Traumatic dental injuries in the first year of life and related risk factors in three regions of Brazil: a multicenter birth cohort study

Abstract

Background

Traumatic dental injuries (TDIs) in early childhood exert a negative impact on the quality of life of children and their families. However, there is no evidence from cohort studies on which to base prevention strategies at the beginning of life, when children are entirely dependent upon supervision. The aim of the present study was to estimate the incidence of TDI in the first year of life and explore risk factors in a birth cohort followed up in three major cities in different regions of Brazil.

Methods

A birth cohort study was conducted with children in the cities of Porto Alegre, Salvador, and Manaus. Socioeconomic, demographic, and anthropometric characteristics were collected at baseline. Behavioral characteristics were collected when the children were six and 12 months of age. After the first year of life, clinical examinations were performed by trained, calibrated dentists for the assessment of TDI (Andreasen’s criteria). Poisson regression models were used to estimate associations between the independent variables and TDI, with the calculation of crude and adjusted relative risk (RR) and respective 95% confidence intervals (CI).

Results

The incidence of TDI in the first year of life (range: 12 to 16 months) was 18.1% (95% CI: 13.6–22.6%). The multivariable analysis revealed a significantly greater risk of TDI in children from non-nuclear families (RR = 1.83; 95% CI: 1.11-3.00) as well as those whose mothers had a higher level of schooling (RR = 2.42; 95% CI: 1.04–5.63) and when tooth eruption began up to six months of age (RR = 2.30; 95% CI: 1.34–3.95). Being the first-born child was a protective factor (RR = 0.48; 95% CI: 0.27–0.87) for the occurrence of the outcome.

Conclusion

The high incidence of TDI in the first year of life indicates the need for primary prevention strategies with an emphasis on active supervision in the first months of life. Risk factors associated with TDI related to the family, mother and child suggest pathways for the planning of such strategies.

Introduction

Traumatic dental injuries (TDIs) affect between one-quarter and one-third of preschool children throughout the world [1,2,3,4,5,6] and can cause pain, chewing difficulty, speech problems, and emotional problems, exerting a negative impact on the quality of life of children and their families [7, 8]. When children suffer TDI in the first two years of life, diagnosis and treatment can be hampered by the emotional impact on the entire family [9,10,11]. Besides harm to the deciduous dentition, there is greater risk at this age of serious consequences to the development of the permanent teeth and occlusion, with possible severe sequelae as well as expensive, long-term treatment requiring a multidisciplinary approach [11,12,13,14,15].

The traditional view that tooth injuries in children are accidents or unpredictable random events has resulted in a global lack of the delineation of prevention strategies [16]. Unintentional injuries, such as TDI in the deciduous dentition, are distributed unevenly among individuals and recognizing factors related to greater exposure to such injuries in children is the first step towards planning preventive interventions [16,17,18]. The first year of life constitutes an additional challenge for caregivers, as it is a time of transition involving three stages of infant development – sitting up, crawling, and walking, which suggests specific mechanisms and causes of injuries and hospitalizations, requiring differentiated care on the part of caregivers as well as specially prepared environments in homes and preschools [17, 19,20,21]. At no other time in childhood or adolescence is a child so dependent on others for her or his safety [22].

The identification of family and individual characteristics related to greater exposure to TDI is an essential part of primary prevention and health education [23]. Although several cross-sectional studies have explored TDI in early childhood, only two cohort studies have investigated risk factors for this outcome in toddlers – one in Brazil and one in Sweden [24, 25]. Thus, there is little evidence on which to base counseling and preventive interventions targeting TDI at the beginning of life.

Therefore, the aim of the present study was to estimate the incidence of TDI in the first year of life and investigate sociodemographic, anthropometric, and behavioral risk factors in a birth cohort followed up in three major cities in different regions of Brazil.

Methods

Study design and participants

This is a prospective cohort nested in an intervention study with six-month and 12-month follow-up carried out with mother-child pairs in three major cities of Brazil: Porto Alegre (state of Rio Grande do Sul, southern region), Salvador (state of Bahia, northeastern region) and Manaus (state of Amazonas, northern region). These cities differ in terms of demographic and socioeconomic characteristics: Porto Alegre: 1.33 million inhabitants, infant mortality rate (IMR) of 7.7; Salvador: 2.57 million inhabitants, IMR of 14.7; Manaus: 2.20 million inhabitants, IMR of 13.6. The original intervention investigated the effectiveness of dietary counseling to mothers who had recently given birth to prevent the early introduction of sugar and ultra-processed foods in the first year of life. Mothers aged 18 years or older, negative for HIV and HTLV1, who gave birth to an apparently normal, single, full-term baby with a birth weight equal to or greater than 2,500 g were eligible for the study. The exclusion criterion was the presence of any congenital anomaly or conditions that could restrict breastfeeding.

The methodological characteristics of the present study, including parameters for the sample size calculation, are detailed elsewhere [26]. Given the fixed sample size of this study (n = 282), this analysis would have an 80% power to detect a difference in the occurrence of TDI among children in whom tooth eruption began up to six months of age (11.4%; n = 15/132) compared to those in whom eruption began after six months of age (24.0%; n = 36/150). Figure 1 displays the flowchart of the cohort.

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Data collection

At baseline, face-to-face interviews with the mothers were carried out in the maternity of the hospitals to collect socioeconomic and demographic characteristics: mother’s age (in complete years), mother’s level of education (in complete years of study), family structure (nuclear [both father and mother live with child] or non-nuclear), number of prenatal appointments, and first-born child (yes/no). Data were also collected from the health records of the infants after childbirth: sex, birth weight (in grams, subsequently categorized in tertiles), and length at birth (in centimeters, subsequently categorized in tertiles). At six and 12 months of age, additional interviews were conducted with the mothers in their homes. Breastfeeding duration, pacifier use, and age at the eruption of the first tooth were collected at both interviews. At 12 months of age, information was also collected on whether the child attended daycare. The mothers were also asked whether they remembered the occurrence of oral injuries, the age of the infant at the time of the injury, and how the injury occurred. The questionnaires used in the present study have been employed previously and the assessment methods are detailed elsewhere [27, 28].

Oral health examinations were performed at the 12-month assessment with the child lying on a mat on a stable, safe surface. After the teeth were brushed and dried with gauze, trained and calibrated dentists performed the dental clinical examination with the aid of a lighted intra-oral mirror. TDI (outcome of this study) was diagnosed based on the criteria established by Andreasen [29]. The presence of crown discoloration was also recorded, which is a TDI outcome that should be investigated, according to the International Association of Dental Traumatology [30].

Training of interviewers and examiners

Before data collection, the main investigator visited each participating center to provide standardized face-to-face training for all investigators. The program consisted of four 2.5-hour sessions, a manual addressing all items on the questionnaire, and specific manuals for the collection of dietary, anthropometric, and oral health variables. After each session, practical data collection exercises were performed with mothers and children of the same age as the participants to simulate what would occur during the study. The main investigator participated in these sessions, orientating and correcting whenever necessary.

Prior to the oral health data collection, an experienced pediatric dentist (center in Porto Alegre) who was previously calibrated using the criteria of the present study (intra-examiner unweighted Kappa = 0.85 after two examinations of 20 children one to three years of age with a 14-day interval between examinations) visited the cities of Salvador and Manaus to train and calibrate the dentists at these two centers for the collection of the oral health data. Theoretical training was performed with the aid of a manual specifically developed for the study that included clinical photographs of the outcomes of interest. Practical training and calibration for the diagnosis of dental caries involved one examiner in Salvador (unweighted inter-examiner Kappa = 0.80 after the examination of 15 children one to three years of age) and two examiners in Manaus (unweighted inter-examiner Kappa = 0.65 to 0.75 after the examination of 12 children one to three years of age).

Statistical analysis

Statistical analysis was performed with the SPSS 20.0 program for Windows (IBM, USA). Associations between the independent variables and TDI were first analyzed using the chi-squared test. Poisson regression with robust variance was then performed to investigate associations between the independent variables and primary outcome, with the calculation of crude and adjusted relative risk (RR) and respective 95% confidence intervals (CI). All variables of the unadjusted model were incorporated into the multivariable model. The significance level was set at 5% (p < 0.05).

Ethical aspects

This study received approval from the Human Research Ethics Committee of Universidade Federal de Ciências da Saúde de Porto Alegre (No. 88214918.3.0000.5345) and was registered with clinicaltrials.gov (nº NCT03841123). All parents signed a statement of informed consent after receiving clarifications regarding the intervention and all phases of the data collection process. This study was performed in line with the principles of the Declaration of Helsinki.

Results

Among the mother-child pairs recruited, 385 (74.6%) and 335 (65.7%) participated in the six-month and 12-month assessments, respectively. The dental examination was not performed on 45 children due to refusal of the parents, uncooperative behavior on the part of the child, or the absence of the child at the time scheduled for the assessment. Moreover, eight children were excluded for being edentulous. The predominant reasons for losses during the first year of life were family or address not located (mainly due to moving to another city) and refusals. The sample analyzed (n = 282) was similar to the originally recruited sample with regards to the baseline variables (Table 1). The majority of families had a nuclear structure (75.2%) and mother’s level of education ranged from one to 17 years, with a mean and standard deviation (SD) of 10.0 ± 2.6 years.

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The prevalence de TDI at the 12-month assessment (range: 12 to 16 months) was 18.1% (95% CI: 13.6–22.6%). Among the 51 children with TDI, 42 had one tooth affected and nine had two teeth affected. The most common type of TDI was enamel fracture (n = 49), followed by enamel/dentin fracture (n = 4), crown discoloration (n = 3), soft tissue laceration (n = 3), intrusive luxation (n = 2), lateral luxation (n = 1), and subluxation (n = 1). The upper central incisor was the most affected tooth (n = 53), followed by the upper lateral incisor (n = 5), lower central incisor (n = 1), and lower lateral incisor (n = 1). Among the 51 children with TDI, 41 mothers provided information on the episodes, with the child’s age ranging from five to 13 months (mean: 9.9; SD: 2.5; interquartile range: 7.0 to 12.0). The most frequent causes reported by the mothers were a fall from the child’s own height (n = 20), fall from the crib (n = 4), fall when sitting (n = 2), fall from stroller or walker (n = 2), and other causes, such as while crawling, rolling, and playing (n = 13).

Table 2 displays the frequencies of TDI according to the independent variables. The prevalence of TDI was significantly higher in children from non-nuclear families (28.6%) compared to those from nuclear families (14.6%; p = 0.009). No anthropometric variables of the children were associated with the outcome. The prevalence of TDI was significantly higher in children whose first tooth erupted up to six months of age (24.0%) compared to those whose first tooth erupted after six months of age (11.4%; p = 0.006).

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Table 3 displays the crude and adjusted relative risk for the occurrence of TDI. The multivariable analysis revealed that the risk of TDI was 80% higher in children from non-nuclear families (RR = 1.83; 95% CI: 1.11-3.00) and more than double (RR = 2.42; 95% CI: 1.04–5.63) when the mother had at least begun a university education compared to mothers who had not surpassed a primary school education. The risk of TDI was less than half among first-born children (RR = 0.48; 95% CI: 0.27–0.87) compared to those who had siblings and the risk was 2.3 times greater among children in whom tooth eruption began up to six months of age (RR = 2.30; 95% CI: 1.34–3.95) compared those in whom tooth eruption began after six months of age. The anthropometric variables continued not to be associated with the outcome after adjustments for confounding factors.

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Discussion

The present study investigated the incidence of TDI and related risk factors in the first year of life in three major cities in different regions of Brazil. The most important findings were the high frequency of the outcome after the first year of life and the identification that children from non-nuclear families were at greater risk, whereas being the first-born child and the eruption of the first tooth after six months of age were protection factors. These findings should be interpreted from the standpoint that tooth injuries are not mere “accidents”, but rather are predictable, preventable, and controllable [16].

Observation studies and a systematic review that investigated the prevalence of TDI in early childhood throughout the world report that between one-quarter and one-third of children are affected [1, 3,4,5, 31].The findings of the present study were obtained from different regions of Brazil and call attention to the high incidence even in the first year of life, which is consistent with findings described in a previous study involving children of the same age in a city in the southern region of the same country [24]. Although a significant portion of the injuries were enamel fractures and may not exert a direct impact on quality of life [32], the occurrence of enamel/dentin fractures, intrusive and lateral luxations, and crown discoloration is worrisome in this age range, considering the high risk of the abnormal formation of permanent successors [13,14,15]. Moreover, as some children have repeated episodes of TDI in early childhood, even the occurrence of enamel fractures should be taken seriously and recorded, as such episodes are predictors of future events, including in the permanent dentition [33,34,35,36].

Unintentional injuries of any nature do not occur in an isolated manner in children and are influenced by family interactions and dynamics that occur within the home [16]. The role of family structure in the occurrence of TDI has been under-investigated, but the greater risk among children from non-nuclear families is consistent with data from a previous cohort study that investigated children in the first year of life [24]. Moreover, the protective role of being an only child is consistent with the results of a cross-sectional study, in which the authors found that a greater number of siblings was associated with a greater occurrence of TDI in children one to four years of age [37]. Although aspects of the family routine were not measured directly in the present study, some factors may be speculated to explain the greater occurrence of the outcome among children in non-nuclear families and with the presence of siblings. These situations may indicate less parental supervision, as a child may receive less care when living with only one of the parents, the presence of siblings may divide the attention of caregivers, or the caregivers in certain family models may be older siblings [38, 39]. Supervision may be inadequate, especially in the first years of life, when the caregiver loses visual contact and believes that “hearing” the child is sufficient. The most important aspect of parental supervision to prevent any injury in small children is physical proximity [20]. The first year of life is a period of complete dependence of the child on the caregivers and the mechanisms or causes of injuries reported in the present study suggest that this supervision may not have been effective. The International Association of Dental Traumatology and American Academy of Pediatrics recommend that parents anticipate the milestones of child development, avoiding falls from the crib or changing table, positioning the child in a safe place when it is being fed, and maintaining a safe leisure environment by covering floors and the corners of furniture and prohibiting the use of walkers [17]. On the other hand, one cannot discard the possibility that some injuries in the present study may have been caused by mistreatment, which is difficult to ascertain in epidemiological studies [40].

General and oral health outcomes in early childhood, such as child mortality, dental caries, and toothache, are distributed unevenly and mainly affect children from families with a low socioeconomic status [41,42,43]. However, the incidence of TDI is higher among preschool children from families with a higher socioeconomic status, which is consistent with data from the only cohort studies conducted with toddlers [24, 25]. Moreover, a greater occurrence of the outcome has been found in children whose mothers have a higher level of schooling [24, 42], whose families have a higher income [2, 25, 44, 45], and who attend private schools [46, 47]. Although consistent, these findings do not have a simple explanation. Higher levels of schooling and income may enable greater work opportunities for mothers, which may be associated with less supervision at this age due to the fact that the child is with another caregiver. Moreover, the results of the studies cited were from preschool children in different regions of Brazil, which is a middle-income country, as well as children who were lived in multicultural areas with a medium to low socioeconomic status in Sweden. In these environments, it is possible that children of families with a higher socioeconomic status have greater access to environments that pose risks of injury without having adequate protection strategies. With regards to the permanent dentition, a recent systematic review showed a consistent association in the opposite direct, with a greater risk of TDI among children and adolescents of families with a lower socioeconomic status [48]. Socioeconomic status is a complex issue that involves different mediating factors, including psychosocial factors of the family [49]. Moreover, the different ways that socioeconomic status is measured and the age group analyzed may reflect different degrees of exposure and protection in environments visited by children – from the home to schools and parks.

Eruption of the first tooth up to six months of age was an important risk factor in the present study. According to the reports of the mothers, at least one-quarter of the injuries occurred within the first seven months of life, making exposure greater among children with earlier tooth eruption. Similar findings were described in a previous birth cohort study [45]. Breastfeeding and the use of a pacifier, which were previously respectively identified as a protection factor and risk factor for the occurrence of TDI in the deciduous dentition [27, 45], were not associated with the outcome in the present investigation. This lack of an association may have occurred because the impact of a factor on an outcome depends on the exposure time and 12 to 16 months was not sufficient for breastfeeding and pacifier use to exert their respective protection and risk effects for the presence of accentuated overjet, which is the most widely recognized risk factor for the occurrence of TDI [18, 50].

Among the implications of the present study, the high prevalence of TDI already in the first year of life indicates that anticipatory counseling with regards to the primary prevention of tooth injuries in the deciduous dentition should be given by the health team in the first months of a child’s life, together with general childcare counseling, which traditionally includes accident prevention. The risk factors identified underscore the importance of specific counseling for the prevention of oral and general injuries, which involves improving the supervision of infants and toddlers in the first year of life and their living environments, especially when infants begin to crawl, stand, and walk. The findings of the present study suggest the need for special attention with regards to non-nuclear families and those with a larger number of children.

Some methodological characteristics of the present study should be considered. Among the limitations, there was a substantial number of losses to follow-up. However, the proportion of losses was similar to that found in cohort studies that follow up children in the first year of life [51]. Moreover, the characteristics of the original cohort and the sample analyzed were similar, indicating a low likelihood of selection bias. The prospective design of the birth cohort is a significant strength of this study, enabling the collection of variables at birth as well as at six and 12 months of life with greater precision and a lower risk of recall bias. However, despite the extensive training and satisfactory reliability among the examiners, measurement errors in the diagnosis of TDI may have occurred, especially due to the age of the children analyzed. However, outcome classification errors are expected to lead to results of association nullity and, therefore, do not explain the risk factors identified. Thirdly, the participants were recruited from three public hospitals in major cities of Brazil; therefore, the findings cannot be generalized to high-income families and those that live in rural areas.

In conclusion, the findings of the present birth cohort study revealed a high incidence of TDI in the first year of life and identified a greater risk of the outcome in children from non-nuclear families, those with siblings, and those whose first tooth erupted up to the sixth month of life. These results indicate the need for primary prevention strategies for tooth injuries, with an emphasis on active supervision in the first months of life, especially for groups of individuals identified as being at greater risk.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

TDI:

Traumatic Dental Injuries

IMR:

Infant Mortality Rate

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