Income inequality and traumatic dental injuries in 12-year-old children: A multilevel analysis

Structural analysis of socioeconomic factors and school jet lag in traumatic dental injury among children

The objective of this study was to analyze the directions by which school jet lag is associated with traumatic dental injury in children, evaluating direct and indirect effects of socioeconomic factors and sleep. A representative, population-based, cross-sectional study was conducted with 739 schoolchildren eight to ten years of age. Parents/guardians answered a sociodemographic questionnaire, the Sleep Disturbance Scale for Children and the Circadian Energy Scale. Four examiners underwent training and calibration exercises for the diagnosis of traumatic dental injury (K > 0.80) using the criteria proposed by Andreasen (2007). Descriptive analysis was followed by structural equation modeling to determine direct and indirect associations between the variables incorporated into the theoretical model. School jet lag [standardized coefficient (SC): -0.238, 95%CI: -0.390-0.087], income (SC: -0.151, 95%CI: 0.0010-0.292), and number of residents in the home (SC: -0.109, 95%CI: -0.212-0.007) were directly associated with traumatic dental injury, whereas sleep disturbances and schooling of the parents/guardians exerted an indirect effect. Sociodemographic factors and school jet lag were associated with traumatic dental injury in children eight to ten years of age.

Incidence of traumatic dental injuries associated with orotracheal intubation in general anesthesia in children during mixed dentition in Damascus, Syria: a prospective longitudinal study

OBJECTIVES

Endotracheal tube intubation by laryngoscope during general anesthesia is a safe procedure with a few complications. However, it may cause some damage to the oral cavity structures, which leads to postoperative pain and discomfort. Traumatic dental injuries associated with endotracheal tube intubation are one of the most common complications. The study aimed to determine the incidence of traumatic dental injuries during oral-endotracheal tube intubation in general anesthesia among children receiving surgery at the Children's Hospital in Damascus City during 2022-2023.

METHODS

It was a prospective longitudinal study which investigated the incidence of traumatic dental injuries during oral-endotracheal tube intubation under general anesthesia in 110 children aged 6-12 years old at the University Children's Hospital in Damascus City in 2022. After ensuring that the child met inclusion criteria and obtained written consent. Each child was examined before, during, and after 12-24 h of entering the operation room. Personal information (gender - age), information related to anesthesia procedures, and some oral cavity characters were collected.

RESULTS

The incidence of traumatic dental injuries during general anesthesia was 9.1%. Most of them intra-oral soft tissue injuries. The concussion is the most common injury related to teeth damage. In addition, the tongue was the most common-place. There is a correlation between the incidence of traumatic dental injuries and the difficulty of intubation, the number of intubation attempts, Mallampati score (p < 0.05).

CONCLUSION

The anesthesiologist should evaluate the condition of each patient carefully. Document every detail in their record and inform the patient of the possibility of dental damage during the procedures especially in the case that has difficulty intubation.

Contextual and individual factors associated with traumatic dental injuries in deprived 12-year-old schoolchildren: A cohort study

AIM

Traumatic dental injuries (TDIs) among children and adolescents have been acknowledged as of public health concern worldwide. The aim of the study was to assess the relationship between contextual and individual characteristics and TDIs in 12-year-old schoolchildren.

MATERIALS AND METHODS

A cohort study was conducted with 355 schoolchildren living in deprived communities in the city of Manaus, Brazil. Contextual factors (place of residence and socio-economic indicators) and individual characteristics, including sex, family income, parents/guardians years of schooling, overjet and open bite (Dental Aesthetic Index), self-esteem (Rosenberg Self-Esteem Scale), sense of coherence (Sense of Coherence Scale), oral health beliefs, social support (Social Support Appraisals) were assessed at baseline. TDIs were measured at baseline and at 2-year follow-up using the O'Brien Index. Data were analysed through confirmatory factor analysis and structural equation modeling.

RESULTS

The baseline prevalence of TDIs was 17.6% and the incidence of TDIs at 2-year follow-up was 26.8%. Better psychosocial status had a direct protective effect on the incidence of TDIs (β = -.184). Better contextual characteristics (β = -.135) and greater overjet (β = -.203) were directly associated with poor psychosocial status. Higher schooling of parents/guardians directly predicted better psychosocial status (β = .154). Psychosocial status mediated the relationship of greater overjet (β = .036), contextual factors (β = .024) and parental/guardian schooling (β = -.027) with TDIs.

CONCLUSIONS

Contextual factors and individual characteristics predicted TDIs. Psychosocial status was a relevant individual attribute in the causal network of TDIs, due to the direct effect on the incidence of TDIs as well as a mediator on the influence of contextual factors, overjet and parents/guardians schooling on the incidence of TDIs.

The role of psychological status in the incidence of traumatic dental injuries in schoolchildren

DESIGN

Cohort study.

DATA ANALYSIS

Confirmatory Factor Analysis (CFA) and Structured Equation Modeling (SEM).

RESULTS

Psychosocial status emerged as the main predictor of traumatic dental injuries (TDIs). Better psychosocial status had a direct protective effect on the incidence of TDIs. The impact of increased overjet and lower parental schooling on TDIs was mediated through psychosocial status. Children residing in areas with poorer contextual socio-economic indicators faced a higher risk of experiencing new TDIs due to psychosocial factors.

CONCLUSIONS

Poor psychosocial status directly correlated to TDIs. Indirectly, psychosocial factors mediated the occurrence of TDIs through overjet, parental schooling and contextual residential area.

Association between socioeconomic status and traumatic dental injury in permanent teeth: A systematic review with meta-analysis

OBJECTIVE

The aim of this study was to systematically review observational studies assessing the association between socioeconomic status (SES) and traumatic dental injuries (TDI) in permanent dentition.

METHODS

Electronic searches were performed in PubMed, EMBASE, Web of Science, LILACS, CINAHL, COCHANE Library and ScoINDEX databases for articles published up to February 2023. Two independent reviewers performed the search and critical appraisal of the studies. The inclusion criteria were observational studies that evaluated the association between individual-level socioeconomic indicators and TDI (clinically examined) in permanent teeth. Quality assessment of included articles was conducted using the Newcastle-Ottawa Scale. Global meta-analysis was performed with all studies and different subgroup analysis based on socioeconomic indicators (household income, educational level or any other indicator), age (children, early adolescents, late adolescents or young adults) and economic classification of the country (high, upper-middle or lower-middle). A random-effects model was used to estimate pooled prevalence ratios (PR) and respective 95% confidence intervals (CI) for each study.

RESULTS

The search strategy retrieved 11 315 publications. According to eligibility criteria, 17 articles were included in the meta-analysis. Individuals with low SES were 17% more likely to have TDI (PR 1.17; 95% CI 1.05-1.30). The subgroup analysis also revealed that the indicator (household income, PR 1.16; 95% CI 1.00-1.34) and the economic classification of the country (upper-middle, PR 1.19; 95% CI 1.07-1.33) influenced the association of SES with TDI occurrence.

CONCLUSIONS

Individuals with lower SES were more likely to present with TDI in permanent dentition than those with higher SES.

The effect of sleep disorders, school jet lag, and anxiety in students 8-10 years of age on traumatic dental injuries

BACKGROUND/AIM

Traumatic dental injuries (TDI) constitute a public health problem. The aim of the present study was to investigate whether sleep disorders, school jet lag, and anxiety are associated with TDI in schoolchildren 8-10 years of age.

METHODS

An analytical, cross-sectional study was conducted with 739 pairs of parents/guardians and children enrolled in public and private schools. The parents/guardians answered a socioeconomic questionnaire, the Sleep Disturbance Scale for Children, Circadian Energy Scale, and Revised Children's Manifest Anxiety Scale. Four examiners underwent calibration exercises for the diagnosis of TDI (K > 0.80) using the criteria proposed by Andreasen (2007). A directed acyclic graph was used for the formulation of the theoretical model and statistical adjustments. Unadjusted and adjusted robust binary logistic regression analyses were performed (α = 5%).

RESULTS

The prevalence of TDI was 16.2%. The following variables remained associated with the outcome in the final model: family income less than or equal to the minimum monthly wage (OR = 1.77; 95% CI: 1.09-2.88; p = .02), child's height >137.6 cm (OR = 1.68; 95% CI: 1.06-2.64; p = .02), the occurrence of school jet lag (OR = 2.12; 95% CI: 1.27-3.53; p = .004), anxiety (OR = 1.77; 95% CI: 1.04-3.00; p = .04) and sleep disorders (OR = 1.63; 95% CI: 1.38-1.93; p = .05).

CONCLUSION

Children from families with a lower income, taller children, those with school jet lag, those with anxiety and those with sleep disorders had a greater occurrence of TDI.

Critical appraisal of confounding factors of observational studies on the association between dentofacial features and dental trauma in a Brazilian population

AIMS/OBJECTIVES

Dental trauma is a highly prevalent dental emergency. Children and adolescents without inadequate lip coverage, increased overjet, and anterior open bite are associated with the occurrence of traumatic dental injuries. Observational studies do not allow the inference of causality, one of the reasons being: the potential confounding factors. Therefore, this review aimed to critically appraise the confounding factors considered in epidemiological studies that associate dentofacial features with the occurrence of dental trauma in Brazilian children and adolescents.

METHODS

Studies included in the qualitative synthesis of a recently published comprehensive systematic review and meta-analysis on the topic were screened. Studies that only mentioned the performance of bivariate analyzes or that did not mention the performance of multivariate analyzes were excluded. Evaluation of control statements for possible confounders and bias consideration was performed for each selected study. Confounding factors in these studies were also identified and categorized according to their domains.

RESULTS

Fifty-five observational studies were screened, of which 11 were excluded due to the mention of only bivariate analyzes or the lack of multivariate analyses. The remaining 44 studies were critically appraised. Of these, 9 studies specifically mentioned the term confounding, and 12 studies mentioned the term bias. However, only 14 studies mentioned limitations on confounding factors in their findings. Among the 99 different variables identified, the most used were type of trauma, followed by sex and age.

CONCLUSION

Most studies did not acknowledge the control for possible confounding factors and rarely stressed the need for caution in interpreting their results. Cross-sectional studies do not allow inferring a cause-and-effect relationship between dentofacial features and dental trauma.

Unemployment and expenditure on health and education as mediators of the association between toothbrushing and global income inequalities

Objective

The study assessed the association of country-level income inequalities with the percentage of schoolchildren toothbrushing-at-least-twice-daily; and the mediating effect of country-level unemployment rate and governmental expenditure on health and education (EH&E).

Methods

This was an ecological study. The dependent variable was country-level toothbrushing-at-least-twice-daily among 11-15-year-old schoolchildren. Data for the period 2009 to 2019 were extracted from two global surveys about schoolchildren’s health and from manuscripts identified through a systematic search of three databases. The independent variable was country-level income inequalities measured by the Gini coefficient (GC) extracted from the Sustainable Development Report 2021. The mediators were the unemployment rate and EH&E. We stratified the sample by the level of GC and assessed the correlation between the dependent and independent variables in each stratum. Linear regression was used to assess the relations between the dependent and independent variables, and mediation path analysis was used to quantify the direct, indirect, and total effects.

Results

Data were available for 127 countries. The mean (SD) percentage of children who brushed-at-least-twice-daily was 67.3 (16.1), the mean (SD) GC = 41.4 (8.2), unemployment rate = 7.5 (4.7) and EH&E = 8.4 (3.3). The percentage of children brushing at-least-twice-daily had weak and non-significant correlation with GC that was positive in countries with the least inequality and negative for countries with higher levels of inequality. A greater percentage of schoolchildren brushing-at-least-twice-daily was significantly associated with higher GC (B = 0.76, 95%CI: 0.33, 1.18), greater EH&E (B = 1.67, 95%CI: 0.69, 2.64) and lower unemployment rate (B=-1.03, 95%CI: -1.71, -0.35). GC had a significant direct positive effect (B = 0.76, 95%CI: 0.33, 1.18), a significant indirect negative effect through unemployment and EH&E (B=-0.47, 95%CI: -0.79, -0.24) and a non-significant total positive effect (B = 0.29, 95%CI: -0.09, 0.67) on the percentage of schoolchildren brushing-at-least-twice-daily.

Conclusion

Unemployment and EH&E mediated the association between income inequality and toothbrushing. Country-level factors may indirectly impact toothbrushing.

The association of inadequate lip coverage and malocclusion with dental trauma in Brazilian children and adolescents - A systematic review and meta-analysis

BACKGROUND/AIM

Dental trauma (DT) occurs frequently in children and adolescents. Therefore, understanding the factors associated with its occurrence in these age groups is important to establish specific preventive measures. The aim of this study was to investigate the relationships of lip coverage, overjet, and open bite to dental trauma in Brazilian children and adolescents.

MATERIAL AND METHODS

The review protocol was registered in the PROSPERO database (CRD42020156290) and the bibliographic search was performed in nine electronic databases until July 2020. The studies included were observational, performed in Brazil, with healthy children and adolescents (0-19 years old), and without the restriction of date or language. Two reviewers assessed the individual risk of bias of the eligible studies with a standardized checklist. The meta-analyses were stratified by dentition stage and age range using fixed or random effects, odds ratio (OR) as the effect measure, and 95% confidence interval. The heterogeneity across studies was assessed with the I² test and the GRADE approach assessed the certainty of evidence.

RESULTS

The search presented 2493 initial results, from which 55 met the eligibility criteria and were included. Most studies (67%) presented a low risk of bias and were published between 2000 and 2019. Children and adolescents with inadequate lip coverage are 1.86-2.36 times more likely to suffer from DT, while those with increased overjet are 1.94-3.11 times more likely. Children with primary dentitions and anterior open bites are 1.76 (95% CI: 1.20-2.59) times more likely to suffer from DT. The certainty of evidence varied from very low to moderate.

CONCLUSIONS

Inadequate lip coverage, increased overjet, and anterior open bite are associated with the occurrence of dental trauma in Brazilian children and adolescents.

Spatial density of adolescents aged 14 years old, victims of dental: A longitudinal study

BACKGROUND/AIM

Knowledge about the spatial density of the domiciles of dental trauma victims can assist in the identification of the most vulnerable areas and contribute to the planning of prevention, promotion, control, and treatment actions, focusing on the most affected areas. The aim of this study was to analyze the spatial density of domiciles of 14-year-old adolescent victims of dental trauma, in the city of Diamantina, Brazil, after a two-year follow-up period.

MATERIAL AND METHODS

This longitudinal study was carried out with 584 adolescents between 2013 and 2015. Dental trauma, overjet, and lip protection were assessed by two trained and calibrated examiners (K > 0.70). Information about binge drinking was collected among the adolescents through the Alcohol Use Disorders Identification Test and sociodemographic indicators were obtained through a questionnaire answered by the caregivers of the adolescents. Spatial analyses were performed to evaluate the spatial density of adolescents with dental trauma and the independent variables of interest according to the domicile using Ripley's K function and the Kernel Map.

RESULTS

Ripley's K function revealed spatial aggregation of the domiciles of adolescent victims of dental trauma in relation to males, binge drinking and overjet, with a confidence interval of 95%. The higher density of domiciles with adolescents with two or more traumatized teeth was found in the north-east region of the city. Boys were the most affected, their homes were located in the north, north-west, and south-east regions at baseline and follow-up. The largest density of domiciles of adolescents with overjet greater than 5 mm and inadequate lip protection was in the north-east region. Similar spatial distribution was identified for binge drinking for both years.

CONCLUSION

The majority of adolescents with dental trauma lived in the north-east and south-east regions, characterized by high population density and greater social vulnerability.

Influence of school environment on occurrence of traumatic dental injuries in 12 years old children

BACKGROUND/AIM

Since children spend most of their time in school, some environmental characteristics of the schools may influence the occurrence of traumatic dental injuries (TDI). Therefore, the aim of this cross-sectional study was to assess the prevalence of TDI in 12 years old children in Quito, Ecuador, and its association with some school environmental aspects.

MATERIAL AND METHODS

Six calibrated examiners evaluated 998 children from 31 public schools of Quito, to evaluate the occurrence of TDI in anterior teeth. School coordinators answered questionnaires on school physical conditions, promotion of health practices and the occurrence of negative episodes in school. The occlusion and socioeconomic status of the participants were also evaluated. Prevalence of TDI, unadjusted and adjusted by the design effect was calculated. Association between individual and contextual explanatory variables and presence of TDI were evaluated using multilevel Poisson regression analysis (P < .05).

RESULTS

TDI prevalence adjusted by design effect was 20.7%. Children studying in schools with patio floor of grass and with access ramps had significantly lower prevalence of TDI than children studying in schools with patio floor of cement and with only stairs, respectively. The prevalence of TDI was also lower in children from schools that offered healthy meals or that had a proper place for oral hygiene.

CONCLUSIONS

Schools with adequate physical structures and that promote health practices to their students have a lower prevalence of TDI.

Dental caries experience and socio-economic status among Iranian children: a multilevel analysis

BACKGROUND

Socio-economic factors are considered as main determinants causing disparities in oral health across different countries. The aim of the present study was to investigate the associations of social and economic factors with dental caries experience among 6- and 12-year-old Iranian children.

METHODS

In this cross-sectional study, a total of 31,146 students, aged 6 and 12 years old, were enrolled from all (31) provinces in Iran. Based on the standardized World Health Organization (WHO) criteria for oral health surveys, dental caries indices in primary and permanent teeth were assessed by clinical examination in schools. Data on socio-economic status was obtained from the modified WHO questionnaire and national data bank. The decayed, missing and filled teeth (dmft/DMFT) indices for primary and permanent dentition were compared at the individual and provincial levels using multilevel regression analysis. Poisson regression analysis was used to evaluate the association of social (demographic and behavioral) determinants with dental caries indices among individuals. To assess the causes of difference in dental caries indices across provinces, justifiable economic factors were also analyzed using poisson regression analysis.

RESULTS

The mean (SE) of dmft and DMFT were 5.84 (0.05) and 1.84 (0.03), for 6-and 12-year-old children, respectively. The differences of dental caries indices were statistically significant among provinces. Higher level of parental education was negatively related to dental caries indices of both age groups. Rural residency was positively and dental flossing was reversely associated with dmft index of 6-year-old children. Negative associations were found between frequency of tooth brushing and preventive dental utilization with dmft and DMFT indices. Gross Domestic Product (GDP) index had negative and Consumer Price Index (CPI) had positive associations with dmft and DMFT indices in both age groups. However, positive relationships were observed between Gini index with DMFT index among 12-year-old children; as well as between the number of dentists per capita with dmft index among 6-year-old children.

CONCLUSION

Socio-demographic and behavioral factors were found to be associated with dental caries experience. However, economic indicators had the greatest importance.

Contextual income inequality and adolescents' oral-health-related quality of life: A multi-level analysis

OBJECTIVES

The aim of this study was to test the association of current contextual income inequality, contextual income inequality experienced during childhood, and individual factors with oral-health-related quality of life (OHRQoL) in adolescents.

METHODS

Individual data of 3,854 adolescents aged 15-19 years from the Brazilian Oral Health Survey (SB Brasil Project) nested within 27 cities and contextual income inequality were analysed. OHRQoL was assessed using the Oral Impacts on Daily Performance (OIDP) questionnaire. The individual variables were demographic characteristics, socio-economic factors, and oral clinical measures. The Gini Index was used to evaluate city-level income inequality in 2003 (during childhood) and in 2010 (current) according to the tertiles of distribution. Multi-level Poisson regression was used to test the association of contextual income inequality and individual characteristics with OIDP extent according to the WHO framework on social determinants of health.

RESULTS

The prevalence of OIDP was 34.5%. In the adjusted analysis, adolescents living in the cities with high-level income inequality during childhood were 1.75 times more likely (95% confidence interval 1.23-2.48) to have a higher mean of OIDP extent. Current income inequality was not associated with OIDP extent in adolescents.

CONCLUSIONS

Contextual income inequality during childhood was a structural determinant of OHRQoL among Brazilian adolescents after adjustment for individual demographic characteristics, socio-economic factors and oral clinical measures. Reducing social inequalities through inter-sectoral actions should be on the political agenda to improve adolescents' oral health.

Prevalence of traumatic crown injuries in German adolescents

OBJECTIVES

Although dental trauma and its unfavorable sequelae are considered major public health problems worldwide, the published data on the prevalence of traumatic crown injuries (TCIs) in Germany are lacking. Therefore, the present study assessed the prevalence of TCIs among adolescents in Bavaria, Germany.

MATERIAL AND METHODS

Ethical approval and parental consents were obtained, and population-based information from 10- (N = 1158), 12- (N = 416), and 15-year-olds (N = 1302) from two different cohort studies performed in Bavaria (GINIplus/LISA and LAGZ) were examined for the presence of TCIs, dental caries, and restorations. Statistical comparisons were made using Mann-Whitney U test and Wilcoxon signed-rank test.

RESULTS

The prevalence of TCIs was 6.3% in the 10- and 12-year-old children and 14.0% in 15-year-old children, and a higher prevalence was observed in boys than in girls. Most (87.5%) of the traumatized teeth were maxillary incisors. The caries prevalence was low in all three populations.

CONCLUSION

The prevalence of TCIs in Bavarian adolescents at a low risk for caries was found to be low.

CLINICAL RELEVANCE

Dental trauma is a prevalent event in children and adolescents, and incisors are the most affected teeth. Therefore, dental practitioners should be able to manage the spectrum of traumatic injuries.

The impact of crown fracture in the permanent dentition on children's quality of life

BACKGROUND/AIM

Among the diseases related to oral health, traumatic dental injuries (TDI) can lead to pain, loss of function and aesthetic problems, with physical, emotional and social consequences for children and their families. The aim of this study was to investigate the relationship between enamel fracture and enamel-dentin fracture with oral health-related quality of life (OHRQoL).

MATERIAL AND METHODS

This cross-sectional study had a representative sample of 1589 children between 8-10 years of age from public schools. The OHRQoL was obtained through the Child Perceptions Questionnaire (CPQ_8-10 ), which is a questionnaire validated for Brazilian children. Clinical data were collected by 4 calibrated examiners (Kappa > 0.7) using the Decay, Missing, Filled Teeth (DMFT) Index, Dental Aesthetic Index (DAI) and TDI. A socio-economic questionnaire was sent to the caregivers to be answered at home. Descriptive statistics and Poisson regression with prevalence ratio (PR) and 95% confidence interval (CI) were used for statistical analysis.

RESULTS

The prevalence of TDI was 10.6%, and among these 10.3% who had an impact on the OHRQoL, it was due to enamel-dentin fracture. Children with enamel-dentin fracture had (PR 1.35; 95% CI 1.07-1.70) higher prevalence of impact on the OHRQoL. Children with enamel fracture had no impact on the OHRQoL (P = .254).

CONCLUSION

Enamel fracture had no significant impact on children's quality of life, while enamel-dentin fracture did have an impact on quality of life.

Area-level income inequality and oral health among Australian adults-A population-based multilevel study

Background

A lack of evidence exists on the association between area-level income inequality and oral health within Australia. This study examined associations between area-level income inequality and oral health outcomes (inadequate dentition (<21 teeth) and poor self-rated oral health) among Australian adults. Variations in the association between area-level income inequality and oral health outcomes according to area-level mean income were also assessed. Finally, household-income gradients in oral health outcomes according to area-level income inequality were compared.

Methods

For the analyses, data on Australian dentate adults (n = 5,165 nested in 435 Local Government Areas (LGAs)) was obtained from the National Dental Telephone Interview Survey-2013. Multilevel multivariable logistic regression models with random intercept and fixed slopes were fitted to test associations between area-level income inequality and oral health outcomes, examine variations in associations according to area-level mean income, and examine variations in household-income gradients in outcomes according to area-level income inequality. Covariates included age, sex, LGA-level mean weekly household income, geographic remoteness and household income.

Results

LGA-level income inequality was not associated with poor self-rated oral health and inversely associated with inadequate dentition (OR: 0.64; 95% CI: 0.48, 0.87) after adjusting for covariates. Inverse association between income inequality and inadequate dentition at the individual level was limited to LGAs within the highest tertile of mean weekly household income. Household income gradients in both outcomes showed poorer oral health at lower levels of household income. The household income gradients for inadequate dentition varied according to the LGA-level income inequality.

Conclusion

Findings suggest that income inequality at the LGA-level in Australia is not positively associated with poorer oral health outcomes. Inverse association between income inequality and inadequate dentition is likely due to the contextual differences between Australia and other high-income countries.