Anterior teeth fractureamong visually impaired individuals, India

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1 J.Adv Oral Research All Rights Res ORIGINAL RESEARCH Anterior teeth fractureamong visually impaired individuals, India RK Varghese* Anil Agrawal AdityaMitra Chinar Fating *M.D.S, Professor, Department of Conservative Dentistry, B.D.S, Senior Lecturer, Department of Public Health Dentistry, M.D.S, Reader,Department of conservative dentistry, M.D.S, Senior Lecturer, Department of Oral medicine and Radiology,New Horizon Dental College & Research Institute, Bilaspur, India. Abstract: 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 99 blind individuals (67.7% males and 3.3% females), they aged from 1-9 years. The investigation was carried out according to WHO criteria and by using WHO classification for teeth fracture. Statistical analysis for the association between occurrence of dental injuries and independent variables was carried out using the chi-square test. Results: An overall prevalence of traumatic injuries was 37.8%. Totally blind subjects (57.1%) had significantly higher percentage of teeth fracture than that of partially sighted (3%) (p=.1). Females (43.1%) were having significantly higher teeth fracture than males (9.9%) (p=.13). Permanent maxillary central incisors were most commonly injured tooth with injuries involving enamel and dentin being the most frequently observed. Increased overjet (85.7%) and inadequate lip coverage (78.6%) had significantly higher risk of sustaining traumatic injuries to teeth (p=.1). Traumatic injuries were independent of age groups.conclusion: Subjects with total blindness suffered higher dental injuries. Key words: Teeth fracture, Prevalence, Visually impaired individuals. Serial Listing: Print ISSN(9-411) Online-ISSN (9-41) Formerly Known as Journal of Advanced Dental Research Bibliographic Listing: Indian National Medical Library, Index Copernicus, EBSCO Publishing Database, Proquest, Open J-Gate. Introduction: Dental injuries may occur throughout life, but they are particularly common in childhood (1). The etiology of teeth injuries are variable and multiple with the dominant factors most likely to cause dental trauma are fall, sports injuries and accidents met at home or outside. Previous literature showed that school age children are considered to be at higher risk (7-15 years) to traumatic dental injuries (, 3). Incisors have an important role in esthetics, phonation, psychological aspects and in functional activities with 9% of traumatic dental injuries involving upper incisors(4). The major risk factors for dental injuries are 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 (3-6). However, traumatic injuries to teeth can involve individuals irrespective, whether they belong to sighted or unsighted groups. Blindness is one of the most prevalent handicap conditions worldwide. According to WHO estimates, approximately 314 million people worldwide live with low vision and blindness, of which about 5 million resides in India (7,8). Blind individuals as disadvantaged and socially marginalized population suffered from many health problems including oral health, which consist of mainly orofacial trauma, dental caries and periodontal diseases, of which orofacial trauma consist of main health hazards for visually impaired individuals (9). It was also seen that traumatic dental injuries are more prevalent in children with visual incompatibility than the sighted children, with prevalence for traumatic dental injuries ranging from 9 to 36.4% among visually impaired (1,11) The etiology of teeth Journal of Advanced Oral Research, Vol ; Issue 3: Oct - Dec 11

2 4 injuries are variable and multiple, with the dominant factors most likely to cause trauma are fall, sports injuries and accidents met at home or outside. The major risk factor for dental injuries is increased over jet and inadequate lip coverage. Few epidemiological studies have been undertaken to determine the prevalence of teeth fracture among visually impaired (5,1-13). Hence, this study was designed to determine the prevalence of anterior teeth fracture among visually impaired individuals in Bilaspur city, India. Material and methods: A cross-sectional survey was conducted in blind school, at Bilaspur, Chhattisgarh, India. The list of blind school was obtained from Government Health Department at Bilaspur, which comprised of one private (6 subjects) school. Before scheduling the survey, the official permission was obtained from the Ethical Committee of New Horizon Dental College and Research Institute, Bilaspur and principal of the blind school. The study population comprised of 99 subjects (67 males and 3 females), they aged from 1-9 years. Without any bias students present on the days of survey were included in the study after inform consent. Subjects who were uncooperative, systemically ill and undergoing or undergone for orthodontic treatment comprised of the exclusion criterion. Clinical examination was performed by a single trained examiner in chair under artificial light source using mouth mirrors and CPI periodontal probes, and the study was conducted during month of July and August 11. The Performa was pilot tested on 3 subjects before starting of main study. The intra examiner reliability for recordings ranged from.87 to.94. Each subject was examined for maxillary incisor overjet with measurement performed using the CPI probe as described by the 1997 WHO Basic Oral Health Survey Guideline(14).Prior to the intraoral examination lip coverage of the incisor teeth was assessed for each participants. If the lips covered the upper incisors in the rest position the lip coverage was considered to be adequate and if, the lips failed to cover the upper incisors and exposing majority of their crown height, it was recorded as inadequate. Next, all maxillary and mandibular permanent teeth from canine to canine were examined for traumatic injury. Trauma was scored according to WHO classification (1993): Enamel fracture, Enamel and dentine fracture without pulp exposure, Enamel and dentine fracture with pulp exposure, Root fracture, Crown-root fracture, Concussion, luxation, Intrusion, extrusion, Avulsion, Soft tissue injuries. Traumatic dental injuries were accessed with different independent variables and to determine probable cause and place of trauma. Independent variables included: type of sightness (partially sighted or totally blind), sex, age, lip coverage and measurement of overjet. Statistical analysis: Data analysis was done using SPSS version 11.5 (SPSS, Inc., Chicago, IL, USA) and included descriptive statistics (frequency distribution and cross tabulation). Statistical analysis for the association between occurrence of dental injuries and independent variables was carried out using the Chi-square test. The level of significance set was p <.5. Results: A total of 99 subjects formed the study sample (67.7% males and 3.3% were females), out of which 78.8% were partially sighted and 1.% were totally blind. It was found that the overall prevalence of teeth fracture was 37.8% In the present study, totally blind subjects (57.1%) were having significantly higher percentage of teeth fracture than that of partially sighted (3.1%) (p=.1). Females (43.1%) were having significantly higher percentage of tooth fracture than males (9.9%) (p=.13), with no significant difference was observed while comparing traumatic dental injuries among age groups (1-19 yrs and -9 yrs). It was found that, participants with overjet of more than 3.5 mm (85.7%) and inadequate lip coverage (78.6%) had significantly increased risk of sustaining traumatic injuries to teeth than the normal counterpart (p=.1) (table1). Overall central incisors accounted for about 67.6% of fractured teeth, with right and left central incisors as most common teeth to be fractured (right central incisors 54.1% and left central incisor 13.5%) (table ). In this study, traumatic injuries were mostly due to falling (54%) followed by collision against object and sports. Regarding place of trauma, indoor was found to be most common billet for traumatic injuries (6.%) followed by outdoor and unknown (graph1, ). Discussion: Trauma to teeth constitutes one of the leading causes of odontological emergencies. In this study, data revealed that prevalence of anterior tooth trauma among visually impaired was 37.8% which is in an agreement with study conducted by Odonell and Agrawal A et al on similar subjects in Udaipur city, India (1, 13) and higher than those reported by MaddiShyamat et al (4.6%) (15) and Greeley et al (7.4%) (5). This is much higher than that of other studies performed on sighted individuals among Journal of Advanced Oral Research, Vol ; Issue 3: Oct - Dec 11

3 41 Table 1: Distribution of teeth fracture by independent variables among visually impaired individuals. Independent variables Type of sightness Totally blind Partially sighted Gender Male Female Age 1-19years -9years Lip coverage Adequate lip coverage Inadequate lip coverage Overjet Overjet 3.5mm Overjet>3.5mm *statistically significant at p <.5 No. of individuals without fractured teeth (%) 9(4.9) 53(68) 47(7.1) 15(46.9) 34(56.7) 8(71.8) 56(78.9) 6(1.4) No. of individuals with fractured teeth (%) 1(57.1) 5(3) (9.9) 17(43.1) 6(43.3) 11(8.) 15(1.1) (78.6) 58(81.7) 4(14.3) 13(18.3) 4(85.7) P value.1*.13*.11.1*.1* Table : Type of teeth fracture among visually impaired individuals according to WHO classification. 11* 1* 1* * 3 43* Total Total *FDI notations of teeth and included only the teeth which had fracture. general Indian population by Baldava P et al (14.9%) and Tangade P S (4.41%) (9,16). The reason behind lower level of prevalence among sighted children in comparison to visually impaired children may be because of visual incompatibility among blinds. In the present study, totally blind subjects had significantly higher percentage of traumatic dental injuries than that of partially sighted, which is in agreement with the study conducted by Odonell and Agrawal A (1, 13). The possible reason for such differences might be the fact that partially sighted individuals have low vision which can sometimes help them to get protected from traumatic injuries. It is well documented that the prevalence of fracture to the anterior teeth is greater in males than females among sighted population, which is about times more (16-18), but the findings of present study raveled that females were having significantly higher percentage of teeth fracture than males. Prevalence of traumatic injuries are reported at peak in -4 years and 8 1 years among sighted individuals, although incidence rate falls during adolescence (19,), results of this study showed subjects of 1-19 years group had more percentage of teeth fracture in comparison to -9 years age group Journal of Advanced Oral Research, Vol ; Issue 3: Oct - Dec 11

4 4 but no statistical difference was observed, although higher incidence of fracture for the years age group subjects is explained by the fact that during this period the individuals indulge in reckless boisterous activities and are unmindful of their personal safety, similar findings were found in study done by Odennell in 6-14 years and 15-4 years age groups for blind individuals and Agrawal A among 1-19 years and -9 years age group (1,13). The observation of this study reveals that a maxillary central incisor was the most affected teeth in both the groups (partially sighted and totally blind). The reason may be due to the upper central incisors being in front part of the face, lies in direction of body movement and tends receive far more trauma than the laterals. Moreover earlier eruption of the central incisors exposes them to the risk of trauma for a longer period. The upper central incisors are generally more forward than the lower centrals and tend to be the first to receive a direct blow producing a fracture. In addition the upper jaw is fixed to the skull which makes it rigid, whereas lower jaw being flexible part tends to reduce the impact forces directed on the lower anterior teeth by its movement (1), which is quite consistent with the findings of other studies among sighted individuals (9,13,). In the present study, traumatic dental injury involving enamel and dentine without pulp accounted as highest hest type of fracture, which is similar to studies conducted on general Indian population by Baldava P et al (9), unlike other studies conducted by Petti S et al in which, enamel was the most commonly fractured (3). This may be due to fact that the sighted children are able to take support during fall but visually impaired children did not take immediate support from nearby things due visual impairment. The most common cause and place of traumatic injuries to anterior tooth has been shown to vary between population and across age groups, in our study fall was most common cause with indoor as common place of injury, which was similar to the study done by Agrawal A et al (1) and unlike other studies reported in sighted individuals were sports related injuries were common (3,4), this can be explained by the fact that individuals with visual impairment spent most of their time inside their home or institutions. As seen with several studies among sighted population, the risk of traumatic injury to anterior teeth th increased significantly with increased incisaloverjet by more than 3-4 mm and inadequate lip coverage (9,13,4-6), 6), which was also found statistically significant factor in present study for occurrence of trauma to anterior tooth among blind individuals. However, our study has some limitations; Firstly, sample size of the present study was small and Secondly; cross-sectional sectional nature of the study may fail to find more accurate findings. Hence, more studies in this field is required with increased sample size and considerably for long duration to find more accurate findings. Our study reveals that there is an very high prevalence of fracture teeth among visually impaired individuals than that of sighted. Graph 1: Relation of fractured teeth with cause of trauma among visually impaired. Graph : Relation of teeth fractured with place of trauma among visually impaired. Conclusion: In the present study, higher prevalence of traumatic dental injuries was found in the present study among blind individuals in comparison to sighted population. Hence, there is distinct need for the strengthening of advocacy programs that will ensure the availability of comprehensive preventive and oral health care for this group. References: 1. Salako N O, Jeboda S O. Dental problems of the handicapped child. Odont-Stomatol Trop 1985; 7: Tesini DA, Fenton SJ. Oral health needs of persons with physical or mental disabilities. Dent Clin North Am 1994; 38: Journal of Advanced Oral Research, Vol ; Issue 3: Oct - Dec 11

5 43 3. Brown JP, Schodel DR. A review of controlled surveys of dental disease in handicapped persons. J Dent Child 1976; 43: Shaw L, MacLaurin ET, Foster TD. Dental study of handicapped children attending special schools in Birmingham, UK. Community Dent Oral Epidemio 1986; l14: Greeley CB, Goldstein PA, Forrester DJ. Oral manifestations in a group of blind students. J Dent Child 1976; 43: Ohito FA, Opinya GN, Wangombe J. Traumatic dental injuries in normal and handicapped children in Nairobi, Kenya. E Afr Med J 199; 69: World Health Organization. Blindness and visual impairment. Available at /en/index.html. 8. Rahi J S, Sripathi S, Gilbert C E, Foster A. Childhood blindness in India: causes in 1318 blind school students in nine states. Journal eye 1995; 9: Baldava P, Anup N. Risk Factors for Traumatic Dental Injuries in an Adolescent Male Population in India. J Contemp Dent Pract 7; 6: David O Odennell. The prevalence of nonrepaired fractured incisors in visually impaired Chinese children and young adults in Hong Kong. Quintessence Int. 199; 3: Senka M, Dragana G P, Sndra A M, Dunja R. Risk Factors of Traumatic Injuries to the Upper Incisors. ActaStomatol Croat 8; 4: Alonge OK, Narendran S, Williamson DD. Prevalence of fractured incisal teeth among children in Harris County, Texas. Dent Traumatol 1; 17: Implementing the survey. Oral health surveys. Basic methods. 4th ed. World health organization. Geneva: 1999; MaddiShyamat, Sabiha A. Al-Mutawa, SiskoHonkalaI. Malocclusions and traumatic injuries in disabled schoolchildren and adolescents in Kuwait. Spec Care Dentist 1; 1: Tangade P S. The Prevalence of Anterior Teeth Fracture and its Relation to Malocclusion in 1 and 15 Year Old School Children Belgaum City, India. J Oral Health Comm Dent 7;1 : Andreasen JO. Etiology and pathogenesis of traumatic injuries, a clinical study of 198 cases. Scand j denta res. 197; 78: Forsberg CM, Tedestam G. Traumatic injuries to the teeth in Swedish children living in an urban area. Swed Dent J 199; 14: Kakabuka 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 1; 17: Kargul B, Caglar E, Tanboga I. Dental trauma in Turkish children, Istanbul. Dent Traumatol 3; 19: Nguyen QV, Bezemer PD, Habets L, Prahlsystematic review of the relationship between overjet size and traumatic dental injuries. European Journal of Orthodontics Andersen B. A 1999; 1: Sanchez AV, Garcia-Godoy Godoy F. Traumatic dental injuries in 3- to 13-year old boys in Monterrey, Mexico. Endodont Dent Traumatol 199; 6: Petti S and Tarsitani G. Traumatic injuries to anterior teeth in Italian school children prevalence and risk factors. Endod Dent Traumatol 1996; 1: Mullane DMO. Some factors predisposing to injuries of permanent incisors in school children. Br Dent J 1973; 134: Bastone EB, Freer TJ, McNamara JR. Epidemiology of dental trauma: A review of literature. Aust Dent J ; 45: Burden DJ. An investigation of the association between overjet size, lip coverage and traumatic injury to maxillary incisors. Eur J Orthod 1995; 17: Agrawal A, Bhatt N, Singh K, Chaudhary H, Mishra P, Asawa K. Prevalence of anterior teeth fracture among visually impaired individuals, India. International Journal of Dental Clinics 1:(4):3-7. Journal of Advanced Oral Research, Vol ; Issue 3: Oct - Dec 11

6 44 Journal of Advanced Oral Research, Vol ; Issue 3: Oct - Dec 11