Eur Arch Paediatr Dent DOI 10.1007/s40368-014-0121-4
ORIGINAL SCIENTIFIC ARTICLE
Prevalence of primary tooth traumatic injuries among children in a large industrial centre of Russian Federation I. Makeeva • M. Sarapultseva • A. Sarapultsev
Received: 4 December 2013 / Accepted: 8 February 2014 Ó European Academy of Paediatric Dentistry 2014
Abstract Background Recently, the number of children seeking dental care for traumatic tooth injuries has increased substantially. Aim This study was aimed at assessing the prevalence of primary tooth traumatic injuries (PTTI) in the paediatric populace of Ekaterinburg, a large industrial centre of the Russian Federation. Design Following ethical approval, an epidemiological investigation of primary dentition was conducted, evaluating 1,149 children aged 6–72 months (males 586/1,149, 51 %; females 563/1,149, 49 %). The average age of subjects overall was 43.9 ± 17.7 months (males 45.1 ± 17.9 months; females 42.6 ± 17.4 months). Results The prevalence of PTTI among paediatric residents of this region was 9.75 %, with uncomplicated crown fracture (36.9 %) as the chief primary dental injury. Dental visits attributable to PTTI were most frequent in the age group of 25–36 months, which clearly constitutes the period of greatest vulnerability. Conclusions The findings of this study suggest that PTTI is a critical issue in children, requiring programmes that address preventive dental care and adhere to established medical treatment standards. I. Makeeva Department of Operative Dentistry, First Moscow State Medical University named by I.M.Sechenov, Moscow, Russia M. Sarapultseva Vital EVV, Medical Firm, Ekaterinburg, Russia A. Sarapultsev (&) Institute of Immunology and Physiology (IIP), Ural Division of Russian Academy of Sciences, ul. Pervomaiskaya 106, 620219 Ekaterinburg, Russia e-mail: [email protected]
Keywords Primary teeth Traumatic injuries Industrial centre Epidemiology
Introduction To date, prevention and treatment of caries has been the focus of paediatric dentistry. Recently, however, the number of patients seeking care for primary tooth traumatic injuries (PTTI) has increased substantially, altering the course of structural disease. The prevalence of PTTI differs dramatically according to sources referenced. A maximum prevalence of 30 % is cited by Andreasen and Ravn (1972), whose investigation involved 3- to 7-year-old children residing in Denmark. Similar age-specific rates (30.8 %) were shown by Otuyemi et al. (1996) for 1- to 5-year-old children in Nigeria. On the other hand, 16.6 % was reported by Sa´nchez et al. (1981), for children aged 3–6 years for PTTI in the Dominican Republic, and comparable rates (15 and 16.3 %, respectively) were shown by both Hargreaves et al. (1999), who researched PTTI in South Africa, and Cunha et al. (2001) in Brazil. On the low end of estimates, the survey performed by Forsberg and Tedestam (1990) in Sweden found a 12 % prevalence of PTTI in children aged 1–6 years, and a prevalence of 11.1 % resulted from studies of paediatric cohorts in Israel implemented by Zadik (1976). Outcomes of various investigations, based on smaller-sized samplings, are presented in Table 1. The data variability observed in such small-scale surveys, as well as in related large-scale investigations, may reflect cultural, behavioural, and socio-economic peculiarities of given countries and regions. Use of nonstandard systems for classifying traumatic injuries may also encourage disparate outcomes.
123
Eur Arch Paediatr Dent Table 1 Summary of recent studies on prevalence of primary teeth traumatic injuries (in accordance with available literature) References
Number of examined patients (patients age, years)
Primary teeth traumatic prevalence (%)
Al-majad et al. (2001) (10)
354 (5–6)
33
Kramer et al. (2003) (11) Beltra˜o et al. (2007) (12)
1,545
35
293 (1–3)
10.2
Rai et al. (2006) (13) Rodrı´guez (2007) (14)
375 (2–10)
16
543 (2–5)
34.2
Adekoya-Sofowora et al. (2008) (15) Aysun and Bengi (2009) (16)
600 (3–5)
23.2
563 (0–3)
17.4
Robson et al. (2009) (17)
419 (0–5)
39.1
On the other hand, significantly fewer tooth injuries occurred in the primary dentition, as noted by a number of studies. In a survey by Skaare and Jacobsen (2005), tooth injuries accounted for 1.3 %, and Huang et al. (2005) reported a prevalence of 0.94 %. It must be emphasised that minor tooth injuries in the primary dentition not infrequently go unnoticed and unreported by parents, and therefore are not registered in epidemiologic surveys of non-specialists (Bastone et al. 2000). Data on the prevalence of PTTI in paediatric Russian Federation (RF) residents is sparse and fragmentary, and no targeted investigations have taken place in this regard. Some awareness of PTTI epidemiology may be of use in planning better preventive dental care and treatment is aimed at providing a foundation for developing social, educational, and training programmes. This investigation of PTTI prevalence in the children of Ekaterinburg, RF is detailed herein.
Materials and methods Study population and data collection This prospective study was conducted in the RF city of Ekaterinburg, which is the main industrial and cultural centre of the Ural Federal District, with a population of nearly 1.5 million people. The prevalence of PTTI was ascertained through clinical and epidemiological assessment of outpatient oral structural complaints registered between December 2010 and December 2012 at the Children’s Dental Polyclinic No 4 Branch of the ANO Stomatology Association of Ekaterinburg and the Vital EBB dental clinic (Ekaterinburg, RF). The Federal State Statistics Service provided information needed for analysis.
123
A total of 1,369 children with primary dentition and dental complaints, ranging in age from 6 to 72 months were invited to participate in an epidemiological parameter survey. Ultimately, 1,149 subjects were enrolled (84 % positive response rate; males 586/1,149, 51 %; females 563/1,149, 49 %). Children with no ongoing orthodontic treatment, whose parents were fluent in the Russian language and who were willing to participate, were eligible for study. Absence of erupted primary teeth, early mixed dentition, and non-consent were grounds for exclusion from the survey. Two clinicians trained in paediatric dentistry, each with a 5-year minimum work experience, performed patient examinations and completed all records according to protocol. A rigorous oral examination was required of each subject, including the following: (1) patient history; (2) inspection of maxillofacial area (external), oral cavity, and dentition; (3) check for presence and severity of caries in primary dentition; (4) mucosal and periodontal oral diagnostics; (5) radiographic assessment of hard teeth and periapical tissues (in all instances of trauma or assumed root fracture); (6) cold test, with thermal stimulus (if necessary); and (7) assessment of orthodontic status. For our purposes, the FDI World Dental Federation notation (ISO 3950) was applied. PTTI were evaluated in accordance with World Health Organization (WHO) classification as follows: (a) Class 1: tooth contusion with insignificant structural damage (enamel cracks), (b) Class 2: uncomplicated crown fracture, (c) Class 3: complicated crown fracture, (d) Class 4: complete crown-root fracture, (e) Class 5: longitudinal crown—root fracture, (f) Class 6: root fracture, (g) Class 7: tooth luxations, and (h) Class 8: exarticulation (avulsion). Two investigators evaluated patient records, and 10 % of each division underwent random re-evaluation by another investigator to gauge inter-examiner reliability (0.9 kappa reliability score). In addition, two investigators checked for presence and extent of intrusions, pathological changes in alveolar bone, pathological root resorption, root fracture, and visible tooth pulp pathology in dental radiographs. As above, 10 % of each division was re-evaluated (0.86 kappa reliability score). Ethical approval # C-3-12-2011 was obtained from the Institute of Immunology and Physiology (IIP) of the Ural Division of Russia Academy of Science, Ekaterinburg, and informed consent was obtained from all parents or legal guardians of subjects recruited for study. Patient consent forms, incorporating Guidelines of Federal Compulsory Medical Insurance Fund of the Russian Federation (1999 # 5470/30-Z/i) and ADA Principles of Ethics and Code of Professional Conduct, were distributed to parents at reception areas of dental clinics (ADA 2012). Requested information included name and date of birth of paediatric
Eur Arch Paediatr Dent
patient; name, relationship to patient, and legal basis for adult to consent on behalf of minor; description of specific treatment undertaken (in simple terms); alternatives to treatment; potential adverse sequelae of treatment; acknowledgement by patient or parent/guardian that all questions were answered; and signed by dentist, parent or legal guardian, and witness.
Table 2 Basic data on dental care needs of a population of preschool children Boys (N)
Girls (N)
Number of visits for caries and its complications
422
371
793
69.02
Number of visits for oral mucosa lesions
26
24
50
4.35
Statistical methods
Number of visits with orthodontic pathologies
25
35
60
5.22
Statistical analysis relied on standard software (SAS v 8.02 for Windows XP; SAS Institute, Cary, NC, USA). Quantitative features in terms of normality of distribution were evaluated using the Shapiro–Wilk test. Levene’s test was used to check equality of variances for the hypothesis. Quantitative data with a normal distribution were expressed as average value ± standard quadratic deviation, whereas data departing from normal distribution were expressed as median, first quartile (25 %), and third quartile (75 %). The Wilcoxon W/Mann–Whitney U test served to compare quantitative attributes. For qualitative data assessment, Chi squared distribution criteria were applied.
Healthy children (no dental pathology identified in examination)
38
96
134
11.66
Number of visits with primary teeth injuries
75
37
112
9.75
586
563
1,149
Results Average age of subjects overall was 43.9 ± 17.7 months (males 45.1 ± 17.9 months; females 42.6 ± 17.4 months). The minimal age of enrollees with dental complaints was 6 months in males and 9 months in females; and the maximum age of subjects, satisfying all required criteria for inclusion in the survey sampling, was 72 months for each gender. The largest number of requests for dental service was registered among males aged 49–60 months (25.1 %) and among females aged 37–48 months (23.8 %). The lowest number of requests originated from the age group \12 months (males 6.1 %; females 5.7 %). The nature and age-distribution of structural dental diseases identified in the study population are compiled in Table 2. The greatest number of visits (Table 2) were prompted by dental caries and related complications/sequelae (males 422 visits; females 371 visits). Hence, the maximal number of visits for this indication was registered in males aged 49–60 months (129 visits) and in females aged 60–72 months (128 visits). The highest number of visits for treatment of caries and related complications in female subsets was 111 visits at ages 49–60 months and 109 visits at ages 37–48 months. No children\1 year of age (male or female) had dental caries. Diseases of oral mucosa (i.e., viral, fungal, and traumatic aetiologies) and pathology of the frenulum were
Total
Total (N)
%
100.0
diagnosed in 4.35 % of children. The highest prevalence of oral mucosal disease was registered in both genders at ages 13–24 months (25 instances each). Prevalence of PTTI The overall prevalence of PTTI in children with structural dental diseases was 9.75 %, and traumatic tooth injuries were twice as common in males (67 % vs 33 %) (Table 3). The average age at which traumatic injury occurred was 38.4 ± 15.3 months in males (minimum age 11 months) and 35.7 ± 11.9 months in females (minimum age 19 months). Multiple injuries were identified in 41.1 % of subjects, with 2.61 % having two damaged teeth and 1.14 % showing damage to three or more teeth. Results of PTTI analyses are shown in Table 4. The most frequently encountered primary tooth lesion was uncomplicated crown fracture (36.9 %). Luxation injuries (26.4 %) were the second most common type of tooth injury recorded, followed by contusions (17.85 %) with minor structural changes. More severe damage, such as complete root-crown fracture (5.3 %), root fracture (5.3 %), and avulsion (5.95 %), was significantly less frequent. Only four instances (2.3 %) of complicated crown fracture were detected. No instances of Class 5 injury (longitudinal crown-root fracture) were identified in this study population. Traumatic injury localisation The aim of this study was to determine the types of injuries amassed through survey responses, specifying teeth affected and frequencies of insults (Table 5). Analysis of pertinent data showed that maxillary primary teeth were most frequently injured (98.2 %), whereas mandibular primary teeth seemed less prone to traumatic
123
Eur Arch Paediatr Dent Table 3 PTTI patients’ distribution of injuries by age groups Gender
Age group
Female
Missing information about age at time of injure
Male
N
% 2
Teeth number
Number of teeth with this damage (%)
5.4 53
0
0
8
21.6
52
21
12.5
25–36 months
11
29.7
51
73
43.45
37–48 months
6
16.2
61
62
36.9
49–60 months
8
21.6
62
9
5.35
Over 60 months
2
5.4
63
0
0
37 3
100.0 4.0
73 72
0 0
0 0
71
2
1.2
1
1.3
81
1
0.6
13–24 months
14
18.7
82
0
0
25–36 months
30
40.0
83
0
0
37–48 months
14
18.7
49–60 months
11
14.7
2
2.7
75
100.0
Missing information about age at time of injure
5
4.5
Under 12 months
1
0.9
13–24 months
22
19.6
25–36 months
41
36.6
37–48 months
20
17.9
49–60 months
19
17.0
4
3.6
112
100.0
Total Missing information about age at time of injure
Over 60 months Total
Over 60 months Total
Number of patients in this table is different from the total number of patients with diagnosed PTTI. It has resulted from the impossibility to determine the age of patients at the moment of traumatic injury (parents neither remembered the incident date or it had passed unnoticed); these instances were naturally excluded from the table analysis
Table 4 Primary classification)
teeth
traumatic
injury
structure
(WHO
Traumatic injury category
Number of teeth with this damage (N)
Number of teeth with this damage (%)
Class 1
30
17.85
Class 2
62
36.9
Class 3 Class 4
4 9
2.3 5.3
Class 5
0
0
Class 6
9
5.3
Class 7
44
26.4
Class 8
10
5.95
injury (1.8 %). A high prevalence (80.35 %) of injuries to central maxillary incisors was also evident, with greater tendency for injury to right-sided central incisors (43.45 % vs 36.9 %).
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Number of teeth with this damage (N)
13–24 months
Under 12 months
Total
Table 5 PTTI localization (according to teeth numbers)
There were no instances of maxillary and mandibular canine or lower lateral incisor injuries were observed.
Discussion The prevalence of PTTI in children with structural dental diseases in Ekaterinburg, RF was 9.75 %. Consequently, PTTI must be viewed as a serious regional medical condition, demanding more in terms of preventive maintenance and therapeutic adequacy. Indeed, a multidisciplinary approach involving dental professionals, paediatricians, teachers, and institutional leaders would be optimal in formulating and achieving needed improvements. A number of past surveys indicate that dental injuries are highest in children aged 13–18 months (Bastone et al. 2000; Kramer et al. 2003; Rodrı´guez 2007; Aysun and Topaloglu 2009). However, the occurrence of PTTI peaked at 25–36 months in both males and females of this cohort (40.0 and 29.7 %, respectively), which is aligned with findings of Al-majad et al. (2001). Major variability in this type of injury was registered by both genders in age groups 25–36 and 49–60 months. These outcomes undoubtedly were affected by behavioural variables in the course of adapting to novel activities. An increase in personal activity does take place at ages 25–36 months, and an upsurge in social growth and interactivity is seen at ages 49–60 months. It is of particular interest that primary tooth damage in males was twice that displayed by females. The latter is likely a natural consequence of emerging gender behavioural differences, namely greater physical mobility. Also of note, primary maxillary teeth were the most prone to injury (98.2 %), whereas traumatic injuries of primary mandibular teeth were much less frequent (1.8 %), and
Eur Arch Paediatr Dent
uncomplicated crown fracture (36.9 %) was the most common type of tooth injury recorded, followed by luxations (26.4 %) and contusions (17.85 %). These figures perhaps reflect the general anatomic diversity of children. Incompetent lips may provide inadequate protective coverage. In falls and collisions, limitations of peripheral vision may be at fault, rendering nasolabial triangle particularly susceptible.
Conclusion This study disclosed a 9.75 % prevalence of PTTI in paediatric inhabitants of Ekaterinburg, a major industrial centre of the RF. In addition, uncomplicated crown fracture was documented as the most common type of tooth damage, and specific developmental periods (25–36 and 49–60 months) where children may be especially vulnerable to PTTI were delineated. Above results should promote awareness among regional professionals and help advance related treatment and prevention efforts.
References Adekoya-Sofowora C, Adesina O, Nasir W. Traumatic dental injuries in nursery school children from Ile-Ife, Nigeria. Internet J Dent Sci. 2008;5(2). http://www.ispub.com/IJDS/5/2/11366. Accessed 15 June 2013. Al-majad I, Murray J, Maquire A. Prevalence of dental trauma in 5–6 and 12–14 years old boys in Riyadh, Saudi Arabia. Dent Traumatol. 2001;174:153–8. American Dental Association (2012) American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012. http://www.ada.
org/sections/about/pdfs/code_of_ethics_2012.pdf. Accessed 26 Sept 2013 Andreasen J, Ravn J. Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample. Int J Oral Surg. 1972;5:235–9. Aysun A, Topaloglu B. Traumatic tooth injuries to primary teeth of children aged 0–3 years. Dent Traumatol. 2009;25:323–7. Bastone E, Freer T, Mcnamara J. Epidemiology of dental trauma: a review of the literature. Aust Dent J. 2000;45:2–9. Beltra˜o E, Cavalcanti A, Albuquerque S, et al. Prevalence of dental trauma in children aged 1–3 years in Joao Pessoa (Brazil). Eur Arch Paediatr Dent. 2007;3:141–3. Cunha R, Pugliesi D, Vieira A. Oral trauma in Brazilian patients aged 0–3 years. Dent Traumatol. 2001;17:206–8. Forsberg C, Tedestam G. Traumatic injuries to teeth in Swedish children living in an urban area. Swed Dent J. 1990;14:115–22. Hargreaves J, Cleaton-Jones P, Roberts G, et al. Trauma to primary teeth of South African pre-school children. Dent Traumatol. 1999;15:73–6. Huang S, Hsiao S, Liu H, et al. The epidemiologic survey of traumatic deciduous teeth in Taiwan. J Hard Tissue Biol. 2005;14:47–50. Kramer P, Zembruski C, Ferreira S, et al. Traumatic dental injuries in Brazilian preschool children. Dent Traumatol. 2003;19:299–303. Otuyemi O, Segun-Ojo I, Adegboye A. Traumatic anterior dental injuries in Nigerian preschool children. East Afr Med J. 1996;73:604–6. Rai B, Madan M, Jain R, et al. Traumatic teeth in 2 to 10 years: in tertiary dental care centre. Internet J Dent Sci. 2006;4(2). http:// www.ispub.com/IJDS/4/2/12593. Accessed 15 June 2013. Robson F, Ramos-Jorge M, Bendo C, et al. Prevalence and determining factors of traumatic injuries to primary teeth in preschool children. Dent Traumatol. 2009;25:118–22. Rodrı´guez J. Traumatic anterior dental injuries in Cuban preschool children. Dent Traumatol. 2007;23:241–2. Sa´nchez J, Sa´nchez R, Garcı´a-Godoy F. Traumatic injuries of the anterior teeth in preschool children. Acta Odontol Pedia´tr. 1981;1:17–23. Skaare A, Jacobsen I. Primary tooth injuries in Norwegian children (1–8 years). Dent Traumatol. 2005;21:315–9. Zadik D. A survey of traumatized primary anterior teeth in Jerusalem preschool children. Community Dent Oral Epidemiol. 1976;4:149–51.
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ORIGINAL SCIENTIFIC ARTICLE
Prevalence of primary tooth traumatic injuries among children in a large industrial centre of Russian Federation I. Makeeva • M. Sarapultseva • A. Sarapultsev
Received: 4 December 2013 / Accepted: 8 February 2014 Ó European Academy of Paediatric Dentistry 2014
Abstract Background Recently, the number of children seeking dental care for traumatic tooth injuries has increased substantially. Aim This study was aimed at assessing the prevalence of primary tooth traumatic injuries (PTTI) in the paediatric populace of Ekaterinburg, a large industrial centre of the Russian Federation. Design Following ethical approval, an epidemiological investigation of primary dentition was conducted, evaluating 1,149 children aged 6–72 months (males 586/1,149, 51 %; females 563/1,149, 49 %). The average age of subjects overall was 43.9 ± 17.7 months (males 45.1 ± 17.9 months; females 42.6 ± 17.4 months). Results The prevalence of PTTI among paediatric residents of this region was 9.75 %, with uncomplicated crown fracture (36.9 %) as the chief primary dental injury. Dental visits attributable to PTTI were most frequent in the age group of 25–36 months, which clearly constitutes the period of greatest vulnerability. Conclusions The findings of this study suggest that PTTI is a critical issue in children, requiring programmes that address preventive dental care and adhere to established medical treatment standards. I. Makeeva Department of Operative Dentistry, First Moscow State Medical University named by I.M.Sechenov, Moscow, Russia M. Sarapultseva Vital EVV, Medical Firm, Ekaterinburg, Russia A. Sarapultsev (&) Institute of Immunology and Physiology (IIP), Ural Division of Russian Academy of Sciences, ul. Pervomaiskaya 106, 620219 Ekaterinburg, Russia e-mail: [email protected]
Keywords Primary teeth Traumatic injuries Industrial centre Epidemiology
Introduction To date, prevention and treatment of caries has been the focus of paediatric dentistry. Recently, however, the number of patients seeking care for primary tooth traumatic injuries (PTTI) has increased substantially, altering the course of structural disease. The prevalence of PTTI differs dramatically according to sources referenced. A maximum prevalence of 30 % is cited by Andreasen and Ravn (1972), whose investigation involved 3- to 7-year-old children residing in Denmark. Similar age-specific rates (30.8 %) were shown by Otuyemi et al. (1996) for 1- to 5-year-old children in Nigeria. On the other hand, 16.6 % was reported by Sa´nchez et al. (1981), for children aged 3–6 years for PTTI in the Dominican Republic, and comparable rates (15 and 16.3 %, respectively) were shown by both Hargreaves et al. (1999), who researched PTTI in South Africa, and Cunha et al. (2001) in Brazil. On the low end of estimates, the survey performed by Forsberg and Tedestam (1990) in Sweden found a 12 % prevalence of PTTI in children aged 1–6 years, and a prevalence of 11.1 % resulted from studies of paediatric cohorts in Israel implemented by Zadik (1976). Outcomes of various investigations, based on smaller-sized samplings, are presented in Table 1. The data variability observed in such small-scale surveys, as well as in related large-scale investigations, may reflect cultural, behavioural, and socio-economic peculiarities of given countries and regions. Use of nonstandard systems for classifying traumatic injuries may also encourage disparate outcomes.
123
Eur Arch Paediatr Dent Table 1 Summary of recent studies on prevalence of primary teeth traumatic injuries (in accordance with available literature) References
Number of examined patients (patients age, years)
Primary teeth traumatic prevalence (%)
Al-majad et al. (2001) (10)
354 (5–6)
33
Kramer et al. (2003) (11) Beltra˜o et al. (2007) (12)
1,545
35
293 (1–3)
10.2
Rai et al. (2006) (13) Rodrı´guez (2007) (14)
375 (2–10)
16
543 (2–5)
34.2
Adekoya-Sofowora et al. (2008) (15) Aysun and Bengi (2009) (16)
600 (3–5)
23.2
563 (0–3)
17.4
Robson et al. (2009) (17)
419 (0–5)
39.1
On the other hand, significantly fewer tooth injuries occurred in the primary dentition, as noted by a number of studies. In a survey by Skaare and Jacobsen (2005), tooth injuries accounted for 1.3 %, and Huang et al. (2005) reported a prevalence of 0.94 %. It must be emphasised that minor tooth injuries in the primary dentition not infrequently go unnoticed and unreported by parents, and therefore are not registered in epidemiologic surveys of non-specialists (Bastone et al. 2000). Data on the prevalence of PTTI in paediatric Russian Federation (RF) residents is sparse and fragmentary, and no targeted investigations have taken place in this regard. Some awareness of PTTI epidemiology may be of use in planning better preventive dental care and treatment is aimed at providing a foundation for developing social, educational, and training programmes. This investigation of PTTI prevalence in the children of Ekaterinburg, RF is detailed herein.
Materials and methods Study population and data collection This prospective study was conducted in the RF city of Ekaterinburg, which is the main industrial and cultural centre of the Ural Federal District, with a population of nearly 1.5 million people. The prevalence of PTTI was ascertained through clinical and epidemiological assessment of outpatient oral structural complaints registered between December 2010 and December 2012 at the Children’s Dental Polyclinic No 4 Branch of the ANO Stomatology Association of Ekaterinburg and the Vital EBB dental clinic (Ekaterinburg, RF). The Federal State Statistics Service provided information needed for analysis.
123
A total of 1,369 children with primary dentition and dental complaints, ranging in age from 6 to 72 months were invited to participate in an epidemiological parameter survey. Ultimately, 1,149 subjects were enrolled (84 % positive response rate; males 586/1,149, 51 %; females 563/1,149, 49 %). Children with no ongoing orthodontic treatment, whose parents were fluent in the Russian language and who were willing to participate, were eligible for study. Absence of erupted primary teeth, early mixed dentition, and non-consent were grounds for exclusion from the survey. Two clinicians trained in paediatric dentistry, each with a 5-year minimum work experience, performed patient examinations and completed all records according to protocol. A rigorous oral examination was required of each subject, including the following: (1) patient history; (2) inspection of maxillofacial area (external), oral cavity, and dentition; (3) check for presence and severity of caries in primary dentition; (4) mucosal and periodontal oral diagnostics; (5) radiographic assessment of hard teeth and periapical tissues (in all instances of trauma or assumed root fracture); (6) cold test, with thermal stimulus (if necessary); and (7) assessment of orthodontic status. For our purposes, the FDI World Dental Federation notation (ISO 3950) was applied. PTTI were evaluated in accordance with World Health Organization (WHO) classification as follows: (a) Class 1: tooth contusion with insignificant structural damage (enamel cracks), (b) Class 2: uncomplicated crown fracture, (c) Class 3: complicated crown fracture, (d) Class 4: complete crown-root fracture, (e) Class 5: longitudinal crown—root fracture, (f) Class 6: root fracture, (g) Class 7: tooth luxations, and (h) Class 8: exarticulation (avulsion). Two investigators evaluated patient records, and 10 % of each division underwent random re-evaluation by another investigator to gauge inter-examiner reliability (0.9 kappa reliability score). In addition, two investigators checked for presence and extent of intrusions, pathological changes in alveolar bone, pathological root resorption, root fracture, and visible tooth pulp pathology in dental radiographs. As above, 10 % of each division was re-evaluated (0.86 kappa reliability score). Ethical approval # C-3-12-2011 was obtained from the Institute of Immunology and Physiology (IIP) of the Ural Division of Russia Academy of Science, Ekaterinburg, and informed consent was obtained from all parents or legal guardians of subjects recruited for study. Patient consent forms, incorporating Guidelines of Federal Compulsory Medical Insurance Fund of the Russian Federation (1999 # 5470/30-Z/i) and ADA Principles of Ethics and Code of Professional Conduct, were distributed to parents at reception areas of dental clinics (ADA 2012). Requested information included name and date of birth of paediatric
Eur Arch Paediatr Dent
patient; name, relationship to patient, and legal basis for adult to consent on behalf of minor; description of specific treatment undertaken (in simple terms); alternatives to treatment; potential adverse sequelae of treatment; acknowledgement by patient or parent/guardian that all questions were answered; and signed by dentist, parent or legal guardian, and witness.
Table 2 Basic data on dental care needs of a population of preschool children Boys (N)
Girls (N)
Number of visits for caries and its complications
422
371
793
69.02
Number of visits for oral mucosa lesions
26
24
50
4.35
Statistical methods
Number of visits with orthodontic pathologies
25
35
60
5.22
Statistical analysis relied on standard software (SAS v 8.02 for Windows XP; SAS Institute, Cary, NC, USA). Quantitative features in terms of normality of distribution were evaluated using the Shapiro–Wilk test. Levene’s test was used to check equality of variances for the hypothesis. Quantitative data with a normal distribution were expressed as average value ± standard quadratic deviation, whereas data departing from normal distribution were expressed as median, first quartile (25 %), and third quartile (75 %). The Wilcoxon W/Mann–Whitney U test served to compare quantitative attributes. For qualitative data assessment, Chi squared distribution criteria were applied.
Healthy children (no dental pathology identified in examination)
38
96
134
11.66
Number of visits with primary teeth injuries
75
37
112
9.75
586
563
1,149
Results Average age of subjects overall was 43.9 ± 17.7 months (males 45.1 ± 17.9 months; females 42.6 ± 17.4 months). The minimal age of enrollees with dental complaints was 6 months in males and 9 months in females; and the maximum age of subjects, satisfying all required criteria for inclusion in the survey sampling, was 72 months for each gender. The largest number of requests for dental service was registered among males aged 49–60 months (25.1 %) and among females aged 37–48 months (23.8 %). The lowest number of requests originated from the age group \12 months (males 6.1 %; females 5.7 %). The nature and age-distribution of structural dental diseases identified in the study population are compiled in Table 2. The greatest number of visits (Table 2) were prompted by dental caries and related complications/sequelae (males 422 visits; females 371 visits). Hence, the maximal number of visits for this indication was registered in males aged 49–60 months (129 visits) and in females aged 60–72 months (128 visits). The highest number of visits for treatment of caries and related complications in female subsets was 111 visits at ages 49–60 months and 109 visits at ages 37–48 months. No children\1 year of age (male or female) had dental caries. Diseases of oral mucosa (i.e., viral, fungal, and traumatic aetiologies) and pathology of the frenulum were
Total
Total (N)
%
100.0
diagnosed in 4.35 % of children. The highest prevalence of oral mucosal disease was registered in both genders at ages 13–24 months (25 instances each). Prevalence of PTTI The overall prevalence of PTTI in children with structural dental diseases was 9.75 %, and traumatic tooth injuries were twice as common in males (67 % vs 33 %) (Table 3). The average age at which traumatic injury occurred was 38.4 ± 15.3 months in males (minimum age 11 months) and 35.7 ± 11.9 months in females (minimum age 19 months). Multiple injuries were identified in 41.1 % of subjects, with 2.61 % having two damaged teeth and 1.14 % showing damage to three or more teeth. Results of PTTI analyses are shown in Table 4. The most frequently encountered primary tooth lesion was uncomplicated crown fracture (36.9 %). Luxation injuries (26.4 %) were the second most common type of tooth injury recorded, followed by contusions (17.85 %) with minor structural changes. More severe damage, such as complete root-crown fracture (5.3 %), root fracture (5.3 %), and avulsion (5.95 %), was significantly less frequent. Only four instances (2.3 %) of complicated crown fracture were detected. No instances of Class 5 injury (longitudinal crown-root fracture) were identified in this study population. Traumatic injury localisation The aim of this study was to determine the types of injuries amassed through survey responses, specifying teeth affected and frequencies of insults (Table 5). Analysis of pertinent data showed that maxillary primary teeth were most frequently injured (98.2 %), whereas mandibular primary teeth seemed less prone to traumatic
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Eur Arch Paediatr Dent Table 3 PTTI patients’ distribution of injuries by age groups Gender
Age group
Female
Missing information about age at time of injure
Male
N
% 2
Teeth number
Number of teeth with this damage (%)
5.4 53
0
0
8
21.6
52
21
12.5
25–36 months
11
29.7
51
73
43.45
37–48 months
6
16.2
61
62
36.9
49–60 months
8
21.6
62
9
5.35
Over 60 months
2
5.4
63
0
0
37 3
100.0 4.0
73 72
0 0
0 0
71
2
1.2
1
1.3
81
1
0.6
13–24 months
14
18.7
82
0
0
25–36 months
30
40.0
83
0
0
37–48 months
14
18.7
49–60 months
11
14.7
2
2.7
75
100.0
Missing information about age at time of injure
5
4.5
Under 12 months
1
0.9
13–24 months
22
19.6
25–36 months
41
36.6
37–48 months
20
17.9
49–60 months
19
17.0
4
3.6
112
100.0
Total Missing information about age at time of injure
Over 60 months Total
Over 60 months Total
Number of patients in this table is different from the total number of patients with diagnosed PTTI. It has resulted from the impossibility to determine the age of patients at the moment of traumatic injury (parents neither remembered the incident date or it had passed unnoticed); these instances were naturally excluded from the table analysis
Table 4 Primary classification)
teeth
traumatic
injury
structure
(WHO
Traumatic injury category
Number of teeth with this damage (N)
Number of teeth with this damage (%)
Class 1
30
17.85
Class 2
62
36.9
Class 3 Class 4
4 9
2.3 5.3
Class 5
0
0
Class 6
9
5.3
Class 7
44
26.4
Class 8
10
5.95
injury (1.8 %). A high prevalence (80.35 %) of injuries to central maxillary incisors was also evident, with greater tendency for injury to right-sided central incisors (43.45 % vs 36.9 %).
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Number of teeth with this damage (N)
13–24 months
Under 12 months
Total
Table 5 PTTI localization (according to teeth numbers)
There were no instances of maxillary and mandibular canine or lower lateral incisor injuries were observed.
Discussion The prevalence of PTTI in children with structural dental diseases in Ekaterinburg, RF was 9.75 %. Consequently, PTTI must be viewed as a serious regional medical condition, demanding more in terms of preventive maintenance and therapeutic adequacy. Indeed, a multidisciplinary approach involving dental professionals, paediatricians, teachers, and institutional leaders would be optimal in formulating and achieving needed improvements. A number of past surveys indicate that dental injuries are highest in children aged 13–18 months (Bastone et al. 2000; Kramer et al. 2003; Rodrı´guez 2007; Aysun and Topaloglu 2009). However, the occurrence of PTTI peaked at 25–36 months in both males and females of this cohort (40.0 and 29.7 %, respectively), which is aligned with findings of Al-majad et al. (2001). Major variability in this type of injury was registered by both genders in age groups 25–36 and 49–60 months. These outcomes undoubtedly were affected by behavioural variables in the course of adapting to novel activities. An increase in personal activity does take place at ages 25–36 months, and an upsurge in social growth and interactivity is seen at ages 49–60 months. It is of particular interest that primary tooth damage in males was twice that displayed by females. The latter is likely a natural consequence of emerging gender behavioural differences, namely greater physical mobility. Also of note, primary maxillary teeth were the most prone to injury (98.2 %), whereas traumatic injuries of primary mandibular teeth were much less frequent (1.8 %), and
Eur Arch Paediatr Dent
uncomplicated crown fracture (36.9 %) was the most common type of tooth injury recorded, followed by luxations (26.4 %) and contusions (17.85 %). These figures perhaps reflect the general anatomic diversity of children. Incompetent lips may provide inadequate protective coverage. In falls and collisions, limitations of peripheral vision may be at fault, rendering nasolabial triangle particularly susceptible.
Conclusion This study disclosed a 9.75 % prevalence of PTTI in paediatric inhabitants of Ekaterinburg, a major industrial centre of the RF. In addition, uncomplicated crown fracture was documented as the most common type of tooth damage, and specific developmental periods (25–36 and 49–60 months) where children may be especially vulnerable to PTTI were delineated. Above results should promote awareness among regional professionals and help advance related treatment and prevention efforts.
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