Rhouma, Ousama Hadi
Epidemiology, socio-demographic determinants and outcomes of paediatric facial and dental injuries in Scotland.
PhD thesis, University of Glasgow.
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Facial injury is less common in childhood than adulthood. However, it is still a significant cause of morbidity and presentation in hospital emergency departments. The pattern, time trends, and key socio-demographic determinants of facial injuries in Scottish adults admitted to hospital have previously been reported but this is not the case in the paediatric population and the question of whether such injuries are equally distributed across all socio-economic groups has not been answered. In contrast to the epidemiology of facial injuries in the paediatric population, traumatic dental injuries in children and adolescents have become one of the most frequent forms of treatment in dental practice. This suggests that traumatic dental injuries are common in childhood and are a significant cause of morbidity and presentation in hospital emergency departments. The relationship between socio-economic circumstances and the commonest dental disease (dental caries) in Scotland is well established and children resident in the most deprived areas experience more dental disease. However, this relationship with regard to dental injuries in Scotland has not yet been established. In the same way, many answers to questions regarding the sequelae and prognosis of pulpal and endodontic treatment among traumatised teeth remain unclear. Furthermore, numerous studies have been published examining the long term variables that might have an effect on treatment outcomes of avulsed teeth, but none have yet been able to estimate the long term prognosis of avulsed and replanted teeth.
Two studies presented in this thesis are largely the result of population based studies investigating the epidemiology of facial and dental injuries in relation to individual demographics. An additional two studies explore the occurrence of paediatric dental trauma and its general treatment outcomes with a specific focus on estimation of the long term prognosis of avulsed and replanted teeth.
To establish the epidemiology of paediatric facial injuries in children and adolescents requiring in-patient hospital admission in Scotland and to report the pattern, time trends, and key socio-demographic determinants of paediatric facial injury in Scotland, a descriptive epidemiological population-based study of the incidence of facial injuries in Scotland (2001-2009) was undertaken. Poisson regression models were employed to assess trends. There were 45,388 (4.7 per 1000 population) facial injury cases registered (2001-2009). 60% of injuries were due to non-intentional causes, 15% to motor vehicle incidents, and 9% to assault. 4.5% were alcohol related. The incidence decreased over time from 5.5/1000 in 2001 to 4.0/1000 in 2009. The risk ratio (RR) for males was 1.98 times greater than females (p < 0.001). RR varied significantly between Health Board areas from 0.68 (Dumfries and Galloway) to 1.76 (Grampian) (p < 0.001). There was a significant association between facial injury and deprivation (p<0.001); SIMD 1 (most deprived) had the highest incidence (6.3 per 1000 population; RR =1.89). The findings of this study provide evidence of a continuing increase in the burden of facial injuries in males especially for those who are living in areas of social deprivation, and in certain geographical areas of Scotland.
A population-based investigation was undertaken to investigate the pattern and time trends of dental injuries and their socio-demographic determinants among primary one (P1) children in Scotland. Records of Scottish Health Boards' Dental Epidemiological Programme (SHBDEP) and National Dental Inspection Programme (NDIP) for the period 1993 to 2007 were retrieved from the Dental Health Services Research unit - Dundee. Annual incidences of dental injuries were calculated by age, gender, Health Board and DEPCAT (Carstairs deprivation categories). 68,354 P1 children were examined and only 405 (0.6%) had suffered dental injuries (5.9 per 1000 population). There was a significant decrease in incidence over time (1993 figures were three times greater than 2007). Virtually the same incidence rates were recorded for the two genders. However incidence varied significantly between Health Boards (p<0.001); the highest rate being reported in Dumfries (14.2 per 1000 population), which was 11 times greater than Ayrshire (1.3 per 1000 population).
There was no significant association between risk of dental injuries and deprivation; in DEPCAT 1 (most affluent) the incidence rate was 6.4 per 1000 population, while in DEPCAT 7 (most deprived) the incidence rate was 5.7 per 1000 population. The findings of this study provide evidence that the incidence of dental injuries had significantly decreased between 1993 and 2007; gender and deprivation level had no effect on the incidence and risk of dental injuries.
A retrospective investigation was undertaken to study the sequelae of non-surgical root canal treatment in traumatised anterior permanent teeth of patients referred to a secondary referral centre. The department dental trauma database was used to randomly identify patients who had sustained dental trauma to their permanent anterior teeth between 1994 and 2008 which required pulpal intervention. A data extraction form was designed and completed for each tooth, and then the data was transcribed and processed. The association between treatment outcomes and clinical variables was studied. 100 permanent anterior teeth (72 patients) were studied. Dental trauma was frequent in the age group 9-11yrs (53.9%). Upper central incisors were the most common teeth involved (43.8%). The male: female ratio was 2:1 with an average age at the time of trauma of 10.31 yrs (SD 2.16 yrs). Home and immediate home environs were the commonest location (18%) while falls (34.8%) and injuries during sport/play (34.8%) were the commonest causes. The commonest injuries in this randomly selected group were enamel-dentine fracture with pulp exposure (34.8%) and avulsion (28%). 66.3% received a first treatment intervention less than 24 hours following the injury. Root canal treatment was the most frequent treatment provided, especially for dental avulsion cases (100%). Treatment outcomes were split into three categories: Success (53.4%); Short-term success but long-term failure (35.6%); and Failure (11%). Significantly fewer failures occurred with: developing roots compared to completed roots (P=0.05); a good quality temporary filling (P<0.003); no mobility (P<0.001); and less than one hour extra alveolar dry time (P =0.02). No significance was reached with regard to: condition of root canal (P=0.095); extra alveolar time (EAT) (P=0.191); and type of storage medium (P=0.43).
To assess and identify early clinical variables that are most predictive of treatment outcomes for avulsed and replanted permanent anterior teeth and to develop a model that will allow estimation of treatment outcome based on these variables, a retrospective study was designed and undertaken, where the dental trauma database was used to randomly identify patients who had sustained dental trauma on their permanent teeth leading to avulsion between 1998 and 2007. A data extraction form was designed and completed for each tooth. Demographic, diagnostic and treatment information recorded in the patient’s records, in addition to radiographs, were viewed and then transcribed and processed. The significance for each early clinical variable was assessed using a univariate logistic regression model. Only significant variables (P ≤ 0.05) were considered eligible for the prediction model and a c-index was then constructed for their respective predictive power. 213 patients who had received treatment for avulsed and replanted teeth between 1998 and 2007 were studied and only 105 fulfilled the criteria for evaluation. Two models (‘at first visit’ and ‘at initial treatment visits’) were produced with a total of five variables holding statistical significance and the greatest predictive power (P ≤ 0.05, high c-index): patient age (P ≤ 0.001, c = 0.80); stage of root formation (P ≤ 0.001, c = 0.76); storage medium (P ≤ 0.047, c = 0.58); tooth mobility after dressing (P ≤ 0.001, c = 0.70); and tooth mobility after splinting (P = 0.03, c = 0.70) (0.5 = no predictive power, 1.0 = perfect prediction). These underwent multivariate analysis and the final models had high predictive abilities (c-index of 0.80 and 0.74). These findings provide an indication that patient age; stage of root formation; storage medium; tooth mobility after dressing and tooth mobility after splinting were the early clinical variables that were most predictive of treatment outcome. These models will enable clinicians to estimate the long term prognosis of avulsed and replanted teeth and will make it easier to plan further treatment with a realistic view of outcome at an early stage.
To conclude, this thesis has made contributions in several areas. The descriptive elements have described the ‘recent’ trends in facial and dental injuries among the paediatric population across Scotland in relation to age, gender, aetiology, socio-economic circumstances and geographic region. The socio-economic analysis has improved the understanding of the extent of socio-demographic trends in paediatric dental and facial injuries in Scotland. The findings of these studies, having been described, will become a baseline reference for the recent burden of dental and facial injury in Scotland with relation to socio-demographic determinants. The retrospective descriptive analysis of dental trauma and especially dental avulsion will enable clinicians to identify and determine the clinical variables that are the most predictive of treatment outcomes and permit the development of models that will enable the prediction of outcomes for future replanted avulsed teeth. These models will make it easier to plan for further treatment with a realistic view of outcome at an early stage.
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