Oral Health-Related Quality of Life in Children and Adolescents with a Traumatic Injury of Permanent Teeth and the Impact on Their Families: A Systematic Review

The aim of this systematic review was to evaluate the impact of a traumatic dental injury (TDI) of permanent teeth in children and adolescents on their oral health-related quality of life (OHRQoL) as well as on their families. A bibliographic search in the biomedical databases (PubMed, Cochrane Library, MEDLINE) was limited to studies published between January 2000 and February 2021. The study selection criteria were cross-sectional, case control, or prospective clinical studies, which analyzed TDI before and after the treatment of permanent teeth in healthy children and adolescent, assessed their OHRQoL, and were written in English. The search found 25 eligible articles that were included in the study. The quality assessment of the studies was performed using the quality assessment checklist for survey studies in psychology (Q-SSP). The results indicated that a TDI of permanent teeth strongly influences the OHRQoL of children and adolescents, and the timely-performed dental management of a TDI allows for preventing further biological and socio-psychological impacts. Sociodemographic status, economic status, parent’s education, gender, age group, and type of schooling were determinants of the TDI impact on OHRQoL.


Introduction
Quality of life is described as "an individual's perception of their place in life concerning goals, aspirations, standards, and concerns in the sense of the culture and values in which they reside" [1]. The definition of oral health-related quality of life (OHRQoL) refers to how oral health or disease affects an individual's everyday work, well-being, and, as a result, their overall quality of life [2]. The quality of life is highly affected by their state of health. Physical and psychological constraints in the field of dentistry can directly affect eating, speech, social interaction, and self-esteem [3]. A traumatic dental injury (TDI) is an irreversible disease that is attracting more consideration from health practitioners at the moment [4]. A TDI, especially in children, is considered a severe health issue. Maxillary anterior teeth are the most affected teeth that cause physical, aesthetic, and psychological problems for children and their parents [5,6]. The quality of life is a complex process, and each person's self-perceptions are shaped by their experiences, future expectations, dreams, and lifestyle [7]. Besides that, people change their view of their OHRQoL over time [8]. The second-most prevalent TDI is a crown fracture involving enamel and dentin (CFED). It is associated with trouble feeding, avoidance of smiling, sensitivity and discomfort, and a higher prevalence of adverse effects on OHRQoL [9,10]. Traumatic dental injuries to permanent teeth are more frequent than in primary dentition [11,12]. Dental injuries primarily concern the maxillary anterior teeth. Falls, sporting events, road traffic accidents, and bicycling are the most common causes of these injuries. Dental trauma predisposing factors may be related to the anatomical characteristics of the individual, such as increased overjet, insufficient lip coverage of the upper anterior teeth, etc. [13,14]. Home and school are areas where dental accidents frequently occur. It was observed that the place of injury was gender-related, i.e., the school followed by the home was the most common place of injury for boys, whereas this finding is vice versa for girls [15][16][17].
In everyday dental practice, treating dental injuries is not an ordinary condition. The result of the procedure is closely linked to the dentist's expertise and skills and the medical assistance at the injury site. Thus, the dentist, parents, teachers, and coaches must have basic knowledge of dental trauma emergency management. However, the rareness of a TDI and the uncertainty of treatment prognosis, an individual with a traumatized tooth becomes a concern for the dentist. It is not a routine operation for most dentists and requires accurate diagnosis, appropriate emergency management, and correct follow-up treatment.
In the case of dental trauma, all treatment methods are aimed to mitigate undesired complications that may contribute to the loss of the tooth and the loss of the alveolar bone and thereby hinder the realization of a potential treatment plan. It is important to remember that traumatic dental injury care is vital for young people. It is essential to realize that treatment of a traumatic dental injury in a young patient is often complicated, unpredictable, expensive, and can continue for the remainder of his/her life. Since most of traumatic injuries in permanent dentition are between the ages of 10-12 years, dental trauma may have a lifelong effect on the child's quality of life [18]. Therefore, the objective of this systematic review aims to assess the impact of a traumatic dental injury of permanent teeth on oral health-related quality of life and to assess the study quality using the Q-SSP checklist.

Materials and Methods
The review protocol was registered at PROSPERO (international prospective register of systematic reviews), bearing registration number CRD42021230281.
This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines [19].

Search Strategy
The following structured question was outlined based on PICO (Patient or problem in question; Intervention of interest; Comparison of intervention; Outcomes): "Does trauma and treatment of traumatic injuries influence the OHRQoL of children and adolescents with a TDI and also how it impacts their family members?".
The electronic search strategy is described in Table 1. A comprehensive electronic search for relevant articles was performed in the following databases: PubMed, Cochrane Library, MEDLINE, and Google Scholar. For all these databases, Boolean operators (OR, AND) were used to combine and narrow down searches that included appropriate MeSH terms, keywords, and other terms following the syntax rules of each database. All references selected in the search were saved in Mendeley Desktop software to remove the duplicates.

Study Selection
The literature search was limited to articles available in English and to those published between January 2000 and February 2021. Each article was assessed carefully and in detail.
Two independent reviewers (PD and LM) read abstracts and titles, and studies not pertaining to the research question were excluded. The remaining relevant studies' full texts were read and analyzed independently. In this selection, if there was a disagreement of opinions, a third reviewer (DJ) was called to achieve a consensus.
The selection of studies was performed with no restrictions of place or year of publication. However, the restriction of language was applied, and only those articles written in English language were included. Titles and abstracts were analyzed to determine whether they fulfilled the inclusion criteria: (i) population: healthy children, adolescents, and family members; (ii) exposition: subjects experienced a TDI; (iii) outcome: impact on OHRQoL. The inclusion and exclusion criteria are depicted in Table 2.  Table 2. Inclusion and exclusion criteria of selecting studies for systematic review.

Inclusion Criteria Exclusion Criteria
• Studies that analyzed TDI in healthy children and adolescents.
• Studies on patients with medical conditions such as systemic diseases, syndromes, and craniofacial anomalies.
• Studies that analyzed TDI before and after treatment of permanent teeth.
• Studies on trauma to deciduous dentition, or where TDI was excluded and other oral health issues were addressed.
• Studies must have assessed OHRQoL.
• Studies that evaluated psychometric properties of instruments of OHRQoL or studies where only a single question of the questionnaire was used, evaluating only one domain.
• Cross-sectional, case control, or prospective clinical study.
• Case reports, review articles, systematic review articles, and book chapters.
• Studies with abstract and full text in English language only.
Two reviewers (LM and SG) conducted the data extraction and collected the information independently. The relevant data of the included studies were extracted in detail, using Excel spreadsheet (Microsoft, Redmond, WA, USA, Version 2007). The extracted data included: title, journal name, year of publication, type of study, author, country, age group, instrument/application form, TDI index, sample size, tooth number, an association between TDI and OHRQoL, result, conclusion, publication, sample, country where the research was conducted, sample age, comparison, instrument applied, instrument purpose, TDI index, and type of treatment. Mean scores for the OHRQoL instruments (total scale and sub-scales) before and after treatment, p-value, and outcome were also identified.

Study Quality Assessment
The quality of the individual studies was assessed by one reviewer (PD) and independently checked for agreement by a second reviewer (LM). In case of disagreement, a third review author (DJ) was consulted. The quality assessment of the included studies was conducted using the quality assessment checklist for survey studies in psychology (Q-SSP) (Figure 1) [20], published in the year 2020, which includes 20 checklist items. The Q-SSP checklist has been developed to standardize responses to uniform quality assessment across researchers [20]. The quality was judged for each domain and is expressed as a percentage by dividing YES (Y) scores by the total (T) number of APPLICABLE items and multiplying by 100. When (T) = 20, then a Y/T ≥ 75% score may be considered acceptable quality. When (T) = 19, then a Y/T ≥ 73% score may be considered acceptable quality. When (T) = 18, then a Y/T ≥ 72% score may be considered acceptable quality. When (T) = 17, then a Y/T ≥ 70% score may be considered acceptable quality. If the report fails to attain a Y score for five items, it may be classified as having questionable quality. The assessment was added to an Excel spreadsheet and then imported into ROBVIS (Risk of Bias Visualization web app software).  Figure 2 presents a flowchart of the systematic review process. The search in the selected databases allowed for the identification of 2677 articles. After removing duplicates, 2350 searches remained. Of these, 2297 were excluded after reading the titles and abstracts. From 53 remaining articles, 25 articles were finally selected after reading the full texts. Table A1 presents a list of the studies excluded after reading the full texts and the justification.  Figure 2 presents a flowchart of the systematic review process. The search in the selected databases allowed for the identification of 2677 articles. After removing duplicates, 2350 searches remained. Of these, 2297 were excluded after reading the titles and abstracts. From 53 remaining articles, 25 articles were finally selected after reading the full texts. Table A1 in Appendix A presents a list of the studies excluded after reading the full texts and the justification.
The included studies used different instruments to assess the OHRQoL (Table 3). From 25 included studies, the most widely used instrument for assessing OHRQoL of permanent teeth was the Child Perceptions Questionnaire (CPQ) (n = 15). The form of application most used was self-administered (n = 22). The Oral Impact on Daily Performances (OIDP) was used in five articles. The Family Impact Scale (FIS) was used in three articles, the Parental-Caregivers Perceptions Questionnaire (P-CPQ) in three articles, and the Oral Health Impact Profile (OHIP) in one study. One study used the National Research in Oral health (SBBrasil2010). Andreasen proposed the index for the TDI registry used by 15 articles. Seven articles used O' Brien, one article used the Dental
The included studies used different instruments to assess the OHRQoL (Table 3). From 25 included studies, the most widely used instrument for assessing OHRQoL of permanent teeth was the Child Perceptions Questionnaire (CPQ) (n = 15). The form of application most used was self-administered (n = 22). The Oral Impact on Daily Performances (OIDP) was used in five articles. The Family Impact Scale (FIS) was used in three articles, the Parental-Caregivers Perceptions Questionnaire (P-CPQ) in three articles, and the Oral Health Impact Profile (OHIP) in one study. One study used the National Research in Oral health (SBBrasil2010). Andreasen proposed the index for the TDI registry used by 15 articles. Seven articles used O' Brien, one article used the Dental Trauma Index (DTI), and two articles used WHO 1997 for TDI registry. Regarding TDI association and impact on OHRQoL, 24 articles indicated an association, whereas one article indicated no association. Figures 3 and 4. Out of the 25 included articles, 21 articles are of acceptable quality scoring ≥75%, whereas 4 articles are of questionable quality with a score of <75%.

Analysis of Quality of the Studies
Risk of bias in included studies is presented in Figures 3 and 4. Out of the 25 included articles, 21 articles are of acceptable quality scoring ≥75%, whereas 4 articles are of questionable quality with a score of <75%.

Synthesis of Results
Due to a high heterogeneity of the data, it was not possible to perform a meta-analysis for all the parameters used in the included studies; therefore, a qualitative assessment was performed. Table 4 shows the value of each domain and its impact on OHRQoL. Children who studied at public schools were more likely to experience a negative impact on the emotional wellbeing and social wellbeing domains. There was no association between traumatic dental injuries and the perception of the impact of OHRQoL, but this may be due to the low prevalence of TDI in the sample. Children who presented with dental caries associated with TDI, as well as dental caries associated with malocclusion, were more likely to experience a high negative impact on their OHRQoL than those without any oral condition. Children with the three oral conditions were 2.01-fold more likely to experience a high negative impact on their OHRQoL (total score) than those without any oral health problems. The mean CPQ8-10 score was 1.38-fold (95% CI: 1.17-1.63; p < 0.001) higher among the girls than boys, and children from families with a higher income had lower CPQ8-10 scores (RR: 0.67, 95% CI: 0.51-0.88; p < 0.004) than those from families with a lower income. Children who sought dental care due to pain or factors other than prevention, those with orofacial dysfunction, and those with a history of TDI also experienced a greater impact on OHRQoL. The central incisors were the most affected teeth. TDI was associated with an overjet equal to or greater than 3 mm. There was also an association of the negative impact on oral health-related quality of life, among patients who presented with TDI, in the social well-being and emotional well-being subscales.
No association between TDI and socioeconomic factors was observed.
Not stated. Children with untreated TDI were 1.2-fold (95% CI = 0.9-1.6) more likely to feel "upset" and 1.2-fold (95% CI = 0.9-1.7) more likely to have "avoided smiling/ laughing" than children without TDI. In the comparison of children with treated fractures and those without TDI, there was no association to the overall CPQ11-14-ISF: 16 score (Fisher = 0.610). Dental pain and difficulty chewing were more prevalent among children with treated teeth than those with no TDI, but this difference did not achieve statistical significance (p > 0.05).  The results revealed that girls were more likely to report a higher level of impact on their OHRQoL and HRQoL than boys following traumatic injury to their permanent incisors.
Not stated. Children and adolescents with traumatic dental injury were more likely to have a greater impact on their life than those with no injuries. Traumatic dental injury actually affects the quality-of-life of children and adolescents and, consequently, it is not enough to treat only its signs and physical symptoms. In fact, oral symptoms but also functional limitations and emotional and social well-being should be considered. Children with untreated dental injuries were approximately three times more likely to report difficulty chewing than those without injury. Subjects with untreated dental trauma were approximately three times more likely to avoid smiling or laughing and four times more likely to report not wanting to talk to other children compared with uninjured controls. The impact of dental trauma to upper incisors on social well-being was greater than on functional and psychological well-being in this sample of 12-14-year-old schoolchildren. Those with untreated dental injuries experienced a higher risk of negative social impact on their daily living than those without injury.

Yes
Regarding occlusal characteristics, crowding in at least one segment was associated with trauma in the maxillary teeth and in mandibular teeth. Crowding in two segments increased the chances of fracture. The spacing/diastema between the arches was a risk factor for enamel fractures, fractures in mandibular teeth, and for any fracture analyzed. The presence of a diastema and mandibular overjet was not associated with any type of TDI. Maxillary overjet (greater than 3 mm) was associated with all fractures in maxillary teeth. Anterior open bite was a protective factor for enamel fractures in maxillary teeth and any analyzed TDI. Not stated.  The impact prevalence was greater in the case group for nearly all the appraised activities.
In the previous six months, 40% of the teenagers with a history of treatment for enamel dentin fractures had at least one negatively affected daily activity, and 16.9% of the teenagers without a history of trauma were found to have some oral impact on their daily lives. The most affected activities in decreasing order were showing teeth when smiling, eating, speaking, maintaining a stable emotional state, and cleaning the mouth. Sleeping, doing school tasks, practicing sports, and going out with friends were all mentioned as activities that no adolescent reported as having an impact. Adolescents with aesthetically-treated enamel dentin fractures were more likely than those who had never experienced dental trauma to present oral impact on daily activities. Treatment for coronary fractures does not completely eradicate the impact of trauma on the adolescents daily lives, but it does help to mitigate it.

Synthesis of Results
Due to a high heterogeneity of the data, it was not possible to perform a meta-analysis for all the parameters used in the included studies; therefore, a qualitative assessment was performed. Table 4 shows the value of each domain and its impact on OHRQoL.  P-CPQ Mean SD Range Significant association (p < 0.05) between oral symptoms and mother's education and family income; emotional wellbeing domain and dental caries experience; social wellbeing domain and children's education, number of siblings; total PCPQ and members in family and dental caries. Children from public schools and children who had dental caries experience (RR = 1.28; p = 0.04 and RR = 1.37; p = 0.018, respectively) had a negative impact on total PCPQ scores. Public school-going children were more likely to experience negative impact on the emotional wellbeing and social wellbeing domains (p < 0.05). Children whose mothers had an educational level < 10 years and children who had dental caries experience showed positive and negative impact on the oral symptoms domain, respectively (RR = 0.75, p = 0.02 and RR = 1.22, p = 0.04, respectively).

OS
The group of trauma affecting both dental and support tissue had the highest levels of impact (A1) and the greatest reduction in impact following therapy (A2  (8)(9)(10), there was no impact on emotional well-being. CPQ (11)(12)(13)(14) scores implied that EWB improved post treatment and had positive impact on OHRQoL in children between the age group of 11-14 years. p-CPQ scores indicated no significant difference. SWB domain: The CPQ(8-10), CPQ (11)(12)(13)(14), and P-CPQ scores indicated that there was no statistical significant difference in score in all three groups. This indicated that SWB did not statistically impact the OHRQoL.
The cumulative scores of all domains indicated that there was significant improvement in OHRQoL for CPQ(8-10), CPQ (9)(10)(11)(12)(13)(14), and P-CPQ after receiving the treatment of TDI. Familiar Impact Scale (FIS) scores: TDI among children involving enamel and dentine fracture did not impact family perspective.  After receiving the treatment, the post6-month follow up of the COHRQoL score was improved in all domains. However, the parental COHRQoL scores were dependent upon the initial COHRQoL scores at p = 0.03 (ANCOVA), but the patient scores were not dependent upon the initial score at p = 0.12 (ANCOVA). The PPQ was statistically significant when compared with baseline values. 12 months:

OS
The parental 12-month results indicated that scores were dependent upon the initial scores (p = 0.001, ANCOVA). The child 12-month results (CPQ8-10, CPQ11-14) were also dependent upon the baseline COHRQoL scores (p = 0.005, ANCOVA). At 12 months, both age groups of children/adolescents reported lasting effects in each of the four CPQ domains, but their parents only saw lasting effects in two domains (oral symptoms and functional limitations), and they did not offer a single response in the emotional and social well-being domains for both age groups.
One year after the injury, the parents of 11-14 year-old patients noticed a significant ongoing effect on their personal QoL. The high initial parental PPQ scores suggest that TDI has a significant impact on the parents' QoL. FIS: There was no significant differences between the FIS scores for the 8-10 years and 11-14 years age group across all time periods. The initial high parental FIS scores suggest that TDI has a significant impact on the parents' QoL. Parents of the older children perceived their child's pain as being greater than the pain reported by the patient, and younger children perceived the initial injury as more painful than the older group.  Children who presented with dental caries associated with TDI were more likely to experience a high negative impact on their OHRQoL, as shown by the total score, than those without any oral condition. The presence of dental caries and its association with TDI were significantly associated with all CPQ(8-10) subscales at p < 0.05.

p-value †-Chi square test ‡-Fisher's test
There were no statistically significant differences between children with untreated TDI and those without TDI in terms of the overall CPQ (11)(12)(13)(14) scores. There was no association between the overall CPQ11-14-ISF:16 score (Fisher = 0.610) in children with treated fractures and those without TDI.   Effect of type of dental trauma on OHRQoL: There was strong association between more severe TDI (fractures involving dentin and/or pulp) and poorer OHRQoL among adolescents. However, mild TDI (enamel fractures only) and restored fractures were not associated with negative impact on OHRQoL.
Overall effect of TDI using the CPQ tool on OHRQoL: The overall CPQ (11)(12)(13)(14) showed that TDI appeared to affect an adolescent's OHRQoL. There is a strong association between the severity of TDI and OHRQoL.    Table 4. Cont.

Locker et al. (2007) [42]
Clinical indicator Mean CPQ11-14 score p-value Associations were significant for all variables except school grade and mother's educational attainment.
Both variables denoting the socioeconomic status of the household in which the child participants lived (annual household income, receipt of government income support) indicated that children from lower-income households had the highest CPQ11-14 short form scores.
In the higher income group, there were no differences in CPQ11-14 scores for children with or without severe injury to the anterior dentition. However, the differences were significant for children in the lower-income group. Children from low-income households had higher scores on a short form of the CPQ11-14 than children from high-income households, indicating poorer oral health-related quality of life.     Effect of individual domain: Parental/ family activity: Parents/caregivers of adolescents who had suffered a fracture involving the dentine or dentine/pulp had higher scores on the parental/family activity subscale than those whose adolescents were diagnosed with an absence of TDI or enamel fracture alone. Greater social vulnerability had a negative impact on families' QoL regarding parental/family activity. The severity of the TDI was significantly associated with negative impacts on the parental activity. Parental emotions: Greater social vulnerability had a negative impact on families' QoL regarding parental emotions. The severity of the TDI was significantly associated with negative impacts on the parental emotion subscale. Family conflict: Greater social vulnerability had a negative impact on families' QoL regarding the family conflict subscales. The severity of the TDI was significantly associated with negative impacts on the family conflict subscales. Financial burden: There was absence of impact on the financial burden subscale, which reflects the fact that TDI is not considered a disease by most parents.
Overall score: Parents/caregivers of adolescents who had suffered a fracture involving the dentine or dentine/pulp had higher scores on overall B-FIS than those whose adolescents were diagnosed with an absence of TDI or enamel fracture alone. Greater social vulnerability had a negative impact on families' QoL regarding the overall B-FIS. Adolescents with a fracture of dentine or dentine/pulp had a 44%-higher chance of increasing their overall B-FIS score by one point (RR = 1.44; 95%zx CI; 1.10-1.88) than those without TDI. A fracture involving dentin or dentin/pulp was associated with a greater likelihood of a negative impact on family's QoL. Adverse impacts on OHRQoL were reported much more frequently among patients who got into failure of replantation compared with patients who got into successful replantation. If patients got into tooth avulsion, then their quality of life was adversely affected.  Income level had no association with TDI. This indicated that family income did not impact the OHRQoL. Effect of parent's education on OHRQoL: Parents education was not associated with TDI outcome. This indicated that parental education did not impact the OHRQoL. Effect of trauma on OHRQoL: Enamel fractures were risk factors for feelings of shame among children (OR 1.27 and 95%CI: 1:05-1:53) and were significantly associated with embarrassment of smiling, whereas dentine/enamel fractures were risk factors for dissatisfaction with their teeth or for feeling embarrassed of smiling and messing up with the study. This type of TDI was also associated with the unadjusted coefficient used to report difficulty with eating. This indicated that dentin fracture or fractures involving pulp impacted the OHRQoL negatively. Mandibular tooth fractures did not affect the quality of life of 12-year-old Brazilian children. The greater the severity of the TDI, the greater its impact on OHRQoL. TDI causes aesthetic, emotional, and functional problems in patients that might be irreversible in some cases.

Treated TDI n (%) p
Effect of mother's education on OHRQoL: There was a statistically significant difference for mother's schooling in comparison of schoolchildren without TDI and those with treated TDI. Effect of individual items on OIDP: Children with untreated TDI experienced a greater negative impact on QoL in comparison with those without TDI in eating and enjoying food and smiling and showing teeth. No impact on OIDP was seen in all children in the treated TDI group for cleaning mouth, speaking, sleeping, and relaxing. No impact on OIDP was seen in all children in the no TDI group, untreated TDI, or in treated TDI group in maintaining usual emotional state and carrying out school-related tasks. Enjoying contact with people: Impact on OIDP was seen in 0.2% of children in the without TDI group and no impact on OIDP was seen in all children in the untreated TDI group and treated TDI group. Overall: Children with untreated TDI experienced a greater negative impact on QoL in comparison with those without TDI.   Effect of individual item on OHRQoL: Eating and enjoying food: Cases were 13.4 times (95% CI = 3.0-61.0) more likely to report an impact for 'eating and enjoying food' than children with no traumatic dental injury. Speaking and pronouncing clearly: This item had the least impact for both case and control groups. Cleaning your mouth: The impact for 'cleaning teeth' was statistically and significantly associated with the group of children with untreated fractured teeth. Children with fractured teeth were more likely to report an impact for this item than children without TDI. Smiling, laughing, and showing teeth without embarrassment: The most prevalent OIDP impact was seen in this item for both cases and controls. Children with fractured teeth were more likely to report an impact for this item than children without a TDI. The appearance of untreated fractured teeth was the main factor affecting this OIDP item. Maintaining emotional state without being irritable: The impact of this item on OIDP was statistically significant. Cases were 11.8 times more likely to report an impact for this item than controls. The appearance of untreated fractured teeth was the main factor affecting this OIDP item. Contact with people: There was a statistically significant association between 'enjoying contact with people' and the presence of fractured teeth. Cases were 10.0 times more likely to report an impact for the item 'enjoying contact with people' when compared to controls. Overall OIDP score: Children with fractured teeth were 20 times more likely to report any impact on their daily living than children with no traumatic dental injury. This shows that children with fractured teeth had significantly higher OIDP scores than those without TDI.

Discussion
This review included 25 studies ( Table 1) that assessed the impact of a traumatic dental injury of permanent teeth on the oral health-related quality of life (OHRQoL) in children and adolescent patients. The subjective evaluation of OHRQoL "reflects people's comfort when eating, sleeping, and engaging in social interaction; their self-esteem; and their satisfaction concerning their oral health" [44]. With a growing emphasis on health promotion and illness prevention in health policy, OHRQoL has evolved to include positive and negative assessments of oral health and health outcomes [45]. As a result, oral health assessments might reveal both negative and positive effects on self-esteem and well-being.
We assessed the quality of the studies using the Q-SSP tool [20]. This tool helps researchers to perform a uniform quality assessment of survey studies in psychology across the globe. Using tools such as the Q-SSP checklist to evaluate study quality will raise the profile of reporting standards and drive greater precision in reporting the survey study methods. Researchers can use the tool to assess the quality of studies as an inclusion criterion in systematic reviews and meta-analyses. In addition, the tool may be used by professional clinicians, physicians, and practitioners wishing to evaluate the quality of psychological evidence that may inform their practice. It may also be helpful for educators to illustrate issues relating to study quality in research method courses.
Most of the studies used for evaluation of OHRQoL of patients with a TDI or a TDI with treatment needs were of acceptable quality, except for four studies [22,25,31,41], which had questionable quality ( Figure 2). Therefore, the conclusion of these articles will be taken with caution. Seven tools were used in this systematic review. These were the P-CPQ tool, P-CPQ + CPQ(8-10), (11-14) + FIS, CPQ(8-10), CPQ(11-14)-16 short form and ten short forms, the Brazilian version of FIS, Oral Health Impact Profile (OHIP-14), Child-OIDP, and OIDP.
The Child-OIDP was the second-most used tool for assessing the OHRQoL in children in five studies [9,28,[34][35][36]. Child-OIDP and CPQ (11)(12)(13)(14) differ in their aim and theoretical framework. The Child-OIDP has an advantage over the CPQ and other OHRQoL measures, as it specifies the different clinical causes of each oral impact [47,48]. The Child-OIDP has a greater sensitivity than CPQ in identifying the impact on the quality of life of schoolchildren with a TDI.
Due to much heterogeneity in the data, it was not possible to perform a meta-analysis for all the parameters used in studies; therefore, qualitative assessment was conducted. However, meta-analysis was possible for only two studies using the Child OIDP tool.
Most of the studies [24,25,29,[31][32][33]35] that evaluated patients with TDI and no TDI revealed that patients with TDI have a negative impact on the OHRQoL, whereas in other studies [37,38,41] where TDI patients were compared based on whether they received treatment or not, they revealed that patients who received treatment had a positive impact on OHRQoL.
All the tools that analyzed the OHRQoL assessed the patient and their parents in various parameters, including sociodemographic status, economic status, parent's education, gender, age group, and type of schooling. All these factors affected the OHRQoL of children, except for the type of schooling.
It was expected that a higher prevalence of TDI is in males compared to females [26], due to males being more engaged in sports and recreational activities involving physical contact. However, due to a change in social roles, adolescent females also pose an equal risk of TDI, as there is an increase in their participation in sports. Females are currently exposed to the same etiological factors. However, variations between genders may oc-cur due to environmental, cultural, and behavioral factors, which are determinants of a stronger or weaker association between TDI and gender [49][50][51]. However, although four studies [25,26,28,31] out of eight [23][24][25][26][27][28]31,41] showed no association between gender and its impact on OHRQoL, another three studies [23,24,41] did imply that there is a strong association of TDI impact on OHRQoL among females compared to males. This outcome can be due to more significant aesthetic concerns of females than males, which negatively impacts their appearance [52][53][54].
All the studies expressed that the child perception of TDI impact on the OHRQoL does not change with age. Children between the age group of 8-10 years have criteria similar to those of children between 11-14 years regarding the self-perception of body image. To evaluate their appearance, children compare themselves to others of their age, and the judgment of peers exerts an influence on the development of self-esteem [55].
However, parents of the older children perceived a more significant reduction in their QoL than the parents of the 8-10-year-old group with TDI. This more remarkable impact on parents of the older children may be due to their children's growing independence suddenly being reversed by the need for parental intervention and supervision [40].
Seven out of 10 studies evaluated another parameter that negatively impacts TDI associated OHRQoL: the family's socioeconomic status of [9,21,24,27,29,30,34]. Due to their existing living conditions, which are usually less privileged and peripheries of urban areas, where facilities and quality healthcare are questionable, children are often exposed to unsafe environments. These underdeveloped areas increase accidents due to poorly-designed urban projects and neglected public spaces [56][57][58].
Even if parents wished to have the child's condition treated, they cannot afford dental care at both private and public centers [59].
Parents' education also impacts the OHRQoL of children with a TDI. Six studies [9,21,24,29,30,34] out of nine reported that fewer years of parents' education level showed a negative impact on OHRQoL of children. The majority of parents in these studies had low education status. This reflects their lack of information, perception, and treatment needs associated with TDI and negatively influenced the child's health behaviors.
Children with severe TDI also impacted the family regarding parental/family activity, parental emotions, family conflict, and financial burden [29,38,40]. Severe types of trauma more often affected the daily life of parents/caregivers. Parents/caregivers of adolescents with fractures involving the dentine or dentine/pulp reported more negative impact on parental/family activities than those with less severe TDI, such as enamel fracture [29]. A TDI is an unexpected event. More severe cases nearly always require urgent care and multiple searches for dental treatment, resulting in parents missing work and spending extra time taking care of their children. From these studies, it can be concluded that severe trauma not only affects the child in question, but it also affects the family.
Individual domains such as oral symptoms (OS), emotional well-being (EWB), social well-being (SWB), and functional limitations (FL) were mainly analyzed by different studies. These domains are individuals perception of TDI and their overall impact on OHRQoL. It was pretty evident that the most affected domains were EWB, OS, and FL. TDI was significantly affected by these three domains. The "emotional well-being" domain contains questions related to emotions such as sad, embarrassed, worried, upset, frustrated, angry, and concerned about what others think. Physical appearance and attractiveness play an essential role in social interactions and psychological well-being among adolescents between the ages of 11 and 14 [60]. Peer relationships are an important factor in an individual's quality of life at this age [61]. Because the mouth is such a significant predictor of face attractiveness, any changes in dental features can have a detrimental or good impact on the quality of life [62]. The 'oral symptoms' domain contains questions about pain, wounds, mouth sores, bad breath, and food remains trapped in the mouth [38]. As this domain contains questionnaires related to lips, teeth, and jaws, the scores were high in this domain and thus affected the OHRQoL. The "functional limitations" domain contains questions related to difficulty with eating, biting, speaking, and sleeping. The overall cumulative effect of the individual domain significantly affected the TDI-associated OHRQoL.
Children with fractured teeth experienced more impacts on their daily living than children with no traumatic dental injury. Their actual daily basic performances such as 'eating and enjoying food', 'cleaning teeth', 'smiling, laughing, and showing teeth without embarrassment', 'maintaining usual emotional state without being irritable', and 'enjoying contact with people' significantly affected the OHRQoL when compared to children with no dental trauma experience [35].
It was observed that, after receiving the treatment of TDI, children were able to enjoy foods, smile, show one's teeth without embarrassment, and socialize. Thus, dental treatment following a TDI is an important prevention strategy regarding biological and socio-psychological impacts [9]. Treatment of TDI improved the OHRQoL considerably.

Conclusions
Traumatic injuries to permanent dentition affect both a child and their caregivers or parents. These injuries affect both genders; however, adolescent girls tend to have a more negative impact on their OHRQoL than boys. A TDI and its severity significantly affect children and their families social and emotional well-being. Parents' education and socioeconomic status play a significant role in providing care and treatment of TDIs in children. Treatment of TDIs improve the aesthetic and functional aspects of dentition and enhance the OHRQoL. Since the majority of studies used well-validated questionnaire tools and were of high quality, it can be concluded that the TDI impact on the OHRQoL is significant.

Acknowledgments:
We thank the Institute of Dental Sciences, Cochrane India Network for helping us with the resources required for the study.

Conflicts of Interest:
The authors declare no conflict of interest.

Author Title Reason for Exclusion
Feldens et al. [82] Enamel fracture in the primary dentition has no impact on children's quality of life: implications for clinicians and researchers This study was conducted in primary dentition.
Scarpelli et al. [83] Oral health-related quality of life among Brazilian preschool children This study was conducted in primary dentition.
Viegas et al. [84] Impact of Traumatic Dental Injury on Quality of Life Among Brazilian Preschool Children and Their Families This study was conducted in primary dentition.
Kramer et al. [85] Exploring the impact of oral diseases and disorders on quality of life of preschool children This study was conducted in primary dentition.
Borges et al. [86] Relationship between overweight/obesity in the first year of age and traumatic dental injuries in early childhood: Findings from a birth cohort study This study was conducted in primary dentition.