Dental Traumatology 2014; doi: 10.1111/edt.

12147

Prevalence and complications of

trauma to the primary dentition in a
subpopulation of Spanish children in
southern Europe

Asuncion Mendoza-Mendoza1,
Alejandro Iglesias-Linares2,
Rosa Mª Yan~ ez-Vico3, Camilo
Abalos-Labruzzi4
1
Paedriatic Dentistry, School of Dentistry,
University of Seville; 2Stomatology IV, School of
Dentistry, Complutense University of Madrid;
3
Orthodontics, School of Dentistry, University of
Seville; 4Restorative Dentistry, School of
Dentistry, University of Seville, Seville, Spain
Key words: tooth traumatism; temporal denti-
tion
Correspondence to: Alejandro Iglesias
Linares, School of Dentistry, Complutense
University of Madrid, Plaza Ramon y 28040.
Madrid, Spain
e-mail: aleigl01@ucm.es
Accepted 26 September, 2014
Abstract – Background: During the first years of life, when children begin
to walk and socialize, they are particularly vulnerable to traumatic injuries
to the primary teeth; indeed, after dental caries, such injuries are the sec-
ond most frequent cause of pediatric dental consultation. Nonetheless, the
reported prevalence of trauma to the primary teeth varies depending on
the literature source, type of injury, the patient’s age, and the most com-
mon associated complications. Aim: To analyze new epidemiological data
and complications associated with traumatic injuries to the primary teeth
of Spanish children. Material and methods: A retrospective study was car-
ried out in a subpopulation of 879 Spanish children in southern Europe
aged between one and 7 years old, with primary and early mixed dentition.
Clinical and radiological records were obtained from all pediatric patients
who presented trauma to the primary teeth, with a follow-up period of
3–5 years. Results: A total of 21.72% of children examined had some
kind of dental trauma and the most common age range for injuries to the
primary teeth was 1–3 years old. The most common injuries in deciduous
teeth were subluxation (47.29% of injuries affected the periodontal liga-
ment), intrusion (23.15%), and avulsion (13.63%). On the other hand,
comparatively more complications were recorded as a result of intrusion
(32 of 47 intruded teeth). Conclusions: In this Spanish subpopulation, a
pediatric dental consultation as a result of traumatic dental injuries in pri-
mary dentition is most frequent in 1- and 2-year-olds, and subluxation is
the commonest injury in the primary dentition. In turn, intrusion is associ-
ated with an increased frequency of complications in both the deciduous
and the permanent teeth.

After caries, a traumatic dental injury is presently the
second most common reason for visiting a pediatric
dentist. The clear decrease in the frequency of caries,
as evidenced by epidemiologic studies in developed
countries, suggests that tooth injuries may become the
leading cause of consultation in pediatric dental prac-
tice (1).
Children are particularly vulnerable to traumatic
injuries to the primary teeth in the first years of life,
which is when they are beginning to walk and social-
ize. According to prospective and retrospective studies,
the prevalence of such injuries varies considerably
between 4% and 33% (2–11). The differences in
reported prevalence are attributed to multiple factors,
including type of lesion, study setting, and population
analyzed (9).
With respect to age, different authors have identified
the age range of 1–4 years as the most vulnerable per-
iod, with the peak incidence between 10 and 24 months
(2–11). No obvious gender differences have been
reported (2, 12), and the teeth most commonly affected
are the upper central incisors (involving the mesioinci-
sal angle), followed by the lateral incisors and the
canines. Most authors have described a strong correla-
tion between protrusion, incompetent lip seal, and den-
tal trauma in both the primary and the permanent
dentition (13–15). Authors such as Andreasen et al. (9)
consider luxation of any degree of severity to be the
most frequent injury to the primary teeth (16, 17).
Traumatic injuries to the primary dentition can
cause complications that range from practically no neg-
ative effects for either the injured tooth or its perma-
nent successor to significant consequences for both
(4–6, 11, 18, 19). The extent of the complication for
the permanent successor depends fundamentally on the
development stage of the permanent tooth and the
intensity of the trauma (11, 18–24). Andreasen & Ravn
(21) found that the successor tooth was affected in

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1
2 Mendoza-Mendoza et al.

63% of cases involving infants of <2 years old, 53% of

Results
3- and 4-year-olds, and 24% of 5 and 6-year-olds.
These results, and the high frequency of dental trauma
Age, gender, and time to pediatric dental consultation
in small children, suggest that special attention should
associated to deciduous tooth trauma
be devoted to such injuries.
The behavior of the child is a factor that must be Of a total of 879 children examined, 191 (21.72%) had
taken into account when deciding on treatment (14). some kind of traumatic injury to the primary dentition
However, most traumatic injuries to the primary between 1 and 6 years of age. In this study, the trauma
teeth lead to the extraction of the affected tooth as a most commonly occurred between the ages of 1 and
result of failure to provide early treatment (10, 25). 3 years old (Table 1).
The evidence-based clinical guides of the Interna- Of 191 children with injured primary teeth, 101 were
tional Association of Dental Traumatology (IADT) boys and 90 girls (Table 1). When we matched the ages
recommend maximal conservative management, based of patients who experienced some dental trauma
on the principles of damage containment (26, 27). against the ages of the overall study sample (1–5 years:
The present study evaluates epidemiologic aspects of 191 traumatic dental injuries in all), 1- and 2-year-olds
injuries to the primary teeth, the extent and severity of made up more than 50% of the trauma cases at all the
such injuries, the time that elapses before visiting the ages recorded, with a total of 100 of 191 trauma cases.
pediatric dental office in preschool children and their More specifically, according to age group, of 191
relation to the age of the patient, and complications in trauma patients with some dental injury, 43 were
both primary and permanent dentition. 1 year old, 57 were 2 years old, 42 were 3 years old, 22
were 4 years old, and 27 were 5 years old or more. By
age and gender, boys were the most frequently affected
Material and methods by dental trauma in all age groups, except in the
3-year-old group, where girls predominated.
Study subjects With respect to the time from trauma until the first
A retrospective study was carried out in southern Eur- pediatric dental consultation, most of the patients were
ope involving a subpopulation of 879 Spanish children seen on the first day after the trauma (n = 94), 23 were
between 1 and 7 years old with primary and early seen in the first week, 19 after 1 month, 25 after
mixed dentition. All children had primary teeth when 6 months, and 30 after more than 6 months. Signifi-
they were examined. cantly, those who were most quickly taken to the den-
tist after the trauma were the youngest children (1- and
2-year-olds) (Table 2). More specifically, most of those
Clinical and radiological assessment taken to the dentist in the first 24 h after the trauma
The clinical records of every child were obtained and were in the 1-year-old group, followed by the 2-year-
also the radiologic records of those patients with olds. In contrast, the group that took more than
trauma to the primary dentition. Clinical and radio- 6 months to visit the dentist basically consisted of chil-
logic evaluations were made both when the patient dren between 5 and 7 years of age (Table 2).
was first examined following the injury and on fol-
low-up visits at one, three, and then every 6 months
until the permanent successor erupted. The clinical Table 1. Sample distribution according to age and gender
assessment of complications was based on recording Gender (F/M)
a series of variables, which included grayish or yel-
low changes of color in the teeth, phlegmons and fis- Age (years) Trauma No trauma % trauma cases1
tulas, periapical radiotransparency, pathological 1 19/24 29 59.72% (43 of 72)
resorption, canal obliteration, delayed or accelerated 2 25/32 73 43.84% (57 of 130)
eruption of successors, and damage to the permanent 3 27/15 145 22.45% (42 of 187)
tooth germ. 4 10/12 175 11.16% (22 of 197)
The same pediatric dentist specialist (A.M.M) carried >5 9/18 266 9.21% (27 of 293)
out all diagnoses, treatment, and clinical and radiologic
F, female; M, male.
controls in a private pediatric dental practice. 1
Percentage of all consultations.

Statistical analysis Table 2. Time from trauma to pediatric dental visit

A descriptive statistical analysis based on frequency Age 1d 1w 1m 6m >6 m
tables was used for qualitative variables, with (years) [n(%)] [n(%)] [n(%)] [n(%)] [n(%)]
calculation of means and standard deviation (SD).
1 30 (31.9) 8 (34.78) 2 (10.52) 2 (10.52) 1 (3.33)
Variables considered were as follows: tooth; gender 2 27 (28.72) 5 (21.73) 10 (52.63) 7 (28) 8 (26.66)
of the patient; type of trauma; complications deriving 3 18 (19.14) 6 (26.08) 2 (10.52) 8 (32) 8 (26.66)
from the injury; age of the patient; and time until 4 9 (9.57) 0 4 (21.05) 5 (20) 4 (13.33)
first visit. The study then explored associations >5 10 (10.63) 4 (17.39) 1 (5.26) 3 (12) 9 (30)
between variables, including type of trauma and its
d, day; w, week; m, month.
complications.

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Tooth traumatism 3

erupted were found to be damaged (two cases of hypo-

Type of trauma and complications
The most common injuries to the primary dentition
were subluxation (47.29% of lesions affected the peri-
odontal ligament), followed by intrusion (23.15%) and
then avulsion (13.63%). It can be stated therefore that,
in the primary teeth, damage to the supporting tissue is
more common than to the hard tissue of the tooth
(68.35% of all lesions) (Table 3). On the basis of our
results, the most commonly affected primary teeth were
the upper central incisors (86.9%). It should also be
noted that 297 lesions were recorded for 191 children
with some dental injury, as some children had more
than one injury affecting different teeth (Table 3).
Regarding intrusion, in 25.53% of cases, more than
50% of the crown of the deciduous tooth was still visi-
ble; in 53.19%, <50% of the crown was visible, and in
the remaining 21.27%, intrusion was complete or
almost complete, with the tooth in some instances dis-
appearing entirely into the alveolar bone. With respect
to the complications associated with the 47 intruded
teeth and the treatment for the 40 teeth that re-erupted
spontaneously (0–6 months), the most common prob-
lem was pathological root resorption, with or without
associated necrosis. With respect to avulsion, we docu-
mented 29 cases (13.63% of lesions affected the peri-
odontal ligament). Of the 297 lesions in our series of
191 patients, we monitored 260 cases, as the rest of the
patients failed to report for follow-up consultations. As
a result, we were only able to assess possible complica-
tions for these 260 lesions.
Intrusion was the type of dental injury that involved
most complications in the primary teeth (32 cases), par-
ticularly pathological resorption associated with pulp
necrosis (12 cases) followed, in order of frequency, by
necrosis (nine cases) and pathological resorption (seven
cases). In addition, the permanent teeth in four of the
44 cases of intrusion that were monitored until they
plasia and two of hypomineralization), and in one case,
the permanent successor showed delayed eruption with
respect to the other central incisor. Necrosis was the
most frequent complication in the remaining cases of
dental trauma.
Discussion
According to the findings of prospective and retrospec-
tive studies, the prevalence of traumatic injuries to the
primary teeth ranges between 4% and 33% (2–11). In
our series, prevalence was found to be 21.72%. In line
with most authors, we consider that the reasons for the
reported differences in prevalence can be attributed to
multiple factors, including lesion classification, study
setting, and population analyzed (9, 11).
The literature reports that traumatic dental injuries
occur most frequently in the first years of life when
children are beginning to walk and socialize, and the
most common underlying cause in these cases is an
accidental fall. Our series agreed with these findings
(6, 12), with the highest incidence corresponding to
2-year-olds who had had a fall. Like Bastone (6) and
Garcia-Godoy (28), we observed no significant gender
differences at this age when accidental falls tend to
occur at home, and the most frequently affected teeth
by far were the upper central incisors (86.9%), proba-
bly because these teeth are most exposed to damage in
the event of an accidental fall or collision (28).
One significant finding was that 30 children in this
age group (1- and 2-year-olds) (57%) were taken to the
dentist within 24 h of the injury. After comparing this
figure against the total number of 879 children studied
(72 of whom were 1 year old and 130 2 years old), it
may be concluded from our study that dental trauma is
a common reason for consulting a pediatric dentist at
this age. In a 2010 series, which included 359 patients

Table 3. Type of traumatism and resulting complications

Complications of PS tooth Complications of primary tooth
Traumatism (n [%]) Delayed eruption Perm. Damage Necrosis Obliteration Pathol. Reabs. Pathol. Reabs. & Necrosis No Re-Eruption
Periodontal ligament lesion (203 [68.35])
Subluxation (961 [47.29%]) – – 13 4 10 1 –
Lateral luxation (192 [9.35%]) – – 8 – – 2 –
Extrusive luxation (12 [5.9%]) – – – – – – –
Avulsion (29 [13.63%]) 1 2 – – – – –
Intrusion (47 [23.15%]) 1 43 9 – 7 12 4
Hard tissue lesion (94 (31.64])
E fracture (304 [31.91%]) – – – – – – –
E/D fracture (28 [29.78%]) – – 9 – – – –
E/D/P fracture (13 [13.82%]) – – 1 – – – –
C C/R fracture (175 [18.08%]) – – – – – – –
R fracture (66 [6.38%]) – – 3 – – – –
PS, permanent successor; E, enamel; D/E, dentoenamel; P/D/E, pulp/dentoenamel; R, root; CC/R, Complicated crown–root.
1
Of a total of 96 subluxations, 82 were satisfactorily monitored, clinically and radiographically, during the indicated periods.
2
Of a total of 19 lateral luxations, 14 were satisfactorily monitored, clinically and radiographically, during the indicated periods.
3
Two cases of damage to permanent tooth were due to hypomineralization and two to hypoplasia.
4
Of a total of 30 enamel fractures, 20 were satisfactorily monitored, clinically and radiographically, during the indicated periods.
5
Of a total of 17 complicated C/R fractures, 16 were satisfactorily monitored, clinically and radiographically, during the indicated periods.
6
Of a total of six complicated C/R fractures, five were satisfactorily monitored, clinically and radiographically, during the indicated periods.

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
4 Mendoza-Mendoza et al.
aged 1–15 years who sought emergency dental care in a
regional hospital, Diaz et al. (29) recorded a prevalence
rate for primary tooth trauma of 12.7% for the 1–6
age group, with the most frequent underlying cause at
this age being an accidental fall. The authors studied
the time that elapsed from injury to emergency treat-
ment in children and adolescents and found that 67.4%
of patients aged 1–15 years sought help in the first
24 h. Our data, however, indicated that, when only the
primary teeth were considered (that is, children from 1
to 6 years old), the percentage of dental trauma
observed was lower. Differences concerning the type of
population or whether the setting is a hospital or a pri-
vate pediatric dental practice may also account for the
observed differences in care for injured teeth in the first
24 h after a trauma.
With regard to the type of lesion, the alveolar pro-
cess in preschool children is characterized by large
bone marrow spaces and is relatively flexible. Further-
more, the periodontal ligament, which acts as a ‘physi-
ological hammock’, is very elastic and so the teeth are
less firmly held in place. As a result, in the event of a
slight traumatic injury, the teeth displace rather than
fracture (2, 3). This would explain the considerable dif-
ference in prevalence that we observed for injuries
affecting the periodontal ligament in the primary teeth
and those affecting the hard tissue and/or pulp. Other
studies (2–4, 17, 30) show that periodontal ligament
damage is the commonest type of lesion in the primary
dentition. In line with this, subluxation was the most
frequently observed dental trauma affecting the pri-
mary dentition in our series, followed by intrusion then
avulsion. It may be worth observing that a subluxation
is not always reported, because it is an injury of lesser
magnitude, and so it would not necessarily be described
as the most frequent type of injury. In fact, many stud-
ies describe luxation and avulsion as the most frequent
types of trauma in the primary dentition (6, 17, 30),
although other authors, such as Diaz in 2010 (29), have
described subluxation as the most common type of
injury in primary teeth (38.6%), followed by avulsion
(16.6%). Our own data showed that intrusion was
more frequent than avulsion in the primary teeth. The
prevalence of avulsion of primary teeth was similar to
that reported by Christophersen et al. (31), who
recorded a rate of 0.8%, which is much lower than the
7–13% cited by Andreasen and Andreasen in the Text-
book and Color Atlas of Traumatic Injuries to the Teeth
(9). However, as Christophersen mentions, the calcula-
tions of the above authors were based on hospital
data.
In our series, intrusion was the second most fre-
quent type of lesion in the primary dentition. In this
respect, and in agreement with other similar studies,
the majority of children who sustained an intrusion
injury were 2 years old or younger, coinciding with
the period when they are learning to walk (4, 28,
32). Like Assuncao Da Silva et al. (33), we found
this to be the commonest type of injury up until the
age of 2 years, although those authors reported a
prevalence of 29.3% for primary tooth intrusion. In
2009, Colak et al. (34) found that only 24.3% of
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
parents whose children had suffered intrusion visited
the pediatric dental office within 12 h of the injury
taking place, whereas 49.2% of children in our series
made an emergency visit in the first 24 h after the
trauma, and 60.93% (57 of 94 patients) of these were
one or 2 years old.
On the other hand, complications in the form of
necrosis were unquestionably more frequent in cases
that involved enamel–dentin fracture (32.14% of all
enamel and dentinal fractures) in comparison with
other more complex kinds of hard tissue injury. This
could have been due to delaying visiting the pediatric
dentist for this type of trauma, in comparison with
other seemingly more alarming injuries that prompt
parents to seek help quickly. Other consequences of
primary teeth trauma have been described, such as
changes in the coloration of the crown, pulp necrosis,
obliteration of the pulp canal, gingival retraction, dis-
placement of the primary tooth, pathological root
resorption (internal or external), abscesses or cellulitis,
alterations in the physiological root resorption pro-
cess, or premature loss of the primary teeth (9, 11,
16–21).
In the permanent dentition, alterations of the crown
(hypocalcification and hypoplasia), of the crown/root
(dilaceration), root (duplication, angulation, dilacer-
ation, and arrested development), disturbances in the
permanent successor (tumors and sequestration of the
entire tooth germ), or alterations in eruption are all, in
turn, consequences of the close relation between the
apex of the primary tooth and the developing perma-
nent successor (9, 11, 20–24, 28). Hypocalcification
and/or hypoplasia (enamel discoloration of and/or
defects) has been described as the most frequent mal-
formative sequelae of trauma in the primary teeth (9).
In a longitudinal study published by Diab et al. (17)
involving 255 traumatized primary teeth, 23% showed
developmental disturbances in the permanent successor,
and intrusive luxation was the lesion type that gave rise
to most sequelae in the primary teeth. Disturbed erup-
tion occurred less frequently and was related to avulsed
primary teeth in two cases and to intrusive luxation in
one. In comparison with the previously mentioned
studies by Andreasen (9), Andreasen and Ravn (21),
Assuncao Da Silva et al. (33), Diab et al. (17), or the
article by Sennhenn-Kirchner (35), which recorded a
20% injury rate, our own data point to a lesser fre-
quency of damage to the permanent successor. Specifi-
cally, of the 176 cases of damage to the periodontal
ligament evaluated, 3.4% involved damage to the per-
manent tooth and only 1.1% involved delayed erup-
tion. In our series, the primary tooth injuries that
produced the most serious sequelae for the permanent
successor germ were intrusion and avulsion, with hypo-
calcification and/or hypoplasia being the commonest
malformative sequelae. Regarding the much less fre-
quent alterations in the chronology of dental eruption,
the observed prevalence was 1.1% for intrusion and
2.2% for traumatic avulsion. There were no cases of
damage to the permanent successor germ recorded as
the result of an injury that damaged the hard tissue or
the hard tissue and dental pulp.

Conclusions
Trauma to the deciduous teeth was observed to be
most prevalent in children of 1 or 2 years of age
(24.10% and 29.23%, respectively, of all injuries in
the primary dentition). Dental trauma is the most
frequent reason for a pediatric dental consultation
in children of these ages (59.72% and 43.48%,
respectively).
Following dental trauma, young infants under
2 years of age are taken to the dental clinic sooner
than older children.
The most frequent primary tooth injury in the pres-
ent study was subluxation (47.29% of all injuries in
the deciduous teeth), followed by intrusion (23.15%)
and avulsion (13.63%).
Necrosis of the primary tooth was the main compli-
cation after dental trauma. In turn, hypoplasia and
hypomineralization were the most frequent sequelae
in the developing permanent tooth, while odonto-
mas and root dilaceration were rare or infrequent.
Traumatic intrusion that gave rise to the largest
number of complications in the primary teeth, with
the most frequently observed being pathological
resorption, with or without associated pulp necrosis.
Likewise, intrusion was the type of trauma that gave
rise to most sequelae for the permanent successor,
with hypoplasia and hypomineralization being the
most frequent alterations.
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