of the independent variables was associated with the presence of dental trauma in children and adolescents with CP (Table 3). However, variables such as gender, age, perceived oral health, family income, type of breathing, and communication skills of children and adolescents were © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Discussion
This study evaluated the prevalence and factors associated with dental trauma in children and adolescents with cerebral palsy, and this is probably one of the few studies carried out in Brazil with the aim of investigating, in these individuals, its association with social, systemic, and oral factors. Despite having used a nonprobability sample, it is also important to highlight the number of subjects examined (eighty), well above other Brazilian (7, 26) and foreign (9, 13) studies. In the present study, the prevalence of dental trauma was 36.3%, similar to results reported in China (13) and India (18), but higher than the prevalence found in other Brazilian studies (5, 11, 17). These differences show that the prevalence of dental trauma can vary between countries and regions within the same country, being related to age, diagnosis criteria, and size and methods of sample selection (5, 17, 18). The high prevalence of TDI found in this study can be explained by the presence of involuntary movements and the presence of primitive reflexes such as spasticity, slow responses to surrounding obstacles, and reflections during chewing and swallowing in patients with CP (5). Upper central incisor was the most affected dental element (63.0%), similar to that reported by other studies (5, 17). This higher prevalence of upper anterior teeth is hypothetically related to their anatomical position, with slight inclination toward the lips, and may not be protected due to lip hypotonia (27, 28), a clinical condition commonly observed in patients with abnormal muscle tone, as in patients with CP (7, 17). Enamel fracture was the most frequent dental trauma, corroborating previous studies (17, 18), which can be attributed to the lack of motor coordination of these patients, restricting their movement and reducing the prevalence of severe dental trauma (17). These injuries often occur at home due to involuntary movements of the head and upper limbs and falls during the performance of daily activities (18). In the pediatric population, the most common causes of dental injuries are falls, collisions, car accidents, and convulsion (27). Nevertheless, some oral factors, if present in these situations, can facilitate the occurrence of dental trauma such as dental caries (27, 29), overjet (18, 27, 29), and lip hypotony (7). In the present work, the presence of dental trauma in children and adolescents with CP was not associated with gender, age, caregiver education, family income, perceived oral health, dental caries, open bite, overjet, lip hypotonia, type of CP (tetraparesy, diparesis, and hemiparesis), epilepsy, type of breathing (nasal or oral), and communication skills, and these results are similar to those obtained by other authors (17). Some studies have assessed dental trauma in individuals with CP and observed its association with the clinical condition of CP (7), lip hypotonia (7), increased overjet (18), and type of CP (18); however, comparisons
474
Cardoso et al.
Table 3. Distribution of children and adolescents with CP in bivariate and multivariate Poisson regression models for the presence of dental trauma and independent variables Dental trauma
Variable Gender Male Female Age 2–6 years 7–18 years Caregiver’s educational level ≤ 4 years of school >4 years of school Family income ≤ 1 minimum wage > 1 minimum wage Oral health perception Good Poor Dental caries in incisive teeth Absent Present Open bite Absent Present Overjet (Deciduous and mixed) ≤ 2 mm >2 mm Overjet (permanent) ≤ 3 mm >3 mm Lip hypotonia Absent Present Location of CP Tetraparesy vs Diparesis vs Hemiparesis Epilepsy Absent Present Type of breathing Nasal Oral Communication skills Normal Mild vs Moderate vs Severe vs
Absent n (%)
Present n (%)
24 (57.1) 27 (71.7)
18 (42.9) 11 (28.9)
17 (77.3) 34 (58.6)
5 (22.7) 24 (41.4)
12 (66.7) 39 (62.9)
Bivariate
Multivariate
Not adjusted RP1
Adjusted RP
2,3
P-value
(CI 95%)
P-value
(CI 95%)
0.206
1.48 (0.806–2.720) 1.00
– –
– –
0.157
1.00 0.54 (0.240–1.259)
– –
– –
6 (33.3) 23 (37.1)
0.774
1.00 0.89 (0.433–1.863)
– –
– –
20 (74.1) 31 (58.5)
7 (25.9) 22 (48.5)
0.196
1.00 0.62 (0.306–1.274)
– –
– –
40 (68.8) 11 (52.4)
19 (32.2) 10 (47.6)
0.187
1.00 0.67 (0.378–1.210)
– –
– –
41 (62.1) 10 (71.4)
25 (37.9) 4 (28.6)
0.532
1.32 (0.548–3.209) 1.00
– –
– –
23 (60.5) 24 (68.6)
15 (39.5) 11 (31.4)
0.477
1.25 (0.670–2.354) 1.00
– –
– –
8 (61.5) 21 (65.6)
5 (38.5) 11 (34.4)
0.793
1.12 (0.484–2.586) 1.00
– –
– –
4 (80.0) 14 (53.8)
1 (20.0) 12 (46.2)
0.363
1.00 0.43 (0.072–2.626)
– –
– –
13 (72.2) 38 (61.3)
5 (27.8) 24 (38.7)
0.428
1.00 0.72 (0.320–1.610)
– –
– –
27 (60.0) 15 (65.2) 9 (75.0)
18 (40.0) 8 (34.8) 3 (25.0)
1.60 (0.564–4.542) 1.39 (0.450–4.301) 1.00
– – –
– – –
21 (67.7) 30 (61.2)
10 (32.3) 19 (38.8)
0.561
1.00 0.83 (0.448–1.546)
– –
– –
17 (81.0) 34 (57.6)
4 (19.0) 35 (42.4)
0.092
1.00 0.45 (0.177–1.140)
– –
– –
5 10 32 4
1 10 13 5
0.210 0.777 0.084
1.00 0.30 (0.460–1.970) 0.90 (0.434–1.868) 0.52 (0.247–1.093)
– – – –
– – – –
(83.3) (50.0) (71.1) (44.4)
(16.7) (50.0) (28.9) (55.6)
0.377 0.566
1
Poisson regression not adjusted for independent variables and presence of dental trauma. Multivariate Poisson regression adjusted for the presence of dental trauma and demographic, socioeconomic, perception, oral, and systemic characteristics (independent variables) by the backward stepwise procedure. 3 Variables incorporated in the multivariate model (P < 0.20): gender, age, perceived oral health, family income, type of breathing, and communication skills. 2
with the results of these studies should be made with caution due to different methodological procedures, sizes, and sample selection criteria adopted. The clinical condition of CP was associated with dental trauma (7), which is probably explained by the lack of coordination of body movements and changes in muscular tone resulting from brain injury, which causes involuntary movements or reflexes and consequently falls that can lead to teeth and periodontal
injuries (2, 3). However, the social, systemic, and oral characteristics evaluated in the group of children and adolescents with CP in this study were not associated with this condition. No association was found between TDI overjet and lip coverage. It is a consensus in the literature (18, 27, 30) regarding the association between these variables, and observing the results of the bivariate analysis, we found that most children with TDI had pronounced © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Dental trauma in children with cerebral palsy overjet and inadequate coverage. This lack of association could be explained by the sample size. In a previous study, the presence of lip hypotony was also associated with dental trauma (7). Lip seal favors the protection of the anterior teeth during the involuntary movements of children with CP (7). It is important to report that the association with lip seal was observed in a sample of children with CP and without CP (7), making the comparison of these results impossible as the present study evaluated exclusively children and adolescents with CP. The socioeconomic factors evaluated in this study showed no associated with dental trauma, confirming previous findings (7, 18). In literature, the relationship of educational level of caregivers of children with CP with dental trauma has been little studied and revealed no association (7). Other variables such as family income and caregiver’s perception about the oral health of children/adolescents with CP showed no association. These findings can be explained by the fact that dental trauma of these individuals is the result of involuntary movements that occur regardless of the different social conditions of patients. The literature shows that the search for dental trauma treatment may be influenced by social factors (7, 17). The population of this study had family income above US$ 27 400, because they received provisions for low-income people with disabilities from governmental programmes; however, they lived in distant neighborhoods and other cities, making use of public transport to attend appointments at the rehabilitation institution, as well as to visits to the dentist. Therefore, it is possible that dental injuries have been ignored by parents or guardians and they have not sought dental care immediately after trauma due to the travel distance, transport costs, and difficulties of transportation and management of patients in treatment centers (7, 17), justifying the high prevalence of untreated lesions found. The literature shows that the time elapsed between dental trauma and dental care ranges from 3 h to 5 years (31). Thus, it is known that involuntary movements and permanence of primitive reflexes can occur in patients with CP and result in dental trauma without association with social, systemic, and oral characteristics of children and adolescents in this group, from these results. However, this study has limitations that affect the interpretation of results such as its cross-sectional design that limits the cause and effect inferences, demonstrating exclusively the presence or absence of associations. In addition, sample size was not calculated. Given the above, further studies seeking to verify the characteristics of patients with CP influencing the presence of dental trauma should be conducted, especially longitudinal and case control studies with larger sample sizes and selection criteria similar to existing studies, in which comparisons can be made. Methods were difficult to achieve due to the limited number and characteristics of patients with CP in some study populations. These results also indicate the need for greater attention by health professionals and caregivers of children and adolescents with CP in relation to the adoption of preventive measures (7, 17) such as padding objects © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
475
and hard surfaces and the safe transportation of these individuals in chairs wheels. Furthermore, pediatric dentists can refer these patients for treatment of motor orofacial dysfunction and increased overjet. Conclusion
Patients with CP showed high prevalence of dental trauma, but none of the studied factors were associated to this condition. Acknowledgments
The authors would like to thank all the children and adolescents with CP and caregivers who participated in the study, directors of the study sites, and local authorities. Acknowledgments are also due to Prof. Ana Maria Gondim Valenca who assisted during Training and Calibration Process. This study was supported by the National Council for Scientific and Technological Development (CNPq), the State University of Paraiba, the Federal University of Paraiba, and the Brazilian Coordination of Higher Education, Ministry of Education (CAPES). Conflict of interests
The authors declare that there is no conflict of interests regarding the publication of this paper. References 1. Oskoui M, Coutinho F, Dykeman J, Jett N, Pringsheim T. An update on the prevalence of cerebral palsy: a systematic review and meta-analysis. Dev Med Child Neurol 2013;55:509–19. 2. Bax M, Goldstein M, Rosebaum P, Leviton A, Paneth N, Dan B et al. Proposed definition and classification of cerebral palsy. Dev Med Child Neurol 2005;47:571–6. 3. Graham HK. Classifying cerebral palsy. J Pediatr Orthop 2005;25:127–8. 4. Abanto J, Ortega AOL, Raggio DP, B€ onecker M, Mendes FM, Ciamponi AL. Impact of oral diseases and disorders on oral-health-related quality of life of children with cerebral palsy. Spec Care Dentist 2014;34:56–63. 5. Santos MTBR, Souza CBC. Traumatic dental injuries in individuals with cerebral palsy. Dent Traumatol 2009;25:290–4. 6. Santos MTBR, Guare RO, Celiberti P, Siqueira WL. Caries experience in individuals with cerebral palsy in relation to oromotor dysfunction and dietary consistency. Spec Care Dentist 2009;29:198–203. 7. Miamoto CB, Ramos-Jorge ML, Ferreira MC, Oliveira M, Vieira-Andrade RG, Marques LS. Dental trauma in individuals with severe cerebral palsy: prevalence and associated factors. Braz Oral Res 2011;25:319–23. 8. Santos MT, Ferreira MC, Mendes FM, Guare RO. Assessing salivary osmolality as a caries risk indicator in cerebral palsy children. Int J Paediatr Dent 2013;23:55–9. 9. Holan G, Peretz B, Efrat J, Shapira Y. Traumatic injuries to the teeth in young individuals with cerebral palsy. Dent Traumatol 2005;21:65–9. 10. Andreasen JO, Andreasen FM, Andersson L. Textbook and color atlas of traumatic injuries to the teeth. Copenhagen, Denmark: Munskgaard International Publishers; 2007. 11. Aldrigui JM, Abanto J, Carvalho TS, Mendes FM, Wanderley MT, B€ onecker M et al. Impact of traumatic dental
476
12.
13.
14.
15.
16.
17.
18.
19.
20. 21.
Cardoso et al. injuries and malocclusions on quality of life of young children. Health Qual Life Outcomes 2011;9:1–7. Viegas CM, Scarpelli AC, Carvalho AC, Ferreira FM, Pordeus IA, Paiva SM. Impact of traumatic dental injury on quality of life among Brazilian preschool children and their families. Pediatr Dent 2012;36:300–6. Du RY, Mcgrath C, Yiu CK, King NM. Oral health in preschool children with cerebral palsy: a case-control community-based study. Int J Paediatr Dent 2010;20:330–5. Santos MTBR, Biancardi M, Guare RO, Jardim JR. Caries prevalence in patients with cerebral palsy and the burden of caring for them. Spec Care Dentist 2010;30:206–10. Roberto LL, Machado MG, Resende VLS, Castilho LS, Abreu MHNG. Factors associated with dental caries in the primary dentition of children with cerebral palsy. Braz Oral Res 2012;26:471–7. Kumar S, Sharma J, Duraiswamy P, Kulkarni S. Determinants for oral hygiene and periodontal status among mentally disabled children and adolescents. J Indian Soc Pedod Prev Dent 2009;27:151–7. Costa MM, Afonso RL, Ruviere DB, Aguiar SB. Prevalence of dental trauma in patients with cerebral palsy. Spec Care Dentist 2008;28:61–4. Jalihal S, Nagarajappa R, Sharda A, Asawa K, Tak M. Assessment of dental trauma among cerebral palsy individuals in Udaipur city. Dent Traumatol 2012;28:448–51. IBGE @ CITIES. Ministry of Planning, Budget and Management. Available at: http://www.ibge.gov.br/cidadesat/. Accessed on 12 May 2014. World Health Organization. Oral health surveys. Basic methods, 4th edn. Geneva: WHO; 1997. Dickinson HO, Parkinson KN, Ravens-Sieberer U, Schirripa G, Thyen U, Arnaud C. Self-reported quality of life of 8-12year-old children with cerebral palsy: a cross-sectional European study. Lancet 2007;369:2171–8.
22. Ballard MB. A statistical study of 200 cases with ten or more years interval between pregnancies. Bull Sch Med Univ Md 1953;38:66–73. 23. Abanto J, Carvalho TS, B€ onecker M, Ortega AOL, Ciamponi AL, Raggio DP. Parental reports of the oral health-related quality of life of children with cerebral palsy. BMC Oral Health 2012;12:2–8. 24. Foster TD, Hamilton MC. Occlusion in the primary dentition: study of children at 21 to 3 years of age. Br Dent J 1969;126:76–9. 25. World Health Organization. Oral health surveys: basic methods, 3rd edn. Geneva: ORH/EPID; 1987. 26. Ferreira MCD, Guare RO, Prokopowitsch I, Santos MTBR. Prevalence of dental trauma in individuals with special needs. Dent Traumatol 2011;27:113–6. 27. 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. 28. Wendt FP, Torriani DD, Assuncß~ao MC, Romano AR, Bonow ML, Costa CT et al. Traumatic dental injuries in primary dentition: epidemiological study among preschool children in South Brazil. Dent Traumatol 2010;26:168–73. 29. Artun J, Behbehani F, Al-Jame B, Kerosuo H. Incisor trauma in an adolescent Arab population: prevalence, severity, and occlusal risk factors. Am J Orthod Dentofacial Orthop 2005;128:347–52. 30. Francisco SS, Filho FJ, Pinheiro ET, Murrer RD, Jesus Soares A. Prevalence of traumatic dental injuries and associated factors among Brazilian schoolchildren. Oral Health Prev Dent 2013;11:31–8. 31. Jesus MA, Antunes LA, Risso PDA, Freire MV, Maia LC. Epidemiologic survey of traumatic dental injuries in children seen at the Federal University of Rio de Janeiro, Brazil. Braz Oral Res 2010;24:89–94.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Dental trauma in Brazilian children and adolescents with cerebral palsy Andreia Medeiros Rodrigues Cardoso1, Clara Regina Duarte brega Gomes2, Silva2, Lays No brega Cesarino Monalisa da No Gomes1, Wilton Wilney Nascimento Padilha2, Alessandro Leite Cavalcanti1 1 Department of Dentistry, Faculty of Dentistry, State University of Paraiba, Campina Grande, PB, Brazil; 2Department of Dentistry, Faculty of Dentistry, Federal University of Paraiba, Cidade ria, Joa ~o Pessoa, PB, Brazil Universita
Key words: Dental trauma; Cerebral palsy; Epidemiology; Prevalence Correspondence to: Alessandro Leite Cavalcanti, Department of Dentistry, Faculty of Dentistry, State University of Paraiba, Avenida das Baraunas, S/N, Bodocongo, 58429-500 Campina Grande, PB, Brazil Tel.: +55 83 33153326 Fax: +55 83 331153355 e-mail: [email protected] Accepted 9 December, 2014
Abstract – Background: Assessing the frequency and factors associated with dental trauma in pediatric populations with cerebral palsy is important for the planning and implementation of prevention and health promotion programs. The aim of this study was to determine the prevalence and factors associated with dental trauma in children and adolescents with cerebral palsy. Material and methods: Cross-sectional study with a nonprobabilistic sample of 80 patients aged 2–18 years was treated in a rehabilitation institution in northeastern Brazil. Caregivers completed a socioeconomic questionnaire, while oral exams were performed by a calibrated investigator (K = 0.75–1.00), with record of the Dental Trauma Index, DMFT and dmft, and Dental Aesthetics and malocclusion indices. Bivariate and multivariate Poisson regression analyses (a = 0.05) were performed with the Statistical Package for Social Sciences, version 17. Results: The prevalence of dental trauma was 36.3%, enamel fracture was the most common trauma (89.1%), and the upper central incisors were the most affected dental elements (63.0%). Patients with dental trauma were male, aged 7–18 years, with family income more than one minimum wage, caregiver’s education over 4 years, increased overjet, lip hypotonia, quadriplegia, epilepsy, oral breathing, and severe communication skills. The presence of dental trauma was not associated with socioeconomic characteristics (gender, age, family income, and caregiver’s educational level), oral health perception, and systemic and oral conditions (dental caries, malocclusion, and lip hypotonia) were evaluated (P > 0.05). Conclusion: The prevalence of dental trauma was high, but not associated with clinical variables and evaluated socioeconomic indicators.
Cerebral palsy (CP) is a neurological disorder with an overall prevalence of 2.11 per 1000 live births (1). It is defined as a set of non-progressive developmental disorders of movement and posture caused by a damage that occurred during the formation of fetal or infant brain (2). These motor disorders are often accompanied by sensation, cognition, communication, behavior, and convulsive alterations (2, 3), which represent constraints for the performance of daily living activities such as eating, mobility, and general hygiene (4, 5). Epidemiological studies have shown that the more severe the neurological damage in individuals with CP, the greater the risk of dental trauma (6–8). The high prevalence of dental trauma found is due to physical and mental disabilities that reduce their defensive reflexes (7, 9), although children and adolescents with CP participate less often in sports activities (7, 9). This oral problem, in addition to causing pain and loss of function in teeth and periodontal tissues (10), can influence the lives of these individuals, bringing functional, esthetic, psychological, and social damage (11, 12). There are several studies with individuals with CP in literature evaluating aspects related to dental caries (6, 8, 13–15), periodontal tissue status (13, 16), and oral © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
hygiene (13, 16). With regard to dental trauma, few studies have analyzed its prevalence (5, 7, 17, 18) and association with demographic (7, 17, 18) and systemic factors (7, 17, 18), referring to dental malocclusion (7, 18), and there are no studies assessing factors such as socioeconomic status, perception, communication, dental caries, and open bite. Given the high frequency of dental trauma and the negative impact that this injury has on the population with CP, there is the need to determine its prevalence and possible associated social, oral, and systemic factors to plan and develop preventive actions. Therefore, the aim of this study was to determine the prevalence and factors associated with dental trauma in children and adolescents with CP. Material and methods Study population
This cross-sectional study was conducted in the city of Campina Grande, state of Paraıba, Brazil. The city has approximately 385 213 inhabitants and Human Development Index of 0.72 (19). 471
472
Cardoso et al.
Inclusion criteria were as follows: children and adolescents aged 2–18 years diagnosed with CP enrolled at APAE; primary caregivers, aged >18 years, defined as responsible for making decisions and carrying out the daily activities of people with CP (14). Exclusion criteria were children with history of orthodontic intervention and primary caregivers who were performing this activity for 4 years of school Family income ≤1 minimum wage >1 minimum wage Total
n
(%)
42 38
52.5 47.5
22 37 21
27.5 46.3 26.2
45 23 12
56.2 28.8 15.0
60 18 2
75.0 22.5 2.5
18 62
22.5 77.5
27 53 80
33.8 66.3 100.0
Table 2. Distribution of children and adolescents with CP according to the presence of dental trauma, affected teeth, and type of trauma Frequency Variables Dental trauma (n = 80) Present Absent Number of affected teeth (n = 29) One Two or more Affected teeth (n = 46) Upper central incisors Upper lateral incisors Lower central incisors Lower lateral incisors Type of injury (per tooth; n = 46) Enamel fracture Enamel and dentin fracture Crown fracture Extrusive luxation Lateral luxation Intrusive luxation Avulsion More than one trauma
n
(%)
29 51
36.3 63.7
15 14
51.7 48.3
29 11 2 4
63.0 23.9 4.4 8.7
41 3 2 0 0 0 0 0
89.1 6.5 4.5 0.0 0.0 0.0 0.0 0.0
In the bivariate analysis, none of the independent variables was associated with the presence of dental trauma in children and adolescents with CP (Table 3). However, variables such as gender, age, perceived oral health, family income, type of breathing, and communication skills of children and adolescents were © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Discussion
This study evaluated the prevalence and factors associated with dental trauma in children and adolescents with cerebral palsy, and this is probably one of the few studies carried out in Brazil with the aim of investigating, in these individuals, its association with social, systemic, and oral factors. Despite having used a nonprobability sample, it is also important to highlight the number of subjects examined (eighty), well above other Brazilian (7, 26) and foreign (9, 13) studies. In the present study, the prevalence of dental trauma was 36.3%, similar to results reported in China (13) and India (18), but higher than the prevalence found in other Brazilian studies (5, 11, 17). These differences show that the prevalence of dental trauma can vary between countries and regions within the same country, being related to age, diagnosis criteria, and size and methods of sample selection (5, 17, 18). The high prevalence of TDI found in this study can be explained by the presence of involuntary movements and the presence of primitive reflexes such as spasticity, slow responses to surrounding obstacles, and reflections during chewing and swallowing in patients with CP (5). Upper central incisor was the most affected dental element (63.0%), similar to that reported by other studies (5, 17). This higher prevalence of upper anterior teeth is hypothetically related to their anatomical position, with slight inclination toward the lips, and may not be protected due to lip hypotonia (27, 28), a clinical condition commonly observed in patients with abnormal muscle tone, as in patients with CP (7, 17). Enamel fracture was the most frequent dental trauma, corroborating previous studies (17, 18), which can be attributed to the lack of motor coordination of these patients, restricting their movement and reducing the prevalence of severe dental trauma (17). These injuries often occur at home due to involuntary movements of the head and upper limbs and falls during the performance of daily activities (18). In the pediatric population, the most common causes of dental injuries are falls, collisions, car accidents, and convulsion (27). Nevertheless, some oral factors, if present in these situations, can facilitate the occurrence of dental trauma such as dental caries (27, 29), overjet (18, 27, 29), and lip hypotony (7). In the present work, the presence of dental trauma in children and adolescents with CP was not associated with gender, age, caregiver education, family income, perceived oral health, dental caries, open bite, overjet, lip hypotonia, type of CP (tetraparesy, diparesis, and hemiparesis), epilepsy, type of breathing (nasal or oral), and communication skills, and these results are similar to those obtained by other authors (17). Some studies have assessed dental trauma in individuals with CP and observed its association with the clinical condition of CP (7), lip hypotonia (7), increased overjet (18), and type of CP (18); however, comparisons
474
Cardoso et al.
Table 3. Distribution of children and adolescents with CP in bivariate and multivariate Poisson regression models for the presence of dental trauma and independent variables Dental trauma
Variable Gender Male Female Age 2–6 years 7–18 years Caregiver’s educational level ≤ 4 years of school >4 years of school Family income ≤ 1 minimum wage > 1 minimum wage Oral health perception Good Poor Dental caries in incisive teeth Absent Present Open bite Absent Present Overjet (Deciduous and mixed) ≤ 2 mm >2 mm Overjet (permanent) ≤ 3 mm >3 mm Lip hypotonia Absent Present Location of CP Tetraparesy vs Diparesis vs Hemiparesis Epilepsy Absent Present Type of breathing Nasal Oral Communication skills Normal Mild vs Moderate vs Severe vs
Absent n (%)
Present n (%)
24 (57.1) 27 (71.7)
18 (42.9) 11 (28.9)
17 (77.3) 34 (58.6)
5 (22.7) 24 (41.4)
12 (66.7) 39 (62.9)
Bivariate
Multivariate
Not adjusted RP1
Adjusted RP
2,3
P-value
(CI 95%)
P-value
(CI 95%)
0.206
1.48 (0.806–2.720) 1.00
– –
– –
0.157
1.00 0.54 (0.240–1.259)
– –
– –
6 (33.3) 23 (37.1)
0.774
1.00 0.89 (0.433–1.863)
– –
– –
20 (74.1) 31 (58.5)
7 (25.9) 22 (48.5)
0.196
1.00 0.62 (0.306–1.274)
– –
– –
40 (68.8) 11 (52.4)
19 (32.2) 10 (47.6)
0.187
1.00 0.67 (0.378–1.210)
– –
– –
41 (62.1) 10 (71.4)
25 (37.9) 4 (28.6)
0.532
1.32 (0.548–3.209) 1.00
– –
– –
23 (60.5) 24 (68.6)
15 (39.5) 11 (31.4)
0.477
1.25 (0.670–2.354) 1.00
– –
– –
8 (61.5) 21 (65.6)
5 (38.5) 11 (34.4)
0.793
1.12 (0.484–2.586) 1.00
– –
– –
4 (80.0) 14 (53.8)
1 (20.0) 12 (46.2)
0.363
1.00 0.43 (0.072–2.626)
– –
– –
13 (72.2) 38 (61.3)
5 (27.8) 24 (38.7)
0.428
1.00 0.72 (0.320–1.610)
– –
– –
27 (60.0) 15 (65.2) 9 (75.0)
18 (40.0) 8 (34.8) 3 (25.0)
1.60 (0.564–4.542) 1.39 (0.450–4.301) 1.00
– – –
– – –
21 (67.7) 30 (61.2)
10 (32.3) 19 (38.8)
0.561
1.00 0.83 (0.448–1.546)
– –
– –
17 (81.0) 34 (57.6)
4 (19.0) 35 (42.4)
0.092
1.00 0.45 (0.177–1.140)
– –
– –
5 10 32 4
1 10 13 5
0.210 0.777 0.084
1.00 0.30 (0.460–1.970) 0.90 (0.434–1.868) 0.52 (0.247–1.093)
– – – –
– – – –
(83.3) (50.0) (71.1) (44.4)
(16.7) (50.0) (28.9) (55.6)
0.377 0.566
1
Poisson regression not adjusted for independent variables and presence of dental trauma. Multivariate Poisson regression adjusted for the presence of dental trauma and demographic, socioeconomic, perception, oral, and systemic characteristics (independent variables) by the backward stepwise procedure. 3 Variables incorporated in the multivariate model (P < 0.20): gender, age, perceived oral health, family income, type of breathing, and communication skills. 2
with the results of these studies should be made with caution due to different methodological procedures, sizes, and sample selection criteria adopted. The clinical condition of CP was associated with dental trauma (7), which is probably explained by the lack of coordination of body movements and changes in muscular tone resulting from brain injury, which causes involuntary movements or reflexes and consequently falls that can lead to teeth and periodontal
injuries (2, 3). However, the social, systemic, and oral characteristics evaluated in the group of children and adolescents with CP in this study were not associated with this condition. No association was found between TDI overjet and lip coverage. It is a consensus in the literature (18, 27, 30) regarding the association between these variables, and observing the results of the bivariate analysis, we found that most children with TDI had pronounced © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Dental trauma in children with cerebral palsy overjet and inadequate coverage. This lack of association could be explained by the sample size. In a previous study, the presence of lip hypotony was also associated with dental trauma (7). Lip seal favors the protection of the anterior teeth during the involuntary movements of children with CP (7). It is important to report that the association with lip seal was observed in a sample of children with CP and without CP (7), making the comparison of these results impossible as the present study evaluated exclusively children and adolescents with CP. The socioeconomic factors evaluated in this study showed no associated with dental trauma, confirming previous findings (7, 18). In literature, the relationship of educational level of caregivers of children with CP with dental trauma has been little studied and revealed no association (7). Other variables such as family income and caregiver’s perception about the oral health of children/adolescents with CP showed no association. These findings can be explained by the fact that dental trauma of these individuals is the result of involuntary movements that occur regardless of the different social conditions of patients. The literature shows that the search for dental trauma treatment may be influenced by social factors (7, 17). The population of this study had family income above US$ 27 400, because they received provisions for low-income people with disabilities from governmental programmes; however, they lived in distant neighborhoods and other cities, making use of public transport to attend appointments at the rehabilitation institution, as well as to visits to the dentist. Therefore, it is possible that dental injuries have been ignored by parents or guardians and they have not sought dental care immediately after trauma due to the travel distance, transport costs, and difficulties of transportation and management of patients in treatment centers (7, 17), justifying the high prevalence of untreated lesions found. The literature shows that the time elapsed between dental trauma and dental care ranges from 3 h to 5 years (31). Thus, it is known that involuntary movements and permanence of primitive reflexes can occur in patients with CP and result in dental trauma without association with social, systemic, and oral characteristics of children and adolescents in this group, from these results. However, this study has limitations that affect the interpretation of results such as its cross-sectional design that limits the cause and effect inferences, demonstrating exclusively the presence or absence of associations. In addition, sample size was not calculated. Given the above, further studies seeking to verify the characteristics of patients with CP influencing the presence of dental trauma should be conducted, especially longitudinal and case control studies with larger sample sizes and selection criteria similar to existing studies, in which comparisons can be made. Methods were difficult to achieve due to the limited number and characteristics of patients with CP in some study populations. These results also indicate the need for greater attention by health professionals and caregivers of children and adolescents with CP in relation to the adoption of preventive measures (7, 17) such as padding objects © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
475
and hard surfaces and the safe transportation of these individuals in chairs wheels. Furthermore, pediatric dentists can refer these patients for treatment of motor orofacial dysfunction and increased overjet. Conclusion
Patients with CP showed high prevalence of dental trauma, but none of the studied factors were associated to this condition. Acknowledgments
The authors would like to thank all the children and adolescents with CP and caregivers who participated in the study, directors of the study sites, and local authorities. Acknowledgments are also due to Prof. Ana Maria Gondim Valenca who assisted during Training and Calibration Process. This study was supported by the National Council for Scientific and Technological Development (CNPq), the State University of Paraiba, the Federal University of Paraiba, and the Brazilian Coordination of Higher Education, Ministry of Education (CAPES). Conflict of interests
The authors declare that there is no conflict of interests regarding the publication of this paper. References 1. Oskoui M, Coutinho F, Dykeman J, Jett N, Pringsheim T. An update on the prevalence of cerebral palsy: a systematic review and meta-analysis. Dev Med Child Neurol 2013;55:509–19. 2. Bax M, Goldstein M, Rosebaum P, Leviton A, Paneth N, Dan B et al. Proposed definition and classification of cerebral palsy. Dev Med Child Neurol 2005;47:571–6. 3. Graham HK. Classifying cerebral palsy. J Pediatr Orthop 2005;25:127–8. 4. Abanto J, Ortega AOL, Raggio DP, B€ onecker M, Mendes FM, Ciamponi AL. Impact of oral diseases and disorders on oral-health-related quality of life of children with cerebral palsy. Spec Care Dentist 2014;34:56–63. 5. Santos MTBR, Souza CBC. Traumatic dental injuries in individuals with cerebral palsy. Dent Traumatol 2009;25:290–4. 6. Santos MTBR, Guare RO, Celiberti P, Siqueira WL. Caries experience in individuals with cerebral palsy in relation to oromotor dysfunction and dietary consistency. Spec Care Dentist 2009;29:198–203. 7. Miamoto CB, Ramos-Jorge ML, Ferreira MC, Oliveira M, Vieira-Andrade RG, Marques LS. Dental trauma in individuals with severe cerebral palsy: prevalence and associated factors. Braz Oral Res 2011;25:319–23. 8. Santos MT, Ferreira MC, Mendes FM, Guare RO. Assessing salivary osmolality as a caries risk indicator in cerebral palsy children. Int J Paediatr Dent 2013;23:55–9. 9. Holan G, Peretz B, Efrat J, Shapira Y. Traumatic injuries to the teeth in young individuals with cerebral palsy. Dent Traumatol 2005;21:65–9. 10. Andreasen JO, Andreasen FM, Andersson L. Textbook and color atlas of traumatic injuries to the teeth. Copenhagen, Denmark: Munskgaard International Publishers; 2007. 11. Aldrigui JM, Abanto J, Carvalho TS, Mendes FM, Wanderley MT, B€ onecker M et al. Impact of traumatic dental
476
12.
13.
14.
15.
16.
17.
18.
19.
20. 21.
Cardoso et al. injuries and malocclusions on quality of life of young children. Health Qual Life Outcomes 2011;9:1–7. Viegas CM, Scarpelli AC, Carvalho AC, Ferreira FM, Pordeus IA, Paiva SM. Impact of traumatic dental injury on quality of life among Brazilian preschool children and their families. Pediatr Dent 2012;36:300–6. Du RY, Mcgrath C, Yiu CK, King NM. Oral health in preschool children with cerebral palsy: a case-control community-based study. Int J Paediatr Dent 2010;20:330–5. Santos MTBR, Biancardi M, Guare RO, Jardim JR. Caries prevalence in patients with cerebral palsy and the burden of caring for them. Spec Care Dentist 2010;30:206–10. Roberto LL, Machado MG, Resende VLS, Castilho LS, Abreu MHNG. Factors associated with dental caries in the primary dentition of children with cerebral palsy. Braz Oral Res 2012;26:471–7. Kumar S, Sharma J, Duraiswamy P, Kulkarni S. Determinants for oral hygiene and periodontal status among mentally disabled children and adolescents. J Indian Soc Pedod Prev Dent 2009;27:151–7. Costa MM, Afonso RL, Ruviere DB, Aguiar SB. Prevalence of dental trauma in patients with cerebral palsy. Spec Care Dentist 2008;28:61–4. Jalihal S, Nagarajappa R, Sharda A, Asawa K, Tak M. Assessment of dental trauma among cerebral palsy individuals in Udaipur city. Dent Traumatol 2012;28:448–51. IBGE @ CITIES. Ministry of Planning, Budget and Management. Available at: http://www.ibge.gov.br/cidadesat/. Accessed on 12 May 2014. World Health Organization. Oral health surveys. Basic methods, 4th edn. Geneva: WHO; 1997. Dickinson HO, Parkinson KN, Ravens-Sieberer U, Schirripa G, Thyen U, Arnaud C. Self-reported quality of life of 8-12year-old children with cerebral palsy: a cross-sectional European study. Lancet 2007;369:2171–8.
22. Ballard MB. A statistical study of 200 cases with ten or more years interval between pregnancies. Bull Sch Med Univ Md 1953;38:66–73. 23. Abanto J, Carvalho TS, B€ onecker M, Ortega AOL, Ciamponi AL, Raggio DP. Parental reports of the oral health-related quality of life of children with cerebral palsy. BMC Oral Health 2012;12:2–8. 24. Foster TD, Hamilton MC. Occlusion in the primary dentition: study of children at 21 to 3 years of age. Br Dent J 1969;126:76–9. 25. World Health Organization. Oral health surveys: basic methods, 3rd edn. Geneva: ORH/EPID; 1987. 26. Ferreira MCD, Guare RO, Prokopowitsch I, Santos MTBR. Prevalence of dental trauma in individuals with special needs. Dent Traumatol 2011;27:113–6. 27. 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. 28. Wendt FP, Torriani DD, Assuncß~ao MC, Romano AR, Bonow ML, Costa CT et al. Traumatic dental injuries in primary dentition: epidemiological study among preschool children in South Brazil. Dent Traumatol 2010;26:168–73. 29. Artun J, Behbehani F, Al-Jame B, Kerosuo H. Incisor trauma in an adolescent Arab population: prevalence, severity, and occlusal risk factors. Am J Orthod Dentofacial Orthop 2005;128:347–52. 30. Francisco SS, Filho FJ, Pinheiro ET, Murrer RD, Jesus Soares A. Prevalence of traumatic dental injuries and associated factors among Brazilian schoolchildren. Oral Health Prev Dent 2013;11:31–8. 31. Jesus MA, Antunes LA, Risso PDA, Freire MV, Maia LC. Epidemiologic survey of traumatic dental injuries in children seen at the Federal University of Rio de Janeiro, Brazil. Braz Oral Res 2010;24:89–94.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
