Traumatic dental injuries in permanent teeth among Arab children: prevalence, and associated risk factors—a systematic review and meta-analysis

Introduction

Children are highly susceptible to traumatic dental injury (TDI), which is well-recognized as a serious problem in public health (Azami-Aghdash et al., 2015; Tello et al., 2016). Injuries to permanent teeth are a common cause of pain and discomfort in the craniofacial area (Andreasen, Andreasen & Andersson, 2018). Traumatic dental injuries can occur to anyone at any time, with an incidence that ranges from 4% to 58% (Abdel Malak et al., 2021). To pinpoint the likely risk factors linked to TDI, numerous research have been carried out. Being of male gender (Dharmani, Pathak & Sidhu, 2019; Ogordi, Ize-Iyamu & Adeniyi, 2019; Ain et al., 2016), an overjet of more than 5 mm at the incisors, inadequate lip coverage (Garg et al., 2017; Al Suwyed et al., 2021), low socioeconomic status, and the presence of severe dental injuries (Lisboa et al., 2013) have all been determined to be significant risk factors. The results indicated that compared to children whose TDIs were successfully treated, those whose TDIs were left untreated were 20 times more likely to report that their condition negatively affected their QoL (Lopez et al., 2019). Children who suffer from TDIs may need hospitalization, and some of these injuries might have lasting effects on their growth and development (Albedewi et al., 2021). Children and adolescents make up about 17.7% of the population in the UAE (Puri-Mirza, 2020). Due to the fact that these injuries are most common in adolescence, these injuries among teenagers are particularly concerning (Petti, Glendor & Andersson, 2018). In Arab countries, there is a lack of data on the prevalence of dental injuries among children. The development of strategies to mitigate the deleterious effects of oral trauma might benefit from a better understanding of some of the characteristics associated with these injuries.

Data from the primary studies show substantial variation and heterogeneity (Oldin et al., 2016; Magno et al., 2020; Abdel Malak et al., 2021). Unfortunately, there is a lack of hard data about long-term tendencies and other crucial criteria, such as socioeconomic status and obesity, for TDI Arab countries. These significant gaps hinder careful planning, improved judgment, and effective intervention design, all of which are necessary for the creation of a successful intervention for the treatment and prevention of TDI.

This study aimed to generate a reliable pooled estimate by conducting a comprehensive review and meta-analysis of the existing literature to assess long-term trends, the prevalence of TDI in permanent dentition, and the detectable correlations between important risk variables in Arab children and adolescents.

A systematic review and meta-analysis of dental trauma in the Arab population may reveal gaps in the literature such as:

Research is limited: It is probable that there is a lack of original studies on oral trauma in the Arab population in the published literature. Lack of knowledge, limited funding, or cultural factors affecting research priorities might all be to blame.

Heterogeneity of methodology: It may be difficult to compare and combine the results of the existing research because they may have used different methodologies, diagnostic standards, and sampling procedures. The validity and dependability of the meta-analysis may be impacted by this heterogeneity.

Geographic representation: The occurrence of dental trauma may range between various Arab nations or regions. The generalizability of the results to the entire Arab population may be constrained by the studies’ insufficient representation of certain Arab countries or areas.

Language bias: Studies published only in certain languages, such as English, may be included, leaving out pertinent studies published in other languages. The review’s thoroughness and representativeness may suffer as a result of this prejudice.

Disparities by gender and age: Dental trauma may occur at a different rate across different age groups and sexes. If the existing research does not adequately represent the diverse age ranges and gender distribution within the Arab population, prevalence figures may be erroneous and distorted.

Lack of standardized reporting: In the known research, there are no standardized reporting processes or guidelines, which could result in inaccurate or inconsistent data reporting. As a result, it may be difficult to accurately collect and synthesize data throughout the systematic review process.

A thorough and methodical strategy is needed to fill in these research gaps. To find a wider variety of research, it entails undertaking a thorough literature search across numerous databases, including both English and non-English sources. Additionally, efforts can be made to persuade researchers to adopt the standardized methodology and reporting practices and to perform studies that especially target oral trauma in the Arab community.

The prevalence of oral trauma in the Arab population can be better understood by solving these research gaps, which can also help to inform clinical practice, guide policy decisions, and identify areas that require further research.

Methods

Protocol and registration: The PRISMA criteria for reporting systematic reviews served as the foundation for this reporting. Before the review began, the review protocol was registered with PROSPERO (ID number CRD42023421734). This study is a systematic review and meta-analysis of previously published data and did not require ethical approval, as no human subjects were used in the preparation of this manuscript.

Strategy

Population: Adolescent [MeSH] OR OR Teen[Text Word] OR Young teen[Text Word] OR Child [Text Word] Population or Schoolchildren [Text] OR Children [Text] Children [Text] OR Children [Text] OR Children [Text] OR Youth [Text].

Exposure: (((trauma“[Subheading] OR (((injuries”[All Fields] OR (((wounds and injuries“[MeSH Terms] OR (((tooth fractures”[MeSH Terms] OR ((tooth“[All Fields] AND” fractures “[All Fields] OR ((tooth”[All Fields] AND “dental fracture”[All Fields])) AND ((dentition, permanent“[MeSH Terms] OR (permanent”[All Fields] AND “dentition”[All Fields] OR (permanent“[All Fields] AND” teeth “[All Fields] OR (permanent”[All Fields] AND “teeth”)).

Outcome: “epidemiology” [Subtitle] EITHER “epidemiology” [Everything Inside the field] OR “prevalence”[MeSH Terms] OR “prevalence” [Everything Inside the field].

Study designs include prospective, cross-sectional, and observational studies. The search terms: #1 AND #2 AND #3 AND #4

Database search: Electronic databases such as MEDLINE, DOAJ, Cochrane, PubMeD Central.

Grey Literature: SIGLE (opengrey.eu) and greylit.org.

Internet search engines: PubMed and Google Scholar.

Results

Description of studies

After conducting the initial electronic database search on DOAJ and PubMed/MEDLINE, a total of 652 relevant titles related to the study issue were identified. There were 358 articles that were identified as duplicates. Following the abstract screening, 294 pertinent titles were chosen by two independent reviewers, and 230 were discarded since they had no bearing on the subject. The reviewers looked over and discussed 64 articles before choosing them for full-text analysis. Manual searches of the selected studies’ reference lists turned up no further articles. Twenty-three studies were included in the data extraction and statistical analysis for the qualitative synthesis (Fig. 1).

Meta-analysis

Prevalence of dental trauma

Twenty-two studies found that dental trauma was common. The frequency of dental trauma in Arab children was calculated to be 26%, with a 95% confidence interval of 10% to 43%. Results were pooled using a random effects model due to high levels of heterogeneity (I² = 99.9%) and significance level (p < 0.05) as presented in Fig. 2.

Damage to the teeth and overjet

In ten experiments, researchers looked at how oral trauma affected overjet. Children with overjet more than 3.5 mm were shown to be 1.78 times more likely to have dental injury than children with normal overjet (pooled odds ratio 1.78; 95% confidence range [1.17–2.70]). The data was 93% heterogeneous and significantly different from one another (p < 0.05), hence a random effects model was used (Fig. 3).

Lip coverage and dental trauma

Eight studies looked at the link between lip protection and tooth damage. Children with inadequate lip covering had an odds ratio of 2.57 times more likely to have oral trauma than children with adequate lip coverage (95% CI [1.82–3.62]). That was considerable (p < 0.05) variability in the data (84%), necessitating the employment of a random effects model (Fig. 4).

Oral injury and gender

Fifteen studies looked at how different sexes were affected by oral trauma. The combined odds ratio found was 2.06 (95% confidence interval [CI][1.72 to 2.47]), meaning that boys used to have a 2.06-fold greater risk of dental trauma than girls. There was high heterogeneity in the data (76%), hence a random effects model was used to analyse the data (p < 0.05) as presented in Fig. 5.

Dental injuries and academic level

There were three studies in total. The pooled odds ratio found was 4.17 (95% CI [0.54–32.43]), meaning that public school students had 4.17 times the odds of dental trauma as compared to private school students. The results were 99% heterogeneous and significant enough to justify a random effects model (p < 0.05) presented in Fig. 6.

Dental pain and a residential setting

There were three research that analysed how living situation is related to dental injury. Children in rural regions had a combined odds ratio of 0.82 (95% CI [0.24–0.63]), indicating an 8.82-fold reduced incidence of dental trauma compared to children in urban areas. There was high heterogeneity in the data (87%), thus a quantitative technique was used and the findings were considerable (p < 0.05) (Fig. 7).

Tooth damage and BMI

Three studies analysed the correlation between oral trauma and body mass index. Children who were overweight were less likely to have dental damage than children who were not overweight, as shown by a combined odds ratio of 0.71 (95% CI [0.28–1.84]). These results are statistically significant (p < 0.05), and the 83% heterogeneity necessitated the employment of a random effects model (Fig. 8).

Publication bias

Each included study is represented by the dot. The Y-axis represents standard error representing study precision where as X-axis shows the estimated effect size, in this case proportions. As shown in Fig. 9, the present funnel plot is asymmetrical. Majority of the studies are seen outside the funnel indicating publication bias. There are less than 95% studies present inside the diagonal dotted 95% confidence interval line.

Discussion

Care should be taken when comparing the prevalence levels of TDI because different researchers have used different sample procedures, dentition types, and diagnostic standards. The current study focused on 12-year-old children to allow comparison with other studies from throughout the world that have been published. This research has several restrictions. For instance, only injuries linked to the teeth were reported because soft tissue injuries during the clinical examination could not be noted. Furthermore, as the study’s results were self-reported, it’s possible that the causes of TDIs were not correctly reflected. Injury episodes are not purely arbitrary; they frequently have predictable causes. Boys were more likely than girls to sustain traumatic dental injuries, which is in line with other researchers’ findings (Al-Bajjali & Rajab, 2014; Telford et al., 2016). Due to their higher degree of behaviour maturity than males, who tend to engage in risk-taking behaviours, girls exhibit a lower occurrence of tooth trauma, which may help to explain why. The control that traditional families exercise over the girls’ behaviour as a result of Arabs’ cultural and religious attitudes is another possible explanation for the low prevalence of TDIs among girls in Arab countries (Hashim, Williams & Murray Thomson, 2009). Few studies on dental trauma take into account socioeconomic considerations. According to the results of Borges and co-workers (Borges et al., 2017), only the mothers’ education levels in this study showed a significant correlation with the occurrence of severe dental injuries. The association between socioeconomic position and the likelihood of experiencing trauma is not well understood in the literature, and the research that has looked into it has come to different conclusions (Oldin et al., 2016; Magno et al., 2020). The fact that the earlier research was carried out in several nations with diverse socioeconomic status patterns may be partly to blame for these contradictory results. To better understand these linkages, more study is required. Increased incisor overjet was found to be a significant predisposing factor for traumatic dental damage, according to the current study’s findings, which are in line with those of recently published systematic reviews (Tewari et al., 2020).

Arraj, Rossi-Fedele & Doğramacı (2019) observed that there was an association between overjet and dental trauma through a meta-analysis, They reported an odds of 3.37 in children 0–6 years of age with an overjet of 3 mm or greater. Children in mixed and secondary dentition with an overjet over 5 mm had an odds ratio of 2.43.

Inadequate lip coverage among schoolchildren greatly increased their chances of developing TDI, proving that it is a risk factor for TDI (Abdel Malak et al., 2021). This study demonstrates unequivocally that collisions and falls were the primary causes of traumatic oral injury. These results concur with those of earlier articles (Dharmani, Pathak & Sidhu, 2019; Al-Jundi, 2002). It is crucial to keep in mind that an “accident” could result in a tiny act of violence. Collisions can also happen during play or a sporting event; in any instance, they might be categorized as falls or sports injuries. Establishing a precise international standard for recording the aetiology of dental injuries is essential for enabling accurate comparisons between countries. In developing solutions to safeguard oral health, it should always be taken into account that the conduct of the children may be directly tied to the appearance of the TDIs. A TDI is frequently connected with behavioural risk factors including violent attitudes (Adekoya-Sofowora et al., 2009). These were the primary activities that took place at home and at school where the majority of the traumatic dental injuries occurred; sports like swimming, football, or running were the main activities that were directly linked to the collisions and falls that resulted in the majority of the children’s traumatic dental injuries. Other researchers (Damé-Teixeira et al., 2013) reported experiencing similar outcomes. As a result, social education at home and in schools should receive special attention. Less traumatic dental injuries will occur in schools when there is a supportive social and physical environment (Eltair et al., 2020). Activities aimed at prevention should be directed toward students. Our findings indicate that it is critical to take into account the methods for lowering the incidence of severe oral injuries. Mouth guard use should be advocated among kids who play contact sports. In order to reduce the likelihood of falls resulting in serious dental injuries in children, it is also imperative that they be closely watched during physical activity. Raising public awareness is necessary for controlling and reducing the prevalence of TDIs in children in the Arab region; this can be accomplished by implementing national and local activities. The majority of TDIs in the included sample simply produced enamel damage and did not need to be repaired. For dental specialists, restoring a tooth that has been damaged is a daily task (Dharmani, Pathak & Sidhu, 2019). Paediatric restorative dentistry requires a lot of time since children have variable levels of compliance and are frequently distracted. Despite the recent introduction of new “bioactive” materials that address these issues, it’s critical to remember that the success of the restorative treatment should not be connected only to the type of material that is chosen, but also to the modification in the child’s and the family’s lifestyle (Lardani et al., 2022). However, almost one-third of TDIs caused dentine injury, and 3% of them had an impact on the enamel, dentine, and pulp, in agreement with Firmino et al. (2014) and de Paiva et al. (2015). This demonstrated the substantial unmet need for dental care. Therefore, in order to promote observable improvements in oral health and to reduce the number of inequalities, in addition to preventive efforts that emphasize the causes of oral problems, appropriate post-traumatic dental therapy should be taken into account. Strategies that attempt to enhance the school setting and raise public awareness, particularly of educators who participate in athletic activities, may help to decrease the frequency of TDIs. Understanding the aetiology of traumatic injuries and their early prevention may lead to a decrease in the incidence of traumatic injuries. For example, early diagnosis and appropriate treatments undertaken by Clinicians may assist in limiting traumatic dental injuries. Raising awareness among public health authorities regarding the substantial influence of TDI management on the broader population is crucial; however, disease prevention—specifically through interceptive orthodontic treatment, the promotion of mouthguard usage, or a combination of both—primarily within the primary dental care context, could serve as a foundational strategy for diminishing TDI incidence within a framework of optimized resources aimed at addressing disparities in oral health status and inequities in access to oral health care (Abbott, 2018).

Traumatic oral injuries may have a significant impact on a child’s quality of life; thus, they should not be disregarded (Freire-Maia et al., 2015; Gherunpong, Tsakos & Sheiham, 2004). Further study is needed to examine the social and personal factors that enhance the TDI risk in order to create and implement a successful preventative strategy to decrease the impact of TDIs in the future.

Conclusion

Significant correlations between TDI and the male gender, increased overjet, and inadequate lip coverage were discovered. A qualitative synthesis also showed a positive correlation between TDI and sociodemographic elements like poor socioeconomic position and rural population, as well as environmental elements like TDI source and location. The data could not be combined in a way that satisfied the requirements for a meta-analysis, though. The prevalence of TDI in children and adolescents in the Arab region appears to be rising over time. Future population-based analytical research should concentrate on documenting the incidence and/or prevalence of TDI among marginalised communities in order to better understand the primary causes of TDI.

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