Epidemiology of traumatic dental injuries

EPIDEMIOLOGY OF TRAUMATIC
DENTAL INJURIES
Presentation by:- Monika
III Yr Post Graduate
Department of Public Health Dentistry
2

CONTENTS:
 Introduction
 Etiology of traumatic dental injuries
 Mechanism of traumatic dental injuries
 Epidemiological triad
a. Host factors
b. Agent factors
c. Enviromental factors 3

 Impact of TDI on Oral health related quality of life
 Classification of traumatic dental injuries
 Public health implications
 Conclusion
 References
4

INTRODUCTION
With the decline in dental caries among children in
developed and developing countries there is increasing
interest in studying other oral health conditions,
including dental trauma.
9

 In the current terminology, the use of the word trauma
implies a reasonable severe, non-physiological lesion to any
part of the body.
10

 TRAUMA: refers to injury, damage, impairment, external
violence producing injury or degeneration.
 DENTAL TRAUMA: Dental trauma is injury to the mouth,
including teeth, lips, gums, tongue, and jawbones. The
most common dental trauma is a broken or lost tooth.
11

 Traumatic dental injuries have always been a
neglected oral condition despite availability of a
sound knowledge about its prevalence, causative
factors, treatment and significant impact on
individuals.
12

 Is traumatic dental injury (TDI) a public health
problem?
 First, trauma to the oral region occurs frequently and
makes up 5% of all injuries for which people seek
dental treatment in all dental clinics and dental
hospitals in country.
 Second, TDIs tend to occur at a young age during
which growth and development takes place.
13

 Third, treating a TDI can often be complicated and
expensive, frequently involving participation of
specialists in several disciplines.
 Fourth, in contrast to many other traumatic injuries
treated on an out patient basis, a TDI is mostly
irreversible and thus treatment will likely continue
for the rest of patient’s life.
14

 Evidence suggests that there is also impact of treatment of
dental trauma on the quality of life(QoL) of the individual.
 On average, children with an untreated TDI were 20 times
more likely to report an impact on QoL because of injury
when compared with children without any TDI.
Cortes MIS, Marcenes W, Sheiham A. Impact of traumatic injuries to the permanent teeth
on the oral health related quality of life in 12-14 year old children. Community Dent Oral
Epidemiol 2002;30: 193-8.
15

ETIOLOGY
 The etiology of TDIs includes oral factors (e.g overjet),
enviromental factors(e.g material deprivation) and human
behaviour (e.g. risk-taking), which can be further separated
into intentional and unintentional TDIs.
16

MECHANISM OF DENTAL INJURIES:
 The extent of soft tissues to the facial area varies
depending on the forces involved, the agent
responsible for trauma, the circumstances and the
location of injury.
 It can be broadly classified into:
 Direct trauma
 Indirect trauma
 Direct trauma:
 When the tooth itself is struck against a surface or
when an object strikes a tooth or teeth e.g. against
playground, equipment, a table or chair or floor.
 Usually involves: anterior dentition.
 Indirect trauma:
 This type of injury is seen when the lower dental arch
is forcefully closed against the upper arch, as by a
blow on the chin in a fight or fall.
 This type of trauma favours crown or crown root
fractures in the premolar or molar region.
17

PREVALENCE OF TRAUMATIC DENTAL INJURIES
 Data from many countries showed that one third of
all preschool children have suffered traumatic dental
injuries involving the primary dentition and one
fourth of all school children and almost one third of
adults have suffered a trauma to the permanent
dentition
18

AGE-WISE:
20

IN PERMANENT DENTITON:
21

IN PRIMARY DENTITON:
22

Author Year Age group Sample size % of dental
injuries
Rai SB and
Munshi(South
Kanara district,
karnataka)
1998 3-16 years 4500 5.29%
David J et al
(kerala)
2009 12 years 838 6%
Ravishankar et al
(Davangere)
2010 12 years 1020 15.1%
Naveen kumar et
al (Andra
Pradesh)
2011 12 years 1020 15.1%
23

Author Year Age group Sample size % of dental
injuries
Nupur Kaur and
S.S Hiremath
(Bangalore)
2011 8-15 years 2000 14.5%
Ankola AV et al
(Belgaum)
2012 6-11 years 13,200 14.74%
Murthy AK et al
(Bangalore)
2014 5-16 years 2,140 9.7%
24

INCIDENCE
 The incidence of dental trauma per 1,000 individuals
varies from between 0.6 and 22.9 per year for 0 to
19 year olds. (Glendor et al 1996).
25

EPIDEMIOLOGICAL TRIAD
 HOST FACTORS
 AGENT FACTORS
 ENVIRONMENTAL FACTORS
26

 HOST FACTORS
 Age
 Gender
 Racial and Ethnic group-Familial and Genetic Pattern
 Anatomic Characteristic of the Teeth & Arrangement of the
Teeth
 Susceptibility of individual teeth to trauma
 Other factors
 Emotional Disturbances
27

 Agent Factors
 Diet
 Sharp objects
 Resilience of the material
 Drug Induced injuries
 Environmental factors
 Place of Residence
 Sports
 Automobile injuries
 Assaults
 Social Factors
28
 Others:
 Oral piercing
 Iatrogenic factors
 Physical limitations
• Cerebral palsy
• Learning difficulties
• Hearing/vision problems.

 AGE
 Infancy
 School children
 Teenagers
 Old age
29

 Results from many studies demonstrate that the majority of
TDIs occur in childhood and adolescence.
 It is estimated that 71-92% of all TDIs sustained in a
lifetime occur before the age of 19 years.
Glendor U, Halling A, Andersson L, Eliert-Peterson E. Incidence of traumatic tooth
injuries in children and adolescents in the county of Vastmanland, Sweden. Sweden Dent
J. 1996;20:15-28.
31

 Cunha et al conducted a study on Brazilian children aged 0-3
years. Dent Traumatol. 2001 Oct;17(5):210-2.
 The prevalence of traumatic injuries was 16.3%. Children
aged 1-2 years (39.9%) and of the maxillary central incisors
(86%).
 Falls were more often the etiology for dental injuries (58.3%).
There was a predominance of uncomplicated crown fractures
(48.4%).
32

 Beltreo et al assessed Prevalence of dental trauma children
aged 1-3 years in Joao Pessoa (Brazil). Eur Arch Paediatr
Dent. 2007 Sep;8(3):141-3
 This was to determine the prevalence and distribution of
traumatic injuries to primary anterior teeth in children from 1
to 3 years-old.
 Fall was main etiological factor for the injury of teeth
33

FINDINGS FROM MOST OF THE STUDIES:
 Traumatic injuries were identified in 10.2% of children. The
largest percentage of injuries was demonstrated by 2-3
years-old, with no significant difference between boys and
girls.
 The most common type of injury was enamel fracture and
enamel-dentine fracture.
 The maxillary central incisor was the most vulnerable to
injury, without differences between the right and left
side.
34

 Teenagers
 Sports
 Road traffic accidents
 Fights
 Outdoor games
 Bicycle injuries
 Horse back riding
 Elders
 Road traffic accidents
 Place of work
 Fights
35

GENDER
 Soriano EP, Caldas Ade F Jr, Diniz De Carvalho
MV, Amorim Filho Hde A.
 Prevalence and risk factors related to traumatic
dental injuries in Brazilian schoolchildren.
 Boys-13.6% 11-13 yr
 Girls-11.6% 11-13 yr
36

 Cecconello R, Traebert J. Traumatic dental injuries in
adolescents from a town in southern Brazil: a cohort
study. Oral Health Prev Dent. 2007;5(4):321-6
 Boys – 27%
 Girls- 18.7%.
37

 Abu-Hussein Muhamad et al.: Traumatic Dental Injuries
to Permanent Anterior Teeth, Relation with Age and
Gender Among 9-12 Years Schoolchildren of Arab Israeli
Community: An Epidemiological Study.
 The results suggested that boys were more susceptible to
traumatic injury of anterior teeth, and the highest
prevalence of dental trauma was determined in the 8 years
age.
38

 Higher than boys in the 11years age girls group type
score 3 (Coronal fracture without pulp exposure).
 The result show that boys with 9-10 years of age
were more susceptible to traumatic injury score 4
type (Fracture from enamel and dentine involve
expose pulp area)
39

BODY WEIGHT
 Glendor U. Aetiology and risk factors related to traumatic
dental injuries – a review of the literature. Dental
Traumatology 2009; 25: 19–31
 Petti and Tarsitani (38) showed that obese schoolchildren
were significantly more prone to dental trauma than non-
obese children.
40

 Soriano EP, Caldas Ade F Jr, Diniz De Carvalho
MV, Amorim Filho Hde A. Prevalence and risk
factors related to traumatic dental injuries in
Brazilian schoolchildren.
 Overweight children have more chances to fall due
to lack of motor coordination
41

RACE &ETHNICITY
 The relationship between dental trauma and race & ethnicity
is obscure.
 Ethnic minorities tend to experience more financial
adversities and live in more deprived areas, making it difficult
to disentangle the effects of these factors.
42

 Marcenes W, Murray S. Changes in prevalence and
treatment need for traumatic dental injuries among 14-
year-old children in Newham, London: a deprived area.
 Prevalence of traumatic dental injury in Newham
increased from 23.7% to 43.8% between 1995-96 and
1998-99.
43

 Area-based measures of deprivation such as an
overcrowded household and ethnicity were
predictors of traumatic dental injuries.
44

ANATOMIC CHARACTERISTIC OF THE TEETH
 Children with accident prone facial profiles are more
susceptible to injuries.
 These include:
 Increased overjet with protrusion of the upper incisors and
insufficient lip closure.
 Angle’s class II div 1 malocclusion
45

 Gabriela A.,V. Cunha Bonini. Trends in the prevalence of
traumatic dental injuries in Brazilian preschool children.
Dental Traumatology 2009; 25: 594–598.
 The relationship between TDI and anatomic predisposing
factors such as overjet, lip coverage, and anterior overbite
was highly statistically significant (P < 0.01).
46

 Shulman JD, Peterson J. The association between incisor
trauma and occlusal characteristics in individuals 8-50 years
of age. Dent Traumatol 2004;20: 67-74.
 This study showed that after adjusting for age, gender and
race-ethnicity, overjet was the only occlusal covariate
significantly associated with maxillary incisor trauma.
47

 In some studies the definition of protrusion begins at ˃3-
3.5 mm, whereas in others at ˃5.0 mm, which makes it
difficult to compare studies.
 To make matters even more complicated, overjet with
protrusion in some studies is combined with inadequate lip
coverage.
48

SUSCEPTIBILITY OF INDIVIDUAL TEETH TO TRAUMA
 Lam R et al. Dental trauma in an Australian rural centre.
 The maxillary central incisors were the most commonly
injured teeth in both the primary and permanent dentitions.
 Uncomplicated crown fractures were the most common injury
followed by luxations and subluxations.
49

OTHER FACTORS
 Emotionally stressful states:
 Nicolau B, Marcenes W, Sheiham A. Prevalence, causes and
correlates of traumatic dental injuries among 13-year-olds in
Brazil. Dent Traumatol 2001;17:213–7.
 Dental trauma has been linked to emotionally stressful
conditions.
51

 Nicolau et al. (35),concluded that adolescents who
experienced adverse psychosocial environments along the life
course had more dental trauma than adolescents who
experienced more favourable environments.
 These adverse environments included living in a non-nuclear
family and experiencing high levels of paternal abuse.
52

 GAV Cunha Bonini, W Marcenes, LB Oliveira, A
Sheiham, M Bönecker. Trends in the prevalence of
traumatic dental injuries in Brazilian preschool
children. Dental traumatology 25 (6), 594-598.
53

Cunha Bonini et al. Trends in the prevalence of traumatic dental
injuries in Brazilian preschool children, Dental Traumatology 2009; 25: 594–598.
54

 Sabuncuoglu O. Traumatic dental injuries and
attentiondeficit/hyperactivity disorder: is there a
link? Dent Traumatol 2007;23:137–42.
 The association between attention-deficit
hyperactivity disorder (ADHD) and dental trauma
has been studied in 8- to 17-year-old children.
 This study suggests that ADHD in children is a
predisposing factor for TDIs.
55

 Agent Factors
 Diet
 Sharp objects
 Resilience of the material
 Drug Induced injuries
56

DIET
Diet
Hard food- fracture of the tooth
Soft food- less trauma to the tooth
57

SHARP OBJECTS
 Few studies have included the category(Inappropriate use
of teeth).
 However many individuals have injured their teeth when
using them as a tool to open hair clips, fix electronic
equipment, cut or hold objects or opening bottles of soda
or beer.
58

 Malikaew P, Watt RG, Sheiham A. Prevalence and factors
associated with traumatic dental injuries (TDI) to anterior
teeth of 11-13 year old Thai children. Community Dent
Health. 2006 Dec;23(4):222-7.
 In the above study it was found that 18.7% of TDIs were
caused by inappropriate use of teeth.
59

 Factors which determine the extent of Injury:
 Energy of Impact
 Resilience of Impacting Object
 Shape of the Impacting Object
 Direction of the Impacting Force
60

 Energy of Impact
 Low velocity – greatest damage to the supporting structures
- tooth fractures are less pronounced
 High velocity- resulting in crown fractures
- less damage to the supporting tissues
- energy of impact is apparently expended in
creating the fracture and is seldom transmitted
to any great extent to the root of tooth 61

 Resilience of the impacting material:
 Tooth is stuck with a resilient or cushioning object, such
an elbow during play, or if the lip absorbs and distributes
the impact, the chance of crown fracture is reduced while
the risk of luxation and alveolar fracture is increased.
 Fall on the floor/platform
 Trauma to teeth
62

 Malikaew P, Watt RG, Sheiham A. Prevalence and
factors associated with traumatic dental injuries
(TDI) to anterior teeth of 11-13 year old Thai
children. Community Dent Health. 2006
Dec;23(4):222-7.
63

 'Falls' was the most common manner causing TDI (24.8%).
Ground surfaces (22.4% of all cases), particularly concrete
surfaces (14.6% of all cases), were the most common
vectors which directly contacted or injured children. Biting
hard material was the most common activity leading to
TDI.
64

 Shape of the Impacting Object
◦ Impact with sharp objects
 Favors clean crown fractures
 Minimum displacement of tooth
◦ Impact with blunt objects
 Impact transmitted to the apical region
 Luxation of root fracture
Energy is spread rapidly
over limited area
Increases
area of
resistance
to force
65

 Direction of the Impacting Force
 Horizontal crown fractures
 Horizontal fractures at neck of tooth
 Oblique crown root fractures
 Oblique root fractures
66

 Drug Related Injuries:
 Crown fractures of molars and premolars- resulting
in violent tooth clenching 3 to 4 hours after drug
intake
 Fractures confined to lingual or buccal cusps
67

 Environmental factors
 Place of Residence & Injury
 Sports
 Automobile injuries/ Traffic accidents
 Assaults
 Social Factors
68

 Place of Residence & Injury:
 Glendor U. Aetiology and risk factors related to traumatic
dental injuries – a review of the literature. Dental
Traumatology 2009; 25: 19–31
 The home and its neighbourhood are the most common place
of injury in preschool and school-aged children, whereas
physical leisure activities, violent incidents and traffic
accidents account for most TDIs among adolescents.
69

 Traebert J, Almeida IC, Marcenes. Etiology of traumatic
dental injuries in 11 to 13-year-old schoolchildren. Oral
Health Prev Dent. 2003;1(4):317-23.
 Common places where the TDI event occurred were at
home (42.6%), in the street (21.5%) and at school (9.5%).
29.2% of TDI were the result of the actions of another
person.
70

 Bittencourt DD et al. Links Aetiology and rates of
treatment of traumatic dental injuries among 12-year-old
school children in a town in southern Brazil. Dent
Traumatol. 2006 Aug;22(4):173-8.
 Majority of the cases of TDI occurred at home (17.8%) and
at school (17.8%). Collisions (24.5%), mainly with doors,
and physical leisure activities (20.0%) such as cycling and
playing soccer were the main activities related to TDI
aetiology.
71

SPORTS:
 Tuli et al. reported that 32.2% of patients with a
TDI visiting a university clinic did so because of
sports injuries.
 Federation Dentaire International places organised
sports into two categories based on risk of TDIs:
 Highrisk sports (such as American football, hockey, ice
hockey, martial sports, rugby, inline skating,
skateboarding and mountain biking)
 medium-risk sports (such as basketball, soccer, team
handball, diving, squash, gymnastics, parachuting and
water polo)
 Ueeck et al. found that horse riding and facial injuries
were often associated with other types of injury.
 Therefore, one way to show TDIs in connection with
horse riding is to show injuries to the head.
 Acton et al. reported that 31% of children under the age
of 15 years with facial injuries as a result of bicycle
accidents had a TDI.
73

 Yin Man Chan, Sheila Williams, Lesley E. Davidson,
Bernadette K. DrummondOrofacial and dental trauma of
young children in Dunedin, New Zealand. Dental
Traumatology 2011; 27: 199–202.
74

 Glendor U. Aetiology and risk factors related to
traumatic dental injuries – a review of the literature.
75

 Material deprivation:
 A major environmental determinant of TDIs is material
deprivation.
 Hamilton et al. and Marcenes and Murray reported 34–44%
prevalence of dental injuries in UK in deprived areas (the
overall prevalence was 15%).
77

SOCIAL FACTORS:
 Human behaviour:
 Odoi et al. demonstrated that children who were
being picked on or bullied by other children
experienced more dental traumas than other
children.
 Wazana, stressed the importance of modifying the
environment in order to reduce injuries among
children. 78

 It is especially important for parents living in poorer
and more crowded neighbourhoods to find safe
routes to and from school and play areas free of
danger and away from streets.
79

 Malikaew P, Watt RG, Sheiham A. Prevalence and
factors associated with traumatic dental injuries (TDI) to
anterior teeth of 11-13 year old Thai children.
Community Dent Health. 2006 Dec;23(4):222-7.
 TDI were more common amongst children living in more
disadvantaged households and whose parents were less
educated.
80

 Assaults:
 Injuries from fights- seen in both younger and older age
groups.
 Closely related to alcohol abuse.
 Results in particular injury pattern- luxation and
exarticulation of teeth/ fractures of roots/ supporting bone
81

 Traffic accidents:
 Traffic accidents include pedestrian, bicycle- and car related
injuries.
 This trauma group is dominated by multiple dental injuries,
injuries to the supporting bone and soft-tissue injuries.
82

 A study in Nigeria reported that rear-seat occupants of
commercial vehicles were the most likely to sustain
maxillofacial injuries.
 Roccia et al. and Mouzakes et al. demonstrated that new
types of facial trauma occur from airbag explosion in cars.
83

 Others:
 Oral piercing:
 Campbell et al. reported a prevalence of chipped teeth of
19.2% among individuals wearing tongue piercing.
 Leichter and Monteith also reported that gingival recession
is almost 7.5 times as likely in a pierced individual
wearing labreth.
84

 Iatrogenic injuries:
 Most TDIs are probably inadvertently caused by direct
pressure during laryngoscopy and intubation, resulting in the
fracture of crowns and roots and luxations or avulsions.
85

 Physical limitations:
 Epilepsy: Bessermann reported that 52% of
epileptic patients had suffered dental trauma, many
of which were of a repetitive nature.
86

 Cerebral palsy
 The prevalence of TDIs in a group of individuals with
cerebral palsy (CP) has been found to be much higher
(57%) than in healthy populations.
87

 Learning difficulties
 A very high frequency of TDIs has been found
among patients with learning difficulties.
88

 Hearing or visual impairment
 Alsarheed et al. (47) noted that hearing-impaired
children, in comparison with visually impaired
children, had significantly more dental trauma.
89

IMPACT OF TRAUMATIC INJURIES OF TEETH ON
QUALITY OF LIFE
 Severe emotional complications are associated with
fractured anterior teeth in children, sufficient to cause
disturbances of their mental attitude.
( Psychological effect of fractured incisors. Br Dent J 1955;
6: 386-8)
90

 Children with fractured incisors were significantly more
dissatisfied with the appearance of their teeth than were
children without any traumatic injury.
(Impact of traumatic injuries to the permanent teeth on the oral
health quality of life in12-14 year old children. Community
Dent Oral Epidemiol 2002; 30: 193-8).
91

 Appearance of untreated fractured teeth was the main
factor affecting the Oral Impact on Daily Performance
items ‘smiling’, ‘laughing’, ‘showing teeth without
embaressment’, ‘maintain usual emotional state without
being irritable’.
 (Impact of traumatic injuries to the permanent teeth on the
oral health quality of life in12-14 year old children.
Community Dent Oral Epidemiol 2002; 30: 193-8).
92

CLASSIFICATION OF TRAUMATIC DENTAL INJURIES
 Classification by Rabinowitch(1956)
 Ellis & Davey classification(1960)
 Bennet classification (1963)
 Andreason classification(1981)
 Johnson classification(1981)
 Garcia Godoy classification (1981)
93

 Modification of Ellis classification by
McDonald,Avery & Lynch(1983)
 Classification by Ulfohn(1985)
 WHO classification(1993)
 Spinas classification (2002)
 Pulver’s classification
94

Rabinowitch's classification (1956)
Class I - Enamel fracture
Class II - Enamel and dentin fracture
Class III - Enamel and dentin fracture with pulp exposure
Class IV- Root fracture
Class V- Communution
Class VI- Exarticulation. 95

 By Ellis and Davey (1960)
 Class I - Simple fracture of crown involving only enamel with
little or no dentin
 Class II - Extensive fracture of crown involving considerable
dentin but not exposing dental pulp.
 Class III - Extensive fracture of crown involving considerable
dentin and exposing dental pulp
 Class IV-- The traumatized tooth that be comes non vital with or
without loss of crown structure
 Class V-Total tooth loss - avulsion
96

Class VI -Fracture of the root with or without loss of
crown structure
Class VII -Displacement of tooth with neither crown or
root fracture
Class VIII -Fracture of crown en masse and its
displacement
Class IX -Traumatic injuries of primary teeth
-- According to Cohen: Cracked tooth
--According to Matthewson: Cyclic dislocation of tooth
97

 By Hargreaves and Craig
 Class I – No Fracture of enamel only with or without
displacement of tooth
 Class II – Fracture of crown involving both enamel and dentin
without exposure of pulp with or without displacement of
tooth
 Class III—fracture of crown exposing the pulp with or
without displacement of tooth
 Class IV—fracture of root with or without coronal fracture,
with or without displacement of tooth
 Class V—Total displacement of tooth
98

 Bennett’s classification
◦ Class I—traumatized tooth
 1a – tooth is firm in alveolus
 1b—tooth is subluxed in alveolus
◦ Class II—coronal fracture
 11a—fracture of enamel
 11b—fracture of enamel and dentin
◦ Class III—coronal fracture with pulp exposure
◦ Class IV—root fracture
 Iv a—without coronal fracture
 Iv b—with coronal fracture
◦ Class V—avulsion of tooth

 Andreasen classification(1981):
 Injuries to hard dental tissues and pulp
 Injuries to periodontal tissues
 Injuries to supporting bone
 Injuries to gingival and oral mucosa
100

PUBLIC HEALTH IMPLICATIONS
 Cost of Dental trauma:
 The annual cost of treatment for traumatic dental
injuries is estimated at US $ 2-5 million per million
inhabitants per year in denmark.
 Seen over a lifetime these costs may be greater when
travel and time for treatment for the patient is taken
into account.
101

 Lay knowledge in society:
 The prognosis of some injuries, especially avulsed teeth is
decided by the correct measures taken in emergency
situations, it is of importance that not only professionals to
have access to knowledge but also key individuals who run
into these situations.(e.g children, parents, teachers, athletic
trainers).
102

 Organisation of emergency care:
 Studies have shown that treatment of dental trauma in
emergency care services is often inadequate (hamilton
et al 1997).
 For this reason it is important that emergency dental
staff have experience of dental trauma treatment.
103

CONCLUSION
Traumatic dental injury is a public health problem in
today’s world.
Probably there will be a further increase in the
prevalence of TDIs in the future.
Still there are various questions regarding traumatic
dental injuries which are of interest.
104

Will TDIs in the future look the same as they do
today?
Or will it be increasing among girls because of their
increasing interest in sports.
To answer these questions, continuous research on this
simple but complicated topic is necessary.
105

 Nicolau B, Marcenes W, Sheiham A. Prevalence,
causes and correlates of traumatic dental injuries
among 13-year-olds in Brazil. Dent Traumatol
2001;17:213–7.
 Burden DJ. An investigation of the association
between overjet size, lip coverage, and traumatic
injury to maxillary incisors. Eur J Orthod
1995;17:513–7.
107

 Sabuncuoglu O. Traumatic dental injuries and
attention deficit/hyperactivity disorder: is there a
link? Dent Traumatol 2007;23:137–42.
 Malikaew P, Watt RG, Sheiham A. Prevalence and
factors associated with traumatic dental injuries
(TDI) to anterior teeth of 11-13 year old Thai
children. Community Dent Health. 2006
Dec;23(4):222-7. 108

 Glendor U. Aetiology and risk factors related to
traumatic dental injuries – a review of the literature.
 Traebert J, Almeida IC, Marcenes. Etiology of
traumatic dental injuries in 11 to 13-year-old
schoolchildren. Oral Health Prev Dent.
2003;1(4):317-23.
109

 Bittencourt DD et al. Links Aetiology and rates of
treatment of traumatic dental injuries among 12-year-old
school children in a town in southern Brazil. Dent
Traumatol. 2006 Aug;22(4):173-8.
 Yin Man Chan, Sheila Williams, Lesley E. Davidson,
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