Dental Trauma Among 12-15 year-old School Girls in Riyadh, Saudi Arabia

Ibrahim Al-Majed*

Assistant Professor / Consultant, Pediatric Dentistry Division, Department of Pediatric Dentistry and
Orthodontics. College of Dentistry King Saud University P.O Box 60169 Riyadh 1154
Correspondence:“Dr. Ibrahim Al-Majed”

How to CITE:
J Pak Dent Assoc.2011; 20 (1): 29-34

OBJECTIVE:
To determine the prevalence of traumatic dental injuries for Saudi school girls aged 12-15 years in
Riyadh, Saudi Arabia.

METHODOLOGY:
A cross sectional study was conducted in which the examination form and questionnaire used in this
study were the same previously designed and utilized forms by Al-Majed et al12 for the purpose of
facilitating the comparison of dental trauma results of the two genders.

RESULT:
A total of 255 girls aged 12-15 years, attending 12 schools in Riyadh were examined at school. The
prevalence of dental trauma in 255 12-15-year-old Saudi girls was 31.4%. The commonest dental
trauma was fracture of enamel (59.4%), discoloration (25%), fractured into dentin (2.3%) and loss of
the tooth due to trauma (1.6%). A significant relationship (p=0.01) between the increased overjet
(≥4mm) and the permanent dentition was reported. The present study found that the treatment of
dental trauma in 12-15-year-old girls was trivial. The current sample of Saudi girls showed slightly
lower prevalence of dental trauma in 12-15year-old girls than the previous Saudi boys study but
higher prevalence rate than the reported results of the United Kingdom children’s Dental Health
Survey of the same age groups.

CONCLUSION:
The prevalence of dental trauma to maxillary incisors in 12-15 year old Saudi schoolgirls was 31.4%
which is considered high. The present study showed a significant relationship between dental
trauma in 12-15 year old schoolgirls and the excessive overjet. The awareness program in dental
trauma prevention should include certain dietary habits and home safety.

KEYWORDS:
Prevalence, dental trauma, Permanent incisors, school girls; Saudi Arabia.

Introduction
Baker wrote in 1884 how in 32 BC the Roman  physician, Celsius, fastened teeth accidentally
loosened by a blow, to those that were firm, with a gold wire which prove that since the time of
Romans
traumatic dental injuries were recognized with sincere attempts to manage them 1. It has been
reported that the prevalence of dental trauma in permanent teeth range from 7.3% to 58% The great
variation in reported
prevalence rates can be attributed to different factors, including type of study [retrospective; e.g
Jarvinen5, Caldas and Burgos 6, cross sectional; e.g Davies et al 7, and other studies were purely
dental injuries population type e.g. Liew and Daly 8, Al-Nazhan et al 9 different dental
trauma classification, sample size, methodology, and also researched in different parts of the world.
The first stage to manage a dental trauma is to know how significance of dental trauma among a
defined population.

In Saudi Arabia, Al-Majed et al 12 carried out the first epidemiological study in Saudi schoolboys; the
study involved 862 boys aged 12-14 years attending 20 schools in Riyadh. The prevalence of dental
trauma was 34%. The commonest dental trauma was fracture of enamel followed fracture into
enamel and dentine then fracture into enamel-dentine and pulp, avulsion and the least was
discoloration. When Al-Majed et al 12 study was compared with the reported results of the United
Kingdom Children’s Dental Health Survey 13 with the same diagnostic index Saudi schoolboys
showed higher prevalence of dental trauma than the UK’s children of the same age groups. There is
a lack of information regarding dental trauma epidemiology in Saudi Arabian girls, aged 12-15 year-
old and a need for further research into dental trauma to establish a baseline for future preventive
and trauma management plans in Saudi Arabia. The objectives of the present study were to
determine the prevalence of dental trauma in the permanent dentitions of 12-15-year-old girls in
Riyadh, to determine the relationship between increased overjet and dental trauma in the permanent
dentitions in Saudi girls and also to found out, what type of treatment provided for dental trauma for
this group

Methodology
Riyadh is the capital city of the Kingdome of Saudi Arabia with a population of a complex structure
with of different ethnic origins. As such it was an appropriate site to study the prevalence, etiology,
predisposing factors and treatment needs for dental trauma in children in Saudi Arabia. The clinical
examination of the study was done by one trained and calibrated dental examiner. The examination
form and questionnaire used in this study were the same previously designed and utilized forms by
Al-Majed et al12 for the purpose of facilitating the comparison of dental trauma results of the two
genders. Official permission was obtained and materials needed to implement the study were
prepared. For the purpose of sampling, Riyadh city was divided into two sections: northern section
and southern section. Schools were listed according to the two sections. A table of random
allocation14 was used to randomly select 12 schools.
It was planed that 20 to 21 children would be examined in each school, giving a predicted sample of
255 girls aged 12-15 years (20 schoolgirls were selected from 9 schools and 21 schoolgirls from 3
schools). Once permission had been obtained from King Saud University College of Dentistry and
the Ministry of Education to visit the schools and conduct a dental examination of schoolgirls, the
Ministry sent official letters to the selected schools. In addition, permission was sought from each
selected school to allow the study to proceed and allow the investigators to carry out the dental
examinations. Those schoolgirls examined in a room usually adjacent to the classroom, with the
child lying on a chair. A portable source of light (halogen 40W lamp) was used for dental
examination together with individually wrapped and sterilized mouth mirrors, gloves and cotton wool
rolls.

A full record of the exact age of the schoolgirls on the visit was recorded then each girl was
examined for dental trauma.

Using the same dental trauma examination’ criteria

which was used previously to examine the schoolboys by Al-Majed et al12 the maxillary permanent
incisors of schoolgirls aged 12-15 years were examined according to the following criteria:

Code 0 No trauma Code 1 Discoloration

Code 2 Fracture involving enamel

Code 3 Fracture involving enamel & dentine

Code 4 Fracture involving enamel, dentine and pulp Code 5 Missing due to trauma

Code 6 Acid-etch composite restoration

Code 7 Permanent replacement including crown, denture, bridge pontic

Code 8 Temporary restoration

Code 9 Assessment could not be made, when the tooth was either missing or badly broken by
dental caries.

Plastic rulers were used to measure the degree of overjet. All coded readings were dictated to a
scribed during clinical examination for entry into an examination sheet. All collected data were
checked for accurate coding and correct data entry into examination sheets, then entered into a
computer data file and verified by the data preparation service at College of Dentistry, King Saud
University. An SPSS statistical Program (version 12.0) was used to analyzed the data descriptively
and a Chi square test examined the relationship between overjet and dental trauma.Upon
completion of the dental examination each schoolgirl was given a certificate of completion of dental
examination with some preventive messages.

To ensure the reproducibility of the diagnostic criteria, 10% of the schoolgirls were re-examined. In
each dental examination session the scribe selected 3-5 children for re-examination without
informing the examiner and another clinical examination was undertaken for the selected children at
that same school visit. Then Cohen’s Kappa 14 was used to test the shift of diagnosis between the
first and second examinations.

Results
Clinical examination in 12-15 year old Saudi school girls:
Of the 255 girls aged 12-15 years dentally examined (mean age 13.04 years, standard deviation ±
0.42), 128 (31.4%) had sustained at least one dental trauma to a permanent maxillary incisor. The
prevalence of dental trauma in the permanent maxillary incisors is recorded in
According to tooth type, the left permanent central incisor was found to be the most traumatized
tooth followed by the right permanent central incisor then the left lateral incisor and the least
traumatized was the right lateral incisor. Fracture of enamel was the most frequent dental injury,
representing 7.5% of 1018 teeth assessed; discoloration (3.1%) then fracture into dentine (0.3%),
whilst 2 (0.2%) incisors were lost due to trauma of the 128 schoolgirls who had sustained trauma to
at least one permanent incisor, only 15 girls (1.5% of the assessed teeth and 11.7% of the
traumatized teeth) had received any definitive dental treatment. This treatment was composite
restoration only.

A Chi square test showed a statistical relationship between the increased overjet (≥4mm) and the
dental trauma of 12-15 year-old Saudi girls (P>0.05). Reproducibility statistics for dental trauma in
permanent incisors: the reproduction of the diagnostic criteria showed a good agreement (0.91)
using Cohen’s Kappa analysis.

Questionnaire survey in 12-15 year old Saudi school girls:

The response rate reached 100% as part of the methodology; schoolgirls aged 12-15 years were
allowed to fill the questionnaires in their classrooms prior to the dental examination which had
ensured immediate and high response rate. Forty schoolgirls reported that they had dental trauma,
then they answered the question related to their experience: Immediately after dental trauma 27 girls
(68%) reported that there were nothing happened or they cannot recall. Only one girl reported loss of
conscious and 12 girls reported they had experienced headache state of drowsiness. In relation to
location and causes of dental trauma in permanent teeth is shown in Tables 2, 3, 4 and 5. Looking at
the dental trauma occurred at home is shown in Table 3

Frequency of trauma: 70% (n=28) reported to occurred once, 20% (n=8) twice, three and above
occurred in 10% (n=4). Kind of fractured teeth: 42.5% (n=17) occurred in permanent teeth, 37.5%
(n=15) occurred only for primary teeth and 20% (n=8) occurred in both dentitions. From the
questionnaire, the forty girls who had dental trauma reported that 50% sought in private clinic, 10
girls 25% did not seek treatment, 15% (n=6) sought dental care in government hospital dental
center.(5%) went to primary care center and other 2 girls (5%) went to emergency clinics in a
hospital. Cause of trauma is shown in Table 4
When they were asked if they had looked at missed tooth or part of the tooth (85%) (n=34)
responded that they did not considered looking at the tooth or part of it. In relation to their knowledge
towards avulsed teeth only 11 girls participated. 6 girls reported that they may use dry tissue and
only one girl who chose milk as mean of transportation of avulsed teeth. Time elapsed after trauma
57.5% (n=23) they went to dentist less than one hour, 25% (n=10) did not seek dental care and 7
girls (17.5%) reported seeking help after two hour of trauma. Protrusion of teeth: About 39% (n=99)
of the 255 feel that their anterior teeth were protruded, and 10% (n=25) received warning of the
effect of the excessive overjet on possibility of trauma. Clinically it was found that 24% (n=62) had
over jet of 4 and above

Chi-square test showed statistically significant relationship between the reported protrusion of teeth
in relation to the professional (dentist) warning of the risk of sustaining dental trauma because of the
excessive overjet as shown in Table 6. Of the 255 girls 20 (8%) believe that there is preventive
measures for dental trauma. In relation to frequency of eating nuts (e.g. Pumpkin & Watermelon
seeds) majority of the sample 73% (n=187) consume nuts (vegetables seeds) from arrange of once
per week to every day consumption there was statistically significant between eating nuts and dental
trauma (P=0.01i.e.P<0.05)
Discussion
This present cross-sectional study was conducted to reveal the dental trauma status among 12-15
year-old Saudi schoolgirls. In addition, prevalence data obtained from the study can be used in direct
public health preventive measures. Comparison of one dental trauma study and another is
considered a very difficult task because of the noticed variations between them in terms of different
diagnostic criteria, different methodologies and different targeted populations 16, 17. The prevalence of
dental trauma to maxillary incisors in 12-15 year old Saudi schoolgirls was 31.4% which is slightly
lowered than
34% previously reported in two epidemiological studies; one schoolboys study in Riyadh by Al-Majed
et al12 and Hamilton et al18 in Manchester’s children of the same age group. Moreover this
prevalence (31.4%) of the current study is higher than the UK’s survey in 1993 of 17% for 12 year
old British children19. In 1983 UK’s national survey Todd and Dodd 20 reported a prevalence of 29%
for 12 years old children and 33% for 14 year old children, which is closely similar to the present
study prevalence. The dental trauma prevalence variation between the UK’s studies and the present
study can be attributed to the different life styles (kind of games and ways of playing), the effect of
different home design in different countries (homes in Saudi Arabia tend to be relatively larger than
in UK which give Saudi children more space for active playing than the British). The finding that
Saudi schoolgirls experienced more dental trauma than Saudi schoolboys also agrees with other
world-wide studies12, 28-30. The left and right permanent central incisors were found to be the most
traumatized tooth followed by the right and left permanent lateral incisors which was similar to the
finding of Saudi boys study12,and other studies like Stockwell et al 21, Hergreaves et al22 and Rocha
MJC and Cardoso23. The most prevalent dental trauma type in 12-15 year old girls was fracture of
enamel of 59% which is in agreement with the findings with UK survey and other studies 26-28.
This type of trauma in the absence of other sign and symptoms would not necessitate a lengthy
dental care. The less common type of dental trauma in 12-15 year old Saudi girls is fracture of
enamel and dentine of 2.3% with no pulpal involvement this finding is much lowered than 15.2% and
5% with fractures involving the pulp found in Saudi boys study. This showed girls sustained lesser
involvement of severe types of dental trauma than boys. These differences between the two studies
can be attributed to the different gender attitude towards dental care in which the present study girls
found to seek treatment of 11.7% of traumatized maxillary permanent incisors more often than Saudi
boys12 of only 2.4%. Moreover boys found to be less motivated towards self care and dental
appearance than girls. The treatment percentage of Saudi schoolgirls is low which in agreement of
the reported treatment neglect of dental trauma in other developing countries such as Syria 26 and
Nigeria 27 which is a reflection of low dental awareness among Saudi children and their parents.
Dentists should motivate and educate children and their parents on the need to treat and follow up
dental traumatic injuries to permanent dentitions.
The present study showed a statistical significant relationship between dental trauma in 12-15 year
old schoolgirls and the excessive overjet ( ≥ 4mm.) this finding is in agreement with several dental
trauma studies 5, 12,15,25 and the UK’s survey20. Preventive measures like mouthguards need to be
implemented to reduce the incidence of dental trauma. The study showed that only 40 schoolgirls
aged 12-15 years recognized that they had dental trauma whereas clinical examination showed 125
girls with different types of fractured anterior incisors. This variation between the examined and the
reported is on accordance with Al-Majed et al12
which can be attributed to the difference between the dentist’s evaluation and the perception of
schoolgirls of the dental trauma as professional examination had included all types of fractures minor
and major whereas the studies age group 12-15 year old schoolgirls were more towards symptoms
based evaluation which may not consider asymptomatic chipped enamel. Most of dental trauma
sustained by schoolgirls in this study occurred at home (67.5%) followed by school (15%) whereas in
the previous schoolboys study16 dental trauma located at home (56%) and then followed by sport
activity (23%). This difference between the two studies is due to different in activities and interest of
the two genders in addition to a social cultural dimension in which most of the Saudi girls activities
occurred at home which may have an influence in the incidence of dental trauma.

Main lounge room is the most commonly used place within homes which increase the chances of
developing dental trauma in this room than the other home places, this necessitate the need for
increased safety measures in main lounge and other places in order to reduce the incidence of
dental trauma. About half of the reported dental trauma in the present study was caused by fall into
ground which reported to be hard concrete ground which could contribute to the occurrence of
different types of dental trauma. Half of schoolgirls went to private dental clinics for management of
dental trauma the other half sought dental care in government clinics,

Which indicate the need to direct dental trauma awareness programs not only to children and their
parents but also dentist, physician in both private and government sectors.Although more than half
of the respondent sought dental care within the first hour, most of these schoolgirls did not look for
the missing tooth or part of it which stressed on the need for educational program showing the
importance of preventing dental trauma and the benefits of immediate treatment and ways of
managing avulsed teeth by child, parents and teachers.

Al-Majed et al12 postulated that an eating habit of consuming different vegetables seeds (e.g.
Pumpkin and watermelons seeds ..etc.) could had an effect on dental trauma among schoolboys in
Riyadh, the current study showed that there is a statistically significant between eating nuts (e.g.
Pumpkin and watermelons seeds..etc.) and the occurrence of dental trauma which may be the
cause of micro to macro fractures of the permanent incisors. Furthers studies are necessary to
assess the magnitude of this dietary habit and its dental implications. Children and their parent
should be aware of this finding and awareness should include messages to reduce the quantity and
frequency of such food consumption.

Conclusion
The prevalence of dental trauma to maxillary incisors in 12-15 year old Saudi schoolgirls was 31.4%
which is considered high. Most of the accidents of fractured teeth in permanent dentitions occurred
at home. Therefore parents should be educated on the safety measures at homes which can reduce
the incidence of dental trauma in various home sites.

There is a strong association between consumption of Pumpkin and watermelons seeds and dental
trauma which could cause micro to macro fractures of the permanent incisors. This finding should be
included in the parents, children awareness program in dental trauma prevention.
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