Dental Traumatology 2016; doi: 10.1111/edt.

12268

Clinical factors and socio-demographic

characteristics associated with dental
trauma in children: a systematic review and
meta-analysis

^a-Faria1, Carolina C.
Patr
ıcia Corre Abstract – Objective: The aim of this systematic review and meta-analysis
1
Martins , Marcelo Bo € necker2, Saul M. was to search for scientific evidence regarding the factors associated with
Paiva1, Maria Let
ıcia Ramos-Jorge3, traumatic dental injury (TDI) in the primary dentition. Methodology: An
Isabela A. Pordeus1 electronic search addressing factors associated with TDI was conducted in
1
Department of Pediatric Dentistry and the PubMed, ISI, LILACS, Cochrane Library, and Embase databases.
Orthodontics, School of Dentistry, Federal Data were extracted and analyzed regarding risk factors, statistical test,
University of Minas Gerais, Belo Horizonte, MG; effect measures, and study design. Results: The online search strategy led
2
Department of Orthodontics and Pediatric to the initial retrieval of 2566 articles. After evaluating the titles and
Dentistry, School of Dentistry, Federal abstracts, 24 papers were selected for complete review and data collection.
University of São Paulo, São Paulo, SP; TDI was associated with males (OR: 1.24; 95%CI: 1.09–1.41), inadequate
3
Department of Pediatric Dentistry, Federal
lip coverage (OR: 1.81; 95%CI: 1.50–2.17), overbite (OR: 1.438; 95%CI:
University of Vales do Jequitinhonha and
Mucuri, Diamantina, MG, Brazil
0.94–2.19), and age (1 vs 2 years – OR: 0.47; 95%CI: 0.38–0.58; 2 vs
3 years – OR: 0.78; 95%CI: 0.67–0.91; 3 vs 4 years – OR: 0.82; 95%CI:
0.71–0.95). Overjet and anterior open bite were associated with TDI in the
majority of studies. Conclusions: Males, older children, and those with
Key words: tooth injuries; systematic review; inadequate lip coverage, overbite, or overjet are more likely to have TDI
tooth, deciduous; etiology
in the primary dentition.
^a-Faria,
Correspondence to: Patr
ıcia Corre
Av. Antonio Carlos, 6627, Faculdade de
Odontologia, UFMG - Campus Universita
rio
31270-901, Belo Horizonte, MG, Brazil
Tel.: +55 38 9228 6791
E-mail: patriciafaria.faria09@gmail.com
Accepted 21 January, 2016

Traumatic dental injury (TDI) is a frequent problem,
especially among preschool children (1). According to
epidemiological studies, TDI affects 8% (2) to 62.1%
(3) of children between 2 and 5 years of age, with
esthetic, physical, and psychological repercussions that
exert a negative impact on quality of life (4–6).
Predisposing factors to TDI include oral aspects,
environmental determinants, and human behavior (7).
However, divergent opinions are found regarding the
influence of different characteristics on the occurrence
of TDI. Studies report that age, dental caries, and
malocclusion, such as increased overjet, are signifi-
cantly associated with TDI (2, 3, 8–13). However, there
are conflicting findings regarding the association
between TDI and lip coverage. In some studies, inade-
quate lip coverage is reported to be a significant predis-
posing factor to TDI (11, 13), whereas other studies
have not found such an association (9, 12). Moreover,
some authors state that boys are more affected by TDI
than girls (2, 13), whereas other studies have found no
difference between sexes (8, 11, 12).
Knowledge on associations between oral character-
istics and the occurrence of TDI in primary dentition
may allow the control of this condition. The evalua-
tion of this association is carried out mainly through
cross-sectional studies, which are limited to making
comparisons and inferences of the findings and there-
fore have low level of evidence. Another limitation of
the cross-sectional design regards the difficulty in
comparing studies, which hinders the establishment of
a consensus on factors associated with TDI. This dif-
ficulty is mainly due to methodological differences
among studies. A systematic review and meta-analysis
allows the unification of scientific evidence from
different studies and offers more reliable, useful infor-
mation for making evidence-based clinical decisions

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1
2 Corr^
ea-Faria et al.

(14–17). To date, no previous systematic review and Table 1. Search strategy used for each electronic database
meta-analysis has been conducted on this subject. Electronic database Search strategy
Thus, the aim of the present study was to conduct a
systematic review and meta-analysis on scientific evi- MEDLINE through PubMed ((Tooth injuries [MeSH terms]
dence of the association between oral characteristics (http://www.pubmed.gov); OR teeth injur* [Text word]
(sex, age, dental caries, and types of malocclusion) and ISI Web of Science OR tooth injur* [Text word]
TDI in the primary dentition. (http://www.isiknowledge.com); OR traumatic dental injur*
Cochrane Library [Text word] OR TDI
(http://www.cochrane.org/index.htm) [Text word]) AND (overjet
Material and methods [Text word] OR overjet,
dental [MeSH] OR dental
The present systematic review was undertaken in accor- overjet [MeSH] OR lip
dance with the guidelines of the Preferred Reporting coverage [Text word] OR
Items for Systematic reviews and Meta-Analyses socioeconomic factors
(PRISMA) (18) (protocol number: PROSPERO [MeSH terms] OR social
CRD42014009383) and is part of a previous systematic class [MeSH terms] OR
review (19). The present systematic review is an original socioeconomic status
study that evaluated clinical factors associated with [MeSH terms] OR educational
TDI, while the previous systematic review (19) reported status [MeSH terms] OR
income [MeSH terms] OR
different variables (only socioeconomic factors were risk factors [MeSH terms])
analyzed). AND (animals [MeSH terms]
NOT humans [MeSH terms]))
Latin American and Caribbean Tooth injury AND educational
Search strategy
Health Sciences (LILACS) through the status; tooth injury AND risk
Epidemiological studies (cross-sectional, case–control, Virtual Health Library (www.bireme.br) factors; tooth injury AND
cohort, and clinical trials) addressing possible associa- and Embase (http://www.elsevier.com/ social class
tions between clinical (e.g., dental caries, types of online-tools/embase)
malocclusion) and socio-demographic (gender, age)
characteristics and TDI in the primary dentition were
included in the present systematic review. No restric- val, and P-values (Tables 2 and 3). When the necessary
tions were imposed regarding language, country in data were not available in the article, the authors were
which the study was conducted, or publication date. contacted to provide such information.
The exclusion criteria were as follows: review arti- Data extracted from categorical variables were con-
cles, case reports, expert opinions, studies conducted sidered risk factors for TDI. The distribution and fre-
on the permanent dentition or involving data from quency of TDI among children exposed to risk factors
both the primary and permanent dentition, and studies vs the distribution and frequency of TDI among chil-
addressing specific groups (e.g., patients with cerebral dren not exposed to risk factors were recorded. The
palsy). following comparisons were made:
The search was conducted in December 2013 by one
of the researchers (P.C.F.) using five databases. 1 Increased overjet vs normal overjet.
Searched databases are shown in Table 1 with the 2 Inadequate lip coverage vs adequate lip coverage.
respective strategies. Manual searches were also per- 3 Male vs female.
formed of the list of references in the studies included. 4 Overbite vs absence of overbite.
The Reference Manager SoftwareÒ (Reference Man- 5 Older age vs younger age.
ager, Thomson Reuters, version 12.0.3, New York,
NY, USA) was used to organize the list of studies.
Assessment of study quality
Study selection was carried out independently and in
duplicate by two independent and calibrated reviewers The quality of the studies was evaluated by two
(P.C.F. and C.C.M.). The title and abstract were read in researchers using the Newcastle-Ottawa Quality Assess-
the first analysis. Studies that met the inclusion criteria ment Scale (NOS) for cohort/case–control studies (36).
were submitted to full-text analysis. In cases of disagree- Cross-sectional studies were evaluated using the modi-
ment, decisions regarding eligibility were discussed fied Newcastle-Ottawa Scale (36). As a calibration exer-
between the researchers until reaching a consensus. cise, 10% of the studies retrieved were evaluated
When information in the title was insufficient and the independently by the researchers. In cases of disagree-
abstract was not available, the full text was obtained for ments, a consensus was reached after a complete dis-
analysis. Studies that did not meet the inclusion criteria cussion of each item on the NOS.
were excluded. Authors were contacted to send their full Risk of bias was evaluated for each question. For
texts or provide additional information when necessary. each question-based entry, the judgment was as fol-
Data extraction was performed using a previously lows: ‘Yes, for low risk of bias’ and it was allocated a
designed chart. Information was collected on the study point (*), and ‘No, for high risk of bias’ and it was
design, setting (location in which the clinical examina- not assigned a point (37). A system of points used for
tion was conducted), sample size, age, index used for studies that fulfilled the methodological requirements
TDI, risk factors analyzed, statistical tests, effect and ranged from one (very poor) to eight (high)
measures (odds ratio, relative risks), confidence inter- points for cross-sectional studies. Points ranging from

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Clinical factors and traumatic dental injury 3

Table 2. Studies addressing factors associated with dental trauma in primary dentition
Authors, year, location of study Design Setting Sample size analyzed Age of subjects
Bonini et al., 2012; Brazil (19) Cross-sectional National Child Vaccination Day 376 3–4 years
Amorim et al., 2011; Brazil (20) Case–control Private pediatric dental clinic 308 with TDI and 4 months to 7 years
150 without TDI
De Vasconcelos Cunha Cross-sectional National Child Vaccination Day 1265 5–59 months
Bonini et al., 2009; Brazil (11)
Dutra et al., 2010; Brazil (8) Cross-sectional National Child Vaccination Day 407 1–4 years
Feldens et al., 2008; Brazil (21) Cohort Municipal health center 378 1 year
Ferreira et al., 2009; Brazil (22) Cross-sectional National Child Vaccination Day 3489 3–59 months
Goettems et al., 2012; Brazil (10) Cross-sectional Private and public schools 501 24–71 months
Granville-Garcia et el., 2006; Brazil (23) Cross-sectional Private and public 2651 1–5 years
schools and preschools
Granville-Garcia et al., 2006; Brazil (24) Cross-sectional Private and public schools 2651 1–5 years
and preschools
Granville-Garcia et al., 2010; Brazil (9) Cross-sectional Municipal daycare centers 820 1–5 years
Jorge et al., 2009; Brazil (25) Cross-sectional National Child Vaccination Day 519 1–3 years
Kawabata et al., 2007; Brazil (26) Cross-sectional Daycare centers 1042 1–3 years
Montandon et al. 1998; Brazil (27) Cross-sectional Pediatric medical clinic 250 0–30 months
Norton and O’Conell, 2012; Irlanda (28) Cross-sectional Schools and daycare centers 839 <84 months
Oliveira et al., 2007; Brazil (29) Cross-sectional National Child Vaccination Day 892 5–59 months
Piovesan et al., 2012; Brazil (12) Cross-sectional National Child Vaccination Day 441 12–59 months
Robson et al., 2009; Brazil (13) Cross-sectional Daycare centers and preschools 419 0–5 years
T€umen et al., 2011; Turkey (2) Cross-sectional Daycare centers 727 2–5 years
Viegas et al., 2010; Brazil (3) Cross-sectional Daycare centers and preschools 388 60–71 months
Viegas et al., 2006; Brazil (30) Cross-sectional National Child Vaccination Day 120 1–3 years
Wendt et al., 2010; Brazil (31) Cross-sectional Schools 571 12–71 months
Scarpari et al., 2004; Brazil (32) Cross-sectional University dental clinic 798 0–48 months
Mu~noz et al., 2006; Chile (33) Cross-sectional Schools 366 3–5 years
Menezes et al., 2004; Brazil (34) Cross-sectional Schools 1338 1–5 years

1 (very poor) to 9 (high) were awarded based on

methodological aspects for case–control and cohort
studies. This scale evaluates case definition, represen-
tativeness of the sample, sample selection, eligibility
criteria, adjustment for confounders, acquisition of
data on the dependent variable, description of bias,
and non-response rate.
The Comprehensive Meta-Analysis software pro-
gram, version 2, was used for the meta-analysis (38).
Heterogeneity, which consists of the variability or dif-
ferences among studies regarding the estimation of
effects, was evaluated using I2 statistics (39). Meta-ana-
lysis was conducted when I2 was below 55%, as values
above 55% would signify moderate to high heterogene-
ity, which may preclude meta-analysis (38). The sensi-
tivity test was conducted when heterogeneity was
notable to exclude studies that would increase hetero-
geneity. Mild heterogeneity was considered for <30%
of variability in point estimates and notable hetero-
geneity was considered for more than 50% of variabil-
ity (39). A random effect model was used when
heterogeneity was notable and a fixed effect model was
used when heterogeneity was close to 0 (40–42). For
statistical heterogeneity above 75%, meta-analysis was
not performed and a qualitative synthesis was per-
formed. For categorical data, risk measures, 95% con-
fidence intervals (CI), and P-values were described in
forest plots and summary risk measures were calcu-
lated. Publication bias was evaluated when at least 10
studies could be grouped in a funnel plot (42). Publica-
tion bias was evaluated by visually inspecting asymme-
try in the funnel plot (43) and using Egger’s test (44).
Results
The study selection process is presented in Fig. 1. The
online search strategy led to the retrieval of 2566 articles.
The screening process of the titles identified 38 articles
that met the inclusion criteria, 14 of which were excluded
after the full-text analysis. Thus, 24 studies were included
in the systematic review: 22 cross-sectional studies, one
cohort study, and one case–control study. No clinical tri-
als were found. Sixteen studies were incorporated in the
meta-analysis (only cross-sectional studies; Fig. 1). Eight
articles were not included in the meta-analysis due to the
impossibility of obtaining OR measurements (28, 31,
33), difficulty in grouping the data due to differences in
the categorization of the variables (23, 32), different
study designs (21, 22), or the repetition of data from
another publication (24). The main reasons for exclusion
were studies involving the permanent dentition, a lack of
investigation of risk factors associated with TDI, a lack
of a control group (children without TDI), and abstracts
presented at scientific meetings. Tables 2 and 3 offer a
summary of the details of the studies included in the
analysis and quality appraisal scores.
Sample size ranged from 120 to 3489 children. Age
ranged from 0 to 5 years. One study was comprised of
children up to 84 months (29) (Table 2). However, only
the data on 5-year-olds were analyzed in the present
systematic review and meta-analysis. Children were
recruited from schools/preschools (2, 3, 10, 13, 21, 25,
27, 32, 34, 35), university clinics (21, 33), and hospitals
(22, 28) as well as during vaccination campaigns
(8, 9, 11, 12, 20, 23, 24, 30, 31). Most studies analyzed

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 4

Table 3. Variables, outcomes, and quality of studies analyzed

Authors, year,
location of study TDI Variables Statistical analysis Outcomes Study quality
Corr^

Bonini et al., 2012; Modified version of Age, sex, overjet, lip Uni- and multivariate Boys had more dental trauma than girls (P = 0.04). Age was not 7 (8)
Brazil (19) Andreasen coverage, anterior significantly associated with dental trauma. Anterior open bite, overjet,
classification open bite and lip coverage were associated with dental trauma. Children with a
combination of anterior open bite or increased overjet and inadequate
lip coverage exhibited a greater frequency of TDI than when
malocclusions were analyzed alone (P < 0.05).
ea-Faria et al.

Amorim et al., 2011; Andreasen and Sex, age, overjet, lip Chi-square test TDI was most prevalent in the 13- to 36-month age-group (P < 0.05). 6 (9)
Brazil (20) Andreasen coverage, overbite No statistically significant difference was found in the distribution of
trauma between genders (P > 0.05). No differences in lip coverage
(P = 0.35); however, overjet >3 mm (P = 0.001) and deep and
negative overbite (P = 0.01) were significantly associated with TDI.
De Vasconcelos Modified version of Ellis Sex, overjet, lip Chi-square test and The difference in prevalence of TDI between boys and girls was not 6 (8)
Cunha Bonini et al., classification coverage, anterior simple logistic statistically significant (P = 0.11). Anterior open bite (OR = 3.18,
2009; Brazil (11) open bite regression 95% CI 2.27, 4.46), overjet (OR = 2.53, 95% CI 1.68, 3.79), and
short upper lip (OR = 2.29, 95% CI 1.48, 3.54) were significant
predisposing factors to TDI in primary teeth.
Dutra et al., 2010; Andreasen and Age, sex, lip coverage, Univariate and multiple The child’s age remained associated with dental trauma (OR. 0.6; 95% 5 (8)
Brazil (8) Andreasen caries in anterior teeth regression model CI: 0.4–0.9; P > .01). Sex (P = 0.47), caries in anterior teeth
(P > 0.45), and lip protection (P < 0.07) were not associated with
dental trauma.
Feldens et al., 2008; Andreasen and Sex, age Simple and multiple No significant association was found between TDI and sex (OR. 1.13; 5 (9)
Brazil (21) Andreasen logistic regression 95% CI: 0.63–2.05) or age (OR. 1.39; 95% CI: (0.77–2.50).
Ferreira et al., 2009; Fracture of the crown, Age Chi-square test The prevalence of dental trauma increased significantly with age 5 (8)
Brazil (22) color alteration, (P < 0.0001)
intrusion, and
extrusion
Goettems et al., Andreasen and Sex, age, overjet, Chi-square test and Dental trauma was associated with overjet (P = 0.02), overbite 6 (8)
2012; Brazil (10) Andreasen malocclusion, open Fisher’s exact test (P = 0.01), age (P < 0.01), occurrence of mild or moderate/severe
bite, overbite, anterior malocclusion (P < 0.01), and canine class (P = 0.04). No association
crossbite, crowding, was found between dental trauma and anterior crossbite (P = 0.16),
rotated teeth, canine open bite (P = 0.84), crowding (P = 0.42), or rotated teeth
class (P = 0.69).
Granville-Garcia et Hinds and Gregory Sex, age Chi-square test Dental trauma was associated with age (P < 0.001) and sex 4 (8)
el., 2006; Brazil (P = 0.012).
(23)
Granville-Garcia Hinds and Gregory Sex, age Simple and multiple Male children exhibited a greater likelihood of suffering trauma (OR: 5 (8)
et al., 2006; Brazil logistic regression 1.27 (1.08–1.15) and this increased with age (P < 0.05)
(24)
Granville-Garcia Hinds and Gregory Sex, age, occlusion, Chi-square test, logistic The probability of a child suffering a trauma increased with age 5 (8)
et al., 2010; Brazil overjet, lip coverage regression (2 years: OR 4.33 (1.26–14.89); 3 years: OR: 6.52 (1.92–22.11);
(9) 4 years: OR: 5.62 (1.65–19.10); 5 years: OR: 6.99 (1.99–22.59)0,
especially among boys (OR: 1.45; 95% CI: 1.02–2.06) with both open
bite and protrusion (OR. 1.72 (1.02–2.91).

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Table 3. Continued
Authors, year,
location of study TDI Variables Statistical analysis Outcomes Study quality
Jorge et al., 2009; Andreasen and Age, sex, dental caries, Chi-square test, simple Age was significantly correlated with the number of teeth affected 5 (8)
Brazil (25) Andreasen lip competence and multiple logistic (P = 0.001), revealing a larger number of injured teeth with an
regression increase in age. Gender, lip coverage, and dental caries were not
significantly associated with the occurrence of trauma (P > 0.05).
Kawabata et al., WHO Age Chi-square test Significant association with age (P < 0.001) 4 (8)
2007; Brazil (26)
Montandon et al. Not informed Age Chi-square test No association with age (P > 0.05) 4 (8)
1998; Brazil (27)
Norton and O’Conell, Andreasen and Overbite, sex, open bite, Simple and multiple TDI significantly associated with overjet <3.5 mm (OR: 0.52; 95% CI: 7 (8)
2012; Irlanda (28) Andreasen overjet logistic regression 0.38–0.71; P = 0.04), overjet >6 mm (OR: 2.99; 95% CI: 2–4.7;
P < 0.001). Significant association with anterior open bite (OR: 2.02;
95% CI: 1.32–3.08; P = 0.22). No significant association with sex
(P > 0.05). TDI significantly associated with overbite only in non-
adjusted regression model (P = 0.03)
Oliveira et al., 2007; Modified version of Ellis Anterior open bite, sex Chi-square, simple and Significant association between TDI and anterior open bite (OR: 2.11; 5 (8)
Brazil (29) classification multiple regression 95% CI: 1.33–3.34; P = 0.001). No significant association with sex
(Female: OR: 0.527; P = 0.496)
Piovesan et al., Children’s Dental Health Age, sex, overjet, lip Simple and multiple Significant association with age (2 years: OR: 2.19; 95% CI: 1.03–4.68; 7 (8)
2012; Brazil (12) coverage regression P < 0.05/3 years: OR: 2.35; 95% CI: 1.11–4.97; P < 0.05/≥4 years:
OR: 3.49; 95% CI: 1.69–7.19; P < 0.01), lip coverage (OR: 0.98;
95% CI: 0.54–1.78), and overjet (OR: 1.63; 95% CI: 1.06–2.53;

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
P < 0.05)
Robson et al., 2009; Hinds and Gregory Sex, overjet, lip Chi-square and simple Significant association between TDI and sex (male: OR: 1.62 (1.1–2.4; 7 (8)
Brazil (13) coverage and multiple P = 0.021), lip coverage (OR: 3.75; 95% CI: 1.8–7.7; P < 0.001),
regression and overjet (P < 0.001)
T€umen et al., 2011; Modified version of Ellis Age, sex, anterior open Chi-square, Fisher’s Significant association between TDI and sex (OR: 0.374; 95% CI: 0.179, 5 (8)
Turkey (2) classification bite, overjet exact test, logistic 0.781); overjet (OR: 0.092; 95% CI: 0.046, 0.184), and anterior open
regression (simple and bite (OR: 0.065, 95% CI: 0.032, 0.130)
multiple)
Viegas et al., 2010; Andreasen Gender, anterior Chi-square test and OR Significant association between TDI and overjet (P = 0.022; OR: 2.24; 5 (8)
Brazil (3) crossbite, anterior 95% CI: 1.11–4.55), anterior crossbite (P = 0.018; OR: 0.38; 95% CI:
open bite, overbite, 0.17–0.87). No association with sex (P = 0.294; OR: 0.80; 95% CI:
dental caries, overjet, 0.53–1.21); lip competence (P = 0.319; OR: 1.34; 95% CI: 0.75–
lip coverage 2.39); anterior open bite (P = 0.501; OR: 1.31; 95% CI: 0.60–2.86);
overbite (P = 0.616; OR: 1.14; 95% CI: 0.68–1.91); dental caries
(P = 0.997; OR: 1; 95% CI: 0.66–1.51); dental caries on maxillary
anterior teeth (P = 0.860; OR: 1.05; 95% CI: 0.62–1.77); DDE
(P = 0.296; OR: 0.80; 95% CI: 0.53–1.21); and DDE on maxillary
anterior teeth (P = 0.063; OR: 0.60; 95% CI: 0.35–1.03).
Viegas et al., 2006; Andreasen and Sex, overjet, lip Chi-square test Significant association between TDI and lip coverage (P = 0.01). No 4 (8)
Brazil (30) Andreasen coverage significant association between TDI and sex (P > 0.05).
Wendt et al., 2010; Andreasen and Sex, age Chi-square test Significant association between TDI and age (P = 0.001/private school). 5 (8)
Brazil (31) Andreasen No significant association with sex (private: 0.05; public: 0.43).
Analysis performed based on type of school (P = 0.05 and
Clinical factors and traumatic dental injury

P = 0.43).
5
6 Corr^
ea-Faria et al.

involved Brazilian children (3, 8–13, 20–28, 30–33).

Study quality
The remaining studies were conducted in Ireland (29),
Turkey (2), and Chile (34).

3 (8)

4 (8)

5 (8)
The studies used different criteria for diagnosis of
TDI: The Andreasen index was used in 11 studies (3, 8,
10, 20–22, 26, 29, 31, 32, 34); the Hinds and Gregory
criteria were used in five studies (9, 13, 24, 25, 35); the
Ellis classification was used in three studies (2, 11, 30);

Significant association between TDI and age (P < 0.001), sex (OR:
the Children’s Dental Health criteria were used in one

No significant association with age (P = 0.44) or sex (P = 0.16)

study (12); and the criteria of the World Health Orga-

1.38; P = 0.007), lip coverage (OR: 1.55; P = 0.002), and

nization were used in one study (27). In one study,
TDI was evaluated based on the presence of crown
fracture, color alteration, intrusion, and extrusion (23).
The study by Scarpari et al. (33) did not report the cri-
No significant association with sex (P > 0.05).

malocclusion (OR: 1.42; P < 0.001). teria that were used.

Oral characteristics investigated

Lip coverage
Lip coverage was evaluated in 12 studies (3, 8, 9, 11–13,
19, 20, 24, 30, 33, 34), eight of which were included in
the meta-analysis (3, 8, 11–13, 19, 25, 33). In the remain-
ing four studies, it was not possible to extract data for
meta-analysis from one (30), two studies were excluded
Outcomes

after the sensitivity test (9, 34), and one was a case–con-
trol study (20). In the meta-analysis, children with inade-
quate lip coverage had a significantly greater frequency
of TDI (OR = 1.81; 95% CI: 1.50–2.17) (Fig. 2).

Malocclusion
logistic regression
Chi-square test and
Statistical analysis

Overbite – Overbite was evaluated in four studies

Chi-square test

Chi-square test

(3, 10, 21, 28), two of which were included in the meta-
analysis (3, 10). The other studies were excluded due to
the impossibility of grouping the data (29) and the use
of a different study design (21). Figure 3 shows the
meta-analysis of two studies regarding the association
between TDI and overbite (3, 10). The pooled effect
measures for the two studies demonstrated that chil-
Sex, age, occlusion, lip

dren with overbite did not have increased frequency of

coverage, overjet

TDI (OR: 1.43; 95% CI: 0.94–2.19).

Other malocclusions, such as anterior open bite,
were evaluated in nine studies (1, 2, 9–11, 20, 29, 30,
Variables
Sex, age

Sex, age

35). Anterior open bite was associated with TDI in the

majority of studies in regression models adjusted for
overjet (2, 20, 29), gender (20, 30), age (2, 20), and lip
coverage (20). Similar results were found using simple
logistic regression (11) and the chi-square test (9).
However, no significant association between these vari-
Hinds and Gregory

ables was found in the studies conducted by Viegas

et al. (3) (OR: 1.31; 95% CI: 0.60–2.86) and Goettems
Not informed

et al. (10) (P = 0.84). In the study by Bonini et al. (20),

Andreasen

the multiple regression analysis demonstrated a statisti-

TDI

cally significant association between anterior open bite

and TDI (OR: 1.46; 95% CI: 1.05–2.01), but this
malocclusion lost its significance when lip coverage was
Table 3. Continued

incorporated into the model (OR: 1.12; 95% CI: 0.68–

Scarpari et al., 2004;

Mu~noz et al., 2006;

2004; Brazil (34)

1.86).
location of study

Menezes et al.,

As the data on the association between increased

Authors, year,

Brazil (32)

Chile (33)

overjet and TDI had statistical heterogeneity among

the studies above 75%, the association between these
variables was discussed qualitatively and meta-analysis
was not performed. Increased overjet was evaluated in

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Clinical factors and traumatic dental injury 7

2566 records identified through

Identification
database searching:
PubMed (555); Web of Science
(378); Cochrane (204); Lilacs
(240); Embase (1189)

1403 duplicate records removed

Screening
1163 records screened

1125 excluded

14 full-text articles excluded:

38 full-text articles assessed for
Eligibility

4 involved permanent dentition;

eligibility
6 did not investigate factors
associated with TDI;
3 had samples only composed of
children with TDI
1 abstract was presented at an event

24 studies included in qualitative

synthesis
Included

16 studies included in quantitative

synthesis (meta-analysis)
Fig. 1. Flow diagram of systematic
review

Study name Statistics for each study Odds ratio and 95% CI

Odds Lower Upper P-Value Relative Relative

ratio limit limit weight weight
Muñoz et al., 2006 1.779 1.391 2.275 < 0.001 25.17
Robson et al., 2009 4.042 1.937 8.435 < 0.001 5.56
de Vasconcelos Cunha Bonini 2.289 1.479 3.540 < 0.001 12.89
et al., 2009
Jorge et al., 2009 1.431 0.974 2.101 0.068 15.36
Viegas et al., 2010 1.340 0.753 2.387 0.320 8.39
Dutra et al., 2010 1.357 0.828 2.224 0.225 10.74
Bonini et al., 2012 1.997 1.213 3.287 0.007 10.58
Piovesan et al., 2012 2.003 1.242 3.229 0.004 11.29
1.810 1.504 2.179 < 0.001

0.01 0.1 1 10 100

Favors adequate Favors inadequate

Fig. 2. Forest plot of meta-analysis for eight cross-sectional studies evaluating lip coverage and TDI in primary dentition. Pooled
summary effect measures [odds ratio (OR) and 95% confidence interval (CI)] indicated that inadequate lip coverage was
significantly associated with TDI. Heterogeneity: I2 = 28.6%.

12 studies, the majority of which confirmed the associa-
tion with TDI in both bivariate analyses (10, 13) and
regression models (2, 3, 11, 12, 29).
Dental caries – Dental caries was evaluated in only
three cross-sectional studies (3, 8, 26), two of which
were included in the meta-analysis (3, 8). No significant
association was found between dental caries and TDI
(pooled OR: 0.87; 95% CI: 0.61–1.26) in this meta-ana-
lysis (Fig. 4).
Socio-demographic characteristics investigated
Gender
Gender was evaluated in 20 studies (2, 3, 8–13, 20–22,
24, 26, 29–31, 33–35), 13 of which were included in the

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
8 Corr^
ea-Faria et al.

Study name Subgroup within study Statistics for each study Odds ratio and 95% CI

Odds Lower Upper

ratio limit limit P-Value
Viegas et al., 2010 cross-sectional 1.141 0.682 1.909 0.616
Goettems et al., 2012 cross-sectional 1.761 1.106 2.806 0.017
1.438 0.940 2.199 0.094
0.01
Favors normal Favors overbite
Fig. 3. Forest plot of meta-analysis for
two cross-sectional studies evaluating
overbite and TDI in primary dentition.
Pooled summary effect measures [odds
ratio (OR) and 95% confidence interval
(CI)] indicated that overbite was not
0.1 1 10 100 significantly associated with TDI.
Heterogeneity: I2 = 33.54%.

Fig. 4. Forest plot of meta-analysis for

two cross-sectional studies evaluating
dental caries and TDI in primary
dentition. Pooled summary effect
measures [odds ratio (OR) and 95%
confidence interval (CI)] indicated that
dental caries was not significantly
associated with TDI. Heterogeneity:
I2 = 0.0%.

Fig. 5. Forest plot of meta-analysis for 13 cross-sectional studies evaluating sex and TDI in primary dentition. Pooled summary
effect measures [odds ratio (OR) and 95% confidence interval (CI)] indicated that male sex was significantly associated with TDI.
Heterogeneity: I2 = 52.6%.

meta-analysis (2, 3, 8–13, 20, 24, 29, 30, 35). It was not
possible to pool the data from four studies for meta-
analysis (26, 31, 33, 34), one was removed after the
sensitivity test (32), one was a cohort study (22), and
one was a case–control study (21). In this meta-analy-
sis, TDI was more frequent among males than females
(pooled OR: 1.24; 95% CI: 1.09–1.41) (Fig. 5). No
publication bias regarding gender and TDI was found
in the visual analysis of the funnel plot (Fig. 6). Egger’s
test also revealed no statistical significance for publica-
tion bias (P = 0.672).
Age
Age was evaluated in 17 studies (2, 9, 10, 12, 21–24,
26–28, 30–35), eight of which were included in the
meta-analysis (9, 10, 12, 20, 24, 27, 30, 35). It was not
possible to pool the data from the other studies
(Fig. 6). In this meta-analysis for TDI comparing pairs
of age-groups, a younger age was a protection factor
against the occurrence of TDI: 1 vs 2 years (pooled
OR: 0.47; 95% CI: 0.38–0.58), 2 vs 3 years (pooled
OR: 0.78; 95% CI: 0.67–0.91), and 3 vs 4 years

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Clinical factors and traumatic dental injury 9

Funnel Plot of Standard Error by Log odds ratio

0.0

0.1

Standard Error
0.2

0.3

Fig. 6. Funnel plot of studies testing

association between gender and TDI 0.4
–2.0 –1.5 –1.0 –0.5 0.0 0.5 1.0 1.5 2.0
(n = 13) for publication bias; Egger’s
test: P = 0.672. Log odds ratio

Group by Study name Subgroup within study Statistics for each study Odds ratio and 95% CI
Subgroup within study
Odds Lower Upper P-Value
ratio limit limit
1 vs 2 years Menezes et al., 2004 1 vs 2 years 0.489 0.303 0.789 0.003
1 vs 2 years Granville-Garcia et al., 2006 1 vs 2 years 0.571 0.394 0.828 0.003
1 vs 2 years Oliveira et al., 2007 1 vs 2 years 0.155 0.019 1.240 0.079
1 vs 2 years Kawabata et al., 2007 1 vs 2 years 0.446 0.315 0.632 0.000
1 vs 2 years Granville-Garcia et al., 2010 1 vs 2 years 0.221 0.065 0.755 0.016
1 vs 2 years Piovesan et al., 2012 1 vs 2 years 0.444 0.233 0.845 0.014
1 vs 2 years 0.475 0.386 0.585 0.000
2 vs 3 years Menezes et al., 2004 2 vs 3 years 0.876 0.612 1.253 0.469
2 vs 3 years Granville-Garcia et al., 2006 2 vs 3 years 0.836 0.642 1.087 0.181
2 vs 3 years Oliveira et al., 2007 2 vs 3 years 0.398 0.177 0.893 0.026
2 vs 3 years Kawabata et al., 2007 2 vs 3 years 0.704 0.528 0.940 0.017
2 vs 3 years Granville-Garcia et al., 2010 2 vs 3 years 0.661 0.387 1.130 0.130
2 vs 3 years Piovesan et al., 2012 2 vs 3 years 1.085 0.620 1.898 0.775
2 vs 3 years Goettems et al., 2012 2 vs 3 years 0.918 0.427 1.974 0.826
2 vs 3 years 0.787 0.677 0.915 0.002
3 vs 4 years Menezes et al., 2004 3 vs 4 years 0.708 0.504 0.994 0.046
3 vs 4 years Granville-Garcia et al., 2006 3 vs 4 years 0.868 0.691 1.091 0.225
3 vs 4 years Oliveira et al., 2007 3 vs 4 years 0.737 0.400 1.355 0.326
3 vs 4 years Granville-Garcia et al., 2010 3 vs 4 years 1.118 0.690 1.810 0.651
3 vs 4 years Bonini et al., 2012 3 vs 4 years 0.904 0.575 1.421 0.662
3 vs 4 years Piovesan et al., 2012 3 vs 4 years 0.727 0.428 1.237 0.240
3 vs 4 years Goettems et al., 2012 3 vs 4 years 0.695 0.435 1.109 0.127
3 vs 4 years 0.823 0.712 0.951 0.008
4 vs 5 years Menezes et al., 2004 4 vs 5 years 1.259 0.907 1.747 0.170
4 vs 5 years Granville-Garcia et al., 2006 4 vs 5 years 1.076 0.869 1.331 0.502
4 vs 5 years Oliveira et al., 2007 4 vs 5 years 1.051 0.588 1.879 0.866
4 vs 5 years Granville-Garcia et al., 2010 4 vs 5 years 0.800 0.499 1.282 0.353
4 vs 5 years Goettems et al., 2012 4 vs 5 years 0.903 0.584 1.397 0.647
4 vs 5 years 1.055 0.907 1.226 0.487
0.01 0.1 1 10 100
Favors younger Favors older

Fig. 7. Forest plot of meta-analysis of studies testing association between age and dental trauma in primary dentition (n = 8).
Study-specific and summary effect estimates [odds ratio (OR) and 95% confidence interval (CI)]. Heterogeneity: I2 = 0.0% in
each age subgroup.

(pooled OR: 0.82; 95% CI: 0.71–0.95). However, no
significant difference was found between 4 and 5 years
(pooled OR: 1.05; 95% CI: 0.90–1.22) (Fig. 7).
Methodological quality
The quality of the cross-sectional studies ranged from 3
to 7 on the 8-point scale. The quality of the case–con-
trol study was 6 on the 9-point scale (Table 2). The
most common shortcomings were a failure to report
eligibility (exclusion) criteria (8, 9, 12, 20, 24, 27, 29,
30, 33, 34), failure to adjust for confounding variables
through regression analysis (21, 23, 24, 27, 28, 31–34),
and failure to report missing data (9, 24, 27, 33, 34).
Discussion
The aim of the present systematic review and meta-
analysis was to find scientific evidence regarding clinical

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
10 Corr^
ea-Faria et al.
characteristics associated with TDI in the primary
dentition. This information is essential for planning
measures of prevention aimed to reduce the occurrence
of TDI in children. The findings demonstrate a consid-
erable tendency toward conducting and publishing
cross-sectional studies. This design of study does not
allow the determination of a causal relation between
clinical factors and TDI. This fact compromises the
quality of evidence (45, 46).
In the evaluation of the methodological quality of the
articles, one of the most common flaws was the absence
of information on the exclusion criteria. Such informa-
tion is important for the comparison of sample charac-
teristics among different studies and allows the
elimination of confounding variables during the sample
selection process. The absence of adjustments for con-
founding variables through regression analysis was
another flaw found in the studies. The adjustment for
confounding variables allows the simultaneous analysis
of other variables that may be risk factors for TDI,
demonstrating the role of each variable in the etiology of
TDI. The lack of such an analysis can compromise the
interpretation of the results, as it is possible for a signifi-
cant association to be the result of the combination of
variables rather than the effect of the variable investi-
gated. Thus, further studies are needed with greater rigor
regarding the description of the sample selection criteria
and the conduction of multivariate analyses.
In this study, younger ages (1–3 years) served as a
protection factor against TDI, whereas children aged 4
and 5 years had a greater chance of exhibiting TDI. This
finding is due to the cumulative characteristic of TDI
(45). This result was confirmed in previous studies (23,
26, 32). Moreover, other studies found no significant dif-
ference in age-groups (2, 22, 34). In cross-sectional stud-
ies, however, it is only possible to compare the number
of teeth affected in children of different ages, which limits
the interpretation of the findings. The cumulative effect
of TDI should be investigated in longitudinal studies,
which allows recording TDI in a given period of time.
While some studies report that boys are more predis-
posed to TDI (2, 20, 25, 35) according to the meta-ana-
lysis, girls had a higher probability of exhibiting this
condition in one publication (13). The greater fre-
quency of TDI among boys may be explained by
behavioral and cultural factors (2). Boys tend to prac-
tice more vigorous play styles and have a more aggres-
sive nature in comparison with girls (30), which
predisposes them to accidents that can result in TDI.
There was no publication bias in the studies selected
according to the funnel plot and Egger’s test. Hetero-
geneity in the present systematic review was considered
notable (I2: 52.6%), which, together with the evidenced
provided by the cross-sectional design, may limit the
association between gender and TDI. Moreover, most
studies showed no statistically significant difference
between sexes (3, 8–12, 22, 29, 30). This finding is justi-
fied by the fact that preschool children are usually
involved in the same activities and are therefore
exposed to the same environmental risk factors.
Increased overjet and inadequate lip coverage
(11–13, 31, 34, 35) expose the anterior teeth to
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
traumatic events and have therefore been associated
with TDI in children. Due to inadequate soft tissue
protection, the force is applied directly to the teeth,
causing fracture or dislocation (47). These clinical char-
acteristics (2, 3, 11–13, 29, 34) were significantly associ-
ated with TDI in most studies; however, caution
should be exercised when comparing the results due to
the use of different cutoff points of overjet (9, 10, 20,
21, 29, 35). Moreover, it is necessary to consider the
possible effect of confounding variables, such as inade-
quate lip coverage, in bivariate analyses.
For several variables such as anterior crossbite
(3, 10), anterior open bite (1, 2, 9, 11, 20, 29, 30, 35),
rotated teeth (10), and canine class (10), the results are
isolated or conflicting precluding a definite conclusion.
Overbite (3, 10) was not associated with TDI in meta-
analysis. However, the evidence is limited due to the
small number of studies submitted to meta-analysis.
The strength of each association was demonstrated
by the significant pooled ORs for gender, age, and lip
coverage. These associations were also relevant when
considering their plausibility and consistency, as con-
firmed by the comparison of the results with previous
descriptions in the literature. However, caution should
be exercised when analyzing the cause-and-effect rela-
tionship, considering the lack of temporality in the pri-
mary studies included in the present systematic review
and meta-analysis (48). Thus, longitudinal studies are
needed to allow the understanding of causal relation-
ships and risk factors for TDI. These studies will be
possible to follow children exposed and not exposed to
the risk factors such as increased overjet and to verify
whether this exposure increases the risk of TDI. More-
over, the majority of studies analyzed were conducted
in Latin America, which constitutes a limitation of the
present systematic review. Further investigations in
other countries should be encouraged.
The findings of the present systematic review and
meta-analysis are useful to healthcare professionals and
the establishment of preventive measures directed at
preschool children regarding the occurrence of TDI.
The confirmation of the association between increased
overjet and TDI suggests the need for early orthodon-
tic treatment for increased overjet (49), which may
reduce the occurrence of TDI. Another aspect that
should be stressed is the abandonment of non-nutritive
sucking habits to avoid the increase in overjet and
inadequate lip coverage (50, 51), which are risk factors
for TDI and use of mouthguards. These measures were
suggested in cross-sectional studies and there is still no
quantitative data on reducing the incidence of TDI
from its implementation. It is suggested that longitudi-
nal studies are undertaken to enable this assessment.
Other preventive measures include intersectoral
actions and health education that aim to ensure protec-
tion and prevention of accidents that may be related to
the TDI, as well as the integration of the multidisci-
plinary team in addressing the risk factors common to
the TDI and other traumatic injuries (52, 53). Clinical
measures combined with parental awareness regarding
the importance of primary teeth and general safety
measures, such as the supervision of children during

play and the use of a seatbelt (54), and awareness for
parents could result in a reduction in the occurrence of
TDI as well as a reduction in treatment costs (55).
Conclusions
In conclusion, this study confirmed the association
between TDI in the primary dentition and increased
overjet, lip coverage, and gender.
Acknowledgements
This study was supported by the following Brazilian fos-
tering agencies: National Research Commission (CNPq;
Ministry of Science and Technology) and the State of
Minas Gerais Research Foundation (FAPEMIG).
Conflict of interest
The authors certify that they have no commercial or
associative ties that represent a conflict of interest in
connection with the manuscript.
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