| Abstract|| |
Aim: The present study aimed to determine the risk factors related to permanent maxillary incisors and soft tissue injuries along with providing information about the age distribution of trauma, overjet, lip competence and physical activity. Methods and Materials: The sample consisted of 2100 school children aged 8–14 years from 15 schools in the Nellore district. The sample was selected adopting a stratified random sampling method and screened applying WHO criteria for the oral examination. The screening was done in classrooms to obtain demographic data, including name, age, gender and children's experience to the maxillary incisor and soft tissue injuries. The injuries were categorized according to Andreasen classification. Overjet and lip competences were recorded, and physical activity was assessed using a questionnaire (PAQ-C). Results: Of the 2100 children, 228 (10.8%) had suffered traumatic injuries. Boys were 1.6 fold more prone to trauma than girls. Enamel fractures were a common type of trauma, and the commonly involved were maxillary central incisors. The relative risk for trauma is 1.215 times higher in increased overjet when compared to normal overjet. Incompetent lips showed 1.189 times greater risk of trauma. The high physical activity showed 1.692 times higher risk for trauma when compared to low physical activity. Conclusion: The prevalence of traumatic dental injuries among 8-14 year children was 10.8%. Boys were more commonly injured than girls. Increased overjet incompetent lips and high physical activities are risk factors for trauma. Enamel fracture was the most common type, and maxillary central incisors were the most common teeth having traumatic injuries.
Keywords: Incisor, overjet, physical activity, tooth injuries
|How to cite this article:|
Challa R, S.G. Nirmala S V, Alahari S, Nuvvula S. Assessing the risk factors for injuries to maxillary permanent incisors and soft tissues among school children – A cross-sectional study. Indian J Dent Res 2021;32:416-22
|How to cite this URL:|
Challa R, S.G. Nirmala S V, Alahari S, Nuvvula S. Assessing the risk factors for injuries to maxillary permanent incisors and soft tissues among school children – A cross-sectional study. Indian J Dent Res [serial online] 2021 [cited 2023 Jan 28];32:416-22. Available from: https://www.ijdr.in/text.asp?2021/32/4/416/345426
| Introduction|| |
Facial aesthetics play an essential role in self-identification, self-image and interpersonal confidence. Furthermore, they affect social behaviour. The mouth is of primary importance in determining facial attractiveness. An attractive dentition and smile are essential features for both children and adults. Traumatic injuries of permanent teeth can appear rather severe, significantly when associated with trauma to supporting tissues. A traumatic dental injury, be it a fracture, discolouration of teeth or avulsion of a tooth will alter facial appearance.
Dental injuries can occur at any age starting from one year of life, which tends to increase as the child begins to crawl, stand or walk, with the peak incidence being school age. The review for trauma among different age groups has reported two prevalent age groups: 2–5 years and 8–12 years. In 2–5 years, during the developmental period, when children are learning to walk and run, they tend to fall due to a lack of adequately developed coordination and judgment. Apart from that, accidents and peer fighting have also been reported. Children tend to spend more number of hours at home; hence, the most common place for the occurrence of traumatic injuries are reported to be at home, followed by school and other places.,
A majority of traumatic dental injuries involve only one permanent tooth, and the most frequently affected teeth are maxillary central incisors., The most frequent types of traumatic dental injuries (TDI) to permanent teeth are enamel fractures, enamel and dentin fractures and enamel-dentin fractures with pulp involvement. Prevalence of dental trauma with increasing overjet and inadequate lip coverage is significant for premaxillary area.
As per our knowledge, there are no other studies in the literature considering the association of physical activity and trauma to teeth. Hence, the present study was conducted to determine the risk factors related to the injuries to permanent maxillary incisors and soft tissues, emphasizing the influence of physical activity.
| Participants and Methods|| |
After the approval from the institutional ethical committee, a total of 25 schools were selected randomly from different geographical regions of the Nellore District. After explaining the nature and the purpose of the study, 15 schools permitted the study. Before the commencement of the study, consent from the respective school authorities and parents were obtained. Participants of this study were 2100 school-going children aged 8–14 years. Pre-investigation calculation of the required sample size was done to find a level of significance alpha = 0.05 at 5% and the power of test at 90%. The results indicated that at least 1500 children should be enrolled. The institutional ethical clearance was obtained on 22-06-2010 (NDC/PG-2009-10/EC/2010).
Inclusion criteria included children between ages 8-14 of either gender, consent given for participation and minimum school population of 50.
Exclusion criteria included children with medical conditions that could predispose them to injury.
Depending on the schools' prevailing conditions, the exact requirements for conducting the present study were determined. Accordingly, schoolchildren were examined in upright chairs or stools with adequate natural light during the daytime outside the classrooms in the corridor. The calibrated examiner examined all the children to avoid inter-examiner variability, and a well-trained assistant recorded the findings throughout the study.
The preliminary interview was conducted in classrooms to obtain children's demographic data, including name, age and gender and to inquire about the children's experience of injury to the maxillary incisors and soft tissues. Examination, data recording and infection control have been adopted as per the World Health Organization Basic Oral Health Survey Guidelines (1997).
Examination of trauma to permanent maxillary incisors
The examiner was positioned in front of the subject to ascertain the evidence of traumatic injury to maxillary incisors. Injuries were categorised according to Andreasen's classification. All the injuries to periodontal tissues except avulsion were grouped under luxation injuries.
Measurement of overjet
When the teeth were in occlusion, the distance from the labioincisal edge of the most prominent upper incisor to the corresponding lower incisor's labial surface was measured using the WHO periodontal probe with a scale in mm held parallel to the occlusal plane to assess overjet. The overjet was measured in millimetres (mm) and recorded into two categories as follows: Normal (0–3.5 mm) and increased (greater than 3.5) according to the Index of Orthodontic Treatment Need (IOTN). Furthermore, the overjet measurement was carried out by calibrations on the WHO probe, i.e., 3.5 mm, 5.5 mm, 8.5 mm and 11.5 mm. The nearest marking was taken as the final reading if the overjet measurement was found between two calibrations. In children where the overjet measurement was just at the halfway mark between the two markings, the mean value was taken as the final reading, i.e., if the measured overjet value on the probe was at the centre of 3.5 and 5.5 mm, then 4.5 mm was taken as the final reading. Lip incompetence was measured when the child was in a relaxed state without forcibly closing the lips.
Evaluation of physical activity
Physical activity was evaluated using the PAQ-C questionnaire. The interviewer read the questions, and the relevant answers revealed by the children were noted in the questionnaire format. The scoring criteria were used according to the PAQ-C manual. A score of 1 indicates low physical activity, whereas a score of 5 indicates high physical activity.
The data were analyzed with various statistical tools. Summary information like descriptive and frequency tabulations are presented. A multivariate statistical technique, Logistic Regression, was applied to study the significant factors for different injury levels. All the statistical analysis was carried out using the PASW SPSS18.0 version, and the graphs were drawn using Microsoft Excel®.
| Results|| |
Among 2100 children, 228 were reported with traumatic dental injuries, 139 boys (60.9%) are in the majority when compared to 89 girls (39.1%). Regarding the soft tissue injuries, upper lip injuries consisted of 0.8% without trauma and 9.7% with trauma, whereas lower lip injuries consisted of 0% without trauma and 3.1% with trauma. Other soft tissue injuries were 0.1% without trauma and 1.8% with trauma. Lip competence was found in 57.6% and 42.4% boys and girls and incompetence was found in 71.9% and 28.16% boys and girls, respectively.
The low physical activity of boys (29.8%) and girls (70.2%) as well as the high physical activity of boys (69.4%) and girls (30.06%) were compared.
A high statistically significant (p = 0.001) association between lip competence and gender to trauma was found. Normal overjet in boys and girls was 58.6% and 41.4%, respectively, whereas increased overjet was seen in 65.5% boys compared to 34.5% girls. In comparison, there is no statistically significant (p-value = 0.296) association between overjet and gender to trauma. The relative risk for trauma is 1.215 times higher in children with increased overjet compared to normal overjet. Children with incompetent lips are at 1.189 times greater risk of trauma compared to those with competent lips. Children with high physical activity are at 1.692 times higher risk for trauma compared to those with low physical activity.
Among all the fractures, enamel fractures accounted for the majority, with girls (47.2%) showing higher number of fractures among boys (42.4%), followed by enamel dentin fracture without pulp involvement, without much difference between girls (34.8%) and boys (32.4%). In soft tissue injuries, upper lip injuries with respect to luxation injuries (40.9%) are more, and with regard to complicated crown fractures, only (22.7%) injuries were observed. As the overjet increases, the majority of fractures are enamel dentin fractures without pulp involvement (37.9%), followed by enamel fractures (32.2%) and luxation injuries (10.3%). Among competent lip children, enamel fractures accounted for about 50%. Under the noncompetent lips category, the most common fracture seen was enamel dentin fracture without pulp involvement (36.2%), followed by enamel fracture (27.6%) and complicated crown fractures (10.3%) [Table 1].
|Table 1: Frequency tabulation for various types of fracture with respect to different parameters|
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Regarding fractures and the number of hours spent in physical activity, it is clear that as the number of hours increases, most of the children are affected with enamel fracture (44.3%) followed by uncomplicated crown fracture (33.3%). The p-value obtained was (0.572), which is statistically not significant. [Table 2].
|Table 2: Physical activities in hours - Type of fracture cross-tabulation|
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A higher number of children were observed with uncomplicated crown type fracture, and among those with overjet with <3.5, half of the children are observed with enamel type of fracture (50%). Similar findings are observed in boys, but most girls have enamel fractures with an increase in overjet measurement. The results showed a significant association of overjet with different types of fractures. Children with increased overjet had more trauma than those with normal overjet. The p-value obtained was (0.013), which is statistically significant. [Table 3].
Physical activity is significant only in an avulsion injury. Overjet is significant in the case of enamel infraction and avulsion. Lip injury is significant only in the case of enamel fracture. The percentage of classification of each injury type is depicted in the [Table 1] and [Table 2]. The odds ratio (OR) explains the probability of risk that a particular individual will have when compared with non-trauma subjects. Based on the last three models and the significant variables, a new subject was classified whether having trauma or not, and through which around 99% of correct identification was made with these significant variables.
If we consider complicated crown fracture (enamel dentin fracture with pulp involvement) as the main injury, then the important parameters to be observed are only the presence or absence of injury and soft tissue injury. Based on these two parameters, one can classify a new subject whether they have enamel infraction injury or not. Here, the odds ratio value for soft tissue is 3.198, which means that the trauma subject will have 3.19 times more risk than a non-trauma subject. Similar interpretations can be given for other types of fractures and their significant parameters and odds ratio values are given in table [Table 4].
|Table 4: Multivariate analysis of the risk factors for oral injuries obtained by logistic regression|
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| Discussion|| |
A total of 2100 school children were recruited for improving the precision of the data in the study. The present study identified a prevalence of 10.8% traumatic injuries to the permanent anterior teeth. This result corroborates with the earlier studies done where the prevalence ranges from less than 6% to nearly 28.3%, although most previous studies have found prevalence rates in the range of 10 to 20%.,, This could be attributed to the discrepancies in the reported prevalence which is due to the sample selected (age range studied, sample size, socio-demographic and behavioural indicators).
In this study, it was observed that boys were affected more than girls, with the ratio being 1.6:1. From an epidemiological point of view, most authors suggest an association between male gender and dental trauma, attributing this difference to their more intense participation in contact sports, behavioural differences, car accidents, teasing during outdoor activities and fights (Grimm et al., 2004). The reason for more trauma in boys may be explained by the fact that boys are more aggressive, involve in more risks and participate in sports activities.
In our study, the age range selected was 8–14 years, which was further divided into two groups. It was evident that the 8–11 year age group was more prone to injuries, followed by the 12–14 year age group. This pattern of the age distribution of traumatic injuries is in accordance with the previous study. However, the findings of the current study are explained as gender wise age distribution in boys. There was a decrease in prevalence from 61.3% in the 8–11 year age group to 35.7% in the 12–14 year age group, whereas, in females, the prevalence was maximum in the 8–11 age group (73.4%) and the least was in the 12–14 years age group (26.6%). The reason could be that in the traditional Indian society, as the girls grow up, more cultural restrictions and household responsibilities are imposed on them, leading to reduced exposure to the predisposing factors for trauma such as contact sports, falls and road accidents, etc., Whereas in the boys' case, as they grow, they get involved more in outdoor activities. However, reduction in the prevalence of trauma in the 12–14 years age group among boys and girls could probably be attributed to a more mature sense of balance control over aggression, which comes with increasing age and also parents giving more importance to studies rather than play activities in Nellore.
In the present study, the soft tissue injuries accounted for 14.5%, which are associated with traumatised teeth. Kahabuka reported that the prevalence of injury to the oral tissues was 43.8% more common among boys, and injury to the upper lip was reported by 5%. In our study, we found an interesting fact that in non-traumatic teeth also, there is an injury to soft tissue, which accounted for 0.26%. Among soft-tissue injuries, the upper lip injuries consisted of 0.8% without trauma and 9.7% with trauma, and lower lip injuries consisted of 0% without trauma and 3.1% with trauma. Other soft tissue injuries were 0.1% without trauma and 1.8% with trauma.
The present study showed that 93.4% of injuries involved permanent maxillary central incisors. These findings agree with earlier studies,,, and the second most frequently injured teeth were maxillary lateral incisors.
In our study, enamel fracture was the most frequent type of injury (48.5%), followed by enamel and dentin fracture without pulp involvement (uncomplicated crown fracture; 36.5%). The results of the study are comparable to other studies.,,,, In contrast to these studies, uncomplicated crown fracture without pulp exposure was the most common injury to the permanent dentition in other studies.,
In the present study, other types of fractures are as follows: enamel infraction (10.8%), luxation injuries (6.14%), complicated crown fractures (4.82%) and avulsion accounted for (1.31%). A study by Skaare AB reported that subluxation (horizontal mobility) (13.6%), subluxation (horizontal and vertical mobility) (3.3%), extrusive luxation (1.3%) lateral luxation (2.1%), intrusive luxation (0.3%) and avulsion (exarticulation) (0.6%) respectively. A study by Kramer showed the injuries as follows avulsion (3%), intrusive luxation (1.5%), a subluxation (1.2%), lateral luxation (0.8%), extrusive luxation (0.5%), and enamel-dentin fracture with pulp exposure (0.3%) respectively.
The correlation between the overjet and prevalence of trauma was statistically significant (p 0.013). As the overjet increases, the severity of trauma also increases. This finding correlates with another study. Similar statistically insignificant correlations have also been reported in some of the previous studies., The attributable reason was the smaller sample size. On the contrary, a review of an earlier study regarding the relationship between overjet size and traumatic dental injuries stated that, because of their behaviour and their involvement in specific sports types, boys are more prone to receive trauma regardless of their overjet.
In the present study, there is no statistically significant association between lip competence and gender to trauma. Children with incompetent lips had a 1.189 times greater risk of trauma compared to those with competent lips. Previous studies concluded that inadequate lip coverage was a predisposing factor related to the occurrence of traumatic dental injuries., However, Hunter et al. did not observe any increased risk of dental trauma in children with competent lip closure, particularly in females similar to the present study.
Children with high physical activity (79.3%) had 1.692 times higher risk of trauma than those with low physical activity (20.7%). As the number of hours of physical activity increased most children were affected with enamel fractures followed by uncomplicated crown fracture. The same phenomenon is observed with respect to boys as well as girls, but in boys, it is also observed that 100% of the children have luxation injuries for 5 hours of physical activity. Similarly, in girls, 100% enamel and uncomplicated crown fractures were observed for 4 and 5 hours of physical activity.
Children and adolescents spend a considerable amount of time participating in numerous recreational and sports activities. Our study found that children of age 8–11 years spend 8 hours in physical activity per week and children aged 12–14 years spend slightly less. Physical leisure activities at home, in kindergarten and at playground sand in schools continue to account for a significant proportion of TDIs in teenagers; on the other hand, children are mostly injured during sports activities, traffic accidents, and some forms of violence (e.g. fights, assault and battery).,,
In our study, the risk of trauma increases with an increase in physical activities. These findings correlate with another study. A study by Canacki concluded that falls were the most common cause of trauma, followed by violence, fight and sports, which is similar to our study. However, the difference is that fighting and sports are considered as physical activities in our study. High physical activity is considered one of the causes of trauma, while earlier studies have considered falls and sports activity separately.
| Conclusion|| |
It can be concluded that children with increased overjet, incompetent lips and high physical activity suffered more severe fractures like luxation injuries and avulsion, in particular, boys. In contrast, children with normal overjet, competent lips and high physical activity suffered less severe fractures like enamel fracture and uncomplicated crown fracture. Soft tissue injuries were significantly present for all types of fractures except enamel infraction and uncomplicated crown fractures (enamel-dentin fracture without pulp involvement). All the subjects with avulsion had increased overjet, high physical activity and soft tissue injury, and only one child had competent lips.
The present study will contribute to the database of the prevalence and risk factors for traumatic injuries in children that can be used to plan school-based preventive programs in the districts for studies in the future.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Ramasubbareddy Challa
Department of Pediatric and Preventive Dentistry, Narayana Dental College, Nellore, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]