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mjiri.iums.ac.ir
Medical Journal
J
of thee Islamic Reppublic of Iran
n (MJIRI)
Iran Universiity of Medical Sciences
Prevvalence, etiology
y, and typ
pes of deental tra
auma in cchildren
n and
adoleescents: systemaatic revieew and meta-ana
m
alysis
2
Sa
aber Azami-Aghdash1, Farbod E
Ebadifard Azar*
A
, Fatemeh Pouurnaghi Az
zar3
4
5
6
Aziz R
Rezapour , Mohamma
ad Moradi--Joo , Ahm
mad Moosa
avi , Sina G
Ghertasi Os
skouei7
Received: 18
8 May 2015
Abstract
Backgrround: Dentaal traumas are
a common among children and ad
dolescents in many socieeties posing healtth and social problems. The aim of this study was
w to condu
uct a systemaatic review and
a
metaanalysis on prevalennce, etiology, types, and other epidem
miologic aspeects of dentaal trauma in
n children
and adoleescents (0-18 years old).
Method
ds: In this systematic meta-analytica
m
al review, data
d
were co
ollected searcching for keey words
includingg traumatic dental injuries, dental trrauma, dentaal injury, den
ntal trauma, tooth injuriies, tooth
trauma, traumatized teeth, denttoalveolar trrauma, oral trauma, epiidemiology, etiology, prrevalence,
incidencee, occurrencee, child*, an
nd adolescennce in the following databases: Scoopus, CINAHL, Science Direect, PubMed and
a Google sccholar.
Resultss: From the total of 319
97 articles, 444 completely
y relevant paapers were inncluded in the study.
The prevvalence of dental
d
traumaa was variabble based on
n geographicaal area and was estimateed 17.5%
in the ppopulation, with higher prrevalence in boys. Falling
g was the major
m
cause fo
for dental trauma, and
the most frequent locaation was hom
me. The most fr
frequent type of
o trauma wass enamel fractuure.
Conclusion: A relaatively high prevalence w
was detected for dental trauma, whicch calls for effective
planning and interveention to preevent the oc currence in children and
d adolescentss. These may
y include
special ccare for children, eliminaating fall-proone areas, installing safety measures at homes, using protective aappliances in sports, education, and rraising the knowledge
k
an
nd availabilitty of servicees to address ennamel fracturre. Region-sp
pecific criteriia should bee taken into account in programs and
a
interventions..
Keyword
ds: Dental Trauma,
T
Preevalence, Etioology, Type, Children and
a
Adolesccents, System
matic Review, Meeta-analysis.
Cite this aarticle as: Azam
mi-Aghdash S, Ebadifard Azar F, P
Pournaghi Azar F, Rezapour A, Moradi-Joo M, Mooosavi A, Ghertasi Oskouei S.
Prevalence,, etiology, and tyypes of dental trau
uma in children aand adolescents: systematic review
w and meta-analyysis. Med J Islam
m Repub Iran
2015 (10 Juuly). Vol. 29:234.
Introduction
Traum
matic injuriees not only pose a heaalth
risk w
worldwide, but are also
a
regardded
among serious soocial probleems (1). O
One
importaant category is dentaal trauma ((2),
________________________________________
_______________
_______________
______________
_____________________________
____________
1
. PhD Studeent, Road Traffic Injury Research Center,
C
Tabriz Unniversity of Mediical Sciences, Tab
briz, Iran. saberazzami@yahoo.com
m
2
. (Correspoonding author) Professor,
P
Health Management andd Economics Reseearch Center, Iran
n University of M
Medical Sciences, Tehran, Iran.
f_ebadi@yahhoo.com
3
. Assistant P
Professor, Road Traffic
T
Injury Ressearch Center, Tabbriz University of
o Medical Scienc
ces, Tabriz, Iran.
pournaghiazzarm@yahoo.com
m
4
. Assistant P
Professor, Departtment of Health Economics,
E
Healtth Management and
a Economics Research Center, IIran University off Medical Sciences, Centerr of Excellence inn Health Manageement and Econoomics, Health Maanagement and Information Sciencces, Iran Universiity of Medical
Sciences, Tehhran, Iran. rezapooor_a57@yahoo.com
5
. MSc, Canccer Research Cennter, Shahid Behesshti University off Medical Sciencees, Tehran, Iran. moradijoo@gmai
ail.com
6
. Assistant P
Professor, Departm
ment of Health
h and Communityy Medicine, Dezfu
ful University of Medical
M
Sciencess, Dezful, Iran.
dr_ahmad_m
mosavi@yahoo.coom
7
. MD, Deparrtment of Pediatrric Dentistry, Facu
ulty of Dentistry,, Tabriz Universitty of Medical Sciiences, Tabriz, Iraan. ghertasis@gm
mail.com
sues) and those studies (2) that were conducted on children and adolescents with
age range of 0-18 years and cross-sectional
studies were also included. Exclusion criteria were as follows: studies on trauma from
sport activities, studies on trauma from
medical interventions such as endoscopy,
studies on individuals with medical or special conditions, conference presentations,
case reports and interventional studies
(such as randomized controlled trials). Two
reviewers evaluated the articles according
to the checklist of strengthening the Reporting of Observational Studies in Epidemiology (STROBE) (Appendex. 1) and controversies were referred to a third party. First,
articles with non-relevant titles to the subject of this review were excluded. Then, the
abstracts and the full texts of the articles
were reviewed respectively to exclude
those articles that matched the exclusion
criteria of the study, or had a weak relevance to the subject of the study. Computer
software for reference management (Endnote X5) was used for organizing and assessing the titles and abstracts as well as
recognizing the repetitive items.
The searches returned 3197 articles, but
those articles that were non-relevant, and
repetitive between databases, with weak
relevance to the study or matched the exclusion criteria were excluded; finally, 44
relevant articles were selected (Fig. 1).
These articles were fully read, and the required data for the systematic review were
extracted into the extraction table designed
for the purpose of the study in spreadsheet
computer software (Excel, Microsoft Office; Microsoft, US). SPSS 17 was used to
analyze some of the quantitative data.
To determine the overall prevalence of
dental traumatic injuries and perform the
meta-analysis, computer software (CMAComprehensive
Meta-Analysis;
Englewood, NJ, USA) was employed. The results were reported using forest plots, in
which the size of each square indicates the
sample size and the lines drawn on each
side of the square indicate the confidence
interval (CI) of approximately 95% for den-
S. Azam
mi-Aghdashh, et al.
Reelevant article id
Excluded at dupliicate = 416
Fig
g.1. Literature rreview and retriieval flow diagrram
tal traum
ma.
The ooverall prevvalence of dental
d
traum
matic injurries was estimated usin
ng the randoom
model. Either all or
o some off the variabbles
were treeated as if they were random. Raandom model was inn contrast with
w the fixxed
model that dem
monstrates the
t
observved
he explanatoory
quantitiies with respect to th
variablees which arre treated as
a if the varriable werre not randoom.
Places
P
with
h the highhest frequeency of
traaumatic den
ntal injuriess are demo
onstrated
in Table 1.
The
T
mean of enamell fracture had the
hig
ghest frequ
uency (55%
%) among th
he types
off dental trauma in chhildren and adolescents (Fig. 3).
To
T perform the meta-aanalysis, thee heterogeeneity index
x was deteermined within the
artticles using
g the heteroogeneity I2 test.
t
Afterr confirmattion of hetterogeneity
y of the
Resullts
From a total of 3197
3
relevan
nt articles, 444
complettely relevannt articles were
w
includded
in the sstudy. Mostt studies weere conductted
in Brazzil (16 articcles), and th
he oldest w
was
conductted in Jorddan (1995); most of tthe
studies were donee in dentall clinics, annd
wo out of thhe 44 (4%) studies weere
only tw
conductted in IRAN
N. The overrall number of
particippants was 69502
6
child
dren and addolescentss aged 0-18 years (meaan, 1579 eaach
study). The mean
SD prevaleence of denttal
% 4.70 among boys annd
trauma was 10.2%
6.5% 3.40 girls,, which waas statisticallly
significcant (p< 0.0001).
The m
mean of faalling was the
t most frrequent ccause of deental traum
ma. The moost
importaant etiological factors of traumattic
dental injuries are shown in Fiig. 1.
Med J Islam
m Repub Iran 2015 (10 July). Vol.
V 29:234.
50
47
Percent
40
30
21
20
17
15
St
Street
Other
10
0
Home
School
60
54.2
Percent
50
40
30
20
10
17.6
14.4
7.7
6.4
0
Enamel dentin Contusion fracture
fracture Fracture
involving
pulp
Other
http://mjiri..iums.ac.ir
Table 1. Extraction table for Prevalence, etiology, and types of dental trauma in children and adolescents
Au-Cu-Ye
Schuch et al [25], Brazil,2012
Sample
1210-children aged 812
prevalence
12.6%
Gender
M (6.8), F(5.8)
Etiology
Fall (35), Assault (40), Accident (8),
Sport (10), other (7)
place
Home (55), School (18)
Street (15).other (12)
Type/teeth affected
Enamel fracture (10.6), dentin
Fracture (3.2), other (.5)
12.7%
31.7%
M (7.9), F(4.8)
M(18.6),
F(13.1)
1528-12-year-old
34.8%
1528-12-year-old
Schoolchildren.
34.79%
M(40.8)
F(28.6 )
792 12-yearold
schoolchildren,
9.7%
891Adolescents from
schools.
24.7%
33.5%
25.6%
M(26.7)
F(24.6)
1612 children
aged 11 to 14
17.1%
M (19.9%)
F (15%)
37.9%
9.5%
M (5.4%)
F (4.1%)
Enamel fractures (44.6), Enamel/dentin fracture (19.0), Intrusive luxation (13.4), Lateral
luxation (7.3), Subluxation( 6.1), Enamel/dentin/pulp fracture (5.5), Crown discoloration(5.2), other (7.1)
S. Azami-Aghdash, et al.
Noori and Al-Obaidi [36], Iraq,
2009
6.1%
M (3.7%)
F (2.4%)
17.4%
M (10.3%)
F (7.1%)
6.4%
M (4.2%)
F (2.2%)
41.6%
11.4%
M (9.6%)
F (6.4%)
16%
Locker[41], Canada,2005
Traebert et al [42], Brazil,2003
18.5%
18.9%
20.4%
M (13.9%)
F (6.5%)
12%
3702-schoolchildren
aged 914 years
199 children aged 8 to 10
years
M (7.2%)
F (4.8%)
M (11.5%)
F (5.1%)
8%
M (5.3%)
F (2.7%)
16.5%
M (10.2%)
F (6.3%)
21.3%
16.6%
M (11.7%)
F (7.2%)
Enamel fractures
fractures (5.7%),
(37.2%),
enameldentin
19.9%
M (12.4%) F
(7.5%)
24.8%
M (14.6%) F
(10.2%)
10.13
M (6.03%) F
(4.1%)
14.5%
11.2%
35.0%
M (22.1%) F
(12.9%)
17.3
M (10.4%) F
(6.9%)
M (5.4%) F
(4.9%)
http://mjiri.iums.ac.ir
10.3
15.2
29.6%
20.4%
M (13.7%) F
(6.7%)
2751 children
14.2%
M (9.2%) F
(5%)
10.5%
33.8%
Home
(29.1%),
school
(23.7%), street (11.1%)
Uncomplicated coronal fracture (26.1), Enamel
fracture (12.5), Lateral luxation (11.2), Contusion (7.7 ), other (42.5)
Fall (94.6%),
M (9.6%) F
(5.6%)
S. Azami-Aghdash, et al.
schoolchildren
838 12-year-old school children
571 preschool children
9.9%
17.7%
M (19.7%) F
(16.9%)
M (5.8%) F
(4.1%)
M (11.1%) F
(6.6%)
studies, the best estimation of the prevalence of trauma was determined based on the random effect model (Fig. 4).
The prevalence of dental trauma in children and adolescents based
on the random effect was determined to be 17.5% (95% CI: 14.6%20.4 %); 95% CI for the prevalence was drawn for each study in the
horizontal line format (Q= 3631.17, df= 43, p<0.001).
The frequency distribution for dental trauma based on the location
variable (continent) is shown in Figs. 5-7.
To assess the publication bias, funnel plot was used (Fig. 8). The
results of funnel plot revealed that there was publication bias among
studies. The shape of funnel plots was not symmetrical.
ning and intervention to prevent their incidence. Moreover, considering the negative influence of dental traumas on individuals quality
of life (39,65), psychological and social problems (66,67), and direct
and indirect costs of treatment (68), developing effective interventional strategies to deal with this issue is of prime importance. The
difference in the prevalence of dental trauma among the studied geographic regions might be a reflection of their different cultural, sanitary, and economic conditions, type of activities and professions
practiced, and ecological characteristics like the fluoride concentration of drinking tap water. For instance, the prevalence of dental
trauma was found to be higher in the continent of America compared
to Asia or Europe, and this could be the result of sports activities of
youth, as most studies in the region pertained to Brazil. Furthermore,
the fluoride concentration of water in regions with mild and humid
weather condition is usually low (69), resulting in lower fluoride
content in teeth which can render teeth more prone to dental trauma.
This notion highlights the importance of local and regional considerations during planning and interventions by policy makers.
Discussion
Dental trauma is a major health problem in many societies
(26,29,30), with higher prevalence rates among children and adolescents (25,26,29,48,64). The present study revealed the prevalence of
dental trauma in children and adolescents (under 18 years of age) to
be 17.5%, but with variances among different geographic regions.
In the present study, the prevalence of dental traumas for all subjects was determined to be 17.5%, which necessitates efficient planMed J Islam Repub Iran 2015 (10 July). Vol. 29:234.
S. Azam
mi-Aghdashh, et al.
wiith previou
us research (79,80). Ensuring
E
thee existence of sound safety meaasures in
sports venuess accompannied by thee use of
pro
otective athletic apppliances such
s
as
mo
outh guardss, and educcating child
dren and
ad
dolescents who
w engage in sports activities
a
aree among suggestions thhat can be effective
e
in reducing th
he incidencce of dentall trauma
in this age raange (81,822). Fights and
a violen
nce were also among tthe causes of
o dental
traauma in children and adolescents in the
present study
y, which iss indicativee of the
beehavioral ch
haracteristiccs of this ag
ge range,
wiith dominan
nt, violent, emotional,, and illog
gical traits. In this reggard, speciaal attentio
on should be
b given to social educcation at
ho
ome and scchool, fosteering a cu
ulture of
sellf-control and social reespect towaards otherss.
The
T finding
gs of this sstudy reveaaled that
deental traumatic accideents occurreed most
freequently at home, and this is in line with
maany previou
us studies ((83-85). Thiis is explaainable by the
t fact thaat children and
a adolesscents spen
nd a signifi
ficant part of their
tim
me at home; and thereefore, speciaal safety
meeasures should be conssidered at houses in
wh
hich familiees live with their childrren.
Based
B
on th
he analysis of the study data,
en
namel fractu
ure was the most frequ
uent type
off dental traaumatic acccidents, con
nfirming
thee findings of
o other stuudies (34,42
2,56,86).
Th
herefore, deentists andd other heaalth-care
pro
ofessionals as well ass lay peoplee should
haave adequate knowleddge regard
ding the
maanagement of dental traumatic events
(87-90).
The
T
analyses perform
med in the present
stu
udy were limited by aage under 18 years.
Th
hus, it is su
uggested too include adults
a
in
futture studiess. The studdy was also
o limited
by
y the fact th
hat it only iincluded arrticles in
En
nglish and Persian
P
and only includ
ded studiess conducted
d since 19955.
Fig.5. T
The prevalence of dental trau
uma in childreen and
adolesceents in the conntinent of Am
merica was estiimated
based oon the random effect of 21.2
2% (95% CI:1 6.6%26.7%);; 95% CI was drawn for eacch prevalence in the
horizonttal line format (I
( 2 = 98.7).
Conclusion
C
n
The
T results of this stuudy indicateed a signifficant prevaalence for ddental traum
matic accid
dents amon
ng childrenn and adollescents,
wh
hich necesssitates efficcient plann
ning and
Fig. 7. T
The prevalencce of dental traauma in childrren
9.
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13