|Year : 2015 | Volume
| Issue : 2 | Page : 51-56
Epidemiology of traumatic dental injuries in Tunisia: A prospective study
Ines Kallel1, Imen Kallel2, Nabiha Douki1
1 Department of Dental Medicine, Sahloul Hospital, Sousse, Faculty of Dentistry, Monastir; Laboratory of Research in Oral Healh and Maxillo Facial Rehabilitation (LR12ES11), Faculty of Dental Medicine, University of Monastir, Monastir, Tunisia
2 Research Group on Molecular and Cellular Screening Processes, Centre of Biotechnology of Sfax, University of Sfax, Sfax, Tunisia
|Date of Web Publication||22-Mar-2016|
Dr. Ines Kallel
Department of Dental Medicine, Hospital Sahloul, 4054 Sousse
Source of Support: None, Conflict of Interest: None
Purpose: The aim of this study was to investigate the epidemiological characteristics of traumatic dental injury (TDI) in Tunisian patients.
Patients and Methods: All the trauma patients who had attended the Department of Dental Medicine, Hospital, Sahloul, Sousse city, during 4 years (2009-2013), were included in this study. Age, sex, etiology, and, time between the TDI and dental cares were recorded. The type of trauma was identified according to Andreasen's classification. Data were evaluated using the Chi-square, ANOVA, and Student's t-test.
Results: TDIs were higher among the age group of 11-20 years (35%), with more males being affected (sex ratio: 2.2:1). Falls was the most common etiological factor causing TDI (33%). The most frequent type of trauma is enamel-dentin fracture without pulp exposure (38%). Only 9% of patients sought dental care within 24 h of the injury. A significant difference of the sex repartition between different trauma etiologies (P = 0.013) was found. Age group repartition and etiology of trauma was significantly associated (P = 0.007) (the most common etiology of TDIs in 11-20 years age group is fall).
Conclusion: In this study, fall is the most common etiology of TDI and that the majority of patients sought dental treatment after more than 24 h of the injury. Therefore, significant strategies of trauma prevention and immediate treatment of injuries such as awareness campaigns in primary schools, colleges for emergency attitudes to adopt in case of dental trauma including total dislocation are needed to change epidemiologic data to the better.
Keywords: Dental education, epidemiology, luxation injuries, tooth fracture, traumatic dental injury
|How to cite this article:|
Kallel I, Kallel I, Douki N. Epidemiology of traumatic dental injuries in Tunisia: A prospective study. Afr J Trauma 2015;4:51-6
| Introduction|| |
There is an increased incidence of dental trauma worldwide resulting from both intentional and unintentional injuries. By the year 2020, the World Health Organization predicts that injuries will become the foremost reason for human life years. , Traumatic dental injuries (TDIs) have become a relative serious public health problem because of its frequency, occurrence at a young age, costs and that treatment may continue for the rest of the patient's life. There are few data about TDI in Tunisian populations. There is evidence that the incidence of TDI is relatively high in many countries such as Brazil, South Africa, and Chile. ,,,
Oral injuries cause esthetic, psychological, social, functional, and therapeutic problems and can cause irreparable dental loss, not only at the time of accident, but also after treatment. There were paucity of data on epidemiology of TDIs compared to dental caries. 
Therefore, this paper aims to study the epidemiological profile of TDI in Tunisian population as a basis for its prevention.
| Patients and Methods|| |
This is a prospective study of all trauma patients who presented to the Department of Dental Medicine, Hospital Sahloul, Sousse, Tunisia, from June 2009 to June 2013 including patients referred from other hospitals.
Data were collected using a questionnaire. The data obtained included individual demographic data (name, age, sex, education), type of accidents (road traffic crash, fall, violence, etc.), type of injury (tooth fractures, luxation injuries, maxillofacial injury), oral and X-ray examination, site(s) of fracture(s) of maxillofacial skeleton, and the time elapsed between injury and seeking of dental care.
The classification of TDIs proposed by Andreasen and Andreasen based on a system adopted by the World Health Organization  was used to classify injuries. The diagnosis was based on both clinical and radiological findings.
Data analysis was undertaken using SPSS for Windows 20.0 statistical software (SPSS, Inc., Chicago, IL, USA). Chi-square tests were used to compare qualitative data and determine statistical significance at level of 5%. The quantitative parameters were presented as mean ± standard deviation and are compared by Student's t-test and ANOVA tests between patients groups. A Ps < 0.05 was considered statistically significant.
| Results|| |
There has been a significant increase in trauma patients during the years of our study, with a peak during 2011; a total of 100 patients were observed in which 45 are seen during 2011, and only 4, 6, 26, 24 patients were seen during 2009-2013, respectively [Figure 1].
The age and sex distribution of study population is shown in [Table 1]. Patients' age ranged from 3 to 60 years (mean 24.7 ± 14.92 years). The highest number of patients 35 (35%) were in the 11-20 years age group. There were significantly more males affected than female (sex ratio: 2.2:1), P = 0.013. There was an overwhelming male preponderance in all age groups.
|Table 1: Distribution of patient with dental injuries trauma by age and gender|
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Most of the trauma cases were due to fall 33 (33%), followed by road traffic crash (31%). Violence was responsible in 27 (27%), occupational accidents (7%), school accidents (1%), and others (1%). The etiological distribution of facial trauma cases according to sex is shown in [Table 2].
|Table 2: Correlation between etiologies, delay of consultation, demographic parameters, and biological markers (age/sex)|
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There was a significant gender difference between different trauma etiologies (P = 0.013). There were more males affected than female by violence than road traffic accidents (P = 0.002). However, no significant difference was found between fall and road accident according to gender.
Furthermore, the different type of etiology was significantly associated with mean age of patient (P* = 0.014). The victims of road traffic crash are older than those with falls (Ps = 0.027) [Table 3]. In trauma cases, due to fall, the most commonly affected age group was the 11-20 years (15%) group.
|Table 3: Distribution of tooth fracture, luxation injuries, and both according to age groups|
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Delay of consultation
Only 9% of patients presented before 24 h after the injury. Most trauma patients presented for dental care between 1 and 3 days after trauma (47%) [Table 2]. Patient affected by road crash present later than patients with assault (P = 0.002). These patients (victims of assault) present also rather late than those who sustained injury from fall (P = 0.05).
Associated maxillofacial trauma
During the study, out of the 100 trauma patients, there are 44 (44%) cases of fractures of maxillofacial skeleton, 35 (35%) cases were mid-face [Figure 2] (zygomatic bones, LeFort II), and 9 are mandible fracture [Figure 3]. The male female ratio was 1.75:1. The highest incidence of maxillofacial fracture was in the age group of 11-20 years (13%). A significant difference was found between the presence of associated maxillofacial fracture and etiology (P = 0.037).
The major causative factor of maxillofacial fracture was road traffic crash (41.1%) followed by aggression (30.4%).
The tooth fracture was found in 64% of our patients and the luxation injury affects 70% of patients. The main type of TDI is fracture with the involvement of enamel and dentine, but without the exposure of the dental pulp (38%) followed by total luxation (26%). In tooth fracture, the most common type was amelodentin fracture without pulp exposure (44%) followed by root fracture (23%), amelodentin fracture with pulp exposure (21%), crown-root fracture (12%). In luxation injuries, the most frequent type was total luxation (25%) followed by subluxation (22%), extrusion (19%), lateral luxation (17%), contusion (16%), and intrusion (1%).
Tooth fracture, luxation injuries, and both type of injuries were found in 7%, 13%, 15%, respectively, among 11-20 years group [Table 3]. The average age of patient with luxation injuries was significantly different (lower) than the average age of patient with tooth fracture (Ps = 0.026). There is no significant difference in sex distribution in tooth fracture, luxation injuries, neither between both kinds of TDI (P > 0.05) [Table 4].
|Table 4: Association of traumatic dental injuries with sex and age parameters|
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| Discussion|| |
The limited number of trauma cases reported in this study may indicate that many patients did not seek dental treatment after minor trauma or that the true incidence of dental trauma is low in Sousse, Tunisia. Even though, we note a trend for increasing of trauma patient incidence in this study [Figure 1], this finding is in agreement with literature that point out increase in these injuries during the past few decades. ,, The peak observed in this study, during 2011 [Figure 1], can be explained by the revolution that took place in our country. Numerous works have shown increasing rate of aggression and that boys are more affected than girls. ,,,,, This study confirms this general finding. In the present work, the male to female ratio was 2.2:1, is reasonably similar to the 2.5:1 ratio found by Guedes et al.,  in Brazilian population and also close to 2:1 ratio found by Díaz et al.,  in Chile, but higher than the male: female ratio (1.4:1) showed by Gábris et al.,  in Budapest and (1.6:1) by Sandalli et al.,  in Turkish population. These difference observations might be explained by that boys participate in more aggressive type of games, more violent behavior, and contact sports. Girls are less prone to TDIs as our social setup and cultural reservations do not allow them to be involved in vigorous outdoor activities. In the present study, the most frequent age group with TDI is 11-20 years, this class constituted 35% of patients, similar to several studies that estimated that 71-92% of all TDIs sustained in a lifetime occur before the age of 19 years, also some studies have reported a decrease after the age of 24-30 years, , but others search found more frequent TDI in younger patients. , In Brazilian population, Guedes et al.  noted that dental injuries were common among the 6-10-year-old patients (31.5%), and in South-East Queensland, Australia, Wood and Freer found 26.2% in the same group age (6-10 years).  This may be attributed to the increasing mobility and activity in this age or could be explained by fact that dental injury is a cumulative defect. However, it is necessary to be cautious at comparing the prevalence among the studies that use different methodologies. Regarding demographic of study population; our study showed a significantly higher incidence of TDI in urban than in rural areas. This results are quite close to the Norwegian study that showed a significantly higher incidence in urban (20/1000) than in rural areas (13/1000 individuals),  this could be related to similar life style adopted by patients. In our study in urban area the second most common etiology of trauma is the road crash, similar results were found in the population-based study by Skaare and Jacobsen in Norway, in fact 10% of TDIs are due to traffi c accidents in teenagers in urban areas. 
Few published data are available as regards the period elapsing between accident and time of presentation for medical care. Oulis and Berdouses  observed that 68% of their patients in Athens presented for treatment on the 3 rd day after the trauma. In Budapest, Gábris et al.  showed that 77% of the cases presented for treatment in the first 3 days. In Temuco, Chile,  a high proportion of the patients received their first emergency attention 24 h after the accident (32.6%). This finding is in agreement with our study in which the majority of patients (47%) consult for dental care from 1 to 3 days after trauma. However, Eyuboglu et al.  mentioned that the percentage of the patients who came to a dental clinic in the first 3 days after the trauma was (22.8%), which was less than patients who came after 3 months and more (45.1%).
In the present work, it was remarkable that patients who presented rather late are those victims of road crash. The delay in initial emergency treatment might be due to (i) the high frequency of patients referred from other cities, (ii) the lack of a dentist at this emergency unit, and (iii) in cases of polytraumatize patients, the emergency management of dental injuries is not the priority.
Traffic crashes have more than 2-fold risk of facial bone fractures when compared with other injury types;  this finding is in accordance with our study in which the major causative factor of maxillofacial fracture was road traffic crashes followed by aggression.
The most common type of injuries was the fracture of crown without pulpal involvement. Similar result were illustrated in different population as in Budapest, in South-East Queensland, Australia, in Istanbul-Turkey, also recently, in Australia, in Eastern Anatolia Region-Turkey, in Brazile, in Romania, in Iraq, and in Jordan ,,,,,,,, but unlike than those findings reported by numerous investigators ,,,,,,,, in which enamel fracture is the most important type of TDI.
The second most important type of injury in this current study is total luxation (26%), which is in contrast to the majority of studies in which dental avulsion represents a very small percentage of TDI for instance in Kuwait, it is 4.4%  and in Budapest (only 4.39%),  also near to the result found in Turkey population (9.9%).  However, values closest to our results, 18.3% were observed by Guedes et al., in Brazilian population.  In Australia, total luxation varies greatly from one study to another, with reported incidence of avulsion cases ranges between 1.9% and 11.2%. 
Variations in the types of dental injury found according to age as luxation injuries were found to be more common in group ages (11-20 years) and rare with older patients. This could be attributed to the ability of bone and periodontal ligament of adult to absorb more energy of the impact, thereby favoring dislocations rather than fractures, this finding is in accordance with others studies. , This can also explain why among older patients, enamel and dentine fracture increases, as with aging the resiliency of bone decrease and the impact of exposure will be on the tooth itself.
There is some variation between the studies and countries regarding the predominant causes of dental trauma, although falls appear to be the most common factor in literature. ,,,,,,,,,,, The same finding was observed in our study in fact the highest etiology of dental trauma is falls (33%) followed by road traffic crash accident (31%).
In Tunisia, there is a fast growth in the volume of road traffic. A substantial rural to urban drift of the productive segment of the population has increased the density of urban population. Deteriorating infrastructure such as bad roads and noncompliance with seat belt and crash helmet legislation can also be considered as the factors contributing to the increasing road traffic crashes in developing countries.
The etiological factors varied according to the age group studied, and this association can be explained by age-related activities and the characteristics of motor coordination development as the majority of TDI cases resulted from falls in age group 0-10 and 11-20 years. With the increase of age, traffic crashes became the main etiologic agent, as reported elsewhere. ,
| Conclusion|| |
This study provides baseline information on TDI in population of Sousse, Tunisia, with hitherto scarce epidemiological data. Therefore, our findings can help the development of preventive policies. More prospective studies from representative populations are required to understand the complexities of dental trauma to develop appropriate strategies to reduce the increasing frequency of dental trauma.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]