| Abstract|| |
Objective: The aim of this systematic review and meta-analysis was to estimate the prevalence of traumatic dental injuries (TDI) in India. The secondary objective was to evaluate the prevalence rate according to the differences in gender, age, regions, type of TDI and risk factors associated with TDI. Methods: The PubMed, LILACS, Web of Science, Cochrane, CINHAL, and Scopus databases, along with the Public Health Electronic Library, TRoPHI and DoPHER were searched from 1st March to 15thApril 2019 without any restriction of language and year of publication. The qualitative synthesis was done regarding the demographics, study methods, cause of trauma, geographic location, increased overjet and inadequate lip coverage. The meta-analysis was undertaken with STATA-14 software (USA). The pooled prevalence of TDI was calculated using data extracted from 48 studies included in qualitative synthesis and meta-analysis. A sub-group meta-analysis was done by extraction of the data for age groups of 6 years and >6 years. Results: The pooled prevalence of TDI in Indian population was 13 cases in 100 individuals. The prevalence of TDI for age groups of ≤6 was 15% (males, 15%; females, 16%) and for >6 years was 12% (males, 13%; females, 8%). The most common cause of TDI was falls, and most frequent location was home. The odds ratio for occurrence of TDI and inadequate lip-coverage was 3.35 and overjet greater than 3 mm was 3.53. Conclusions: The pooled prevalence of TDI was 13% and slightly higher in children less than 6 years of age. Inadequate lip coverage and increased overjet are the risk factors associated with TDI. Heterogeneity was observed among the studies in terms of design, variables recorded, sampling, study methods and statistical methods. Majority of them also suffered from moderate to high risk of bias.
Keywords: Dental trauma, permanent teeth, prevalence, primary teeth, tooth fracture, traumatic dental injuries
|How to cite this article:|
Tewari N, Mathur VP, Siddiqui I, Morankar R, Verma AR, Pandey RM. Prevalence of traumatic dental injuries in India: A systematic review and meta-analysis. Indian J Dent Res 2020;31:601-14
|How to cite this URL:|
Tewari N, Mathur VP, Siddiqui I, Morankar R, Verma AR, Pandey RM. Prevalence of traumatic dental injuries in India: A systematic review and meta-analysis. Indian J Dent Res [serial online] 2020 [cited 2020 Oct 31];31:601-14. Available from: https://www.ijdr.in/text.asp?2020/31/4/601/298427
| Introduction|| |
Traumatic dental injuries (TDI) have been projected as the fifth most prevalent disease worldwide. In a global systematic review by Petti et al., the estimated number of individuals, from 7 to 65 years of age, with injured permanent teeth was approximately 900 million. The projected number of children with at least 1 TDI involving primary teeth was 180 million globally. Several authors have emphasised that changing lifestyles, recreational behaviours and exposure to adventure/violent content through Web-based media can be considered primary causes of increased TDI.,,,
All non-communicable diseases have been known to have regional and cultural variations. TDI has also shown variations in different parts of the world. Researchers have elucidated the population and registry data from different countries with distinct prevalence, cause and site of injury, location of injury and risk factors., These differences can also be attributed to certain peculiar behaviours or preferences in some cultures, such as participation in contact sports or adventure games. Awareness of means for the prevention of injuries, such as the use of helmets and mouthguards, and access to emergency care after TDI are also responsible for these variations.,
It is important to understand the global similarities along with regional variations. This is essential for the formulation of effective interventions for improvement of awareness, prevention of TDI, emergency care and comprehensive management. Regional variations are important for community-based programs and the advocacy of prudent measures in general health/trauma/sports safety/road safety and oral health policies of governments in different states and nations.,
India is a vast country with a total area of 3.3 million square kilometres, divided into 29 states and 7 Union territories. Its location in the South Asian Peninsula endows it with a wide range of geographical, linguistic and cultural diversity. It is second highest in terms of population in the world (over 1.2 billion). The first study to estimate the prevalence of TDI in India was published in 1967. Since then, numerous studies have been reported from different regions of the country.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, Until now, there has been no pan-India survey or registry for estimation of the prevalence and risk factors for TDI. The last National Oral Health Survey was conducted in 2003-04 by the Dental Council of India, which did not record TDI.
The studies conducted in different parts of the country exhibited the prevalence of TDI ranging from 1% to 76%. A scoping literature review showed a lack of uniformity in terms of design, dental trauma assessment and statistical methods among studies.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, Hence, it was decided to conduct a systematic review and meta-analysis to estimate the prevalence of TDI in India. The secondary objective was to evaluate the prevalence rate according to the differences in gender, age, regions, type of TDI and risk factors associated with TDI.
An a priori protocol as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was prepared after group discussions among the reviewers and was registered with Open Science Framework (OSF278334) (https://osf.io/). It had the following components:
The research question in PECO was about patients/population(s): individuals (irrespective of age and sex) living in India, exposure(s): TDI assessed using a standard method, comparator(s): individuals (irrespective of age and sex) living in India, and outcome(s): prevalence of TDI, causative factors and risk factors.
Inclusion and exclusion criteria
The cohort studies, case-control and cross-sectional studies with validated methods of recording TDI were included in the review. The epidemiological surveys done in any part of India were included while the studies done in clinical settings or those with inadequate information regarding the recording of TDI were excluded. The studies conducted in special groups, such as athletes, visually impaired, and special-needs children, were also excluded from the review.
The PubMed, LILACS, Web of Science, Cochrane, CINHAL, and Scopus databases, along with the Public Health Electronic Library, TRoPHI and DoPHER were searched from 1st March to 15th April 2019 without any restriction as to language and year of publication. A search of the grey literature was performed in Google Scholar and OpenGrey. Reference lists of eligible studies were cross-checked to identify additional studies.
Literature search strategy [Figure 1]
The search strategy included the use of text words and MeSH terms. The broad-based search was implemented individually with keywords: 'Traumatic-Dental-Injuries', 'Dental-Trauma', 'Dental-Injury', 'Tooth-Fracture', 'Tooth-Trauma', and 'Tooth-Injuries'. Partial searches with the Boolean tools AND and OR were done with the above keywords individually with 'India' and in different possible combinations. The three strategies for partial searches were (1) Search ((Dental-trauma [Text Word]) OR Dental-injury [MeSH Terms]) OR Dental-injuries [MeSH Terms], (2) Search (tooth injuries [MeSH Terms]) OR teeth injur*[Text Word]) OR tooth injur*[Text Word] OR Tooth-Fracture [Text Word] OR Tooth-Trauma [Text Word]) OR traumatic dental injur*[Text Word]), (3) Search (India [Text Word] OR Indian [Text Word]). Authors of the studies were contacted for additional details when required. The titles and abstracts were evaluated for suitability of inclusion in a systematic review, and duplicates were removed by means of EndNote reference management software. Two authors (NT and IS) performed the literature search independently according to this predefined strategy. Three authors (NT, MR, and AV) analysed the selected full-text articles to verify their inclusion in the systematic review independently according to the inclusion and exclusion criteria. High level of agreement was found between the three reviewers in a pilot of three studies. In any event of disagreement, it was resolved after discussion with the senior reviewer (VM).
Three reviewers (NT, MR and AV) independently performed data extraction using a self-designed pretested form. In the event of differences of opinion, the senior reviewer (VM) was consulted.
The sheet included details of study demographics such as authors, journal, city, state and region; study methods such as sample size calculation, sampling strategy, age group of subjects, gender, classification used and format used for recording; and other details such as injured patients, injured teeth, most injured region, most injured tooth, most common injury, cause of trauma, risk factors description evaluation of treatment needs.
The modified Newcastle Ottawa scale (NOS), adapted for observational cross-sectional studies by Corrêa-Faria and Petti, was used for the assessment of the risk of bias., It was based on a score system ranging between 0 (lowest quality) and 9 (highest quality). For cross-sectional studies, a modified version of NOS was used with scores ranging between 0 and 8, based on the following items: (i) case definition, (ii) sample representativeness, (iii) sample selection procedure, (iv) risk factor exposure assessment, (v) adjustment for confounders, (vi) reliability of diagnosis, (vii) description of bias and (viii) non-response rate. Study quality was considered high risk when scores were less than 3, moderate risk when score was 4–6 and low risk with scores 7 and 8. Two reviewers (NT and MR) assessed the risk of bias. In event of any disagreement, senior reviewer (VM) was consulted and it was resolved.
The meta-analysis was undertaken with STATA-14 software (USA). The pooled prevalence was calculated by the use of weighted average in a random-effects model with 95% confidence interval (CI) boundaries. The sub-group analysis for pooled prevalence was undertaken for age (<6 years/>6 years) and gender. This was plotted as a forest plot exhibiting effect sizes, I2 values (representing the level of heterogeneity) and confidence intervals. The associated factors, such as type of TDI, cause, location of injury, lip coverage and overjet, were subjected to separate meta-analyses with limited number of studies for the assessment of effect size or odds ratio. Publication bias was assessed by deriving a funnel plot for the studies included in meta-analysis. Statistical significance of the funnel plot was assessed using the modified regression method (Peters et al. 2006). The pooled prevalence was also subjected to meta-regression for identifying any regional differences in TDI.
| Results|| |
The predefined search strategy revealed 6497 records. After duplicates were removed, 4872 records were identified as titles. Of these, 59 in full text were downloaded for evaluation. Eleven were excluded because they had been conducted in special groups like visually impaired and special-needs children. In total, 48 studies were included for qualitative synthesis and meta-analysis as depicted in PRISMA flow chart [Figure 1].
The first study had been published in 1967. Forty studies (83.33%) had been conducted in the decade 2010 to 2018.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, The regional distribution of studies can be seen in [Figure 2]. Numerous studies (21)(43.75%) had been conducted in the southern states of India, with no studies reported in the northeastern region.
|Figure 2: Regional distribution of epidemiological studies done in India|
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Forty-seven studies were conducted in schools and in the age groups of 1 to 18 years. Only one study was performed in a community of mineworkers aged 20–60 years. Among the included studies, 58.33% had not specified the basis for calculation of sample size. Minimum sample size was 200 (Yadav et al., 2015), while the maximum was 15000 (Chandra and Chawla 1976). The sampling methods were not mentioned in 12 studies, while 20 (41.67%) had used convenience or simple random sampling methods. Other studies had used stratified random cluster sampling (4), two-stage cluster sampling (4) and multistage random sampling (8) methods. There was also a lack of uniformity in types of TDI classification methods, the most popular being Ellis's (n = 18) followed by Andreasen's (n = 9) and the WHO classification (n = 8). The details of pilot testing of the data recording forms had not been mentioned or done in 40 studies. The number of examiners was not mentioned in 13 studies. The intra- and inter-examiner validities had been checked in 18 (37.5%) studies [Table 1].
|Table 1: General characteristics of studies included in systematic review|
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Risk of bias assessment
The risk of bias as assessed by modified New Castle Ottawa Scale ranged from 6 to 8 in all the included studies which categorised them as having a moderate or high risk of bias [Table 1].
The prevalence of reported TDI ranged from 1% (Chandra and Chawla 1976; Sarkar and Basu 1981) to 76% (Bhayya and Shyagali 2013). The studies had a variable age range, with only 3 performed exclusively in the primary dentition (Shekhar and Mohan 2011;Bhayya and Shyagali 2013;Chalisserry et al. 2016) [Table 2]. The details of the 48 studies highlighted the most common region affected by TDI as the maxillary anterior (45, 93.75%), with the most common teeth being maxillary central incisors 11 and 21 (72.92%). The most common injury recorded in the studies was uncomplicated crown fracture (enamel and enamel-dentin), while the least common was luxation injury. These findings were common for both primary and permanent teeth. Twenty studies reported the presence and absence of TDI without specifying the type of injury [Table 1] and [Table 2].
|Table 2: Showing Age range, sample size and TDI reported in studies included for meta-analysis|
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The cause of TDI could be categorised as sports injuries, road traffic accidents, falls, collisions and violence, including falls on stairs, bicycle injuries, biting, injuries from hand pump handles, in 29 out of 48 studies. Few studies even mentioned the descriptions of sports injuries and falls. There were only 13 studies with complete information about the geographical place where the TDI occurred. The most common places mentioned were home, school, playground, street, park, road and school bus/rickshaw. The risk factors had been elucidated by 30 (62.5%) studies, and included profile, molar relation, overjet, lip coverage, socio-economic factors and weight/BMI. However, there was a lack of uniformity in the risk factors identified. Treatment needs were identified in 12 studies and ranged from 88.75 to 98% [Table 1].
The pooled prevalence of TDI was calculated from data extracted from the 48 studies [Figure 3]. Due to variability in the study methods, it was assumed that the observed estimates of prevalence would vary. Hence, a random effects model was used for performing meta-analysis. There was a high publication bias too for the studies included in meta-analysis, as explained by the Funnel plot and statistical evaluation using modified regression method. This reflected that the publication of the primary studies could have been influenced by the results. It was found to be less when a sub-group plotting was done for studies published in PubMed indexed journals [Figure 4]. The overall effect size or TDI prevalence for age groups (from 3 to 60 years, all genders) was 13% (95% CI: 11–14, I2 = 99.55%, P < 0.05) [Figure 3]. There were two outliers: Bhayya and Shyagali (2013) (76%) and Yadav et al. (2015) (50%). The sensitivity analysis was done by removing these outliers from the meta-analysis. However, the overall effect size remained unchanged. The pooled prevalence was also subjected to meta-regression for identifying the regional differences. The difference was not found to be statistically significant [Figure 5].
|Figure 4: (a) Publication bias among all the studies included for meta-analysis, (b) Publication bias among the studies published in PubMed indexed journals, (c) Publication bias among the studies published in Non PubMed indexed journals. Statistical analysis using modified regression revealed it to be statistically significant|
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|Figure 5: Meta-regression of effect size in terms of regions of included studies. It was found to be statistically significant (P < 0.05)|
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Sub-group analysis (age and gender)
A sub-group analysis was done based on data extracted for the age groups of ≤6 years and >6 years. Only the studies which presented the data in specified age ranges were included in sub-group analysis. Sub-group analysis of TDI prevalence in the age range ≤6 years was 15 per 100 population (95% CI: 4–26; I2 = 99.85%). The TDI prevalence in the group >6 years of age was 12 per 100 population (95% CI: 10–14; I2 = 99.5%) [Table 3].
Pooled prevalence in males was 13% (95% CI: 10%–17%; I2 = 99.37%). It was estimated to be 15% (95% CI: 0.00–29%; I2 = 99.82%) in the ≤6 years of age group and 13% (95% CI: 11%–15%; I2 = 98.24%) in the >6 years of age group. TDI pooled prevalence in females was 10% (95% CI: 8%–12%; I2 = 98.39%). It was estimated to be 16% (95% CI: 5%–26%; I2 = 99.40%) in the ≤6 years of age group and 8% (95% CI: 7%–10%; I2 = 97.60%) in the >6 years of age group [Table 3].
Causes of trauma
Only 29 studies could provide data for performing the meta-analysis for causes of trauma. There was variability in methods for recording the causative factors. To estimate the pooled effect of the causative factors, they were grouped under categories of sports injuries, road traffic accidents, falls, collision, violence, 'others' and 'can't recollect'. The highest effect size was seen in falls (43%), followed by sports (26%), collision (12%), road traffic accidents (8%), violence (7%) and 'others'(7%). The estimated effect size for 'can't recollect' was 15%. The overall heterogeneity, I2, reported was 98% [Table 4].
|Table 4: Effect size, 95% confidence intervals, weights and heterogeneity of the causative factors reported in different studies P <0.005|
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Geographical location of trauma
There were 13 studies which could be included in this analysis. The geographical locations where trauma occurred were grouped as school, home, outside and 'others'. The most common was estimated to be home (43%), followed by outside (25%), 'others' (24%) and school (20%). The overall heterogeneity, I2, reported was 98.4% [Table 5].
|Table 5: Effect size, 95% confidence intervals, weights and heterogeneity of the location of TDI reported in different studies P <0.005|
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Inadequate lip coverage
Seventeen studies were included in the analysis of the effect of inadequate lip coverage. The pooled data interpreted that the individuals with inadequate lip coverage have 3.35 times higher odds than the individuals with adequate lip coverage to experience TDI (95% CI: 2.6–4.32; I2 = 89%) [Figure 6]a.
|Figure 6: (a) Forest Plot showing pooled odds ratio analysis for effect of lip coverage on prevalence of TDI, (b) Pooled odds ratio for effect of overjet on prevalence of TDI|
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Thirteen studies had adequate data to be included in calculations of the odds ratio for effect of overjet on TDI, grouped as ≤3 mm and >3 mm for analysis. The pooled data interpreted that the individuals with overjet >3 mm have 3.53 times higher odds than the individuals with overjet ≤3 mm to experience TDI (95% CI: 2.32–5.36; I2 = 96.1%) [Figure 6]b.
| Discussion|| |
Epidemiological data for any disease serves multiple purposes, the most pertinent being for the identification of the problem, severity, risk factors, burden and treatment needs. These aspects help in the formulation of effective preventive strategies and planning interventions specific to a region. These features are also the basis of health policies at state, national and international levels. TDI have largely been an ignored segment of non-communicable oral diseases. Their prevalence in India has been based upon sporadic data from studies done at the regional level, without pan-India surveys or a national registry. This systematic review and its meta-analysis were aimed to address these major gaps in the scientific literature.
This systematic review was planned according to PRISMA guidelines, and efforts were made to include a comprehensive literature search strategy, conducted by a review team with defined roles and followed by sound statistical analysis. Broad literature search strategy and a combination of short searches, without any barriers as to language and year of publication, have been found to yield adequate literature, and this process was followed in this review. However, all the literature was published in the English language. The studies performed in clinical settings and/or among special groups like athletes, visually impaired and special-needs children, etc., were excluded, as they might influence the prevalence and risk factors being explored. This was in accordance with the systematic review reported by Aldrigui et al.
The 48 studies included in this review spanned over 51 years and various geographical regions within India.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, The present systematic review specified the regions of India such as East and North East which lacked any data for TDI and its risk factors. The studies also showed high degrees of variability, as expected a priori, in terms of design, methods, outcome variables and statistical tools, further resulting in a high level of heterogeneity in the assessment of pooled prevalence and other meta-analytic variables. The studies showed a high level of publication bias; however, better results were shown in studies from PubMed indexed journals. This can be attributed to strict peer-review process in these journals that ensures published studies follow standard guidelines and protocols. This systematic review was also aimed to highlight the methodological variability and shortcomings among the included studies. It is highly recommended that future epidemiologic studies in dental traumatology in India should follow the STROBE guidelines, with standardised criteria for the identification of injuries and evaluation of the associated factors.
This endeavour will pave the way for reduced heterogeneity in data and create a road map for a pan-India register for TDI. These problems have also been specified by Lam in identifying the challenges in trauma research. Andersson and Andreasen have also highlighted the critical elements in planning epidemiological and clinical studies in dental traumatology.
The TDI prevalence reported among various age groups ranged from 1% to 76%, with maxillary anterior being the most common region, maxillary central incisors the most common teeth and uncomplicated crown fracture (enamel and enamel-dentin) the most common type of injury. This was similar to the findings of Petti et al., Glendor, Lam, and Azumi-Aghdash et al. Systematic reviews for epidemiological studies usually require a random-effects model for meta-analysis., The overall effect size or TDI prevalence presented a combined data of primary and permanent teeth. It reflected that in 100 individuals of 3- to 60-year-old individuals of any gender, 13 individuals had TDI. The regional variation in the effect size was evaluated using meta-regression. However, there was no statistical difference observed. For the ≤6-year-old age group, the pooled prevalence of TDI was 15%, while it was 12% for age groups >6 years. The prevalence of TDI in ≤6-year-old children reflected the injuries of primary dentition while those in >6 years age group comprised the trauma to permanent anterior teeth. These ranges were similar to the global trends reported by Petti et al. and the regional TDI prevalence reported for Latin American and Caribbean nations.
The meta-analysis also exhibited a difference in pooled prevalence for males and females in age groups >6 years old. Males had a pooled prevalence of TDI of 13%, while females had 8%. This reflected that in a population of 100 males, there was a probability of TDI in 13 individuals and similarly for 100 females, there would be 8 having TDI. This was not seen in age groups ≤6 years, which showed 15% in males and 16% in females. The literature of dental traumatology emphasizes two peaks in the incidence of TDI in males at 2–3 and 11–12 years while only one in females at 2–3 years. The present review also found a similar pattern which was in accordance with the findings of Glendor and Lam. However, the high level of heterogeneity as explained by I2 >99.5% in overall pooled prevalence and sub-group was a cause of concern which should be addressed in future studies.
The effect size of the causes of TDI in this meta-analysis revealed falls as the most prevalent, with sports injuries as second. Lam reported falls as the most common cause of TDI in primary dentition and sports injuries as the major cause in permanent dentition. The most common place for trauma to occur was found to be home, while schools were the third most common. This can also be attributed to variability in the methods of recording this factor and the reliability of information provided by the children. This was similar to the findings of Lam, who reported home as the most common location for TDI to occur.
Inadequate lip coverage, the proclination of teeth and convex profiles have been regarded as the primary risk factors for TDI.,, The present meta-analysis calculated the odds ratio for inadequate lip coverage and overjet >3 mm and evaluated the pooled odds ratio. The pooled data interpreted that the individuals with inadequate lip coverage have 3.35 times higher odds than the individuals with adequate lip coverage to experience TDI. The pooled data interpreted that the individuals with overjet >3 mm have 3.53 times higher odds than the individuals with overjet ≤3 mm to experience TDI. Corrêa-Faria andPetti assessed the association of lip coverage with TDI by pooled odds ratio, which was reported as 1.81 in their systematic review. These associations have also been highlighted by Petti et al., Glendor and Lam.
The present systematic review is the first attempt to evaluate epidemiological studies related to TDI in India and perform meta-analysis of the reported data. The major limitation of this review is the high degree of variability in primary studies. This was further compounded by the heterogeneity in the data as reflected in the meta-analysis. The reviewers attempted to reduce the methodological errors while performing the systematic review; however, the data of pooled prevalence and odds ratio must be viewed with consideration of these limitations.
It is, hence, recommended that the problems identified in primary studies included in this review must be addressed in future epidemiological studies so that they have low risk of bias and future meta-analysis can elucidate a value of pooled prevalence with less heterogeneity.
| Conclusions|| |
- The pooled prevalence of TDI for age groups and genders in India was estimated as 13%
- The pooled prevalence of TDI in children less than 6 years of age was found to be slightly higher than their older counterparts
- Inadequate lip coverage and increased overjet are the risk factors associated with TDI
- Heterogeneity was observed among the studies in terms of design, variables recorded, sampling, study methods and statistical methods. Majority of them also suffered from moderate-to-high risk of bias
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Vijay Prakash Mathur
Division of Pedodontics & Preventive Dentistry, 6th Floor, Centre for Dental Education & Research, All India Institute of Medical Sciences, New Delhi - 110029
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]