Prevalence of traumatic dental injury andassociated factors among12-year-old schoolchildren in Floriano¤ polis, Brazil

With the important decline in dental caries amongchildren in developed (1^3) anddeveloping countries(4,5) there is increasing interest in studying other oralhealth conditions, including dental trauma.Traumaticdental injuries canbecomean important

public health problem (6) not only because their pre-valence is relatively high (7^11) but also because theyhave substantial impact on children’s daily life (9,12).This is because of physical andpsychological discom-fort, pain, and other implications such as a tendencyto avoid laughing or smiling, which can a¡ect socialrelationships (7). High levels of violence, tra⁄c acci-dents and a greater participation of children in sportshave contributed to transform dental traumatic inju-ries into a public health problem (7).A Medline search has shown that relatively few

population-based studies have been published relat-ing the prevalence, aetiology and impact of dentaltrauma in Latin America. A total of seven studieswere published.Two of them were carried out in the

Dominican Republic (13,14), one in Mexico (15) andfour in Brazil (9,16^18).This study was carried out in order to assess the

prevalence and type of accidents that resulted intraumatic injuries to the permanent dentition of12-year-old school children in Floriano¤ polis, Brazil.

Methods

A dental trauma cross-sectional survey was carriedout in Floriano¤ polis, the capital of the SouthernBrazilian State of Santa Catarina in 1999. The stud-ied population involved12-year-old children enrolledinpublic primary schools. For the sample calculation,a prevalence of 15% (9) was adopted, a sample errorof 5% and a con¢dence interval of 95%. In addition,a correction factor of 1.5 was applied due to the utili-sation of a multistage sampling technique. Two hun-dred eighty-three school children were necessary tosatisfy the requirements for the minimum sample

Dental Traumatology 2003; 19: 15–18 Copyright # Blackwell Munksgaard 2003Printed in Denmark. All rights reserved DENTAL TRAUMATOLOGY

ISSN 1600–4469

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TraebertJ, Peres MA, BlankV, Bo« ell RS, PietruzaJA. Prevalence oftraumatic dental injury and associated factors among12-year-oldschool children in Floriano¤ polis, Brazil. DentTraumatol 2003;19:15^18.# Blackwell Munksgaard, 2003.

Abstract ^ The objective of this study was to assess the prevalenceand type of accidents that resulted in traumatic injuries to thepermanent dentition of 12-year-old school children inFloriano¤ polis, Brazil. A dental trauma cross-sectional survey wascarried out through clinical examination of upper and lowerpermanent incisors and interviews with 30712-year-old schoolchildren enrolled in public primary schools. Intra-examinerdiagnosis variability was good, measured by kappa values ontooth-by-tooth basis.The prevalence of dental injury was18.9%.There was no statistical di¡erence in the prevalence between boysand girls (P¼ 0.103).The main types of accidents that resulted indental injurieswere falls andcollisionswith objects or people. It canbe concluded that the prevalence of dental injuries in Floriano¤ polis,Brazil is high and they have a great potential to be considered anemerging public health problem.

Jefferson Traebert1, Marco Aure¤ lioPeres2, Vera Blank2, Rubia da SilvaBo« ell3, Joa‹ o Alberto Pietruza31School of Dentistry, Southern Santa CatarinaUniversity, Tubara‹ o; 2Department of Public Health,Health Science Centre, Federal University of SantaCatarina, Floriano¤ polis; 3Federal University of SantaCatarina, Floriano¤ polis, Brazil

Key words: dental trauma; prevalence; types ofaccidents

JeffersonTraebert, Rua Coronel Teixeira de Oliveira,380, 88160-000 Biguacu/SC, BrazilTel./Fax:þ55 48 2434390e-mail: jtraebert@uol.com.br

Accepted 7 June, 2002

size. Twenty per cent more school children wereadded to compensate for possible non-responses.Consequently, a total of 350 school children wererequired.A multistage sampling procedure was performed.

The¢rstunit includedallprimaryschoolsofFloriano¤ -polis. The second unit included all students enrolledin the selected schools.Twenty schoolswere randomlyand proportionally selected according to the numberof students enrolled, following a sample selectionscheme used in dental surveys co-ordinated by theBritish Association of Community Dentistry (19). Arandom sample was obtained using a list with all stu-dents enrolled inthe selected schools.A letterwas sentto educational authorities explaining the aim andimportance of the study. Another letter was sent toparents asking permission for their children’s partici-pation. Dental examinations were carried out andquestionnaires were applied by a single dentist(RSB) supportedbya secretary. Before the ¢eldwork,both examiner and secretary participated in a cali-brationexercise that involved 36 11-year-old children,as described ina studybyPeres et al. (20). Intra-exam-iner variability was checked through duplicate exam-ination of every 10th child. Kappa statistics wereused on a tooth-by-tooth basis. The exams were per-formedat schoolduringclass time.Theexaminerusedaplanemirror, gauzeandnatural lightand sat in frontof the children.The dentist adopted strict cross-infec-tion preventive measures.The criteria for dental traumatic injuries used by

O’Brien (21)wasadopted.Thequestionnaireprovidedinformation about the children’s sex, and the locationand type of accident that resulted in dental traumaticinjury.Epi-info 6.0 softwarewasused for the statisticalanalysis. The descriptive statistic included frequencydistribution.Associationsbetweenoccurrence of den-tal trauma and gender were tested using Chi-square(w2) test.

Results

Atotal of 307 (87.7%) of the 350 childrenwere exam-ined and interviewed; 52.4% were boys and 47.6%were girls. The main reason for a lack of responsewas the lack of the parent’s agreement for the child’sparticipation.Kappavalues were calculated for clinicalmeasures

onatooth-by-toothbasis inorder to checkintraexami-ner diagnosis variability.The minimum kappa valuewas 0.7.Theprevalenceofdental injury inthe studypopula-

tionwas18.9%. Boys (22.4%) experiencedmore den-tal injury than girls (15.1%), but this di¡erence wasnot statistically signi¢cant (P¼ 0.103) (Table1). Atotal of 28.0% incisors were damaged (Table 2). Frac-tures in enamel only (21.6% incisors) and fractures

in enamel and dentine (5.7% incisors) were the mostcommontypes of injuries.Other types of injurieswereless common (Table 2).The main types of accidents that resulted in dental

injuries were falls (47.9%) and collisions with objectsor people (37.5%) while 10.4% of the school childrendid not know the type of accident inwhich their inci-sors were damaged (Table 3).Themajority of the fallsoccurred when the children were bicycling (21.8%)and skating (13.0%).The majority of accidents occurred at home

(60.4%) followed by school (18.6%) and outside inthe street (18.6%).Themost frequent activities under-takenby the children at the time of the accidentwereleisure (72.1%) and sports activities (11.6%).

Table1. Prevalence of dental injuries to permanent incisors in school children(n¼ 307) aged 12, Floriano¤ polis, Brazil, 1999

GenderDental injury,

n (%)No dental injury,

n (%) P (w2-test)

Boys 36 (22.4) 125 (77.6) 0.103Girls 22 (15.1) 124 (84.9)

Total 58 (18.9) 249 (81.1)

Table 2. Rate per thousand incisors of different types of dental injuries inFloriano¤ polis, Brazil, 1999 (n¼ 2456 incisors)

Type of dental injuryFrequency,

nRelative frequencyof incisors (%)

Enamel fracture alone 53 21.6Enamel/dentine fracture 14 5.7Enamel/dentine fracture

with pulp exposure1 0.4

Other injury 1 0.4

Table 3. Frequency distribution of factors related to dental injuries in 58school children who have experienced injuries to the permanent incisors,Floriano¤ polis, Brazil, 1999

Injury characteristicFrequency,n (%)

Knowledge about injuryYes 48 (82.8)No 10 (17.2)

Type of accident that resulted in dental injuryFall (all reasons) 23 (47.9)Collision against objects or people 18 (37.5)Traffic accident 1 (2.1)Eating 1 (2.1)Unknown 5 (10.4)

Place of dental injuryHouse 26 (60.4)School 8 (18.4)Outside, in the street 8 (18.6)Swimming pool 1 (2.4)

Traebert et al.

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Discussion

This study found a prevalence of 18.9% of traumaticdental injuries to the permanent incisors of 12-year-old school children in Floriano¤ polis. It is importantto highlight that di¡erent methodologies have beenused in Latin American studies, so caution shouldbe taken when comparing prevalence ¢gures. It isinappropriate, for instance, to compare ¢gures foundin clinic- and hospital-based studies with popula-tion-based studies. It is known that clinic- and hospi-tal-based studies provide less epidemiologicalevidence than population-based studies (22). Varia-tion in sampling and diagnostic criteria between dif-ferent studies may also explain di¡erent ¢ndings (9).The sample of theMexican studycarriedout inMon-terrey was composed only by male school childrenenrolled in four private schools (15). The Dominicanstudies involved school children in San Pedro deMacoris (13) and Santo Domingo (15) but there werenodetails about thecriteriaused for sample sizecalcu-lation. The population studies of the four publishedBrazilian studies were representative of populationsof school children in the age of study. Since thereported Brazilian studies used similar methodolo-gies, which were similar to the methodology used inthis study, the prevalences found are comparable.In the Dominican Republic, a prevalence of dental

trauma ranging from 7.4% at age 7 to 19.4% at age14 was reported in San Pedro de Macoris (13). In thecapital, Santo Domingo, the prevalence of traumaticinjuries in a sample of 1200 school children aged6^17 years was 12.2%. At age 12, the prevalence was11.7% (14), a prevalence lower than the ¢gure foundin this study. In Monterrey, Mexico, the prevalencein 8-year-old school children was 20.0 and 40.0% atthe age of 12 (15). This ¢gure is higher than the18.9% found in our study.In Brazil, a study was performed in the city ofJara-

gua¤ do Sul, in the Southern State of Santa Catarina,with a sample of 476 children representing all 12-year-old school children in the city. Children wereexaminedand interviewed inacross-sectional survey.The prevalence of traumatic injuries to the teeth was15.3% (9). In the city of Blumenau, also in the Stateof Santa Catarina, a cross-sectional survey was car-ried out and included a random sample of 65212-year-oldchildren, attendingpublicandprivatepri-mary schools.The reported prevalence of dental inju-ries was 58.6% (17). Another Brazilian study carriedout inBeloHorizonte, intheSouth-eastStateofMinasGerais, reported a prevalence of 13.6% at the age of12. The prevalence rose from 8% at age 8 to 16.1%in 14-year-olds (18). A study carried in the city ofCianorte in the Southern State of Parana¤ showed aprevalenceof20.4%attheageof 13(16). InallreportedBrazilian studies, theuppercentral incisorsweremore

a¡ectedby trauma andusually one or two teethweretraumatised.Di¡erent than that observed in several studies (7,9,

17), inthis study,boysdidnothavemoredentaltraumathan girls (P¼ 0.103). Also, in the Dominican studyof Santo Domingo, the di¡erencewas not statisticallysigni¢cant (14).The most commonly identi¢ed forms of damage

were fractures of enamel only and enamel^dentinefractures, similar to the ¢ndings in the DominicanRepublic (14) and in the Brazilian cities (9,16^18).In this study, the main reported types of accidents

that resulted indental injurieswere falls andcollisionswith objects and people. These ¢ndings are similarto those found in Jaragua¤ do Sul (9). Falls were themain type of accidents that resulted in damage tothe incisors in both studies, but in Jaragua¤ do Sul,the second related typewas tra⁄c accidents, includedin the broader category of violence. Although explicitviolence was not reported by the school children inthis study, it is important to note that falls and colli-sions from pushing, for example, are minor formsof violence (9). The researcher should be aware ofthe underlying causes of violence in dental injurystudies.In this study, the majority of accidents occurred at

home, school and outside in the street, during leisureand sports activities. This is of special importancefor health policy makers seeking accident preventionstrategies that result in facial and dental injury.This study showed that the main types of accidents

that resulted indental injurieswere falls andcollisionswith objects or people. The majority of the falls andcollisions occurred when children were bicycling,skating at home, at school or outside in the street, dur-ing leisure and sports activities. Because the impactof traumatic dental injury in children’s daily life isgreat, in terms of physical and psychological discom-fort andpain, there is a need for speci¢c public healthpolicies that seek to decrease the high prevalence oftraumatic dental injury among school children andminimise their e¡ects on children’s quality of life.These policies can include providing speci¢c andappropriate public places for leisure and sports activ-ities,with impact-absorbing surfaces aroundthe itemsfrom and on which children are most likely to fall.Also, national and local campaigns and programmesshould increase social awareness about dental injury.In addition, speci¢c local laws requiring and regu-

lating the use of safety equipment are necessary.Familiesandeducationalauthoritiesmustprovide safeenvironments and equipment for children’s activitiessuchasbicyclingandskatingwithhelmetsandmouth-guards. Moreover, contact sports should be playedunder competent supervision on appropriate surfacesand with complete safety equipment in order to pre-vent traumatic dental injuries.

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Prevalence of traumatic dental injury

The prevalence of traumatic dental injuries inFloriano¤ polis is high and their expected impact onchildren’s daily life in terms of physical and psycholo-gical discomfort may be great. For these reasons, wecan conclude that injuries to permanent dentitionhave great potential to be considered an emergingpublic health problem.It is very important to highlight the need of more

complete studies including other clinical and socio-economicaspects inorder to clarify the impactof den-tal trauma on children’s daily life.

Acknowledgements ^ Rubia da Silva Bo« ell receivedsupport from CNPq (Brazilian Council forImprovement of Research).

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