Prevalence, Etiology, and Risk Factors of Traumatic Dental Injuries in Children with Special Needs of Puducherry

DISCUSSION

The Union Territory of Puducherry is situated in the southeast Asian location, the 29th most populous state and the third most densely populated Union Territory of India. The present study is the first data on the prevalence of TDI in children and adolescents with SHCN in Puducherry. The present research revealed a 40.5% prevalence of dental trauma in children with special healthcare needs. which falls within the range of worldwide prevalence (4.13–68.2%- according to a recent meta-analysis 2020¹¹ of TDI in children with Special care needs. The findings of the present study identified a similar prevalence (45.2%) in Brazil as reported by Franca et al.⁶ In India only, three prevalence studies among special needs children were documented in the literature, that is, in the cities of Dharwad (28.6%),⁴ Indore (18.7%),⁷ and Bangalore (12.1%)¹² thereby the prevalence of TDI in India ranges between 12 and 40.5%.

Of the 49 children with special needs who presented trauma, 41% were men and 39% were women. There was no significant gender difference that could be attributed to the disability, implying that disabled children of both genders have similar lifestyles. Apart from that, a small amount of difference in females may be attributed to the cultural variation of the Indian scenario which may have played the role of lower prevalence of trauma. Though there was no statistically significant difference (p-value = 0.605) in TDI prevalence according to age, the prevalence percentage increased with age. Special needs children have delayed milestones of development and hence restricted movement, due to which walking is delayed which might be one reason for the lower prevalence of trauma in small children. Physical activities increase as they grow older or engage in leisure activities which might have increased the probability of trauma in the older age group of children.

The present study findings have shown that children with ADHD had a higher incidence of TDI followed by children with Down’s syndrome and Autism. Though the findings were not statistically significant (p = 0.915), a recent meta-analysis by Alnmes S et al.,¹¹in 2020 stated that patients with ADHD are more likely to experience dental trauma. The fact that children with ADHD sustained more dental trauma in the present study could be because of the hyperactive nature of the ADHD condition which caused falls. The study by AlSarheed et al.,¹³ have investigated the prevalence of trauma, malocclusion, and dental caries among children with Downs syndrome and found a higher incidence of trauma among them. In the present study, the second-highest prevalence of TDI was seen in Down’s syndrome, which could be because these children had a higher predisposition to malocclusion, macroglossia, and an accident-prone profile which could have caused trauma. In the present study, TDI in children with Autism could be due to cognitive impairment. The study done by Al-Sehaibany FS et al.,¹⁴ had evaluated the prevalence of trauma in children with Autism and found it to be 25.7%. On the contrary, the studies done by Nayak et al.,⁴ Murthy et al.,¹² have observed a higher incidence of trauma in children with mental retardation. The prevalence of TDI in permanent maxillary central incisors was statistically high as reported in the literature.^3,4,7,15–¹⁷ The studies conducted by Avsar et al.,¹⁶ Murthy et al.,¹² AlSarheed et al.,¹³ Al-Batayneh et al.,¹⁸ and Franca et al.⁶ showed a higher prevalence of uncomplicated crown fractures. The present study also showed a higher extent of enamel fracture among traumatic dental injuries. In accordance with the previous study, by Al-Batayneh et al.¹⁸ who observed that the treatment-seeking behavior was less among special needs children. The present study also found that there is a lesser percentage of children who had undergone treatment for the traumatized teeth due to unawareness. The present results showed that fall injury due to slipping and tripping over a staircase was the most common cause followed by the collision with an object, which was due to the lack of motor coordination and self-injury. Similar results were found in studies conducted by Kumar and Dixit et al.,⁷ Nayak et al.,⁴ Bagattoni S et al.,³ and Ferreira et al.⁵ In the present study, the traumatic episodes which had commonly occurred at home and school were entitled to the sudden activity of the children when they were left unsupervised. Similar findings were observed by Nayak et al.,⁴ Al- Batayneh et al.,¹⁸ and dos Santos et al.¹⁹

An important finding in this study was that nearly 98% of the patients were examined by a dental surgeon for the first time. Concerning dental treatment for people with special needs, a questionnaire was used to elicit information about the possible reasons for not seeking dental care. The various reasons which were given for not taking treatment were unawareness/negligence regarding the importance of dental treatment of the traumatized tooth, fear of uncooperation from their child, and lack of time/transport. Additionally, communication with the special needs population is a challenge and an impediment to dental care. Hence social workers should play a major role in helping these parents or caregivers to seek treatment.

In the present study, risk factors such as facial form, facial profile, facial divergence, lip competence, lip coverage, molar relationship, overjet, overbite, presence of diastema, and open bite were examined for all children, and all these factors are related to traumatic dental injuries. Thus, there is a positive correlation in the presence of convex facial profile and it was shown that children with Angle’s Class II molar relationship had a positive association with traumatic dental injury due to the fact of proclined incisors. Anterior open bite could be a possible risk factor but in the present study, no significant correlation with TDI was found. It was assessed that the amount of lip coverage and incompetent lips is a risk factor since the lip is an important soft tissue characteristic and it is crucial in the prevention of traumatic dental injury. When compared to those with normal overjet, those with increased overjet and inadequate lip coverage had a high incidence of TDIs. Similar results were discovered in prior studies by Kumar and Dixit et al.,⁷ Nayak et al.,⁴ Shyama et al.,¹⁵ Altun et al.,¹⁷ Al- Batayneh et al.,¹⁸ and Munot et al.²⁰ On the contrary, no significant positive correlation was found with overjet and trauma in the study conducted by Holan G et al.²¹

The present study’s findings would contribute to the literature on the prevalence of TDI in the special needs population in the Union Territory of Puducherry in the Southern part of India. This study could create awareness about dental traumatic injuries and help in preventive and therapeutic treatment needs for those affected children. Effective policies for injury prevention, treatment, and malocclusion correction must be developed in these children to prevent TDIs. Policies regarding Health Education on TDI, its management, and prevention programs should be fundamental by the government. Social workers, medical practitioners, healthcare workers, caregivers should be trained on identification, diagnosis, and timely referral to a dentist. Regular motivational programs with preventive professional care should be made mandatory. Disable - friendly environment with insufficient accessibility is lacking in India which is a must and thus could reduce the incidence of trauma in these individuals. The importance of incorporating oral health care into these everyday living must be emphasized.