|Year : 2015 | Volume
| Issue : 3 | Page : 239-243
Impact of dental trauma on oral health-related quality of life among 12 years Lucknow school children: A cross-sectional survey
Sanjukta Bagchi, Sabyasachi Saha, Vamsi Krishna Reddy, Pooja Sinha
Department of Public Health Dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Web Publication||14-Sep-2015|
Department of Public Health Dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Dental trauma has become an important attribute of dental public health inducing feelings of embarrassment to smile, laugh, and show teeth affecting social relationships. Available literature regarding the impact of dental trauma on the quality of life of children in Lucknow is scarce. Aims: To assess the impact of traumatic dental injuries (TDI) on oral health-related quality of life (OHRQoL) among 12-year-old school going children of Lucknow. Materials and Methods: A cross-sectional survey was conducted among 12-year-old Lucknow school children. A total of 492 school children were selected through multistage cluster random sampling. The participants completed the child perceptions questionnaire (CPQ 11-14) - impact short form: 16 followed by an assessment of TDI. Unpaired t-test was used to determine the association of TDI with CPQ 11-14 because it involved two separate groups; one with dental trauma and other without dental trauma. Results: The prevalence of TDI was 10.8%. Maxillary central incisors (8.73%) were the frequently traumatized teeth. Enamel fracture (7.11%) was the most common type of TDI. OHRQoL had statistically significant association with TDI. Conclusions: TDI has a negative impact on OHRQoL of children affecting their personal relationships and school performance.
Keywords: Oral health-related quality of life, socioeconomic factors, traumatic dental injuries
|How to cite this article:|
Bagchi S, Saha S, Reddy VK, Sinha P. Impact of dental trauma on oral health-related quality of life among 12 years Lucknow school children: A cross-sectional survey. J Indian Assoc Public Health Dent 2015;13:239-43
|How to cite this URL:|
Bagchi S, Saha S, Reddy VK, Sinha P. Impact of dental trauma on oral health-related quality of life among 12 years Lucknow school children: A cross-sectional survey. J Indian Assoc Public Health Dent [serial online] 2015 [cited 2020 Nov 24];13:239-43. Available from: https://www.jiaphd.org/text.asp?2015/13/3/239/165225
| Introduction|| |
One of the greatest assets a person can have is a "smile." Dental trauma after dental caries is the second most prevalent kind of dental injury during childhood.  An untreated and unsightly fracture of an anterior tooth can result in pain, discoloration, and induce feelings of less attractive, embarrassed to smile, laugh, and show teeth among friends thereby affecting their daily living and progress in school. Trauma to anterior teeth is undesirable, and prevention of this is beneficial to the personality development of the child. Thus, it becomes important to measure the impact of traumatic dental injuries (TDI) on the quality of life of children as traditional dental indicators alone cannot provide sufficient information on oral well-being.
Earlier studies have been conducted by Traebert et al., Bendo et al. and others on Brazilian school children regarding this issue. But, there is no data emphasizing the relationship between socio-dental impacts of TDI on children in Lucknow.
Therefore, the aim of the present study was to measure the impact of TDI on the oral health-related quality of life (OHRQoL) of 12-year-old school going children of Lucknow.
- To assess the prevalence of dental traumatic injuries (TDI) to maxillary incisors in 12-year-old school going children of Lucknow
- To measure the impact of dental traumatic injuries on the OHRQoL of children.
| Materials and methods|| |
A cross-sectional survey was designed to determine the association between TDI and OHRQoL among 12-year-old school going children of Lucknow from February to August 2014. Ethical clearance was obtained from the Institutional Ethical Committee. Approval was obtained from the principals of the concerning schools. A written consent was obtained from the parents of the participating school children. The study group comprised school going children aged 12 years of Lucknow.
A pilot study was conducted on 50 school going children to check the validity of the questionnaire and operational feasibility of the study. Cronbach's alpha was applied for measuring the intra-examiner reliability of the questionnaire for assessing the knowledge on oral health problems and their effect on OHRQoL having five responses on a Likert scale. The questionnaire items were analyzed for difficulty in understanding, interpreting, and answering correctly without any difficulty. The same set of questions were asked to the same group of children 2 weeks after the first administration of the questionnaire. These two sets of responses (i.e., the first and the second administration) were then used in calculating Cronbach's Alpha Coefficient for internal consistency, which was found to be 0.84. No adjustments were found to be necessary.
Sample size was calculated using the standard formula: n = z 2 (p [1 − p])/e 2 where n = size of the sample; p = approximate prevalence rate; z = critical value at a specified level of confidence; e = difference between sample proportion and population proportion. According to the above-mentioned equation and results of the pilot study a sample of 492 school going children was obtained.
The estimated sample was selected by multistage cluster random sampling technique.
In the first stage, Lucknow city was divided geographically into 5 areas, that is, East, West, North, South, and Central. List of all the wards from the 5 geographic areas was obtained from Census Enumeration Areas Data A list of schools located within the Lucknow municipality was obtained from District School Officer. Approximately, 22 wards came under each of these geographic areas. In the second stage, one ward was randomly selected from each of these geographic areas. In the third stage, two schools from each of the 5 wards were randomly selected. This was followed by a school survey in which all the students aged 12 years meeting the following inclusion and exclusion criteria participated in the study to finally attain a sample of 492.
- School children who were present on the day of examination
- Parents of children who gave consent.
Method of data collection
- Children who were apprehensive and anxious
- Children with special health care needs like physically handicapped children.
The single investigator was trained and calibrated before the commencement of the survey, and the kappa coefficient was estimated to be 0.86. The study had two parts: The first part consisted of structured questionnaire, including demographic details and self-perceived quality of life using the child perception questionnaire (CPQ 11-14) - impact short form: 16 Jokovic et al.  A five - point Likert scale is used, with the following options: "Never" = 0; "Once/twice" = 1; "Sometimes" = 2; "Often" = 3; and "Everyday/almost every day" = 4. The total score can range from 0 to 64. The second part of the proforma consisted of dental examination for recording of traumatic injuries in maxillary incisors as per Ellis and Davey's (1960) classification.  The children were examined as per ADA Type III criteria using mouth mirrors while seated on a chair under natural light.  However, Type VI injury was not recorded as dental radiographs were not available for diagnosis in the in-school field conditions.
The data were collected, tabulated, and subjected to statistical analysis by means of Statistical Package for the Social Sciences (SPSS) version 21 developed by IBM Corporation. Association of CPQ 11-14 and its domains with TDI between two separate groups (one group of children with anterior teeth fracture and another group of children without anterior teeth fracture) was done with the help of unpaired t-test. The P value was set at <0.05.
| Results|| |
Out of 492 school children who were clinically examined, 58.54% were male participants and 41.46% were female participants [Table 1]. [Table 2] highlights the prevalence of TDI among 12 years school children, which was estimated to be 10.8% with an increased tendency toward boys (13.2%) than girls (7.4%). [Table 3] depicts the distribution of fractured teeth according to Ellis and Davis classification of dental injury. Most common type of fractures were simple enamel fracture of the crown involving little or no dentin (Type I) which accounted to be 7.1% followed by fracture of the crown involving dentin but not dental pulp (Class II) which was found to be 1.83%. About 1.42% of children were affected with Class III (fracture of crown involving dentin and dentinal pulp) and Class IV (traumatized teeth that become nonvital with or without a loss of crown structure). As per [Table 4], maxillary central incisor (8.73%) was the most common traumatized tooth followed by maxillary lateral incisor (2.03%). The mean CPQ 11-14 score was significantly higher among those who had TDI (16.57 ± 7.77) as compared to those without TDI (1.42 ± 2.82). There were significant differences in all the four domains of CPQ 11-14 between children who had TDI with those children who did not have TDI. Although there was significant associations with t-test of all the domains of CPQ 11-14 with TDI, the mean score for social well-being was higher (5.15 ± 2.41) followed by emotional well-being (4.75 ± 2.23), oral symptoms (3.75 ± 3.76), and functional limitations (3.00 ± 3.11) as compared to other domains of the CPQ 11-14 questionnaire [Table 5].
|Table 2: Prevalence of dental traumatic injuries among study subjects by gender |
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|Table 3: Distribution of fractured teeth according to Ellis and Davis classification of dental injury |
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|Table 5: Assessment of dental trauma associated with overall CPQ 11 - 14 and its domain |
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| Discussion|| |
Dental injuries may occur throughout life, but TDI is a very significant problem among children. Trauma to anterior teeth is undesirable and prevention of this is beneficial to the personality development of the child.
The present cross-sectional survey identified the prevalence of TDI to the permanent anterior teeth in 12-year-old school children and its impact on their daily living, including school performance and personal relationships.
As TDI are very common among children, it can result in feeling embarrassed to smile, laugh, and show teeth, difficulty in social relationships, irritability, and an inability to maintain a healthy emotional state. Hence, it becomes important to measure and evaluate the impact of TDI on the quality of life of children affecting their school performance, personal relationships, and other daily activities.
This survey identified the prevalence of TDI to the permanent anterior teeth in 12-year-old school children as 10.8%. A similar observation was reported by Ingle et al. in 11-13-year-old school going children of Maduravoyal, Chennai, where a marginally higher prevalence of 11.5% of TDI was observed.  A study by Prasad et al. reported a higher percentage of 12.8% of TDI among 12-15 years school children of Farukhnagar (Gurgaon), Haryana.  Another study by Patel and Sujan found a prevalence of 8.79% in Vadodara city which was lesser than the prevalence found in the present study.  This difference in findings may be explained on the basis of variations in sample size and diagnostic criteria used between different studies.
The present survey was carried out in 12-year-old school going children. According to Moule et al. more than 20% of the children experience damage to their permanent dentition by 14 years of age.  The age 12 years has been chosen as the global indicator age group for international comparisons and surveillance of disease trends.  Although dental injuries can occur at any age, the incidence increases in the very active range of 8-12 years as children are exposed to various different outdoor sport activities such as bicycling, skating, etc. 
In the present survey, it was found that the boys were more affected by trauma than girls, which corroborates the findings of other studies by Ahlawat et al. who also observed a higher prevalence of dental trauma in boys (53.1%) than in girls (46.9%).  This observation of more tendency of TDI in boys outnumbering girls was also supported by various other studies. ,, In a developing and conservative country like India, boys are preferred over girls to go to school to receive formal education, where apart from education boys find a place to explore various outdoor activities and sports. Hence, boys tend to be more energetic and inclined toward vigorous outdoor activities, including various contact and collision sports as compared to girls. Also, it is important to note that falls and collisions from pushing due to minor forms of violence can be reported maximally in boys rather than girls, hence resulting in anterior teeth fracture. While girls are nurtured from the very young age to stay at home and indulge in household activities and indoor games.
Ellis and Davey classification of dental traumatic injuries (1960) was used in the present study for recording the types of dental traumatic injuries in children.  As the main aim of the study was to find the impact of TDI on OHRQoL of children, this simplified, less time consuming, and effective classification was opted. A study done by Meadow et al. has also preferred using the standard Ellis classification of tooth fracture over other classification systems for traumatic injuries as it was felt that Ellis classification was the simplest and easiest method to use in clinical and epidemiological studies. 
The most common identified forms of damage were fractures involving enamel only followed by fractures involving enamel and dentine. Previous studies reported by Piovesan et al., Traebert et al. and Marcenes et al. have also portrayed the same picture where fractures involving the enamel and enamel dentin were the most prevalent dental trauma among children. ,, Few Indian studies have also reported the same observation. ,
In the present study, the maxillary central incisors were the most common affected teeth by dental trauma followed by the maxillary lateral incisors and was identical to several reported studies. ,, This probably relates to the vulnerable position of the maxillary central incisors. These are the first front teeth often exposed to the outer environment, hence most commonly affected by any kind of external injury. In addition, these teeth are frequently protruded and may have inadequate lip coverage. Bastone et al. in a review of literature about the epidemiology of dental trauma have reported a large maxillary overjet and incompetent lip closure as an important predisposing risk factor for dental traumatic injuries.  Strokes et al. in a case-control study, however, demonstrated that increased overjet may not always play an important role in dental trauma as trauma to maxillary central incisors can also be sustained via contact or collision sports due to their front or anterior location. 
In order to evaluate the OHRQoL in children, CPQ 11-14 short form developed by Jokovic et al. was used. This child OHRQoL instrument has previously been employed in many studies to associate dental trauma and quality of life because this measure has been specifically and appropriately developed for assessing OHRQoL in children at this particular age group.  When analyzing the results of the present study by domain (i.e., oral symptoms, functional limitations, emotional, and social well-being), associations with t-test between TDI and oral symptoms, functional limitations, emotional and social well-being were observed. The present study demonstrated that the main concerns of the children with dental trauma involve social interactions and perceptions of others regarding their dental appearance than those living without dental trauma. This can be attributed to the fact that children are not independent beings. Their family and friends play important roles in their relationships and feelings affecting markedly their perception of quality of life.  At 11-14 years of age, relationships between peers are important components of an individual's perception regarding health and quality of life. Also, judgment on the part of peer groups can affect an individual's emotional state and relationships with others. Thus, any alteration in dental aspects such as having an anterior tooth fracture or discoloration of anterior teeth can have a negative impact on quality of life of children. 
The cross-sectional design of this study can be considered an important limitation. Further longitudinal studies are needed to better understand and interpret OHRQoL measures in children as these could provide information on the possible etiological relationship between the adverse impacts of TDI on their quality of life.
- Preventive oral health educational programs for the parents and school teachers should be conducted at regular intervals to inform them about the TDI
- Periodic continuing dental education programs about the latest technologies in the management of traumatized teeth should be organized for the dental and medical practitioners
- Promotion of usage of intraoral and extraoral devices such as mouth guards during sports
- Adoption of health promotion and safety policies and closer supervision of children to avoid indulgence in violent activities.
| Conclusions|| |
Prevalence of TDI among 12 years school going children was 10.8% with boys outnumbering girls. Maxillary central incisors were the most common traumatized anterior teeth. Children with dental trauma in anterior teeth were more likely to experience a negative impact on social well-being, especially with regard to avoid smiling or laughing and been concerned about what other people may think or say which negatively affected their social interaction and activities in school.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Traebert J, Lacerda JT, Foster Page LA, Thomson WM, Bortoluzzi MC. Impact of traumatic dental injuries on the quality of life of schoolchildren. Dent Traumatol 2012;28:423-8.
Jokovic A, Locker D, Guyatt G. Short forms of the Child perceptions questionnaire for 11-14-year-old children (CPQ11-14): Development and initial evaluation. Health Qual Life Outcomes 2006;4:4.
Finn SB. The care of injuries to the anterior teeth of children. In: Clinical Pedodontics. 4 th
ed. Philadelphia: WB Saunders; 2001. p. 224.
Peter S. Preventive and Community Dentistry. 4 th
edition. Arya (Medi) Publishing House: New Delhi. 2009. p. 291.
Ingle NA, Baratam N, Charania Z. Prevalence and factors associated with Traumatic Dental Injuries (TDI) to anterior teeth of 11-13 year old school going children of Maduravoyal, Chennai. J Oral Health Community Dent 2010;4:55-60.
Prasad S, Tandon S, Pahuja M, Wadhawan A. Prevalence of traumatic dental injuries among school going children in Farukhnagar, District Gurgaon. Int J Sci Study 2014;2:44-9.
Patel MC, Sujan SG. The prevalence of traumatic dental injuries to permanent anterior teeth and its relation with predisposing risk factors among 8-13 years school children of Vadodara city: An epidemiological study. J Indian Soc Pedod Prev Dent 2012;30:151-7.
Ahlawat B, Kaur A, Thakur G, Mohindroo A. Anterior tooth trauma: A most neglected oral health aspect in adolescents. Indian J Oral Sci 2013;4:31-7.
World Health Organization. Oral Health Surveys - Basic Methods. 4 th
ed. Geneva: World Health Organization; 1999.
Govindarajan M, Reddy VN, Ramalingam K, Durai KS, Rao PA, Prabhu A. Prevalence of traumatic dental injuries to the anterior teeth among three to thirteen-year-old school children of Tamilnadu. Contemp Clin Dent 2012;3:164-7.
Meadow D, Lindner G, Needleman H. Oral trauma in children. Pediatr Dent 1984;6:248-51.
Piovesan C, Abella C, Ardenghi TM. Child oral health-related quality of life and socioeconomic factors associated with traumatic dental injuries in school children. Oral Health Prev Dent 2011;9:405-11.
Traebert J, Peres MA, Blank V, Böell Rda S, Pietruza JA. Prevalence of traumatic dental injury and associated factors among 12-year-old school children in Florianópolis, Brazil. Dent Traumatol 2003;19:15-8.
Marcenes W, Zabot NE, Traebert J. Socio-economic correlates of traumatic injuries to the permanent incisors in school children aged 12 years in Blumenau, Brazil. Dent Traumatol 2001;17:222-6.
Bastone EB, Freer TJ, McNamara JR. Epidemiology of dental trauma: A review of literature. Australian Dental Journal 2000;45:2-9.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]