|Year : 2015 | Volume
| Issue : 1 | Page : 19-23
Dental trauma prevalence and disability types: A comparative study among children and adolescents in Dharwad, India
Prajna Pramod Nayak1, Prasad V Kakarla2, Preetha J Shetty2, Manohar Y Bhat3
1 Department of Public Health Dentistry, Vivekanandha Dental College For Women, Tiruchengode, Tamil Nadu, India
2 Department of Public Health Dentistry, SDM College of Dental Sciences, Dharwad, Karnataka, India
3 Department of Public Health Dentistry, KVG Dental College, Sullia, Karnataka, India
|Date of Web Publication||19-Mar-2015|
Dr. Prajna Pramod Nayak
No. 203/1A, Raj Apartments, 4th Main, 9th Cross, KSRTC Layout, 2nd Phase, J. P. Nagar, Bengaluru - 560 078, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Dental trauma (DT) has become an important attribute of dental public health. However, in the disabled population, the risks and consequences of DT have been barely studied. Aim: The aim was to assess and compare the prevalence of DT among disabled children and adolescents studying in special needs schools in the twin cities of Hubli-Dharwad, India. Materials and Methods: About 714 children and adolescents who were classified as visual impairment, speech and hearing (SH) disability, physical disability, mentally subnormal and multiple disabilities (MD) and in the age group of 4-19 years, studying in 14 special needs schools of Hubli-Dharwad were included. DT was recorded based on Ellis and Davey's classification. Association between the trauma prevalence and disability types were analyzed using Chi-square test. Results: The prevalence of DT was found to be 28.6%. MD children sustained highest trauma (40.90%) and SH children experienced lowest trauma (18%). Statistically significant association was found between trauma prevalence and gender, geographic location, anterior teeth protrusion and lip coverage. Maxillary central incisors were most affected, and Ellis class 1 fracture was the most common type of traumatic injury. None of the children had undergone any treatment for DT. Conclusions: This should alert caregivers to carry out intense investigation of the events, and there is a need to take up preventive measures by dental professionals and public health authorities to reduce this type of morbidity.
Keywords: Children, dental trauma, disabled, prevalence, traumatic dental injuries
|How to cite this article:|
Nayak PP, Kakarla PV, Shetty PJ, Bhat MY. Dental trauma prevalence and disability types: A comparative study among children and adolescents in Dharwad, India. J Indian Assoc Public Health Dent 2015;13:19-23
| Introduction|| |
An estimated 10% of world's population experiences some form of disability or impairment.  Enhanced survival, more sophisticated medical care and increased longevity have increased the number of disabled individuals. , According to the 2011 national census, out of 26.8 million disabled people in the country - that constitutes about 2.21% of the total population - 0.41% are visually impaired, 0.16% speech impaired, 0.42% "hearing" impaired, 0.45% "movement" impaired, 0.12% "mentally" retarded, 0.06% "mental" illness, 0.17% with "multiple disabilities (MD)" and 0.41% are with "any other disability," which is not a trivial figure. 
Children with special health care needs are entitled to equal standards of health and care as their able bodied cohorts. However, data collected from Rehabilitation Council of India, the statutory body in bringing disabled into mainstream of society, points out to the fact that there are <2500 special schools in country, which are located mainly in urban areas and run by non-governmental organizations and voluntary organizations. These statistics clearly verbalizes the magnitude of neglect shown on disabled children and adolescents.  Furthermore, there is evidence that they experience poorer oral health , and difficulty in accessing appropriate dental services ,,, though prevention is especially advantageous for them because treatment often incurs high costs and more risks than usual.
The epidemic of general injuries is rated one among the most neglected health problems of 21 st century. And among 7-30 years old about a quarter of all bodily injuries are oral injuries.  After a remarkable decline in the prevalence and severity of dental caries in many countries, dental trauma (DT) has now become the most serious dental public health problem in children and adolescents. , It can frequently lead to tooth lesions, affecting both supporting dental structures and hard tissues. Not only these, it also directly or indirectly influences children and adolescent's lives, affecting their appearance, speech and teeth position, as well as causing psychological and social problems. 
Thus, despite its importance and magnitude, there are a very few studies available on the epidemiology of DT among the disabled population particularly in developing countries. Hence, the present study was conducted to assess and compare the prevalence of DT among disabled children and adolescents studying in special needs schools in twin cities of Hubli-Dharwad. The objectives were to study the factors associated with DT and to find out the type of dental care facilities available at special needs schools.
| Materials and Methods|| |
A cross-sectional survey was carried out in all 14 special needs schools in Hubli-Dharwad, among children and adolescents aged between 4 and 19 years. The disabled children were classified by the Guidelines for Evaluation of Various Disabilities and Procedure for Certification (2008)  into five categories as visual impairment, Speech and hearing (SH) disability, locomotor/physical/orthopedic disability: With cerebral palsy, arthritis, congenital deformities, poliomyelitis, spina bifida (physical disability [PD]), mental retardation (MR) with Down's syndrome, autism, learning disability (MR) and MD: With a combination of above disabilities (MD).
A proforma was used to collect data on demographic variables like name, age at last birthday, gender and residence from parents/guardians/school teachers prior to the child's dental examination. Furthermore, mode of dental health care facility in the school was obtained. All the anterior teeth, that is, from right maxillary canine to left maxillary canine and from left mandibular canine to right mandibular canine were examined for DT using the Ellis and Davey's classification (1960).  Any sequel in traumatized teeth and any treatment given was recorded. Lip competence was assessed by direct observation of the lips of the children using the method of Ballard. 
Ethical clearance for the present study was obtained from Institutional Ethics Committee. Informed consent was obtained from school authorities before the start of the study. Subjects were included, if they were present on the day of examination and were willing to participate. Subjects were excluded from the study if they were uncooperative or had medical conditions which contraindicated an oral examination without appropriate modifications, such as infective endocarditis, coagulopathy, abscess, etc.
Training and intra-examiner calibration were performed to ensure uniform interpretation of DT. The examiner practiced the examination on a group of 20 subjects twice on successive days. Intra-examiner reliability was assessed using the kappa statistic, which was found to be 0.78 showing a good degree of consistency in the observations.
Data collected was subjected to statistical analysis using the statistical package - STATA 9.2. (StataCorp. 2005. Stata Statistical Software: Release 9. College Station, TX: StataCorp LP, USA) Association between the trauma prevalence and disability types were analyzed using Chi-square test with P < 0.05 indicating statistical significance. Association between the occurrence of dental injuries and gender, age, geographic location, anterior maxillary overjet and lip competency were tested using Chi-square test.
| Results|| |
Among 714 children and adolescents examined, MR formed the highest proportion (37.39%) and MD, the least (3.08%). Mean age of study population was 12.9 years. About three quarters of individuals were urban based (76.5%) and one quarter, were from rural origin (23.5%) [Table 1].
|Table 1: Descriptive characteristics of study population according to disability types |
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The prevalence of DT was found to be 28.6% (n = 204). Highest prevalence of trauma was sustained by MD children (40.9%) and lowest in SH children (18%). Chi-square analysis showed a significant association in the trauma prevalence between genders (P = 0.0002). Among 112 children with >5 mm anterior teeth protrusion, 64 of them (57.1%) experienced trauma. Whereas, in 602 children with <5 mm of anterior teeth protrusion, 140 (23.3%) experienced trauma. Among 533 children without an adequate lip coverage, 109 (20.5%) had trauma. And in 181 children without adequate lip coverage, 95 (52.5%) of them experienced trauma. Chi-square analysis showed a significant association of the trauma prevalence with anterior teeth protrusion and adequacy of lip coverage (P = 0.0000) [Table 2].
|Table 2: Comparison of prevalence of DT by gender, geographic location, anterior teeth protrusion and lip coverage |
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In 204 children with DT 298 teeth were affected. Ellis Class I was the most common type of fracture (39.3%) [Table 3]. All the disability types revealed maximum number of trauma, that is, 232 (77.85%) to central incisors. In both the dentitions canines did not sustain any trauma. 90.3% of traumatized teeth were permanent teeth, with only 9.7% being deciduous teeth.
|Table 3: Distribution of traumatic injuries to teeth based on Ellis classification among disability types |
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Homes (44.1%) and schools (25.5%) were the most common locations where DT occurred; 17.9% occurred at other places like streets and parks and 12.5% of individuals did not recall the location of injury. Most of the injuries had occurred due to fall from height or due to tipping (44.1%) followed by collision (34.8%) and fall during play (15.7%) and accidentally biting hard material (5.4%).
Among 204 children with DT, 9 (4.6%) children had swelling/fistulous tract. None of the child had got any treatment done to traumatized teeth. Among 14 special needs schools in the twin cities of Hubli-Dharwad, 7 (50%) schools organized periodic oral health screening and treatment camps, 6 (42.85%) made appropriate referrals to dentist, 1 (7.14%) had no facility available in their schools. None of the schools recruited any full-time or part-time dentists or collaborated with neighborhood clinic or hospital for oral health care of children.
| Discussion|| |
"Special health care needs" children are termed "Disabled" in the guidelines for evaluation of various disabilities and procedure for certification (2008) given by the Ministry Of Social Justice And Empowerment by the Government of India.  Hence, the term "Disabled" is used throughout the study. The reason for using Ellis and Davey's Classification instead of WHO classification or any other classifications was because of simplicity and ease of epidemiological field applicability. , Studies conducted by Ferreira et al.  and Shyama et al.  took account of only the presence or absence of DT. In a study conducted by Avsar et al.  DT was recorded using the classification of World Health Organization and modified by Andreasen and Andreasen.
The present study identified a prevalence of 28.6% of DT to anterior teeth. This corroborates with the study conducted by Nunn and Murray where the prevalence was found to be 28.8%.  However, lower prevalence was found in the studies conducted by Ferreira et al. (9.2%)  and Shyama et al. (16.9%).  The reason can be attributed to sample selected, that is, the age range studied, regional variations, urban, rural population, classification used to report DT, classification of disability, the type of study and methodology used.
Among all disabled groups, MD children showed the highest prevalence of trauma (40.9%). This is similar to the studies conducted by Holan et al. (57%)  Reason for this sizable proportion of DT in this group could be due to the tangle of two or more impairments resulting in more frequent injuries. These children endure more epileptic seizures and severe locomotor disabilities, which could be the reason for increased prevalence. The lowest prevalence of DT was found among SH children (18%), which is in accordance with the study conducted by Shyama et al. (19.8%). 
The present study showed a higher prevalence of trauma in males than in females, similar to other studies. ,, Higher prevalence in males may be explainable by the fact that males are more aggressive, venture into more risks and participate more in sports activities. Apart from that, in Indian scenario, cultural trends also have a role to play in lower prevalence of trauma in females. , Higher frequency of trauma in rural children, when compared to that of urban could be because of higher parental knowledge and more protective environment for urban children.
Ellis Class I fractures were most common in all the disability types, findings of which can be consistent with other studies. ,, Highest proportion of Ellis Class I fractures were seen in PD group (46.9%). This indicates that, there is a higher predilection toward milder forms of injury in PD children. Highest proportion of tooth avulsion, that is, Ellis Class V was noted in MD children, which indicates the severe forms of DT in this group.
"Fall" was the most common cause of injury, which is similar to that conducted by Patel and Sujan.  It was observed that most of DT occurred at home, followed by at school and outside, which was similar to other studies. , The alarming fact was that none of the children had received any treatment for traumatized teeth, though the reason could be because of presence of other major health issues to deal with or the financial inabilities that parents go through.
Nonetheless, the study has few limitations. Inclusion of healthy controls would have given more scope for comparison, not only among disabled groups, but also with the able bodied cohorts.
There is a need to devise a suitable system for the delivery of preventive measures. Protective mouth guards during play or other activities should be utilized. A custom-made mouth protector could also be used to assist those who cannot use their hands to perform many functions. Young children and their parents should be targeted for oral health promotion interventions and early dental attendance.
| Conclusion|| |
Prevalence of traumatic injuries to teeth among disabled children studying in special needs schools in twin cities ranged from 18% to 40.9% in various disability types. DT was most prevalent among children with MD and least among SH impaired children. DT was more frequent in males, in children with anterior teeth protrusion of >5 mm and in those with inadequate lip coverage. None of the children had got any treatment done to their traumatized teeth.
The sizable prevalence of DT in these children further emphasizes the need for disabled children to receive dental attention concerning these conditions. Furthermore, there is a distinct need for strengthening organized preventive and curative programs for this disabled school population.
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[Table 1], [Table 2], [Table 3]
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