a b s t r a c t

Background: The aim of this study was to determine the prevalence of facial trauma among victims of Road traffic accidents and investigate factors associated with it.

Methods: A cross-sectional study was carried out using the medical and dental charts of 2570 victims of road traffic accidents with bodily and/or facial injuries between 2008 and 2011. sociodemographic variables of the victims and characteristics of the accidents and injuries were evaluated. Statistical analyses included the ?² test as well as the Poisson univariate and multivariate regression analyses for the determination of the final hierarchical model.

Results: The prevalence of facial injuries was 16.4%. Most of the victims were male. Among the victims with facial injuries, 44.3% had polytrauma to the face. The prevalence of facial injuries was high among accidents that occurred at night (Prevalence Ratio (PR), 1.42; 95% confidence interval [CI], 1.10-1.84; P = .007) and victims up to 9 years of age (PR, 2.31; 95% CI, 1.03-5.17; P = .041). Moreover, the prevalence of facial injuries was lower among victims of Motorcycle accidents than victims of automobile accidents (PR, 0.59; 95% CI, 0.44-0.89; P = .001).

Conclusion: The prevalence of facial injuries was high in this study and was significantly associated with the place of residence, time of day, age group, and type of accident.

(C) 2014

Introduction

Background

Facial injuries are considered a serious Public health problem in both developed and Developing countries [1-4]. The epidemiology of facial trauma varies across Geographic regions and populations and depends on a number of factors, such as cultural and lifestyle differences, population density, and socioeconomic status [1,5].

? Sources of support: Conselho Nacional de Pesquisa (CNPQ) and Fundacao de Apoio a Pesquisa do Estado da Paraiba (FAPESQ).

?? Conflict of interest: The authors declare no conflicts of interest. Funding from the

Brazilian funding agencies Conselho Nacional de Pesquisa (CNPQ) and Fundacao de Apoio a Pesquisa do Estado da Paraiba (FAPESQ) had no influence on the study design, data collection and analysis, editorial decisions, or the drafting of the manuscript.

* Corresponding author. Av. das Baraunas, n? 351, Departamento de Odontologia, Bairro Universitario, CEP: 58.429-500, Campina Grande, PB, Brazil. Tel.: +55 0833315.3326.

E-mail addresses: [email protected] (L.M. Nobrega), [email protected] (G.M.S. Cavalcante), [email protected] (M.M.S.M. Lima), [email protected] (R.C.R. Madruga), [email protected] (M.L. Ramos-Jorge), [email protected] (S. d’Avila).

According to international statistics, 300000 individuals die every year as a result of road traffic accidents (RTAs), and more than 8000000 are injured. Moreover, the rate of fatal accidents is increasing approximately 5% each year [6]. Road traffic accidents are among the main causes of facial injuries [1,5,7] and can lead to disability and death. They also exert considerable economic impact in the form of lost productivity [1,8-10]. Facial injuries are often associated with a loss of function, disfiguration, and psychological problems [1].

Injuries stemming from traffic accidents are a problem faced in a large number of countries [1,3,5,8,9,11], and their prevention is one of the priorities of public health authorities [11]. Thus, knowledge of the factors associated with facial injuries stemming from RTAs is important for the prognosis, the identification of groups at risk, and the establishment of measures to minimize the economic, emotional, psychological, and social impacts of these events.

Importance

Several studies in the literature have described the frequency and severity of injuries based on hospital data, usually over short periods [4-7,9,11]. However, studies in Departments of Forensic Medicine are rare

[12] and are usually mortality studies. This study contributes data that

http://dx.doi.org/10.1016/j.ajem.2014.08.054

0735-6757/(C) 2014

differ from those of other studies because they include victims of morbidity. The findings increase our understanding of these events and their victims and can contribute to public policies aimed at preventing trauma and the establishment of an integrated vigilance system interlinking police stations, forensic services, and emergency departments.

Goals of this investigation

The aim of this study was to determine the prevalence of facial trauma among victims of RTAs and investigate the associated factors.

Material and methods

Study design

A cross-sectional study was carried out at a forensic medicine and dentistry center in a metropolitan area in northeastern Brazil. This institution is a referral center for 23 municipalities, reaching a population of 687545 inhabitants. In a 12-year period (2000-2012), the number of vehicles in these municipalities increased by 185% [13]. The sample comprised victims of nonlethal RTAs with some type of bodily and/or facial trauma recorded over a 4-year period (January 2008 to December 2011). The records were completed by employees who worked as medical or dental experts at the time the victim received a physical examination to determine the extent of the damage caused by the trauma.

Setting

The research was conducted at the Department of Forensic Medicine and Dentistry (NUMOL), which is a police department where reports are filed for victims for whom corpus delicti must be established or who died a violent death.

The reports were originally completed by the medical and dental experts involved in the examination. The report was completed at the time the victim was sent to the corpus delicti examination, an examination that records the extent of the damage caused by trauma. Legible reports by individuals who were alive at the time of the examination were included. In cases of illegible reports, a more thorough analysis by the physician or surgeon-dentist who was on duty at the time of data collection was requested. Thus, 0.2% of all reports were excluded because of incomprehensible information.

Methods of measurement

Data collection was conducted using a form specifically drafted to record data on facial trauma (absent/present) stemming from RTAs. This form contained 2 parts: part I-sociodemographic data, and part II- data related to the accident and any resulting injuries. The following sociodemographic data were recorded: age (in 10-year intervals), sex (male/female), conjugal status (in stable relationship/single), place of residence (urban/suburban/rural), and Employment status (unemployed/ salaried worker/unsalaried worker). The following characteristics related to the accidents and injuries were recorded: type of accident (automobile/motorcycle/pedestrian), day of the week (weekday/ weekend day), time of day (daylight hours/evening or night), part of the body affected (head/neck/upper limb/lower limb/thorax/ abdomen)[14], part of the face affected (upper third/middle third/ lower third/more than one third)[15], type of injury (soft tissue/bone fractures/dentoalveolar fracture/other), and side of the face affected (left/right/bilateral/forehead). The recommendations were explained in the “STROBE Statement”.

Statistical analysis

Data analysis was performed using the Statistical Package for Social Sciences (SPSS for Windows, version 20.0, SPSS Inc, Chicago,

Illinois) and involved frequency distributions and descriptive statis- tics of the sociodemographic factors and characteristics of the accident and injuries. Pearson ?² test was used to compare factors associated with the type of trauma.

A hierarchical approach was used [16,17] with the variables grouped in categories from distal to proximal determinants. The following categories were used (in this order): sociodemographic variables of the victim and characteristics of the RTA. For each level, a Poisson regression analysis with robust variance was performed to correlate facial trauma with the independent variables. This analysis was performed to include variables with P b .20 in the univariate analysis. Explanatory variables were selected for the final models when they had a P value b.05 after adjusting for variables on the same level. In these analyses, the result was treated as dichotomous, as in previous studies [18,19]. A 95% confidence interval (CI) was considered.

Ethical considerations

This study was carried out in compliance with international norms and national legislation governing ethics in studies involving human subjects and was authorized by the institution at which it was conducted. The study also received approval from an ethics committee (process N? 0652.0.133.203-11).

Results

Baseline characteristics

A total of 2570 charts of RTA victims were analyzed. The mean age of the victims was 34.38 +- 15.00 years, and 1112 (47.7%) were between 30 and 59 years of age. A total of 2003 victims (78.1%) were male (proportion of men to women, 3.5:1). Most were single (n = 1312, 56.5%), had up to 8 years of schooling (n = 821, 55.7%), were unsalaried workers (n = 1068, 52.1%), and resided in a urban area (n = 1259, 51.6%) (Table 1).

Table 2 displays the data on facial and bodily injuries. Most injuries were caused by motorcycle accidents (n = 1689, 67.8%) and occurred during daylight hours (n = 1.199, 55.8%) and on weekdays (n = 1.580, 62.9%). Facial injuries occurred in 421 cases (16.4%); poly-

Table 1

Absolute and relative frequencies of sociodemographic variables

Variable No.^a (%)

Sex

Male 2003 (78.1)

Female 562 (21.9)

Age group, y

5 to 14 47 (2.0)

15 to 24 204 (8.8)

25 to 34 790 (33.9)

35 to 59 1112 (47.7)

>=60 178 (7.6)

Place of residence

Urban 1259 (51.6)

Suburban 496 (20.3)

Rural 686 (28.1)

Conjugal situation

With partner 1009 (43.5)

Single 1312 (56.5)

Schooling

None 81 (5.6)

Up to 8 y of study 812 (55.7)

9 to 11 y of study 424 (29.1)

>=12 y of study 141 (9.7)

Employment status

Unemployed 300 (14.6)

Salaried worker 680 (33.2)

Unsalaried worker 1068 (52.1)

^a Differences in category totals due to loss of data.

Table 2

Absolute and relative frequencies of variables related to RTAs and resulting injuries Variable No.^a (%)

resided in areas adjacent to metropolitan areas (PR, 1.41; 95% CI, 1.02- 1.96; P = .038) and those who resided in municipalities beyond these adjacent areas (PR, 1.50; 95% CI, 1.10-2.26; P = .010) than those who

Day of week

Type of accident Automobile	484 (19.4)	resided within metropolitan areas, among victims up to 9 years of age (PR, 2.31; 95% CI, 1.03-5.17; P = .041) than individuals in other age
Motorcycle	1689 (67.8)	groups, and among accidents that occurred at night (PR, 1.42; 95% CI,
Pedestrian	317 (12.7)	1.10-1.84; P = .007) than those that occurred during daylight hours.

Weekday 1580 (62.9)

Weekend day 932 (37.1)

Period of day

Day 1199 (55.8)

Night 950 (44.2)

injury site

Face 199 (7.7)

Body 2147 (83.5)

Both 224 (8.7)

Facial injury

Present 421 (16.4)

Absent 2149 (83.6)

Region of face affected

Upper third 101 (24)

Middle third 101 (24)

Lower third 32 (7.6)

More than one region 186 (44.3)

Type of facial injury

Soft tissue 240 (57.5)

Bone fracture 141 (33.9)

Dentoalveolar fracture 22 (5.3)

Other 13 (3.1)

Side of face affected

Left 109 (31.5)

Right 91 (26.3)

Bilateral 88 (25.4)

Forehead 58 (16.8)

Region of body affected

Head 311 (12.1)

Neck 14 (0.5)

Moreover, the prevalence of facial injuries was 41% lower among victims of motorcycle accidents than victims of automobile accidents (PR, 0.59; 95% CI, 0.44-0.89; P = .001).

Discussion

The records of 2570 victims of RTAs who had bodily and/or facial trauma were analyzed in this study. The prevalence of facial trauma was 16.4%. A study carried out at the Forensic Medicine Institute in the city of Porto, Portugal, reports a similar prevalence [12]. According to the cited authors, this type of injury can have serious long-term consequences for the victim.

A number of epidemiological studies report that RTAs are among the main Etiological factors of facial trauma [20-23]. In this study, accidents involving motorcycles were the most prevalent (67.8%). In contrast, Caldas et al [12] found that accidents involving automobiles were the most prevalent.

The prevalence of facial trauma was 41% lower among victims of motorcycle accidents compared with victims of automobile accidents. In Brazil, there has been an intensification of educational campaigns and monitoring regarding the use of individual protection equipment

Table 3

Associations between facial trauma and sociodemographic variables, day of week, and time of day of RTAs

Upper limb 443 (17.3)

Lower limb 964 (37.6)

Thorax 51 (2.0)

Abdomen 40 (1.6)

More than one region 740 (28.9)

^a Differences in category totals due to loss of data.

trauma to the face accounted for the largest proportion of such cases (n = 186, 44.3%), and soft tissue injuries were the most prevalent type (n = 240, 57.5%). The lower limbs were the most affected part of the body (n = 964, 37.6%), followed by polytrauma (n = 740, 28.9%). Statistically significant associations were found between the type of trauma (facial or bodily) and age group, place of residence, conjugal status, schooling, employment status, type of accident, day of the

week, and time of day (Table 3).

Facial trauma P

Present Absent

No. (%) No. (%)

Sex
Male	331 (78.6)	1672 (78.0)	.773
Female	90 (21.4)	472 (22.0)
Age group, y
0 to 9	12 (3.1)	35 (1.8)	.008
10 to 19	40 (10.4)	164 (8.4)
20 to 29	151 (39.3)	639 (32.8)
30 to 59	156 (40.6)	956 (49.1)
>=60 or more Place of residence	25 (6.5)	153 (7.9)
Urban	176 (44.3)	1083 (53.0)	.003
Suburban	84 (21.2)	412 (20.2)
Rural	137 (34.5)	549 (26.9)
Conjugal status

	With partner	138 (36.8)	817 (44.8)	.004
3.2. Characteristic analysis	Single Schooling	237 (63.2)	1075 (55.2)

The Poisson univariate hierarchical regression analysis was carried out on 2 levels. Level 1 consisted of sociodemographic data and characteristics of the RTA, in which age group, place of residence, conjugal status, schooling, employment status, type of accident, and time of day were significantly associated (P b .05) with the dependent variable (type of trauma) (Table 4). In level 2, the analysis of the different groups of variables revealed that age group and place of residence (sociodemographic variables) as well as the type of accident and time of day (characteristics of the RTA) were significantly associated (P b .05) with the dependent variable.

multivariable regression“>3.3. Multivariable regression

Thus, the final multivariate model comprised 4 covariables (Table 5). The prevalence of facial injuries was higher among individuals who

None	17 (7.1)	64 (5.3)	.028
Up to 8 y of study	148 (61.7)	664 (54.5)
9 to 11 y of study	51 (21.3)	373 (30.6)
>=12 y of study Employment status	24 (10.0)	117 (9.6)
Unemployed	55 (16.6)	245 (14.3)	.008
Salaried worker	86 (25.9)	594 (34.6)
Unsalaried worker	191 (57.5)	877 (51.1)

Type of accident

Automobile 106 (25.8) 378 (18.2) .001

Motorcycle 253 (61.6) 1436 (69.1)

Pedestrian 52 (12.7) 265 (12.7) Day of week

Weekday 232 (56.7) 1348 (64.1) .005

Weekend day 177 (43.3) 755 (35.9) Time of day

Day	165 (47.4)	1034 (57.4)	.001
Night	183 (52.6)	767 (42.6)

Table 4

Results of Poisson univariate regression analysis for facial trauma suffered during RTAs

Variable Unadjusted PR (95% CI) P

Sociodemographic factors Place of residence

Urban	1
Suburban	1.37 (0.99-1.89)	.058
Rural	1.44 (1.06-1.96)	.017
Conjugal status With partner	1
Single Age group,y	1.24 (0.95-1.62)	.102
>=60	1
30 to 59	1.19 (0.68-2.09)	.528
20 to 29	1.13 (0.64-2.02)	.658

observed in men, which may be related to the increase in the number of female drivers.

The mean age of the victims was 34.4 +- 15.0 years, which is similar to figures described in others studies [12,20-34]. In the present investigation, age remained part of the final Poisson regression model. Facial trauma was significantly more prevalent among victims up to 9 years of age than among those 60 years or older, which is a worrisome finding. Children require specific Safety measures based on their age and the form of transportation being used, and these are not always obeyed or monitored. It is common to find children being transported in an irregular fashion and without adequate protective equipment. Higher prevalences of facial trauma were also found for the other age groups analyzed than for

10 to 19	1.44 (0.74-2.78)	.275	individuals 60 years and older, but these differences were not
Up to 9	2.50 (1.15-5.41)	.020	statistically significant.

The highest prevalence of facial trauma was observed in residents of areas suburban. In these areas and rural areas, there is generally less compliance with traffic laws, protective equipment is used less often, and driving at excessive velocities is more common. The use of protective equipment, adequate traffic studies, and educational campaigns are either nonexistent or ineffective, and individuals are more prone to injuries stemming from RTAs.

Schooling
None	1
Up to 8 y of study	0.96 (0.58-1.61)	.897
9 to 11 y of study	0.55 (0.31-0.97)	.040
>=12 y of study Employment status	0.83 (0.43-1.57)	.567
Unemployed	1
Salaried worker	0.64 (0.44-0.94)	.024
Unsalaried worker	0.82 (0.58-1.16)	.270
Characteristics of accident
Type of accident
Automobile	1
Motorcycle	0.57 (0.43-0.77)	b.001
Pedestrian	1.01 (0.69-1.47)	.960
Time of day
Day	1
Night	1.45 (1.12-1.87)	.005
Day of week
Weekday	1
Weekend day	1.29 (0.99-1.67)	.052

Nighttime was a negative factor for the occurrence of facial trauma stemming from RTAs, with a 42% higher prevalence compared to daylight hours. Nighttime is associated with limited visibility, greater imprudence, increased alcohol consumption, excessive velocities, less regard for traffic signs due to the lower level of traffic than during daylight hours, as well as both physical and mental weariness [35].

Table 5

Poisson multivariate analysis and final hierarchical model of variables associated with facial trauma

such as helmets [24] and compliance with legislation that prohibits

Alcohol intake in combination with driving [25].

Studies have demonstrated that alcohol in the blood produces different neuromotor alterations at different concentrations: 0.3 dg/L (corresponding to a single drink [14 g of alcohol]) leads to a reduction in attentiveness, a false perception of velocity, euphoria, and difficulty spatially discerning different light intensities; 0.6 dg/L leads to slow reaction times and sleepiness; and 0.8 dg/L leads to a reduction in peripheral vision and poor performance in routine activities [26].

These data led the Brazilian Congress to reduce the level of alcohol permitted among drivers to zero (Law n? 11.705 of 2008), increase the penalty for driving under the influence of alcohol, and criminalize drivers who operate motor vehicles with blood alcohol levels of 0.6 dg/L or higher [25].

Moreover, the greater prevalence of facial trauma among victims of automobile accidents than among victims of motorcycle accidents may be due to the use of airbags, which, despite reducing the incidence and severity of injuries in general [27-29], may contribute to facial injuries [30]. Although the prevalence of facial trauma was 14% higher among victims of run-over accidents than victims of automobile accidents, the difference did not achieve statistical significance.

A total of 78.1% of the victims were male, which is consistent with data reported in previous studies [23,31,32]. The proportion of males

Variable Adjusted PR (95% CI) P

Sociodemographic factors-level 1 Place of residence

Urban	1
Suburban	1.36 (0.98-1.90)	.065
Rural	1.45 (1.06-1.97)	.018
Age group, y >=60	1
30 to 59	1.25 (0.71-2.21)	.436
20 to 29	1.21 (0.67-2.17)	.521
10 to 19	1.47 (0.75-2.87)	.255
Up to 9	2.60 (1.18-5.75)	.018
Characteristics of accident Type of accident Automobile	1
Motorcycle	0.59 (0.44-0.79)	b.001
Pedestrian	1.04 (0.71-1.52)	.822
Time of day Day	1
Night	1.43 (1.10-1.85)	.006
Final model-level 2 Place of residence Urban	1
Suburban	1.41 (1.02-1.96)	.038
Rural	1.50 (1.10 - 2.06)	.010
Age group, y >=60	1
30 to 59	1.47 (0.83-2.61)	.181

to females was 3.5:1, which is lower than the figure described by	20 to 29	1.50 (0.83-2.73)	.177
Bayan et al [33] in a study carried out in India (5:1) and the 13:1 ratio	10 to 19	1.61 (0.83-3.09)	.155
described by Moafian et al [32] in a study carried out in Iran but higher than the proportion described by Fasola et al [31] in a study conducted in Nigeria (2.9:1). These findings demonstrate a lack of an established	Up to 9 Type of accident Automobile Motorcycle	2.31 (1.03-5.17) 1 0.59 (0.44-0.89)	.041 .001
pattern across cultures.	Pedestrian	1.14 (0.76-1.72)	.523

Males and females exhibited similar proportions of facial and bodily trauma. The number of facial injuries due to traffic accidents among women is proportionally approaching the level

Time of day

Day 1

Night 1.42 (1.10-1.84) .007

Limitations

Because of the cross-sectional design, these findings demonstrate mere associations rather than causality; therefore, caution is required when analyzing the data. Moreover, it should be stressed that the data were limited to nonfatal accidents. Longitudinal studies are needed for a more in-depth understanding of factors related to the occurrence of facial trauma among victims of RTAs. Nonetheless, the findings increase our understanding of these events and their victims and can contribute to public policies aimed at preventing trauma and the establishment of an integrated vigilance system interlinking police stations, forensic services, and emergency departments.

Conclusion

The prevalence of facial injuries among victims of RTAs was high in this study and was significantly associated with place of residence, time of day, age group, and type of accident.

Acknowledgments

The authors are grateful to the Forensic Medicine and Dentistry Center (NUMOL) where this study was conducted and the Brazilian funding agencies CNPQ (Official notice: MCT/CNPq N? 14/2010) and FAPESQ (official notice: 02/2009 PPSUS) for financial support.

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