ARTÍCULOS ORIGINALES

Traumatic dental injuries and associated factors among Brazilian preschool children aged 1-5 years

 

Ana F. Granville-Garcia¹, Ítala Tarciane de Almeira Vieira², Maria J. Pereira da Silva Siqueira² , Valdenice Aparecida de Menezes², Alessandro Leite Cavalcanti¹

¹ Department of Pediatric Dentistry, School of Dentistry, State University of Paraíba, Campina Grande, Paraíba, Brazil.
² Department of Pediatric Dentistry, School of Dentistry, Higher Education Association of Caruaru, Pernambuco, Brazil.

CORRESPONDENCE Ana Flavia Granville-Garcia Rua Capitao Joao Alves Lira, 1325/410 Bela Vista, Campina Grande, Paraiba, Brasil 58101281 Tel: +55- 21- 83- 3341-0268 e-mail: anaflaviagg@hotmail.com

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ABSTRACT

The aim of this study was to evaluate the prevalence of dental trauma in children aged 1 to 5 years old and its associated factors (gender, age group, malocclusion and labial-closing), interviewing parents and guardians for additional information on the trauma occurrence. A transversal study of 820 preschool children from the City of Caruaru, Pernambuco, Brazil was conducted. Data were collected by means of a clinical examination and a structured interview. The statistical analysis included a distribution of frequencies, a bi- and a multi-variate analysis at a significance level of 5%. Trauma prevalence was 20.1%, tooth 61 was the most often affected, and enamel fractures followed by the fractures of the enamel and the dentine were the most frequent alterations. Trauma prevalence was highest in 3- to 5-year-old males with malocclusion (open bite and protrusion) (p<0.05). According to most parents and/or guardians, the most usual etiology was falling and the place most often cited was home. All the variables studied, except for lip coverage, were associated with dental trauma. The outcome of the present study showed high prevalence of dental trauma in a pediatric population under the age of 5 years. Falls and accidental collisions were the etiological factors most often cited. The front upper incisors were the teeth most often affected, and enamel fracture was the trauma most often observed.

Key words: Pediatric dentistry; Epidemiology; Tooth injuries; Primary dentition.

RESUMO

Traumatismos dentários e fatores associados entre pré-escolares Brasileiros de 1 a 5 anos de idade

O objetivo deste estudo foi avaliar a prevalencia de trauma dentario em criancas de 1 a 5 anos de idade e os fatores associados (genero, faixa etaria, maloclusao e selamento labial), por meio de entrevistas com os pais e responsaveis para a obtencao de informacoes adicionais sobre a ocorrencia do trauma. Um estudo transversal com 820 pre-escolares foi realizado na cidade de Caruaru, Pernambuco, Brasil. Os dados foram coletados por meio de exame clinico e de uma entrevista estruturada. A analise estatistica incluiu a distribuicao de frequencias, analise bi e multi-variada com um nivel de significancia de 5%. A prevalencia de trauma foi de 20,1%, sendo o dente 61 o mais afetado e as fraturas de esmalte e fraturas de esmalte e dentina as alteracoes mais frequentes. A prevalencia de trauma foi maior nos meninos de 3 a 5 anos com maloclusao (mordida aberta e protrusao) (p<0,05). De acordo com a maioria dos pais e responsaveis, a etiologia mais frequente foi a queda, e o lugar da ocorrencia a residencia. Todas as variaveis estudadas, exceto o selamento labial, mostraram-se associadas com o trauma dentario. Este estudo revelou uma alta prevalencia de traumatismo dentario na populacao infantil abaixo dos 5 anos de idade. Quedas e colisoes acidentais foram os fatores etiologicos mais frequentemente citados. Os incisivos centrais superiores os dentes mais atingidos e a fratura de esmalte o trauma mais observado.

Palavras chave: Odontopediatria; Epidemiologia; Traumatismo dentario; Denticao decidua.

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INTRODUCTION

The high prevalence of dental trauma in preschool children has become a public health concern¹. The main objectives of diagnosis and treatment of traumatic injuries affecting children with primary dentition are pain management and prevention of possible damage to the developing tooth germ². The age-group and gender of higher risk are controversial in the literature^3-6. The most common age group in which primary tooth injury occurs is 1.5 to 2.5 years. Injuries to the dentition of infants are infrequent during the first year of life because infants’ teeth do not start erupting until the child is 6 months of age, and infants are limited in their ability to move about in their environment⁷.
Protrusion of upper incisors, open bite, lip closure and epilepsy are among predisposing factors^3,8. Maxillary teeth are more frequently traumatized than mandibular teeth and there is general agreement that maxillary central incisors are injured most frequently, probably due to their vulnerable position9. When they are lost at the beginning or even in the middle of their biological cycle, there are esthetic alterations, with a reduction of the child’s self-esteem, making speech difficult or even contributing to install deleterious habits¹⁰. The purpose of this retrospective study was to determine the prevalence of traumatic injuries to primary anterior teeth and associated factors in preschool children from the city of Caruaru, Pernambuco, Brazil. The analysis of the oral health conditions of different groups and age ranges contributes information that is essential for planning and establishing health promotion action.

MATERIAL AND METHODS

Population
A transversal and an analytical epidemiological study were performed with retrospective components in an interview with parents and/or guardians. The sample was composed of 820 children aged 1 to 5 years, regularly enrolled in 7 municipal day care centers of the city of Caruaru, in Pernambuco State, located in the northeast of Brazil. The clinical examinations were performed in the first semester of 2007. Ethical consent for the study was obtained and written consent for participation was obtained from at least one of each child’s parents prior to the study, according to the ethical guidelines of the Declaration of Helsinki.

Examinations
Children were examined in predetermined order in selected rooms under natural light. During the clinical examination, children sat on school desks, in plain natural light. Children under two years old went through a foot-foot, or knee-knee system¹¹. A mouth mirror #3, tweezers for cotton and a CPI periodontal probe were used in the examination, prior to which dental biofilm was removed using antiseptic gauze. The classification suggested by Hinds and Gregory¹² was used for recording traumas. The criteria are discoloration, enamel fracture, enamel and dentin fracture; enamel, dentin and pulp fracture; avulsion, lateral luxation, intrusive and extrusive, restoration caused by trauma; combined traumas. Immediately prior to the examination, lip coverage was recorded (adequate or not) with facial musculature in apparent rest, when the child was distracted and unaware of the occurrence of the examination¹³. Overjet was measured with teeth in centric occlusion; the probe parallel to the occlusal plane to register dental protrusion (protrusion greater than 3mm). When there was no contact between the anterior teeth and the posterior teeth remained in occlusion, open bite was diagnosed¹⁴. Examination criteria were diagnosed and standardized in order to ensure precise results and minimize the occurrence of intra-examiner error. The examiner repeated the clinical examination on 10% of the children in the sample within 24 hours in order to determine intra-examiner agreement, which was thus found to be greater than 0.90. When trauma was diagnosed, parents or guardians were interviewed individually in order to obtain additional information. Standardized or structured interviews were used, and the reliability of the results was tested using the “face” validation method in 10% of the interviews¹⁵.

Statistical Analysis
All recorded data were analyzed with the software SPSS version 11.0. Entire distributions, uni- and bi-variate percentages (descriptive statistics techniques) were obtained to analyze data, and the Pearson independence Chi-square test was performed. Odds Ratio (OR) values and reliability ranges were obtained to study the link between independent and dependent variables in a bi-variate study, considering the first or the last category as reference values. In order to determine the influence of independent variables upon the dependent variable (child with trauma), two sample techniques of logistic regression were adjusted along with the three independent variables selected during the bi-variate study that were significant with the dependent variable or the answer at the level of 5.0%.

RESULTS

Table 1 shows that trauma prevalence increases with age, from 4.2% for one-year-olds to 25.5% for 5-year-olds. The link between trauma and age group becomes important according to the value of p, to the value of OR and to the OR intervals excluding the value 1.00. Trauma prevalence was 5.5% higher among boys than girls (p<0.05; OR=1.41 [1.00-2.00]).

Table 1: Trauma prevalence assessment according to age and gender.

Enamel fracture was the most frequent type of trauma, representing 56.4% of the cases, followed by 17.6% with fracture of the enamel and the dentine, intrusion (7.9%) and avulsion (7.3%). The teeth most often affected by trauma were 61 and 51, making up 62.4% and 58.8% of the sample with trauma, respectively (Table 2).

Table 2: Relative and absolute distribution of the type of trauma and affected tooth (52, 51, 61 and 62).

Trauma prevalence was very similar in children with adequate or inadequate lip coverage (20.9% x 19.4%) and there is no major association between the two variables (p>0.005; OR=1.10 [0.78-1.55]). Trauma prevalence was higher in children with isolated open bite (23.7%), or in those with both open bite and dental protrusion (31.2%), showing a significant link between the type of occlusion and trauma (p<0.05) (Table 3).

Table 3: Trauma prevalence assessment according to age and gender.

Table 4 shows that the majority of parents or guardians of children who suffered trauma (79.9%) did not react immediately; 4.9% sought help later, and only 15.2% acted promptly. The two places where the child suffered trauma most often cited were at home (42.4%) and at school (38.2%). Falls and accidental collisions were the etiological factors most often cited, with percentages of 64.8% and 20.6%, respectively.

Table 4: Trauma assessment, according to parents’ behavior, location and etiology.

Table 5 shows a logistic regression. The OR values in the table show that the probability of a child suffering a trauma increases with age, especially for boys with both open bite and protrusion.

Table 5: Logistic regression results for trauma prevalence.

DISCUSSION

This research was motivated by the high prevalence of dental trauma in childhood and the small number of Brazilian studies on this topic in primary dentition. The literature shows that it is at the preschool age that children are most vulnerable to trauma, either due to not yet having fully-developed motor skills, or due to their increased curiosity and independence during this phase. Therefore, the exploration of this topic as well as the knowledge of factors related to trauma occurrence will contribute to its prevention through health care policies^5,6,9. Hinds and Gregory’s classification in the final report of National Diet and Survey: children aged 1 . to 4 . years was selected for this study. This classification takes into account the findings, according to the clinical aspects, of accidents that affected teeth, and is therefore appropriate and useful for epidemiological purposes and adequate for this study, in the absence of an X-ray examination¹². The prevalence of trauma found in this study was 20.1%. No agreement exists on the prevalence of traumatic dental injuries, as it has differed from study to study and from country to country⁹. Retrospective and prospective studies report frequencies ranging from 9.4 to 41.6%^{1,3-6,8,9,16,17}. These differences are probably due to the population tested, the methodology or the type of classification used.
Enamel fracture was the most frequent type of alteration (56.4%), followed by enamel and dentine fracture (17.6%). This result is similar to those in others studies^1,4,5,8,9,17. It is important to point out that because this study was performed at day care centers, the frequency of small-scale traumas was higher than in hospitals. Most studies of dental traumas involve front upper teeth due to the discreet prevalence of teeth with trauma in the inferior arch^5,16,18. Based upon that, the teeth most often affected were 61 and 51 and these results are similar to previous studies5,6,19. However, there are no studies in the literature on deciduous teeth showing that the left side is more often affected in dental traumas. The age group was a variable related to dental trauma (p<0.05). Trauma occurrence increased with age, with 3- to 5-year-olds being the most affected. This is supported by previous studies in Brazil^5,6,8,9 and Cuba¹. These results were confirmed in the logistics regression analysis. Regarding gender, there was a significant link with dental trauma, where males were the most affected (p<0.05). Studies maintain that there is no gender difference related to traumas in the age group studied^8,17,19. However, it is shown here that boys are more often affected by trauma^1,5,9, with the likelihood of boys having dental trauma being 1.45 times higher than for girls (Table 5). There are few studies of malocclusion, lip coverage and traumas in primary dentition in the literature. Dental protrusion, open bite and inadequate lip coverage are not trauma predisposing factors in primary dentition3. In this study, the facts showed no relationship between lip coverage and trauma, but did show a relationship between type of occlusion and trauma for the age group studied (p<0.05). The logistic regression analysis confirmed that children with open bite and dental protrusion are 1.72 times more likely to have dental traumas (Table 5).
School and home were the places most often cited for the occurrence of dental trauma. These are the places where children in this age group spend most time²⁰. Falls were the etiological factor most often mentioned by parents, in agreement with many studies in the literature^3,5,16,17. Only 15.2% of parents sought immediate help after trauma, while 4.9% did so later. Negligence regarding the treatment of children in relation to this problem has been mentioned^3,5,8.
This is probably due to the fact that little attention is paid to primary dentition and that there is a lack of information about possible damage to permanent dentition as well. There is a need to provide adequate preventive and treatment care for preschool children⁹. Therefore, prevention and orientation campaigns regarding common risk factors such as accidents must be prioritized and incorporated in health care general instructions.

CONCLUSION

The outcomes of the present study showed a high prevalence of dental trauma in a pediatric population under the age of 5. Falls and accidental collisions were the etiological factors most often cited. The front upper incisors were the teeth most often affected and enamel fracture was the trauma most frequently found.

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