DOI: 10.1111/ipd.
12092
Impact of traumatic dental injuries and malocclusions on
quality of life of preschool children: a population-based study
JENNY ABANTO1, GUSTAVO TELLO1, GABRIELA CUNHA BONINI2,
€
LUCIANA BUTINI OLIVEIRA2, CHRISTIANA MURAKAMI1 & MARCELO BONECKER1
1
Department of Pediatric Dentistry and Orthodontics Department, Dental School, University of S~
Brazil, and 2Department of Pediatric Dentistry, S~
ao Leopoldo Mandic School of Dentistry, Campinas, Brazil
International Journal of Paediatric Dentistry 2015; 25: 18–28
Background. Few studies assessed the impact of
traumatic dental injuries (TDI) and malocclusions
on the oral health-related quality of life (OHR-
QoL) in preschool children.
Aim. To assess the impact of the presence of TDI
and malocclusions, as well as its severity and
types, respectively, on the OHRQoL of preschool
children.
Design. The study was conducted in 1215 chil-
dren aged 1–4 years old who attended the
National Day of Children Vaccination in Diadema,
Brazil. Parents answered the Brazilian version of
the Early Childhood Oral Health Impact Scale
(B-ECOHIS) and socio-demographic conditions.
Calibrated dental examiners performed the oral
Introduction
Traumatic dental injuries (TDI) are a public
dental health problem mainly in preschool
children population due to its frequency,
costs, and treatment, which may continue for
the rest of the patient’s life1. In this respect,
only one study reporting trends of TDI in
Brazilian preschool children showed a signifi-
cant increase in the prevalence of TDI in the
last years with its treatment seriously
neglected2. Moreover, some types of maloc-
clusions such as increased overjet and ante-
rior open bite have been also reported as
predisposing factors of TDI2.
Nevertheless, there are few studies assessing
the impact of TDI and malocclusions on the
oral health-related quality of life (OHRQoL)
Correspondence to:
Jenny Abanto, Faculdade de Odontologia de S~ ao Paulo,
Departamento de Odontopediatria, Av. Professor Lineu
Prestes, 2227, Cidade Universitaria, CEP: 05508-000. S~
ao
Paulo, SP, Brasil. E-mail: jennyaa@usp.br
18 © 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
ao Paulo-USP, S~
ao Paulo,
examinations for TDI and malocclusions. Poisson
regression models adjusted by dental caries associ-
ated the clinical and socio-demographic conditions
with the outcome.
Results. The multivariate adjusted models showed
associations between some individual domains of
the B-ECOHIS and clinical and socio-demographic
conditions (P < 0.05). The severity of TDI showed
a negative impact on the symptoms domain and
self-image/social interaction domain (P < 0.05).
Children with complicated TDI were more
likely to experience a negative impact on total
B-ECOHIS scores (PR = 2.10; P = 0.048).
Conclusions. The presence of complicated TDI and
dental caries were associated with worse OHRQoL
of Brazilian preschool children, whereas malocclu-
sions do not.
in preschool children3–6 and the evidence is
conflicting. Although some studies reported
that children’s OHRQoL was not influenced
by the presence of TDI, as determined by clin-
ical examination5,6, other studies observed a
negative impact of this clinical condition3,4.
Three of these studies also assessed the impact
of malocclusions on the preschool children’s
OHRQoL3,4,6. Only a previous study, found
an association between the presence of mal-
occlusion and OHRQoL in total scores3.
Furthermore, to the best of our knowledge,
there are no studies in representative
samples, which evaluate not only the impact
of the presence of TDI and malocclusions, but
also the impact of the severity of TDI and
different types of malocclusions on preschool
children’s OHRQoL.
Therefore, the purpose of this study was to
assess the impact of the presence of TDI and
malocclusions, as well as its severity and
types, respectively, on the OHRQoL of
preschool children in a Brazilian population-
based sample.

Methods
This study was independently reviewed and
approved by the Research Ethics Committee
of the School of Dentistry of the University of
S~
ao Paulo. All parents/caregivers received
information regarding the aim of the study
and signed informed consent forms.
Study population and data collection
A cross-sectional study was performed in 2012
on a population-based sample of children aged
1–4 years old living in Diadema, S~ ao Paulo,
Brazil. Diadema had an estimated population
of 357,064 inhabitants that included 35,034
children under 5 years old. The sample size
was calculated to give a standard error of 3%, a
design effect of 1.2 with a 95% confidence
interval. The prevalence of oral impact from
the oral conditions on preschool children’s
OHRQoL considering a representative sample
was set at 17.3%3. To cover non-response, the
sample was increased by 20% to 879 children
and their parents/caregivers.
Participants were systematically selected
from all children attending the National Day
of Children’s Vaccination carried out in the
city of Diadema. The vaccination programme
in Diadema consistently had uptake rates of
above 94% of preschool children7. Quota
sampling was selected from all children
attending each of the 19 health centres in
Diadema. Health centres were used as sam-
pling points because the city was administra-
tively divided into 19 regions. Each fifth child
in the queue for vaccination was invited to
participate in the study. If parents/caregivers
did not agree to participate, the next child in
the queue was selected. This systematic pro-
cess was the same for all of the 19 health
centres. Children of both genders, with no
systemic diseases and/or neurological diseases
and with parents/caregivers who were fluent
in Brazilian Portuguese, were included.
On the National Day of Children’s Vaccina-
tion, one of the parents/caregivers (preferably
the one who spent most of the time with the
child) was invited to answer two structured
questionnaires in a face-to-face interview: one
on socio-demographic conditions and other on
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Complicated dental trauma harms quality of life 19
the child’s OHRQoL. Interviews were carried
out by 19 dental assistants who were blind to
the clinical oral examinations. They were
trained in the reading and intonation of each
question and option of responses to the OHR-
QoL instrument. Socio-demographic condi-
tions such as parental age, number of children,
and family income were collected as discrete
quantitative variables, whereas parental level
of education and family structure were
collected as ordinal and nominal qualitative
variables, respectively. All these socio-demo-
graphic data were then categorised for statisti-
cal analysis as follows: parental age (≤30 or
>30 years); parental levels of education (≤8 or
>8 years); family structure (children living
with both parents, mother, father, or others);
and number of children (=1 or ≥2). Family
income was categorised in terms of the
Brazilian minimum wage (BMW), which
corresponds to approximately US$ 320.00 per
month (up to 2 BMW or >2 BMW).
Nineteen previously calibrated examiners
from each health centre in Diadema
independently carried out the children’s oral
examination. The examiners were all
graduate dentists who had previous experi-
ence in previous epidemiological surveys. All
examiners underwent two sessions of training
and calibration exercises for a 6-h period with
pictures of clinical cases for the studied
clinical conditions, with an interval of 1 week
between sessions to obtain intra- and
inter-examiner reliability kappa values. Kappa
values were calculated on a tooth-by-tooth
basis.
Children’s oral examination
The clinical examinations were performed in
a dental unit using an operating light, a 3-in-
1 syringe, plane dental mirror, and millimetre
ruler.
Severities of TDI in anterior upper primary
incisors were classified according to Glendor
et al.8 modified for epidemiological studies.
Uncomplicated injuries were defined as those
in which the pulpal tissue was not exposed
and the tooth was not dislocated (crown frac-
ture of only enamel, crown fracture of
enamel, and dentin or tooth discoloration).
26 J. Abanto et al.
malocclusions at this age in total B-ECOHIS
scores3, whereas Goettems et al.6 found that
only the anterior open bite presence was neg-
atively associated with the child’s function
domain. In contrast to these authors, we did
not find associations for the presence of dif-
ferent types of malocclusions in general; how-
ever, this is the first study that conversely
found a positive impact of the presence of
malocclusions only on the family function
domain, which comprises items such as taken
time off from work and financial impact on
the family. One reason for the positive impact
of malocclusions on the family function
domain may be that this condition is often
associated with non-nutritive sucking habits,
such as the use of pacifier sucking. In our
study, the most prevalent malocclusion was
anterior open bite, and although we did not
find association of this type of malocclusion
on the OHRQoL or investigate their associated
factors, it is recognised that anterior open bite
also results of this deleterious habit20,21. As
many children and parents at this age prefer
the maintenance of the use of pacifiers due to
the child’s emotional necessities or facility for
calming the child, leaving behind the occlusal
and aesthetic changes produced by the bad
position of teeth, it can be expected that these
parents do not need to take time off from
work and spent money in the treatment for
malocclusion at this age. In spite of all this,
the presence of malocclusions was not associ-
ated with a negative impact on the total
B-ECOHIS scores.
Previous studies have shown that dental
caries had a negative impact on the preschool
children’s OHRQoL3,6,16,17. We have con-
firmed similar findings in our results. For this
reason, it is important that studies focused on
children’s OHRQoL adjust the impact of oral
diseases and disorders for dental caries in
their analyses.
Previous studies focused on schoolchildren
have reported that different socio-economic
conditions were associated with the impact of
oral diseases and disorders on OHRQoL22–24,
but the magnitude of this effect in preschool
children still remains controversial3,6,16,17.
This was one of the reasons for including
these variables in our models. The socio-
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
demographic variable more associated in
these studies to the OHRQoL is family
income. Although some studies showed that a
high family income has a protective effect on
preschool children’s OHRQoL16,17, others did
not observed this association3,6. In agreement
with the latter authors, we did not find asso-
ciation between socio-demographic conditions
such as family income and the OHRQoL. The
main reason for this is that, in accordance
with the information provided by local
authorities and a previous study25, the socio-
economic status in the area of the survey was
homogeneous for this age group. Children in
Diadema are mainly from low socio-economic
backgrounds. Certainly, our study would
have benefited from a more balanced sample
in relation to socio-economic status.
Substitutions of the fifth child by the sixth
child in the queue occurred when parents/
caregivers did not agree to participate in the
study. This could result in a bias if we consid-
ered that some of the substituted children
would have shown different clinical condi-
tions and/or impacts than those who were
selected. The frequency of substitutions was
however low as indicated by the non-
response rate of the study (6%). Moreover,
the sample size was increased by 20% to
cover non-response, minimising the risk of
affecting the results.
It is important to mention that only Bra-
zilian studies in the literature have assessed
the association between TDI and malocclu-
sions on the OHRQoL of preschool chil-
dren3–6. There is the need for further studies
assessing the impact of these clinical condi-
tions in other countries, ethnicities, and cul-
tures to make transcultural comparisons of
our results. Moreover, the assessment of the
impact of oral conditions on OHRQoL is a
relevant issue because it turns possible to
verify the demand and the distribution of
treatment needs within the target popula-
tion. Future research, however, evaluating
these impacts not only according to parental
proxy -reports, but also using child’s self-
report at this age is needed to confirm our
results, as conceptually it is strongly recom-
mended to include both for assessing OHR-
QoL in children26,27.
28 J. Abanto et al.
21 Vasconcelos FM, Massoni AC, Heimer MV, Ferreira
AM, Katz CR, Rosenblatt A. Non-nutritive sucking
habits, anterior open bite and associated factors in
Brazilian children aged 30–59 months. Braz Dent
J 2011; 22: 140–145.
22 Locker D. Disparities in oral health-related quality of
life in a population of Canadian children. Community
Dent Oral Epidemiol 2007; 35: 348–356.
23 Piovesan C, Antunes JL, Guedes RS, Ardenghi TM.
Impact of socioeconomic and clinical factors on child
oral health-related quality of life (COHRQoL). Qual
Life Res 2010; 19: 1359–1366.
24 Paula JS, Leite IC, Almeida AB, Ambrosano GM,
Pereira AC, Mialhe FL. The influence of oral health
conditions, socioeconomic status and home envi-
ronment factors on schoolchildren’s self-perception
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
of quality of life. Health Qual Life Outcomes 2012; 13:
6.
25 B€onecker M, Marcenes W, Sheiham A. Caries reduc-
tions between 1995, 1997 and 1999 in preschool
children in Diadema, Brazil. Int J Paediatr Dent 2002;
12: 183–188.
26 Barbosa TS, Gavi~ ao MB. Oral health-related quality
of life in children: part III. Is there agreement
between parents in rating their children’s oral heal-
th-related quality of life? A systematic review. Int J
Dent Hyg 2008; 6: 108–113.
27 Abanto J, Tsakos G, Paiva SM et al. Cross-cultural
adaptation and psychometric properties of the Bra-
zilian version of the Scale of Oral Health Outcomes
for-5-year-old children (SOHO-5). Health Qual Life
Outcomes 2013; 11: 16.
 22

Table 3. Univariate analysis of socio-demographic and clinical condition variables associated with total and each domain scores of the Brazilian version of the Early
Childhood Oral Health Impact Scale (B-ECOHIS).

Child impact section Family impact section B-ECOHIS

SD FD PD SSD PDD FFD Total Score

Independent
variables PR (95% IC) P PR (95% IC) P PR (95% IC) P PR (95% IC) P PR (95% IC) P PR (95% IC) P PR (95% IC) P
J. Abanto et al.

Socio-demographic conditions
Child’s age
1 year
2 years 0.55 0.024 1.01 0.962 0.45 0.001 0.14 0.082 1.07 0.856 1.27 0.582 0.72 0.157
(0.33–0.92) (0.57–1.80) (0.27–0.73) (0.02–1.27) (0.52–2.15) (0.53–3.08) (0.46–1.13)
3 years 0.72 0.168 1.04 0.881 0.40 0.001 0.86 0.847 1.15 0.664 1.11 0.812 0.78 0.212
(0.45–1.15) (0.61–1.79) (0.24–0.67) (0.20–3.73) (0.59–2.26) (0.47–2.60) (0.53–1.15)
4 years 1.51 0.046 2.13 0.002 0.69 0.101 1.51 0.498 1.84 0.041 2.42 0.021 1.49 0.023
(1.01–2.25) (1.32–3.44) (0.45–1.07) (0.46–4.92) (1.03–3.32) (1.14–5.10) (1.06–2.09)
Child’s gender
Female
Male 0.72 0.043 1.20 0.290 1.08 0.656 0.61 0.333 1.05 0.800 1.31 0.317 1.03 0.806
(0.53–0.99) (0.86–1.68) (0.77–1.52) (0.22–1.66) (0.69–1.62) (0.77–2.22) (0.79–1.35)
Mother’s age
≤30 years
>30 years 1.01 0.914 1.06 0.733 0.95 0.789 0.74 0.576 0.86 0.348 0.92 0.743 0.96 0.782
(0.74–1.38) (0.75–1.49) (0.66–1.36) (0.25–2.16) (0.51–1.26) (0.53–1.57) (0.73–1.26)
Mother’s education
≤8 years
>8 years 0.94 0.759 0.65 0.028 1.39 0.143 1.14 0.817 0.74 0.225 1.04 0.886 0.87 0.400
(0.67–1.35) (0.45–0.95) (0.89–2.15) (0.36–3.63) (0.46–1.19) (0.55–1.97) (0.63–1.20)
Father’s age
≤30 years
>30 years 0.846 0.339 0.91 0.646 0.72 0.097 0.43 0.154 0.71 0.168 1.36 0.367 0.82 0.211
(0.59–1.19) (0.61–1.36) (0.48–1.06) (0.13–1.36) (0.43–1.15) (0.69–2.70) (0.60–1.11)
Father’s education
≤8 years
>8 years 1.02 0.907 0.86 0.461 1.21 0.408 0.80 0.749 0.95 0.855 0.23 0.642 1.01 0.934
(0.71–1.47) (0.58–1.28) (0.77–1.88) (0.41–2.70) (0.57–1.59) (0.64–2.59) (0.74–1.38)
Family structure
Live with mother and father
Live with mother 1.19 0.425 1.58 0.035 1.19 0.415 1.57 0.445 1.13 0.672 0.52 0.297 1.32 0.131
(0.77–1.83) (1.03–2.41) (0.77–1.84) (0.49–5.01) (0.63–2.01) (0.46–1.49) (0.91–1.92)
Live with father 0.73 0.745 0.45 0.401 1.67 0.328 3.76 0.125 2.58 0.346 0.51 0.925 0.71 0.501
(0.11–4.78) (0.07–2.93) (0.59–4.75) (0.66–8.52) (0.98–1.44) (0.12–1.02) (0.26–2.02)
Live with other 1.01 0.947 1.24 0.434 1.49 0.141 2.26 0.379 2.13 0.238 1.97 0.236 1.34 0.148
members of (0.58–1.78) (0.72–2.15) (0.87–2.56) (0.15–3.90) (0.10–3.13) (0.53–1.28) (0.89–2.01)
the family

© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
(Continued)
 Table 3 (Continued)

Child impact section Family impact section B-ECOHIS

SD FD PD SSD PDD FFD Total Score

Independent
variables PR (95% IC) P PR (95% IC) P PR (95% IC) P PR (95% IC) P PR (95% IC) P PR (95% IC) P PR (95% IC) P

Number of children
One
Two or more 1.30 0.096 1.42 0.043 0.98 0.903 3.99 0.011 1.35 0.180 0.77 0.355 1.25 0.110
(0.95–1.78) (1.01–1.98) (0.69–1.39) (1.36–11.68) (0.87–2.07) (0.44–1.33) (0.95–1.62)
Family income (BMW per month)
Up to 2 BMW
>2 BMW 0.65 0.077 0.67 0.166 0.99 0.983 0.29 0.118 0.79 0.439 1.71 0.093 0.81 0.316
(0.40–1.05) (0.38–1.18) (0.59–1.66) (0.06–1.36) (0.44–1.41) (0.91–3.21) (0.54–1.21)
Clinical conditions
Severity of TDI
Absence
Uncomplicated 1.19 0.349 0.65 0.076 0.75 0.190 0.98 0.986 0.48 0.018 0.80 0.548 0.75 0.084
injuries (0.83–1.69) (0.41–1.05) (0.49–1.15) (0.29–3.26) (0.26–0.88) (0.39–1.64) (0.55–1.03)
Complicated 3.19 0.008 2.46 0.076 2.05 0.217 13.18 0.001 3.49 0.017 2.71 0.136 2.97 0.002
injuries (1.35–7.53) (0.91–6.63) (0.66–6.43) (2.98–8.13) (1.24–9.80) (0.73–10.06) (1.50–5.88)
TDI experience
Absence
Presence 1.29 0.142 0.75 0.201 0.82 (0.54–1.24) 0.349 1.63 0.354 0.64 0.122 0.90 0.765 0.87 0.392
(0.92–1.82) (0.48–1.17) (0.57–4.65) (0.37–1.12) (0.47–1.75) (0.64–1.18)
Types of malocclusion
Absent
Anterior open 0.88 0.504 0.98 0.920 0.73 0.170 1.58 0.399 0.86 0.619 0.42 0.034 0.84 0.334
bite (0.60–1.28) (0.66–1.44) (0.46–1.15) (0.55–4.53) (0.48–1.55) (0.19–0.94) (0.60–1.18)

© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Anterior cross 1.03 0.938 0.99 0.995 0.73 0.371 1.92 0.245 1.14 0.702 0.19 0.103 0.86 0.604
bite (0.53–2.00) (0.45–2.17) (0.37–1.44) (0.35–3.93) (0.58–2.24) (0.03–1.39) (0.50–1.49)
Posterior cross 1.21 0.692 0.98 0.982 0.72 0.646 1.93 0.148 0.81 0.757 1.30 0.789 0.94 0.896
bite (0.47–3.09) (0.32–3.03) (1.84–2.85) (0.62–4.27) (0.21–3.11) (0.19–9.06) (0.43–2.07)
Increased 0.87 0.672 0.64 0.225 1.05 0.857 1.85 0.448 1.32 0.501 0.55 (0.21–1.43) 0.222 0.90 0.688
overjet (0.48–1.61) (0.32–1.31) (0.60–1.84) (0.37–9.18) (0.58–2.95) (0.54–1.48)
Malocclusion
Absence
Presence 0.915 0.584 0.91 0.602 0.79 0.193 1.29 0.607 0.99 0.975 0.45 0.013 0.86 0.294
(0.66–1.25) (0.64–1.28) (0.55–1.12) (0.48–3.46) (0.63–1.55) (0.24–0.85) (0.65–1.13)
Dental caries
Absence
Presence 3.22 <0.001 2.68 <0.001 2.11 <0.001 4.26 0.004 4.07 <0.001 3.86 <0.001 2.96 <0.001
(2.40–4.34) (1.90–3.77) (1.46–3.05) (1.59–11.40) (2.66–6.21) (2.28–6.53) (2.26–3.87)
Complicated dental trauma harms quality of life

PR, prevalence ratio; SD, symptom domain; FD, function domain; PD, psychological domain; SSD, self-image/social interaction domain; PDD, parent distress domain; FFD, family function
domain; TDI, traumatic dental injuries.
23
24 J. Abanto et al.
action domain, respectively (P < 0.05). The
child’s age of the sample showed to have a
positive impact on the psychological domain
(P < 0.001). The presence of malocclusion
showed a positive impact on the family func-
tion domain (PR = 0.43; P = 0.009). For total
B-ECOHIS scores, 2- and 3-year-old children
had a positive OHRQoL (PR = 0.65 and 0.56,
respectively; P < 0.05) compared with those
who are 4 years old. Moreover, children with
complicated TDI were more likely to experi-
ence a negative impact on their OHRQoL
(PR = 2.10; P = 0.048). The presence of den-
tal caries showed to have a negative impact
for all the domains included in the children
and family impact sections (P < 0.05) and for
total B-ECOHIS scores (PR = 3.09; P < 0.001).
Discussion
This study evaluated the impact of TDI and
malocclusions on the OHRQoL of Brazilian
preschool children according to parental
proxy reports. To the best of our knowledge,
this is the first study that also assessed the
impact of the severity of TDI and different
types of malocclusions on the OHRQoL in a
population-based sample at this age.
The presence of TDI and different types of
malocclusions may cause loss function, aes-
thetics problems, and effect on emotional and
social well-being by themselves in preschool
children. Up to now, however, few studies
can be found assessing the impact of TDI on
preschool children’s OHRQoL3–6; however,
methodological differences regarding sam-
pling4, TDI classification criteria, and analy-
sis3,5,6 can be observed among them and our
study. In line with our results, some of these
studies5,6 found no association between the
presence of TDI and children’s OHRQoL in
total B-ECOHIS scores. Conversely, only one
recent study3 reported a negative impact of
the presence of this clinical condition on the
OHRQoL. A potential explanation is partly
due to the use of different TDI criteria diag-
nosis among them. It is worth noting that the
present study and a previous one4, which use
the same classification for severity of TDI,
however, in a convenience sample, confirmed
in their multivariate adjusted models that
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
complicated TDI were more likely to have a
negative impact on OHRQoL than those with-
out TDI or those diagnosed with uncompli-
cated TDI, when considering total B-ECOHIS
scores. This emphasises the need for using
similar clinical classifications, population-
based samples, and analysis in studies with
the same purpose to confirm previous results
and avoid methodological discrepancies that
complicate comparisons.
Our study not only assessed the impact of
TDI on total B-ECOHIS scores, but also on
individual domains. There is only one more
study6 in the literature that also assessed the
B-ECOHIS domains using regression analysis;
however, it considered only the presence of
TDI, but not its severity. Despite that this latter
study found no associations between the vari-
ables, the present study showed that compli-
cated TDI has a negative impact on the
symptoms and self-image/social interaction
domains. Our results corroborate the findings
of another study4 that used mean comparisons
and found statistically negative differences for
complicated TDI in the same domains. The
symptoms domain comprised an item related
to pain because of dental problems, and, at this
respect, it is expected that complicated TDI
produce a great magnitude of discomfort con-
sidering the involvement of the pulp tissue
and/or dislocation of the tooth. The negative
impact on the self-image/social interaction
domain can be explained as a result of some
dislocation of the tooth or dental avulsions that
can produce an aesthetic discomfort because
they change or loss teeth position and damage
the harmony of the smile avoiding smiling and
speaking. Furthermore, the child’s age of the
sample showed to have a positive impact on
the psychological domain. These results are in
agreement with a previous study6, which dem-
onstrated that child’s age (4 year old or more)
was significantly associated with this domain.
In our study, this association remained also
significant for 2- and 3-year-old children.
Three previous studies also assessed the
impact of malocclusions on the preschool
children’s OHRQoL3,4,6, but only Kramer
et al.3 and Goettems et al.6 found some
associations on the OHRQoL. Kramer et al.3
found a negative impact of the presence of
 Table 4. Multivariate adjusted model of socio-demographic and clinical condition variables associated with total and each domain scores of the Brazilian version of the
Early Childhood Oral Health Impact Scale (B-ECOHIS).

Child impact section Family impact section B-ECOHIS

SD FD PD SSD PDD FFD Total Score

Independent
variables PR (95% IC) P PR (95% IC) P PR (95% IC) P PR (95% IC) P PR (95% IC) P PR (95% IC) P PR (95% IC) P

Socio-demographic conditions
† † † † †
Child’s age
1 year
2 years 0.39 <0.001 0.65 0.047
(0.24–0.62) (0.42–0.99)
3 years 0.29 <0.001 0.56 0.003
(0.18–0.48) (0.38–0.82)
4 years 0.42 <0.001 0.89 0.559
(0.26–0.68) (0.62–1.29)
Clinical conditions
† † † †
Severity of TDI
Absence
Uncomplicated 1.11 0.555 0.91 0.882 0.75 0.068
injuries (0.78–1.56) (0.27–3.08) (0.55–1.03)
Complicated 2.47 0.032 9.71 0.007 2.10 0.048
injuries (1.08–5.63) (1.86–50.59) (1.01–4.39)
† † † † †

© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Malocclusion
Absence
Presence 0.43 0.009 0.87 0.319
(0.23–0.80) (0.67–1.13)
Dental caries
Absence
Presence 3.15 <0.001 2.68 <0.001 2.96 <0.001 3.11 0.069 4.08 <0.001 3.97 <0.001 3.09 <0.001
(2.35–4.24) (1.92–3.77) (1.96–4.47) (0.92–10.54) (2.65–6.29) (2.33–6.75) (2.28–4.20)

PR, prevalence ratio; SD, symptom domain; FD, functional domain; PD, psychological domain; SSD, self-image/social interaction domain; PDD, parent distress domain; FFD, family function
domain; TDI, traumatic dental injuries.
†
Variables not associated with the respective domains in the final multivariate model after the adjustment.
Complicated dental trauma harms quality of life
25
26 J. Abanto et al.
malocclusions at this age in total B-ECOHIS
scores3, whereas Goettems et al.6 found that
only the anterior open bite presence was neg-
atively associated with the child’s function
domain. In contrast to these authors, we did
not find associations for the presence of dif-
ferent types of malocclusions in general; how-
ever, this is the first study that conversely
found a positive impact of the presence of
malocclusions only on the family function
domain, which comprises items such as taken
time off from work and financial impact on
the family. One reason for the positive impact
of malocclusions on the family function
domain may be that this condition is often
associated with non-nutritive sucking habits,
such as the use of pacifier sucking. In our
study, the most prevalent malocclusion was
anterior open bite, and although we did not
find association of this type of malocclusion
on the OHRQoL or investigate their associated
factors, it is recognised that anterior open bite
also results of this deleterious habit20,21. As
many children and parents at this age prefer
the maintenance of the use of pacifiers due to
the child’s emotional necessities or facility for
calming the child, leaving behind the occlusal
and aesthetic changes produced by the bad
position of teeth, it can be expected that these
parents do not need to take time off from
work and spent money in the treatment for
malocclusion at this age. In spite of all this,
the presence of malocclusions was not associ-
ated with a negative impact on the total
B-ECOHIS scores.
Previous studies have shown that dental
caries had a negative impact on the preschool
children’s OHRQoL3,6,16,17. We have con-
firmed similar findings in our results. For this
reason, it is important that studies focused on
children’s OHRQoL adjust the impact of oral
diseases and disorders for dental caries in
their analyses.
Previous studies focused on schoolchildren
have reported that different socio-economic
conditions were associated with the impact of
oral diseases and disorders on OHRQoL22–24,
but the magnitude of this effect in preschool
children still remains controversial3,6,16,17.
This was one of the reasons for including
these variables in our models. The socio-
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
demographic variable more associated in
these studies to the OHRQoL is family
income. Although some studies showed that a
high family income has a protective effect on
preschool children’s OHRQoL16,17, others did
not observed this association3,6. In agreement
with the latter authors, we did not find asso-
ciation between socio-demographic conditions
such as family income and the OHRQoL. The
main reason for this is that, in accordance
with the information provided by local
authorities and a previous study25, the socio-
economic status in the area of the survey was
homogeneous for this age group. Children in
Diadema are mainly from low socio-economic
backgrounds. Certainly, our study would
have benefited from a more balanced sample
in relation to socio-economic status.
Substitutions of the fifth child by the sixth
child in the queue occurred when parents/
caregivers did not agree to participate in the
study. This could result in a bias if we consid-
ered that some of the substituted children
would have shown different clinical condi-
tions and/or impacts than those who were
selected. The frequency of substitutions was
however low as indicated by the non-
response rate of the study (6%). Moreover,
the sample size was increased by 20% to
cover non-response, minimising the risk of
affecting the results.
It is important to mention that only Bra-
zilian studies in the literature have assessed
the association between TDI and malocclu-
sions on the OHRQoL of preschool chil-
dren3–6. There is the need for further studies
assessing the impact of these clinical condi-
tions in other countries, ethnicities, and cul-
tures to make transcultural comparisons of
our results. Moreover, the assessment of the
impact of oral conditions on OHRQoL is a
relevant issue because it turns possible to
verify the demand and the distribution of
treatment needs within the target popula-
tion. Future research, however, evaluating
these impacts not only according to parental
proxy -reports, but also using child’s self-
report at this age is needed to confirm our
results, as conceptually it is strongly recom-
mended to include both for assessing OHR-
QoL in children26,27.

Conclusion
The presence of complicated TDI and dental
caries was associated with worse OHRQoL of
Brazilian preschool children, whereas maloc-
clusions do not.
Why this paper is important to paediatric dentists:
● This paper shows the negative impact of complicated
TDI on the OHRQoL and asserts the need to be seen
as a public health problem in preschool children
indicating the importance of its treatment in this
population.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
This study was financially supported by
Fundacß~ao de Amparo  a Pesquisa do Estado de
S~
ao Paulo (FAPESP), process numbers: 2011/
18412-8, 2012/00944-6, and 2013/10330-8.
The authors also wish to thank the local
authorities (Health Council) Secretaria Muni-
cipal de Sa
ude de Diadema, the dental exam-
iners, and assistants for their cooperation in
carrying out this study. Also, the authors
wish to thank the participants of the Post-
Graduate Pediatric Dentistry Seminar of
FOUSP for their critical comments.
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