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REVIEW

Australian Dental Journal 2000;45:(1):2-9

Epidemiology of dental trauma: A review of the literature


Elisa B. Bastone,* Terry J. Freer,* John R. McNamara*

Abstract This article reviews recent reports describing the aetiology of dental trauma from national and international studies as well as the different classifications currently used to report dental injuries. It also discusses possible preventive measures to reduce the increasing frequency of dental trauma. Reported studies demonstrate that males tend to experience more dental trauma in the permanent dentition than females, however, there does not appear to be a difference between the sexes in the primary dentition. Accidents within and around the home were the major sources of injury to the primary dentition, while accidents at home and school accounted for most of the injuries to the permanent dentition. The most frequent type of injury was a simple crown fracture of the maxillary central incisors in the permanent dentition while injuries to the periodontal tissues were more common in the primary dentition. When preventive measures are being planned, knowledge of aetiology is important. More prospective studies from representative populations are required to understand the complexities of dental trauma epidemiology and to allow implementation of preventive strategies to reduce the increasing frequency of dental trauma.
Key words: Trauma, epidemiology, aetiology, risk factors, prevention. (Received for p u b l i c a t i o nJuly 1998. Revised September 1998. Accepted September 1998.)

Most of the reported studies of dental trauma have concentrated on specific subpopulations such as children from public or private schools, localized geographical sites or limited age groups. Furthermore, most of the dental trauma data available have been collected retrospectively from cross-sectional studies or from longitudinal studies of patient records. Retrospective studies Retrospective studies are designed to test aetiological hypotheses and are derived by collecting data relating to characteristics of the persons under study or to events or experiences that have occurred in their past. Retrospective studies on dental trauma are abundant but these are mostly limited to specific subpopulations. A major disadvantage of retrospective studies in this context is that certain dental and oral injuries such as alveolar fractures and soft tissue injuries may not always be evident at the time of the examination if the injury occurred some time beforehand. Other injuries could also be missed if signs and symptoms do not exist at the time of the examination. Another shortcoming of retrospective studies is that a patients recall of the injury may not always be accurate if the accident occurred months or even years before the examination, particularly in children. Prospective studies Prospective or cohort studies are observational studies of a large population over a long period in order to generate reliable incidence rates in the population subsets. Data are collected as the nominated events occur so there is minimal risk of recall bias. It should be recognized that prospective studies are not without disadvantages.These studies will only record injuries if the patient seeks dental treatment. This may occur rarely with minor enamel and dentine fractures or trauma without displacement injuries.
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Introduction Epidemiological data provide a basis for evaluation of the concepts of effective treatment, resource allocation and planning within any health environment. It is interesting to note the limited amount of epidemiological data in the field of dental and oral trauma in Australia. Costs to the injured person and the community arising from such injuries are substantial. It is uncertain why more emphasis is not placed on trauma prevention.

*Dental School, University of Queensland.


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Table 1. Classifications of dental trauma


Andreasen11 Crown infraction. Incomplete fracture of the enamel Uncomplicated crown fracture. A fracture confined to the enamel or dentine but not exposing the pulp Complicated crown fracture.A fracture involving enamel and dentine, and exposing the pulp. Uncomplicated crown-root fracture. A fracture involving enamel,dentine, cementum, not exposing the pulp Complicated crown-root fracture. A fracture involving enamel, dentine and cementum, and exposing the pulp Root fracture.A fracture involving dentine, cementum, and the pulp Concussion. Injury without abnormal loosening or displacement but with marked reaction to percussion Subluxation (loosening). Injury with abnormal loosening but without displacement of the tooth Intrusive luxation (central dislocation) Extrusive luxation (peripheral dislocation, partial avulsion) Lateral luxation Exarticulation (complete luxation) Comminution of alveolar socket Fractures of facial or lingual alveolar socket wall Fractures of alveolar process with and without involvement of the socket Fractures of the mandible or maxilla with and without involvement of the tooth socket Laceration of gingiva or oral mucosa Contusion of gingiva or oral mucosa Abrasion of gingiva or oral mucosa World Health Organization 12 Fracture of enamel of tooth Fracture of crown without pulpal involvement Fracture of crown with pulpal involvement Fracture of root of tooth Garcia-Godoy13 Enamel crack Enamel fracture Ellis14 Simple fracture of the crown, involving little or no dentine Extensive fracture of the crown, involving considerable dentine, but not the dental pulp Extensive fracture of the crown, involving considerable dentine and exposing dental pulp The traumatized tooth that becomes non-vital,with or without loss of crown structure Total tooth loss

Enamel-dentine fracture without pulp exposure Enamel-dentine fracture with pulp exposure Enamel-dentine-cementum fracture without pulp exposure Enamel-dentine-cementum fracture with pulp exposure Root fracture

Fracture of crown and root of tooth Fracture of tooth, unspecified Luxation of tooth

Fracture of the root, with or without loss of crown structure Displacement of tooth, without fracture of crown or root Fracture of the crown en masse and its replacement

Intrusion or extrusion of tooth Avulsion of tooth Other injuries including laceration of oral soft tissues

Concussion

Luxation Lateral displacement Intrusion Extrusion Avulsion

Most of the prospective studies are based on subpopulations such as school children,1-6 children presenting to a paediatric dental service, 7 or patients presenting to an accident and emergency department.8,9 One Australia-wide study attempted to analyse all trauma patients presenting to members of the Australian Society of Endodontology over a two year period.10 The limited number of trauma cases reported in this study (313 patients over two years) may indicate that participation by the clinicians was low, that many patients did not seek dental treatment after minor trauma or that the true incidence of dental trauma is low in Australia. There is a lack of prospective Australian dental trauma studies which are representative of the general population. It is necessary to establish the frequency and causes of dentofacial trauma in a representative Australian population in order to identify risk
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groups, treatment demand and costs, and ultimately to implement preventive strategies which will reduce the personal and financial burdens associated with trauma. The purpose of this review was to compare national and international studies and to establish any common trends in the aetiology of dental trauma.The authors intended to compare and collate data from different studies in order to develop a broader understanding of the complexities of dental trauma epidemiology. Classification of dental injuries Comparing and accumulating data from different studies is extremely difficult due to the differences in the definitions and classifications used (Table 1). Andreasens classification 11 contains 19 groups and includes injuries to the teeth, supporting structures, gingiva and oral mucosa.Whilst this classification is
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a modification of the World Health Organizations (WHO) classification,12 it is a more comprehensive system which allows for minimal subjective interpretations. The WHO classification of oral trauma describes injuries to the internal structures of the mouth. Luxation injuries are grouped as one and not divided into intrusive, extrusive and lateral luxations as is the case with the Andreasen classification. Injuries to the alveolar socket and fractures of the mandible or maxilla are not grouped under oral injuries with the WHO standards, but rather are classified separately as fractures of face bones. There is a broad group incorporated with the WHO standards which allows for other injuries including laceration of oral soft tissues. These types of open ended groupings may lend themselves to misinterpretation by investigators. Garcia-Godoys classification13 differs somewhat but is also a modification of the WHO system. This classification differs from others mainly by separating dental fractures into those involving cementum or not. Broad terms such as complicated or uncomplicated fractures are not used with the Garcia-Godoy classification, however, there are no groupings for subluxation or alveolar injuries and mandible or maxilla fractures. The Ellis classification14 is another modification of the WHO system which has been used by various authors for recording dental trauma. This system is a simplified classification which groups many injuries and allows for subjective interpretation by including broad terms such as simple or extensive fractures. Injuries to the alveolar socket and fractures of the mandible and maxilla are not classified here. Whilst there are numerous classification systems currently available, some investigators have opted to record only specific injuries, hence creating their own classification and augmenting the difficulties when comparing studies. Tables 2a and 2b illustrate some of the different specifications of dental and oral trauma reported in the literature. Incidence and prevalence of dental trauma Determining the incidence of a particular event requires information on the number of new cases in a specified time period divided by the number of persons exposed to the risk during this period.15 The denominator is often calculated as the average size of the population or the estimated population at the midperiod. Most studies cited here are cross-sectional in design and therefore the number of new cases in a specified time period cannot be determined.6,16-25 The studies that have examined the new cases at the time of the accident have rarely had a specified denominator population and therefore the incidence was incalculable. 7,9,10,26-31
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Table 2a. Classification of dental trauma from prospective (incidence) studies


Reference Stockwell
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Classification Fracture of enamel only Fracture of crown involving enamel and dentine, but not the pulp Fracture of the crown with exposure of the pulp Fracture of the root Luxation of the tooth without fracture Avulsion of the tooth Concussion without fracture, displacement or avulsion but loss of vitality during survey period Trauma to a previously traumatized tooth resulting in either dislodgement of a restoration, or further fracture, dislodgement or avulsion of the tooth Intra-oral and/or extra-oral soft tissue injury Presence or absence of fracture/displacement to teeth Alveolar fracture Crown fractures were analysed according to Ellis classification system Crown fractures without pulp exposure Crown fractures with pulp exposure Crown-root fractures Root fractures Subluxation Subluxation with intrusion Subluxation with extrusion Luxation Fracture of the alveolar socket Dento-alveolar fracture Fractures of the mandible/maxilla Injuries to the soft tissues Other injuries World Health Organization Classification World Health Organization Classification (partially modified) Andreasen Classification Andreasen Classification Fracture confined to enamel Fracture involving dentine Fracture with pulp exposed Intrinsic discolouration Abnormal mobility Infra-occlusion Presence of sinus or s welling in the mucosa over a tooth

Perez et al. 7

Galea9

Davis and Knott10 Oulis and Berdouses 26 Liew and Daly34 Martin et al.
27

Hamilton et al. 32

Caliskan and Turkun28 Andreasen Classification Onetto et al.29 Lee-Knight et al.36 Andreasen Classification Tooth infraction Chipped tooth Fractured tooth Lacerated lip Traumatized TMJ

Kaba and Marechaux 30 Ellis Classification Dearing31 Osuji


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Fractures only Andreasen and Ellis Classification

An Australian study by Stockwell4 determined that the incidence of trauma to the anterior permanent teeth in 6-12 year old school children was 1.7 patients/100 children/year while involving 2.1 teeth/ 100 children/year. An English study by Hamilton et al.32 determined the incidence of trauma to permanent
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Table 2b. Classification of dental trauma from cross-sectional (prevalence) studies


Reference Kania et al.
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Classification Sweet Classification52 Enamel injury only Enamel and dentine injur y Pulpal exposure Fracture at or below the gingival margin Restoration present, trauma status not determinable Crown fracture Concussion Subluxation Subluxation with enamel fracture Subluxation with lingual or labial displacement Intrusion Extrusion Full displacement Root fracture Crown-root fracture Alveolar bone fracture Fracture involving dentine and/or pulp Devitalization Avulsion Enamel fracture Enamel-dentine fracture Fracture involving pulp Root fracture Luxation,subluxation Exarticulation Discolouring Garcia-Godoy Classification Garcia-Godoy Classification Garcia-Godoy Classification World Health Organization Classification
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Bijella et al. 16

Burton et al. 17

Forsberg and Tedestam18

Garcia-Godoy19 Garcia-Godoy et al.20 Garcia-Godoy et al. Hargreaves et al.22 Zerman and Cavalleri
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Fracture of enamel,including enamel chipping Fracture of enamel-dentine without pulpal involvement Fracture of enamel-dentine with pulpal involvement Fracture of root Crown-root fracture with pulpal involvement Concussion Subluxation Intrusive luxation Extrusive luxation Lateral luxation Avulsion Fracture Discolouration Absence of any maxillary incisor teeth Fracture (enamel) Fracture (enamel and dentine) Fracture (involving pulp) Discolouration Acid etch restoration Other restoration

Hunter et al. 24

Burden25

incisors and related soft tissues as four cases/100 children/15 months, which was almost twice the incidence of the Australian study. There were significantly more children in the lower socio-economic groups receiving dental injuries compared with the higher socio-economic groups in the English study. This, together with the inclusion of soft tissue injuries
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in the English study, may provide a possible explanation for the large differences between the two studies, particularly if the socio-economic status was not evenly distributed in the two geographical locations. Calculating the prevalence of dental trauma is a relatively simple task and most studies have calculated this figure.16,22,24,25,30-33 Prevalence is defined as the number of events, in this case the number of children experiencing dental trauma, in a given population at a designated time point. 15 The prevalence of dental trauma in various epidemiological studies has also been found to differ considerably. The great variation may be due to a number of different factors such as the trauma classification, the dentition studied, geographical and behavioural differences between study locations and countries. The prevalence of dental trauma in high school children ranged between 6 per cent in an Australian study by Burton et al.17 to 34 per cent in an English study by Hamilton et al.32 Another study by Forsberg and Tedestam18 in Sweden observed a relatively high prevalence of traumatized teeth in children aged 7-15 years (30 per cent) but this study also included traumatized primary teeth. A New Zealand study by Dearing31 observed a prevalence of traumatized incisors of 19 per cent, while a Swiss study by Kaba and Marechaux30 revealed a prevalence of trauma to permanent teeth in children aged 6-18 years of 11 per cent. A South African study by Hargreaves et al.22 found an overall trauma prevalence of 16 per cent in primary school children.The black population had a dental trauma prevalence of 13 per cent and the white population a prevalence of 21 per cent. However, an American study by Kania et al.6 found an overall prevalence of traumatized incisor teeth to be significantly higher among non-Caucasians compared with Caucasians, 17.5 per cent and 21.7 per cent respectively.6 A study by Bijella et al.16 examined trauma to the primary teeth in a house by house survey in Brazilian children aged 10-72 months. This study found a high prevalence of 30 per cent of children with traumatized primary teeth; however, injuries such as concussion, root fracture and alveolar bone fracture were also included in this study. These injuries are not usually included in other cross-sectional studies due to difficulties obtaining radiological data. Prevalence rates in the primary dentition peaked at age 10-24 months in a Brazilian study,16 while the frequency of trauma to the permanent dentition in school age children peaked in the age group 9-15 years.4,18,20,29 Studies investigating all age groups have observed trauma frequency peaks in the 18-23 year olds,34 6-13 year olds, 9,23,27 and 11-15 year olds.28
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Table 3. Causes, types and dental locations of traumatic injuries


Reference Stockwell4 Cause/where injury occurred (%) Fell or pushed 22.7 Bicycle 9.3 Swimming/diving 4.9 Impact with person 15.9 Impact with object 15.3 Hit by ball 3.7 Unspecified 13.2 Falls 46.0 Fights 14.0 Road traffic accidents 13.0 Accident 12.0 Bicycle 8.0 Sports 5.0 Child abuse 1.0 Primary Home 60.0 Simple falls 31.0 Falls from height 27.0 Permanent On the street 40.0 Female home 33.0 Males work/sports 33.0 Type of injury (%) Enamel fracture 31.2 Crown fracture not involving pulp 42.7 Crown fracture involving pulp 4.6 Root fracture 0.4 Luxation 3.5 Avulsion 4.0 Concussion 1.0 Soft tissue injury 58.0 Displacement 62.0 Alveolar fractures 5.5 Sensitivity to percussion 37.0 Direct extrusion from socket 29.0 Intrusion into socket 12.0 Avulsion 22.0 Primary Subluxation, displacement 80.0 Intrusion 12.3 Soft tissue injury 47.0 Permanent Subluxations 35.0 Crown fractures 31.0 Subluxations and extrusions 13.0 Luxations 10.0 Root fractures 4.0 Crown-root fractures 4.0 Subluxations and intrusions 2.0 Crown fracture not involving pulp 58.0 Crown fracture involving pulp 13.7 Crown and root fracture without pulp 1.2 Crown and root fracture with pulp 8.5 Subluxation 23.0 Displacement 7.9 Avulsion 5.2 Enamel cracking or fracture without dentine exposure 3.5 Enamel fractures with dentine exposure and without pulp 70.1 Fracture of enamel and dentine with pulp exposure 24.4 Dental location (%) Maxillary central incisors 71.9 Maxillary lateral incisors 6.2 Maxillary canines 0.4 Mandibular central incisors 16 Mandibular lateral incisors 5.1 Mandibular canines 0.4 Not given

Perez et al.7

Galea9

Primary Maxillary central incisors 71.0 Maxillary lateral incisors 23.7 Permanent Maxillary central incisors 53.1 Maxillary lateral incisors 17.7 Mandibular central incisors 13.3 Soft tissue injury 58.0

Davis and Knott10

All sport 33.5 Bicycle/tricycle 15.7 Assault 10.2 Road traffic accidents 5.1

Maxillary central incisor 66.6 Maxillary lateral incisor 15.7 Mandibular central incisor 9.8 Mandibular lateral incisor 7.87

Oulis and Berdouses26

Not given

Maxillary central incisors 91.8 Maxillary lateral incisors 4.0 Mandibular incisors 3.8

Sex distribution Males experienced significantly more dental trauma to the permanent dentition than females in all Australian and most international surveys cited.The male:female ratio ranged from 1.3-2.3:1.4,6,7,9,10,17,18,26,28-32 Although Garcia-Godoy19,20 observed a male:female ratio of 0.9:1.0 in a study from three private schools in the Dominican Republic, and 1.1:1.0 in another study in public and private school children, the sex distribution was not significantly different. Two Australian studies by Liew and Daly34 and Martin et al.27 observed a relatively higher male:female ratio of 2.6:1.0.These two studies examined patients attending after hours clinics which resulted in a higher incidence of 18-23 year olds compared with other studies. This age group may also reflect a greater number of males participating in sports and violent behaviour in the evenings and on weekends compared with females. The difference in sex distribution among children in the primary dentition has not been so obvious.
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Bijella et al.16 observed a slight insignificant difference between males and females of 1.3:1.0, while Onetto et al.29 observed that the male:female ratio was 0.9:1.0 for children less than seven years old. Aetiology of dental trauma Accidents within and around the home have been reported as being the major source of injury to the primary dentition, while accidents at home and school accounted for most injuries to the permanent dentition.4,9,10,18,29,35 Table 3 indicates there is some variation between studies and countries regarding the predominant causes of dental trauma, although accidents due to falls appear to be the most common factor in both primary and permanent dentitions. Accidents as a result of sports, violence and road traffic accidents were also common causes of dental trauma. Injuries The number, type and severity of dental injuries per patient differ according to the patient age and
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Table 3. Causes, types and dental locations of traumatic injuries (continued)


Reference Liew and Daly 34 Cause/where injury occurred (%) Falls 26.6 Sports 18.0 Bicycle 14.2 Assault/fights 13.3 Struck by object 9.4 Road traffic accidents 8.2 Pool/surf 5.6 Collision/bump 4.7 Falls 26.0 Sport (team) 16.0 Bicycle 15.0 Fights 13.0 Road traffic accidents 9.0 Collision 8.0 Undefined falls 45.0 Sport 22.6 Road traffic accidents 11.3 Violence 11.3 Miscellaneous 9.7 Primary Home 68.0 Falls 82.0 Striking an object 13.0 Permanent School 38.0 Street 33.0 Falls 58.0 Striking an object 19.0 Bicycle 9.0 Not given Type of injury (%) Primary Luxation 46.9 Permanent Crown fractures without pulp 25.0 Luxation 23.5 Dental location (%) Maxillary central incisor s Maxillary central incisors 66.3 Maxillary lateral incisors 18.9 Permanent Maxillary central incisors 55.8 Maxillary lateral incisors 18.8 Maxillary canines 3.5 Maxillary central incisors 63

Martin et al.27

Luxation 26.0 Crown fracture not involving pulp 25.0 Subluxation 16.0 Avulsion 13.0 Crown fracture with pulp 11.0 Crown root fracture 4.0 Root fracture 4.0 Enamel dentine fractures were the most common injury

Caliskan and Turkun28

Maxillary central incisors 66.2 Maxillary lateral incisors 21.1 Mandibular central incisors 8.5 Mandibular lateral incisors 4.1 Not given

Onetto et al.29

Primary Luxation 26.0 Intrusion 21.0 Subluxation 18.0 Permanent Uncomplicated crown fracture 34.0 Complicated crown fracture 21.0

Kaba and Marechaux30

Crown fracture with/without dentine 14.2 Crown fracture with dentine, not involving pulp 52.6 Crown fracture,with dentine and involving pulp 7.4 Non-vital without loss to crown structure 2.9 Avulsion 5.2 Root fracture 1.1 Luxation 9.7 Intrusion 3.6 Extrusion 1.1 Crown fractures 2.2

Maxillary central incisors 79.9 Maxillary lateral incisors 10.1 Mandibular central incisors 6.8 Mandibular lateral incisors 1.6 Maxillary canines 0.7 Mandibular canines 0.0 Mandibular premolars 0.6

the cause of the accident. Uncomplicated crown fracture without pulp exposure was the most common injury to the permanent dentition in most studies (Table 3). 4,6,10,18,20,21,25,26,28-30,33,36 However, subluxations and complete luxations were the most frequently occurring injuries in two hospital studies, particularly in the primary dentition.9,27 Displacement (luxation) of teeth has occurred more frequently in the younger age groups studied.9,16,18,29,34,35,37 Some authors have indicated that the supporting structures (alveolar bone and periodontal ligament) in the primary dentition are resilient, thereby favouring dislocations rather than fractures.2,38-41 The maxillary central incisors were the most frequently injured teeth in all studies for both the primary and secondary dentitions. The second most frequently injured teeth were maxillary lateral incisors in all studies except that by Forsberg and Tedestam18 where mandibular central incisors were the second most frequently injured teeth.
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The number of injuries per patient has varied from between 1.1 and 2.0, but this variation could have been influenced by the actual injuries being recorded, the classification used and the type of study location. The two Australian studies by Liew and Daly 34 and Martin et al.,27 conducted in all age groups from after hours dental clinics, reported more severe injuries to older patients and involved more teeth per patient than had been found in the Australian private practice study by Davis and Knott.10 The number of injured teeth per patient also varied between countries and sites of the studies. The type of study centre also affected the frequency of multiple injuries per person. One tooth was more frequently injured than multiple teeth in most prospective studies conducted at school dental services and general clinics.4,10,26,28,29 Those studies conducted in hospital casualty departments and after hours clinics have observed injuries to one and two teeth in equal proportions27,34 or two teeth more frequently than one.9 This may be a function of
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people experiencing more severe injuries after hours and it may also indicate that people attend hospitals rather than dental clinics for more severe injuries. Predisposing and risk factor s An important predisposing factor reported for dental trauma was a large maxillary overjet and incomplete lip closure.6,25,31,33 Galea9 observed that the severity of injuries appeared to increase when there was an associated injury to the lower lip, while a third of the accidents occurred in subjects with some form of malocclusion. Female subjects with prominent maxillary incisors and incompetent lip closure often had multiple injuries to the supporting structures of the teeth.9 Burden25 observed that subjects with an overjet greater than the normal range (0-3.5 mm) were significantly more likely to have received an injury to the maxillary incisors. It also appeared that the prevalence of dental trauma in females increased as overjet increased. Dearing31 and Hunter et al.24 also observed a significant difference in the frequency of fractured incisors between patients with an increased overjet. Increased overjet, however, may not play an important role when trauma is sustained via contact or collision sports, as was demonstrated in a case-control study by Stokes et al.33 It should be noted, however, that there were only 36 cases and controls in this study. Competent lip coverage was also an important predictor of dental trauma.6,25,31 Burden25 observed that children with inadequate lip coverage were at greater risk of dental trauma, regardless of their overjet size. Hunter et al.,24 however, did not observe an increased frequency of dental trauma with incompetent lip closure, particularly in females. Hamilton et al.32 observed that significantly more children in the lower socio-economic groups received injuries compared with the higher socio-economic brackets, while Onetto et al.29 observed that a high percentage of patients receiving injuries had suffered previous dental trauma. Another important factor found to increase the risk of dental trauma while playing sports was the lack of a properly fitted mouthguard and/or faceguard.42-45 The value of mouthguards may be demonstrated by Lee-Knight et al.36 who reported that none of the athletes who sustained dental injuries in the Canada Games was wearing a mouthguard. Johnsen and Winters46 suggest that many dental injuries can be avoided by informing the population of the importance of these protective devices whilst playing sport. Jolly et al.47 observed that when a mouthguard was not worn during football games, the likelihood of a fractured or avulsed tooth was at least twice that of when a mouthguard was worn.
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Conclusion It is extremely difficult to compare the results of the different investigations of dental injuries, partly because information is lacking or inaccurate, the studies are based on specific groups (age, class and location) or comprise trauma patients exclusively. However, the main reason is that the trauma classifications terminology and the data recorded differ substantially from study to study. It is desirable to unify recording standards to make effective use of data that may be compared with other similar studies. In the last decade, a number of studies have attempted to examine the trauma problem on a population basis using cross-sectional examinations of groups claimed to be representative of the nation. However, cross-sectional studies will miss many minor but significant injuries if they do not happen to occur just prior to the time of the examination. It is an obvious advantage to be able to undertake a prospective examination but it is essential to register all or almost all cases within a reasonably short space of time, or there will be no advantage of prospective studies over their cross-sectional counterparts. It appears that gender, age and history of trauma are important predisposing factors which increase the risk of dental trauma. A number of studies also confirm the relationship between overjet and lip incompetence and the tendency to sustain dental injuries. Apart from orthodontic treatment, there are very few options for introducing preventive strategies. The exception, of course, would be to ensure the use of fitted mouthguards whilst playing contact and hard ball sports such as football, cricket, basketball and water polo and wearing appropriate helmets whilst cycling. Traumatic injuries in children and adolescents are a common problem and several studies have reported that the prevalence of these injuries has increased during the past few decades.48-51 More epidemiological studies from representative populations using standardized trauma classifications are needed in order to understand the complexities of dental trauma epidemiology and to ultimately help reduce the increasing frequency of dental trauma. Acknowledgements This study was supported in part by the Motor Accident Insurance Commission/Centre of National Research on Disability and Rehabilitation Medicine and the Australian Research Committee. References
1. Parkin SF. A recent analysis of traumatic injuries to childrens teeth. J Dent Child 1967;34:323-325. 2. Ravn JJ. Dental injuries in Copenhagen schoolchildren, school years 1967-1972.Community Dent Oral Epidemiol 1974;2:231245.
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3. Harrington MS,Eberhart AB, Knapp JF. Dentofacial trauma in children.J Dent Child 1988;55:334-338. 4. Stockwell AJ. Incidence of dental trauma in the Western Australian School Dental Service. Community Dent Oral Epidemiol 1988;16:294-298. 5. Timoney N, Saiveau M, Pinsolle J, Shepherd J. A comparative study of maxillo-facial trauma in Bristol and Bordeaux. J Craniomaxillofac Surg 1990;18;154-157. 6. Kania MJ, Keeling SD, McGorray SP, Wheeler TT, King GJK. Risk factors associated with incisor injury in elementary school children.Angle Orthod 1996;66:423-432. 7. Perez R, Berkowitz R, McIlveen L, Forrester D. Dental trauma in children:a survey. Endod Dent Traumatol 1991;7:212-213. 8. Acton CHC, Nixon JW, Clark RC. Bicycle riding and oral/ maxillofacial trauma in young children. Med J Aust 1996;165:249251. 9. Galea H. An investigation of dental injuries treated in an acute care general hospital. J Am Dent Assoc 1984;109:434-438. 10. Davis GT, Knott SC. Dental trauma in Australia. Aust Dent J 1984;29:217-221. 11. Andreasen JO. Traumatic injuries of the teeth. 2nd edn. Copenhagen:Munksgaard, 1981:19-24. 12. World Health Organization. Application of the International Classification of Diseases to Dentistry and Stomatology (ICD-DA). Geneva: World Health Organization,1978:88-89. 13. Garcia-Godoy F. A classification for traumatic injuries to primary and permanent teeth. J Pedod 1981;5:295-297. 14. Ellis RG. The classification and treatment of injuries to the teeth of children. 5th edn. Chicago: Year Book Medical Publishers, 1970:56-199. 15. Last JM.A dictionary of epidemiology. 3rd edn. Oxford: Oxford University Press,1995. 16. Bijella MF, Yared FN, Bijella VT, Lopes ES. Occurrence of primary incisor traumatism in Brazilian children: a house-byhouse survey. J Dent Child 1990;57:424-427. 17. Burton J, Pryke L, Rob M, Lawson JS. Traumatized anterior teeth amongst high school students in northern Sydney. Aust Dent J 1985;30:346-348. 18. Forsberg CM,Tedestam G.Traumatic injuries to teeth in Swedish children living in an urban area.Swed Dent J 1990;14:115-122. 19. Garcia-Godoy FM. Prevalence and distribution of traumatic injuries to the permanent teeth of Dominican children from private schools. Community Dent Oral Epidemiol 1984;12:136-139. 20. Garcia-Godoy F, Morban-Laucer F, Corominas LR,Franjul RA, Noyola M.Traumatic dental injuries in schoolchildren from Santo Domingo. Community Dent Oral Epidemiol 1985;13:177-179. 21. Garcia-Godoy F, Morban-Laucer F, Corominas LR,Franjul RA, Noyola M. Traumatic dental injuries in preschoolchildren from Santo Domingo. Community Dent Oral Epidemiol 1983;11:127130. 22. Hargreaves JA, Matejka JM, Cleateon-Jones PE, Williams S. Anterior tooth trauma in eleven-year-old South African children. J Dent Child 1995;62:353-355. 23. Zerman N, Cavalleri G. Traumatic injuries to permanent incisors. Endod Dent Traumatol 1993;9:61-66. 24. Hunter ML, Hunter B, Kingdon A, Addy M, Dummer PM, Shaw WC. Traumatic injury to maxillary incisor teeth in a group of South Wales schoolchildren. Endod Dent Traumatol 1990;6:260-264. 25. Burden DJ. An investigation of the association between overjet size,lip coverage,and traumatic injury to maxillary incisors. Eur J Orthod 1995;17:513-517. 26. Oulis CJ, Berdouses ED. Dental injuries of permanent teeth treated in private practice in Athens. Endod Dent Traumatol 1996;12:60-66. 27. Martin IG,Daly CG,Liew VP. After-hours treatment of anterior dental trauma in Newcastle and western Sydney: a four-year study. Aust Dent J 1990;35:27-31. 28. Caliskan MK, Turkun M. Clinical investigation of traumatic injuries of permanent incisors in Izmir, Turkey. Endod Dent Traumatol 1995;11:210-213.
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29. Onetto JE, Flores MT, Garbarino ML. Dental trauma in children and adolescents in Valparaiso, Chile. Endod Dent Traumatol 1994;10:223-227. 30. Kaba AS, Marechaux SC. A fourteen-year follow-up study of traumatic injuries to the permanent dentition. J Dent Child 1989;56:417-425. 31. Dearing SG. Overbite, overjet, lip-drape and incisor tooth fracture in children. N Z Dent J 1984;80:50-52. 32. Hamilton FA, Hill FJ, Holloway PJ. An investigation of dentoalveolar trauma and its treatment in an adolescent population. Part 1:The prevalence and incidence of injuries and the extent and adequacy of treatment received.Br Dent J 1997;182:91-95. 33. Stokes AN, Loh T, Teo CS, Bagramian RA. Relation between incisal overjet and traumatic injury:a case control study. Endod Dent Traumatol 1995;11:2-5. 34. Liew VP, Daly CG. Anterior dental trauma treated after-hours in Newcastle, Australia.. Community Dent Oral Epidemiol 1986;14:362-366. 35. Osuji OO. Traumatised primary teeth in Nigerian children attending university hospital: the consequences of delays in seeking treatment. Int Dent J 1996;46:165-170. 36. Lee-Knight CT, Harrison EL, Price CJ. Dental injuries at the 1989 Canada Games: An epidemiological study. J Can Dent Assoc 1992;58:810-815. 37. Wilson S, Smith GA,Preisch J,Casamassimo PS. Epidemiology of dental trauma treated in an urban pediatric emergency department. Pediatr Emerg Care 1997;13:12-15. 38. Judd PL. Paediatric dental trauma: a hospital survey. Ont Dent 1985;62:19-23. 39. Meadow D, Needleman H, Lindner G. Oral trauma in children. Pediatr Dent 1984; 6:248-251. 40. Henry RJ. Pediatric dental emergencies. Pediatr Nurs 1991;17:162-167. 41. Andreasen FM, Daugaard-Jensen J. Treatment of traumatic dental injuries in children.Curr Opin Dent 1991;1:535-550. 42. Welbury RR, Murray JJ. Prevention of trauma to teeth. Dent Update 1990;17:117-121. 43. Chapman JP. Mouthguard protection in sports. (Letter to the editor.) Aust Dent J 1996;41:212. 44. Padilla R,Dorney B, Balikov S. Prevention of oral injuries. CDA J 1996:24:30-36. 45. Rodd HD, Chesham DJ. Sports-related oral injury and mouthguard use among Sheffield school children. Community Dent Health 1997;14:25-30. 46. Johnsen DC, Winters JE. Prevention of intraoral trauma in sports. Dent Clin North Am 1991;35:657-666. 47. Jolly KA, Messer LB, Manton D. Promotion of mouthguards among amateur football players in Victoria. Aust N Z J Public Health 1996;20:630-639. 48. Andreasen JO, Ravn JJ. Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample.Int J Oral Surg 1972;1:235-239. 49. Andreasen JO. Etiology and pathogenesis of traumatic dental injuries: a clinical study of 1,298 cases. Scand J Dent Res 1970;78:339-342. 50. Hedegard B,Stalhane I.A study of traumatized permanent teeth in children aged 7-15 years. I.Sven Tandlak Tidskr 1973;66:431452. 51. Schatz JP, Joho JP. A retrospective study of dentoalveolar injuries. Endod Dent Traumatol 1994;10:11-14. 52. Sweet C.A classification and treatment for traumatized anterior teeth.J Dent Child 1955;22:144-149.

Address for correspondence/reprints: Professor Terry Freer, The University of Queensland, Dental School, Turbot Street, Brisbane, Queensland 4000.
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