Epidemiology of Maxillofacial Injuries in Ontario, Canada Mahmoud Al-Dajani, DDS, MSc, PhD(OMFS), MSc(DPH),* Carlos Qui~ nonez, DMD, MSc, PhD,y Alison K. Macpherson, BA, DipAdm, MSc, PhD,z Cameron Clokie, PhD, DDS, DipABOMS,x and Amir Azarpazhooh, DDS, MSc, PhDk Purpose: The aims of this study were to 1) calculate rates for maxillofacial (MF) injury-related visits in emergency departments (EDs) and hospitals in Ontario, Canada, 2) identify and rank common causes for MF injuries, 3) investigate the variation and trends in MF injuries according to gender, age, and socioeconomic status, and 4) describe the geographic distribution of MF injuries. Materials and Methods:
An 8-year retrospective study design was implemented. The Discharge Abstract Database and the National Ambulatory Care Reporting System datasets were used. After examining demographic and diagnostic information, frequencies, percentages, and rates were calculated. Color-coded maps were created using ArcGIS to display the geographic distribution of MF injuries.
Results:
From 2004 through 2012, 1,457,990 ED visits and 41,057 hospitalizations occurred as a result of MF injury in Ontario. The mean age of patients for each ED visit was 30.6 years and for each hospitalization was 52.6 years. Rates of ED visits and hospitalizations owing to MF injury show a slight decrease during the 8-year period. MF injuries were most frequent in the evening, during the weekends, and during the summer. Falls were reported as the leading cause of MF injuries. Rural areas had higher rates of ED visits and hospitalizations.
Conclusions: This study highlighted the public health impact of MF injuries, offering policy makers important epidemiologic information, which is fundamental to formulate and optimize measures aimed at protecting Canadians from injuries that are largely predictable and preventable. Future injury prevention programs should enhance the population-based approach and focus on high-risk groups such as male youth and elderly women in low-income families. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 73:693.e1-693.e9, 2015
During the past 3 decades, there has been substantial improvement in population oral health, as evidenced by decreases in the prevalence and severity of dental caries.1 This decrease in the incidence of caries, especially in developed countries, has led to growing attention being paid to other oral-related problems
affecting vulnerable populations.1 One of these conditions is maxillofacial (MF) injury. MF injuries, also called MF trauma, include cranial and facial bone fractures, cranial nerve injuries, oral and dental injuries, soft tissue injuries, and associated injuries, mainly of the head, ear, nose, and eye. These injuries are very
*Assistant Professor, Department of Maxillofacial Surgery and
by Dr Al-Dajani in conformity with the requirements for the degree
Diagnostic Sciences, College of Dentistry, Aljouf University,
of Master of Science in Dental Public Health at the Faculty of
Kingdom of Saudi Arabia.
Dentistry, University of Toronto.
yAssociate Professor, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada.
Address correspondence and reprint requests to Dr Al-Dajani: Department of Maxillofacial Surgery and Diagnostic Sciences, Col-
zAssociate Professor, Faculty of Health, York University, Toronto,
lege of Dentistry, Aljouf University, Kingdom of Saudi Arabia;
ON, Canada.
e-mail: [email protected]
xProfessor, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada.
Received October 11 2014 Accepted December 2 2014
kAssistant Professor, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada.
Ó 2015 American Association of Oral and Maxillofacial Surgeons 0278-2391/14/01713-3
Dr Al-Dajani presented an abstract of this study at the Interna-
http://dx.doi.org/10.1016/j.joms.2014.12.001
tional Association for Dental Research General Session; Seattle, WA; March 2013. These results constitute part of a thesis submitted
693.e1
693.e2 common worldwide. Several studies have concluded that MF injury occurs in approximately 5 to 33% of patients experiencing severe trauma.2-4 MF injuries place a heavy burden not only on patients with the injury and their families, but also on the health care system. MF injury management requires pertinent documentation, injury surveillance, and research data that adequately describes the whole spectrum of these injuries.5 Although much of the current literature relating to MF injuries in Ontario has focused on their treatment, very few studies have addressed their etiology or epidemiology.6-10 Bridging this current information gap would enable Ontario health planners and clinicians to specifically address the burden of MF injuries and thus develop suitable prevention programs aimed at lowering the incidence of these injuries. This study aimed to fill this gap by providing a detailed epidemiologic description of MF injuries in Ontario and exploring their characteristics and sociodemographic variation.
Materials and Methods This retrospective, descriptive, epidemiologic research was approved by the University of Toronto (Toronto, ON, Canada) research ethics board (number 27,783) and is a secondary data analysis of hospitalization and emergency department (ED) records from the Canadian Institute for Health Information (CIHI). Two CIHI datasets for Ontario were used.
EPIDEMIOLOGY OF MAXILLOFACIAL INJURIES
Data were obtained from 2004 to 2005 (the earliest possible year when complete data were available) up to 2011 to 2012. The following record-level data were obtained for patients who visited hospital EDs or who were admitted to the hospital for MF injuries: patient demographic data (age, gender, and geographic area of residence); case description (ED visit, hospitalization, or in-hospital death); reasons or external causes according to the ICD-10-CA; the intent of injury; length of stay; and the date and time of ED visits. The analysis included calculating rates of MF injury-related ED visits and hospitalizations. Population estimates from Statistics Canada were used as a denominator while calculating these rates. Then, the numbers and rates were ranged according to different factors (ie, frequency and type of injury, age group and gender, date and time of injury, location of injury, and postal codes) to describe the patient and visit characteristics. The geographic area of residence was determined from the first segment of the postal code or the Forward Sortation Area.9 These data were linked to an area-based measurement of income quintile depending on census tract data.9 In accordance with the CIHI’s privacy policy, cells with counts from 1 to 5 were suppressed. To display the geographic distribution of MF injuries in Ontario counties, color-coded geographic information system (GIS) maps were created using ArcGIS (ArcGIS Desktop 10, Environmental Systems Research Institute, Redlands, CA). All data were analyzed using IBM SPSS 21.0 (SPSS, Inc, Chicago, IL).
DISCHARGE ABSTRACT DATABASE
This dataset contains demographic, administrative, and clinical data for hospital discharges. Data are coded using the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canadian Enhancement (ICD-10-CA) codes by medical record clerks and subsequently submitted electronically to the CIHI on a monthly basis.11 The ICD-10-CA is the classification used universally in Canadian health care facilities to record problems, diagnoses, symptoms, and other conditions necessitating contact with health care providers. NATIONAL AMBULATORY CARE REPORTING SYSTEM
As an outpatient database collecting data on ED visits, the National Ambulatory Care Reporting System (NACRS) includes demographic, diagnostic, procedural, and administrative information from hospital EDs and urgent care settings in Ontario.8,12 Data are collected from 186 participating facilities at the time of client visit and submitted to the CIHI within 30 days of this visit. The main diagnosis is coded in the NACRS using ICD-10-CA codes.11,12
Results From fiscal year 2004 to 2005 through 2011 to 2012 in Ontario, 1,457,990 ED visits and 41,057 hospitalizations occurred because of MF injuries (Table 1). The average age of patients for each ED visit was 30.6 years and for each hospitalization was 52.6 years. Overall, the majority (62%) of those who had MF injury-related ED visits or hospitalization were male (male-to-female ratio, 1.6:1). The mean length of stay in hospital was 9.6 days. Most MF injury-related hospitalizations lasted 2 to 7 days. Children and youth more frequently had shorter hospitalizations (#2 days), whereas older patients more frequently had longer hospitalizations ($7 days). RATES OF ED VISITS AND HOSPITALIZATIONS DUE TO MF INJURIES IN ONTARIO, 2004 THROUGH 2012
Rates of ED Visits and Hospitalizations by Age and Gender The rates of MF injury-related ED visits and hospitalizations were higher in male children, youth, and adults younger than 25 years. The highest rates of ED
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Table 1. NUMBER OF MF INJURY-RELATED ED VISITS, HOSPITALIZATIONS, AND IN-HOSPITAL DEATHS BY AGE GROUP IN ONTARIO, 2004 THROUGH 2012
Age Group (yr) 0-4 5-9 10-14 15-19 20-44 45-64 65-84 $85 Total all ages
Population Size per Age Group
MF Injury-Related ED Visits, n
MF Injury-Related Hospitalizations, n
MF Injury-Related In-Hospital Deaths, n
Ratio of ED Visits to Hospitalizations to In-Hospital Deaths
5,594,573 5,858,849 6,449,003 6,978,376 36,819,428 27,448,518 12,104,221 1,713,897 102,966,865
279,695 146,097 112,523 153,407 392,594 188,274 133,622 51,778 1,457,990
1,380 1,440 1,641 3,348 10,811 7,729 9,614 5,094 41,057
7 * 9 62 175 261 721 546 1,781
39,956:197:1 29,219:288:1 12,503:182:1 2,474:54:1 2,243:62:1 721:30:1 185:13:1 95:9:1 816:23:1
Note: Data were obtained from the National Ambulatory Care Reporting System and Discharge Abstract Database of the Canadian Institute for Health Information. Abbreviations: ED, emergency department; MF, maxillofacial. * Cell size smaller than 6. Al-Dajani et al. Epidemiology of Maxillofacial Injuries. J Oral Maxillofac Surg 2015.
visits were recorded for infants and young children, whereas the lowest rates of ED visits were recorded for adults 30 to 74 years old. Hospitalizations were highest for older patients. Female patients at least 85 years old had a higher rate of ED visits and hospitalizations compared with male patients of the same age (Fig 1).
Geographic and Time Patterns of ED Visits and Hospitalizations MF injury mapping showed that rural counties had higher rates of MF injury-related ED visits. Two counties (ie, Prince Edward and Haliburton) had MF injury-related ED visit rates that were 80% higher than the provincial average (Fig 2). In general, rural
FIGURE 1. Rate of MF injury-related ED visits and hospitalizations per 100,000 population by age group and gender in Ontario from 2004 through 2012 as determined from the National Ambulatory Care Reporting System and Discharge Abstract Database of the Canadian Institute for Health Information. ED, emergency department; MF, maxillofacial. Al-Dajani et al. Epidemiology of Maxillofacial Injuries. J Oral Maxillofac Surg 2015.
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FIGURE 2. Rate of maxillofacial injury-related emergency department visits per 100,000 population by county in Ontario from 2004 through 2012 as determined from the National Ambulatory Care Reporting System of the Canadian Institute for Health Information. Al-Dajani et al. Epidemiology of Maxillofacial Injuries. J Oral Maxillofac Surg 2015.
counties had higher rates of MF injury-related hospitalizations, whereas urban counties had lower rates. MF injury-related ED visits also showed a time pattern, being highest in the evening (7 to 9 PM) and lowest in the morning (5 to 7 AM), highest during the weekends, and highest during the summer (from May to August) and lowest in February. Intent of MF Injuries Unintentional MF injuries were notably highest in 0to 4-year-old children. Intentional MF injuries occurred more frequently from assault rather than from a selfinflicted cause. Intentional MF injuries were notably high in youth and young adults (ie, 15 to 24 years of age). Falls caused unintentional MF injuries 9 times more frequently than being struck by or against a person or object, which ranked second. Being struck by or against a person or object caused assault-related MF injury 26 times more frequently than a cut or pierce, the second ranked cause. The most common cause of self-inflicted MF injury was a cut or pierce. Common Causes of MF Injuries Overall, the top 3 causes of ED visits for MF injuries were 1) falls, 2) being struck by or against a person or object, and 3) traffic collisions. Falls and traffic collisions were the leading causes for hospitalizations and inhospital deaths (Table 2). Male patients more frequently had MF-injury related ED visits for most of the common causes, whereas female patients more frequently visited EDs for injuries related to overexertion and drowning. Neighborhood Income ED visits for MF injuries were highest in families living in low-income neighborhoods for all ages. The
highest rates were in 0- to 14-year-old children of low-income families (Fig 3). Similarly, hospitalizations for these injuries were highest in families living in low-income neighborhoods for all ages. However, the highest rates of hospitalizations were in older people ($65 years) of low-income families. Contribution to Total ED Visits and Hospitalizations In 2010 to 2011, 1 in 30 ED visits and 1 in 195 hospitalizations in Ontario were related to MF injuries. Of all ED visits in Ontario, 3.3% in patients of all ages and 7.7% in 5- to 9-year-old children were due to MF injuries (Fig 4). TREND ANALYSIS OF ED VISIT RATES, 2004 TO 2005 THROUGH 2011 TO 2012
In Ontario, from 2004 to 2005 through 2011 to 2012, the MF injury ED visit rate decreased by 5% (from 1,500 to 1,434 per 100,000 population). The largest relative decrease in ED visit rates was recorded in 2006 to 2007 compared with 2005 to 2006. The highest ED visit rate was 1,526 per 100,000 population recorded in 2005 to 2006, whereas the lowest rate was 1,341 per 100,000 population recorded in 2007 to 2008. Male patients maintained a higher rate of ED visits than female patients. This difference between male and female patients narrowed with time. Most of this narrowing resulted from the decrease in male ED visit rates. TREND ANALYSIS OF HOSPITALIZATION RATES, 2004 TO 2005 THROUGH 2011 TO 2012
In Ontario, from 2004 to 2005 through 2011 to 2012, the MF injury hospitalization rate decreased by 14%
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Table 2. RATE OF MF INJURY-RELATED ED VISITS, HOSPITALIZATIONS, AND IN-HOSPITAL DEATHS PER 100,000 POPULATION BY COMMON CAUSES OF INJURY IN ONTARIO, 2004 THROUGH 2012
Common Causes of MF Injury Fall Struck by or against an object or a person Motor vehicle traffic Natural or environmental Cut or pierce Other land transport Other bicycle (non-motor vehicle collision) Overexertion Machinery Other pedestrian (non-motor vehicle collision) Poisoning Hot object or substance Firearm Fire or flame Drowning Suffocation Other and nonspecified Total
Rate of MF Rate of MF Injury-Related Injury-Related Rate of MF Injury-Related Ratio of ED Visits to ED Visits per 100,000 Hospitalizations per In-Hospital Deaths per Hospitalizations to Population 100,000 Population 100,000 Population In-Hospital Deaths 547.5 187.8
146.18 39.52
1.054 0.024
519:139:1 7,825:1,647:1
65.3 44.4 38.1 9.5 3.7
42.86 4.14 5.00 5.28 1.06
0.195 0.004 0.002 0.017 0.003
335:220:1 11,100:1,035:1 19,050:2,500:1 559:311:1 1,233:353:1
3.5 3.1 1.3
0.30 0.99 0.99
0.001 0.000 0.007
3,500:300:1
0.6 0.3 0.2 0.2 0.1 0.1 61.4 967.1
0.89 0.09 0.72 0.11 0.04 0.16 13.16 32.68
0.002 0.000 0.020 0.000 0.000 0.002 0.043 1.373
300:445:1
186:141:1
10:36:1
50:80:1 1,428:306:1 704:24:1
Note: Data were obtained from the National Ambulatory Care Reporting System and Discharge Abstract Database of the Canadian Institute for Health Information. Abbreviations: ED, emergency department; MF, maxillofacial. Al-Dajani et al. Epidemiology of Maxillofacial Injuries. J Oral Maxillofac Surg 2015.
(from 45 to 39 per 100,000 population). Most of this decrease was recorded during the first half of the study period, whereas the second half showed a slight gradual increase. The highest rate was 45 per 100,000 population recorded in 2004 to 2005, whereas the lowest rate was 37 per 100,000 population recorded in 2007 to 2008 and 2008 to 2009. Male patients maintained a higher rate of hospitalizations than female patients. ED VISIT COMPARISONS
When comparing the number of ED visits for MF injuries in Ontario with other visits for select conditions in Canada, MF injury ranked third (3.3%) in 2010 to 2011 (injuries ranked first, 21.69%; falls ranked second, 6.58%). Comparatively, ED visits for MF injuries in Ontario were greater than ED visits for pneumonia (1.3%), dental problems (0.93%), asthma (0.90%), acute myocardial infraction (0.26%), and influenzal pneumonia (0.01%) in Canada.9,12,13 Figure 5 shows a comparison between Ontario MF injury-related and Canadian disease-related ED visits in 2010 to 2011 by age group. Children 19 years and younger visited EDs
most frequently for asthma and MF injuries (46.5% and 45.8%, respectively) compared with other age groups. Most ED visits by young adults 20 to 44 years old were for dental problems (52.8%).
Discussion This study establishes provincially representative estimates of ED visits related to MF injury and hospital admissions for all ages. These estimates can help health planners and policy makers in addressing the burden of MF injuries in Ontario and in planning, implementing, and evaluating public health programs concerned with injury prevention. The 3 leading causes of ED visits for MF injuries were 1) falls, 2) being struck by or against an object or a person, and 3) motor vehicle collisions. Falls and motor vehicle collisions were the leading causes for hospitalizations and in-hospital deaths. An increase in the frequency of ED visits and hospitalizations for MF injuries was noted for the weekend, which could be related to the simultaneity of weekend activities, such as traveling and increased alcohol consumption.
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FIGURE 3. Rate of MF injury-related ED visits per 100,000 population by age group and income quintile in Ontario from 2004 through 2012 as determined from the National Ambulatory Care Reporting System of the Canadian Institute for Health Information. Rates were adjusted to the 2006 Census of Canada Population. ED, emergency department; MF, maxillofacial. Al-Dajani et al. Epidemiology of Maxillofacial Injuries. J Oral Maxillofac Surg 2015.
The sharp increase in ED visits for MF injuries recorded in children no older than 14 years might be related to the precautionary attitude of parents in seeking EDs as a first line of treatment for their injured children. Further studies are needed to explore the reasons behind this finding. Gender was an important risk marker for the frequency of MF injury. Male youth 15 to 24 years old visited EDs 2.6 times more frequently and were hospitalized for MF injuries 3.6 times more frequently than their female counterparts. This finding is supported by many previous studies in which, consistently, male youth have more injuries generally and more MF injuries specifically.3,7,14-19 Male patients were more likely to report being struck by or against as a main cause of MF injury than were female patients (male patients, 75.7%; female patients, 24.3%; male-to-female ratio, 3:1). This trend needs a more societally based approach to investigate the idea that female patients are not truly reporting the cause of MF injury. For example, a female patient exposed to domestic violence might be selfreporting an assault injury as a fall injury. In general, the observed differences in ED visits owing to MF injuries between male and female patients require further societal based studies that can
be directed toward addressing in detail the modifiable, occupational, or other predisposing risk factors. An important question that stands out in these findings is whether this difference between male and female youth might be related to youth violence, domestic violence, suicidal behavior, or other factors. The large number of intentional MF injuries in youth and young adults shows an alarming level of violent behavior in these vulnerable groups. Considering the serious consequences of head and facial injuries, targeting male youth and young adults should remain a priority in public health programs concerned with injury prevention. In contrast, women at least 85 years old more frequently visited EDs and were hospitalized owing to MF injury compared with men of similar age. The increased percentages of hospitalizations in older women could be a consequence of the increased risk of chronic diseases in general and the use of alcohol in particular.20 Although older women considerably outnumber older men in the Ontario general population, the use of rates overcomes this potential limitation in interpretation. Comorbidity of MF injuries is an important aspect to explore in future studies. For example, health care personnel need to know how many of those who have MF injuries also have a coincident hip fracture. It
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FIGURE 4. Percentages of total ED visits and hospitalizations caused by MF injury by age group in Ontario from 2010 through 2011 as determined from the National Ambulatory Care Reporting System and Discharge Abstract Database of the Canadian Institute for Health Information. ED, emergency department; MF, maxillofacial. Al-Dajani et al. Epidemiology of Maxillofacial Injuries. J Oral Maxillofac Surg 2015.
can be hypothesized that exploring the comorbidity of these patients can help substantially in lessening the burden of MF injuries by targeting prevention to these 2 conditions. Furthermore, the general health status of patients with MF injury is another important factor that requires further investigation. The present findings also raise an important clinical question, that is, why do older women have more MF injuries? Is it due to poor vision, osteoporosis, medications, or muscle weakness? Families living in low-income neighborhoods showed ED visit rates markedly higher than their counterparts in wealthier neighborhoods. A possible explanation for these high rates might be that these families are more likely to seek EDs and hospitals as the first line of treatment, because the absence or limited availability of dental insurance might restrict their ability to access needed dental care in the private sector.
The use of GIS in mapping the rates of MF injuryrelated visits and hospitalizations in Ontario provided a better understanding of the geographic distribution of these injuries and in particular identifying the high-risk counties by age, gender, and economic status. Targeting future prevention programs to these counties could help in controlling and decreasing the burden of such injuries. The present study highlights that in Ontario rural counties showed higher rates of ED visits and hospitalizations related to MF injury compared with their urban counterparts. Although this difference is a good hypothesis to test in the future, one should keep in mind that rural areas are more likely to have low-income communities with limited access to dentists or to insurance coverage for dental services. Supporting current injury prevention interventions should be the cornerstone in decreasing the
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EPIDEMIOLOGY OF MAXILLOFACIAL INJURIES
FIGURE 5. MF injury compared with disease-related main problems of emergency department visits in Canada by age group from 2010 through 2011 as determined from National Ambulatory Care Reporting System of the Canadian Institute for Health Information. *In Ontario only. Total emergency department visits in Ontario and Canada were 5,582,863 and 8,171,876, respectively. ^From 2003 through 2006 in Ontario only.9 MF, maxillofacial. Al-Dajani et al. Epidemiology of Maxillofacial Injuries. J Oral Maxillofac Surg 2015.
occurrence of MF injuries. Successfully preventing MF injuries requires the implementation of proven specific interventions (eg, wearing a mouth guard while playing ice hockey or a helmet while cycling). Owing to the nature of secondary data, the authors were limited to variables collected in the Discharge Abstract Database (DAD) and NACRS datasets. These datasets lack information on some important factors, such as alcohol use, substance abuse, occupation, work hours, and education. In addition, MF injuryrelated ED visits and hospitalizations were included based on the date of registration or admission of each case. Therefore, the number of visits might not be the same as the number of patients. Another limitation of this study is the possible error in coding across different EDs and hospitals. Moreover, the sample was provincially representative of hospital-based visits and admissions for MF injuries; however, the overall prevalence of MF injury could have been underestimated because some MF injury cases might be treated in the private sector or these patients might die before they reach an ED or a hospital. Such cases are not captured by the NACRS and DAD datasets and thus remain beyond the scope of this study. Despite these limitations, to the best of the authors’ knowledge, this study is the largest on the MF injury population in Ontario and Canada. It highlights the public health burden of MF injuries, offering policy makers a detailed epidemiologic description of these injuries. This study has established an important baseline for future studies and interventions aimed at preventing these injuries in the Ontario population. In the spirit of ‘‘what gets inspected gets respected,’’ the present research contributes to policy efforts
aimed at protecting Canadians from injuries that are largely predictable and preventable. Based on the results of this study, the authors present the following recommendations. 1. Partnerships among health services, local authorities, and families should be enhanced to maximize the benefits of interventional injury prevention programs that are already in place. For example, protecting children from dental injuries in organized sports requires the use of mouth guards. Ontario law mandates this use. However, commitment by children requires, in most cases, their parents’ awareness and continuous encouragement in organized and unorganized settings. 2. Future MF injury prevention programs should enhance the population-based approach and concurrently focus on high-risk groups (especially male youth and older women in lowincome families). 3. Targeting male youth and young adults should remain a priority in public health programs. 4. Families with seniors living among them need to be encouraged to implement modifications that make their home accessible, decrease the risk of falls, and improve home safety. This approach can be combined with governmental tax incentives because injuries in older patients require long hospitalization and thus consume more resources. This 8-year retrospective epidemiologic study presents the most detailed description of ED visits and
AL-DAJANI ET AL
hospitalizations related to MF injuries ever conducted in Ontario and in Canada. This study comprehensively quantified the rates of ED visits and hospitalizations for MF injuries and investigated the variation in their epidemiologic and geographic distribution. This study also identified and ranked the most common causes for MF injuries. Compared with other diseases and conditions, ED visits for MF injuries were greater than those for pneumonia, dental problems, asthma, acute myocardial infraction, and influenzal pneumonia. This study highlighted the public health impact of MF injuries, offering policy makers important epidemiologic information, which is fundamental to formulate and optimize measures aimed at protecting Canadians from injuries that are largely predictable and preventable. Future MF injury prevention programs should enhance the population-based approach and focus on high-risk groups (especially male youth and older women in low-income families). Targeting male youth and young adults should remain a priority in public health programs. Acknowledgments The authors thank Dr Dina Al-Dajani, from the Faculty of Architecture, Damascus University, Syria, for performing geographic mapping. In addition, they acknowledge the kind efforts of the staff of the Ontario Ministry of Health and Long-Term Care and the Canadian Institute for Health Information.
References 1. Locker D: Prevalence of traumatic dental injury in grade 8 children in six Ontario communities. Can J Public Health 96: 73, 2005 2. Shahim FN, Cameron P, McNeil JJ: Maxillofacial trauma in major trauma patients. Aust Dent J 51:225, 2006 3. Goodisson D, MacFarlane M, Snape L, et al: Head injury and associated maxillofacial injuries. N Z Med J 117:U1045, 2004
693.e9 4. Hayter JP, Ward AJ, Smith EJ: Maxillofacial trauma in severely injured patients. Br J Oral Maxillofac Surg 29:370, 1991 5. Gassner R, Tuli T, H€achl O, et al: Cranio-maxillofacial trauma: A 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg 31:51, 2003 6. Hogg NJ, Stewart TC, Armstrong JE, et al: Epidemiology of maxillofacial injuries at trauma hospitals in Ontario, Canada, between 1992 and 1997. J Trauma 49:425, 2000 7. Sojot AJ, Meisami T, Sandor GK, et al: The epidemiology of mandibular fractures treated at the Toronto general hospital: A review of 246 cases. J Can Dent Assoc 67:640, 2001 8. Qui~ nonez C, Gibson D, Jokovic A, et al: Day surgery visits for dental problems. Community Dent Oral Epidemiol 37:562, 2009 9. Qui~ nonez C, Gibson D, Jokovic A, et al: Emergency department visits for dental care of nontraumatic origin. Community Dent Oral Epidemiol 37:366, 2009 10. Qui~ nonez C, Ieraci L, Guttmann A: Potentially preventable hospital use for dental conditions: Implications for expanding dental coverage for low income populations. J Health Care Poor Underserved 22:1048, 2011 11. CIHI: Coding Standards for Version 2009 ICD-10-CA and CCI, Revised September 2009. Ottawa, ON, Canada, Canadian Institute for Health Information, 2009 12. CIHI: Products and Services Guide, 2011-2012. Ottawa, ON, Canada, Canadian Institute for Health Information, 2011 13. Macpherson AK, Schull M, Manuel D, et al: Injuries in Ontario. ICES Atlas. Toronto, ON, Canada, Institute for Clinical Evaluative Sciences, 2005 14. Al Ahmed HE, Jaber MA, Abu Fanas SH, et al: The pattern of maxillofacial fractures in Sharjah, United Arab Emirates: A review of 230 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:166, 2004 15. Lim LH, Kumar M, Myer CM: Head and neck trauma in hospitalized pediatric patients. Otolaryngol Head Neck Surg 130:255, 2004 16. Hung YC, Montazem A, Costello MA: The correlation between mandible fractures and loss of consciousness. J Oral Maxillofac Surg 62:938, 2004 17. Olson RA, Fonseca RJ, Zeitler DL, et al: Fractures of the mandible: A review of 580 cases. J Oral Maxillofac Surg 40:23, 1982 18. Motamedi MH: An assessment of maxillofacial fractures: A 5-year study of 237 patients. J Oral Maxillofac Surg 61:61, 2003 19. Rajendra PB, Mathew TP, Agrawal A, et al: Characteristics of associated craniofacial trauma in patients with head injuries: An experience with 100 cases. J Emerg Trauma Shock 2:89, 2009 20. Hu G, Baker SP: Recent increases in fatal and non-fatal injury among people aged 65 years and over in the USA. Inj Prev 16: 26, 2010
An 8-year retrospective study design was implemented. The Discharge Abstract Database and the National Ambulatory Care Reporting System datasets were used. After examining demographic and diagnostic information, frequencies, percentages, and rates were calculated. Color-coded maps were created using ArcGIS to display the geographic distribution of MF injuries.
Results:
From 2004 through 2012, 1,457,990 ED visits and 41,057 hospitalizations occurred as a result of MF injury in Ontario. The mean age of patients for each ED visit was 30.6 years and for each hospitalization was 52.6 years. Rates of ED visits and hospitalizations owing to MF injury show a slight decrease during the 8-year period. MF injuries were most frequent in the evening, during the weekends, and during the summer. Falls were reported as the leading cause of MF injuries. Rural areas had higher rates of ED visits and hospitalizations.
Conclusions: This study highlighted the public health impact of MF injuries, offering policy makers important epidemiologic information, which is fundamental to formulate and optimize measures aimed at protecting Canadians from injuries that are largely predictable and preventable. Future injury prevention programs should enhance the population-based approach and focus on high-risk groups such as male youth and elderly women in low-income families. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 73:693.e1-693.e9, 2015
During the past 3 decades, there has been substantial improvement in population oral health, as evidenced by decreases in the prevalence and severity of dental caries.1 This decrease in the incidence of caries, especially in developed countries, has led to growing attention being paid to other oral-related problems
affecting vulnerable populations.1 One of these conditions is maxillofacial (MF) injury. MF injuries, also called MF trauma, include cranial and facial bone fractures, cranial nerve injuries, oral and dental injuries, soft tissue injuries, and associated injuries, mainly of the head, ear, nose, and eye. These injuries are very
*Assistant Professor, Department of Maxillofacial Surgery and
by Dr Al-Dajani in conformity with the requirements for the degree
Diagnostic Sciences, College of Dentistry, Aljouf University,
of Master of Science in Dental Public Health at the Faculty of
Kingdom of Saudi Arabia.
Dentistry, University of Toronto.
yAssociate Professor, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada.
Address correspondence and reprint requests to Dr Al-Dajani: Department of Maxillofacial Surgery and Diagnostic Sciences, Col-
zAssociate Professor, Faculty of Health, York University, Toronto,
lege of Dentistry, Aljouf University, Kingdom of Saudi Arabia;
ON, Canada.
e-mail: [email protected]
xProfessor, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada.
Received October 11 2014 Accepted December 2 2014
kAssistant Professor, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada.
Ó 2015 American Association of Oral and Maxillofacial Surgeons 0278-2391/14/01713-3
Dr Al-Dajani presented an abstract of this study at the Interna-
http://dx.doi.org/10.1016/j.joms.2014.12.001
tional Association for Dental Research General Session; Seattle, WA; March 2013. These results constitute part of a thesis submitted
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693.e2 common worldwide. Several studies have concluded that MF injury occurs in approximately 5 to 33% of patients experiencing severe trauma.2-4 MF injuries place a heavy burden not only on patients with the injury and their families, but also on the health care system. MF injury management requires pertinent documentation, injury surveillance, and research data that adequately describes the whole spectrum of these injuries.5 Although much of the current literature relating to MF injuries in Ontario has focused on their treatment, very few studies have addressed their etiology or epidemiology.6-10 Bridging this current information gap would enable Ontario health planners and clinicians to specifically address the burden of MF injuries and thus develop suitable prevention programs aimed at lowering the incidence of these injuries. This study aimed to fill this gap by providing a detailed epidemiologic description of MF injuries in Ontario and exploring their characteristics and sociodemographic variation.
Materials and Methods This retrospective, descriptive, epidemiologic research was approved by the University of Toronto (Toronto, ON, Canada) research ethics board (number 27,783) and is a secondary data analysis of hospitalization and emergency department (ED) records from the Canadian Institute for Health Information (CIHI). Two CIHI datasets for Ontario were used.
EPIDEMIOLOGY OF MAXILLOFACIAL INJURIES
Data were obtained from 2004 to 2005 (the earliest possible year when complete data were available) up to 2011 to 2012. The following record-level data were obtained for patients who visited hospital EDs or who were admitted to the hospital for MF injuries: patient demographic data (age, gender, and geographic area of residence); case description (ED visit, hospitalization, or in-hospital death); reasons or external causes according to the ICD-10-CA; the intent of injury; length of stay; and the date and time of ED visits. The analysis included calculating rates of MF injury-related ED visits and hospitalizations. Population estimates from Statistics Canada were used as a denominator while calculating these rates. Then, the numbers and rates were ranged according to different factors (ie, frequency and type of injury, age group and gender, date and time of injury, location of injury, and postal codes) to describe the patient and visit characteristics. The geographic area of residence was determined from the first segment of the postal code or the Forward Sortation Area.9 These data were linked to an area-based measurement of income quintile depending on census tract data.9 In accordance with the CIHI’s privacy policy, cells with counts from 1 to 5 were suppressed. To display the geographic distribution of MF injuries in Ontario counties, color-coded geographic information system (GIS) maps were created using ArcGIS (ArcGIS Desktop 10, Environmental Systems Research Institute, Redlands, CA). All data were analyzed using IBM SPSS 21.0 (SPSS, Inc, Chicago, IL).
DISCHARGE ABSTRACT DATABASE
This dataset contains demographic, administrative, and clinical data for hospital discharges. Data are coded using the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canadian Enhancement (ICD-10-CA) codes by medical record clerks and subsequently submitted electronically to the CIHI on a monthly basis.11 The ICD-10-CA is the classification used universally in Canadian health care facilities to record problems, diagnoses, symptoms, and other conditions necessitating contact with health care providers. NATIONAL AMBULATORY CARE REPORTING SYSTEM
As an outpatient database collecting data on ED visits, the National Ambulatory Care Reporting System (NACRS) includes demographic, diagnostic, procedural, and administrative information from hospital EDs and urgent care settings in Ontario.8,12 Data are collected from 186 participating facilities at the time of client visit and submitted to the CIHI within 30 days of this visit. The main diagnosis is coded in the NACRS using ICD-10-CA codes.11,12
Results From fiscal year 2004 to 2005 through 2011 to 2012 in Ontario, 1,457,990 ED visits and 41,057 hospitalizations occurred because of MF injuries (Table 1). The average age of patients for each ED visit was 30.6 years and for each hospitalization was 52.6 years. Overall, the majority (62%) of those who had MF injury-related ED visits or hospitalization were male (male-to-female ratio, 1.6:1). The mean length of stay in hospital was 9.6 days. Most MF injury-related hospitalizations lasted 2 to 7 days. Children and youth more frequently had shorter hospitalizations (#2 days), whereas older patients more frequently had longer hospitalizations ($7 days). RATES OF ED VISITS AND HOSPITALIZATIONS DUE TO MF INJURIES IN ONTARIO, 2004 THROUGH 2012
Rates of ED Visits and Hospitalizations by Age and Gender The rates of MF injury-related ED visits and hospitalizations were higher in male children, youth, and adults younger than 25 years. The highest rates of ED
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Table 1. NUMBER OF MF INJURY-RELATED ED VISITS, HOSPITALIZATIONS, AND IN-HOSPITAL DEATHS BY AGE GROUP IN ONTARIO, 2004 THROUGH 2012
Age Group (yr) 0-4 5-9 10-14 15-19 20-44 45-64 65-84 $85 Total all ages
Population Size per Age Group
MF Injury-Related ED Visits, n
MF Injury-Related Hospitalizations, n
MF Injury-Related In-Hospital Deaths, n
Ratio of ED Visits to Hospitalizations to In-Hospital Deaths
5,594,573 5,858,849 6,449,003 6,978,376 36,819,428 27,448,518 12,104,221 1,713,897 102,966,865
279,695 146,097 112,523 153,407 392,594 188,274 133,622 51,778 1,457,990
1,380 1,440 1,641 3,348 10,811 7,729 9,614 5,094 41,057
7 * 9 62 175 261 721 546 1,781
39,956:197:1 29,219:288:1 12,503:182:1 2,474:54:1 2,243:62:1 721:30:1 185:13:1 95:9:1 816:23:1
Note: Data were obtained from the National Ambulatory Care Reporting System and Discharge Abstract Database of the Canadian Institute for Health Information. Abbreviations: ED, emergency department; MF, maxillofacial. * Cell size smaller than 6. Al-Dajani et al. Epidemiology of Maxillofacial Injuries. J Oral Maxillofac Surg 2015.
visits were recorded for infants and young children, whereas the lowest rates of ED visits were recorded for adults 30 to 74 years old. Hospitalizations were highest for older patients. Female patients at least 85 years old had a higher rate of ED visits and hospitalizations compared with male patients of the same age (Fig 1).
Geographic and Time Patterns of ED Visits and Hospitalizations MF injury mapping showed that rural counties had higher rates of MF injury-related ED visits. Two counties (ie, Prince Edward and Haliburton) had MF injury-related ED visit rates that were 80% higher than the provincial average (Fig 2). In general, rural
FIGURE 1. Rate of MF injury-related ED visits and hospitalizations per 100,000 population by age group and gender in Ontario from 2004 through 2012 as determined from the National Ambulatory Care Reporting System and Discharge Abstract Database of the Canadian Institute for Health Information. ED, emergency department; MF, maxillofacial. Al-Dajani et al. Epidemiology of Maxillofacial Injuries. J Oral Maxillofac Surg 2015.
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FIGURE 2. Rate of maxillofacial injury-related emergency department visits per 100,000 population by county in Ontario from 2004 through 2012 as determined from the National Ambulatory Care Reporting System of the Canadian Institute for Health Information. Al-Dajani et al. Epidemiology of Maxillofacial Injuries. J Oral Maxillofac Surg 2015.
counties had higher rates of MF injury-related hospitalizations, whereas urban counties had lower rates. MF injury-related ED visits also showed a time pattern, being highest in the evening (7 to 9 PM) and lowest in the morning (5 to 7 AM), highest during the weekends, and highest during the summer (from May to August) and lowest in February. Intent of MF Injuries Unintentional MF injuries were notably highest in 0to 4-year-old children. Intentional MF injuries occurred more frequently from assault rather than from a selfinflicted cause. Intentional MF injuries were notably high in youth and young adults (ie, 15 to 24 years of age). Falls caused unintentional MF injuries 9 times more frequently than being struck by or against a person or object, which ranked second. Being struck by or against a person or object caused assault-related MF injury 26 times more frequently than a cut or pierce, the second ranked cause. The most common cause of self-inflicted MF injury was a cut or pierce. Common Causes of MF Injuries Overall, the top 3 causes of ED visits for MF injuries were 1) falls, 2) being struck by or against a person or object, and 3) traffic collisions. Falls and traffic collisions were the leading causes for hospitalizations and inhospital deaths (Table 2). Male patients more frequently had MF-injury related ED visits for most of the common causes, whereas female patients more frequently visited EDs for injuries related to overexertion and drowning. Neighborhood Income ED visits for MF injuries were highest in families living in low-income neighborhoods for all ages. The
highest rates were in 0- to 14-year-old children of low-income families (Fig 3). Similarly, hospitalizations for these injuries were highest in families living in low-income neighborhoods for all ages. However, the highest rates of hospitalizations were in older people ($65 years) of low-income families. Contribution to Total ED Visits and Hospitalizations In 2010 to 2011, 1 in 30 ED visits and 1 in 195 hospitalizations in Ontario were related to MF injuries. Of all ED visits in Ontario, 3.3% in patients of all ages and 7.7% in 5- to 9-year-old children were due to MF injuries (Fig 4). TREND ANALYSIS OF ED VISIT RATES, 2004 TO 2005 THROUGH 2011 TO 2012
In Ontario, from 2004 to 2005 through 2011 to 2012, the MF injury ED visit rate decreased by 5% (from 1,500 to 1,434 per 100,000 population). The largest relative decrease in ED visit rates was recorded in 2006 to 2007 compared with 2005 to 2006. The highest ED visit rate was 1,526 per 100,000 population recorded in 2005 to 2006, whereas the lowest rate was 1,341 per 100,000 population recorded in 2007 to 2008. Male patients maintained a higher rate of ED visits than female patients. This difference between male and female patients narrowed with time. Most of this narrowing resulted from the decrease in male ED visit rates. TREND ANALYSIS OF HOSPITALIZATION RATES, 2004 TO 2005 THROUGH 2011 TO 2012
In Ontario, from 2004 to 2005 through 2011 to 2012, the MF injury hospitalization rate decreased by 14%
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Table 2. RATE OF MF INJURY-RELATED ED VISITS, HOSPITALIZATIONS, AND IN-HOSPITAL DEATHS PER 100,000 POPULATION BY COMMON CAUSES OF INJURY IN ONTARIO, 2004 THROUGH 2012
Common Causes of MF Injury Fall Struck by or against an object or a person Motor vehicle traffic Natural or environmental Cut or pierce Other land transport Other bicycle (non-motor vehicle collision) Overexertion Machinery Other pedestrian (non-motor vehicle collision) Poisoning Hot object or substance Firearm Fire or flame Drowning Suffocation Other and nonspecified Total
Rate of MF Rate of MF Injury-Related Injury-Related Rate of MF Injury-Related Ratio of ED Visits to ED Visits per 100,000 Hospitalizations per In-Hospital Deaths per Hospitalizations to Population 100,000 Population 100,000 Population In-Hospital Deaths 547.5 187.8
146.18 39.52
1.054 0.024
519:139:1 7,825:1,647:1
65.3 44.4 38.1 9.5 3.7
42.86 4.14 5.00 5.28 1.06
0.195 0.004 0.002 0.017 0.003
335:220:1 11,100:1,035:1 19,050:2,500:1 559:311:1 1,233:353:1
3.5 3.1 1.3
0.30 0.99 0.99
0.001 0.000 0.007
3,500:300:1
0.6 0.3 0.2 0.2 0.1 0.1 61.4 967.1
0.89 0.09 0.72 0.11 0.04 0.16 13.16 32.68
0.002 0.000 0.020 0.000 0.000 0.002 0.043 1.373
300:445:1
186:141:1
10:36:1
50:80:1 1,428:306:1 704:24:1
Note: Data were obtained from the National Ambulatory Care Reporting System and Discharge Abstract Database of the Canadian Institute for Health Information. Abbreviations: ED, emergency department; MF, maxillofacial. Al-Dajani et al. Epidemiology of Maxillofacial Injuries. J Oral Maxillofac Surg 2015.
(from 45 to 39 per 100,000 population). Most of this decrease was recorded during the first half of the study period, whereas the second half showed a slight gradual increase. The highest rate was 45 per 100,000 population recorded in 2004 to 2005, whereas the lowest rate was 37 per 100,000 population recorded in 2007 to 2008 and 2008 to 2009. Male patients maintained a higher rate of hospitalizations than female patients. ED VISIT COMPARISONS
When comparing the number of ED visits for MF injuries in Ontario with other visits for select conditions in Canada, MF injury ranked third (3.3%) in 2010 to 2011 (injuries ranked first, 21.69%; falls ranked second, 6.58%). Comparatively, ED visits for MF injuries in Ontario were greater than ED visits for pneumonia (1.3%), dental problems (0.93%), asthma (0.90%), acute myocardial infraction (0.26%), and influenzal pneumonia (0.01%) in Canada.9,12,13 Figure 5 shows a comparison between Ontario MF injury-related and Canadian disease-related ED visits in 2010 to 2011 by age group. Children 19 years and younger visited EDs
most frequently for asthma and MF injuries (46.5% and 45.8%, respectively) compared with other age groups. Most ED visits by young adults 20 to 44 years old were for dental problems (52.8%).
Discussion This study establishes provincially representative estimates of ED visits related to MF injury and hospital admissions for all ages. These estimates can help health planners and policy makers in addressing the burden of MF injuries in Ontario and in planning, implementing, and evaluating public health programs concerned with injury prevention. The 3 leading causes of ED visits for MF injuries were 1) falls, 2) being struck by or against an object or a person, and 3) motor vehicle collisions. Falls and motor vehicle collisions were the leading causes for hospitalizations and in-hospital deaths. An increase in the frequency of ED visits and hospitalizations for MF injuries was noted for the weekend, which could be related to the simultaneity of weekend activities, such as traveling and increased alcohol consumption.
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FIGURE 3. Rate of MF injury-related ED visits per 100,000 population by age group and income quintile in Ontario from 2004 through 2012 as determined from the National Ambulatory Care Reporting System of the Canadian Institute for Health Information. Rates were adjusted to the 2006 Census of Canada Population. ED, emergency department; MF, maxillofacial. Al-Dajani et al. Epidemiology of Maxillofacial Injuries. J Oral Maxillofac Surg 2015.
The sharp increase in ED visits for MF injuries recorded in children no older than 14 years might be related to the precautionary attitude of parents in seeking EDs as a first line of treatment for their injured children. Further studies are needed to explore the reasons behind this finding. Gender was an important risk marker for the frequency of MF injury. Male youth 15 to 24 years old visited EDs 2.6 times more frequently and were hospitalized for MF injuries 3.6 times more frequently than their female counterparts. This finding is supported by many previous studies in which, consistently, male youth have more injuries generally and more MF injuries specifically.3,7,14-19 Male patients were more likely to report being struck by or against as a main cause of MF injury than were female patients (male patients, 75.7%; female patients, 24.3%; male-to-female ratio, 3:1). This trend needs a more societally based approach to investigate the idea that female patients are not truly reporting the cause of MF injury. For example, a female patient exposed to domestic violence might be selfreporting an assault injury as a fall injury. In general, the observed differences in ED visits owing to MF injuries between male and female patients require further societal based studies that can
be directed toward addressing in detail the modifiable, occupational, or other predisposing risk factors. An important question that stands out in these findings is whether this difference between male and female youth might be related to youth violence, domestic violence, suicidal behavior, or other factors. The large number of intentional MF injuries in youth and young adults shows an alarming level of violent behavior in these vulnerable groups. Considering the serious consequences of head and facial injuries, targeting male youth and young adults should remain a priority in public health programs concerned with injury prevention. In contrast, women at least 85 years old more frequently visited EDs and were hospitalized owing to MF injury compared with men of similar age. The increased percentages of hospitalizations in older women could be a consequence of the increased risk of chronic diseases in general and the use of alcohol in particular.20 Although older women considerably outnumber older men in the Ontario general population, the use of rates overcomes this potential limitation in interpretation. Comorbidity of MF injuries is an important aspect to explore in future studies. For example, health care personnel need to know how many of those who have MF injuries also have a coincident hip fracture. It
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FIGURE 4. Percentages of total ED visits and hospitalizations caused by MF injury by age group in Ontario from 2010 through 2011 as determined from the National Ambulatory Care Reporting System and Discharge Abstract Database of the Canadian Institute for Health Information. ED, emergency department; MF, maxillofacial. Al-Dajani et al. Epidemiology of Maxillofacial Injuries. J Oral Maxillofac Surg 2015.
can be hypothesized that exploring the comorbidity of these patients can help substantially in lessening the burden of MF injuries by targeting prevention to these 2 conditions. Furthermore, the general health status of patients with MF injury is another important factor that requires further investigation. The present findings also raise an important clinical question, that is, why do older women have more MF injuries? Is it due to poor vision, osteoporosis, medications, or muscle weakness? Families living in low-income neighborhoods showed ED visit rates markedly higher than their counterparts in wealthier neighborhoods. A possible explanation for these high rates might be that these families are more likely to seek EDs and hospitals as the first line of treatment, because the absence or limited availability of dental insurance might restrict their ability to access needed dental care in the private sector.
The use of GIS in mapping the rates of MF injuryrelated visits and hospitalizations in Ontario provided a better understanding of the geographic distribution of these injuries and in particular identifying the high-risk counties by age, gender, and economic status. Targeting future prevention programs to these counties could help in controlling and decreasing the burden of such injuries. The present study highlights that in Ontario rural counties showed higher rates of ED visits and hospitalizations related to MF injury compared with their urban counterparts. Although this difference is a good hypothesis to test in the future, one should keep in mind that rural areas are more likely to have low-income communities with limited access to dentists or to insurance coverage for dental services. Supporting current injury prevention interventions should be the cornerstone in decreasing the
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FIGURE 5. MF injury compared with disease-related main problems of emergency department visits in Canada by age group from 2010 through 2011 as determined from National Ambulatory Care Reporting System of the Canadian Institute for Health Information. *In Ontario only. Total emergency department visits in Ontario and Canada were 5,582,863 and 8,171,876, respectively. ^From 2003 through 2006 in Ontario only.9 MF, maxillofacial. Al-Dajani et al. Epidemiology of Maxillofacial Injuries. J Oral Maxillofac Surg 2015.
occurrence of MF injuries. Successfully preventing MF injuries requires the implementation of proven specific interventions (eg, wearing a mouth guard while playing ice hockey or a helmet while cycling). Owing to the nature of secondary data, the authors were limited to variables collected in the Discharge Abstract Database (DAD) and NACRS datasets. These datasets lack information on some important factors, such as alcohol use, substance abuse, occupation, work hours, and education. In addition, MF injuryrelated ED visits and hospitalizations were included based on the date of registration or admission of each case. Therefore, the number of visits might not be the same as the number of patients. Another limitation of this study is the possible error in coding across different EDs and hospitals. Moreover, the sample was provincially representative of hospital-based visits and admissions for MF injuries; however, the overall prevalence of MF injury could have been underestimated because some MF injury cases might be treated in the private sector or these patients might die before they reach an ED or a hospital. Such cases are not captured by the NACRS and DAD datasets and thus remain beyond the scope of this study. Despite these limitations, to the best of the authors’ knowledge, this study is the largest on the MF injury population in Ontario and Canada. It highlights the public health burden of MF injuries, offering policy makers a detailed epidemiologic description of these injuries. This study has established an important baseline for future studies and interventions aimed at preventing these injuries in the Ontario population. In the spirit of ‘‘what gets inspected gets respected,’’ the present research contributes to policy efforts
aimed at protecting Canadians from injuries that are largely predictable and preventable. Based on the results of this study, the authors present the following recommendations. 1. Partnerships among health services, local authorities, and families should be enhanced to maximize the benefits of interventional injury prevention programs that are already in place. For example, protecting children from dental injuries in organized sports requires the use of mouth guards. Ontario law mandates this use. However, commitment by children requires, in most cases, their parents’ awareness and continuous encouragement in organized and unorganized settings. 2. Future MF injury prevention programs should enhance the population-based approach and concurrently focus on high-risk groups (especially male youth and older women in lowincome families). 3. Targeting male youth and young adults should remain a priority in public health programs. 4. Families with seniors living among them need to be encouraged to implement modifications that make their home accessible, decrease the risk of falls, and improve home safety. This approach can be combined with governmental tax incentives because injuries in older patients require long hospitalization and thus consume more resources. This 8-year retrospective epidemiologic study presents the most detailed description of ED visits and
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hospitalizations related to MF injuries ever conducted in Ontario and in Canada. This study comprehensively quantified the rates of ED visits and hospitalizations for MF injuries and investigated the variation in their epidemiologic and geographic distribution. This study also identified and ranked the most common causes for MF injuries. Compared with other diseases and conditions, ED visits for MF injuries were greater than those for pneumonia, dental problems, asthma, acute myocardial infraction, and influenzal pneumonia. This study highlighted the public health impact of MF injuries, offering policy makers important epidemiologic information, which is fundamental to formulate and optimize measures aimed at protecting Canadians from injuries that are largely predictable and preventable. Future MF injury prevention programs should enhance the population-based approach and focus on high-risk groups (especially male youth and older women in low-income families). Targeting male youth and young adults should remain a priority in public health programs. Acknowledgments The authors thank Dr Dina Al-Dajani, from the Faculty of Architecture, Damascus University, Syria, for performing geographic mapping. In addition, they acknowledge the kind efforts of the staff of the Ontario Ministry of Health and Long-Term Care and the Canadian Institute for Health Information.
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693.e9 4. Hayter JP, Ward AJ, Smith EJ: Maxillofacial trauma in severely injured patients. Br J Oral Maxillofac Surg 29:370, 1991 5. Gassner R, Tuli T, H€achl O, et al: Cranio-maxillofacial trauma: A 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg 31:51, 2003 6. Hogg NJ, Stewart TC, Armstrong JE, et al: Epidemiology of maxillofacial injuries at trauma hospitals in Ontario, Canada, between 1992 and 1997. J Trauma 49:425, 2000 7. Sojot AJ, Meisami T, Sandor GK, et al: The epidemiology of mandibular fractures treated at the Toronto general hospital: A review of 246 cases. J Can Dent Assoc 67:640, 2001 8. Qui~ nonez C, Gibson D, Jokovic A, et al: Day surgery visits for dental problems. Community Dent Oral Epidemiol 37:562, 2009 9. Qui~ nonez C, Gibson D, Jokovic A, et al: Emergency department visits for dental care of nontraumatic origin. Community Dent Oral Epidemiol 37:366, 2009 10. Qui~ nonez C, Ieraci L, Guttmann A: Potentially preventable hospital use for dental conditions: Implications for expanding dental coverage for low income populations. J Health Care Poor Underserved 22:1048, 2011 11. CIHI: Coding Standards for Version 2009 ICD-10-CA and CCI, Revised September 2009. Ottawa, ON, Canada, Canadian Institute for Health Information, 2009 12. CIHI: Products and Services Guide, 2011-2012. Ottawa, ON, Canada, Canadian Institute for Health Information, 2011 13. Macpherson AK, Schull M, Manuel D, et al: Injuries in Ontario. ICES Atlas. Toronto, ON, Canada, Institute for Clinical Evaluative Sciences, 2005 14. Al Ahmed HE, Jaber MA, Abu Fanas SH, et al: The pattern of maxillofacial fractures in Sharjah, United Arab Emirates: A review of 230 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:166, 2004 15. Lim LH, Kumar M, Myer CM: Head and neck trauma in hospitalized pediatric patients. Otolaryngol Head Neck Surg 130:255, 2004 16. Hung YC, Montazem A, Costello MA: The correlation between mandible fractures and loss of consciousness. J Oral Maxillofac Surg 62:938, 2004 17. Olson RA, Fonseca RJ, Zeitler DL, et al: Fractures of the mandible: A review of 580 cases. J Oral Maxillofac Surg 40:23, 1982 18. Motamedi MH: An assessment of maxillofacial fractures: A 5-year study of 237 patients. J Oral Maxillofac Surg 61:61, 2003 19. Rajendra PB, Mathew TP, Agrawal A, et al: Characteristics of associated craniofacial trauma in patients with head injuries: An experience with 100 cases. J Emerg Trauma Shock 2:89, 2009 20. Hu G, Baker SP: Recent increases in fatal and non-fatal injury among people aged 65 years and over in the USA. Inj Prev 16: 26, 2010
