Parental perception versus the presumption of the occurrence of dentoalveolar trauma in their children

ABSTRACT Objective: This cross-sectional, observational study sought to ascertain the perception of parents vis-à-vis the presumption of a dentoalveolar trauma, with regard to the main sequelae, social relationships, expected reactions of the children, and the feelings of the child. Methods: A total of 74 parents were selected at random, who were presented with six color photographs taken from a book, having the clinical appearance of traumatic injury. The responses were recorded with the aid of a voice recorder and were transcribed and stratified using semantic approximation. The data were tabulated using the SPSS software program and evaluated using descriptive statistics. Results: The main sequelae ascribed to dentoalveolar trauma by the parents were as follows: loss of the tooth (43%) and damage to the permanent tooth (18%). The majority of parents believed there would be no change in terms of the children’s relationship with their parents (68.9%), while for 54.1%, there might be some alienation by children in the neighborhood, and for 90.5%, schoolchildren might tease or make fun of them. Of the expected reactions, 86.5% of parents believed their child would feel differently in relation to their friends, because of their appearance. With regard to feelings, for 85.1%, the trauma could lead to the children experiencing shame or embarrassment, 79.7% replied shyness or introversion, and 60.8% sadness. Conclusion: It was concluded that the loss of a tooth and the risk of involvement of the permanent successor tooth germ were the main sequelae ascribed by the parents. Dentoalveolar trauma may have a detrimental effect on the social relationships of the children with others in the neighborhood, and mainly at school, and they may feel differently towards their friends on account of their appearance. Moreover, the children may experience shame or embarrassment, shyness or introversion, and sadness.


INTRODUCTION
In recent years, dentoalveolar trauma has been considered a public health problem due to the high prevalence, cost of treatment and the implications for the patient's oral health [1]. The concept of dentoalveolar trauma has been expanded, in that its sequelae are not limited merely to the oral condition but also the overall state of the individual, including his/her emotional stability and consequences for the family unit [2,3]. For this reason, traumas that involve the oral cavity should always be analyzed as a special situation, since they almost always transform into dramatic experiences for the parents and children [4].
In pre-school children, dental traumas have a negative impact on the quality of life, particularly cases of discolored crowns, enamel/dentin fracture and avulsion. However, enamel fractures do not have a significant impact, it being necessary to exclude them from studies that seek to evaluate the impact of dental traumas on the quality of life [5][6][7]. Fractures of both enamel and teeth had a significant impact on children's quality of life, while the same could not be said for a simple enamel fracture [8].
Dental traumas can lead to pain, loss of function and esthetic problems, with physical, emotional and social consequences for children and their families [5]. Depending on the gravity, they can culminate in serious complications of a morphological, physiological or emotional nature [9], for example: debilitated masticatory function, speech limitations, esthetic impairment and psychological problems involving social interaction, to the point of avoiding to smile or talk [10].
Permanent tooth loss in the anterior region, especially in the upper dentition, in children between the ages of 11 and 14, may lead to feelings of insecurity related to appearance, making them more shy and prone to dissatisfaction with relationships and interactions [11]. In addition, they may be concerned about being judged by others [11,12].
Specifically, the esthetic impairment of the anterior teeth in children may determine a bigger psychosocial impact and influence the perception of others in relation to their appearance. Children with dental traumas in the anterior teeth suffered a negative impact on their well-being, mainly with regard to avoiding to smile or laugh and being worried about what other people might think or say [11].
In a study conducted in Great Britain, an investigation was conducted into the way in which children see their colleagues who may or may not have visible tooth fractures in their anterior teeth. Younger children viewed the photographs of children with this type of trauma more negatively compared to those whose incisors were intact. On the other hand, the converse was observed when the evaluation was made by adolescents, this difference being attributed to increased emotional maturity [13].
Based on the above, the aim of the present work was to ascertain the perception of parents vis-à-vis the presumption of a dentoalveolar trauma, with regard to the main sequelae, social relationships, the expected reaction of their children and their children's feelings.

METHODS
The present work consists of a cross-sectional, observational study and a convenience sample with parents of children between the age of 3 and 12, who frequented the Pediatric Dental Clinic of a public institution between February 2016 and January 2017. The study began after the approval of the Research Ethics Committee (CAAE: 58103516.0.0000.5060) and interviews were preceded by the signing of a Free and Informed Consent Form.
Six color photographs taken from a book [14], and with the clinical appearance of traumas in young deciduous and permanent teeth, were shown to the parents. An interview script was then applied by the researcher, comprising both open and closed questions. The interviews were recorded and subsequently transcribed and stratified using semantic approximation, for the content evaluation procedure [15].
The questions were arranged in thematic sections with the aim of obtaining the psychosocial aspects, as well as the parents' notions of aspects related to traumatic injury, given the possibility of it happening to their own children. The thematic sections used were as follows: A) Social relationships of children vis-à-vis the presumption of an occurrence of dentoalveolar trauma; B) Expected reactions of their child vis-à-vis the possibility of the incidence of a dentoalveolar trauma.
The data were tabulated by means of the Statistical Package for the Social Sciences, version 21.0 (SPSS Inc., Chicago, IL, USA). The statistical evaluation was performed by way of a descriptive analysis, with the production of graphs and frequency tables.

RESULTS
The sample comprised 74 parents, of which 64 (86.5%) were female and 10 (13.5%) were male, aged between 19 and 59 (35.53±8.39 years). In total, 36.5% said they were single parents, 55.4% were in a common-law marriage, 6.8% were divorced and 1.4% were widowed. On the subject of level of schooling, it was noted that the majority of parents had completed secondary education (figure 1). As for the children's ages, 41.9% of parents stated they had children in the 3 to 5 age range, 39.2% in the 6 to 9 age range and 18.9% between the ages of 10 and 12. 75.7% of the children had previously visited a dentist while just 24.3% stated it was the first time.
The participants were questioned about previous experience of dentoalveolar trauma. Approximately 99% of the sample thought it was important to look after teeth that have suffered trauma, although 70.3% had never had such an experience.
The participants were then evaluated by means of hypothetical situations. When asked about what they imagined might occur following a traumatic episode, the most frequent responses indicated sequelae such as the loss of a tooth (43.2%), as can be seen in figure 2. Among the changes in children's behavior described by parents, accounts of whining, petulance and irritability were observed. The percentage of alternatives ticked in terms of social relationships, vis-à-vis the presumption of the occurrence of a dentoalveolar trauma, is displayed in table 1. Among those participants who believed there would be a change in children's relationships with their parents (n=23; 31.1%), these modifications would be in the form of taking more care to avoid a fresh trauma (9.5%), and in terms of behavior and social relations, such as feelings of anger with the situation, embarrassment or a child avoiding smiling (21.6%). As for changes that might occur in the child's relationship with adult parents, among those parents who believed there would be a change (n=31; 41.9%), these changes would constitute a significant motive for embarrassment (25.7%), teasing (5.4%), mean comments (5.4%), prejudice (2.7%) and alienation (2.7%). Table 2 lists the results in relation to the expected reactions of the child vis-à-vis the possibility of dentoalveolar trauma. Among the participants who said that the trauma might modify the child's behavior (n=56; 75.7%), the majority (58.1%) mentioned that he/she might become introverted, and 17.6% believed they would have problems of a social nature, such as bullying. In figure 3, the responses of the parents can be observed with regard to the sentiments that a trauma might provoke in their child, and 85.1% believed their children might feel ashamed or embarrassed.

DISCUSSION
Approximately 99% of parents considered care of teeth affected by dentoalveolar trauma to be important. This finding repudiates the assertion that many parents do not acknowledge the impact of dentoalveolar trauma on diurnal activities and their children's quality of life [16]. In one longitudinal case-control study, dental traumas did not have a negative impact on the quality of life in pre-school children [17]. However, in a systematic review study, using meta-analysis, the principal findings indicated that the presence of dental traumas causes a negative impact on the oral-health related quality of life in pre-school children. It is important to stress that the degree of severity of the dental trauma may be related to the greater impact on the quality of life of preschoolers [5].
The majority of participants reported no changes or negative influences in respect of the children's relationships with their adult parents. On this point, there is some disagreement with regard to the conclusions of other studies that reveal a heavy influence on activities and emotions, resulting in family conflict [2,4].
The results of this study also point to the fact that the neighborhood's children and school colleagues could distance themselves from these children. Although part of a scenario that differs from the study in question, one study carried out recently in Sudan, based on the evaluation of standardized photographs, looked into the way the children view their colleagues, whether or not they have a visible dental trauma in the incisors. Those children with traumas were looked upon more negatively than those who did not have any trauma [18].
It was found that 90% of the parents believed that schoolchildren might tease or make fun of a child who has suffered a dentoalveolar trauma. These findings may be compared with a study conducted in Korea into violence amongst adolescents, which showed that victimization is, among other factors, associated with dissimilarities, such as appearance, among groups of adolescents [19].
With regard to the expected reactions of the child, it was found that dentoalveolar trauma would probably modify his/her behavior. This analysis is in line with studies which asserted that esthetics, in the psychosocial context, have a direct relationship between untreated traumas and social wellbeing, and could lead to social, behavioral changes, particularly with regard to avoiding to smile or laugh and being worried about what other people might think or say [11].
In addition, 78.4% of parents reported that dentoalveolar trauma could cause the child to be dissatisfied or upset with regard to their image. This item of data is consistent with previous studies that revealed that, associated with pain and infection, the consequences of dental trauma also include changes in physical appearance, speech defects and emotional impacts that affect the child's quality of life [5,9,10].
The parents stated that, because of his/her appearance, the child would feel differently in relation to his/her friends, and that, as far as the child is concerned, there would be limited or restricted social relationships. With regard to the feelings that traumas might produce in the child, the data presented in this study showed that children may feel shame or embarrassment, shyness, sadness, anxiety, which validate the literature, also adding that the children might feel less prone to speaking, smiling or laughing [9,10,12]. However, 51.4% of parents stated that the fracture of an anterior tooth does not predispose the child to irritable behavior, contrary to what some researchers have asserted [17]. The highest prevalence of the impact of trauma is related to pain (19.4%), followed by difficulty in ingesting certain foods (16.4%), difficulty in drinking (11.9%) and irritability or frustration (11.9%) [19].
The findings indicate the need for programs of prevention, early diagnosis, immediate treatment of traumatic injuries occurring in early infancy, to avoid detrimental conditions, as well as preventive measures such as the control of risk factors, including guidance on the safety of the target environment [5].
This study contains a number of limitations, most notably the sample size, it being a reduced, non-probabilistic and convenience sample, which limits the possibility of extrapolation to the general population. Future investigations should also consider individual characteristics of children and other factors not targeted in the present study. Nonetheless, this study does present important findings that show that dentoalveolar trauma can create psychosocial impacts. As a result, the implementation of targeted educational programs and measures is suggested, both for the community and the schools, that seek to promote prevention and a reduction in the rates of dentoalveolar trauma, encouraging immediate treatment to be sought when faced with this complication.