TRAUMATIC DENTAL INJURIES AND ASSOCIATED FACTORS AMONG BRAZILIAN PRESCHOOL CHILDREN AGED 1-5 YEARS

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1 47 TRAUMATIC DENTAL INJURIES AND ASSOCIATED FACTORS AMONG BRAZILIAN PRESCHOOL CHILDREN AGED 1-5 YEARS Aa F. Graville-Garcia 1, Ítala Tarciae de Almeira Vieira 2, Maria J. Pereira da Silva Siqueira 2, Valdeice Aparecida de Meezes 2, Alessadro Leite Cavalcati 1 1 Departmet of Pediatric Detistry, School of Detistry, State Uiversity of Paraíba, Campia Grade, Paraíba, Brazil. 2 Departmet of Pediatric Detistry, School of Detistry, Higher Educatio Associatio of Caruaru, Perambuco, Brazil. ABSTRACT The aim of this study was to evaluate the prevalece of detal trauma i childre aged 1 to 5 years old ad its associated factors (geder, age group, malocclusio ad labial-closig), iterviewig parets ad guardias for additioal iformatio o the trauma occurrece. A trasversal study of 820 preschool childre from the City of Caruaru, Perambuco, Brazil was coducted. Data were collected by meas of a cliical examiatio ad a structured iterview. The statistical aalysis icluded a distributio of frequecies, a bi- ad a multi-variate aalysis at a sigificace level of 5. Trauma prevalece was 20.1, tooth 61 was the most ofte affected, ad eamel fractures followed by the fractures of the eamel ad the detie were the most frequet alteratios. Trauma prevalece was highest i 3- to 5-year-old males with malocclusio (ope bite ad protrusio) (p<0.05). Accordig to most parets ad/or guardias, the most usual etiology was fallig ad the place most ofte cited was home. All the variables studied, except for lip coverage, were associated with detal trauma. The outcome of the preset study showed high prevalece of detal trauma i a pediatric populatio uder the age of 5 years. Falls ad accidetal collisios were the etiological factors most ofte cited. The frot upper icisors were the teeth most ofte affected, ad eamel fracture was the trauma most ofte observed. Key words: pediatric detistry, epidemiology, tooth ijuries, primary detitio. TRAUMATISMOS DENTÁRIOS E FATORES ASSOCIADOS ENTRE PRÉ-ESCOLARES BRASILEIROS DE 1 A 5 ANOS DE IDADE RESUMO O objetivo deste estudo foi avaliar a prevalêcia de trauma detário em criaças de 1 a 5 aos de idade e os fatores associados (gêero, faixa etária, maloclusão e selameto labial), por meio de etrevistas com os pais e resposáveis para a obteção de iformações adicioais sobre a ocorrêcia do trauma. Um estudo trasversal com 820 pré-escolares foi realizado a cidade de Caruaru, Perambuco, Brasil. Os dados foram coletados por meio de exame clíico e de uma etrevista estruturada. A aálise estatística icluiu a distribuição de freqüêcias, aálise bi e multi-variada com um ível de sigificâcia de 5. A prevalêcia de trauma foi de 20,1, sedo o dete 61 o mais afetado e as fraturas de esmalte e fraturas de esmalte e detia as alterações mais frequetes. A prevalêcia de trauma foi maior os meios de 3 a 5 aos com maloclusão (mordida aberta e protrusão) (p<0,05). De acordo com a maioria dos pais e resposáveis, a etiologia mais frequete foi a queda, e o lugar da ocorrêcia a residêcia. Todas as variáveis estudadas, exceto o selameto labial, mostraram-se associadas com o trauma detário. Este estudo revelou uma alta prevalêcia de traumatismo detário a população ifatil abaixo dos 5 aos de idade. Quedas e colisões acidetais foram os fatores etiológicos mais frequetemete citados. Os icisivos cetrais superiores os detes mais atigidos e a fratura de esmalte o trauma mais observado. Palavras chave: odotopediatria, epidemiologia, traumatismo detário, detição decídua. INTRODUCTION The high prevalece of detal trauma i preschool childre has become a public health cocer 1. The mai objectives of diagosis ad treatmet of traumatic ijuries affectig childre with primary detitio are pai maagemet ad prevetio of possible damage to the developig tooth germ 2. The age-group ad geder of higher risk are cotroversial i the literature 3-6. The most commo age group i which primary tooth ijury occurs Vol. 23 Nº 1 / 2010 / ISSN Acta Odotol. Latioam. 2010

2 48 Aa F. Graville-Garcia, Ítala Tarciae de Almeira Vieira, et al. is 1.5 to 2.5 years. Ijuries to the detitio of ifats are ifrequet durig the first year of life because ifats teeth do ot start eruptig util the child is 6 moths of age, ad ifats are limited i their ability to move about i their eviromet 7. Protrusio of upper icisors, ope bite, lip closure ad epilepsy are amog predisposig factors 3,8. Maxillary teeth are more frequetly traumatized tha madibular teeth ad there is geeral agreemet that maxillary cetral icisors are ijured most frequetly, probably due to their vulerable positio 9. Whe they are lost at the begiig or eve i the middle of their biological cycle, there are esthetic alteratios, with a reductio of the child s self-esteem, makig speech difficult or eve cotributig to istall deleterious habits 10. The purpose of this retrospective study was to determie the prevalece of traumatic ijuries to primary aterior teeth ad associated factors i preschool childre from the city of Caruaru, Perambuco, Brazil. The aalysis of the oral health coditios of differet groups ad age rages cotributes iformatio that is essetial for plaig ad establishig health promotio actio. MATERIAL AND METHODS Populatio A trasversal ad a aalytical epidemiological study were performed with retrospective compoets i a iterview with parets ad/or guardias. The sample was composed of 820 childre aged 1 to 5 years, regularly erolled i 7 muicipal day care ceters of the city of Caruaru, i Perambuco State, located i the ortheast of Brazil. The cliical examiatios were performed i the first semester of Ethical coset for the study was obtaied ad writte coset for participatio was obtaied from at least oe of each child s parets prior to the study, accordig to the ethical guidelies of the Declaratio of Helsiki. Examiatios Childre were examied i predetermied order i selected rooms uder atural light. Durig the cliical examiatio, childre sat o school desks, i plai atural light. Childre uder two years old wet through a foot-foot, or kee-kee system 11. A mouth mirror #3, tweezers for cotto ad a CPI periodotal probe were used i the examiatio, prior to which detal biofilm was removed usig atiseptic gauze. The classificatio suggested by Hids ad Gregory 12 was used for recordig traumas. The criteria are discoloratio, eamel fracture, eamel ad deti fracture; eamel, deti ad pulp fracture; avulsio, lateral luxatio, itrusive ad extrusive, restoratio caused by trauma; combied traumas. Immediately prior to the examiatio, lip coverage was recorded (adequate or ot) with facial musculature i apparet rest, whe the child was distracted ad uaware of the occurrece of the examiatio 13. Overjet was measured with teeth i cetric occlusio; the probe parallel to the occlusal plae to register detal protrusio (protrusio greater tha 3mm). Whe there was o cotact betwee the aterior teeth ad the posterior teeth remaied i occlusio, ope bite was diagosed 14. Examiatio criteria were diagosed ad stadardized i order to esure precise results ad miimize the occurrece of itra-examier error. The examier repeated the cliical examiatio o 10 of the childre i the sample withi 24 hours i order to determie itra-examier agreemet, which was thus foud to be greater tha Whe trauma was diagosed, parets or guardias were iterviewed idividually i order to obtai additioal iformatio. Stadardized or structured iterviews were used, ad the reliability of the results was tested usig the face validatio method i 10 of the iterviews 15. Statistical Aalysis All recorded data were aalyzed with the software SPSS versio Etire distributios, ui- ad bi-variate percetages (descriptive statistics techiques) were obtaied to aalyze data, ad the Pearso idepedece Chi-square test was performed. Odds Ratio (OR) values ad reliability rages were obtaied to study the lik betwee idepedet ad depedet variables i a bi-variate study, cosiderig the first or the last category as referece values. I order to determie the ifluece of idepedet variables upo the depedet variable (child with trauma), two sample techiques of logistic regressio were adjusted alog with the three idepedet variables selected durig the bi-variate study that were sigificat with the depedet variable or the aswer at the level of 5.0. Acta Odotol. Latioam ISSN Vol. 23 Nº 1 / 2010 / 47-52

3 Detal Trauma i Primary Detitio 49 Table 1: Trauma prevalece assessmet accordig to age ad geder. Variable Trauma Value of p OR (IC at 95) Yes No Total N Age (years) p(1) = 0.002* 4.53 ( ) 6.85 ( ) 6.13 ( ) 7.67 ( ) Total Group Geder Male Female p(1) = 0.049* 1.41 (-2.00) Total Group (*): Sigificace at 5.0; (1): Based o Pearso's Chi-square test. RESULTS Table 1 shows that trauma prevalece icreases with age, from 4.2 for oe-year-olds to 25.5 for 5-year-olds. The lik betwee trauma ad age group becomes importat accordig to the value of p, to the value of OR ad to the OR itervals excludig the value. Trauma prevalece was 5.5 higher amog boys tha girls (p<0.05; OR=1.41 [-2.00]). Eamel fracture was the most frequet type of trauma, represetig 56.4 of the cases, followed by 17.6 with fracture of the eamel ad the detie, itrusio (7.9) ad avulsio (7.3). The teeth most ofte affected by trauma were 61 ad 51, makig up 62.4 ad 58.8 of the sample with trauma, respectively (Table 2). Trauma prevalece was very similar i childre with adequate or iadequate lip coverage (20.9 x 19.4) ad there is o major associatio betwee the two variables (p>0.005; OR=1.10 [ ]). Trauma prevalece was higher i childre with isolated ope bite (23.7), or i those with both ope bite ad detal protrusio (31.2), showig a sigificat lik betwee the type of occlusio ad trauma (p<0.05) (Table 3). Table 4 shows that the majority of parets or guardias of childre who suffered trauma (79.9) did ot react immediately; 4.9 sought help later, ad oly 15.2 acted promptly. The two places where the child suffered trauma most ofte cited were at home (42.4) ad at school (38.2). Falls ad accidetal collisios were the etiological factors most ofte cited, with percetages of 64.8 ad 20.6, respectively. Table 5 shows a logistic regressio. The OR values i the table show that the probability of a child sufferig a trauma icreases with age, especially for boys with both ope bite ad protrusio. Table 2: Relative ad absolute distributio of the type of trauma ad affected tooth (52, 51, 61 ad 62). Variable Type of trauma Discoloratio Eamel Fracture Eamel ad detie Fracture Eamel, detie ad pulp Fracture Avulsio Lateral luxatio Itrusio Combied traumas TOTAL Trauma affected tooth BASE (1) (1) : Because a sigle child ca be affected by more tha oe tooth with trauma, the base is used to calculate percetages istead of the total. Vol. 23 Nº 1 / 2010 / ISSN Acta Odotol. Latioam. 2010

4 50 Aa F. Graville-Garcia, Ítala Tarciae de Almeira Vieira, et al. Table 3: Trauma prevalece assessmet accordig to age ad geder. Variable Trauma Value of p OR (IC at 95) Yes No Total N lip coverage Adequate Iadequate p(1) = ( ) Group Total Occlusio With protrusio With detal protrusio With ope bite Ope bite/detal Protrusio p(1) = 0.003* 0.67 ( ) 1.48 ( ) 2.16 ( ) Group Total (*) : Sigificace at 5.0; (1): Through Pearso Chi-square test. Table 4: Trauma assessmet, accordig to parets behavior, locatio ad etiology. Questio What did you do after the trauma? Sought help immediately Sought help later Did othig TOTAL (1) Where did the trauma occur? School Home Other Do t remember TOTAL How did the trauma occur? Fall Accidetal Collisio Sports/traffic accidets Do't remember TOTAL (1) : This iformatio is uavailable for the subject DISCUSSION This research was motivated by the high prevalece of detal trauma i childhood ad the small umber of Brazilia studies o this topic i primary detitio. The literature shows that it is at the preschool age that childre are most vulerable to trauma, either due to ot yet havig fully-developed motor skills, or due to their icreased curiosity ad idepedece durig this phase. Therefore, the exploratio of this topic as well as the kowledge of factors related to trauma occurrece will cotribute to its prevetio through health care policies 5,6,9. Hids ad Gregory s classificatio i the fial report of Natioal Diet ad Survey: childre aged 1 ½ to 4 ½ years was selected for this study. This classificatio takes ito accout the fidigs, accordig to the cliical aspects, of accidets that affected teeth, ad is therefore appropriate ad useful for epidemiological purposes ad adequate for this study, i the absece of a X-ray examiatio 12. The prevalece of trauma foud i this study was No agreemet exists o the prevalece of traumatic detal ijuries, as it has differed from study to study ad from coutry to coutry 9. Retrospective ad prospective studies report frequecies ragig from 9.4 to ,3-6,8,9,16,17. These differeces are probably due to the populatio tested, the methodology or the type of classificatio used. Eamel fracture was the most frequet type of alteratio (56.4), followed by eamel ad detie fracture (17.6). This result is similar to those i others studies 1,4,5,8,9,17. It is importat to poit out that because this study was performed at day care ceters, the frequecy of small-scale traumas was higher tha i hospitals. Most studies of detal traumas ivolve frot upper teeth due to the discreet prevalece of teeth with trauma i the iferior arch 5,16,18. Based upo that, the teeth most ofte affected were 61 ad 51 ad Acta Odotol. Latioam ISSN Vol. 23 Nº 1 / 2010 / 47-52

5 Detal Trauma i Primary Detitio 51 Table 5: Logistic regressio results for trauma prevalece. Variables icluded i the sample Geder Male Female Trauma Uadjusted Odds ratios ad IC (95) 1.41 (-2.00) P-Value p(1) = 0.049* Adjusted Odds ratios ad IC (95) 1.45 ( ) Value of p i adjusted sample p = 0.040* Age group 1 year old 2 years old 3 years old 4 years old 5 years old ( ) 6.85 ( ) 6.13 ( ) 7.67 ( ) p(1) = 0.002* 4.33 ( ) 6.52 ( ) 5.62 ( ) 6.99 ( ) p = 0.024* p = 0.020* p = 0.003* p = 0.006* p = 0.002* Occlusio Without protrusio Ope bite With protrusio Ope bite ad protrusio ( ) 1.48 ( ) 2.16 ( ) p(1) = 0.003* 0.54 ( ) 1.18 ( ) 1.72 ( ) p = 0.032* p = p = p = 0.042* (*) : Sigificace level 5.0. these results are similar to previous studies 5,6,19. However, there are o studies i the literature o deciduous teeth showig that the left side is more ofte affected i detal traumas. The age group was a variable related to detal trauma (p<0.05). Trauma occurrece icreased with age, with 3- to 5-year-olds beig the most affected. This is supported by previous studies i Brazil 5,6,8,9 ad Cuba 1. These results were cofirmed i the logistics regressio aalysis. Regardig geder, there was a sigificat lik with detal trauma, where males were the most affected (p<0.05). Studies maitai that there is o geder differece related to traumas i the age group studied 8,17,19. However, it is show here that boys are more ofte affected by trauma 1,5,9, with the likelihood of boys havig detal trauma beig 1.45 times higher tha for girls (Table 5). There are few studies of malocclusio, lip coverage ad traumas i primary detitio i the literature. Detal protrusio, ope bite ad iadequate lip coverage are ot trauma predisposig factors i primary detitio 3. I this study, the facts showed o relatioship betwee lip coverage ad trauma, but did show a relatioship betwee type of occlusio ad trauma for the age group studied (p<0.05). The logistic regressio aalysis cofirmed that childre with ope bite ad detal protrusio are 1.72 times more likely to have detal traumas (Table 5). School ad home were the places most ofte cited for the occurrece of detal trauma. These are the places where childre i this age group sped most time 20. Falls were the etiological factor most ofte metioed by parets, i agreemet with may studies i the literature 3,5,16,17. Oly 15.2 of parets sought immediate help after trauma, while 4.9 did so later. Negligece regardig the treatmet of childre i relatio to this problem has bee metioed 3,5,8. This is probably due to the fact that little attetio is paid to primary detitio ad that there is a lack of iformatio about possible damage to permaet detitio as well. There is a eed to provide adequate prevetive ad treatmet care for preschool childre 9. Therefore, prevetio ad orietatio campaigs regardig commo risk factors such as accidets must be prioritized ad icorporated i health care geeral istructios. CONCLUSION The outcomes of the preset study showed a high prevalece of detal trauma i a pediatric populatio uder the age of 5. Falls ad accidetal collisios were the etiological factors most ofte cited. The frot upper icisors were the teeth most ofte affected ad eamel fracture was the trauma most frequetly foud. Vol. 23 Nº 1 / 2010 / ISSN Acta Odotol. Latioam. 2010

6 52 Aa F. Graville-Garcia, Ítala Tarciae de Almeira Vieira, et al. CORRESPONDENCE Aa Flávia Graville-Garcia Rua Capitão João Alves Lira, 1325/410 Bela Vista, Campia Grade, Paraíba, Brasil Tel: REFERENCES 1. Rodriguez JG. Traumatic aterior detal ijuries i preschool Cuba childre. Det Traumatol 2007;23(4): Flores MT. Traumatic ijuries i the primary detitio. Det Traumatol 2002;18(6): Bijella MFT, Yared FNFG, Bijella VT, Lopes ES. Occurrece of primary icisor traumatism i Brazilia childre: a houseby-house survey. J Det Child 1990;57(6): Kramer P, Zebruski C, Ferreira SH, Feldes CA. Traumatic detal ijuries i Brazilia preschool childre. Det Traumatol 2003;19(6): Graville-Garcia AF, Meezes VA, Lira PIC. Detal trauma ad associated factors i Brazilia preschoolers. Det Traumatol 2006;22(6): Ferreira JM, Ferades de Adrade EM, Katz CR, Roseblatt A. Prevalece of detal trauma i deciduous teeth of Brazilia childre. Det Traumatol 2009;25(2): Wilso CFG. Maagemet of trauma to primary ad developig teeth. Det Cli North Am 1995;39(1): Oliveira BL, Marcees W, Ardeghi TM, Sheiham A, Böecker M Traumatic detal ijuries ad associated factors amog Brazilia preschool childre. Det Traumatol 2007;23(2): Beltrão EM, Cavalcati AL, Albuquerque SS, Duarte RC. Prevalece of detal trauma childre aged 1-3 years i Joao Pessoa (Brazil). Eur Arch Paediatr Det 2007;8(3): Rocha MJC, Cardoso M. Federal Uiversity of Sata Cataria edodotic treatmet of traumatized primary teeth - part 2. Det Traumatol 2004;20(6): Pikham JR, Casamassio PS, Fields HW, Mctigue D, Nowak A. Pediatric detistry - Ifacy Through Adolescece. 4th ed. WB Sauders, Uited Kigdom, p. 12. Hids K, Gregory JR. Natioal diet ad utritio survey: childre aged 1 ½ to 4 ½ years. Volume 2 Report of detal survey. HMSO, Lodo, p. 13. Burde DJ. A ivestigatio of the associatio betwee overjet size, lip coverage, ad traumatic ijury to maxillary icisors. Eur J Orthod 1995;17(6): Petti S, Tarsitai G. Traumatic ijuries to aterior teeth i Italia schoolchildre: prevalece ad risk factors. Edod Det Traumatol 1996;12(6): Frakfort-Nachimias C, Nachimias D. Research methods i the social scieces. 4th ed. Lodo: Edward Arold, p. 16. Sachez AV, Garcia-Godoy F. Traumatic detal ijuries i 3- to 13-year-old boys i Moterrey, Mexico. Edod Det Traumatol 1990;6(2): Jorge KO, Moysés SJ, Ferreira e Ferreira E, Ramos-Jorge ML, de Araújo Zarzar PM. Prevalece ad factors associated to detal trauma i ifats 1-3 years of age. Det Traumatol 2009;25(2): Adrease JO. Etiology ad pathogeesis of traumatic detal ijuries. A cliical study of 1,298 cases. Scad J Det Res 1970;78(4): Wilso S, Smith G, Preisch J, Casamassimo PS. Epidemiology of detal trauma treated i a urba pediatric emergecy departmet. Pediatr Emerg Care 1997;13(1): Mestriho HD, Bezerra AC, Carvalho JC. Traumatic detal ijuries i Brazilia pre-school childre. Braz Det J 1998; 9(2): Acta Odotol. Latioam ISSN Vol. 23 Nº 1 / 2010 / 47-52