DENTAL INJURIES IN 0-15 YEAR OLDS AT THE KENYATTA NATIONAL HOSPITAL, NAIROBI. H. M. MURIITHI, M. A. MASIGA and M. L.

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1 592 EAST AFRICAN MEDICAL JOURNAL November 2005 East African Medical Journal Vol. 82 No. 11 November 2005 DENTAL INJURIES IN 0-15 YEAR OLDS AT THE KENYATTA NATIONAL HOSPITAL, NAIROBI H. M. Muriithi, BDS, MDS, M. A. Masiga, BDS, MSc, Department of Paediatric Dentistry and M. L. Chindia, BDS, MSc, FFDRCSI, Department of Oral and Maxillofacial, Oral Medicine and Oral Pathology, Faculty of Dental Sciences, University of Nairobi, P. O. Box 19676, Nairobi, Kenya Request for reprints to: Dr. H. M. Muriithi, Department of Paediatric Dentistry, Faculty of Dental Sciences, P. O. Box 19676, Nairobi, Kenya DENTAL INJURIES IN 0-15 YEAR OLDS AT THE KENYATTA NATIONAL HOSPITAL, NAIROBI H. M. MURIITHI, M. A. MASIGA and M. L. CHINDIA ABSTRACT Objective: To determine the pattern of occurrence of dental injuries in the 0-15 year-olds. Design: A retrospective study. Setting: Kenyatta National Hospital, Nairobi. Subjects: Five hundred and five patient records with dental injuries were retrieved and analysed. Results: A total of 505 patient records with dental injuries were retrieved and analysed. Most of the injuries were recorded in the year 1999 (22.2%). Boys were more affected (63.0%) than girls (37.0%).The main presenting complaint recorded was pain (75.8%).The majority of the patients (69.5%) presented for treatment during the same day or the day after trauma. Falls were the leading cause of injuries (73.5%). Most injuries involved two teeth (47.1%) and the maxillary central incisors were the most affected teeth both in the primary (67.5%) and permanent (64.0%) dentitions. Luxation injuries were the most common type of dental trauma with 47.5% occurring in the permanent teeth and 77.3% in the primary teeth. The main radiographic investigation performed was intraoral periapical views (52.9%) following which dental extraction (34.4%) was the main treatment modality offered. Conclusion: Prospective cross-sectional studies to determine the prevalence of dental injuries are needed. Furthermore improving the knowledge of dental practitioners through continuing dental education programmes would help in updating them on current trends in managing these injuries. INTRODUCTION Traumatic dental injuries in children are a common presentation to the general dental practitioner and constitute a problem of major dental public health concern (1). Complications arising from dental injuries have been shown to impact negatively on the growing patient. Fractured teeth and tooth avulsions can lead to psychological, aesthetic and functional disturbances in the child (2). Orthodontically, traumatic dental injuries can result in the loss of space within the dental arch and may complicate orthodontic tooth movement especially where ankylosis, dilaceration and root resorption have set in. Attempted replacement of avulsed teeth in children with prostheses such as bridges is delayed to facilitate reduction of the pulp size of abutment teeth and the establishment of the gingival margin of the existing dentition. Numerous studies on the prevalence of traumatic dental injuries in children and adolescents have been reported worldwide with documented incidence ranging from 4-33% depending on the sex, age and the study design selected (3). The aim of the present study was to analyse data pertaining to traumatic dental injuries from records of patients aged 0-15 years, who sought treatment at the dental department of Kenyatta National hospital (KNH) from January 1998 to December MATERIALS AND METHODS The material for the study was obtained from the dental records at KNH following approval of the proposal by the Ethics, Research and Standard Committee of Kenyatta National Hospital and University of Nairobi (Approval Ref. No. KNEI- ERC/01/1830). The records of all patients aged 0-15 years who had presented with dental injuries from January 1998 to December 2002 were filtered out and examined for the collection of data. A sample of the data obtained crossexamined and calibrated by two clinicians. Cases with incomplete information were excluded from the study. The type of trauma was classified as follows: (i) Enamel and dentine fractures (uncomplicated crown fracture) (ii) Fracture involving the pulp (iii) Root fractures (iv) Luxation and avulsion injuries The data were processed and analysed by means of the Statistical Package for the Social Sciences (SSPS PC Version 10.0). The Chi-square and Mann-Whitney U-tests were used to compare qualitative data and determine the statistical significance set at P<0.05.

2 November 2005 EAST AFRICAN MEDICAL JOURNAL 593 RESULTS During the period January 1998 to December 2002, 10,563 patients aged between 0-15 years attended the dental department for dental care. Out of these, 505 (4.8%) patients had suffered traumatic dental injury. The distribution of dental injuries according to year of presentation is shown in Figure 1, with the year 1999 recording the highest number of injuries 22.2% while the year 2002 the least at 16.8%. No statistically significant difference was found between the occurrence of injury and the year. Of the 505 cases presenting with dental injuries 318 were boys (63.0%) and 187 were girls (37.0%), giving a male: female ratio of 1.7:1. This difference was found to have been statistically significant with boys being more affected than girls (p=0.008). In both boys and girls, the dental injuries occurred most frequently at the age of four years (13.5% and 13.3%, respectively). This was found to have been statistically significant when compared with the other age groups when the Pearsons Chi-square test was applied (p=0.001). The distribution of patients with dental injuries according, to age and gender is presented in Table 1. Table 1 Distribution of patients according to age and gender Age (Years) Boys Girls Total (%) Total Table 2 Distribution of injuries by gender and aetiology Type of injury Gender Male (%) Female (%) Total (%) Fall 227 (45.0) 144 (28.5) 371 (73.5) Assault 42 (8.3) 13 (2.6) 55 (10.9) Traffic Accident 26 (5.1) 16 (3.2) 42 (8.3) Collisions 16 (3.2) 12 (2.4) 28 (5.5) Epileptic falls 6 (1.2) - 6 (1.2) Donkey kick 1 (0.2) - 1 (0.2) Cow kick - 1 (0.2) 1 (0.2) Dog bite 1 (0.2) - 1 (0.2) Total 319 (63.2) 186 (36.8) 505 (100)

3 594 EAST AFRICAN MEDICAL JOURNAL November 2005 Figure 1 Distribution of patients according to year of attendance Figure 2 Distribution of dental injuries by type and dentition The most common presenting complaint recorded was pain (75.8%) followed by a broken tooth (15.2%), displaced tooth (6.6%), discoloured tooth (1.0%), gum swelling (0.8%) and missing tooth (0.6%). The time taken prior to seeking treatment following an injury ranged between the same day of the injury to five years. The majority of the patients sought treatment within the day of the injury (38.6%) while 156 (30.9%) came one day after the trauma. The mean duration of attendance following injury was calculated at 17.9 days (SD 117, median 1 day). For most of the patients (77.0%), treatment was commenced within the same day of attendance. In a small number of the cases (0.4%) treatment started 1-3 years after examination. The mean duration of time taken prior to commencement of treatment was 6.6 days (SD 54, median <1 day). In about half of the cases seen (50.7%), the treatment was completed in less than a day while in 85 (16.8%) of the patients treatment was completed within 1-7 days. In a minority of the cases (0.6%) treatment took over six months. The mean duration of completion of treatment was 14.9 days (SD: 50, median <1 day). The distribution of dental injuries per patient ranged from one to eight traumatised teeth per patient. In all, 238 patients (47.1%) had two teeth traumatised, 185 children (36.6%) had only one tooth injured while the remaining 82 patients (16.3%) had three or more teeth traumatised. The most common cause of dental trauma in both girls and boys was falling (73.5%). Falls as a cause of injury were found to have been highly statistically significant in the ages of 2-4 years for both sexes (p=0.001). Table 2 shows the ditribution of patients according to gender and cause of injury. The total number of teeth traumatised in patients who attended with dental injuries was 985. Of these, 486 were permanent teeth and 499 were deciduous teeth. Luxation injuries were predominant in both the permanent and deciduous dentitions. The injuries sustained by the permanent dentition were luxations (47.5%), uncomplicated crown fractures (20.8%), avulsions (17.5%), complicated crown fractures with a closed apex (7.8%), complicated crown fractures with an open apex (3.1%) and root fractures (3.3%). On the other hand, the injuries sustained by deciduous teeth were luxation injuries (77.2%), avulsions (13.2%). uncomplicated crown fractures (8.2%) and root fractures (1.4%) (Figure 2). There was a significantly higher occurrence of luxation injuries in the 0-5 year old age group (p=0.022) than there were uncomplicated crown fractures in the 6-15 year age group (p=0.041). Of the permanent teeth, maxillary central incisors were the most frequently traumatised teeth (64.0%) followed by the maxillary lateral incisors (15.4%). mandibular lateral incisors (11.5%), mandibular lateral incisors (4.9%) and maxillary canines (1.6%). The number of teeth traumatised in the right quadrants was almost similar to those in the left. The distribution of traumatised teeth in both the permanent and deciduous teeth followed a similar pattern where in the deciduous dentition, the maxillary central incisors (67.5%) were the most commonly injured teeth. This was followed by the maxillary lateral incisors (16.8%), mandibular central incisors (7.4%). mandibular lateral incisors (3.8%). maxillary canines (2.4%), mandibular first molars (1.0%) and mandibular canines (0.8%). The number of teeth traumatised in the left quadrants was marginally higher than those on the right. Table 3 shows the different radiographic investigations carried out prior to treating the various dental injuries. Periapical views were the most common x-rays taken (52.9%) followed by upper standard occlusal (19.2%). Combination x-rays were taken in 46 (9.1%) of the cases. No form of radiographic investigation was done in 65 (12.5%) of the patients with dental injury. Regarding therapy, of the 499 traumatised teeth in the deciduous dentition, 274 (54.9%)

4 November 2005 EAST AFRICAN MEDICAL JOURNAL 595 were extracted and 225 (45.1%) received no treatment. Extractions were done in 38 (92.0) of the cases involving uncomplicated crown fracture. On the other hand, of the 486 traumatised permanent teeth, the modalities of treatment included no treatment (50.4%), splinting (17.7%), composite restorations (9.1%), root canal treatment (6.4%). extraction (6.2%), partial denture (5,6%), and to a lesser extent surgical repositioning (1.6%), apexification (1.0%), pulpotomy (0.8%), apicectomy (0.8%), orthodontic extrusion (0.4%) and direct pulp capping (0.2%). Table 4 shows how the various injuries in the permanent dentition were treated, The most common form of splint applied to the luxated permanent teeth was arch-bars (65.0%), followed by composite splinting (33.0%) and the figure of eight wire (2.0%), Most luxation injuries (86,0%) were splinted for between 2-4 weeks. One case had an extended duration of splinting of 20 weeks. The mean duration of sprinting was calculated at 3.8 weeks. Table 3 Radiographic investigation performed on traumatised teeth Type No. of cases (%) Intraoral periapical (IOPA) Upper standard occlusal (USO) Lower standard occlusal (LSO) Orthopantomogram (OPG) IOPA/OPG IOPA/Occlusal None Total Table 4 Treatment modalities done to various types of injuries to permanent teeth Type of Injury Complicated crown Complicated fracture crown fracture Treatment Uncomplicated (open apex) with closed Luxation Root fracture Avulsion given crown fracture (n=15)% apex (n=38)% (n=231)% (n=16)% (n=85)% (n=101)% No treatment Extraction Splinting 35.6 Restoration 41.6 Root canal Partial denture 30.6 Pulpotomy 27.0 Apexification 33.0 Apicectomy 4.0 Orthodontic Extrusion 0.8 Direct pulp cap 3.0 Total

5 596 EAST AFRICAN MEDICAL JOURNAL November 2005 DISCUSSION The present study has shown that there was a greater frequency of traumatic dental injuries among boys than girls. Boys were 1.7 times more prone to having dental injuries than girls. Other studies have shown similar findings (4, 5). This might be explained by the observation that boys engage in more physical activities than girls and therefore are at a greater risk of sustaining dental injuries (6-8). Andreasen (9) reported that as a child begins to walk and run, the incidence of dental injuries increases due to reduced motor co-ordination until an initial peak around the age of four years followed by a second peak at the age of 8-10 years caused by an increase in physical activity. The results of this study concurred with earlier studies showing a first peak at the age of four years and a second at the age of eight years. A high statistically significant difference was found between the occurrence of a dental injury and age and gender when using the Pearsons Chi-square test. In contrast with previous studies that have shown the majority of patients sustaining a one tooth injury per patient (10, 11), this study showed that most of the patients (47.1%), presented with two injured teeth while in 36.6% of the cases was one tooth traumatised. This may suggest that the forces involved in producing these injuries maybe greater in our set-up. In this study, as supported by the existing literature (9,10), the maxillary central incisors were more frequently traumatised than the mandibular incisors in both the primary and permanent dentitions. The explanation for this probably relates to the vulnerable anterior position of the maxillary central incisors. In addition, these teeth may be protruded and may have inadequate lip coverage to cushion an impact (12). It was, however, not possible to establish these facts in a retrospective study. The finding in this study that the aetiology of traumatic injuries was mostly due to fall (73.5%) is similar to most of the studies in the literature (6,13,14). Traumatic dental injuries due to falls occur in young children, probably because the children are gaining mobility and independence, yet there is lack of full coordination and judgment. Falls as one type of the causes of the injury in this study was found to have been highly statistically significant (p=0.001) in the 2-4 year old age group where inco-ordination may be highest. The results of this study show that the most common type of injury to the primary dentition was luxation (77.2%) followed by avulsion (13.2%) cases, crown fractures (8.2%) and root fractures (1.4%). Previous studies have consistently demonstrated that most primary tooth trauma results in displacement injury (15). This is attributed to the alveolar bone which is more elastic in the young child and tends to absorb and distribute the impact. In addition, a low force is generated when a child falls due to their small mass. Low energy impacts cause the greatest damage to the supporting structures of the dentition, the chance of crown and root fractures is reduced while the risk of luxations is increased. In the permanent dentition, there was also a predominance of luxation injuries (47.5%) than crown fractures (20.8%) which is contrary to the findings of most studies (16,17) that have showed a preponderance of crown fractures in permanent teeth. Considering that most patients in this study, presented with injuries to two teeth rather than one, it can be hypothesised that the impact was re-distributed to more teeth hence it was insufficient to cause a crown fracture but rather a luxation injury. Avulsion injuries were found to have been 17.5% in the permanent dentition, while root fractures comprised 3.3%. These values corroborate well with results of previous researchers. Few published data are available regarding the period elapsing between injury and time of presentation for dental care. Two previous studies reported that 77% (l8) and 68% (8) of patients attended for treatment on the same day or the day after trauma occurred. In the present study, 69.5% of the patients came for treatment within the same day following trauma and 77% were treated within the same day. It is notable that trauma situations were taken seriously by patients who attended hospital promptly and medical officers who instituted treatment promptly. Radiographic investigations were performed on 445 patients (87.1%) and omitted in the remaining 12.9% of the cases. Single X-rays views were taken most often (78%) while combination radiographs were requested in only 9.1% of the cases. It has been advocated that a minimum of two different views are required to ascertain identification of a dental injury (19). The reason for this discrepancy in this study maybe attributed to additional cost of x-rays needed for treatment or may have been an oversight on the part of the clinicians. The X-rays taken for dental injuries were not available in the records since they were given to the patients for keeping. Regarding therapy of the traumatised teeth in the deciduous dentition, extraction was the treatment of choice in all the various types of dental injury sustained (54.9%). Various authors in the literature have suggested that initial treatment of traumatised primary teeth should be restricted to close observation of the situation except for cases of excessive mobility and displacement, evidence of pulpal necrosis or closeness to natural exfoliation. In these situations, extraction of the traumatised tooth is recommended (20). On the other hand, various treatment modalities were instituted in the management of the diverse injuries sustained to the traumatised permanent teeth. There was a general tendency in opting for the more conservative forms of treatment such as observation rather than performing the recommended restorative and splinting procedures that might have tended to be more time consuming to the doctor and expensive to the patient. No cases of reimplatation were documented despite there having

6 November 2005 EAST AFRICAN MEDICAL JOURNAL 597 been 85 cases of avulsion injury in the permanent dentition. This may be due to the lack of knowledge on this mode of treatment on the part of the patients who may not have carried their teeth along with them or stored them properly. On the whole, the results of this study showed a similar trend regarding the pattern of occurence of paediatric dental injuries as in most previous studies. Males sustained the majority of the dental injuries involving the upper central incisors caused mainly by falling. ACKNOWLEDGEMENTS To the staff in the records department, KNH for their diligence in retrieving the case files. REFERENCES 1. Norberg, E. Injuries as a public health problem in sub- Sahara Africa. East Afr. Med. J. 2000; 77: Avery, D. R. Management of trauma to the teeth and supporting tissues. In: McDonald R. E., Avery D. R., Eds. Dentistry for the child and adolescent. AII India Traveler Book Seller: Delhi. 2001; Dewhurst, S. N. Emergency treatment of orodental injuries: a review. Brit. J. Oral Maxillofacial Surg. 1998; 38: Ngang'a, P. M. and Valderhaug, J. The prevalence of fractured permanent incisors in year old school children in Nairobi. Afr. Dental J. 1988; 2: Otuyemi, O. D. and Adegboye, A. A. Traumatic anterior dental injuries in Nigerian pre-school children. East Afr. Med. J. 1996; 73: Ohito, F. A. Opinya, G. and Wang'ombe, J. Traumatic dental injuries in normal and handicapped children in Nairobi, Kenya. East Afr. Med. J. 1992; 69: Kahabuka, F. K. Oro-dental injuries and their management among children and adolescents in Tanzania. East Afr. Med. J. 1999; 76: Gabris, K., Tarjan, I. and Rozsa, N. Dental trauma in children presenting for treatment at department of Dentistry for children and Orthodontics, Budapest ; Dent Traumatol. 2001; 17: Andreasen, J. O. and Andreasen, F. M. Dental traumatology: quo vadis. Endod Dent Traumatol. 1990; 6: Petti, S. and Tarsitani, C. Traumatic injuries to anterior teeth in Italian school children: prevalence and risk factors. Endod Dent Traumatol. 1996; 12: Rajab, L. D. Traumatic dental injuries in children presenting for treatment at the Department of Paediatic Dentistry, Faculty of Dentistry University of Jordan Dental Traumatol. 2003; 19: Forsberg, C. M. and Tedestanm, C. Etiological and predisposing factors related to traumatic injuries to permanent teeth. Swed Dent. J. 1993; 17: Isil, S. and Hayriye, S. The prevalence of traumatic injuries treated in the pedodontic clinic of Ankara University, Turkey, during 18 months. Dental Traumatol. 2002; 18: Rai, S. B. and Munshi, A. Traumatic injuries to the anterior teeth among South Kanara school children. A prevalence study. J. Indian Soc. Ped. Preven. Dent. 1988; 16: Clifton, O. and Dummett, Jr. Dental management of traumatic injuries to the primary dentition. CDA J. 2000; 28: Kramer, P. F. and Zembruski, C. Traumatic dental injuries in Brazilian preschool children. Dent. Traumatol. 2003; 19: Andreasen, J. O. Aetiology and pathogenesis of traumatic dental injuries. A clinical study of 1298 cases. Scand J. Dent. Res. 1970; 78: Josefsson, E. and Karlander, E. L. Traumatic injuries to permanent teeth among Swedish school children living in a rural area. Swed. Dent. J. 1994; 18: Andreasen, F. M. Treatment of traumatic dental injuries. J. Current Opinion Dent. 1991; 1: Braham R.L, Roberts M.W. Management of dental trauma in children and adolescents. J. Trauma. 1977; 17:

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