p e d i a t r i c d e n t a l j o u r n a l 2 6 ( 2 0 1 6 ) 6 7 e7 3

Available online at www.sciencedirect.com

Pediatric Dental Journal

journal homepage: www.elsevier.com/locate/pdj

Original Article

Prevalence and risk factors of traumatic dental

injuries to permanent anterior teeth among 8e12
years old school children in Egypt
Mona H. El-Kenany BDS, DPD, Diploma in Pediatric Dentistry*,
Salwa M. Awad BDS, PhD, Assistant Professor of Pediatric Dentistry,
Salwa A. Hegazy BDS, PhD, Assistant Professor of Dental Public Health
Pediatric Dentistry and Dental Public Health Department, Faculty of Dentistry, Mansoura University, Mansoura,
Egypt

article info

abstract

Article history:

Background: Despite such a high prevalence of traumatic dental injuries (TDIs), very less

Received 30 September 2015

attention has been paid to TDIs, its etiology and prevention. Aim: The present study was

Received in revised form

carried out to identify prevalence of TDIs to permanent anterior teeth in children aged

25 January 2016

from 8 to 12 years old in Dakahlia governorate, Egypt.

Accepted 8 February 2016

Method: A cross-sectional study was conducted over a period of six months, 7983 children

Available online 3 April 2016

of age 8e12 years were examined from 38 primary schools which were selected by
multistage random sampling.

Keywords:

Results: The prevalence of TDIs was 14.6% (1166 children); boys (17%) experienced more

Trauma

injuries than girls (12.3%). TDIs were more common in
12 years old (19.5%). Single tooth

TDIs

fracture (75%), maxillary central incisors (82%) and enamel fracture (80.1%) were the most

Prevalence

common types of TDIs. Falls were the main cause (38.3%). School (46.1%) & home (30.2%)

School children

were the most common places. Only 5.7% (67) were treated. TDIs were more common in
children with combinations of Angle's class II (16.6%), overjet >4 mm (23%) and in-adequate
lip coverage (23%). Public schools showed higher trauma prevalence than private schools
(15.9% and 12.3% respectively). There was a significant association between TDIs and type
of occlusion, overjet, lip coverage, crossbite, gender, age & school type. No association was
found between the presence of openbite, district & residence and TDIs.
Conclusion: The results showed the need of preventive measures against falls at school and
home and methods of providing 1st aid in TDIs.
2016 Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: 201000495385.

E-mail address: dr_mona_hussien@yahoo.com (M.H. El-Kenany).
http://dx.doi.org/10.1016/j.pdj.2016.02.002
0917-2394/ 2016 Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.

68

1.

p e d i a t r i c d e n t a l j o u r n a l 2 6 ( 2 0 1 6 ) 6 7 e7 3

Introduction

One of the greatest assets a person can have is a smile that

shows beautiful, natural teeth. Oral region is the fourth most
common area of bodily injuries among 7e30-years old person
and makes up to 5% of all injuries [1]. Worldwide, the decline
in the prevalence and severity of dental caries amongst children recently has drawn attention to other aspects of oral
health such as TDIs [2] which may exceed dental caries and
periodontal disease as the most significant threat to dental
health among young people [3]. Prevalence of TDIs has
increased during the past few decades [4] and may further
increase in the future simply because more individuals will be
at risk [5]. Existing data on Prevalence of orofacial trauma in
various epidemiological studies has been found to differ
considerably among different countries, it could be related to
the discrepancies of the performed sampling procedures [4,6].
TDIs are a serious perplexing problem among children that
can endanger dental health and lead to aesthetic, psychological, behavioral and therapeutic problems that influence the
children and their parents especially if untreated [7]. The
frequency of TDIs to the permanent dentition in school age
children peaked at the age group 9e15 years [8]. As it represents the maximum physiologic growth and development
while the children are actively involved in many outdoor activities which increase the liability to injury due to loss of
balance and impaired movements [9,10]. Maxillary central
incisors are the most affected teeth followed by maxillary
lateral incisors [11,12]. The most frequent injury type is
enamel fracture followed by enameledentin fracture [13,14].
Falls are found as the most frequent causes of trauma followed by sports, bicycling, car accidents and violence [14]. The
habit of eating raw nuts and dried melon seeds may lead to
micro and macro fracture of enamel [15]. Most injuries occur
at home or at school [16]. Some predisposing anatomical factors can increase the susceptibility to TDIs. Among which are
Angle Class II malocclusion, with increased overjet (>4 mm),
openbite, short or hypotonic upper lip and mouth breathing
patients [17]. Also, carious teeth lesions, large number and
extension of restorations and endodontically treated teeth are
another risk factors to TDIs [18]. In most studies, boys experienced significantly more TDIs to the permanent dentition
than girls [6,7]. As girls are generally more mature in their
behavior than boys [12]. At the present time, there may be a
reduction in this difference, due to increasing risk among girls
participating in traditionally male dominated sports [19]. In
Egypt, there is a lack of information regarding the etiology and
the prevalence of TDIs to anterior teeth. Hence, this study
aimed to determine the prevalence of fractured anterior teeth
and its relation with various predisposing risk factors among
8e12 years old school children in Dakahlia governorate, Egypt.

2.

Materials and methods

This cross-sectional study was conducted among children of

primary (public and private) schools among 8-12-year-old
schoolchildren of both sexes as it was noticed that there's a
late eruption of anterior teeth among Egyptian children so we

took the sample from 8 years old to the end of primary stage at
12 years old as a safe edge [20]. The study was enrolled in both
rural and urban sectors. Sample size consisted of 7983 and
calculated according n t2 p1  p=m2 formula [21] with
selecting almost equal number of boys and girls (3992 boys
and 3991 girls). Thirty eight schools were randomly selected
from public and private schools were included with a sampling by a probability proportional to the school size from five
districts of Dakahlia which selected by multistage cluster
random sample. It was selected on the basis of ease of
accessibility. First 5 centers were selected from Dakahlia,
Egypt (from all geographical sides: Mansoura at the center,
Talkha east, Dekrnas west, Sherbin north and El-Sinbelween
south.) then schools were selected from urban and rural
areas of each center and then from each school one class was
selected from each grade of both sexes. The approvals of the
Ethics Committee, students and their parents were obtained.
The planning schedule had included time for: Introducing the
examiner to the school directorates, choosing an appropriate
class room to carry out the examination and setting up the
equipments. It started at October 2013 and finished at April
2014. Examination of each child took about 3e4 min and the
number examined per day were about 60e80 children for
4e5 h/d by researcher and data were recorded by trained
school nurse. Infection control measures were taken. Students were examined in their seats during class hours while
sitting in straight-backed chairs with facing good natural day
light to receive maximum illumination and the examiner in
the front of them. Portable lighting device was used to provide
more illumination that may be needed for more accurate details. Only objective findings at the examination were registered as TDIs. Prior to oral examination, each child was asked
if they had an injury to the teeth at the front of the mouth. If
yes, where, when and how this happened and the circumstances that resulted in the injury were recorded. The children
in whom the permanent anteriors were lost due to caries or
cause other than trauma or those having partial/complete
anodontia involving permanent anteriors were not included
in this study. Visual inspection for lip coverage was noticed
when the subject entered the examination area without subject's awareness. The following data were obtained from each
record: Patient demographic criteria like age and sex, size of
incisal overjet, cause, site and type of TDIs, number of teeth
involved, time elapsed between the time of TDIs and seeking
care, reasons for delayed presentation after trauma and
presence of any clinical signs related to TDIs. Type of injury
was recorded according to Andresen's epidemiological classification of TDIs to anterior teeth including WHO codes [22]. It
is a comprehensive system which allows for minimal subjective interpretations [4] as the following codes: i) Code 0: No
injury, ii) Code 1: Treated dental injury, iii) Code 2: Enamel
fracture only, iv) Code 3: Enamel/dentin fracture, v)Code 4:
Pulp injury, vi) Code 5: Missing tooth due to trauma, vii) Code
6: Excluded tooth (Any missing tooth isn't related to trauma,
e.g. caries, orthodontic purpose or periodontal diseases).
School children who didn't remember the cause of trauma
were grouped in cannot recollect the cause of trauma. Injuries such as concussion, root fracture and alveolar bone
fracture were not included in this study since no radiographs
were taken. The occlusion of the subject was judged using

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p e d i a t r i c d e n t a l j o u r n a l 2 6 ( 2 0 1 6 ) 6 7 e7 3

Angle's classification. Measurement of maxillary overjet was

made with the teeth in centric occlusion and using disposable
elastic scale was measured in mm. Statistical analysis: Data
were collected and analyzed using SPSS 21.0 and included
descriptive statistics (frequency distribution and cross tabulation). Chi-square test was used to determine significant
differences and spearman correlation also was included. The
level of statistical significance was set at p < 0.05.

3.

Results

The sample consisted of 7983 school children, with an age

range of 8e12 years old, mean age 10.15 1.3 years old. About
50% were boys and 50% were girls. They were examined from
public (34) and private (4) schools and were distributed into
five age groups. The overall prevalence of TDIs to the anterior
teeth was found to be 1166 children (14.6%). Boys (17%)
showed significantly higher TDIs prevalence in comparison to
girls (12.3%). The observed prevalence of TDIs was significantlly higher in boys (58.1%) than in girls (41.9%) (P < 0.05).
There was a significant Negative correlation. (P < 0.05). The
highest prevalence of traumatized children was found to be at
the age
12 years old (19.5%) followed by 11e12 years old
(19%), there was a statistically significant difference (P < 0.05)
and a significant positive correlation (P < 0.05) [Table 1]. The
total number of traumatized teeth was 1512 teeth, Single tooth
fracture was the most common and found to be (75%) followed
by two teeth fracture (21.8%). It appeared that, the upper jaw
was found to be more involved by dental trauma (88.8%) than
the lower jaw which resembled only (11.1%). The permanent
maxillary central incisors were found to be the most affected
by TDIs (82%) [Fig 1]. Results showed that Enamel fracture
(80.1%) was found to be the most common type of TDIs, followed by enamel and dentine fracture (14.2%), pulp injury
(1.1%), avulsion (0.2%) and only 4.4% of dental injuries were
treated. Only 1.3% of the children with TDIs exhibited clinical
signs. Discoloration of the teeth was present in the affected
part, mainly bluish hue. The main reason for the trauma were
Falls (38.3%) while (19.6%) did not remember the cause of the
trauma cannot recollect group [Table 2]. The majority of
TDIs occurred at school (46.1%) and at home (30.3%) during
physical leisure activities [Table 3]. It was found that only
(28.9%) went to the dentist and seek care. Among them, only
(67 children) were treated and the time to visit the dentist

Fig. 1 e Distribution of the most affected teeth in both

upper and lower jaws.

Table 2 e Distribution of the most common causes of

trauma.
Cause
Falls
Accident and Traffic accident
Playing and Sports
Violence and Fighting
Biting and Teeth misuse
Home Abuse
Cannot recollect group
Total

446
157
127
108
88
11
229
1166

38.3%
13.5%
10.9%
9.3%
7.5%
0.9%
19.6%
100%

Table 3 e Distribution of the most common place of

trauma occurrence.
Place

School
Home
Street
Other
Total

537
353
185
91
1166

46.1%
30.2%
15.9%
7.8%
100%

Table 1 e Prevalence of TDIs according to gender and age and correlation between them.
N

Gender
Boys
Girls
Age
8e9
9e10
10e11
11e12

12
Mean SD

% Of trauma within Variable

% Within Trauma

X2 (P value)

R (P)

Trauma

No Trauma

Total

677
489

3315
3502

3992
3991

17%
12.3%

58.1%
41.9%

35.442 (0.00)

0.067 (0.00)

79
175
286
311
315
10.15 1.3

914
1450
1825
1325
1303

993
1625
2111
1636
1618

8%
10.7%
13.5%
19%
19.5%

6.8%
15%
24.5%
26.7%
27%

112.393 (0.00)

0.116 (0.00)

70

p e d i a t r i c d e n t a l j o u r n a l 2 6 ( 2 0 1 6 ) 6 7 e7 3

since the trauma occurred was variant; a large majority came

before the first week (42.1%). The main reason of treatment
delay was found to be home negligence (81.7%) [Table 4].
Regarding dental variables showed in [Table 5]:Traumatized children were more common with combinations of class
II (16.6%). There was significant difference between TDIs and
the type of occlusion (P < 0.05). Class II was significantly higher
than class I (P < 0.05). Children with increased overjet were 1.8
times more prone to injuries in comparison to those having
normal overjet, the maximum injuries occurred in children
with increased overjet >4 mm (23%) (P < 0.05). Children with
inadequate lip coverage showed significantly higher number
of TDIs (23.6%) and 2.5 times more prone to TDIs as compared
to those with adequate lip coverage (9.6%). There was significant difference (P < 0.05). TDIs was found to be (10%) in the
children with openbite and resembled (1.2%) of traumatized
children. The difference was insignificant (P > 0.05). Only
(1.2%) of traumatized children had crossbite. Children with no
crossbite had significantly higher TDIs than those with
crossbite (14.8% and 7.6% respectively) (P < 0.05).
Regarding demographic data [Table 6]: There was no significant difference between trauma and centers of the study
and between trauma and the area of residence (urban and
rural). Public schools showed significantly higher trauma
prevalence than private schools (15.9% and 12.3%
respectively).

4.

Discussion

Traumatic dental injuries (TDIs) form a common challenging

problem to oral health professionals which may continue for
the rest of the patient's life [1]. Total prevalence of TDIs in this
cross-sectional study was evaluated as 14.6% that corroborates the results of various recent studies [11,23]. The prevalence noted is higher as compared to studies done by Patel and
Sujan [10] (8.79%), Zhou et al. [14] (7.1%). On the other hand, it
was lower than Al-Bajjali and Rajab [24] (16.3%).

Table 4 e Distribution of the children who seek care and

time elapsed between TDIs and seeking care and cause of
treatment delay.
Seeking care

Went to the dentist

- Treated
- Not treated
Never went to the dentist
Total

337
67
270
827
1166

28.9%
5.7%
23.2%
71.1%
100%

Time Elapsed

Before the first week

Within a month
Later
Total

142
113
82
337

42.1%
33.5%
24.3%
100%

Cause of treatment delay

Home Negligence
Dentist Negligence
Total

916
205
1121

81.7%
18.3%
100%

In present study, there was a significant difference in

dental trauma between genders, boys experience TDIs more
than girls, boys: girls ratio was 1.38:1. Similar findings were
observed by the majority of studies [2,7]. Traebert et al. [25]
found that girls can be exposed to the same TDIs risk factors
as boys. On the other hand, in a study described by GarciaGodoy [26], gender distribution was not significantly different.
In this study, the peak age to sustain injury was found to be
11e12 and
12 years which is in agreement with other studies
described by Faus-Damia et al. [3] and Yassen et al. [28]. This
study also showed that TDIs prevalence increased with age
more prevalent with age in agreement with Saroglu and
Sonmez [29] and Gupta et al. [30] reports. But Rouhani et al.
[31] suggested that, it does not mean that elderly children are
more susceptible to TDIs but it shows a cumulative characteristic of TDIs records in time.
It was found that single tooth injuries were more than
multiple teeth injuries. Maxillary central incisors were the
most common traumatized teeth in this study. This can be
explained by the bone density of the alveolar process in the
age group studied and the anatomical position of the maxillary central incisor, often associated with the presence of
pronounced overjet and inadequate lip coverage [32]. This
results in agreement with previous studies by Navabazam and
Farahani [12], Altun et al. [27], Rouhani et al. [31]. The 2nd most
affected teeth were the mandibular central incisors followed
by the maxillary lateral incisors. This result agreed with the
result of Forsberg and Tedestam [33] study and in contrast
with most of studies [11e13] that found the 2nd most affected
teeth were the maxillary lateral incisor. This could be due to
early eruption of maxillary central incisors and lower central
incisors than the maxillary lateral incisors and thus are at risk
for a longer period of time. The lowest rate of injury was in the
permanent canines in both arches, it may be due to their late
eruption, Also this could be related to their position in sides of
the arches as the direction of the blow is mostly directed
frontally to the face. Generally traumatized maxillary incisors
are more frequent than mandibular incisors because blows to
mandibular teeth are dissipated due to no rigid connection of
mandible to the cranial base [10].
Enamel fractures was (80.1%) as the most common injuries
followed by enamel-dentin fractures (14.2%) so lower rates of
signs were found as TDIs were far away from the pulp. Our
results are in agreement with most other studies [10,23]. This
could be related to the enamel brittleness or blow direction.
In this study, the most common cause of TDIs was fall
(38.4%) which was similar to the prevalence reported by
Navabazam and Farahani [12] and Yassen et al. [28]. The
percentage of school children that did not remember the
cause of trauma was high (19.6%) and could have resulted in
the under-reporting of the various etiologic factors. This result
is along with the results of other reports [6,29]; this may
possibly be explained by a high prevalence of minor injuries,
for which children and their parents, not being very concerned by the traumatic event and forgot its circumstances in
a short time. In many instances children were reluctant to
reveal to cause of the injury suggesting that the proportion
due to violence may be underestimated.
The school (46.5%) were the most common followed by at
home, this result may be related to the age group selected, as

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p e d i a t r i c d e n t a l j o u r n a l 2 6 ( 2 0 1 6 ) 6 7 e7 3

Table 5 e Dental variables in relation with TDIs.

Variables

Occlusion

Overjet
Lip Coverage
Openbite
Crossbite

Class I
Class II
Class III
0-4 mm
4 < mm
Adequate
In-adequate
Present
Absent
Present
Absent

Trauma

No Trauma

Total

898
253
15
856
310
494
672
14
1152
14
1152

5439
1274
104
5781
1036
4640
2177
126
6691
170
6647

6337
1527
119
6637
1346
5134
2849
140
7843
184
7799

% Of trauma within Variable

% Within trauma

X2 (p)

14.2%
16.6%
12.6%
12.9%
23%
9.6%
23.6%
10%
14.7%
7.6%
14.8%

77%
21.7%
1.3%
73.4%
26.6%
42.4%
57.6%
1.2%
98.8%
1.2%
98.8%

6.0591 (0.048)

92.138 (0.00)
286.491 (0.000)
2.424 (0.120)
7.394 (0.007)

Table 6 e Demographic variables in relation with TDIs.

Variables

District

Residence
School type

Mansoura
Talkha
Dekrnas
Sherbin
Sinbelween
Urban
Rural
Public
Private

Trauma

No Trauma

Total

396
176
214
175
205
596
570
1002
164

2177
1011
1196
1264
1169
3504
3313
5647
1170

2573
1187
1410
1439
1374
4100
3883
6649
1334

the older patients spend more time outside. It should be noted

that most of TDIs was occurred in the schools was due to of
the hustle and scramble in aggressive manner on school stairs
and playground and this highlights the importance of school
staff who are most often required to respond initially to the
traumatic incident. These findings are in agreement with
other results described in previous studies carried out in other
countries [1,4,6].
In this study, the majority of children (71.1%) who had a
history of TDIs didn't refer to dental professionals in order to
obtain professional assessment. Similarly, to the study by
Gupta et al. [30]. The treatment rate was relatively low and
from (28.9%) of children went to the dentist, only 5.7% (67
children) were treated which was in concordance to the
epidemiological studies done in other parts of the world
[11,14,15]. Forty two percent of children who seek dental care,
went to the dentist within the first week, while the rest sought
for treatment later when pain and discomfort occurred or
esthetics needed. Also this phenomenon could be related to
the uncomplicated injuries that are not perceived as a situation which needs immediate treatment as symptoms are absent; children thus often do not go to the hospital until acute
symptoms develop [34]. Lack of adequate knowledge and
proper motivation of both parent and dentist compounded by
limitations imposed due to socioeconomic constraints and
non-affordability of the cost of the treatment could also
explain the high percentage of untreated injuries as home
negligence (81.7%) was found to be the main reason of treatment delay; as parents may not be aware of possible longterm consequences of dental trauma as the majority of the

% Of trauma within Variable

% Within trauma

X2(P value)

15.4%
14.8%
15.2%
12.2%
14.9%
14.5%
14.7%
15.1%
12.3%

34%
15.1%
18.4%
15%
17.6%
51.1%
48.9%
15.1%
12.3%

8.690 (0.069)

0.033 (0.857)
6.865 (0.009)

TDIs were limited to enamel so the children didn't complain

and parents were unaware about what happened to their
children while dentist negligence (18.3%) was the second
cause Some dentists just prescribed a medicine symptomatic treatment to the children with TDIs and left them
without any treatment.
The maximum number of TDIs were seen in Angle's Class II
Division I (19.1%) molar relationship that is similar to earlier
observation by Patel and Sujan [10]. Increased overjet has been
found to be associated with increased severity of fractures, this
enhanced risk is confirmed with many other previous studies
[4,27,30]. Inadequate lip coverage has been shown as an
important risk predictor [4]. In this study, a statistically significant difference was reported between TDIs and lip coverage.
Children with inadequate lip coverage had 2.5 times more injuries as compared to the other group. This result is confirmed
by previous studies [11,17]. However Patel and Sujan [10] and
Andressa et al. [35] revealed that there was not a statistically
significant relationship between the type of lip coverage and
occurrence of TDIs. It is suggested that the protective effect of
lip closure, in addition to adequate occlusal contact area of
maxillary and mandibular teeth in normal occlusion, tends to
decrease the impacting force of trauma [36].
There was no statistically significant difference between
the prevalence of TDIs and anterior open bite. Our findings are
in agreement with results described by Viegas et al. [37].
Conversely, another investigation described by Robson et al.
[38] found a statistically significant association between TDIs
and anterior open bite. Whereas, there was a significant difference between trauma and the presence of crossbite.

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p e d i a t r i c d e n t a l j o u r n a l 2 6 ( 2 0 1 6 ) 6 7 e7 3

Moreover, the presence of anterior crossbite appeared to be a

protective factor against the occurrence. This result is in
agreement with results described by Viegas et al. [37].
Our study showed a higher prevalence of TDIs in children
attending public school (15.9%) than private school (12.3%).
These findings are in agreement with other results described
by Hamilton et al. [39] and Soriano et al. [40]. There was a
significant relationship between trauma and the type of
schools (public and private schools). This may be due to private schools environment and school staffs are more concerned about children and their safety and in constant contact
with parents more than public school. Conversely, Grimm
et al. [41], reported a higher prevalence of TDIs in children
attending private (higher social economic status) schools than
in public (lower social economic status) schools. Soriano et al.
[11] argued in their study that whether the child goes to a
private or public school is an indication of his/her socioeconomic condition and consequently determines the type
of environment where the pupils live in. The association between socio-economic indicators and TDIs is inconsistent and
needs to be clarified.
This study has some limitations; since the study was crosssectional, causal relationships could not be established and
the observed association could be due to other unexplored
factors. Moreover, trauma was detected visually and without
taking radiographs. The children who did not go to school
were not studied that will limit generalizability of our results.
However, strength of our study was providing an overview of
burden of the TDIs among Egyptian children in Egypt for the
first time and it can be a benchmark for future comparisons by
the public health personnel and decision makers.

5.

Conclusions

TDIs prevalence in permanent anterior teeth among 8e12

school children in Dakahlia governorate eEgypt is relatively
high (14.6%). Single tooth fracture, maxillary central incisors
and enamel fracture were the most common type of TDIs. The
main reason of TDIs was falls, the majority occurred at school
followed by home. Few children had access to dental treatment after TDIs and home negligence was found to be the
main reason. Boys experience TDIs more than girls and the
peak age to sustain TDIs was found to be 11-
12 years. The
prevalence of TDIs was influenced by school type, class II
occlusion, lip incompetence, increased overjet and anterior
crossbite. Residence of the study, anterior open bite had no
influence over the prevalence of TDIs.

Conflict of interest

[2]

[3]

[4]
[5]

[6]

[7]

[8]
[9]

[10]

[11]

[12]

[13]

[14]

[15]

[16]

[17]

[18]

There is no conflict of interest to declare.

[19]

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[20]

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