Krishna ORIGINAL Murthy ARTICLE et al
Prevalence and Associated Factors of Traumatic Dental Injuries Among 5- to 16-year-old Schoolchildren in Bangalore City, India Archana Krishna Murthya/Pramila Mallaiah b/Ranganath Sangac Purpose: To investigate the prevalence and associated factors of traumatic dental injury (TDI) among 5- to 16-year-old schoolchildren in Bangalore City, India. Materials and Methods: In this cross-sectional study, a probabilistic sample of 2,140 schoolchildren was administered a questionnaire and examined intraorally to record TDI using the Ellis classification. Descriptive statistics and regression models were used for analysis of the data. Results: The prevalence of TDI among 5- to 16-year-old schoolchildren in Bangalore City was 9.7%. Boys (12.2%) were affected more than girls (7.1%). About 85% of the injuries occurred in maxillary anterior teeth and 89% in the permanent dentition with fractures in enamel as the most common type of TDI. Unknown causes accounted for 53.6% and falls (36.7%) were the most common reported cause. Only 3.9% of children with TDI had sought treatment. Children from public schools aged less than 10 years and boys had significantly higher TDIs as compared to private schoolchildren, those over 10 years of age and girls. Conclusion: The present study revealed a moderate prevalence of dental trauma. An emergent problem such as TDI should be met by public health policies that emphasise the prevention of TDI based on the knowledge of the risk factors. Children, parents and schoolteachers should be educated about the prevention and timely management of dental trauma in children. Key words: children, prevalence, traumatic dental injury (TDI) Oral Health Prev Dent 2014;1:37-43
Submitted for publication: 08.10.12; accepted for publication: 19.12.12
doi: 10.3290/j.ohpd.a31226
T
he prevalence and characteristics of traumatic dental injury (TDI) in schoolchildren have been extensively studied (Bendo et al, 2010), but no agreement exists on the prevalence of TDI, as it has differed from study to study and from country to country. Studies report frequencies ranging from 9.4% to 41.6% in primary dentition (Norton et al, 2012). With respect to permanent dentition, the prevalence of TDIs among adolescents in the Americas and Europe varied from 15% to 23% and 23% to 35%, respectively. The corresponding prevalence a
Assistant Professor, Department of Public Health Dentistry, M. R. Ambedkar Dental College, Bangalore, India.
b
Professor and Head, Department of Public Health Dentistry, M. R. Ambedkar Dental College, Bangalore, India.
c
Senior Lecturer, Department of Public Health Dentistry, M. R. Ambedkar Dental College, Bangalore, India.
Correspondence: Assistant Professor Archana Krishna Murthy, Department of Public Health Dentistry, M. R. Ambedkar Dental College, Bangalore, India. Tel: +91-0984-562-0292. Email: archanakm20@ gmail.com
Vol 12, No 1, 2014
rates in Asia and Africa ranged from 4% to 35% and 15% to 21% (Gupta et al, 2011). The aetiology and predisposing factors of TDIs are well documented. Research has demonstrated strong associations with gender, incisal overjet and lip coverage (Livny et al, 2010; Norton et al, 2012). Additionally, environmental factors and social characteristics such as type of school, time elapsed after the injury and treatment given or lack thereof also contribute to the better understanding of TDI and aid in planning public health policies that emphasise the prevention of TDI. On the other hand, data on the prevalence of dental injuries in India is relatively sparse. Apart from a few sporadic studies in different parts of India (Rai and Munshi et al, 1998; David et al, 2009; Gupta et al, 2011; Dua and Sharma, 2012; Govindarajan et al, 2012), no published literature is available on the prevalence and etiology of TDI among schoolchildren in Bangalore City. Hence, this study was undertaken to gather information
37
Krishna Murthy et al
about TDI to primary and permanent teeth among Indian schoolchildren living in Bangalore City. The specific objectives were to assess the prevalence of trauma to primary and permanent anterior teeth among 5- to 16-year-old schoolchildren and to investigate associations between TDI and independent anatomic and demographic variables.
MATERIALS AND METHODS This cross-sectional study was carried out among 5- to 16-year-old schoolchildren enrolled at public and private schools in Bangalore City. According to the 2011 census, Bangalore City has 84,25,970 inhabitants, with nearly 1 million schoolchildren in 2076 public and private schools (Census, 2011). The age group of 5–16 years is relevant, as in India a child commences formal schooling at the age of 5 years and at 16 years the child is in the 10th grade, which is the last grade of schooling. A probabilistic sample was calculated with a standard error of 2%, 95% confidence level and a 14% prevalence of TDI (Kaur and Hiremath, 2011). A correction factor of 1.5 was applied to increase the precision as a multistage sampling method was adopted rather than random sampling (Bendo et al, 2010). The minimum sample size needed to satisfy the requirements was estimated at 1,733 individuals. However, an additional 20.0% were asked to participate in the study (N = 2,140) in order to compensate for potential refusals. Information on the study had previously been given in the classrooms to all the children and classes. A letter was sent to all the parents outlining the aims and procedures of the study, and their consent was obtained. This study received the clearance from Eth-
ics Committee of M. R. Ambedkar Dental College, Bangalore. A total sample of 2,132 children aged from 5 to 16 years was randomly selected to represent the population of schoolchildren in Bangalore city. Data were collected using a questionnaire and clinical examination. The following relevant variables were collected from the child: age, gender, cause and place of injury, time elapsed since injury and reasons for not seeking treatment, where applicable. A dental examination was performed by two examiners using the Ellis classification for defining and recording TDI (Table 1) (Naidoo et al, 2009). A pilot study was performed on 140 randomly selected children (not part of the study sample) to assess the level of consistency between the examiners regarding TDI examination. The mean Kappa values were 0.96 for intra-examiner and 0.85 for inter-examiner agreement regarding TDI, thereby demonstrating good consistency. Overjet was measured using a Community Periodontal Index probe which was dichotomised to ≤ 3 mm and > 3 mm during the analysis. Lip coverage was classified as adequate when lips covered the anterior teeth completely in the at-rest position and as inadequate if the majority of the crown height was exposed and visible. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS for Windows, version 16.0, SPSS; Chicago, IL, USA). Descriptive statistical analyses were initially performed including frequency distributions and cross tabulations. Regression models analysing the variables of age ( 12 months
Unknown
Frequency (%)
31 (15)
23 (11.1)
42 (20.3)
111 (53.6)
Reason for not seeking treatment
Already treated
No problem
Not aware
Uninterested parents
High cost
Fear of pain
Frequency (%)
8 (3.9)
102 (49.3)
83 (40.1)
6 (2.9)
5 (2.4)
3 (1.4)
*As per Ellis classification (Table1).
40
Oral Health & Preventive Dentistry
Krishna Murthy et al
Table 3 Frequency analysis and logistic regression of the association between the variables studied and dental trauma in 5- to 16-year-old children (N = 2132) Trauma at clinical examination Yes N
No %
n
Total
OR (95% CI)
P-value
%
School
OR for school (government/ private)
Government
145
13.2
950
86.8
1095
Private
62
6
975
94
1037
2.40 (1.76-3.27)
Age (years)
P < 0.001
OR for age (< 10 / ≥ 10)
< 10
85
20.1
339
79.9
424
≥ 10
122
7.1
1586
92.9
1708
3.96 (2.41-4.4)
Gender
P < 0.001
OR for gender (male/ female)
Male
132
12.2
942
87.8
1074
Female
75
7.1
983
92.9
1058
1.83 (1.36-2.47)
Overjet
P < 0.001
OR for overjet (>3 mm/3 mm
18
8.7
188
91.3
206
≤ 3 mm
189
9.8
1737
90.2
1926
1.136 (0.68 – 1.89)
Lip coverage
P = 0.62
OR for lip coverage (inadequate/adequate)
Inadequate
24
12.8
163
87.2
187
Adequate
183
9.4
1762
90.6
1945
1.418 (0.899-2.23)
P = 0.131
OR: odds ratio; CI: confidence interval
(2012). TDI most often involved maxillary central incisors both in the permanent and primary dentitions, a fact generally supported by the existing literature (David et al, 2009; Guedes et al, 2010; Ravishankar et al, 2010; Dua and Sharma, 2012). The prominent and vulnerable position of the maxillary incisors is responsible for their more frequent involvement in fractures than other anterior teeth. In the present study, single enamel fractures were the most common both in permanent and primary dentitions, in accordance with earlier observations (Rai and Munshi, 1998; Ravishankar et al, 2010; Kumar et al, 2011; Govindarajan et al, 2012). The severity and number of affected teeth seems to vary according to the aetiology of trauma. More severe impacts, such as those resulting from traffic accidents, may increase the number of teeth
Vol 12, No 1, 2014
involved (Guedes et al, 2010), which are better represented in hospital- and institution-based studies. In turn, it is likely that less severe injuries such as enamel fractures are less common in samples derived from a hospital setting (Patel and Sujan, 2012). Falls were the most frequently reported cause of injury in the present study, as previously shown (Rai and Munshi, 1998; et al, 2011; Dua and Sharma, 2012; Patel and Sujan, 2012). The majority of the children did not know the cause of the injury because of the retrospective nature of the study. It was possible that some children did not recall the circumstances of a traumatic event that led to minor enamel fractures (Govindarajan et al, 2012). Moreover, unknown causes have been postulated as a strategy to conceal the real causes (e.g. phys-
41
Krishna Murthy et al
ical abuse and assaults) because of shame or fear (Taiwo and Jalo, 2011). When a TDI is a result of violence, children tend to report they do not remember what caused the injury (Bendo et al, 2010). Children in an adverse family environment experience higher degrees of parental punishment, physical abuse and domestic violence (Nicolau et al, 2003). Thus, it is important for oral health professionals to recognise the signs and symptoms of violence and report suspected cases to the authorities. The relationship between overjet and adequate lip coverage with TDI has been investigated extensively by different authors and has yielded conflicting results. This is further complicated by the observation that the chosen cut-off points for overjet differ, ranging from 3 mm (Gupta et al, 2011; Kumar et al, 2011) to ≥ 5 mm (Bendo et al, 2010; Livny A et al, 2010; Dua and Sharma, 2012) or ≥ 6 mm (Schatz et al, 2012). Upon reviewing the literature, many Indian studies (Gupta et al, 2011; Kumar et al, 2011) have used 3 mm as a difference to look for in overjet. Further, a meta-analysis (Nguyen et al, 1999) and a review (Bastone et al, 2000) have also shown significant increases in TDI when 3 mm was taken as the criterion. Hence, the same classification was followed in the present study. Nevertheless, the present study did not find this positive association, as also asserted by Kumar et al (2011), who showed an insignificant relation between overjet and TDI. Based on the findings of the present study and the conflicting results in the existing literature, consideration of overjet as a risk factor for TDI should be done cautiously. There are two reasons for this: first, the effect of overjet on TDI is more often influenced by confounding factors such as age, gender, lip coverage and tooth development. Thus, the statistical method of choice should be a model analysis to take into account the effects of confounders (Nguyen QV et al, 1999). Second, the overjet is reported as a categorical variable by introducing an empirically based cut-off point, which leads to loss of information. Instead, treating overjet as a continuous variable and analysing its relation to TDI along with the confounding effects will give provide greater insight into the risk factors for dental injuries. Only 3.9% of children with TDI had undergone treatment, which agrees with the studies by Bendo et al (2010) and Govindarajan et al (2012). This indicates a low level of awareness among the children and their parents about the importance of
42
treating TDIs. It may also be due to the nature of the injuries (enamel fractures). It is possible that the children and the parents were not concerned about enamel fractures, as injury is not a disease and as such did not merit dental care in their opinion (Taiwo and Jalo, 2011).
CONCLUSION Educational programmes need to be developed for children, parents and schoolteachers with emphasis on ways of preventing dental trauma and providing emergency care for fractured teeth. Primary preventive policies should aim to create an appropriate and safe environment at home, school and the playground.
REFERENCES 1. Bastone EB, Freer TJ, McNamara JR. Epidemiology of dental trauma: A review of the literature. Aust Dent J 2000;45:2–9. 2. Bendo CB, Paiva SM, Oliveira AC, Goursand D, Torres CS, Pordeus IA, et al. Prevalence and associated factors of traumatic dental injuries in Brazilian schoolchildren. J Public Health Dent 2010;70:313–318. 3. Bendo CB, Paiva SM, Torres CS, Oliveira AC, Goursand D, Pordeus IA, et al. Association between treated/untreated traumatic dental injuries and impact on quality of life of Brazilian schoolchildren. Health Qual Life Outcomes 2010;8:114. 4. Carvalho ML, Moysés SJ, Bueno RE, Shimakura S, Moysés ST. A geographical population analysis of dental trauma in school-children aged 12 and 15 in the city of Curitiba-Brazil. BMC Health Serv Res 2010;10:203. 5. Census, 2011, Bangalore (Bengaluru) District. Available from http://www.census2011.co.in/census/district/242bangalore.html (accessed on 12th May 2012) 6. David J, Astrøm AN, Wang NJ. Factors associated with traumatic dental injuries among 12-year-old schoolchildren in South India. Dent Traumatol 2009;25:500–505. 7. Dearing SG. Overbite, overjet, lip-drape and incisor tooth fracture in children. N Z Dent J 1984;80:50–52. 8. Dua R, Sharma S. Prevalence, causes, and correlates of traumatic dental injuries among seven-to-twelve-year-old school children in Dera Bassi. Contemp Clin Dent 2012;3:38–41. 9. Govindarajan M, Reddy VN, Ramalingam K, Durai KS, Rao PA, Prabhu A. Prevalence of traumatic dental injuries to the anterior teeth among three to thirteen-year-old school children of Tamilnadu. Contemp Clin Dent 2012;3:164–167. 10. Guedes OA, Alencar AHG, Lopes LG, Pécora JD, Estrela C. A retrospective study of traumatic dental injuries in a Brazilian dental urgency service. Braz Dent J 2010;21:153–157.
Oral Health & Preventive Dentistry
Krishna Murthy et al 11. Gupta S, Kumar-Jindal S, Bansal M, Singla A. Prevalence of traumatic dental injuries and role of incisal overjet and inadequate lip coverage as risk factors among 4-15 years old government school children in Baddi-Barotiwala Area, Himachal Pradesh, India. Med Oral Patol Oral Cir Bucal 2011;16:e960–965. 12. Jose A, Joseph MR. Prevalence of dental health problems among school going children in rural Kerala. J Indian Soc Pedod Prev Dent 2003;21:147–151. 13. Kaba AS, Marechaux SC. A fourteen-year follow-up study of traumatic injuries to the permanent dentition. J Dent Child 1989;56:417–425. 14. Kaur N, Hiremath SS. Prevalence of traumatic injuries to permanent anterior teeth among 8–15 years old government and private schoolchildren in Bangalore city. JIAPHD 2011;17:357–363. 15. Kumar A, Bansal V, Veeresha KL, Sogi GM. Prevalence of traumatic dental injuries among 12- to 15-year-old schoolchildren in Ambala district, Haryana, India. Oral Health Prev Dent 2011;9:301–305. 16. Livny A, Sgan-Cohen HD, Junadi S, Marcenes W. Traumatic dental injuries and related factors among sixth grade schoolchildren in four Palestinian towns. Dent Traumatol 2010;26:422–426. 17. Naidoo S, Sheiham A, Tsakos G. Traumatic dental injuries of permanent incisors in 11- to 13-year-old South African schoolchildren. Dent Traumatol 2009;25:224–228.
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18. Nguyen QV, Bezemer PD, Habets L, Prahl-Andersen B. A systematic review of the relationship between overjet size and traumatic dental injuries. Eur J Orthod 1999;21:503–515. 19. Nicolau B, Marcenes W, Sheiham A. The relationship between traumatic dental injuries and adolescents’ development along the life course. Community Dent Oral Epidemiol 2003;31:306–313. 20. Norton E, O’Connell AC. Traumatic dental injuries and their association with malocclusion in the primary dentition of Irish children. Dent Traumatol 2012;28:81–86. 21. Patel MC, Sujan SG. The prevalence of traumatic dental injuries to permanent anterior teeth and its relation with predisposing risk factors among 8–13 years school children of Vadodara city: an epidemiological study. J Indian Soc Pedod Prev Dent 2012;2:151–157. 22. Rai SB, Munshi AK. Traumatic injuries to the anterior teeth among South Kanara school children–a prevalence study. J Indian Soc Pedod Prev Dent 1998;16:44–51. 23. Ravishankar TL, Kumar MA, Ramesh N, Chaitra TR. Prevalence of traumatic dental injuries to permanent incisors among 12-year-old school children in Davangere, South India. Chin J Dent Res 2010;13:57–60. 24. Schatz JP, Hakeberg M, Ostini E, Kiliaridis S. Prevalence of traumatic injuries to permanent dentition and its association with overjet in a Swiss child population. Dent Traumatol 2013;29:110–114. 25. Taiwo OO, Jalo HP. Dental Injuries in 12-year Old Nigerian Students. Dent Traumatol 2011;27:230–234.
43
Prevalence and Associated Factors of Traumatic Dental Injuries Among 5- to 16-year-old Schoolchildren in Bangalore City, India Archana Krishna Murthya/Pramila Mallaiah b/Ranganath Sangac Purpose: To investigate the prevalence and associated factors of traumatic dental injury (TDI) among 5- to 16-year-old schoolchildren in Bangalore City, India. Materials and Methods: In this cross-sectional study, a probabilistic sample of 2,140 schoolchildren was administered a questionnaire and examined intraorally to record TDI using the Ellis classification. Descriptive statistics and regression models were used for analysis of the data. Results: The prevalence of TDI among 5- to 16-year-old schoolchildren in Bangalore City was 9.7%. Boys (12.2%) were affected more than girls (7.1%). About 85% of the injuries occurred in maxillary anterior teeth and 89% in the permanent dentition with fractures in enamel as the most common type of TDI. Unknown causes accounted for 53.6% and falls (36.7%) were the most common reported cause. Only 3.9% of children with TDI had sought treatment. Children from public schools aged less than 10 years and boys had significantly higher TDIs as compared to private schoolchildren, those over 10 years of age and girls. Conclusion: The present study revealed a moderate prevalence of dental trauma. An emergent problem such as TDI should be met by public health policies that emphasise the prevention of TDI based on the knowledge of the risk factors. Children, parents and schoolteachers should be educated about the prevention and timely management of dental trauma in children. Key words: children, prevalence, traumatic dental injury (TDI) Oral Health Prev Dent 2014;1:37-43
Submitted for publication: 08.10.12; accepted for publication: 19.12.12
doi: 10.3290/j.ohpd.a31226
T
he prevalence and characteristics of traumatic dental injury (TDI) in schoolchildren have been extensively studied (Bendo et al, 2010), but no agreement exists on the prevalence of TDI, as it has differed from study to study and from country to country. Studies report frequencies ranging from 9.4% to 41.6% in primary dentition (Norton et al, 2012). With respect to permanent dentition, the prevalence of TDIs among adolescents in the Americas and Europe varied from 15% to 23% and 23% to 35%, respectively. The corresponding prevalence a
Assistant Professor, Department of Public Health Dentistry, M. R. Ambedkar Dental College, Bangalore, India.
b
Professor and Head, Department of Public Health Dentistry, M. R. Ambedkar Dental College, Bangalore, India.
c
Senior Lecturer, Department of Public Health Dentistry, M. R. Ambedkar Dental College, Bangalore, India.
Correspondence: Assistant Professor Archana Krishna Murthy, Department of Public Health Dentistry, M. R. Ambedkar Dental College, Bangalore, India. Tel: +91-0984-562-0292. Email: archanakm20@ gmail.com
Vol 12, No 1, 2014
rates in Asia and Africa ranged from 4% to 35% and 15% to 21% (Gupta et al, 2011). The aetiology and predisposing factors of TDIs are well documented. Research has demonstrated strong associations with gender, incisal overjet and lip coverage (Livny et al, 2010; Norton et al, 2012). Additionally, environmental factors and social characteristics such as type of school, time elapsed after the injury and treatment given or lack thereof also contribute to the better understanding of TDI and aid in planning public health policies that emphasise the prevention of TDI. On the other hand, data on the prevalence of dental injuries in India is relatively sparse. Apart from a few sporadic studies in different parts of India (Rai and Munshi et al, 1998; David et al, 2009; Gupta et al, 2011; Dua and Sharma, 2012; Govindarajan et al, 2012), no published literature is available on the prevalence and etiology of TDI among schoolchildren in Bangalore City. Hence, this study was undertaken to gather information
37
Krishna Murthy et al
about TDI to primary and permanent teeth among Indian schoolchildren living in Bangalore City. The specific objectives were to assess the prevalence of trauma to primary and permanent anterior teeth among 5- to 16-year-old schoolchildren and to investigate associations between TDI and independent anatomic and demographic variables.
MATERIALS AND METHODS This cross-sectional study was carried out among 5- to 16-year-old schoolchildren enrolled at public and private schools in Bangalore City. According to the 2011 census, Bangalore City has 84,25,970 inhabitants, with nearly 1 million schoolchildren in 2076 public and private schools (Census, 2011). The age group of 5–16 years is relevant, as in India a child commences formal schooling at the age of 5 years and at 16 years the child is in the 10th grade, which is the last grade of schooling. A probabilistic sample was calculated with a standard error of 2%, 95% confidence level and a 14% prevalence of TDI (Kaur and Hiremath, 2011). A correction factor of 1.5 was applied to increase the precision as a multistage sampling method was adopted rather than random sampling (Bendo et al, 2010). The minimum sample size needed to satisfy the requirements was estimated at 1,733 individuals. However, an additional 20.0% were asked to participate in the study (N = 2,140) in order to compensate for potential refusals. Information on the study had previously been given in the classrooms to all the children and classes. A letter was sent to all the parents outlining the aims and procedures of the study, and their consent was obtained. This study received the clearance from Eth-
ics Committee of M. R. Ambedkar Dental College, Bangalore. A total sample of 2,132 children aged from 5 to 16 years was randomly selected to represent the population of schoolchildren in Bangalore city. Data were collected using a questionnaire and clinical examination. The following relevant variables were collected from the child: age, gender, cause and place of injury, time elapsed since injury and reasons for not seeking treatment, where applicable. A dental examination was performed by two examiners using the Ellis classification for defining and recording TDI (Table 1) (Naidoo et al, 2009). A pilot study was performed on 140 randomly selected children (not part of the study sample) to assess the level of consistency between the examiners regarding TDI examination. The mean Kappa values were 0.96 for intra-examiner and 0.85 for inter-examiner agreement regarding TDI, thereby demonstrating good consistency. Overjet was measured using a Community Periodontal Index probe which was dichotomised to ≤ 3 mm and > 3 mm during the analysis. Lip coverage was classified as adequate when lips covered the anterior teeth completely in the at-rest position and as inadequate if the majority of the crown height was exposed and visible. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS for Windows, version 16.0, SPSS; Chicago, IL, USA). Descriptive statistical analyses were initially performed including frequency distributions and cross tabulations. Regression models analysing the variables of age ( 12 months
Unknown
Frequency (%)
31 (15)
23 (11.1)
42 (20.3)
111 (53.6)
Reason for not seeking treatment
Already treated
No problem
Not aware
Uninterested parents
High cost
Fear of pain
Frequency (%)
8 (3.9)
102 (49.3)
83 (40.1)
6 (2.9)
5 (2.4)
3 (1.4)
*As per Ellis classification (Table1).
40
Oral Health & Preventive Dentistry
Krishna Murthy et al
Table 3 Frequency analysis and logistic regression of the association between the variables studied and dental trauma in 5- to 16-year-old children (N = 2132) Trauma at clinical examination Yes N
No %
n
Total
OR (95% CI)
P-value
%
School
OR for school (government/ private)
Government
145
13.2
950
86.8
1095
Private
62
6
975
94
1037
2.40 (1.76-3.27)
Age (years)
P < 0.001
OR for age (< 10 / ≥ 10)
< 10
85
20.1
339
79.9
424
≥ 10
122
7.1
1586
92.9
1708
3.96 (2.41-4.4)
Gender
P < 0.001
OR for gender (male/ female)
Male
132
12.2
942
87.8
1074
Female
75
7.1
983
92.9
1058
1.83 (1.36-2.47)
Overjet
P < 0.001
OR for overjet (>3 mm/3 mm
18
8.7
188
91.3
206
≤ 3 mm
189
9.8
1737
90.2
1926
1.136 (0.68 – 1.89)
Lip coverage
P = 0.62
OR for lip coverage (inadequate/adequate)
Inadequate
24
12.8
163
87.2
187
Adequate
183
9.4
1762
90.6
1945
1.418 (0.899-2.23)
P = 0.131
OR: odds ratio; CI: confidence interval
(2012). TDI most often involved maxillary central incisors both in the permanent and primary dentitions, a fact generally supported by the existing literature (David et al, 2009; Guedes et al, 2010; Ravishankar et al, 2010; Dua and Sharma, 2012). The prominent and vulnerable position of the maxillary incisors is responsible for their more frequent involvement in fractures than other anterior teeth. In the present study, single enamel fractures were the most common both in permanent and primary dentitions, in accordance with earlier observations (Rai and Munshi, 1998; Ravishankar et al, 2010; Kumar et al, 2011; Govindarajan et al, 2012). The severity and number of affected teeth seems to vary according to the aetiology of trauma. More severe impacts, such as those resulting from traffic accidents, may increase the number of teeth
Vol 12, No 1, 2014
involved (Guedes et al, 2010), which are better represented in hospital- and institution-based studies. In turn, it is likely that less severe injuries such as enamel fractures are less common in samples derived from a hospital setting (Patel and Sujan, 2012). Falls were the most frequently reported cause of injury in the present study, as previously shown (Rai and Munshi, 1998; et al, 2011; Dua and Sharma, 2012; Patel and Sujan, 2012). The majority of the children did not know the cause of the injury because of the retrospective nature of the study. It was possible that some children did not recall the circumstances of a traumatic event that led to minor enamel fractures (Govindarajan et al, 2012). Moreover, unknown causes have been postulated as a strategy to conceal the real causes (e.g. phys-
41
Krishna Murthy et al
ical abuse and assaults) because of shame or fear (Taiwo and Jalo, 2011). When a TDI is a result of violence, children tend to report they do not remember what caused the injury (Bendo et al, 2010). Children in an adverse family environment experience higher degrees of parental punishment, physical abuse and domestic violence (Nicolau et al, 2003). Thus, it is important for oral health professionals to recognise the signs and symptoms of violence and report suspected cases to the authorities. The relationship between overjet and adequate lip coverage with TDI has been investigated extensively by different authors and has yielded conflicting results. This is further complicated by the observation that the chosen cut-off points for overjet differ, ranging from 3 mm (Gupta et al, 2011; Kumar et al, 2011) to ≥ 5 mm (Bendo et al, 2010; Livny A et al, 2010; Dua and Sharma, 2012) or ≥ 6 mm (Schatz et al, 2012). Upon reviewing the literature, many Indian studies (Gupta et al, 2011; Kumar et al, 2011) have used 3 mm as a difference to look for in overjet. Further, a meta-analysis (Nguyen et al, 1999) and a review (Bastone et al, 2000) have also shown significant increases in TDI when 3 mm was taken as the criterion. Hence, the same classification was followed in the present study. Nevertheless, the present study did not find this positive association, as also asserted by Kumar et al (2011), who showed an insignificant relation between overjet and TDI. Based on the findings of the present study and the conflicting results in the existing literature, consideration of overjet as a risk factor for TDI should be done cautiously. There are two reasons for this: first, the effect of overjet on TDI is more often influenced by confounding factors such as age, gender, lip coverage and tooth development. Thus, the statistical method of choice should be a model analysis to take into account the effects of confounders (Nguyen QV et al, 1999). Second, the overjet is reported as a categorical variable by introducing an empirically based cut-off point, which leads to loss of information. Instead, treating overjet as a continuous variable and analysing its relation to TDI along with the confounding effects will give provide greater insight into the risk factors for dental injuries. Only 3.9% of children with TDI had undergone treatment, which agrees with the studies by Bendo et al (2010) and Govindarajan et al (2012). This indicates a low level of awareness among the children and their parents about the importance of
42
treating TDIs. It may also be due to the nature of the injuries (enamel fractures). It is possible that the children and the parents were not concerned about enamel fractures, as injury is not a disease and as such did not merit dental care in their opinion (Taiwo and Jalo, 2011).
CONCLUSION Educational programmes need to be developed for children, parents and schoolteachers with emphasis on ways of preventing dental trauma and providing emergency care for fractured teeth. Primary preventive policies should aim to create an appropriate and safe environment at home, school and the playground.
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