Pediatric Dentofacial Trauma during COVID-19 Lockdown Period in North Indian Population: The changed Trends
1,3,5Department of Pedodontics, Postgraduate Institute of Dental Sciences, Rohtak, Haryana, India
2,4Department of Oral and Maxillofacial Surgery, Postgraduate Institute of Dental Sciences, Rohtak, Haryana, India
Corresponding Author: Ruchi Singhal, Department of Pedodontics, Postgraduate Institute of Dental Sciences, Rohtak, Haryana, India, Phone: +91 8053452451, e-mail: email@example.com
Received on: 10 September 2022; Accepted on: 02 October 2022; Published on: 26 December 2022
Background/aims: Coronavirus disease 2019 (COVID-19) pandemic has impacted the life of mankind, including the epidemiology and pattern of dentofacial traumatic (DFT) injuries. The aim of the present study is to quantify and analyze the characteristics of DFT among children during the COVID-19 pandemic lockdown period in 2020 and to compare this to data over the same period in 2019 (prepandemic/prelockdown period).
Materials and methods: Data of patients aged 0–12 years who suffered DFT was collected retrospectively from the beginning of the lockdown period, that is, 24th March 2020, till the day lockdown restriction was eased, that is, 31st May 2020. The children aged 0–12 years with similar characteristics who reported during a similar time period in the year 2019 were kept as the comparator group. The outcomes studied were epidemiology, etiology, and pattern of injury.
Result: Total number of children who suffered DFT increased during the pandemic lockdown in 2020 as compared to the prepandemic period. The place where the injury occurred was significantly changed to the indoor environment. Fall was still the major cause of trauma. Luxation injuries were more frequent than tooth fractures (p < 0.05). Conservative management was more favored during the lockdown period.
Conclusion: Results suggest that the lockdown period had affected the epidemiology, etiology, and diagnosis of traumatic dentofacial injuries in children. We must plan our resources considering the expected wave/school shutdowns in the future and the increased incidence of traumatic dental injuries in children. While trends were evident in the collected data, these must be carefully interpreted as this was a single-center study with a small sample size.
How to cite this article: Singhal R, Singh V, Namdev R, et al. Pediatric Dentofacial Trauma during COVID-19 Lockdown Period in North Indian Population: The changed Trends. J South Asian Assoc Pediatr Dent 2022;5(3):117-120.
Source of support: Nil
Conflict of interest: None
Keywords: Children, Coronavirus disease 2019, Dentofacial trauma, Lockdown, Pandemic, Pediatric
The COVID-19 pandemic has severely affected mankind. India is the world’s second most densely populated developing economy catering to almost 1.3 billion populations. The government of India implemented a complete lockdown on 24 March 2020, to restrict the spread of this contagious disease. This resulted in the closure of all nonessential services, including traveling, educational institutions, and even routine healthcare services were restricted. Life of citizens was profoundly affected as national advisers were released to stay at home. The health authorities ordered the dental facilities to suspend nonemergency dental treatment.1 Many studies have shown the impact of COVID-19 on the epidemiology and utilization changes of emergency services among the adult population.2-7 Most studies concluded that the incidence of traumatic injuries to the maxillofacial region has reduced in adults, which were attributed to their restriction of outdoor activities and almost negligible road traffic. But only a few studies have shown the data pertaining to the influence of the COVID-19 pandemic on DFT injuries in children.8,9 The aim of the present study was to quantify and analyze the characteristics of DFT among children during the COVID-19 pandemic lockdown period in 2020 and to compare this to data over the same period in 2019 (prepandemic/prelockdown period).
MATERIALS AND METHODS
Data were collected retrospectively from the records of the Department of Pedodontics and Emergency Dental Services of the institute from the beginning of the lockdown period, that is, 24th March 2020, till the day lockdown restriction were eased, that is, 31st May 2020. Since the study involved the retrospective collection of data of patients who had already been managed and their identity shall not be disclosed at any point of time, the ethical approval was waived by the institutional ethical board. The data of patients <12 years of age who reported the complaint of DFT was recorded. Patients who presented with pain and infections of dentoalveolar origin were excluded from the data registry. The children aged 0–12 years with similar characteristics who reported during similar time periods in the year 2019 were kept as the comparator group. The outcomes studied were epidemiology, etiology, and pattern of injury. Traumatic dental injuries were classified as hard tissue injuries (enamel ± dentine fracture, fracture involving enamel-dentine-pulp complex, crown root fracture, and root fracture) and periodontal tissue luxation injuries (concussion, subluxation, extrusion, lateral luxation, intrusion, and avulsion).
Continuous variables are presented as mean and standard deviation. Categorical variables are presented as n (%) and analyzed through Statistical Package for the Social Sciences statistics, version 20.0 (IBM Corp., Armonk, New York, United States of America) using the chi-squared test. The significance level was set at 0.05.
In 2019, 20 children suffered DFT out of a total of 632 patients reported, which accounts for approximately 3.07%, whereas, in 2020, it increased to approximately 32 out of 640 (4.76%), and the difference was statistically significant. During both time periods, males were significantly more affected than females (15 males out of a total of 20 children in 2019 and 26 males out of a total of 32 children in 2020). The place where the injury occurred was significantly changed to an indoor environment during the COVID-19 pandemic at 90.625% as compared to 45% during prepandemic phase (Fig. 1). Table 1 shows the etiology of traumatic injuries, which show that fall was still the major cause. However, earlier it attributed 60%, which later on increased to 87.5%, but trauma due to roadside accidents, outdoor sports, and assault/fights dropped to 0%. Table 2 shows the distribution pattern of DFT during both time periods, with a significant increase in soft tissue injuries as compared to hard tissue injuries (p < 0.05). Luxation injuries were more frequent than tooth fractures (p < 0.05). Tooth intrusion among luxation injuries and the enamel-dentine fracture was the most common type of tooth fracture (Table 3). Conservative management was more favored during the lockdown period (Table 4).
|Etiology of traumatic injuries||Cases during 2019||Cases during 2020|
|Fall||12 (60%)||28 (87.5%)|
|Roadside accident||3 (15%)||0|
|Outdoor sport activities||3 (15%)||0|
|Animal bite injuries||0||2 (6.25%)|
|Other (electrocution and seizures)||0||2 (6.25%)|
|Pattern of injury||Cases during 2019||Cases during 2020 (lockdown period)|
|Soft tissue||10 (7+3)||22 (19+3)|
|Hard tissue||13 (10+3)||13 (10+3)|
|Types of TDI|
|• Luxation injuries||7||9|
|Incidence of fracture||2019||2020 (lockdown period)|
|Enamel ± dentine fracture||3||3|
|Enamel-dentine pulp fracture||2||1|
|Crown root fracture||0||0|
|Incidence of luxation injuries||2019||2020 (lockdown period)|
|Treatment provided at the initial visit||Cases during 2019||Cases during 2020 (lockdown period)|
The present study is a descriptive analysis of young children affected by DFT during the first wave of the COVID-19 pandemic, and a comparative analysis was done with a similar cohort in the previous year. Due to the rapid transmission of COVID-19 through contact, droplet, and sometimes claimed to be airborne routes also, people get reluctant to go to public places, including medical and dental hospitals.2,10-12
The overall number of pediatric patients seeking emergency dental care has increased during the lockdown period as compared to the previous year, maybe due to more playing hours and a lack of authoritative supervision by teachers. At school, children would more likely benefit from a more structured day with less opportunity for traumatic dental-facial injuries to occur.7,8 Another possible justification for the surge in the number of pediatric patients may be the closure of all private dental clinics and referral of all injured patients to the government emergency dental unit. Studies done on adult patients show contradictory results with decreased incidence of traumatic dental injuries.2-4,6,7 It could be due to hesitancy to visit the hospital out of the potential risk of contracting the viral infection and self-management at home for minor injuries. Nevertheless, few authors reported an increased incidence of trauma due to possible domestic violence.5
Few studies had shown a declining trend of gender disparities due to the restriction of outdoor activities and reduced violence during the lockdown, but in our study, we found male preponderance.2,4
The etiological factors causing traumatic dental injuries in children and young adolescents are quite different than in adults.12,13 According to earlier studies, in the preschool age group, falls are the most common cause, whereas, in schoolgoing children, injuries due to outdoor sports activities and fight among kids are quite common.12 In the adult population, roadside accidents and assault are the dominant etiological factors.13 In the present study, falls were the leading etiological factors, but trauma due to roadside accidents, outdoor sports, and assault/fights dropped to 0%. The place where the injury occurred was significantly changed to an indoor environment during the COVID-19 pandemic (90.625%) because children were mostly restricted to their houses during the lockdown. This was quite higher as compared to studies done in other countries.8,9 A study conducted on the United Kingdom (UK) population reported that people in the UK were allowed outside for daily exercise, meaning injuries from running, bicycles, and scooters were still likely to occur.8
A significant increase in soft tissue injury was noted over hard tissue injuries, which may be because the intensity of trauma, which occurred mostly at home, was not that severe. Among luxation injuries, tooth intrusion was most frequent because falls mainly lead to forces in the axial direction, forcing the tooth into the alveolar bone.4 Other types of luxation injuries, such as avulsion, extrusion, or lateral luxation, are more likely due to non-axial impacts, which are common during contact sports, violence, and fights.
Dentistry involves proximity between patients and treating dental practitioners, making them more prone to the exposure and spread of this contagious virus.6,10,14 The treatment guidelines for treating acute dental trauma were modified to safeguard the well-being of staff and patients while still ensuring those with the most acute need could be seen and treated.1 These modifications were done to mitigate the risk of patient attendance (and possible contraction of COVID-19) against the benefit of receiving immediate treatment.8 Teledentistry can play a pivotal role as patients who suffer minimal injury and can be managed at home can avoid unnecessary visits to hospitals and decrease the risk of contracting COVID-19.
The attention of the health fraternity and government administration is mainly on measures to control the spread of COVID-19 infection. However, possible health consequences resulting from restrictions imposed and fear of this infection should not be overlooked. Understanding the present situation is helpful in terms of predicting future dental needs. It also highlights that in the scenario of staff redeployment to help manage an increased number of COVID-19 patients, skilled operators are still required to manage complex acute dental trauma, especially in children, because of the deep psychosocial impact on children and their parents.15,16 This is a key treatment area that should not be neglected in any future “lockdowns” as dental-facial trauma continues to present, as demonstrated in this age group.
Within the limitation of this study, our results suggest that the lockdown period had affected the epidemiology, etiology, and diagnosis of traumatic dentofacial injuries in children. COVID-19 is here to stay, and we have to adapt ourselves according to the conditions and coordinate to implement comprehensive prevention and control measures in future dental care. We must plan our resources considering the expected wave/school shutdowns in the future and the increased incidence of traumatic dental injuries in children. While trends were evident in the collected data, these must be carefully interpreted as this was a single-center study with a small sample size. Future perspectives recommended are nationwide multicentric studies with the inclusion of a large sample population to validate the current results and better interpretation of data.
Ruchi Singhal https://orcid.org/0000-0002-5514-2482
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