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Chin J Traumatol
Chin J Traumatol
Chinese Journal of Traumatology
1008-1275
1008-1275
Elsevier

S1008-1275(23)00045-7
10.1016/j.cjtee.2023.05.003
Systematic Review
Impact of dental and orofacial trauma on oral health-related quality of life in adults: A systematic review
Verma Santosh Kumar a
Jha Awanindra Kumar b
Prakash Om c
Ekram Subia c
Tigga Chandmani c
Noorani Mohammad Kashif d
Mehta Vini e
Meto Aida f
Meto Agron f
Fiorillo Luca efgh
Cicciù Marco mcicciu@unime.it
i∗
a Department of Periodontology & Oral Implantology, Dental College, Rajendra Institute of Medical Sciences, Ranchi, 834009, Jharkhand, India
b Department of Orthodontic and Dentofacial Orthopedic, Dental College, Rajendra Institute of Medical Sciences, Ranchi, 834009, Jharkhand, India
c Department of Oral and Maxillofacial Surgery, Dental College Rajendra Institute of Medical Sciences, Ranchi, 834009, Jharkhand, India
d Prosthodontics and Crown and Bridge and Oral Implantology, 800001, Patna, India
e Department of Public Health Dentistry, Dr. D.Y. Patil Dental College and Hospital, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune, 411018, Maharashtra, India
f Department of Dentistry, Faculty of Dental Sciences, University of Aldent, 1007, Tirana, Albania
g Department of Biomedical and Dental Sciences, Morphological and Functional Images, University of Messina, 98100, Messina, Italy
h Multidisciplinary Department of Medical-Surgical and Dental Specialties, Second University of Naples, 80100, Naples, Italy
i Department of Surgery and Surgical Specialties, University of Catania, 95100, Catania, Italy
∗ Corresponding author. mcicciu@unime.it
27 5 2023
9 2024
27 5 2023
27 5 249253
26 11 2022
17 4 2023
3 5 2023
© 2023 Chinese Medical Association. Production and hosting by Elsevier B.V.
2023
Chinese Medical Association
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Purpose

Dental and orofacial trauma among the adult population constitutes a major public health problem. The impact is not just physical but also psychological. To analyse the impacts of dental and orofacial trauma on oral health-related quality of life (OHRQoL) in adults and determine whether the 2 variables are closely interlinked.

Methods

This is a systematic review. The terms “dental trauma”, “orofacial trauma”, “oral health”, “oral health related impact life”, “OHRQoL”, “positive and negative affect scale”, “quality of life”, “facial injuries”, “adults”, and “young adults” were researched in the databases of PubMed, ScienceDirect, Scopus and Google Scholar for associated studies up to December 30, 2022. A comprehensive search was designed and the articles were independently screened for eligibility by 2 reviewers. The included studies’ author, year of publication, the country where the study was conducted, population demographics (number and age), an instrument used for assessing OHRQoL and the relevant result were recorded and compared. The quality of the evidence was assessed using Joanna Briggs Institute checklist for observational studies.

Results

Out of 482 unique records, 3 articles were included for data extraction. Observational studies were included. Two studies did not mention confounding factors. Different scales were used for dental and orofacial trauma and OHRQoL. OHRQoL has a directly proportional relationship with orofacial trauma. Adolescents with orofacial trauma have a significant impact on this value with a prevalence of 88.4%.

Conclusion

The highest impact on OHRQoL was seen immediately after the diagnosis of an orofacial trauma. The impact increases with the severity of the trauma. Therefore, to promote overall dental and general health, health education initiatives should include information on the causes, prevention, and requirement for prompt responses by the populace in seeking dental intervention.

Keywords

Dental trauma
Oral health
Oral health-related quality of life
Orofacial trauma
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pmc1 Introduction

The oral region is the 6th most frequently damaged body part, followed by the hands, feet, knees, head, and face. This suggests that trauma to dentition and its related soft tissues is relatively common.1,2 Adult dental trauma has been the subject of very little population-based research, yet estimates of its occurrence range from 13% to 28%.2, 3, 4, 5, 6, 7

The various trauma classification systems that have been employed, and the majority lack epidemiological value, which makes it difficult to compare findings on adults.8 Injury to the teeth is a common component of oral injuries. It is well-recognised that permanent tooth damage can result in tooth loss, discolouration, vitality loss, and inflammatory root resorption.2,3 However, more data are needed from adult population longitudinal follow-up research.

The study of different aspects of an individual's self-reported oral health is part of oral health-related quality of life (OHRQoL) research, which helps enhance the delivery of dental treatment.9 Dental trauma is prevalent3, and it can cause physical, mental, and functional problems for the rest of one's life and a persistent financial burden if continuous dental rehabilitation is necessary.10 Dental trauma has been shown to hurt children's quality of life in several studies.11, 12, 13, 14 The question of whether this also applies to adults must be clarified.

One of the measures typically used to gauge OHRQoL is the condensed oral health impact profile – 14 (OHIP-14). Despite being created initially for older people, it has been demonstrated to be reliable in various age groups.15 To better understand OHRQoL, data on relevant personality traits may be collected. Treatment of dental injuries with severe physiological, financial, and emotional effects is time-consuming, and their complications tend to be generally expensive, ongoing, and frequently fraught with a high risk of failure. As a result, the dental system, patients, and their families are heavily burdened by the treatment of these injuries caused by orofacial trauma.12

According to estimates, 17% of those aged under 18 years and 20% of adults have experienced irreversible tooth damage.13, 14, 15 There are differences in the prevalence of dental trauma around the world, ranging from 2% to 59%. This high variation level can be attributed to the use of varied research approaches and the impact of various socioeconomic and cultural variables in the populations in the studies.16,17

Few prospective, long-term studies evaluate the frequency and causation of tooth damage. They are often cross-sectional clinical investigations of a certain age range. The outcomes of examining a patient's medical records are often presented in these studies, many of which are retrospective.18, 19, 20 The risk of underestimating data exists for both prospective and retrospective investigations. These studies are based on a population that visited a dentist for care, omitting individuals who sustained a traumatic tooth injury but did not receive medical attention.21 We aimed to analyse the impacts of dental and orofacial trauma on OHRQoL in adults and determine whether the 2 variables are closely interlinked.

2 Methods

2.1 Population (including animal species), exposure, comparator, and outcomes statement

According to the population, exposure, comparator, and outcomes question statement, the results as follows: Population: subjects ≥ 16 years of age and regardless of gender; Exposure: subjects with dental trauma (including fractures of the maxilla and mandible); Comparator: subjects without dental trauma; Outcomes: OHRQoL.

2.2 Protocol employed

This systematic review was performed as per the Preferred Reporting Items for Systematic Review and Meta-analysis strategy.22 It was registered with the International Prospective Register of Systematic Reviews on November 10, 2022, which was following the guidelines. (Provisional registration No. CRD42023398983).

2.3 Focused question

To investigate the impacts of dental and orofacial trauma on OHRQoL in adults and determine whether the 2 variables are closely interlinked.

2.4 Search strategy

Electronic databases were scrutinized for appropriate studies that would satisfy the study purpose: PubMed-Medline, ScienceDirect, Scopus and Google Scholar. The terms “dental trauma” OR “orofacial trauma” OR “oral health” OR “oral health related impact life” OR “OHRQoL” OR “positive and negative affect scale” were searched in PubMed-Medline; “dental trauma” OR “orofacial trauma” OR “oral health” OR “oral health related impact life” OR “OHRQoL” OR “positive and negative affect scale” OR “quality of life” “facial injuries” OR “adults” OR “young adults” were searched in Scopus. Additional sources such as major journals were explored from the earliest available date up to December 30, 2022, without restriction on language. Contact with authors was done for any unpublished studies.

Articles published in the English language that contained observational studies which included a population ≥ 16 years were included. Validated questionnaire-based investigations (for recording OHRQoL) were considered for inclusion in our review.

The papers were independently scanned by 2 reviewers, first by the title and abstract. Case reports, letters, and narrative/historical reviews were not included in the study. If the search keywords were present in the title and/or the abstract, the papers were selected for full text reading. Paper without abstract, but with title suggesting that it was related to the objectives of this review was also selected to screen the full text for eligibility. After selection, full text papers were read in detail by 2 reviewers. Those papers that fulfilled all of the selection criteria were processed for data extraction. Two reviewers hand-searched the reference lists of all selected studies for additional relevant articles. Disagreements between the 2 reviewers were resolved by discussion. If a disagreement persisted, the judgment of a third reviewer was considered decisive.

2.5 Data extraction

Two independent reviewers searched relevant articles by using the appropriate keywords in various databases and online search tools. The chosen articles were compared, and a third reviewer was brought in if there was a dispute. After choosing the articles, the same 2 reviewers independently extracted the following data: author, year of publication, the country where the study was conducted, population demographics (number, age), an instrument used for assessing OHRQoL and relevant result. The data were compared and any differences were discussed with a third reviewer.

2.6 Quality assessment

The quality of the evidence was assessed using Joanna Briggs Institute checklist for observational studies.23 It includes 8 parameters scoring as yes, no, unclear, and not applicable. Two reviewers independently graded the included articles and the third reviewer's decision was considered for consensus.

3 Results

There was a total of 482 documents discovered after an extensive search, and 169 of the papers were selected initially. Following that, 115 similar/duplicate articles were eliminated, which resultantly made 58 separate papers available at first. The abstracts and titles of submissions were then reviewed, and a further 55 papers were eliminated. Finally, 3 documents that met the requisite inclusion and exclusion criteria were chosen, which were included in this study.

Electronic databases identified 482 unique records (Fig. 1). Among them, 169 duplicates were removed and 313 articles were selected for title screening, 58 articles were selected for full text screening and 3 articles were included for data extraction. An overview of the selected studies24, 25, 26 and their characteristics are presented in Table 1.Fig. 1 Flowchart summarizing the article selection process.

Fig. 1

Table 1 Characteristics of the included studies.

Table 1Study	Sample size (n)	Country	Age (year)	Instrument used	Study inference	
Bahho et al.24	110	New Zealand	17 – 26	Oral health impact profile-14	- Dental trauma were mainly fractures reported in 70% and aversion in 10% of the respondents.

- The impact reported 29.1% student patients affected just by dental trauma as compared to 21.2% students with dental trauma and other maxillofacial injures.

	
Conforte et al.25	66	Brazil	18 – 65	Oral health impact profile-14	- Their results suggested a direct relationship of trauma with OHRQoL exist.

- The extension of their results also demonstrated the impact on quality of life was greater as compared to any other surgical intervention

	
Thelen et al.26	95	Albania	16 – 19	Oral impact on daily performances	Adolescents with dental trauma reported 88.4% prevalence of OHRQoL impact as compared to 58.9% of controls significant at p < 0.001.	
OHRQoL: Oral health-related quality of life.

3.1 Characteristics of included studies

Studies included were from New Zealand, Brazil and Albania. The study of Bahho et al.24 was a cross-sectional study, Thelen et al.26 employed a case-control design and Conforte et al.25 was a cohort study. OHIP-14 elicited the OHRQoL in the study of Bahho et al.24 and Conforte et al.25, while oral impact on daily performances was used in the study of Thelen et al.26 Trauma cases by Thelen et al.26 were measured by trauma index by O'Brain. At the same time, Bahho et al.24 relied on self-reporting of dental trauma. Methodological quality assessed suggested articles were eligible to be included in the review as seen in Table 2. In the study of Thelen et al.26, the methodological foundation was strong due to the fact that it considered all possible confounders of trauma such as dental caries, periodontal condition, irregularly placed teeth and even maternal education level. The other 2 studies did not mention confounding factors (Table 1).Table 2 Quality assessment of studies included as Joanna Briggs institute checklist.

Table 2Criteria	Bahho et al.24	Conforte et al.25	Thelen et al.26	
Were the criteria for inclusion in the sample clearly defined?	Yes	Yes	Yes	
Were the study subjects and the setting described in detail?	Yes	Yes	Yes	
Was the exposure measured in a valid and reliable way?	Yes	Yes	Yes	
Were objective, standard criteria used for measurement of the condition?	Yes	Unclear	Yes	
Were confounding factors identified?	No	No	Yes	
Were strategies to deal with confounding factors stated?	No	No	Yes	
Were the outcomes measured in a valid and reliable way?	Yes	Yes	Yes	
Was appropriate statistical analysis used?	Yes	Yes	Yes	
Overall risk of bias	Low risk	High risk	Low risk	

3.2 Summative inference

Out of the 3 studies qualitatively assessed, 2 reported a significant association between trauma and OHRQoL.25,26 But these results should be projected with caution considering the scant literature and minimal sample.

3.3 Quality assessment

Two studies24,26 were at low risk of bias and 1 study25 was considered at high risk of bias (Table 2). Furthermore, this manuscript has been checked with the Fi-index tool and obtained a score of 0.00 for the first author only on the date February 15, 2023 according to SCOPUS®.27,28 The Fi-index tool aims to ensure the quality of the reference list and limit any auto-citations use.

4 Discussion

The studies selected for our review shed light upon the incidence of dental trauma and its effect on OHRQoL on the sufferers and was observed inconclusive evidence between the 2 factors. The study by Bahho et al.24 looked into the relationship between oral trauma experience and OHRQoL in young individuals residing in university residence halls. Poorer OHRQoL was detected among those reporting prior dental caries experience, despite the 2 not being strongly linked. This observation was shared by the results observed in the study by Thelen et al.26, where the age group under observation was 16 – 19 years old and the OHRQoL was found to be worse in the group where the treatment needs of the young adults (such as dental caries and trauma-induced injuries) remained unmet. These results are also similar in nature to the ones observed by Haugejorden et al.29, where there was a noticeable caries predilection of the study population, although the sample size comprised 12 − 18 years old which was not the target population for this review.

A majority of the studies those are mentioned in the literature about the impact of orofacial injuries on the OHRQoL of the patient have been limited to just children and early adolescents. But the fact stands that dental trauma can occur at any age and its subsequent effects on the individual can be detrimental not just at a young age but in adulthood as well. In light of the aforementioned information, the study of Janapareddy et al.30 sought to ascertain the oral health condition and OHRQoL among the production line and administrative staff of the steel industry in the city of Visakhapatnam, which the authors believe is a pioneer study concerning the incidence of orofacial trauma and its effects on the OHRQoL on factory workers. The study found that the workers on the assembly line had a greater frequency of dental trauma, such as cracked teeth. This is likely a result of their demanding job duties, which call for constant alertness and attention to a variety of sophisticated machinery that might injure the orofacial region. This study could not be included in our review as the study population was not exclusively assessed for dental trauma but for overall oral health status.

Amongst the factors affecting OHRQoL in patients with dental trauma seemed to be the generally expensive nature of dental treatment as well as the follow-up restorations that needed to be performed if the tooth in question underwent avulsion. Although not directly interlinked, the socioeconomic status of the families of the sufferers was also observed to be a major source of stress and resultantly in poor OHRQoL. For example, in the investigation by Olczak-Kowalczyk et al.31, both male and female respondents reported equal rates of injuries, their causes, therapy, and post-traumatic sequelae and parents' low levels of education and low socioeconomic status elevated the risk of damage. As noted by the authors, the causation of tooth injuries, the accessibility of dental care, and the course of treatment can all be affected on multiple levels by socioeconomic circumstances.13,32 An observation by Scott et al.33 was that, even though the majority of trauma were minor in nature, the eventual cost of their medical care was so high, which further inflated with more severe initial damage. Orofacial trauma appeared to have a significant long-term societal cost and a correspondingly worse impact on patients' OHRQoL.

The condensed OHIP-14 questionnaire, which consists of 14 questions with 2 questions under each of the 7 domains, was the data collection tool used in 2 studies. The domains assessed were functional limitation, physical discomfort, psychological unease, physical disability, psychological disability, social impairment, and handicap employing a Likert scale measuring responses to the questions ranging from 0 (never) to 4 (very often). The tool is comprehensive to includes all aspects affecting the quality of life and is considered reliable.34

The lack of appropriate studies determining the link between the incidence of dental/orofacial trauma in adulthood and how it affects OHRQoL limited the number of articles that we could select for our review and that could be considered to be a noticeable limitation of our systematic review. Also, the lack of large population-based studies is a factor to not be overlooked. Hence, the authors feel that several investigations need to be carried out regarding the effects of dental trauma on the OHRQoL levels of adults.

The patient's quality of life though impacted by orofacial/dental injuries was not conclusive. The OHRQoL has a directly proportional relationship with orofacial trauma, performing the highest value immediately after the diagnosis of an orofacial trauma accordingly to included studies. The impact increases with the severity of the trauma. Therefore, to promote overall dental and general health, health education initiatives should include information on the causes, prevention, and requirement for prompt responses by the populace in seeking dental intervention.

Fundings

Nil.

Ethical statement

Not applicable.

Declaration of competing interest

Authors declare no conflict of interests.

Author contributions

Santosh Kumar Verma, Awanindra Kumar Jha: conceptualization; Luca Fiorillo: methodology; Om Prakash: software; Subia Ekram, Chandmani Tigga: validation; Mohammad Kashif Noorani: formal analysis; Vini Mehta: investigation; Santosh Kumar Verma: writing—original draft preparation; Luca Fiorillo: writing—review and editing; Agron Meto: supervision; Marco Cicciù: project administration.

Peer review under responsibility of Chinese Medical Association.
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