Prevalence, Etiology, and Risk Factors of Traumatic Dental Injuries in Children with Special Needs of Puducherry.

Background/aim: Dental trauma draws attention in special children due to its risks and consequences. The aim of this study was to estimate the prevalence, etiology, and risk factors of traumatic dental injuries in children with special healthcare needs of Puducherry. Materials and methods: A cross-sectional survey among 121 special children aged 4-18 years was carried out in Puducherry. The children were examined for the presence of traumatic dental injuries (TDI) and associated risk factors for the occurrence of trauma and classified according to the WHO epidemiological field survey classification.
Results: Prevalence of TDI was 40.5%. The majority of them were restricted to enamel fractures and the most commonly affected were permanent maxillary central incisors. The most common cause of injury was ˝falling over˝ and home was the frequent place of injury to occur. The risk factors associated with TDI were mesoprosopic facial form, convex facial profile, increased overjet, Angles Class II molar relationship, posterior facial divergence, and incompetent lips which were statistically significant.
Conclusion: The study concludes the prevalence of TDI is more prevalent in CSHCN, thereby it is necessary to create awareness, health education, and periodic screening for efficient treatment. How to cite this article: Martin AG, GS Prathima, Sanguida A, et al. Prevalence, Etiology, and Risk Factors of Traumatic Dental Injuries in Children with Special Needs of Puducherry. Int J Clin Pediatr Dent 2022;15(1):104-108.

Introduction

Children with special needs constitute a considerable sector of the community, accounting for an estimated 10% of the worldwide population. Lately, the phrase “disability” has been defined as “an impairment that restricts or limits daily activity in some manner.”[1] In India, as per the 2011 census report, approximately 26.8 million people are classified as disabled.[2] Compared to the healthy population, children with special needs are at a higher risk of developing oral diseases throughout their lives.[3] These children have the equal right to health care as their able-bodied counterparts.[4] Multiple studies examined the oral health of special needs children reporting worldwide prevalence ranging between 9.2%[5] and 45.2%.[6] Despite the in-depth review of literature only three studies were documented from India and are available as a database regarding the prevalence of traumatic dental incident (TDI) in adolescents and children with special needs.

Traumatic dental incidents (TDIs) in children and young adults are a serious public health issue.[7] Traumatic dental injuries (TDI) and orofacial injuries are extremely common around the world, affecting an estimated 20–30% of the permanent teeth and frequently leading to compromised esthetics and function.[8] In addition, recent studies showed that dental trauma experience had a negative impact on children's and parents’ quality of life.[9] Dental trauma in special healthcare needs people occurs both at a young age, during which growth and development take place, and also in adulthood. The nature of their health condition, as well as their neurodevelopmental, intellectual, behavioral, and functional limitations, increase susceptibility to unintentional injury, which causes facial and dental tissue damage.[3] Dental trauma may also lead to dental injuries, impacting both maxillofacial structures and bone, resulting in functional, aesthetic, mental, and social aspects.

While there are very few studies on TDI in the diverse sample of children with special needs, the prevalence and the associated etiological/risk factors of traumatic dental injuries remain unexplored in Indian statistics, especially in the South Indian population. In view of the above findings as aims and objectives, this study was conducted in children with SHCN attending special schools.

Materials and Methods

Ethical Approval

The study was approved for ethical clearance from the Institutional Review Board and the Institutional Ethical Committee. Permissions were also obtained from the school institution to screen the children. For their children's participation, the parents/legal guardians provided their written consent.

Sample Selection

A cross-sectional investigation was conducted in special schools among children and young adults ranging in the age group from 4–18 years. The minimum sample size needed to estimate significance was determined using a power calculation. With a confidence level of 90% and a margin of error of 5%, the minimum sample size needed was 121. The inclusion criteria were children with at least one or more disabilities and who were present at school on the day of examination. Exclusion criteria included children undergoing orthodontic treatment, teeth with developmental defects, and teeth that are lost due to reasons other than traumatic dental injuries. Prior to the children's clinical examination, a case template was used to gather data on demographic characteristics such as name, age at last birthday, gender, socioeconomic status of the parents, and residential address of parents/guardians. Medical records were used to determine the child's clinical diagnosis and condition.

Clinical examinations were conducted in daylight-filled classrooms using the ADA type III technique. Participants sat in chairs in the presence of a caretaker from the school/center staff who assisted with children's behavior for optimal assessment methods. A single investigating officer conducted the oral examination, and data was collected by a calibrated assistant. The clinical examination consisted of the presence/absence of TDI determined by direct orofacial and dental examination.

Details about trauma were recorded as remembered by their parents/caretakers

Previous and present TDI history, which includes location, time, and cause.

TDI treatment sought:

If treatment was done, the parent was asked to specify whether it was restorative, endodontic, or invasive.

If treatment for the trauma was not done, the parent was questioned about the reasons for not seeking treatment.

TDIs were recorded based upon the field screening for Epidemiological classification of Traumatic Dental Injuries (TDIs) including codes of the WHO International Classification of Diseases to Dentistry and Stomatology which is as follows:[10]

Statistical Analysis

The Statistical Package for the Social Sciences (SPSS version 17) for Windows was used for data input and statistics. Tests of the association between trauma and variables were carried out using the Chi-square tests. Significant differences in data were set at a 95% confidence level (p < 0.05).

Results

A total of 140 informed consent forms were distributed to the parents of children aged 4–18 years from the selected schools. A total of 124 parents agreed to take part in the study out of a total of 140. Three children were removed from the study because they did not satisfy the inclusion criteria. and the final sample size was about 121 comprising 67 boys and 54 girls which were about 55.4% (boys) and 44.6% (girls), respectively. Those with intellectual disability had the highest percentage of traumatic dental injury among the study groups (58.7%). The distribution of the study children based upon demographic characteristics and their medical condition is presented in (Table 1).

Table 1

Distribution of children based upon demographic characteristics and medical condition

Factors	Categories	Special needs children n (%)
Gender	Boys	67 (55.4)
	Girls	54 (44.6)
Age	4–6 years	6 (5)
	7–9 years	17 (14)
	10–13 years	38 (31.4)
	14–18 years	60 (49.6)
Socioeconomic status	Upper class	6 (5)
	Upper-middle class	25 (20.7)
	Lower-middle class	20 (16.5)
	Upper-lower class	69 (57)
	Lower class	1 (.8)
Medical condition	Mental retardation	71 (58.7)
	Cerebral palsy with mental retardation	28 (23.1)
	Autism	10 (8.3)
	Downs syndrome	9 (7.4)
	ADHD	3 (2.5)

Among 121 children,49 children had dental trauma, that is, the prevalence of traumatic dental injuries was reported to be 40.5% (Fig. 1).

Fig. 1

Prevalence of traumatic dental injury in Puducherry special needs children

Dental trauma was more common in men. It was most common in children with ADHD followed by Downs syndrome and autism. Older children tend to have sustained traumatic dental injuries than younger children. Yet the difference among gender, based on the medical condition and age were not statistically significant (Tables 2).

Table 2A

Genderwise distribution of traumatic dental injuries

Prevalence by gender
Male	Females
41.8%	38.9%

Most of the injuries occurred at home (19%) and school (16.5 %) and they mainly fell injuries (24.8%), followed by collisions against objects (12.4%). Of those who had trauma, only 1.7% had undergone restorative treatment for the injury.

Enamel fracture (code 2) was the most frequent type of trauma among dental tissues followed by pulp injuries (28.2%). Permanent maxillary central incisors were the most often injured teeth (31.46%). In the primary dentition, three primary lateral incisors had enamel fracture and one had enamel dentin fracture (Table 3).

Table 3

Distribution of the injured teeth based upon the epidemiological classification of traumatic dental injuries

Tooth injured	Classification							Chi-square test
	Coding
	Code 0	Code 1	Code 2	Code 3	Code 4	Code 5	Code 9
11	0 (0%)	1 (2.0%)	30 (61.2%)	5 (10.2%)	0 (0%)	0 (0%)	0 (0%)	0.000
21	0 (0%)	0 (0%)	17 (34.7%)	11 (22.4%)	1 (2.0%)	0 (0%)	0 (0%)
12	0 (0%)	0 (0%)	3 (6.1%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)
22	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)
51	0 (0%)	0 (0%)	0 (0%)	1 (2.0%)	0 (0%)	0 (0%)	0 (0%)
52	0 (0%)	0 (0%)	2 (4.1%)	1 (2.0%)	0 (0%)	0 (0%)	0 (0%)
61	0 (0%)	0 (0%)	1 (2.0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)
62	0 (0%)	0 (0%)	1 (2.0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)

Both convex facial profile, Angles class II molar relationship were significantly associated with increased prevalence of trauma. A significant relationship was revealed between trauma incidence and anterior teeth protrusion and lip coverage adequacy (p0.05) using Chi-square analysis.

Discussion

The Union Territory of Puducherry is situated in the southeast Asian location, the 29th most populous state and the third most densely populated Union Territory of India. The present study is the first data on the prevalence of TDI in children and adolescents with SHCN in Puducherry. The present research revealed a 40.5% prevalence of dental trauma in children with special healthcare needs. which falls within the range of worldwide prevalence (4.13–68.2%- according to a recent meta-analysis 2020[11] of TDI in children with Special care needs. The findings of the present study identified a similar prevalence (45.2%) in Brazil as reported by Franca et al.[6] In India only, three prevalence studies among special needs children were documented in the literature, that is, in the cities of Dharwad (28.6%),[4] Indore (18.7%),[7] and Bangalore (12.1%)[12] thereby the prevalence of TDI in India ranges between 12 and 40.5%.

Of the 49 children with special needs who presented trauma, 41% were men and 39% were women. There was no significant gender difference that could be attributed to the disability, implying that disabled children of both genders have similar lifestyles. Apart from that, a small amount of difference in females may be attributed to the cultural variation of the Indian scenario which may have played the role of lower prevalence of trauma. Though there was no statistically significant difference (p-value = 0.605) in TDI prevalence according to age, the prevalence percentage increased with age. Special needs children have delayed milestones of development and hence restricted movement, due to which walking is delayed which might be one reason for the lower prevalence of trauma in small children. Physical activities increase as they grow older or engage in leisure activities which might have increased the probability of trauma in the older age group of children.

The present study findings have shown that children with ADHD had a higher incidence of TDI followed by children with Down's syndrome and Autism. Though the findings were not statistically significant (p = 0.915), a recent meta-analysis by Alnmes S et al.,[11]in 2020 stated that patients with ADHD are more likely to experience dental trauma. The fact that children with ADHD sustained more dental trauma in the present study could be because of the hyperactive nature of the ADHD condition which caused falls. The study by AlSarheed et al.,[13] have investigated the prevalence of trauma, malocclusion, and dental caries among children with Downs syndrome and found a higher incidence of trauma among them. In the present study, the second-highest prevalence of TDI was seen in Down's syndrome, which could be because these children had a higher predisposition to malocclusion, macroglossia, and an accident-prone profile which could have caused trauma. In the present study, TDI in children with Autism could be due to cognitive impairment. The study done by Al-Sehaibany FS et al.,[14] had evaluated the prevalence of trauma in children with Autism and found it to be 25.7%. On the contrary, the studies done by Nayak et al.,[4] Murthy et al.,[12] have observed a higher incidence of trauma in children with mental retardation. The prevalence of TDI in permanent maxillary central incisors was statistically high as reported in the literature.[3,4,7,15-17] The studies conducted by Avsar et al.,[16] Murthy et al.,[12] AlSarheed et al.,[13] Al-Batayneh et al.,[18] and Franca et al.[6] showed a higher prevalence of uncomplicated crown fractures. The present study also showed a higher extent of enamel fracture among traumatic dental injuries. In accordance with the previous study, by Al-Batayneh et al.[18] who observed that the treatment-seeking behavior was less among special needs children. The present study also found that there is a lesser percentage of children who had undergone treatment for the traumatized teeth due to unawareness. The present results showed that fall injury due to slipping and tripping over a staircase was the most common cause followed by the collision with an object, which was due to the lack of motor coordination and self-injury. Similar results were found in studies conducted by Kumar and Dixit et al.,[7] Nayak et al.,[4] Bagattoni S et al.,[3] and Ferreira et al.[5] In the present study, the traumatic episodes which had commonly occurred at home and school were entitled to the sudden activity of the children when they were left unsupervised. Similar findings were observed by Nayak et al.,[4] Al- Batayneh et al.,[18] and dos Santos et al.[19]

An important finding in this study was that nearly 98% of the patients were examined by a dental surgeon for the first time. Concerning dental treatment for people with special needs, a questionnaire was used to elicit information about the possible reasons for not seeking dental care. The various reasons which were given for not taking treatment were unawareness/negligence regarding the importance of dental treatment of the traumatized tooth, fear of uncooperation from their child, and lack of time/transport. Additionally, communication with the special needs population is a challenge and an impediment to dental care. Hence social workers should play a major role in helping these parents or caregivers to seek treatment.

In the present study, risk factors such as facial form, facial profile, facial divergence, lip competence, lip coverage, molar relationship, overjet, overbite, presence of diastema, and open bite were examined for all children, and all these factors are related to traumatic dental injuries. Thus, there is a positive correlation in the presence of convex facial profile and it was shown that children with Angle's Class II molar relationship had a positive association with traumatic dental injury due to the fact of proclined incisors. Anterior open bite could be a possible risk factor but in the present study, no significant correlation with TDI was found. It was assessed that the amount of lip coverage and incompetent lips is a risk factor since the lip is an important soft tissue characteristic and it is crucial in the prevention of traumatic dental injury. When compared to those with normal overjet, those with increased overjet and inadequate lip coverage had a high incidence of TDIs. Similar results were discovered in prior studies by Kumar and Dixit et al.,[7] Nayak et al.,[4] Shyama et al.,[15] Altun et al.,[17] Al- Batayneh et al.,[18] and Munot et al.[20] On the contrary, no significant positive correlation was found with overjet and trauma in the study conducted by Holan G et al.[21]

The present study's findings would contribute to the literature on the prevalence of TDI in the special needs population in the Union Territory of Puducherry in the Southern part of India. This study could create awareness about dental traumatic injuries and help in preventive and therapeutic treatment needs for those affected children. Effective policies for injury prevention, treatment, and malocclusion correction must be developed in these children to prevent TDIs. Policies regarding Health Education on TDI, its management, and prevention programs should be fundamental by the government. Social workers, medical practitioners, healthcare workers, caregivers should be trained on identification, diagnosis, and timely referral to a dentist. Regular motivational programs with preventive professional care should be made mandatory. Disable - friendly environment with insufficient accessibility is lacking in India which is a must and thus could reduce the incidence of trauma in these individuals. The importance of incorporating oral health care into these everyday living must be emphasized.

Limitations

The present investigation only included children with special care needs; whereas including healthy children would have provided more opportunities for comparison, not only among CHSN groups but also with their able-bodied cohorts. Another constraint is that the correlation of TDI in the individual type of medical condition could have been focused on for a better assessment of the condition and to add on to the data.

Conclusion

This study concluded that:

Seventy-four traumatized teeth were found in 40.5% of the children with special needs.

There was no significant difference between genders, ages, or medical conditions.

All teeth that had been traumatized were maxillary teeth.

Only 1.7% of children received treatment for traumatized teeth.

Most prevalent type of trauma was enamel fracture, followed by enamel-dentin fracture.

According to these findings, traumatic dental injuries are a common issue in children with special healthcare needs.

Orcid

Prathima GS https://orcid.org/0000-0001-6379-9567

Code	Injury	Criteria
Code 0	No injury	No evidence of treated or untreated dental injury
Code 1	Treated dental injury	Composite restoration, bonding of the tooth fragment, crown, denture or bridge pontics replacing missing teeth due to TDI, restoration located in the palatal/lingual surface of the crown suggesting endodontic treatment and no evidence of decay, or any other treatment provided due to TDI Note: Composite restorations may be difficult to recognize
Code 2 (N 502.50)	Enamel fracture only	Loss of a small portion of the crown, including only the enamel
Code 3 (N 502.51)	Enamel/dentin fracture	Loss of a portion of the crown, including enamel and dentin without pulp exposure
Code 4 (N 502.52) (N 502.53) (N 502.54) (N 503.20) (N 503.21)	Pulp injury	Signs or symptoms of pulp involvement due to dental injury. It includes fractures with pulp exposure, dislocation of the tooth, presence of sinus tract and/or swelling in the labial or lingual vestibule without evidence of caries and discoloration of the crown. The examiner must check if pulp involvement was due to caries (presence of treated or untreated caries lesion), and ask the subject whether they have a history of a harmful incident involving the front teeth/mouth
Code 5	Missing tooth due to trauma	Absence of the tooth due to a complete avulsion. Code 5 should be used only for teeth judged to be missing due to trauma. A positive history of trauma is needed to record missing due to trauma and the examiner must ask the subject if the avulsion was due to a harmful incident involving the front teeth/mouth or if teeth have been extracted due to caries
Code 9	Excluded tooth	Signs of traumatic injury cannot be assessed, i.e., presence of appliances or all permanent incisors missing due to caries

Table 2B

Agewise distribution of traumatic dental injuries

Prevalence by age
4–6 years	7–9 years	10–13 years	14–18 years
16.7%	35.3%	42.1%	43.3%

Table 2C

Distribution of traumatic dental injuries based upon the medical condition

Prevalence based on medical condition
Intellectual disability	Cerebral palsy with intellectual disability	Autism	Downs syndrome	ADHD
39.4%	39.3%	40%	44.4%	66.7%