A 10-year retrospective study of dental trauma in permanent dentition

Abstract

Objective

This study aims to identify the characteristics and factors associated with TDI treated at a referral service.

Material and methods

A ten-year period cross-sectional retrospective analysis of medical records of patients with TDI in their permanent teeth was performed, and injury-related data were collected. Statistical analysis was performed using the chi-square association test and complex analysis (p < 0.05).

Results

Records of 545 patients, totaling 1438 traumatized teeth, were evaluated, and a male prevalence at a 2.4:1 ratio was found. The age group with highest incidence was 13–19 years. Central maxillary incisors and dislocations were the most affected teeth and TDI, respectively. Statistical analysis showed different TDI causes according to age: children are often victims of falls, traffic accidents, aggression and collisions, whereas adolescents are involved in sports accidents, and young adults in traffic accidents, falls and collisions.

Conclusion

Considering the scope of this retrospective study at a single referral center, a profile of young male patients with TDI in superior central incisors due to falls, collisions, traffic accidents or sports could be detected.

Resumen

Objetivo

Identificar las características y los factores asociados con el traumatismo dentoalveolar (TD) atendido en un servicio de referencia.

Material y métodos

Ha sido realizado un análisis retrospectivo de los pacientes con TD en dientes permanentes en un período de10 años. Fueron extraídos los datos relacionados con el TD. El análisis estadístico se realizó mediante el test de asociación chi-cuadrado y el análisis de los residuos (p < 0,05).

Resultados

Los registros de 545 pacientes con un total de 1.438 dientes traumatizados fueron incluidos. Se constata la prevalencia en el sexo masculino, con una proporción de 2,4:1. El grupo etario con mayor incidencia fue el de 13-19 años. Los incisivos centrales superiores fueron los dientes más afectados y el traumatismo dentario más diagnosticado fueron las luxaciones. El análisis estadístico ha mostrado una asociación de diferentes causas de TD con la edad: los niños son víctimas, con mayor probabilidad, de caídas, accidentes de tránsito, agresiones y colisiones, mientras que los adolescentes los son de accidentes deportivos, y los adultos jóvenes de accidentes de tráfico, caídas y colisiones.

Conclusión

Considerando el alcance de este estudio retrospectivo en un único servicio de referencia, se detectó un perfil de jóvenes pacientes del sexo masculino con la presencia de TD en los incisivos centrales superiores por las caídas, colisiones, accidentes de tráfico o prácticas deportivas.

Introduction

Traumatic dental injuries (TDI) accounts for about 5.0% of all bodily trauma.^1–3 However, its incidence and characteristics changes according to age group and socio-demographic factors involved, as is the case of children injuries, in which TDI represents 17.0–20.0% of all traumas they were involved in.⁴

Unlike other injuries, the incidence of these lesions decreases from the second decade of life.^1,2,4 This can be explained by periodontal ligament space characteristics, upper incisor exposure and lack of lip sealing during the growth phase. In addition, there is an association between Class II malocclusion and TDI.⁵ Among dental elements, the upper central incisors are most commonly affected due to their projection and exposure.⁵ Less complex injuries such as single crown fracture and concussion are more frequent than complicated crown fractures or severe dental dislocations.^6,7

TDI is a public health hazard due to its high frequency and association with violence, traffic accidents and sports activities.^8–10 These injuries have an impact on the quality of life of patients by impairing chewing, phonation, esthetics, as well as their physical and psychological condition.^7,11,12

Knowledge of TDI characteristics is important for the establishment of preventive action and treatment so as to reduce associated costs and improve the population's quality of life.^9,12 This study aims to identify the characteristics and factors associated with TDI in patients treated at a specialized service for a ten-year period.

Material and methods

The present cross-sectional retrospective study was reviewed and approved by an Institutional Research Ethics Committee for Human Beings (protocol n. 049/2007). Records of patients treated at an Oral and Maxillofacial Surgery Department (Pelotas, south of Brazil) during a ten-year period were evaluated. Patients with DAT records in permanent teeth were included in the study, but those with incomplete records or showing other kinds of injury were excluded.

After researcher calibration, data were collected and transferred in duplicate to a table specifically created for the study. The collected variables were age, gender, cause of trauma, presence and type of dislocation, tooth fracture and bone plate fracture. Data were analyzed by means of descriptive statistics, and the chi-square test at 95% significance level was performed; when the null hypothesis was rejected, complex analysis to verify the association between variables was carried out.

Results

After collection, 545 records of patients treated at the service were included in the study, 387 of whom (71.0%) were male and 158 (29.0%) female. As to age, there was an average of 20.77 ± 12.04 years, and the study included patients ranging from six to 63 years, with a median of 17 years.

The prevailing age group was between 13 and 19 years (30.6%), followed by 6–12 years (27.9%) and 20–29 years (22.2%). The most common etiologies were bicycle (20.4%) and traffic (16.9%) accidents, falls (16.1%) and aggression (16.0%) (Table 1).

Table 1.

Distribution of TDI cause according to gender, age, TDI type. Chi-square association test and complex analysis.

	TDI cause									χ^2
	Falls	Bicycle accidents	Traffic accidents	Fall from height	Aggression	Sports accidents	Collision	Other	Total
Gender
Male	44^*	79	60	25	74^*	38^*	50	17	387	p < 0.001
Female	44^*	32	33	6	13^*	5^*	22	3	158
Age
7–12 years	39^*	32	8^*	12	11^*	12	34^*	4	152	p < 0.001
13–19 years	22	37	25	9	30	20^*	17	7	167
20–29 years	9^*	26	41^*	4	23	8	8^*	2	121
30–39 years	7	10	9	1	9	3	6	2	47
40–49 years	5	5	8	2	8	–	3	1	32
More than 50 years	5	1	2	3	5	–	3	3	22
Not reported	1	–	–	–	1	–	1	1	4
TDI type
Dental fracture (I)	26	38^*	22	9	15	11	15	3	139	p = 0.037
Dislocation (II)	42	47	31^*	12	38	27^*	38	13	248
Alveolar bone fracture (III)	1	–	1	1	2	1	2	–	8
Association between I + II	17	24	25	9	20	3^*	14	3	115
Association between I + III	–	1	2	–	2	–	1	–	6
Association between II + III	1	1	7	–	9	1	2	1	22
Association between I + II + III	1	–	4^*	–	1	–	1	–	7
Total	88	111	93	31	87	43	72	20	545

*

Statistically significant association through complex analysis.

The 545 patients included in the study had a total of 1304 teeth affected by TDI, an average of 2.39 ± 1.69 teeth per patient. Twelve was the maximum number of affected teeth in one isolated patient, with four cases. The most affected dental elements were the maxillary central incisors (57.0%), followed by upper lateral incisors (17.7%), lower central incisors (9.3%) and lower lateral incisors (6.7%) (Table 2).

Table 2.

Distribution of affected tooth according to age, TDI cause and TDI type. Chi-square association test and complex analysis.

	Tooth							χ^2
	Upper central incisor	Upper lateral incisor	Inferior central incisor	Inferior lateral incisor	Upper canine	Other	Total
Age
7–12 years	123^*	44	17^*	8^*	3^*	5^*	292	p < 0.001
13–19 years	236	74	35	21	7^*	23	396
20–29 years	166^*	62	31	26	22^*	15^*	322
30–39 years	53^*	17	15	15^*	9	17	126
40–49 years	43^*	21	14	9	6	1	94
More than 50 years	26^*	11	8	6	5	9^*	65
Not reported	4	2	1	2	–	–	9
TDI cause
Falls	138^*	30	3	7^*	5^*	1^*	184	p < 0.001
Bicycle accidents	162	51	8	20	21	16	278
Traffic accidents	123^*	53	18^*	37^*	20	20	271
Fall from height	38	13	2	10	5	8^*	76
Aggression	114^*	43	15^*	24	22	12	230
Sports accidents	49	11	1	9	6	3	79
Collisions	96^*	20	4	10	7	9	146
Other	23	10	1	4	1	1	40
TDI type
Dental fracture (I)	244	70	33	25	16	25	413	p < 0.001
Dislocation (II)	415	136	70	45	25	36	727
Alveolar bone fracture (III)	10^*	3	6^*	5	3	6^*	33
Association between I + II	47^*	10	4	4	–	–	65
Association between I + III	3^*	1	4^*	3^*	–	2	13
Association between II + III	22	10	4	5	8^*	1	50
Association between I + II + III	2	1	–	–	–	–	3
Total	743	231	121	87	52	70	1304

*

Statistically significant association through complex analysis.

Concerning TDI, 1438 injuries were observed, among which dental dislocations were found in 55.8% of cases alone, whereas 9.0% were associated with dental and/or bone fractures. Dental fractures occurred isolatedly in 31.7% of cases whereas in 6.2% of them were associated to other kinds of injuries. Alveolar bone fractures occurred in isolation in 2.5% of cases as contrasted to 1.2% associated with tooth fractures or dislocations (Table 2).

Among dental fracture types, uncomplicated crown (52.6%) and complicated crown (20.9%) were the most frequent. As to dislocation, subluxation and avulsion occurred most frequently, with 25.0% and 24.5% respectively (Table 3).

Table 3.

Distribution between age and TDI classification.

TDI classification	Age							Total
	7–12 years	13–19 years	20–29 years	30–39 years	40–49 years	More than 50 years	Not reported
Dental fracture
Uncomplicated crown fracture	84	80	52	22	18	–	4	260
Complicated crown fracture	20	41	31	2	5	3	1	103
Root fracture	–	7	18	9	9	3	1	47
Complicated crown-root fracture	8	8	13	5	–	–	–	34
Infraction	1	3	11	3	–	–	–	18
Uncomplicated crown-root fracture	–	3	12	1	–	–	–	16
Enamel fracture	1	1	4	–	3	–	–	9
Not specified	1	3	3	–	–	–	–	7
Total	115	146	144	42	35	6	6	494
Dislocation
Subluxation	59	50	38	13	20	31	–	211
Avulsion	61	66	47	12	14	5	2	207
Lateral luxation	16	55	20	15	3	10	–	119
Extrusion	18	28	29	11	9	7	–	102
Concussion	15	12	28	15	2	2	1	75
Intrusion	14	7	5	–	3	2	–	31
Not specified	16	42	17	13	9	3	–	100
Total	199	260	184	79	60	60	3	845
Alveolar bone fracture	11	26	41	14	1	6	–	99

The chi-square association test was statistically significant upon crossing all categories of variables (p ≤ 0.05), except for gender and age (p = 0.06), gender and dental element (p = 0.57), gender and TDI type (p = 0.42), and age and TDI type (p = 0.65). Tables 1 and 2 include variable crossings that showed statistically significant associations, as well as complex analysis which highlight the associated pairs of variables.

Regarding the cause of trauma, statistical analysis mainly demonstrates a positive association between male patients with aggression, falls and sport accidents; age (7–12 years) with falls and collisions; age (13–19 years) with sports accidents; age (20–29 years) with traffic accidents; dental fractures with bicycle accidents; and dislocations with traffic and sports accidents (Table 1).

Concerning the involved tooth in trauma, upper central incisors were associated all ages, except 13–19 years which was associated with upper canines. About cause, upper central incisors had association with falls, traffic accidents, aggression and collisions; inferior central incisors with traffic accidents and collisions; and lateral inferior incisors with traffic accidents (Table 2).

Discussion

The present retrospective study was conducted at a permanent tooth trauma monitoring and treatment center of a public institution service. Patients treated in this service are usually forwarded to Emergency Hospitals due to facial injuries. TDI cross-sectional studies allow monitoring higher age and gender prevalence, in addition to the association between different TDI and causing factors.^7,9

A male prevalence at a 2.4:1 ratio was found. This finding is supported by other research in the literature, and it is agreed that boys play sports and high risk competitions of intense contact; in adult men, in turn, TDI is additionally related to traffic accidents and aggression.^9,13,14 In this study, an association between gender and cause was also found, inasmuch as men, regardless of age, showed TDI due to falls, aggression and sports.

One of the major TDI risk factors is age, and the most affected age group consists of children and adolescents.^1–3 The high number of injuries in this population can be explained by their daily activity characteristics, with great time spent in recreation and sports.¹⁵ In this retrospective study, 58.5% of cases were reported in patients between six and 19 years of age. The average age of 20.77 years observed in the study was similar to that found in literature.^7,16

The cause–age association showed that children aged seven to 12 years suffer TDI by fall, collision with objects, traffic accidents and aggression, in this order. Falls and collisions are major causes related to school recreational activities.¹⁷ In these cases, preventive actions are rare and difficult to implement.¹⁶ However, aggression cases can be accounted for by school fights and domestic violence, and the evaluation of these patients is essential to the identification of likely domestic aggression and its report to authorities.¹⁸ The main etiology for teenagers between 13 and 19 was associated to sports, which is also in agreement with that described in literature, and reinforces the need to use mouth guards to prevent these injuries.^5,19

Dental dislocations were the most prevalent TDI type, being present in 64.8% of cases. This type of TDI occurs mainly in children and adolescents^6,20 due to anatomical characteristics during the phase of mixed dentition and facial growth.⁵ In this period, the periodontal ligament space is increased, being a dislocation predisposition and, since the mandible has not its fully developed yet, there may be lack of lip seal and excessive incisor exposure. In this study, 54.3% of dental dislocations affected patients of up to 19 years.

Higher impact etiologies are related to a greater transmission of forces to supporting tissues, dental dislocations and bone fractures.¹⁶ Medical records of the evaluated patients showed an association between bicycle accidents and dental fractures, traffic accidents with dental and bone fractures, and sports accidents with either isolated dislocations or associated with dental fractures. Thus, in the face of TDI due to higher impact accidents, injuries to the periodontal tissues should be investigated, since they show greater severity and a worse prognosis.^7,13

As to TDI classification, infraction, enamel fracture and uncomplicated crown fracture accounted for only 19.9% of all injuries. The high prevalence of other lesions with pulp and/or supporting tissue involvement can be explained by the characteristics of the evaluated service. Because it is an institutional public care TDI specific service, less severe cases are resolved in the public health network, without the need for referral. Among dental elements, the results found in this study are in agreement with those in literature, which point to upper incisors as the most usually affected teeth.^3,13

The knowledge of dental trauma epidemiology has an important role in clinical treatment of those injuries. According to patient profile (age, gender and cause of trauma) the attendance may be prepared for the most associated diagnosis and involved teeth. Thus, it may improve the early treatment and prognosis of the injuries.

Considering the limitations of a retrospective analysis conducted at a single TDI-referral center, TDI prevalence in children and adolescents was found along a ten-year period due to falls, collisions and traffic and sports accidents. Most TDI showed an involvement of supporting and/or pulp tissues, the upper central incisor being the most affected tooth.

Ethical responsibilities

Protection of human and animal subjects

The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).

Confidentiality of data

The authors declare that they have followed the protocols of their work center on the publication of patient data.

Right to privacy and informed consent

The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.

Conflict of interest

The authors declare no conflict of interest.