Dental Traumatology 2008; 24: 663–670; doi: 10.1111/j.1600-9657.2008.00689.x
Dental trauma in an Australian rural centre Raymond Lam1, Paul Abbott1, Christopher Lloyd2, Carmel Lloyd2, Estie Kruger3, Marc Tennant3 1 School of Dentistry, The University of Western Australia, Nedlands; 2Private Dental Practice, Bunbury; 3Centre for Rural and Remote Oral Health, The University of Western Australia, Nedlands, WA, Australia
Correspondence to: Prof. Paul V. Abbott, School of Dentistry, The University of Western Australia, 17 Monash Avenue, Nedlands, WA 6009, Australia Tel.: 61 8 9346 7665 Fax: 61 8 9346 7666 e-mail:
[email protected] Accepted 19 January, 2008
Abstract – Background/Aim: There is little epidemiological research regarding dental trauma in Australia. Previous research has largely focused on specific sub-populations with data not necessarily applicable to a general rural Australian population. Studies from other countries have presented variable data and the relevance of their findings to the Australian setting is questionable. The aim of this study was to investigate the prevalence, causes and presentation of dental trauma in a large rural centre in Australia. Materials and methods: A retrospective analysis was performed of the dental records of 323 consecutive patients who had attended a private general dental practice in Bunbury, Western Australia following an injury to their teeth and/or mouths during the period from May 2000 to December 2005 (inclusive). Injuries were classified using the Andreasen system (1994). Data analysis was carried out using spss software and Chi-Square tests were performed with the level of significance set at 5%. Results: There were 528 teeth injured and eight patients had only soft tissue injuries. Males (68.1%) significantly outnumbered females (31.9%) and the ages ranged from 10 months to 78 years. The highest number of injuries occurred in children and adolescents, specifically the 0- to 4-year age group followed by the 5- to 9-year age and 10- to 14-year age groups. Trauma was most frequently the result of falls, accidents while playing and participating in sports activities. Conclusions: The maxillary central incisors were the most commonly injured teeth in both the primary and permanent dentitions. Uncomplicated crown fractures were the most common injury followed by luxations and subluxations. No significant differences in frequency were reported for the different days of the week, the different months or seasons of the year. Only one-third of the patients presented for dental treatment within 24 h of the injury while the remainder delayed seeking treatment for varying times up to 1 year.
Dental trauma is an injury to the teeth and/or oral cavity. It is usually sudden, circumstantial, unexpected, accidental and often requires emergency attention. Although dental trauma is more common among children and teenagers, it can occur in any age group and is not confined to individuals of poor health. Costs to the injured person and to the community can be substantial (1). Currently, there is a paucity of epidemiological data in the field of dental trauma in Australia and the limited information available has mainly focused on specific subpopulations (1–6). Internationally, research in dental trauma has been more substantial (7–20), but its applicability and relevance to Australia can be questioned. The factors that influence the prevalence of dental trauma may be complex, culture specific and multifactorial. They include access and availability of dental and/or hospital treatment, the type of local work and industries, and the risk of each type of sport or recreational activity. Many factors lead to a great variation in the literature with regards to the cause, severity and prevalence of dental trauma in different locations (1–20). Existing studies regarding the incidence and causes of dental trauma have been reported from many different countries and communities with obvious biases towards their social, sporting and
cultural activities as causes of dental trauma (1–20). Even within Australia, there may be significant variations between communities but this can not currently be confirmed nor quantified because of the lack of data. A better knowledge and understanding of the factors unique to this country could not only assist academic staff in preparing dental students and in developing continuing professional development curricula, but would also enable the local dental practitioners to better plan the emergency services for their community equipped with information that reflects the patterns of health at that location. The aim of this study was to examine the pattern and characteristics of dental trauma, including the type, causes and incidence in Bunbury, a large rural centre in Western Australia. Bunbury is the second most populated location in Western Australia with a resident population of over 30 000 people and a large ‘feeder’ population from surrounding farming areas and smaller towns. According to the Rural, Remote and Metropolitan Classification released by the Australian Government’s Department of Health and Ageing, Bunbury is considered to be a large rural centre. However, Bunbury lacks the dental facilities, both in terms of access and specialization, that are housed in the major teaching
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hospitals in Perth, the capital city of Western Australia. The lack of dental facilities includes specialist endodontists, paediatric dentists, oral and maxillofacial surgeons and specific after-hours emergency clinics. Hence, the onus of managing dental trauma in Bunbury falls primarily on private general dentists within the town. Materials and methods
A retrospective analysis of dental records from a private general dental practice in Bunbury was undertaken. These records concerned 323 consecutive patients who had suffered an injury to their teeth and/or mouths over a 66-month period from May 2000 to December 2005 (inclusive) and who had presented to the dental practice for management of their injury/injuries during this period. The patients were examined by dentists within the practice, with most of them being examined by one of the two practice principals. Approval from the University of Western Australia’s Human Research Ethics Committee was granted to examine the de-identified patient records. The data were categorized according to the patient’s age and gender, the cause, type and date of the injury, the tooth injured and the time delay in seeking dental treatment. The Andreasen classification of traumatic injuries to the teeth (21) was used and teeth were designated according to the FDI system. Data analysis was carried out using spss software (SPSS for Windows, version 16.0, SPSS Inc., Chicago, IL, USA). Chi-square tests were used, where appropriate, to investigate the association between the various factors relating to the causes and characteristics of dental trauma. The level of significance was set at 5% (i.e. P < 0.05). Results
The age of the patients at the time of the injury ranged from 10 months to 78 years. Males significantly outnumbered females (220 males (68.1% of all patients), 103 females (31.9%), v2 = 37, P < 0.001), with the male to female ratio being 2.1:1. The mean ages were 11.6 years for the females and 14.1 years for the males. Approximately, 92% of the patients were 0.07). The date on which the injury occurred was analysed according to the day of the week, the month of the year and the season. Accidents on the days leading up to and immediately after the weekend (Thursdays, 16%; Fridays, 20%; Mondays, 17%) were slightly more common than on other days of the week (ranged from 9% on Sundays to 14% on Wednesdays) but the differences were not significant (P > 0.7). Similarly, when grouped into months, February and August recorded the highest frequencies but there were no significant differences between all the months (range 6–11%). There were also no significant differences between the number of injuries in each of the four seasons of the year (P = 0.2) and no statistical difference between gender and the incidence of trauma by seasons (P > 0.07). There were statistically significant differences in the causes of injuries between the primary and permanent dentitions (Fig. 2). Falls accounted for over half of the injuries in the primary dentition followed by accidents while playing. However, in the permanent dentition there was a greater range of causes with sports and accidents while playing predominating. A significant association was noted between age and the cause of the injury
60
No. of patients
50
40 Males Females
30
20
10
0 0–4
5–9
10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65 +
Age groups (years)
Fig. 1. Distribution of the patients according to age and gender.
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Table 1. Frequency of dental injury according to the type of dentition Primary dentition
Permanent dentition
All teeth
Injury type
n
%
n
%
n
%
UC/R# RESTN ROOT# CC/R# CC# UCC# INT LUX CONC AVULSION EXT LUX LAT LUX SUBLUX Total
0 3 3 7 2 18 18 5 13 18 36 37 160
0 1.9 1.9 4.4 1.3 11.3 11.3 3.1 8.1 11.3 22.5 23.1 100
2 9 13 17 26 151 3 25 19 17 35 51 368
0.5 2.4 3.5 4.6 7.1 41.0 0.8 6.8 5.2 4.6 9.5 13.9 100
2 12 16 24 28 169 21 30 32 35 71 88 528
0.2 2.3 3.0 4.6 5.3 32.0 4.0 5.7 6.1 6.6 13.5 16.7 100
UC/R#, Uncomplicated crown:root fracture; RESTN, Restoration fracture; ROOT#, Root fracture; CC/R#, Complicated crown:root fracture; CC#, Complicated crown fracture; UCC#, Uncomplicated crown fracture; INT LUX, Intrusive Luxation; CONC, Concussion; AVULSION, Avulsion; EXT LUX, Extrusive Luxation; LAT LUX, Lateral Luxation; SUBLUX, Subluxation.
90
85
85
Permanent dentition 80
Primary dentition 70
70
No. of teeth
60 50
46
44 39
44
38
40
34
30 20
12
Fig. 2. The causes of injury in the primary and permanent dentitions. (MVA, Motor vehicle accident).
12 7
7
10
3
1
0 Assault
(P < 0.001). In the 0-to 4-year age group, the predominant causes of dental trauma were falls (65%) and accidents while playing (18%). In the 5- to 9-year age group, falls and accidents while playing predominated, but the number of falls reduced (18%) and accidents while playing increased (52%). Sporting injures were first recorded in this group, representing 10% of the injuries. The number of injuries resulting from falls decreased as age increased and simultaneously, the number of accidents while playing and during sporting activities increased to a maximum in the 20- to 24-year age group. Sporting injuries were the most common injuries in the 15- to 19-year group (42%) and in the 25- to 29-year group (27%). Injuries from assaults had their highest frequencies in the 20-to 24-year age groups (25%) and 25- to 29-year (27%) age groups. Overall, the most common activities at the time of the accident were falls (24%), playing (21%), and participating in sport (18%). These activities collectively accounted for 63% of all injuries. Males outnumbered females in all categories of
Bike
Fall
MVA
Other
Play
Work
Sport
Cause of injury
Table 2. Cause of dental trauma according to gender Gender
Assault Bike Fall Motor vehicle accident Other Play Sport Work Total
Male n (%)
Female n (%)
Total n (%)
19 18 45 5 23 52 42 16 220
3 7 38 2 18 22 9 4 103
22 25 83 7 41 74 51 20 323
(8.6) (8.2) (20.5) (2.3) (10.4) (23.6) (19.1) (7.3) (68.1)
(2.9) (6.8) (36.9) (1.9) (17.5) (21.4) (8.7) (3.9) (31.9)
(6.8) (7.7) (25.7) (2.2) (12.7) (22.9) (15.8) (6.2) (100)
cause except feinting, accidents, and leisure activities (Table 2). A fall was the most common cause of injuries for females (36.9%) while playing was the most common cause in males (23.6%).
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50%
Fall
45%
MVA
40%
Other
35%
Play
30%
Sport
25%
Work
20% 15% 10%
Injury type
SOFT TIS
SUBLUX
LAT LUX
EXT LUX
AVULSION
CONC
INT LUX
UCC#
CC#
CC/R#
ROOT #
RESTN
0%
UC/R#
5%
Fig. 3. Cause of injury according to the type of injury. (UC/R#, Uncomplicated crown:root fracture; RESTN, Restoration fracture; ROOT #, Root fracture; CC/R# Complicated crown:root fracture; CC# Complicated crown fracture; UCC#, Uncomplicated crown fracture; INT LUX, Intrusive Luxation; CONC, Concussion; AVULSION, Avulsion; EXT LUX, Extrusive Luxation; LAT LUX, Lateral Luxation; SUBLUX, Subluxation; SOFT TIS, Soft tissue injury only).
There were 116 soft tissue injures; 108 of these occurred concurrently with other injuries and the other eight cases only had injuries to the soft tissues. Figure 3 shows the association between the causes of injuries and the resultant injuries to the teeth and soft tissues. The most frequently injured teeth were the maxillary central incisors in both the primary and permanent dentition. In the primary dentition, the three most commonly injured teeth were the maxillary central incisors (74.2%), maxillary lateral incisors (15.7%) and maxillary canines (3.1%). Similarly, in the permanent
dentition, the most commonly injured teeth were the maxillary central incisors (62.8%), followed by maxillary lateral incisors (18.5%), mandibular central incisors (9.7%) and mandibular lateral incisors (4.6%). Collectively, maxillary central incisors accounted for 66.2% of all teeth injured. Table 3 shows the proportion of traumatized teeth by gender and tooth type. Injury to the anterior teeth significantly outnumbered injury to the posterior teeth in all categories – male, female and total sample (P < 0.001). The majority of the injured teeth were in the maxillary arch (461 teeth,
Table 3. Injured tooth types according to gender and dentition Gender Males Tooth Permanent maxillary teeth Central incisor Lateral incisor Canine First premolar Second premolar First molar Permanent mandibular teeth Central incisor Lateral incisor Canine Second premolar Second molar Primary maxillary teeth Central incisor Lateral incisor Canine First molar Second molar Primary mandibular teeth Central incisor Lateral incisor Canine Second molar Total
Females Total %
Total n (%)
(44.7) (11.3) (2.0) (2.0) (1.3) (0)
12.7 3.2 0.6 0.6 0.4 0
231 68 5 3 2 1
(43.8) (12.9) (0.9) (0.6) (0.4) (0.2)
2 1 0 1 0
(1.3) (0.7) (0) (0.7) (0)
0.4 0.2 0 0.2 0
36 17 2 1 2
(6.8) (3.2) (0.4) (0.2) (0.4)
14.8 2.8 0.8 0.4 0.2
40 10 1 0 0
(26.7) (6.7) (0.7) (0) (0)
7.6 1.9 0.2 0 0
118 25 5 2 1
(22.4) (4.7) (0.9) (0.4) (0.2)
0.4 0.2 0.2 0.2 71.5
1 1 0 1 150
(0.7) (0.7) (0) (0.7) (100)
0.2 0.2 0 0.2 28.5
3 2 1 2 527
(0.6) (0.4) (0.2) (0.4) (100)
n (%)
Total %
n (%)
164 51 2 0 0 1
(43.5) (13.5) (0.5) (0) (0) (0.3)
31.1 9.7 0.4 0 0 0.2
67 17 3 3 2 0
34 16 2 0 2
(9.0) (4.2) (0.5) (0) (0.5)
6.5 3.0 0.4 0 0.4
78 15 4 2 1
(20.7) (4.0) (1.1) (0.5) (0.3)
2 1 1 1 377
(0.5) (0.3) (0.3) (0.3) (100)
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Percent of patients
Dental trauma in an Australian rural centre 50 45 40 35 30 25 20 15 10 5 0
36
10 5
