Clinical and Epidemiological Profile of Oral and Maxillofacial Trauma at Two Quaternary Hospitals in Mozambique in 2016
Nádia Armindo Henriques Fortes 1, Prem Yohannan 2
1. Oral and Maxillofacial Surgery Unit, Department of Surgery, Maputo Central Hospital,
2. Department of Orthopaedic Surgery, Maputo Central Hospital
Correspondences to: Nádia Armindo Henriques Fortes;E-mail:
Abstract
Introduction: Maxillofacial trauma is characterized by anatomical and functional changes on the face and oral cavity, caused by traffic accidents, physical violence, sports injuries, industrial accidents, and animal bites, among others. The care and treatment of maxillofacial trauma is challenging and multidisciplinary. Objectives: To evaluate the clinical and epidemiological profile of maxillofacial trauma in patients attended at the Maputo Central and Nampula Central hospital, in the year 2016. Material and methods: To conduct a descriptive cross-sectional retrospective study; based on clinical records of all patients with maxillofacial trauma that attended the consultations or were admitted in the wards of the maxillofacial surgery services at the Central Hospitals of Maputo and Nampula from January to December of 2016. Statistical tests were performed looking for significance levels of 5 % in SPSS (version 20 for Windows). Results: It was found that trauma accounted for 482 (35.65%) of patients treated at the Central Hospitals of Maputo and Nampula. 373 (77.4%) of the patients fell in the 15-44 years’ age-group, 363 (75.31%) were male and 430 (89.21%) were of the African race. The majority of patients treated at these hospitals were outpatients 259 (53.77%). It was found (however without statistical significance) that the most frequent cause of trauma had been physical violence. The lower floor of the face was more frequently involved 279 (57.88%) and the most common treatment employed was closed reduction 238 (49.38%). Conclusion: The characteristic clinical and epidemiological profile of patients with maxillofacial trauma is mainly fractures of the lower floor of the face. These types of injuries are usually severe, and the development of preventative and multidisciplinary conducts and treatment protocols for these patients is highly imperative.
Trauma causes deaths in all age groups, all around the world. The World Health Organization indicates that trauma is among the leading causes of death and morbidity in the world (1). maxillofacial trauma is special, because it not only has emotional and functional repercussions, but also has the ability to cause permanent deformities on the face (2). Facial injuries are considered a serious public health problem in developed and developing countries (2,3).
Trauma constitutes a total of 20-25% of admissions to the emergency room. According to the Strategic Plan 2008-2014 of trauma in Mozambique, it was observed that with increasing urbanization there is a reduction of certain types of trauma, such as falls from trees, burns, drowning and even suicides. However, there is an increase in traffic accidents as a result of alcohol consumption and drug abuse; ranging from simple to complex, that require a high level of skill and of experience for best results regarding the treatment (4,5,6,7,8,9,10,11,12,13,14, 15).
The Provinces of Maputo and Nampula are among the most populous in Mozambique. Two public health units, namely Maputo Central Hospital (HCM) and Nampula Central Hospital (HCN) were selected for this retrospective study. They are both quaternary hospitals, HCM being the national reference. This study aims to assess the clinical and epidemiological profile of oral and maxillofacial trauma in patients attended to at the Maputo and Nampula Central hospitals in the year 2016.
Method
We performed an observational study which was retrospective, transversal and descriptive, in character. This study was conducted after approval by the Institutional Bioethics Committee of the Eduardo Mondlane School of Medicine (CIBS FM&HCM/087/2018). The study was based on clinical records of all patients with maxillofacial trauma including soft tissue and bony injuries, and included all ages and genders, as registered in the outpatient and inpatient registers of HCM and HCN, from 1 January 2016 to 31 December 2016.
We excluded records with incomplete data (case-sheets without data regarding the variables under study) and those of any non-traumatic pathologies.
Descriptive results (of the variables age, sex, race, care, patient's condition upon arrival) were presented in the form of tables and frequency charts. In the analytical section we seek to establish 3
associations between the different variables under study: the relationship between the age of patients and gender; relationship between the condition of the patient in relation to alcohol consumption and age of patients. Statistical tests using Fisher’s and Pearson method (chi-square) were conducted looking for a significance level of 5% (p <0.05) in SPSS (version 20 for Windows) which was also used for the analysis performed in this study where the collected data was introduce.
Results
In a non-random sample of about 1352 consecutive patients, the study population was n = 482 trauma patients. We performed a univariate analysis of the variables described (table 1). The age group was stratified according to ICD-10 of WHO.
It was found that 77.39% (n = 373) of trauma patients were aged between 15-44 years and only 1.8% (n=9) were older than 64 years of age. It was also found that 75.31% (n = 363) were males and 24.69% (n=119) were females. 89.21% (n = 430) of these were African and 53.73% (n = 259) did not require admission. It was also observed that about 89.42% (n = 431) of traumatized patients had no clinical records specifying their state in relation to alcohol consumption upon arrival at the hospital.
In the study, the youngest patient was 1 year of age and the oldest was 78 years old. The median age was found to be 27 years.
The vast majority of hospital medical records (70.90%) did not comment on the etiology of maxillofacial trauma variable at both the hospitals, but from the few records that did, 13.4% occurred as a result of road traffic accidents (collisions and runovers). 9% were as a result of Physical aggression (violence).
According to Table 2, it was found that 57.88% (n = 279) involved the lower floor of the face (jaw).
The distribution of mandibular fractures according to anatomical region was studied. Parasymphyseal fractures (33%) and bilateral fractures of the body of the mandible (35%) together accounted for 68% of mandibular fractures. Other fractures involved the jaw angle region (13%), simphyseal region (6%), mandibular condyle (2%), and the ascending ramus of the mandible (1%).
According to Table 3., 49.30% (n = 238) had a closed reduction and inter-maxillary fixation as treatment.
In this study the association between the variables of age and gender with maxillofacial trauma were analyzed. Age group were stratified according to WHO ICD-10 criteria.
In this evaluation, the Fisher's exact test showed p = 0.006 showing therefore a statistically significant association between age/gender in maxillofacial trauma.
It can be seen that out of 362 patients who were males, 289 were between 15-44 years, 45 patients were between 1-14 years, 26 between the 45-64 years age and only 2 patients over the age of 64 years.
The study also analyzed the relationship between the patient's condition in relation to alcohol ingestion at the time of admission and age. Fisher test (p = 0.091) showed no statistical association. Out of the 11 patients observed to have consumed alcohol, 9 were aged between 15 to 44 years, and 1 patient was between 1-14 years and 1 patient was between 45-64 years.
Discussion
In Mozambique, there are no published studies on the subject with which to compare our findings. This study is the first of its kind in this area, and will make available relevant information which can be compared with similar studies from other countries.
The demographic profile of maxillofacial trauma patients in both the hospitals studied in Mozambique in 2016 is similar; most trauma patients belong to the 15-44 years age group, with a mean age 27 years; maxillofacial trauma is more prevalent in African males.
These results of the variables of age, sex and race are not very different from studies carried out in Nigeria and South Africa (15).
The 15-44 years age group is also the most physically active age group; this group includes students and also a large chunk of the working population. Particularly in the African context, this age-group also includes individuals with significant degrees of social responsibility: many in the group are sole bread-winners in their respective families.
This active age group also has a predilection to the consumption of alcohol and the use of recreational drugs. They are more likely than any other age-group to be at social gatherings at bars, clubs, discos, etc. This could justify the findings in this study of the disproportionate prevalence of maxillofacial injury as a result of physical violence and road traffic accidents in the 15-44 years age-group. According to WHO violence is among the leading causes of death worldwide for people between 15-44 years of age (1).
In this study there is a marked difference in the prevalence of maxillofacial trauma in men and women in the two hospitals. This is in line with the findings of studies done in South Africa (15).
It is also seen that the prevalence of women in maxillofacial trauma has shown an increase (15). It should be noted that especially in the last three decades, there is a growing incidence of trauma in women, usually aged up to 40 years. This is due to the behavioral changes of women in society, with a greater number of women drivers, the combination of alcohol and driving, inserting them in extra-domestic’s work (3,4,5,16).
The lower prevalence of maxillofacial trauma in the vulnerable age groups of 1-14 years and
>64 years age-groups may be due to the decreased incidence of high-risk behavior for trauma in these groups. maxillofacial fractures have been found to be less frequent in children (1-14 years) and in elderly over the age of 60 years (3,17,18,19).
In regards to the treatments performed on an outpatient or inpatient basis and the consumption of alcohol; we cannot draw conclusions by the lack of data in this study. In literature consulted, all the traumas resulting from traffic accidents, alcohol was associated in 65% of cases (1).
Studies in Pakistan, South Africa and Brazil indicated physical aggression as the primary cause of maxillofacial traumas (1,18, 19), this study in Mozambique cannot yet say conclusively that from the few duly completed clinical reports physical aggression and traffic accidents are among the leading causes of maxillofacial trauma.
In this study it was found that traumas of the lower floor of the face is the most prevalent type of maxillofacial trauma, mandibular fractures being the most common diagnosis; this finding is in agreement with the findings of similar studies in the literature consulted (17). The regions of the body, the jaw angle and parasymphyseal area of the mandible are the most common locations of these fractures (10,11,12,13).
The study also finds that closed reductions are the most common treatment again in agreement with available literature (7,8,9,14,15,20). It should be noted that wound suture and open reductions were also frequent modalities of treatment used.
Conclusion
Trauma is a major cause of disease in the country, but despite the study bringing evidence considered important from the point of view of Public Health, this study showed that more than one third of patients treated at the Maxillofacial Surgery Service had maxillofacial trauma in the year 2016. Maxillofacial Trauma is one of the leading causes of hospitalization at HCM and HCN.
The characteristic epidemiological profile of patients with maxillofacial trauma is mainly lower facial floor fractures. This type of trauma is severe and common in males between the ages of 15-44; who had regards to the treatment, a similar clinical management in both hospitals in Mozambique.
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