Mahmoodi et al.

BMC Oral Health (2015) 15:139

DOI 10.1186/s12903-015-0124-5

RESEARCH ARTICLE Open Access

Traumatic dental injuries in a university

hospital: a four-year retrospective study
Benjamin Mahmoodi1*, Roman Rahimi-Nedjat2, Jens Weusmann1, Adriano Azaripour1, Christian Walter2
and Brita Willershausen1

Abstract
Background: Traumatic dental injuries present complex injuries of the dentoalveolar system. Aim of this study was
to investigate the frequency and patterns of traumatic dental injuries in a University dental emergency service over
four years.
Methods: A retrospective investigation on all dental trauma patients presenting at the dental emergency service of
the University Medical Center Mainz, Germany between 01/2010 and 12/2013 was conducted. Demographic data,
the cause and type of trauma and the initial therapy were analyzed.
Results: Out of 16,301 patients, 1,305 patients (8 %; average age 14.7 years ±15.7; 60.1 % male, 39.9 % female)
came due to trauma. 63.9 % of the traumas occurred on weekends. The most frequent reason for injuries was falls
(54.6 %). No correlation could be found between the cause and the kind of trauma. In 48.6 % of the cases only one
tooth was involved, in 33.5 % two. The permanent dentition was traumatized in 56.6 % of cases, the deciduous
teeth in 41.1 %. The most frequently affected tooth was the central upper incisor (61.0 %). Hard-tissue injuries were
significantly more frequent in the permanent dentition, while periodontal injuries were seen significantly more
often in the deciduous dentition.
Conclusion: Eight percent of all patients seeking help at the dental emergency service presented with trauma,
meaning that dental traumatology is one of the major topics in emergencies. To improve the quality of care,
further public education, expert knowledge among dental professionals and a well-structured emergency service
are necessary.
Keywords: Dental trauma, Dentoalveolar-trauma, Prevalence, Tooth injury

Background frequently injured part of the body [7, 8]. Mostly, TDIs
Traumatic dental injuries (TDIs) often present as serious involve anterior teeth and represent painful events that
and complex injuries of the dentoalveolar system. Preva- may result in complications such as crown discoloration,
lences vary depending on cultural and social factors [1– pulp necrosis, apical periodontitis, ankyloses, and in-
3]. Mostly, TDIs occur at a young age, but they are ob- flammatory root resorption and tooth loss as a conse-
served in any age group [3, 4]. Factors associated with quence of the above mentioned complications or
higher prevalences of dental injuries are increased over- primary event [9]. In addition to functional problems,
jet, class II type malocclusion, having orthodontic needs, traumatic dental injuries (TDIs) may cause aesthetic,
and male gender [5, 6]. psychological and social problems by affecting the ap-
Studies show that dental trauma accounts for about pearance and speech of patients [10]. To minimize com-
5 % of all injuries leading to inpatient or outpatient plications and to save the affected tooth, immediate and
treatment and that the oral region is the sixth most appropriate management is required.
The incidence of TDIs is higher in the late evenings
* Correspondence: [email protected] and on weekends, which is associated with the lifestyle
1
Department of Operative Dentistry and Periodontology, University Medical
Center of the Johannes Gutenberg-University Mainz, Augustusplatz 2, 55131
[7, 11]. Consequently many patients present in dental
Mainz, Germany emergency service units since they usually operate
Full list of author information is available at the end of the article

© 2015 Mahmoodi et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
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Mahmoodi et al. BMC Oral Health (2015) 15:139 Page 2 of 7

outside the dentists’ regular clinical hours. Available data Statistical analysis
on the frequency and patterns of dental traumas in For statistical analysis, Microsoft Excel 2010 (Redmond,
Germany are sparse but necessary to provide recom- WA, USA) and SPSS 22 (IBM, Armonk, NY, USA) were
mendations for prevention and improvement in the used. The chi-square test was used for analysis of un-
quality of the therapy. even distributions between two groups, such as the gen-
As our institution is one of two university medical der distribution and the distributions of the different
centers in the Rhine-Main-metropolitan region, which kinds of traumas in relation to the dentition and/or the
has 5.5 million inhabitants, our dental clinic is fre- cause of trauma.
quently sought out by dental emergency patients and in
fact sees these patients daily. The aim of this retrospect- Results
ive study was to investigate the frequency of TDIs Out of the 16,301 patients seen in the four-year period,
among all patients who presented to the dental emer- 8.0 % presented with TDIs (n = 1305; average age
gency service within a period of four years. 14.7 years ±15.7, 60.1 % male [14.4 years ± 13.8] and
39.9 % female [15.2 years ± 18.2]), with a male to female
ratio of 1.5:1. Men were significantly more often affected
Methods than females (p < 0.001). The youngest patient presented
All patients that presented in the dental emergency out- at an age of 7 months, while the oldest patient was
patient department of the University Medical Center of 88 years. More than half of the trauma collective
the Johannes Gutenberg-University in Mainz between (54.6 %; n = 713) was under the age of ten (Fig. 1).
January 2010 and December 2013 were included. Concerning the year and month of visit, a homoge-
Altogether, 16,301 patients were seen in the dental neous distribution of trauma cases was found (Fig. 2). In
emergency outpatient department in the four-year 2010, 280 patients were treated, in 2011 354, in 2012
period (average age 35.3 years ±19.5, 54.4 % male 349 and in 2013 322 patients. Nearly two-third (63.9 %;
[34.9 years ± 19.1] and 45.6 % female [35.8 years ± 19.9]). n = 833) of all TDIs occurred on weekends (Fig. 3). 74
A retrospective investigation on these patients was then patients (5.7 %) came on a public holiday. The most fre-
carried out concerning epidemiologic factors, the cause quent reasons for TDIs (Table 1) were falls (54.6 %; n =
and the type of trauma as well as concomitant soft tissue 713), followed by sport accidents (13.4 %), and recre-
injuries and the initial therapy. For this, electronic health ational accidents (8.8 %). Most of the sport accidents oc-
records were reviewed and subjected to further analysis. curred in the patient group aged between 10 and
Inpatient cases that had already had treatment in other 19 years (46.3 %), followed by the 0–10 year-olds
departments, such as the departments for oral and max- (30.3 %). Significant differences were seen in the fre-
illofacial surgery, trauma surgery, and neurosurgery, due quency of the causes between the genders. While as-
to more severe injuries were excluded since these pa- saults were more often the trauma reason in male
tients are usually transferred or presented at a later stage patients (p < 0.001), the frequency of falls was higher
to the dental department and could thereby introduce a among females (p < 0.001). Most assaults occurred in the
bias regarding the prognosis and sufficient treatment of 20–29 year age group (48.3 %), followed by the 10–
the affected teeth. 19 year-olds (31 %).
Due to the hospital laws of each state in Germany Among the 1,305 patients, 2,319 teeth were trauma-
(Landeskrankenhausgesetz), no ethical approval is neces- tized (mean: 1.8 teeth per patient). In 48.6 % (n = 634) of
sary in retrospectively performed studies evaluating pa- the cases, only one tooth was involved; in 33.5 % (n =
tient data that already exist. All patients were informed 437) two teeth were injured, and in 16.7 % (n = 216)
of the anonymized use of their records at the time they three or more teeth were injured. 337 patients (25.8 %)
contacted the hospital for dental care. had a concomitant soft tissue injury. 18 patients (1.4 %)
presented with a soft-tissue injury without dental
involvement.
Classification of dental injuries The permanent dentition was traumatized in 56.6 %
Traumatic dental injuries were classified as follows [12]: (n = 739) of cases, the deciduous teeth were traumatized
(i) enamel crack, (ii) enamel fracture, (iii) enamel-dentin in 41.1 % (n = 537), and eleven patients (0.8 %) had
fracture without pulp exposition, (iv) enamel-dentin trauma to the transitional dentition with affection of the
fracture with pulp exposition, (v) vertical crown-root deciduous and permanent dentition (Fig. 4).
fracture, (vi) root fracture, (vii) concussion, (viii) sublux-
ation, (ix) lateral luxation, (x) intrusion and (xi) avulsion. Permanent dentition
(i)-(iv) were summarized as hard tissue injuries, (v) and Among the 739 patients with permanent dentition, the
(vi) as root fractures and (vii)-(xi) as periodontal injuries. average age was 23.0 years ±16.5 (63.1 % male [21.2 years
Mahmoodi et al. BMC Oral Health (2015) 15:139 Page 3 of 7

Fig. 1 Age and gender distribution of trauma patients

± 13.9] and 36.9 % female [26.0 years ± 19.7]), and the teeth per patient was 1.7 (921 teeth in 537 patients).
male to female ratio was 1.7:1. With a total of 1398 in- 88.2 % of traumatized teeth were located in the upper
jured teeth, there was an average of 1.9 permanent den- jaw. Subluxation (33.7 %) was the most common diagno-
tition injuries per patient. 84.5 % of the traumatized sis, followed by lateral luxation (27.6 %), avulsion
teeth were located in the upper jaw. The most frequently (15.6 %) and intrusion (15.6 %, Fig. 5).
affected tooth was the central upper incisor (61.0 % n =
853, Fig. 4). Enamel dentin-fracture was the most fre- Type of trauma
quently diagnosed condition (38.2 %), followed by sub- No correlation could be found between the cause of the
luxation (23.0 %) and lateral luxation (17.9 %, Fig. 5). trauma and the type of TDIs, but a comparison of the
different dentitions showed significant differences in the
Decidious dentition type of trauma. While hard-tissue injuries appeared sig-
Among the 537 patients with deciduous dentition, the nificantly more often in patients with permanent denti-
average age was 3.6 years ±2.0 (55.7 % male [3.7 years ± tion (p < 0.001), periodontal injuries were found to be
2.3] and 44.3 % female [3.4 years ± 1.7]), and the male to more frequent in the deciduous dentition (p < 0.001).
female ratio was 1.3:1. The mean number of injured There was no statistical difference in the distribution of

Fig. 2 Distribution of TDIs among the months of the year

Mahmoodi et al. BMC Oral Health (2015) 15:139 Page 4 of 7

Fig. 3 Distribution of TDIs among the days of the week

root fractures (p = 0.412). 10.2 % (n =133) of patients treatment are fully covered by health insurance. Patients
had a combination of hard tissue injury (diagnoses i-iv) in Korea must pay out-of-pocket for emergency treat-
and periodontal injury (diagnoses vii-xi), while the most ment, so that only patients with severer problems might
common combination of diagnoses was subluxation and visit the clinic [13]. The range of prevalences might also
uncomplicated enamel-dentin-fracture (4.1 %; n = 54). be influenced by different socioeconomic and cultural
diversities as well. Although the studies mentioned refer
Initial therapy to TDIs in dental trauma, a deeper view on the various
In 60.2 % of cases a dental, surgical and/or medical kinds, causes and localizations of TDIs was not given.
treatment was provided. The treatment measures are In contrast to other investigation, no seasonal increase
summarized in Table 2. As a matter of course, the re- of TDIs during warm months was found [13, 15]. The
mainder of the patients was seen by the dentist on duty, weekly distribution showed that the major prevalence of
but no interventional therapy was indicated or possible. TDIs were on Saturdays, followed by Sundays and Fri-
days. This is associated with intense social activity,
Discussion sports and leisure time as well as greater alcohol con-
The prevalence of dental trauma in emergency patients sumption on the weekends. These findings agree with
(8 % in the present study) distinctly varies depending on former studies [11, 13, 17].
the countries where the studies were conducted. The Men were more likely to visit the dental emergency
prevalence is reported to be 66 % in Korea [13], 27.7 % service due to TDIs than women; men tend to be more
in the United Kingdom [14], 11 % in Greece [15], and prone to trauma than women [4, 9, 11, 18], perhaps be-
8.4 % in France [16]. This range could be explained by cause of more violent behavior and participation in more
the different health insurance systems; for example, in aggressive types of sports [19]. Our results show that the
Germany basic dental treatment and emergency rate of sport accidents as well as assaults was higher

Table 1 Causes of trauma

Cause of trauma Number of patients n (%) Male n (%) Female n (%) Permanent dentition n (%) Decidious dentition n (%)
Total 1305 (100) 784 (100) 521 (100) 739 (100) 537 (100)
Falls (domestic) 257 (19.7) 144 (18.4) 113 (21.7) 76 (10.3) 172 (32.0)
Falls (outdoors) 456 (34.9) 228 (29.1) 228 (43.8) 214 (29.0) 236 (43.9)
Work accident 22 (1.7) 17 (2.2) 5 (1.0) 22 (3.0) 0
Sport accident 175 (13.4) 128 (16.3) 47 (9.0) 146 (19.8) 25 (4.7)
Assaults 87 (6.7) 79 (10.1) 8 (1.5) 81 (11.0) 5 (0.9)
Traffic accident 81 (6.2) 56 (7.1) 25 (4.8) 66 (8.9) 12 (2.2)
Recreation accident 115 (8.8) 66 (8.4) 49 (9.4) 65 (8.8) 47 (8.8)
Other 112 (8.6) 66 (8.4) 46 (8.8) 68 (9.2) 40 (7.4)
Mahmoodi et al. BMC Oral Health (2015) 15:139 Page 5 of 7

Fig. 4 Affected dentition

among the male collective. The difference in gender was The most common injury in the permanent dentition
less pronounced in patients with trauma in the decidu- in our investigation was enamel-dentin-fractures without
ous dentition, which is consistent with the literature [20, pulp involvement (38.4 %). This is consistent with the
21]. international literature, with a described range between
An age peak was noticed in the 0–9 year-olds, with a 20.2 % and 51.6 % [4, 9, 18, 22, 23]. In the deciduous
continuous decrease with advancing age. Children are dentition, subluxation was the injury most frequently
prone to TDIs because of their lack of motor coordin- seen (33.7 %). Other studies have shown a similar trend
ation and curious and exploratory behavior [13], and the in the distribution of TDIs, with a higher number of
data presented here are in accordance with the literature soft-tissue injuries in the deciduous dentition and an in-
[3, 4, 9, 13]. 71–92 % of all TDIs occur before the age of crease in hard tissue injuries in the permanent dentition
19 years [3]. The proportion was 74.6 % in this study. [4, 22–24]. Because of the higher elasticity of the

Fig. 5 Distribution of type of trauma

Mahmoodi et al. BMC Oral Health (2015) 15:139 Page 6 of 7

Table 2 Provided treatment and to achieve better prognoses through immediate and
Soft tissue Hard tissue Root correct treatment. Efforts to reduce environmental (e.g.
injury injury fractures unsafe school grounds and playgrounds) and behavioral
Temporary filling 52 287 4 risk-factors (e.g. alcohol consumption, school-bullying,
Trepanation 12 44 4 high-risk sport activities, etc.) for TDIs may have an im-
Suture 88 70 1 pact on prevention. Despite all efforts, they cannot be
avoided in most situations. Sport injuries, which were
Splinting 220 68 4
the reason for trauma in 13.4 % of cases, present oppor-
Extraction 47 10 6
tunities for prevention. The use of mouth guards has
Presciption of 138 59 3 been regarded as an effective measure to prevent or re-
antibiotics
duce the severity of dental trauma in sports [25]. From
Prescription of 109 51 2 this perspective, it is important to sharpen about the
analgetics
awareness of the positive effects of these devices among
coaches as well as the athletes themselves.
supporting tissues, the relatively small roots and reduced A limitation of the present study is the lack of follow-
alveolar bone support, the deciduous dentition has a up. Based on our findings, future studies on clinical out-
predisposition for periodontal injuries, while permanent comes, complications and the long time survival rates
teeth are embedded more firmly in the alveolar bone could be conducted. However, our data give an overview
and may be more likely to fracture [12]. In addition, the of the prevalence of TDIs in a German metropolitan
number of luxation injuries might be underestimated region.
since minor luxation in patients with mixed dentition or The high proportion of weekend injuries that usually
periodontal disease are difficult to diagnose, and the pa- need immediate treatment to prevent long-term defi-
tients might be less likely to consult a dentist. ciencies shows the importance of dental emergency units
Altogether, 1.8 teeth per trauma patient were injured, so that patients receive the required care as soon as
which is consistent with the range of 1.6 to 1.9 teeth per possible.
patient described in the literature [4, 11, 18, 22].
In agreement with the results of previous studies, the Conclusion
central and lateral upper jaw incisors were the teeth With an 8 % share of all patients presenting to the emer-
most frequently affected [3, 4, 18]. They account for gency dental service and the impact on esthetics and
78.2 % of all injured teeth in the permanent dentition function, we think TDIs can be regarded as a legitimate
and 85.5 % in the deciduous dentition. public health issue. To improve the quality of care, fur-
A high share of patients presenting to our emergency ther public education, expert knowledge on the diagno-
dental department did not receive any immediate inter- sis and treatment of TDIs among dental professionals
ventional treatment. Some of these were patients with and a well-structured emergency service will be the key.
periodontal injuries in the deciduous dentition that were
near exfoliation stage. In such patients, a conservative, Abbreviations
TDIs: Traumatic dental injuries.
“wait-and-watch” philosophy was applied rather than
interventional treatment. Some patients presented with Competing interests
minimal hard tissue defects, such as enamel fractures The authors declare that they have no competing interests.
with or without dentine involvement that did not in-
Authors’ contributions
clude the pulp. In these patients, no emergency proce- BM carried out the study, was involved in the design and analysis and
dures were needed, but they were provided with an contributed to the write up the paper. RR was involved in the statistical
appointment at a mutually beneficial time. Certain analysis and the write up of the paper. CW participated in the design of the
study and was involved in the statistical analysis. JW was involved in the
pediatric patients also did not receive interventional design and contributed to the write up the paper. AA was involved in the
emergency treatment; these were children with isolated design and statistical analysis. BW participated in the design and
dental avulsion injuries who either did not bring the coordination of the study. All authors read and approved the final
manuscript.
tooth along with them or were cases where the avulsed
tooth was a highly resorbed primary tooth that would Author details
1
have exfoliated in due course anyway. Department of Operative Dentistry and Periodontology, University Medical
Center of the Johannes Gutenberg-University Mainz, Augustusplatz 2, 55131
Mostly TDIs happen in everyday life situations, which Mainz, Germany. 2Department of Oral and Maxillofacial and Facial Plastic
make them largely unavoidable. As a result, dental Surgery, University Medical Center of the Johannes Gutenberg-University
trauma is hard to prevent. Educational programs for Mainz, Augustusplatz 2, 55131 Mainz, Germany.
teachers, parents, caregivers, coaches and paramedics Received: 17 June 2015 Accepted: 21 October 2015
could help to minimize the long term effects of trauma
Mahmoodi et al. BMC Oral Health (2015) 15:139 Page 7 of 7

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