Indian Journal of Dental Research

: 2013  |  Volume : 24  |  Issue : 6  |  Page : 664--668

Prevalence of anterior teeth fracture among visually impaired individuals, India

Anil Agrawal, Nagesh Bhatt, Harshvardhan Chaudhary, Karanprakash Singh, Prashant Mishra, Kailash Asawa 
 Department of Community Dentistry, Pacific Dental College and Hospital, Debari, Udaipur, Rajasthan, India

Correspondence Address:
Anil Agrawal
Department of Community Dentistry, Pacific Dental College and Hospital, Debari, Udaipur, Rajasthan


Aim: The aim of the study was to determine the prevalence of anterior teeth fracture among visually impaired individuals. Materials and Methods: A cross-sectional study was carried out among 103 blind individuals (70 males and 33 females), with age ranges from 10 years to 29 years, the survey was carried out according to World Health Organization (WHO) criteria and by using WHO classification for teeth fracture. All subjects were divided into two groups on the basis of whether they are partially sighted or totally blind. Data were analyzed using Chi-square test, with keeping the level of significance at P < 0.05. Results: Overall prevalence of 34.95% of traumatic injuries to anterior teeth was found in the study population with no significant difference between both groups (P < 0.05). Female were having significantly more fracture than males (P < 0.005). Fall being indoor was the most common cause. Permanent maxillary central incisors were most commonly injured with injuries involving enamel and dentin being the most frequently observed. Increased overjet and inadequate lip coverage were significantly associated with the occurrence of trauma (P = 0.0001). Conclusion: The prevalence of dental injuries in a group of individuals with blind. This should alert caregivers to carry out a profound investigation of the events and suggest methods to reduce this type of morbidity.

How to cite this article:
Agrawal A, Bhatt N, Chaudhary H, Singh K, Mishra P, Asawa K. Prevalence of anterior teeth fracture among visually impaired individuals, India.Indian J Dent Res 2013;24:664-668

How to cite this URL:
Agrawal A, Bhatt N, Chaudhary H, Singh K, Mishra P, Asawa K. Prevalence of anterior teeth fracture among visually impaired individuals, India. Indian J Dent Res [serial online] 2013 [cited 2022 Jun 27 ];24:664-668
Available from:

Full Text

The World Health Organization (WHO) defines an individual with handicap as one who, over an appreciable time, is prevented by a physical or mental condition from full participation in the normal activities of his/her age group, including those of a social, recreational, educational and vocational nature. [1] The term "disability" has recently been defined as just any impairment that restricts or limits daily activity in some manner. [2] Previous studies have noted that children with disabilities have higher levels of dental disease and lower levels of care. [3],[4] Traumatic injuries are more prevalent in children with disabilities compared to normal children. [5],[6]

Blindness is one of the most prevalent handicap conditions world-wide, it occurs mainly in low income or developing countries like India than in high income countries. According to WHO estimates, approximately, 314 million people world-wide live with low vision and blindness of these, 45 million people are blind and 269 million have low vision. Of which about 5 million reside in India and it is estimated that at least 200,000 children in India have severe visual impairment or blindness and approximately 15,000 are in schools for the blind, main causes of blindness includes corneal scarring and inadequate sanitations. [7],[8] Blind individuals suffer from many health problems including oral health, which consist of mainly orofacial trauma, dental caries and periodontal diseases, of this orofacial trauma consist of the main health hazards for visually impaired individuals. [9]

School age children are considered to be at higher risk (7-15 years) to traumatic injuries. The percentage presented in the literature ranges from 2.6% to 50% [10] and among visually impaired it ranges from 27.4% to 36.4%. [5],[11] Incisors have a significant role in esthetics, phonation and psychological aspects and in functional activities; upper incisors are the most frequently affected teeth by trauma, over 90% according to Mestrovic et al. [10] The etiology of teeth injuries are variable and multiple, the dominant factors most likely to cause the trauma are fall, sports injuries and accidents met at home or outside. The major risk factor for dental injuries is increased overjet and inadequate lip coverage. In addition to pain and possible infection, the consequences of incisor trauma include alteration in physical appearance, speech defects and psychological/emotional impacts; thus, affecting the child's quality-of-life. [12] The prevalent nature of incisor trauma, its substantial impact on quality-of-life. [12]

Hence, a study was carried out with the aim to find out the prevalence of anterior teeth fracture among blind individuals in Udaipur City and the objective was to know the probable cause and risk factors of anterior teeth trauma and to suggest preventive measures and to create awareness of traumatic injuries among blind individuals.

 Materials and Methods

This cross-sectional study was conducted among 103 visually impaired individuals who were recruited from all the available Blind Schools of Udaipur City, Rajasthan, India, which includes one government and one private blind school. All subjects available at the time of study were included. Study was conducted on the month of 5-June and 30-July. Informed consent was taken from all participants. The approval for the study was obtained from the Ethical Committee of Pacific Dental College and Hospital and before the commencement of study from both blind school authorities.

Inclusion criteria

Individuals those who were willing to participate in the studyIndividual's not undergone or undergoing orthodontic treatment.

Exclusion criteria

Individuals undergoing or undergone orthodontic treatmentSupernumerary teethRestored teeth.

All subjects were divided on the basis of whether they are partially sighted or totally blind. Partially sighted individuals were further not divided on the basis of type of partial sightness to prevent more complications. The proforma was pilot tested on 20 subjects before starting of the main study and those did not participate in the final study.

A type III examination was carried out by one examiner. A single examiner, trained and calibrated for the criteria used, conducted both interview and the clinical examination. The clinical examination was carried out under natural daylight conditions with subjects seated on a chair with a high backrest and the examiner standing behind the subject. The standard conditions for examination, infection control and data recording were followed according to the WHO basic Oral Health Survey Guidelines (1997). [13] A sufficient number of plane mouth mirrors, Community Periodontal Index (CPI) probes and gauze pads were packed for each day of work. Each subject was then examined for the measurement of maxillary incisor overjet using the CPI probe as described by the 1997 WHO Basic Oral Health Survey Guideline. [13] Prior to the intraoral examination and without the subject being aware of being observed, the lip coverage of the incisor teeth was assessed for each child. If the lips covered the upper incisors in the rest position the lip coverage was considered to be adequate. If however, the lips failed to cover the upper incisors and the majority of their crown height was exposed the lip coverage was recorded as inadequate.

Next, all maxillary and mandibular anterior teeth from canine to canine were examined for traumatic injury. Trauma was scored according to: WHO classification (1993): 873.60-Enamel fracture, 873.61-Enamel and dentine fracture without pulp exposure, 873.62-Enamel and dentine fracture with pulp exposure, 873.63-Root fracture, 873.64-Crown-root fracture, 873.66-Concussion, luxation, 873.67-Intrusion, extrusion, 873.68-Avulsion, 873.69-Soft tissue injuries.

All mentioned teeth were examined to know the type of fracture, cause of trauma and place of trauma.


Data analysis was carried out using the SPSS version 11.5 (SPSS, Inc., Chicago, IL, USA) and included descriptive statistics (frequency distribution and cross tabulation). Statistical significance for the association between the occurrence of dental injuries and lip coverage and maxillary overjet among both partially sighted and totally blind individuals adjusted with age and sex was carried out using the Chi-square test. The level of significance set was P < 0.05.


A total of 103 subjects formed the study sample: 70 (68%) males and 33 (32%) were females. Of them 73.8% were partially sighted and 26.2% were totally blind [Graph 1].


Prevalence and distribution of anterior tooth injuries

It was found that the overall prevalence of teeth fracture was 34.95% with prevalence of fracture of teeth among males was 27.1% and females was 51.5%, which is statistically significant at P < 0.05 [Table 1]. Fracture of anterior teeth tends to correspond to a certain age group and growth phases. [14] The blind individuals were divided in two groups on the basis of fracture of their anterior teeth, 10-19 years in which 71.4% were partially blind and 66.7% were totally blind and 20-29 years in which 28.6% were partially blind and 33.3% were totally blind, it was found that totally blind were statistically significant between both age group (P < 0.05) and partially sighted group was not significant (at P < 0.05) [Table 2].{Table 1}{Table 2}

All subjects were having single tooth fracture, with right and left central incisors as most common teeth to be fractured (right central incisors 52.8% and left central incisor 13.9%) and overall central incisors accounted for about 24 (66.7%) of fracture teeth, it was observed that partially blind subjects were having more fracture 58.3%, out of which right central incisor 61.9% was the most common tooth to be fractured followed left central incisors and left lateral incisor, among totally blind individuals it was found that 41.7% had a fracture of their teeth with 40% was right central incisors and 20% had left central incisors, followed by left and right lateral incisors. It was found that only one maxillary canine was fractured in both groups with only one mandibular canine was fractured in partially blind individuals, it was statistically not significant between partially sighted and totally blind individuals [Table 3].{Table 3}

It was seen that most of teeth having fracture were involving enamel and dentine in both groups (52.3% among partially sighted and 60% among totally blind individuals) with fractures involving only enamel was 33.3% among totally blind and 38.09% among partially sighted subjects. Fracture involving pulp was very less with only tooth in both groups, which was found to statistically not significant between both groups [Table 3].

Risk factors

It has also been found that overjet of more than 3.5 mm increases risk of sustaining traumatic injuries to teeth 24 (85.7%) with only 16% of teeth having normal overjet were fractured which was statistically significant (P = 0.0000). 81.3 % of blind individuals with adequate lip coverage did not have teeth fracture while 78.6% of the non-adequate lip coverage blind individuals had teeth fracture [Table 4], Graph 2].{Table 4}


Cause of injuries

Nearly, 52.8% injury to teeth was due to fall in both groups followed by collision 22.2%, sports 19.4% and unknown 2.8%, which was found to be statistically not significant (P value = 0.66) between both groups, 61.1% of injury were indoor for both group followed by 30.6% for outdoor and 8.3% unknown, which was statistically significant [Graphs 3 and 4].




This cross-sectional study evaluated the prevalence of anterior teeth trauma among visually impaired individuals, the overall prevalence of teeth fracture among both partially sighted and totally blind individuals was found to be 35.9%, of them partially sighted individuals was 58.33%, who had sustained a fracture of anterior teeth and 41.67% of totally blind had a fracture of anterior teeth in the present study, which was also similar to study reported by 36.4% by O'Donnell (1992), [11] 27.4% by Greeley et al. (1976), [5] and 24.6% by Shyama et al. 2001 among blind individuals. [15]

In this study, it was found that females had significantly more teeth fracture than males (P < 0.05), which was in contrast to other studies in which males suffered teeth fracture 1.2-2.3 times more than females in the sighted population and 4 times more in persons with attention deficit/hyperactivity disorder. [16],[17],[18],[19]

Prevalence of traumatic injuries decreases during adolescence, adolescents do continue to experience dental injuries most often because of sports related accidents among sighted individuals, [20],[21] among totally blind individuals there was statistical significant difference between 10 years and 19 years age group and 20-29 years (more among 10-19 age group), but no substantial difference was found between partially sighted and totally blind individuals, similar findings were found in the study carried out by O'Donnell in 6-14 years and 15-24 years aged blind individual. [11]

In the present study, trauma was found more often in the maxilla and in the central incisor and in both partially sighted and totally blind individuals, which is consistent with the findings of other studies on sighted individuals [22],[23] and disabled children. [15] The reason being its venerable position in the oral cavity, frequent protrusion of incisors and inadequate lip coverage hence reducing the cushioning effect. In the present study, injury involving enamel and dentine was found to be most common in both groups independent of type of blindness, which is similar to studies conducted by Baldava and Anup, [9] unlike other studies conducted by Petti and Tarsitani, in which enamel was most commonly fractured. [24]

The most common cause of traumatic injuries to anterior tooth has been shown to vary between population and across age groups, indoor fall was most common cause irrespective of type of blindness in our study, similar finding were reported by the study conducted in cerebral palsy patient, [25] unlike other studies reported in sighted individuals where sports related injuries were most common, [24],[26] this can be explained by the fact that visually impaired children spent most of their time indoors.

As seen with several studies of sighted individuals the risk of injury to anterior teeth increased significantly with the increase in incisor overjet by more than 3-4 mm [27],[28] and inadequate lip coverage, [26] which is also a statistically significant factor in the present study for occurrence of trauma to anterior tooth among blind individuals.

The sample size of this present study was less, so the findings cannot be generalized to the entire blind population. Hence, more studies in this field is required with increased sample size to find the more accurate findings as our findings indicate that there is a very high prevalence of fracture teeth among visually impaired individuals than the other studies conducted in sighted individuals. Moreover, there are very few studies on dental trauma among visually impaired and only one study on the prevalence of anterior tooth fracture among this population, [5],[11],[15] so the findings of our study has been compared with individuals from sighted, disabled, handicapped and attention-deficit/hyperactivity disorder populations.


Although, a higher prevalence along with more severe traumatic injuries to anterior teeth were found in the present study among blind individuals and they receive less oral healthcare as compared to subjects from the general population.

Hence, there is a distinct need for the strengthening of advocacy programs that will ensure the availability of comprehensive preventive and oral healthcare for this group. It is important for preventive measures and instruction to be institutionalized at an early age. The Ministry of Health should provide in-service training to institutional staff and to parents to promote good oral health in children and adults with visual impairment to help them access care. Coordinated efforts between social services and oral healthcare providers should be strengthened to ensure that the profession adequately serves these children. Screening programs could be conducted for blind children to identify those with high anatomic and behavioral risk for occurrence of traumatic injury to the anterior teeth, so appropriate preventive measures such as preventive orthodontic treatment and use of mouth guards can be implemented.


1Salako NO, Jeboda SO. Dental problems of the handicapped child. Odontostomatol Trop 1985;8:119-23.
2Tesini DA, Fenton SJ. Oral health needs of persons with physical or mental disabilities. Dent Clin North Am 1994;38:483-98.
3Brown JP, Schodel DR. A review of controlled surveys of dental disease in handicapped persons. ASDC J Dent Child 1976;43:313-20.
4Shaw L, Maclaurin ET, Foster TD. Dental study of handicapped children attending special schools in Birmingham, UK. Community Dent Oral Epidemiol 1986;14:24-7.
5Greeley CB, Goldstein PA, Forrester DJ. Oral manifestations in a group of blind students. ASDC J Dent Child 1976;43:39-41.
6Ohito FA, Opinya GN, Wang'ombe J. Traumatic dental injuries in normal and handicapped children in Nairobi, Kenya. East Afr Med J 1992;69:680-2.
7World Health Organization. Blindness and visual impairment. Available from: [Last accessed on 2009 Aug 15].
8Rahi JS, Sripathi S, Gilbert CE, Foster A. Childhood blindness in India: Causes in 1318 blind school students in nine states. Eye (Lond) 1995;9:545-50.
9Baldava P, Anup N. Risk factors for traumatic dental injuries in an adolescent male population in India. J Contemp Dent Pract 2007;8:35-42.
10Meštroviæ S, Gabriæ Panduriæ D, Aniæ Miloševiæ S, Dunja Ribariæ. Risk factors of traumatic injuries to the upper incisors. Acta Stomatol Croat 2008;42:10.
11O'Donnell D. The prevalence of nonrepaired fractured incisors in visually impaired Chinese children and young adults in Hong Kong. Quintessence Int 1992;23:363-5.
12Alonge OK, Narendran S, Williamson DD. Prevalence of fractured incisal teeth among children in Harris County, Texas. Dent Traumatol 2001;17:218-21.
13World Health Organization. Implementing the survey. Oral Health Surveys: Basic Methods. 4 th ed. Geneva: World Health Organization; 1999. p. 16-20.
14Andreasen JO. Etiology and pathogenesis of traumatic dental injuries. A clinical study of 1,298 cases. Scand J Dent Res 1970;78:329-42.
15Shyama M, al-Mutawa SA, Honkala S. Malocclusions and traumatic injuries in disabled schoolchildren and adolescents in Kuwait. Spec Care Dentist 2001;21:104-8.
16Andreasen JO, Ravn JJ. Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample. Int J Oral Surg 1972;1:235-9.
17Forsberg CM, Tedestam G. Traumatic injuries to teeth in Swedish children living in an urban area. Swed Dent J 1990;14:115-22.
18Sabuncuoglu O. Traumatic dental injuries and attention-deficit/hyperactivity disorder: Is there a link? Dent Traumatol 2007;23:137-42.
19Parkin SF. A recent analysis of traumatic injuries to children's teeth. J Dent Child 1967;34:323-5.
20Kahabuka FK, Plasschaert A, van't Hof M. Prevalence of teeth with untreated dental trauma among nursery and primary school pupils in Dar es Salaam, Tanzania. Dent Traumatol 2001;17:109-13.
21Kargul B, Caðlar E, Tanboga I. Dental trauma in Turkish children, Istanbul. Dent Traumatol 2003;19:72-5.
22Sanchez AV, Garcia-Godoy F. Traumatic dental injuries in 3-to 13-year-old boys in Monterrey, Mexico. Endod Dent Traumatol 1990;6:63-5.
23Fleming P, Gregg TA, Saunders ID. Analysis of an emergency dental service provided at a children's hospital. Int J Paediatr Dent 1991;1:25-30.
24Petti S, Tarsitani G. Traumatic injuries to anterior teeth in Italian schoolchildren: Prevalence and risk factors. Endod Dent Traumatol 1996;12:294-7.
25Holan G, Peretz B, Efrat J, Shapira Y. Traumatic injuries to the teeth in young individuals with cerebral palsy. Dent Traumatol 2005;21:65-9.
26O'Mullane DM. Some factors predisposing to injuries of permanent incisors in school children. Br Dent J 1973;134:328-32.
27Bastone EB, Freer TJ, McNamara JR. Epidemiology of dental trauma: A review of the literature. Aust Dent J 2000;45:2-9.
28Burden DJ. An investigation of the association between overjet size, lip coverage, and traumatic injury to maxillary incisors. Eur J Orthod 1995;17:513-7.