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Year : 2013  |  Volume : 4  |  Issue : 1  |  Page : 31-37

Anterior tooth trauma: A most neglected oral health aspect in adolescents

1 Department of Pediatric and Preventive Dentistry, BRS Dental College and Hospital, Sultanpur (Panchkula), Haryana, India
2 Department of Pediatric and Preventive Dentistry, Bhojia Dental College and Hospital, Budh, Baddi, Himachal Pradesh, India
3 Private Practitionerh, Chandigarh, India

Date of Submission30-Dec-2012
Date of Acceptance02-Apr-2013
Date of Web Publication20-Sep-2013

Correspondence Address:
Avninder Kaur
Department of Pediatric and Preventive Dentistry, Bhojia Dental College and Hospital, Budh, Baddi, Himachal Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0976-6944.118532

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Aim: The aim of this study was to ascertain the prevalence of anterior tooth trauma (ATT) in school children between the age range of 10 and 17 years of Barwala, Panchkula, India.
Methodology: A cross-sectional survey was carried out in 1052 (585 boys and 467 girls) government and private school children. The data regarding the traumatic injuries to anterior teeth along with various risk factors were recorded using the Ellis and the Davey's classification. Statistical analysis was carried out by the Chi-square test.
Results: Prevalence of ATT was found to be 18.25%. Out of which 53.1% were boys, whereas 46.9% girls, gender difference was not related with the occurrence of type of fracture (P = 0.227). The prevalence of ATT in government and private school children is 12.4% and 16.8%, respectively. The prevalence of Ellis class I fracture was 83.9%, and class II was 12.5%. Majority of ATT were untreated (98.4%), and the type of treatment given was related to the occurrence of the type of fracture (P < 0.001).
Conclusion: Overjet and overbite more than 3 mm were found to be important contributing factors for type of traumatic dental injuries (P = 0.013 and 0.037, respectively).

Keywords: Anterior tooth trauma, increased overjet and overbite, upper lip coverage

How to cite this article:
Ahlawat B, Kaur A, Thakur G, Mohindroo A. Anterior tooth trauma: A most neglected oral health aspect in adolescents. Indian J Oral Sci 2013;4:31-7

How to cite this URL:
Ahlawat B, Kaur A, Thakur G, Mohindroo A. Anterior tooth trauma: A most neglected oral health aspect in adolescents. Indian J Oral Sci [serial online] 2013 [cited 2019 Nov 21];4:31-7. Available from: http://www.indjos.com/text.asp?2013/4/1/31/118532

  Introduction Top

Traumatic dental injuries (TDI) and maxillofacial injuries are common occurrences and affected world-wide approximately, 20-30% of the permanent dentition that often lead to compromised esthetics and function. [1] More than 20% of children experience damage to their permanent dentition by 14 years of age, with men outnumbering women with the ratio of 2:1 and peak incidence at 8-10 years of age. [2] Although most injuries occur as a result of falls and play accidents, [3] trauma from traffic accidents, risk taking activities, violence, and child physical abuse has also been reported. [4],[5],[6]

Studies in dentistry are concentrating on dental caries; its etiology, prevalence, and various restorative materials used. Despite high prevalence of dental trauma, less attention has been given to TDI; its etiology and prevention. Risk evaluation for dental trauma is not carried out during the routine dental examination and even for those who participate in various sports. Since the majority of these injuries are preventable, there is a rising consensus that TDI constitute a major public health problem. Oral health promotion programs to prevent such injuries are required in populations where they are either frequent or severe.

The term anterior tooth trauma (ATT) is used in the article as studies report the most susceptible tooth is the maxillary central incisor, which sustains approximately 80% of dental injuries followed by the maxillary lateral and the mandibular central and lateral incisors. [7],[8] There is lack of published data regarding the traumatic injuries among school children in Barwala, Panchkula region. Hence, the present article reports the pioneer study conducted to assess the prevalence and risk evaluation of traumatic injuries involving permanent anterior teeth in adolescents and the type of treatment provided.

  Methodology Top

A cross-sectional study was carried out in 1052 children (585 boys and 467 girls) aged 10-17 years enrolled in two government and two private schools of Barwala (Rural Panchkula), Haryana, India. Schools selected were within the vicinity of BRS Dental College and Hospital, Sultanpur (within a radius of 5 km from the college). Out of these children, 750 were from government and 302 were from private schools. The permission for conducting the study was taken from the District Education Officer, Panchkula. The principals of the schools were informed about the nature of the study. Written consent forms explaining the aim and mode of the study were distributed to the children who were willing to participate in the study. Only the children having forms duly signed by the parents were included in the study. The children with any special health-care needs or who were physically, mentally, and emotionally disturbed were excluded from the study.

Stratified simple random sampling technique was used, that is, the children present on the day of examination were included in the study. The children were examined in their respective schools, during school hours, under natural light by visual and digital examination with the aid of mouth mirrors and blunt probe. The intra-oral clinical examination was carried out by a single examiner although a trained assistant recorded the observations on a specially designed proforma. The recording procedure was standardized by repeated sessions of calibrations between the examiner and the supervisor before the actual examination. The data regarding the traumatic injuries to anterior teeth were recorded using the Ellis and the Davey's classification. [9] Radiographs were not taken to aid in clinical diagnosis; thus, root fractures or Ellis class VI were not diagnosed and coded as unspecified.

Various intrinsic and extrinsic risk factors were recorded. Lip seal was categorized as by Sutcliffe [10] and lip coverage was categorized as by Addy et al. [11] Overjet is the horizontal overlap of the incisors and was recorded as the distance measured between palatal surface of upper incisors and labial surface of lower incisors. For measuring that, metallic scale was modified or trimmed, so that measurement starts from the calibration present on the scale. Scale was kept horizontally starting from the labial surface of lower incisors, and the distance was measured. Overbite is the vertical overlap of the incisors. The incisal edges of maxillary incisors overlap the mandibular incisors and from this point distance was measured until the gingival margin of the clinical crown of mandibular incisors. The measured value was then subtracted from the total length of lower incisor to obtain the overbite. Mode of breathing was also assessed by performing cotton butterfly test and water holding test. The data were analyzed using the Statistical Package for the Social Sciences (SPSS) for Windows (version 15.0; SPSS Inc., Chicago, IL, USA). Statistical analysis was carried out by the Chi-square test. P < 0.05 is considered statistically significant.

  Results Top

The study identified the overall prevalence of ATT to be 18.25% (192). Out of which 161 subjects (83.9%) had Ellis I fracture, 24 subjects (12.5%) with Ellis II, 5 subjects (2.6%) with Ellis IV, 1 subject (0.5% and 0.5%) with Ellis V and unspecified or VI, respectively.

The observed prevalence of dental trauma was higher in boys (53.1%) than in girls (46.9%) though the difference was not statistically significant. Gender difference was not related with the occurrence of type of fracture (P = 0.227)[Table 1]. The frequency of occurence of type of fracture in government and private schools is shown in [Table 2].
Table 1: Prevalence of traumatic dental injuries to permanent incisors

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Table 2: Cross-tabulation showing frequency of occurrence of type of fracture with type of schools

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The reason for ATT was unknown in 148 subjects (77.1%), sports activities in 15 subjects (7.8%), fall in 19 subjects (9.9%), hit by hand pump in 7 subjects (3.6%), during biting in 2 subjects (1.1%), and fight in 1 subject (0.5%).

Out of 192 subjects, only 23 (12.3%) had habit of mouth breathing. Mouth breathing does not contribute to the occurrence of type of fracture (P = 0.877).

Overjet [Table 3] and overbite [Table 4] more than 3 mm were found to be important contributing factors for type of ATT and were statistically significant (P = 0.013 and P = 0.037, respectively).
Table 3: Cross-tabulation of the occurrence of type of fracture with over jet

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Table 4: Cross-tabulation of the occurrence of type of fracture with overbite

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  Discussion Top

The present study reported prevalence of ATT to be 18.25%, which is higher than the prevalence, that is, 14.5% reported in the nearby area (Dera Bassi) by Dua and Sharma. [12] Gupta et al. [13] in South Kanara district reported 13.8%, 14.9% in adolescent NCC cadets in South India by Baldava and Anup, [14] 15.1% in Davangere by Ravishankar et al., [15] 5.29% by Rai and Munshi [16] in South Kanara, 12.8% by Adekoya-Sofowora et al. [17] in sub-urban Nigerian adolescents, 10.5% by Soriano et al. [18] in Brazil, 14.2% by Rajab [19] in Jordan. Similar results (18.9%) were found by Traebert et al. [20] in Florianopolis, Brazil. A higher prevalence of 24% was found by Kahabuka and Mugonzibwa [21] in Tanzania, 34% by Blinkhorn [22] in England, 43.8% in Newham, London, UK by Marcenes and Murray [23] and 58.6% in Blumenau, Brazil by Marcenes et al. [24]

The prevalence of dental trauma in various epidemiological studies has been found to differ considerably. The great variation might be due to a number of factors such as the trauma classification used, status of dentition, geographical, and behavioral differences between locations and countries. [25] It is inappropriate, for instance, to compare figures found in the clinic-and hospital-based studies with population-based studies. It is known that clinic-and hospital-based studies provide less epidemiological evidence than population-based studies. [26] Variation in the sampling and diagnostic criteria between different studies may also explain different findings. [27]

The maxillary incisors play an important role in esthetics, phonetic and functional activities. Because of their morphology and location these are more susceptible to trauma. In our study, maxillary central incisors were the teeth most commonly affected by dental trauma. The result corroborate with most of the previous studies reporting the maxillary central incisors as the most common teeth to receive trauma. [18],[28],[29],[30],[31],[32],[33],[34]

Enamel fractures were the most frequent types of traumatic injuries observed in the study sample [Table 1]. Sanchez et al., [35] Naqvi et al., [36] and Delattre et al. [37] found similar results although on the contrary other authors found that the most common type of injury was dentine fracture [38],[39] or soft-tissue injury. [40],[41]

Males were affected more by dental trauma (53.1%) than females (46.9%), but no statistical significance was observed between sex and the occurrence of trauma in the present study [Table 1]. Glendor [42] in a review on epidemiology of TDI had showna reduction in the gender difference in sports, which may simply reflect an increased interest in sports among girls. The findings of the other studies, [32],[43],[44],[45] depicted the male-to-female ratios being 1.3-2.3:1. [25]

Various intrinsic risk factors evaluated in the study were overjet, overbite, profile, upper lip coverage, and lip seal. In relation to overjet, particular value should be regarded as an increased overjet or not. Numerous studies recognized an increased overjet when the value is >3 mm. [7],[21],[46],[47] A systemic review by Nguyen et al. [48] concluded that children with an overjet larger than 3 mm are approximately twice as much at risk of ATT than those with lesser overjet. Others reported higher risk when it is more than 5 mm. [27],[43],[49],[50] The findings of the present study; however, showed a significant association between the presence of ATT and overjet of >3 mm, corroborating the assertion that the frequency of dental trauma increases proportionally in relation to an increased overjet [Table 3].

Overbite >3 mm, a less reported factor in the literature is also found in our study to be responsible for ATT [Table 4]. Children with convex profile were more prone to ATT [Table 5].
Table 5: Cross-tabulation of the occurrence of type of fracture with profile

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In our study, the subjects with inadequate lip coverage of maxillary incisors were found to be more prone to ATT, though the results are not statistically significant [Table 6]. Prevalence of ATT increased from complete coverage of maxillary incisors to partial coverage of maxillary incisors though it did not increase to further decrease in lip coverage.In a study carried out with adolescents by O'Mullane, [51] the 12-year-old group also presented a strong positive relationship between the presence of inadequate lip coverage and ATT. Thus, inadequate lip seal was also considered a risk factor for ATT [Table 7] concluding that upper lip coverage and lip seal act as protective barriers against ATT.
Table 6: Cross-tabulation showing frequency of occurrence of type of fracture with various lip positions

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Table 7: Cross-tabulation of the occurrence of type of fracture with lip seal

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The extrinsic factors for ATT were sports activities in 7.8%, fall in 9.9%, hit by hand pump in 3.6%, during biting in 1.1% and fight in 1 subject (0.5%). In addition, the percentage of schoolchildren who did not remember the etiology was also high (77%), whether they actually did not know the cause or hiding some facts, which could be related to violence. Traebert et al. [20] also suggested substantial underestimation of violence as the cause of TDI.

In our study, the type of treatment given was found to be related to the occurrence of type of fracture [Table 8]. Adolescents who suffered enamel or dentin fracture without symptoms or visible complications frequently received no treatment. Only two subjects (1%) had undergone treatment, which indicates a low level of awareness among the parents about the importance of dental treatment. The treatment of ATT was observed according to the severity of dental trauma as 1 child with missing anterior tooth was wearing a partial denture. This finding is in accordance with the survey carried out by Rai and Munshi [16] among South Kanara school children. Only 1.68% of traumatized teeth had undergone treatment. A survey carried outby Mohandas and Chandan [52] to assess the level of knowledge, attitude, and practice of physical education teachers in Bangalore city with regards to emergency management of dental injuries, indicates that there is lack of knowledge and practice among physical education teachers in Bangalore city regarding emergency management of dental trauma.
Table 8: Cross-tabulation of occurrence of type of fracture with the type of treatment given

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  Conclusions Top

The study reported prevalence of 18.25% in adolescents in the area. Enamel fractures were higher compared to other fractures. A total of 98% injuries were untreated. The study highlighted the need for attention to be given to etiology, prevention, and unmet treatment needs of ATT.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]

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