Clinical and Expe imen al Den al Resea ch
REVIEW ARTICLE
P e alence o Den al T auma in Spain: Sys ema ic Re iew
and Me a‐Analysis
Elda Es he Ga cía Méndez
1
| Da id Ribas‐Pé ez
1
| Diego Rod íguez Menacho
1
| Ignacio Ba be o Na a o
1
|
E a Rosel Galla do
2
| An onio Cas año Séique
1
1
Facul ad de Odon ología, Uni e sidad de Se illa, Se ille, Spain |
2
Facul ad de Odon ología, Uni e sidad de G anada, G anada, Spain
Co espondence: Da id Ribas‐Pé ez ([email p o ec ed])
Recei ed: 14 No embe 2024 | Re ised: 20 Ma ch 2025 | Accep ed: 25 Ma ch 2025
Funding: The au ho s ecei ed no speci ic unding o his s udy.
Keywo ds: adolescen s | child en | den al ac u es | me a‐analysis | p e alence | Spain | sys ema ic e iew | auma ic den al inju ies
ABSTRACT
Objec i es: To es ima e he p e alence o TDI in he Spanish popula ion h ough a sys ema ic e iew and me a‐analysis,
iden i ying di e ences by sex, age, and s udy se ing.
Ma e ials and Me hods: An exhaus i e sea ch was conduc ed in da abases such as PubMed, Scopus, Embase, O id Medline,
and CINAHL, including g ay li e a u e and o he al e na i e sou ces. Obse a ional s udies e alua ing he p e alence o TDI in
Spain, wi h a o al o 8662 pa icipan s. The me hodological quali y o he s udies was assessed using he JBI ool, and he
PRISMA guidelines we e ollowed o ensu e anspa ency and ep oducibili y.
Resul s: The es ima ed o e all p e alence o TDI was 9.94% (95% CI: 5.98%–16.6%). The esul s showed a highe p e alence in
males (10.5%) compa ed o emales (5.7%), and in child en (11.1%) compa ed o adolescen s (6.1%). F ac u es we e he mos
common ype o TDI (56.5%), ollowed by a ulsion (4.0%). High he e ogenei y was obse ed among he s udies, sugges ing
a iabili y in da a collec ion me hods and TDI classi ica ion.
Conclusions: This s udy is he i s o es ima e he p e alence o TDI in Spain, which sheds ligh on he need o a s anda dized
app oach in u u e esea ch. Al hough i p esen s signi ican me hodological s eng hs, limi a ions such as high he e ogenei y
and lack o s anda diza ion should be conside ed when in e p e ing he esul s.
1 | In oduc ion
T auma ic den al inju ies (TDI) a e he second mos common
o al disease a e den al ca ies, a ec ing be ween 900 million
and 1.2 billion people wo ldwide, o which app oxima ely 180
million a e child en unde 6 yea s o age (Pe i, Glendo ,
e al. 2018; Pe i, And easen, e al. 2018).
Acco ding o a me a‐analysis by Pe i, Glendo , e al. (2018), i
anks i h in he lis o he mos p e alen diseases o auma ic
inju ies wi h 15.2% globally, a e den al ca ies, ension head-
ache, i on de iciency anemia and hea ing loss.
The p e alence o TDI a ies conside ably be ween egions,
being 14% in he Eu opean egion (Pe i, Glendo , e al. 2018);
bu i also a ies be ween coun ies and e en wi hin each
coun y as a consequence no only o he socioeconomic and
cul u al di e si y o he cus oms and li es yles o each socie y,
bu also due o he absence o a s anda dized sys em o i s
egis a ion and classi ica ion due o he a ie y o classi ica ion
sys ems: And easen, O'B ien, Ellis; and added o he ac ha
many esea che s c ea e hei own classi ica ion sys ems o
modi y exis ing ones (Feliciano and Caldas 2006). These limi-
a ions a e expec ed o diminish ollowing he app o al by he
Wo ld Heal h O ganiza ion (WHO) in 2022 o he NAOD
This is an open access a icle unde he e ms o he C ea i e Commons A ibu ion License, which pe mi s use, dis ibu ion and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly
ci ed.
© 2025 The Au ho (s). Clinical and Expe imen al Den al Resea ch published by John Wiley & Sons L d.
1o 9Clinical and Expe imen al Den al Resea ch, 2025; 11:e70128
h ps://doi.o g/10.1002/c e2.70128
classi ica ion o TDI (inju y o ee h o suppo ing s uc u es)
based on he And easen classi ica ion (Pe i e al. 2022).
TDI has a high incidence in p e‐school child en be ween 2
and 3 yea s o age wi h no gende di e ences due o he
de elopmen o mo o coo dina ion a his s age (Oldin
e al. 2015), and be ween 8 and 10 yea s o age wi h a p e-
dominance o males due o hei p opensi y o isky and
mo e agg essi e beha io , high in ol emen in physical
ac i i ies and ac i e spo s (B a ebe g e al. 2018; Lembache
e al. 2022).
The an e osupe io ee h a e he mos a ec ed by TDI, bo h in
he p ima y and pe manen den i ion, p edominan ly in he
g oup o uppe inciso s, due o hei ana omical posi ion p o-
uding in on o he lowe inciso s and he di ec ion o he
impac s ha gene ally occu om he on (Lam 2016). On he
o he hand, he p esence o malocclusions and de o ming o al
habi s (digi al sucking and mou h b ea hing) a e associa ed
wi h a signi ican ly highe equency o auma ic den al inju-
ies (Al‐Ba ayneh e al. 2017; Jeyash ee e al. 2022). S udies by
Gup a e al. (2011) and Basha e al. (2021) conclude ha chil-
d en wi h inc eased o e je (> 3 mm) a e 4–5 imes mo e likely
o de elop TDI, while hose wi h inadequa e lip co e age a e
2–3 imes mo e a isk.
Den al auma has a nega i e impac on he quali y o li e in
ela ion o o al heal h, whe he in child en, adolescen s o
adul s. The epe cussions no only include he physical‐
in lamma o y al e a ions inhe en o he inju y, such as pain
and unc ional impo ence, bu also es he ic al e a ions, highly
cos ly ea men o he indi idual and o he na ional sys em,
and a s ong psychological bu den wi h a nega i e impac on
quali y o li e (Milani e al. 2021;El‐Kalla e al. 2017). A e y
impo an aspec is he epe cussions on he de elopmen o
successi e pe manen ee h, wi h possible sequelae such as
co ona y, oo and enamel de ec s, oo dilace a ions, pulp
obli e a ions, nec osis and delays in oo h de elopmen and
e up ion (Siahi‐Benla bi e al. 2012).
Acco ding o da a p o ided by he WHO in i s epo s on he
s a e o o al heal h (WHO 2023), in Eu ope he annual ex-
pendi u e due o o al diseases amoun s o abou 113 billion
dolla s, he second highes igu e among all egions, bu wi hin
hese o al condi ions he WHO does no include TDI despi e i s
high p e alence in he wo ld.
Wi h his we can a i m ha i is a neglec ed condi ion and o a
ce ain ex en unde alued by hose esponsible o heal h
policies, making i di icul o alloca e adequa e esou ces and
implemen p e en i e p og ammes. I is he e o e necessa y o
each coun y o ake a de ailed look a he end, p esen a ion
pa e ns and isk ac o s o TDI, o es ablish compa isons wi h
o he coun ies, o mula e heal h policies and imp o e eme -
gency ca e, educing cos s in he long e m, which leads us o
ask he ollowing ques ion: Wha is he p e alence o den oal-
eola auma in Spain?
Wi h he aim o es ima e he p e alence o TDI in he Spanish
popula ion h ough a sys ema ic e iew and me a‐analysis his
s udy was made.
2 | Ma e ials and Me hods
The guidelines o he P e e ed Repo ing I ems o Sys ema ic
Re iews and Me a‐Analyses (PRISMA) (Page e al. 2021) we e
ollowed o he p epa a ion o he inal esea ch epo . The
p o ocol was published on he In e na ional Pla o m o Re-
gis e ed P o ocols o Sys ema ic Re iews and Me a‐Analyses
(INPLASY), egis a ion numbe INPLASY202480076 (Ga cía
Méndez e al. 2024).
2.1 | Selec ion C i e ia
We included obse a ional s udies ha examined he p e a-
lence o den oal eola auma in he Spanish popula ion. The
s udies had o mee he ollowing c i e ia: c oss‐sec ional o
coho design; Spanish pa icipan s o long‐ e m esiden s in
Spain; assessmen o he p e alence o den al auma; publi-
ca ion in Spanish, English, Basque, Ca alan, Galician, o Va-
lencian; and de ini ion o he c i e ia used o de ine he ypes
o auma. The clinical con ex in which he s udy was con-
duc ed was also conside ed, since esea ch ca ied ou in
eme gency depa men s may end o o e es ima e he p e a-
lence o TDI. Those ha analyzed auma in he con ex o
c anio acial anomalies, neu ological diso de s o sys emic
diseases we e excluded, as well as hose ha ocused ex-
clusi ely on spo s‐ ela ed auma. Case‐con ol s udies we e
also excluded.
2.2 | PEO Ques ion
As his is a sys ema ic e iew o p e alence s udies, no di ec
compa ison is speci ied, so he ques ion is a PEO ques ion, no a
PECO one. The elemen s o he ques ion we e:
•Popula ion (P): Child en and adolescen s pa icipa ing in
Spanish s udies on den al auma.
•Exposi ion (E): T auma ic den al inju ies (TDI).
•Ou come (O): P e alence o auma ic den al inju ies (TDI).
And inally he ques ion was:
Wha is he p e alence o auma ic den al inju y (TDI) in he
Spanish popula ion o child en and adolescen s?
2.3 | Sou ces o In o ma ion
An exhaus i e sea ch was ca ied ou in he PubMed, Scopus,
Embase, O id Medline and CINAHL da abases. Sea ch e ms
included keywo ds ela ed o “den oal eola auma,”“den al
ac u e,”“den al a ulsion,”“den al luxa ion,”“Spain,”and
among o he s ha we e iden i ied h ough p elimina y sea -
ches. In addi ion, eco ds o p ep in s, e e ence lis s o
he selec ed a icles we e consul ed and a sea ch o g ay li -
e a u e was ca ied ou in Google Schola and in he eposi-
o ies o bachelo 's, mas e 's and doc o al heses o Spanish
uni e si ies.
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2.4 | Sea ch S a egy
Sea ch s a egies we e adap ed o he cha ac e is ics o each
da abase. These we e cons uc ed by combining con olled
e ms and ee ex e ms, using Boolean ope a o s, unca ed
wo ds and wildca ds. Resul s we e limi ed o s udies published
in one o he languages al eady de ined, wi hou es ic ion by
publica ion da e. No il e s we e applied o he sea ch ela ed o
s udy design, o iden i y all obse a ional s udies ha me he
inclusion c i e ia. The sea ch s a egy can be ound in he
published p o ocol (Ga cía Méndez e al. 2024).
2.5 | Regis a ion o S udies
2.5.1 | Da a Managemen
The sea ch esul s we e expo ed o he Rayyan so wa e
(Ouzzani e al. 2016), an online ool ha acili a es he selec ion
and managemen o s udies o sys ema ic e iews, as well as
he coo dina ed wo k o he esea ch eam. This so wa e was
used o de ec and elimina e duplica e a icles, as well as an
ini ial sc eening h ough a semi‐au oma ed da a mining ool
ha ca ego ized and labeled s udies acco ding o inclusion and
exclusion c i e ia.
2.6 | Selec ion P ocess
The selec ion o s udies was done in wo phases. In he i s
phase, wo independen e iewe s, blinded o each o he 's deci-
sion, assessed he i les and abs ac s o he iden i ied s udies.
S udies ha passed his i s phase we e e ie ed in ull ex and
assessed in he second phase by he same e iewe s, applying he
inclusion and exclusion c i e ia. Disag eemen s be ween e-
iewe s we e esol ed by consensus o , i necessa y, wi h he
in ol emen o a hi d e iewe . The sequence o he selec ion
p ocess was documen ed ollowing he PRISMA low cha .
2.6.1 | Da a Ex ac ion
A e iewe , using a s anda dized o m, ex ac ed he ollowing
da a om he selec ed s udies: au ho , yea o publica ion, s udy
design, sample size, age, and sex o pa icipan s, p e alence
(and hei 95% con idence in e als [CIs]) o den oal eola
auma in gene al and o each speci ic ype ( ac u es, disloca-
ions, and a ulsions), and de ini ion o he c i e ia used o
classi y he ypes o auma. In case o incomple e o unclea
da a, we a emp ed o con ac he au ho s o he o iginal s udies
o addi ional in o ma ion.
2.7 | De ini ion o he Ou come Va iable
The main a iable was he p e alence o den oal eola auma
in he Spanish popula ion, exp essed as a pe cen age. The
ou comes assessed we e adap ed om hose ha al eady e-
po ed in ano he me a‐analysis [1]: TDI in child en, adoles-
cen s and adul s, TDI o bo h biological sexes, TDI in he
p ima y den i ion and TDI in he pe manen den i ion. The
se ing in which he s udy was conduc ed was also conside ed.
2.8 | Assessmen o Me hodological Quali y
To assess he me hodological quali y o he included s udies, he
JBI C i ical App aisal Checklis o P e alence S udies
(Munn 2020) was used, which assesses aspec s such as ep e-
sen a i eness o he sample, sample size, da a collec ion me h-
ods and s a is ical analysis. This ool has nine assessmen i ems,
each o which can be assessed as: Yes, No, Unclea and No
applicable. Two e iewe s independen ly assessed he quali y o
each s udy, and any disag eemen s we e esol ed by consensus
o wi h he in ol emen o a hi d e iewe .
2.9 | Da a Syn hesis
F om he ex ac ed da a, a andom e ec s me a‐analysis was
pe o med using R so wa e (R Co e Team 2021) and he “me a”
package (Schwa ze e al. 2015). O e all and subg oup p e a-
lence was calcula ed, wi h co esponding 95% con idence
in e als. S udies wi h high he e ogenei y we e analyzed o
possible sou ces o he e ogenei y, and sensi i i y analyses we e
pe o med o assess he impac o indi idual s udies on he
o e all esul s. To assess he e ogenei y be ween s udies, s a is-
ical es s such as calcula ion o he I
2
s a is ic, τ2 and he
p edic ion in e al we e used.
An assessmen o he ce ain y o e idence a he ou come le el
was no pe o med because he ou come a iable does no
equi e a a ing o he quali y o e idence, as i is a poin
p e alence and no an e ec . Publica ion bias was also no
assessed due o he lack o s a is ical powe o he a ailable
e idence when ew s udies a e included in he me a‐analysis
(Fu uya‐Kanamo i e al. 2018).
3 | Resul s
3.1 | Selec ion o S udies
A o al o 2403 s udies we e iden i ied h ough he i e da abase
chosen (PubMed 481, Scopus 792, Embase 647, O id Medline
347, and CINAHL 136). A e emo ing duplica es, 2331 i les
and abs ac s we e e iewed, o which 2318 we e excluded as
hey did no mee he inclusion c i e ia. O he 13 s udies
selec ed o ull‐ ex e iew, only 11 could be e ie ed because
wo o hem we e published in jou nals ha we e discon inued
many yea s ago. Finally, se en s udies we e included in he
sys ema ic e iew and me a‐analysis (Za agoza e al. 1998;
Tapias e al. 2003; Segu a and Poya o 2003; Faus‐Damia
e al. 2011; Mendoza‐Mendoza e al. 2015; Faus‐Ma oses
e al. 2020; Veloso Du an e al. 2022) (Figu e 1).
3.2 | Cha ac e is ics o he Included S udies
The s udies included in his e iew we e conduc ed in only ou
Spanish p o inces and in ol ed a o al popula ion o 8662
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pa icipan s. Sample sizes anged om 251 o 4000 subjec s,
wi h a gene ally balanced gende dis ibu ion. The age o pa -
icipan s anged om 1‐yea ‐old child en o 77‐yea ‐old adul s.
Mos s udies we e conduc ed in den al clinics. Va ious classi-
ica ion sys ems we e used o assess den oal eola auma, wi h
he Ha g ea es and C aig and And easen sys ems being he
p edominan ones. The ypes o TDI analyzed included a ul-
sions, ac u es, disloca ions and in usions, wi h epo ed
p e alence anging om 4.5% o 21.72%, e lec ing he e oge-
nei y in he me hodologies and popula ions s udied (Table 1).
3.3 | Assessmen o Me hodological Quali y
The assessmen o he me hodological quali y o he included
s udies showed se e al inconsis encies in he applied me hod-
ology. The e we e majo inconsis encies in he desc ip ion
o he sampling ame and in he cha ac e iza ion o he
pa icipan s, which calls in o ques ion he ep esen a i eness o
he epo ed esul s. In addi ion, mos o he s udies ailed o
adequa ely iden i y and con ol o possible biases, such as
selec ion and classi ica ion biases, which a ec s he in e nal
alidi y o he indings. On he o he hand, mos s udies p e-
sen ed an adequa e sample size and applied app op ia e s a is-
ical analyses o es ima e p e alence (Figu e 2).
3.4 | P e alence o TDI
The o e all es ima ed p e alence o den oal eola auma in he
Spanish popula ion was 9.94% (95% CI: 5.98%–16.6%). The
p edic ion in e al o he p e alence was 1.42%–45.6%, indi-
ca ing high he e ogenei y be ween s udies.
The esul s o he subg oup analysis indica ed ha he p e alence
o den oal eola auma was highe in male pa icipan s (10.5%
FIGURE 1 | Flowcha o he s udy selec ion p ocess.
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TABLE 1 | Ca ac e is ics o he s udies included.
S udy S udy design Loca ion
Scope o he
s udy
Sample
size
Age o he
pa icipan s Gende
Classi ica-
ion used
Type o
den i ion TDI
Gene al
TDI
p e alence
Za agoza
e al. (1998)
C oss sec ional,
obse a ional
s udy.
Valencia School 4000 Range: 6–12 Male: 2140
(53.5%)
Female:
1860
(46.5%)
Ha g ea es &
C aig
Mixed A ulsion
F ac u e
227 (5.7%)
Tapias
e al. (2003)
C oss sec ional,
obse a ional
s udy.
Mad id Clínic 470 10 yea ss Males: 246
(52.3%)
Females: 224
(47.7%)
Only
ac u es
Mixed F ac u e 82 (17.44%)
Segu a and
Poya o (2003)
C oss sec ional,
obse a ional
s udy.
Se illa Kinde ga den 337 3 yea s Males: 192
(56.97%)
Females: 145
(43.03%)
Ha g ea es &
C aig
Deciduous F ac u e 49 (14.54%)
Faus‐Damia
e al. (2011)
C oss sec ional,
obse a ional
s udy.
Valencia School 1325 Range: 6–18 Males: 678
(51.2%)
Females: 647
(48.8%)
IADT Pe manen
Mixed
A ulsion
Luxa ion
F ac u e
82 (6.2%)
Mendoza‐
Mendoza
e al. (2015)
C oss sec ional,
obse a ional
s udy.
Se illa Clínic 879 Range:
1–7 años
No
speci iced
No speci iced Deciduous A ulsion
Luxa ion
F ac u e
In usion
191 (21.72%)
Faus‐Ma oses
e al. (2020)
C oss sec ional,
obse a ional
s udy.
Valencia Clínic 251 Mean: 16
Range 1–77
Males: 157
(62.5%)
Females: 94
(37.5%)
And easen Deciduous
Pe manen
Mixed
A ulsion
Luxa ion
F ac u e
In usion
Concusion
Ex usion
Subluxa ion
No a ailable
Veloso Du an
e al. (2022)
C oss sec ional,
obse a ional
s udy.
Ba celona Clínic 1400 G oups: 3–5
6–8
9–11
12–14
Males: 733
(52.4%)
Females: 667
(47.6%)
No a ailable Deciduous
Pe manen
Mixed
No speci ied 63 (4.5%)
Abb e ia ion: TDI, auma ic den al inju ies.
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[6.3%–16.9%]) compa ed o emale pa icipan s (5.7% [3.4%–9.3%]),
as well as in child en (11.1% [6.3%–18.9%]), and in child en (11.1%
[6.3%–18.6%]) compa ed o adolescen s (6.1% [4.7%–7.8%]). I was
no possible o es ima e he p e alence o TDI in adul s. S udies
conduc ed in day‐ca e cen e s and den al clinics epo ed highe
p e alences han hose conduc ed in school se ings. High he -
e ogenei y was obse ed in mos o he subg oups analyzed, pa -
icula ly in s udies conduc ed in clinical se ings and in he
child en's g oup, sugges ing conside able a iabili y be ween he
s udies included in he e iew (Figu e 3).
F ac u e was he mos equen ype o auma, wi h a p e a-
lence o 56.5% acco ding o ou s udies, al hough wi h con-
side able he e ogenei y. On he o he hand, a ulsion had a
much lowe p e alence o only 4.0%, also wi h high he e oge-
nei y. The emaining ypes o auma, such as disloca ion,
FIGURE 2 | Summa y o he assessmen o he me hodological quali y o he included s udies. No e: Q1: Was he sampling ame app op ia e
o add ess he a ge popula ion; Q2: Was an adequa e sample o s udy pa icipan s d awn; Q3: Was he sample size adequa e; Q4: We e he s udy
subjec s and se ing desc ibed in de ail; Q5:Was he da a analysis conduc ed wi h su icien co e age o he iden i ied sample; Q6: We e alid
me hods used o he iden i ica ion o he condi ion unde s udy; Q7: Was he condi ion measu ed in a s anda d and eliable way o all
pa icipan s; Q8: Was an adequa e s a is ical analysis pe o med; Q9: Was he esponse a e adequa e? I no , was he low esponse a e adequa ely
managed?
FIGURE 3 | P e alence o den oal eola auma by subg oups. No e: k: numbe o s udies. P e alence is exp essed as a pe cen age. CI, con i-
dence in e al.
6o 9 Clinical and Expe imen al Den al Resea ch, 2025
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subluxa ion and in usion, showed p e alences o 12.1%, 9.2%,
32.3%, and 15.8%, espec i ely, al hough hese esul s a e om
one o wo s udies pe ype and show a iabili y in he he -
e ogenei y epo ed (Figu e 4).
4 | Discussion
The esul s o his sys ema ic e iew and me a‐analysis p o ide
a comp ehensi e o e iew o he p e alence o TDI in he
Spanish popula ion, highligh ing a ia ions by gende , age and
s udy se ing. The o e all es ima ed p e alence o TDI was
9.94%, which is in line wi h p e ious s udies (Pe i, Glendo ,
e al. 2018) epo ing a p e alence in Eu ope o be ween 9.8% o
18.9%, albei wi h a high deg ee o he e ogenei y among he
included s udies. This high deg ee o he e ogenei y may be a -
ibu ed o di e ences in da a collec ion me hods, inclusion
c i e ia and classi ica ion o TDI, as well as he di e si y o
se ings in which he s udies we e conduc ed.
The esul s indica ed a highe p e alence o TDI in males
(10.5%) compa ed o emales (5.7%). This inding has also been
epo ed by o he au ho s. Pe i, Glendo , e al. (2018). ound
ha he p e alence in he Eu opean egion in men was 1.48
(95% CI: 1.20–1.83) imes highe han in women, a esul ha
was consis en wi h o he egions o he wo ld. Ano he au ho
(Ald igui e al. 2014), in a sys ema ic e iew and me a‐analysis
conduc ed o es ima e he p e alence o TDI in Sou hame ica,
also ound ha men we e mo e a isk han women o TDI
(OR: 1.72 [95% CI: 1.57–1.89]). This inding could be explained
by he g ea e in ol emen o males in isky physical ac i i ies
and mo e agg essi e beha io s.
The highe p e alence o TDI in child en (11.1%) compa ed o
adolescen s (6.1%) can be explained by se e al ac o s associa ed
wi h child en's physical de elopmen and beha io . In younge
child en, he lack o ull de elopmen o ine mo o skills and
coo dina ion makes hem mo e p one o alls and acciden s,
especially du ing he ea ly s ages o childhood. These acciden s
o en occu du ing e e yday o ec ea ional ac i i ies, such as
play a home o a school, which inc eases he isk o TDI.
Howe e , he e idence is con adic o y. On he one hand,
Ald igui e al. (2014) a gue ha inju ies a e cumula i e e en s,
so ha he p e alence o inju ies is expec ed o be highe in
olde popula ions; while, on he o he hand, o he s udies
(Lembache e al. 2022; And easen and Ra n 1972; Slay on and
Palme 2019) sugges ha he inc eased ulne abili y o young
child en o e e yday acciden s and he lack o adequa e p o-
ec i e mechanisms, such as limi ed use o mou hgua ds o
cons an pa en al supe ision, coun e ac his accumula ion o
isk. Thus, while i is ue ha adolescen s may ha e accumu-
la ed inc eased exposu e o isky si ua ions o e ime, he
na u e o childhood ac i i ies, combined wi h physical and
de elopmen al ac o s, appea s o p edispose child en o a
highe equency o TDI compa ed o adolescen s.
S udies conduc ed in clinical and day ca e se ings epo ed
highe p e alences han hose conduc ed in school se ings,
sugges ing ha he p e alence o TDI may be in luenced by he
se ing in which he s udy was conduc ed, wi h possible biases
owa ds highe de ec ion in se ings whe e moni o ing o in-
di iduals' gene al heal h is sys ema ic. This a iabili y high-
ligh s he need o a s anda dized app oach o he assessmen
and eco ding o TDI o acili a e compa abili y ac oss s udies
and egions.
Den al ac u e, as in se e al s udies (Gopina h e al. 2008;
Gojanu e al. 2015), eme ged as he mos equen auma ic
inju y wi h 56.5% o TDIs. On he o he hand, al hough a ulsion
was conside ably less equen , occu ing in only 4.0% o cases, i
emains a highly se ious inju y due o he di icul y o success-
ully eimplan ing he a ulsed oo h and he high ailu e a es o
hese p ocedu es, especially i p ope managemen is no pe -
o med in he c i ical ime a e auma (Fouad e al. 2020).
This s udy has se e al clinical and public heal h implica ions.
The indings unde line he impo ance o implemen ing p e-
en i e and educa ional p og ammes, especially a ge ing a ‐
isk popula ions, such as young child en and adolescen s, and
in se ings whe e a highe p e alence o TDI is obse ed. Fu -
he mo e, he need o imp o e da a collec ion and uni o mi y in
he classi ica ion o TDI o p o ide mo e accu a e and compa-
able es ima es is highligh ed.
The sys ema ic e iew has se e al no able s eng hs. I is he
i s known s udy ha a emp s o es ima e he p e alence o
FIGURE 4 | P e alence o he di e en ypes o den oal eola auma. No e: k: numbe o s udies. P e alence is exp essed as a pe cen age.
CI, con idence in e al.
7o 9
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TDI in Spain, using a comp ehensi e sea ch s a egy ha
includes g ey li e a u e and al e na i e me hods o e e ence
iden i ica ion. In addi ion, a da a mining ool based on machine
lea ning was used, which imp o ed he e iciency o a icle
selec ion (Li e al. 2023). The JBI ool o he e alua ion o
p e alence s udies allowed o he comp ehensi e assessmen o
s udies, analyzing key aspec s such as ep esen a i eness o he
sample, measu emen p ecision and in e nal alidi y, ensu ing
ha he assessmen o he implica ions o he indings is done
wi hin an app op ia e amewo k. In addi ion, adhe ence o
PRISMA guidelines ein o ces he anspa ency and ep oduc-
ibili y o he me hodological p ocess.
Howe e , he s udy aces signi ican limi a ions, such as he
high he e ogenei y among he included s udies, he lack o
s anda diza ion in he classi ica ion o TDI and he s udy se -
ings, as well as me hodological sho comings in he analyzed
s udies and s udy con ex s, as well as me hodological sho -
comings in he s udies analyzed. These limi a ions may a ec
he gene alizabili y and accu acy o he esul s ob ained, un-
de lining he need o in e p e hem wi h cau ion and o
imp o e me hodological quali y in u u e esea ch.
Fu u e s udies seeking o es ima e he p e alence o TDI should
adop a mo e s anda dized and me hodologically igo ous
app oach o o e come he limi a ions iden i ied in his e iew.
Fi s , he use o a uni o m and in e na ionally alida ed clas-
si ica ion sys em o TDI, such as he WHO‐app o ed NAOD
classi ica ion (Pe i e al. 2022), is essen ial and would acili a e
compa ison o esul s ac oss s udies and egions. Fu he mo e,
i is c ucial ha u u e s udies use a clea ly de ined sampling
ame ha is ep esen a i e o he a ge popula ion, ensu ing
he inclusion o di e se egions and socioeconomic con ex s o
imp o e he gene alizabili y o indings. I is also ecommended
ha longi udinal s udy designs be implemen ed o assess em-
po al ends in TDI.
5 | Conclusions
This sys ema ic e iew p o ides an es ima e o he p e alence o
den al auma in Spain, showing a high equency o hese
e en s, especially in child en and adolescen s. Al hough his
s udy p o ides aluable in o ma ion, he me hodological limi-
a ions iden i ied in he exis ing li e a u e unde line he need
o u u e esea ch wi h mo e s anda dized and igo ous ap-
p oaches, which will allow mo e p ecise and compa able es i-
ma es o he p e alence o den al auma o be ob ained.
Au ho Con ibu ions
All au ho s con ibu ed equally o he publica ion o he a icle.
Acknowledgmen s
To D . Joseph o his dedica ion and suppo in me hodology. The au-
ho s ecei ed no speci ic unding o his wo k.
Con lic s o In e es
The au ho s decla e no con lic s o in e es .
Da a A ailabili y S a emen
The da a ha suppo he indings o his s udy a e a ailable om he
co esponding au ho upon easonable eques .
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