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The BAOMS United Kingdom survey of facial injuries part 1: aetiology and the association with alcohol consumption. British Association of Oral and Maxillofacial Surgeons

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  • National Facial Oral and Oculoplastic Research Centre

Abstract and Figures

To determine the age and sex distribution, timing, causes, geographical location, and nature of facial injuries in the UK and to determine the association of these factors with alcohol consumption by the patient or any other involved person. A 12-section proforma was completed on all patients with facial injuries covering their age and sex, time and day of injury and presentation, the cause and type of injury and where it occurred, the treatment the patient received, any other injuries, and alcohol consumption by the patient and any other involved person. The total attendances for the study week and the catchment population for each A&E department were recorded. 163 of the A&E departments in the UK served by 137 of the UK's oral and maxillofacial departments. All patients who presented with facial injuries to these 163 A&E departments in England, Scotland, Wales and Northern Ireland over the study week from 09.00 hours on Friday 12 September 1997 to 08.59 hours on Friday 19th September 1997. 6114 patients with facial injuries presented over the week, out of a total of 152,692 A&E attendances. The male:female ratio was 68:32. This rose to 79:21 in assault cases. The mean age of all patients was 25.3 years, of males 23.2 years, and of females 29.8 years. Forty per cent of the facial injuries were caused by falls. A large proportion of these happened to the under-5 age group in the home. Eleven per cent of all falls were associated with alcohol consumption. Twenty-four per cent of the facial injuries were caused by assault. The commonest sites for assault were the street followed by public drinking establishments. More women than men were assaulted at home. Fifty-five per cent of assaults were related to alcohol consumption. Eight per cent of assaults were with bottles or glasses. Five per cent of the facial injuries occurred in road traffic accidents (RTAs). Fifteen per cent of RTA victims had consumed alcohol. The 15-25 age group suffered the greatest number of facial injuries caused by assault and RTAs and had the highest number associated with alcohol consumption. At least 22% of all the facial injuries in all age groups were related to alcohol consumption within 4 hours of the injury. In the over 15 age groups, alcohol consumption was associated with 90% of facial injuries occurring in bars, 45% on the street, and 25% in the home. Assault, RTA and alcohol consumption conveyed an increased risk of serious facial injury. Campaigns should be instituted to educate young people about the link between excessive alcohol consumption, assault, road traffic accidents and serious facial injury.
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The BAOMS United Kingdom Survey of Facial Injuries Part 1: Aetiology
and the association with alcohol consumption
I. L. Hutchison, I? Magennis, J. I? Shepherd, A. E. Brown
On Beldf’of the British Association
qf
Oral und
Musillqfucid Surgeons
SUMMARY. Objective
- To determine the age and sex distribution, timing, causes, geographical location, and
nature of facial injuries in the UK and to determine the association of these factors with alcohol consumption by the
patient or any other involved person.
Design
- A 12-section proforma was completed on all patients with facial
injuries covering their age and sex, time and day of injury and presentation, the cause and type of injury and where
it occurred, the treatment the patient received, any other injuries, and alcohol consumption by the patient and any
other involved person. The total attendances for the study week and the catchment population for each A&E
department were recorded.
Setting
- 163 of the A&E departments in the UK served by 137 of the UK’s oral
and
maxillofacial departments.
Subjects
- All patients who presented with facial injuries to these 163 A&E departments
in England, Scotland, Wales and Northern Ireland over the study week from 09.00 hours on Friday 12 September
1997 to OS.59 hours on Friday 19th September 1997.
Results
- 6114 patients with facial injuries presented over the
week, out of a total of 152 692 A&E attendances. The male:female ratio was 68:32. This rose to 79:21 in assault
cases. The mean age of all patients was 25.3 years, of males 23.2 years, and of females 29.8 years. Forty per cent of
the facial injuries were caused by falls. A large proportion of these happened to the under-5 age group in the home.
Eleven per cent of all falls were associated with alcohol consumption. Twenty-four per cent of the facial injuries were
caused by assault. The commonest sites for assault were the street followed by public drinking establishments. More
women than men were assaulted at home. Fifty-five per cent of assaults were related to alcohol consumption. Eight
per cent of assaults were with bottles or glasses. Five per cent of the facial injuries occurred in road traffic accidents
(RTAs). Fifteen per cent of RTA victims had consumed alcohol. The 15-25 age group suffered the greatest number
of facial injuries caused by assault and RTAs and had the highest number associated with alcohol consumption. At
least 22% of all the facial injuries in all age groups were related to alcohol consumption within 4 hours of the injury.
In the over 15 age groups, alcohol consumption was associated with 90% of facial injuries occurring in bars, 45% on
the street, and 25% in the home. Assault, RTA and alcohol consumption conveyed an increased risk of serious facial
injury.
Conclusions
- Campaigns should be instituted to educate young people about the link between excessive
alcohol consumption, assault, road traffic accidents and serious facial injury.
1NTRODUCTION
There have been many studies on the epidemiology of
facial injuries, but hitherto there has been no prospec-
tive comprehensive national study on this subject.
Individual hospitals and departments dealing with
facial trauma have conducted surveys on facial
trauma in their distinct catchment populations.’ 3
However, these local studies usually only include
severe facial injuries referred to the treating depart-
ment and do not record the many minor injuries
requiring no treatment or treated in the accident and
emergency department. Furthermore, they may not be
representative of a whole country including urban
and rural communities.
Data on facial injuries is also generated nationally.
For example, in the UK, the Department of the
Environment, Transport and the Regions and the
Home Ofice produce national reports on RTA” and
assault statistic9 respectively which are obtained from
police, coroners’ reports and death certificates. These
only note those events reported to the authorities, and
do not focus exclusively on facial injuries. The British
Crime Survey,h also produced by the Home Office,
avoids the bias towards reported crime by interview-
ing approximately 16 500 randomly selected families
in the UK about criminal activity they have experi-
enced in the preceding year. However, this is retro-
spective and relies heavily on the memory of the
interviewee. Once again, this survey does not deal
specifically with facial injuries. Therefore, these
national studies are likely to be incomplete both in
numbers and in details of the facial injuries.
Nonetheless, all these diverse studies have sug-
gested trends in the aetiological factors responsible for
facial trauma, notably a reduction in severe facial
injuries caused by RTAs, and an increase in these
injuries caused by assault and sport.’ The RTA
decrease is ascribed to legislation on alcohol restric-
tion for drivers and the compulsory wearing of seat
belts, the introduction of front passenger air bags and
safety glass in car windscreens, and the construction
of better roads. The rise in sports injuries is attributed
to an overall increase in participation in leisure activi-
ties by the population.
Also, several studies on assault have noted the
strong association between excessive alcohol con-
sumption by victims or their assailants and severe
3
4 British Journal of Oral and Maxillofacial Surgery
facial injury requiring referral to oral and maxillo-
facial surgeons.8
Oral and maxillofacial surgeons treat most severe
facial injuries in the UK. They have been an under-
used resource in quantifying the national burden and
causes of facial trauma. Our national organization,
the British Association of Oral and Maxillofacial
Surgeons (BAOMS), sought to remedy this by orga-
nizing this one-week national study. The study was
designed to examine the aetiological factors responsi-
ble for facial injuries, the places where facial injuries
occurred, and the association between these injuries
and activities such as sport or work. The types of
injury would be recorded, the severity of injury and
association with injuries at other sites in the body. The
alcohol consumption of patients and any other per-
son involved would be noted. All these results would
be compared.
MATERIALS AND METHODS
Preparation
The survey took place over one week between Friday
12 September 1997 (09.00 hours) and Friday 19
September 1997 (08.59 hours). It was felt that enthusi-
asm for the study could be maintained over one week,
that one week’s figures would be representative and
that sufficient numbers of facial injuries would pre-
sent in this period to enable accurate analysis. The
British Association of Accident and Emergency
Medicine (BAAEM) were asked for their support,
which they offered unreservedly. Letters were sent to
all consultants in oral and maxillofacial surgery
(OMFS) in the UK inviting them to participate in a
national study. At the same time, all members of the
BAAEM were contacted informing them of the study
and requesting their co-operation. Both groups were
asked to co-ordinate their efforts at a local level.
Registration was received from 137 of the 156 oral
and maxillofacial units in the UK with a total of 155
consultant surgeons volunteering to participate.
Proforma design
A proforma was designed and piloted in the Royal
London Hospital. After this successful pilot study, the
proforma was modified and printed in numbered pads
of 100 sheets. Participating units received 4 unique
pads and a letter of advice based on the pilot study.
This written advice was followed up with telephone
calls to all the participating consultants, emphasizing
the anticipated difficulties and strategies to overcome
them.
The proforma consisted of six sections to be com-
pleted by A&E staff and 4 further sections to be com-
pleted by OMFS surgeons if the patient was referred
on to them. The patient’s age and sex, the dates and
times of injury and presentation were recorded in the
first section. The next 4 sections dealt with the type of
facial injury, where it happened, the cause of the
injury and whether alcohol was consumed by the
patient or other party within 4 hours of the injury.
The alcohol status of patients and any other party
involved in the causation of the facial injury was
ascertained by direct questioning of the patient. The
final part of this section recorded the outcome of
management in A&E. The four maxillofacial boxes
dealt in more detail with the nature of the injury,
specifying the type of facial bone fracture or dental
injury, the complexity of soft tissue lacerations, the
presence of injuries to other parts of the body, and a
final outcome box.
Patient selection
All patients presenting to participating hospitals for
treatment of their facial injuries during the study
week were included in the survey (scalp and neck
injuries were excluded).
Form processing
Each unit made its own arrangements for form initia-
tion and collection. Proformas were initiated at the
first point of contact for the patient, completed as
the patient was processed and collected by the local
maxillofacial surgeons.
At the end of the study week, all completed forms
were returned to the central office of the BAOMS.
Additional information was requested on the total
A&E patients at each of the study hospitals for that
week, and the catchment population of each A&E
department studied. The participating oral and
maxillofacial surgeons were also asked to estimate the
accuracy of their local survey by comparing the total
number of completed forms with the computerized
record of facial injuries in A&E.
A database was constructed on Microsoft AccessTM
for entering the proformas. Completed facial injury
forms were entered onto computers by the junior
OMFS staff and secretarial staff at the Royal London
and Walton Hospitals and the Dental Hospital,
Liverpool. The results were analysed and tested for
statistical significance using the x2 test within
Microsoft ExcelTM.
RESULTS
Overall results
In all, 6114 facial injuries were recorded on the facial
injury sheets in 163 A&E departments during the
BAOMS national survey. The average number of
facial injuries per department was 38 with a range of
2-154 and a standard deviation (SD) of 25 patients.
During the week studied, a total of 152 692 patients
attended the participating A&E departments with an
average per department of 937 and a range of
83-2466 (SD 491). The percentage of patients attend-
ing A&E departments with facial injuries was on
BAOMS UK Survey of Facial Injuries 5
Number
Of 400
patients
300
.4
.
c l
\
\
\
-Home
- D Pub/club
- * street
Fig. 1 Geographical location of facial injury and age of patient.
average 4.0% with a range of 0.4%16.0% (SD 2.5%).
As some departments estimated completed forms to
be less than 25% of all facial injuries, it is certain that
4% is an underestimate.
Injuries were subdivided into minor and severe.
The minor category was used if no treatment was
required or they were treated by A&E staff The severe
category was used for those cases requiring admission,
an immediate opinion from OMFS, or an out-patient
specialist opinion. Whilst the majority, 3843 (67%) of
injuries were minor, 1798 (29%) were sufficiently
serious to require admission or specialized treatment
outside the A&E department.
The total catchment area covered by the participat-
ing A&E departments was 43 651 089. This is proba-
bly an overestimate because of overlapping catchment
areas. The average facial injuries per 100 000 of catch-
ment population per week was 16 with a range of
1-68 and a standard deviation of 11. Calculating this
up to a year would mean there would be 832 facial
injuries per 100 000 population per year.
Regional, metropolitan and county town distribution
Participating hospitals were subdivided into the
Department of Health regions and into whether they
were situated in a large metropolis or a county town
serving a rural population. There was no statistical
difference between individual regions for any aspect of
facial injuries. However, when the regions were subdi-
vided arbitrarily into north and south (by a line pass-
ing from east to west so that the west midlands lay
south of the line), there was a statistically significant
increased proportion of assaults in the north (north
25%: south 22% PcO.05) and alcohol-related injuries
(north 38%: south 34”/0
P < 0.05).
The A&E departments in metropolitan areas num-
bered 80 whilst 83 county town A&E departments
were included in the study. There was no statistical
difference between the overall number of patients
with facial injuries attending metropolitan (3077) and
county towns (3037), nor in the percentage of facial
injuries per total patients seen or injuries per 100 000
catchment population.
Age of patient
The average age of patients with facial injuries was
25.3 years (SD 22) with the oldest patient 97 years and
the youngest 4 weeks. Male patients had an average
age of 23.2 (SD 19) and females 29.8 (SD 28). This
difference was statistically significant
(P < 0.05).
The age groups were subdivided for analysis into
pre-school (under 5s); school (5515); young adult
(15-25); and 10 year cohorts until the over 55s.
Children below the age of 15 sustained 39% of all
facial injuries attending A&E but most of these (72%)
were minor injuries caused in the main by falls at
home. On the other hand, those between the ages of
15 and 45 represented a similar percentage (43%) of
those attending A&E departments during the week
and yet 52% of this age group had serious injuries.
The peak age for facial injuries in the public bar
location was 15525 years. A similar age peak was seen
in the street location, but there was also an additional
lower peak in the 55-75 age group for injuries at this
site conciding with a peak for falls by elderly people.
There was a dramatic peak for home-based injuries in
the under-5 age group (Fig. 1).
The age distribution and nature of injury is shown
in Figure 2.
Sex of patient
Male patients represented the majority of patients atten-
ding with facial injuries, 4139 (68%), compared to 1975
(32%) females. The sex distribution across age groups is
illustrated in Figure 3. It can be seen that males are in the
majority in all age groups except in those over 55. A sta-
tistically significant higher proportion of male patients
6 British Journal of Oral and Maxillofacial Surgery
Fig.
2 -Age and nature of injury
q
(blank)
Fig.
3 - Age and sex of patients with facial
injuries.
experienced serious injuries (31%) than the proportion
for females (25%) (P < 0.05).
Aetiology of injury (Table 1)
Falls were the major cause of facial injury, 2416
(40%). Assault caused 1457 (24%) of all injuries, other
accidents/sports injuries, 1277 (21%), and RTAs 304
(5%). However, the number of RTAs which resulted in
serious injuries was the highest proportionately (130
or 43% of RTAs). Most falls took place in the home
and only 590 (24%) resulted in serious injuries. The
majority of patients with facial injuries caused by a
fall presented in A&E departments from 09.00 hours
to 21.00 hours with very few falls presenting at night.
The majority of assaults occurred on the street or in a
public bar, 930 (64%) and 548 of all assaults (38%)
resulted in serious injury.
Table 1
- Cause of facial injury in 6114 surveyed patients
Cause of injury Total numbers % of injuries
Fall 2416 40
Assault 1457 24
Sport / other accident 1277 21
Not recorded 551 9
RTA 304 5
Therefore, both assaults and RTAs caused a larger
percentage of serious injuries than would be expected
from their overall percentage in the survey. Figure 4
illustrates how the aetiology of the injury changes
with the age of the patient. Notice the bimodal distri-
bution of falls with peak ages under 5 years and over
75 years of age. The peak age where assault is the
cause of facial injury is in the 15-25 age group.
Location where injury occurred (Table 2)
Injuries occurring in a public drinking establishment
were described as occurring in a public bar. Injuries
occurring in a public place other than a drinking estab-
lishment were reported as occurring on the street.
Slightly more facial injuries occurred in the street,
1969 (32%), than in the home, 1870 (31%), and 1005
(16%) happened during sporting or other recreational
Table
2 - Location where facial injury occurred
Place of injury Total number % of total injuries
Street 1969 32
Home 1870 31
Sport I recreation 1005 16
Public bar 419 7
Work 294 5
School 194 3
BAOMS UK Survey of Facial Injuries 7
Fig. 4 - Aetiology of facial injury and age of patient.
Fig. 5 - Day of presentation of injuries and
association with alcohol consumption.
activity. Four hundred and nineteen (7%) occurred in
public bars, 294 (5%) at work and 194 (3%) at school.
Assaults were responsible for 300 (72%) injuries in
public bars. Serious injuries occurred significantly
more frequently in the street and in public bars than
would be expected if serious injuries were distributed
evenly across locations (P < 0.05).
In sporting activities, unspecified accidents
accounted for the vast majority of facial injuries, 77%
(these might include collisions with fixed objects on
the playing pitch, blows from racquets, and collisions
with other players). There were lower proportions of
falls, 12%, and assaults, 6’%1 during sport. At work,
58% of facial injuries were caused by unspecified
accidents, possibly with machinery, whilst falls and
assaults accounted for 20% and 15% respectively.
Day and time of presentation
The majority of facial injuries, 3274 (54%), occurred
at the weekend (Friday, Saturday and Sunday) and the
24-hour period beginning at 09.00 hours on Saturday
morning was the busiest with 20% of all facial injuries
(Fig. 5). Half of all facial injuries presented in the late
afternoon and early evening (Fig. 6).
Nature of injury
At the initial assessment, 158 (3%) patients had no
obvious injury, 2771 (45%) had facial bruising, 3610
(59%) had a facial laceration, 328 (5%) had damaged
teeth, and 792 (13%) had a suspected facial fracture.
Most patients had a combination of more than one
type of injury.
Management of injury
Of the 6114 patients presenting to A&E with facial
injuries, 1003 (16%) were discharged without treat-
ment being necessary, and 2783 (46%) were treated in
A&E. A further 1261 (21%) with more serious injuries
were referred for an oral and maxillofacial opinion,
487 (8%) required admission to a ward and of these,
16 were admitted to an intensive care unit.
Association of alcohol with facial injuries
As the alcohol figures had 2 boxes with 3 variables,
there were a large number of possible combinations.
To simplify analysis, the alcohol statistics were calcu-
lated as follows: if the patient or the other party or
both had consumed alcohol within 4 hours of the
injury then this was categorized as positive, if the ‘no
alcohol’ boxes were marked either for the patient
alone or for both patient and other party where
another person was involved (e.g. assault or RTA),
these cases were recorded as ‘no alcohol consumed’. If
the alcohol status of the patient or other party was
not known or left blank the incident was ‘alcohol
unknown’.
8 British Journal of Oral and Maxillofacial Surgery
Fig. 6 - Time of presentation of facial injuries and
association with alcohol consumption. Time ot presentation
Fig. 7 -Age ranges of injured patients and association
with alcohol consumption.
Therefore, the alcohol figures can be subdivided
into 3 categories: overall numbers; exclusively patient-
related alcohol consumption; and exclusively ‘other
party’ alcohol consumption. At least 22% of all the
facial injuries were associated with alcohol consump-
tion. One thousand two hundred and sixty (21%)
patients consumed alcohol within four hours of the
injury, 4108 (67%) denied consuming alcohol before
their injury, and the alcohol status was unknown in
746 (12%) patients.
Twenty two per cent of other parties (i.e. assailants
or people involved in RTAs), were recorded as positive
for alcohol consumption. It is probable that some of
the 64% of ‘other party’ reports where the alcohol
status was ‘unknown’ were also positive.
Age, sex and alcohol
The 15-25 year age group experienced the greatest
number and proportion of alcohol-related facial in-
juries. The extremes of age - under 15 and over 75 years
- had very low incidences of alcohol-related injuries
(Fig. 7). The ratio of males to females was increased in
the 1274 injuries associated with alcohol (75% male to
25% female) compared with the ratio for all the 6114
facial injuries (68% male to 32% female) (P < 0.05).
Only 3 of the 1231 patients in the under-5 age
group and 21 of the 1184 patients in the 5-15 age
group sustained alcohol-related facial injuries.
Therefore, to avoid the large number of injuries in
children’s age groups skewing analysis of the results,
detailed study of the alcohol statistics has been
restricted to the 3544 patients aged 15 and over.
Aetiology and alcohol
Figure 8 shows the association between the cause of
injury and alcohol consumption. More assault and
RTAs were positive for alcohol than were not.
Location of injury and alcohol
Alcohol consumption was associated with 90% of
facial injuries occurring in bars, 45% of facial injuries
in the street, and 25% of facial injuries sustained in
the home in the over- 15 age group.
Day and time of presentation and alcohol
The highest proportion of alcohol-related facial
injuries presented during the weekend (Fig. 5). In the
over-15 age group, alcohol was associated with 48% of
all facial injuries during the 24-hour period beginning
09.00 hours on Friday, 43% of those beginning at 09.00
hours on Saturday and 37% beginning at 09.00 hours
on Sunday. During the week, Tuesday was the quietest
24-hour period with only 22% of the facial injuries
BAOMS UK Survey of Facial Injuries 9
Fig. 8 - Aetiology of facial injury in patients over 15
years and association with alcohol consumption.
Fig. 9 -Age distribution of assaulted patients and
association with alcohol consumption.
directly associated with alcohol, compared to Monday
(27%), Wednesday (28%) and Thursday (29%).
The busiest period of the day for alcohol-related
injuries was 21 .OO hours03.00 hours (Fig. 6).
Nature
qf
injury and alcohol
In the over-l 5s at least 36% (731) of the facial lacera-
tions were associated with alcohol consumption, 45%
(285) of the suspected facial fractures and 50% (76) of
the dental injuries. Of the patients referred to maxillo-
facial departments, 44% of the patients with definite
facial bone fractures had consumed alcohol within 4
hours of the injury. These figures support the finding
that alcohol consumption is associated with more
serious facial injury.
Severity qf’ injury and alcohol
In the over-l 5 age group, 43% of the more severe
injuries were associated with alcohol consumption
compared with 35% of patients who had definitely
not consumed alcohol. In minor injury in the same
age group, only 32% had definitely consumed alcohol
compared with 44% who had definitely not consumed
alcohol. The consumption of alcohol is therefore
significantly associated with an increased severity of
facial injury (WO.05).
Assault in detail
Metropolis and county toivn
Assaults made up a larger proportion of facial
injuries in A&E departments in the metropolis (26%)
than in those A&E departments serving county towns
(21%) (P < 0.05). This distribution was repeated for
assaults on males and females when they were
examined separately. However, a greater percentage of
females were assaulted at home in county towns (52%)
compared with the metropolis A&E figures (38%)
(P<O.O5), whilst fewer females were assaulted in pub-
lic bars in the county town compared to the metropo-
lis (7% vs 11%). In males, the street was a more likely
site for assault generated facial injuries in metropo-
lises (49% of all metropolis assaults occurred on the
street) than in county towns (43%) (P < 0.05).
Age, sex and assault
The 15-25 age group suffered the greatest number of
assaults (46%) of injuries in this age group were caused
by assault) and alcohol-related assaults (Fig. 9).
Assault was a rare cause of facial injury at the
extremes of life. The average age of patients involved
in assault was 25.2 with an SD of 22 years and a range
of 4 months to 97 years.
10
British Journal of Oral and Maxillofacial Surgery
Table 3 - Location where patient was injured and percentage of these injuries due to alcohol-related assault
Location where assault occurred
(total number of injuries at this
location)
Injuries due to assault at % of all injuries at this location % of assaults alcohol related
this location (all ages) due to assault (all ages) (patients > 1.5 years)
Public bar
(n =
419) 300 12 90
Street
(n =
1969) 630 32 63
School
(n =
194) 39 20 0
Home (n = 1870) 264 14 51
Work
(n = 294)
43 15 18
Sport/recreation (n = 547) 88 9 34
Of the 1457 patients assaulted, 1144 (79%) were
male and 313 (21%) female. The type of assault
matched this pattern between the sexes except where
injuries were caused by bottles/glass when there was
an even greater proportionate risk for males, 83%
(102) compared to 17% (21) females (P c 0.05).
Location where assault occurred (Table 3)
The highest proportion of assaults, 630 (43%), took
place in the street. Public drinking places such as bars,
clubs and public houses with 300 (21%) were the next
most common sites, followed closely by the home with
264 (18%). Many street assaults may occur after clients
have recently left the public drinking location. This tits
in with the peak time for facial injuries caused by
assaults from 21.00 hours-03.00 hours, when these
establishments are closing (Fig. 10). The remaining
Fig. 10 -Time of presentation of assaults and
association with alcohol consumption. 500
250
Fig. 11 Location of assault and sex of patient.
locations in order of frequency were sport/recreation,
88 (6%) work, 43 (30/o), and school, 39 (3%).
More females than males were assaulted in the
home (137 female: 127 male). This was the only
situation where the 68:32 overall male:female sex ratio
moved toward female. In fact, 44% of all assaults on
females took place at home and, in at least 48% of
these, one or both parties had drunk alcohol. This
contrasts with 11% of total assaults on males occur-
ring in the home. Figure 11 illustrates the ratio
between the sexes for assaults at each location.
In public bars in the over-l 5 age group, 73% of
facial injuries were caused by assault and 90% of these
were alcohol related. At work, 15% of facial injuries
were caused by assault (18% associated with alcohol).
At school 20% of facial injuries were caused by
assault. Of facial injuries occurring during sport, 5%
were caused by assault and 12% of these were alcohol
related in the over-l 5 age group. On the street, 32% of
BAOMS UK Survey of Facial Injuries I I
Fig. 12 Injuries caused by assault in those over I5
years of age and association with alcohol
consumption.
facial injuries were caused by assault, whilst in the
over-15s the figure rose to 41%. In 63% of patients
over 15, this assault in the street was associated with
alcohol consumption by either or both the patient and
assailant.
Duy and time qf assault
Figure 10 demonstrates the time of presentation of
patients with assault and the association of the injury
with alcohol. It can be clearly seen that, at all times
of the day, assaults associated with alcohol out-
number those where no alcohol was involved.
Saturday and Friday were the busiest 24-hour periods
with 23% and 22% of all the assaults occurring then
respectively.
Blunt trauma, that is, assault with parts of the body
or a blunt instrument, made up 89% of assaults
(1300), bottle/glass was used in 122 (W), knives in 3 1
(2X), and guns in 4.
Sixty-two of the assaults with bottle or glass (just
over half) occurred in public bars and all but 2 of these
were alcohol related. Thirty five of the street assaults
(6% of street assaults) were with glasses or bottles and
of these, at least 25 (73%) were alcohol related. At
home, 17 assaults were perpetrated with glass or bottles
(6% of home assaults) and 8 were alcohol related.
One gun injury was definitely alcohol related whilst
the other 3 facial injuries caused by guns happened to
children less than 15 years of age.
At least 46% of knife wounds, 80% of glass or
bottle facial injuries and 62% of blunt assaults were
associated with alcohol consumption.
Association of asscrult u’ith ulcohol
In total, at least 55% of assaults in all age groups
(805) were related to alcohol consumption. At least
51% of patients and 26% of assailants had consumed
alcohol within 4 hours of the incident (in 61% of
assaults the alcohol status of the assailant was not
known).
Assault caused 30’%, of all serious injuries even though
it made up only 240/o of all injuries. Of the 1457
patients assaulted, 867 (59%) had bruising, 711 (49%)
had lacerations or abrasions, 72 (5%) had damaged
teeth and 354 (24%) had sustained a suspected frac-
ture. Indeed, whereas assault only caused 24% of
facial injuries it was responsible for 45% of all the
suspected facial fractures.
Outcome qfputients with assault
Most patients who were assaulted were treated by
A&E staff, 807 (55X), but 396 (27%) required referral
or outpatient review and 160 (11%) were admitted to
hospital (two men required admission to Intensive
Care). At least one patient died as a result of her
injuries. The relative proportions of injuries caused by
assault are displayed in Fig. 12.
Falls
The mean age of those affected by falls was 26 years,
but this rose to 40 years of age if alcohol was involved
and fell to 19 years of age if alcohol was not involved,
because falls were the commonest cause of injury in
children (Fig. 4).
Most falls occurred in the home (1143) falls
making up 6 1% of the facial injuries which occurred at
home. Five per cent of these were associated
with alcohol. The second highest site of facial in-juries
caused by falls was the street with 714 cases, represent-
ing 36% of facial injuries which occurred at this loca-
tion. At least 20% of these were alcohol related. At
school, 45% of the facial injuries were caused by falls
whilst at work, 20% of facial injuries were caused by
falls and 7% of these were alcohol related. Falls only
accounted for 9% of facial injuries in public bars, but
74% of these were alcohol related. Overall, at least
11% of falls were associated with alcohol.
12 British Journal of Oral and Maxillofacial Surgery
Road traffic accidents
RTAs only caused 5% of facial injuries in this study
(Table I), but they were associated with an increased
frequency of serious injuries (7% of the total serious
injuries). The mean age of RTA victims was 25 years
and Figure 4 shows a peak age incidence from 5 years
to 25 years of age.
Fifteen per cent of RTA victims had consumed
alcohol within 4 hours of the injury, but in three-
quarters of the RTAs the alcohol status of the other
party was unknown.
DISCUSSION
This is the first prospective study of one nation’s facial
injuries. It was carried out in 163 A&E departments,
covering a catchment population of approximately 40
million people (over two-thirds of the total popula-
tion of the UK), during one week in September 1997.
The study had an equal proportion of patients from
conurbations and county towns and it covered all
regions of the country. Therefore, its findings were
representative of the whole of the UK.
A total of 6114 patients with facial injuries were
available for detailed analysis. They accounted for
4% of all A&E attendances during the study but this
figure was a significant underestimate because all
departments recognized that their data collection had
been incomplete and some departments had com-
pleted facial injury proformas on less than 25% of the
total number of facial injuries attending their A&E
departments over the study week.
One of the most striking features of the study was
the involvement of the 15-25 age group. They suffered
the highest number and proportion of all alcohol-
related facial injuries. They experienced the greatest
number of assaults - in this age group 46% of facial
injuries were caused by assault. They suffered the
highest number and proportion of alcohol related
assaults. Theirs was the peak age for facial injuries
occurring in public bars and on the street and for all
RTAs and alcohol-related RTAs. They sustained the
highest number of severe facial injuries.
Overall, twice as many males were injured as
females but this rose in assault cases to a male:female
ratio of 4 to 1. In the home, more women were
assaulted than men, 44% of all assaults on women
occurred in the home, and nearly half of these
assaults on women were associated with alcohol
consumption. Assault conveyed an increased risk of
serious injury, for example, nearly half of all the sus-
pected facial fractures were caused by assault. Over
half of the victims of assault had consumed alcohol
within 4 hours of the injury. The peak time for assault
was 21.00 hours to 03.00 hours. The highest number
of assaults took place in the street but the highest pro-
portion of assaults occurred in the public bar loca-
tion. The coincidence of the peak times for street and
public bar assaults suggests that many of the street
assaults may be related to drinking in public bars and
may be caused by, or happen to, clients who have
recently left this location. Eighty per cent of the
assaults with bottles or glasses were associated with
alcohol consumption.
Almost one-quarter of all the facial injuries in this
study were related to alcohol consumption. Nearly
90% of the facial injuries occurring in public bars, just
under one half of those occurring in the street, and
one quarter of facial injuries occurring in the home
were associated with alcohol in the over-l 5 age group.
There was a strong association between alcohol con-
sumption and assault and RTAs. Alcohol consump-
tion conferred an increased risk of serious injury. For
example, 44% of all patients who sustained facial
bone fractures had consumed alcohol themselves
within 4 hours of injury. However, even these high
alcohol figures probably underestimate the true
situation. This is because the assailant, or other party
in an RTA, was usually unavailable for questioning in
A&E so no assessment of their alcohol consumption
was made and they were recorded as
‘alcohol
unknown’.
Large numbers of the pre-school age group (over
900) suffered facial trauma from falls in the home
environment. Fortunately, these injuries were usually
of a minor nature. However, it may be worthwhile for
the Department of Health to develop a campaign
educating parents on the risks around the home for
young children, for example, stairs and sharp-edged
furniture situated at toddlers’ face height, and advis-
ing parents on how to minimize the possibility of their
children suffering facial injury.
In the school age group, 20% of facial injuries were
caused by assault. All teachers try to ensure that their
schools provide a safe environment for pupils and
anti-bullying campaigns have been in place for several
years. However, despite this, the results from this
study show that assault still plays a significant part in
the generation of facial trauma at schools. It is clear
therefore that the reporting of intimidation and
threats of assault by pupils should continue to be
taken seriously and strategies to minimize assault in
schools should be re-evaluated.
Injuries to the face can be life-threatening, causing
airway obstruction or provoking severe haemorrhage.9
The facial injury may cause permanent derangement
of functions such as vision, smell, taste mastication
and swallowing. The trigeminal and facial nerves may
be irreparably damaged resulting in anaesthesia
dolorosa and impaired facial expression respectively.
Facial appearance is important in all societies.
Therefore, even minor alterations in the patient’s
facial appearance after trauma may cause severe psy-
chological morbidity. lo The psychological legacy of
the facial injury can persist long after the injury. The
low self-esteem generated by the patient’s perception
of their own deformity limits their ability to achieve
their full potential in society. Furthermore, every time
the patient examines their face in the mirror, the dis-
figurement they see reminds them of the traumatic
event that led to their injury.
If, as has been demonstrated, the 15-25 age group
is at greatest risk of severe facial injury and perma-
nent facial disfigurement, it is possible that there is a
large cohort of young people who, because of their
BAOMS UK Survey of Facial Injuries I3
psychological distress, under achieve for the whole of
their adult lives. These young peoples’ physical, emo-
tional and social problems may not only be a drain on
state resources, but their close family and friends may
also have to devote significant energy and resources to
supporting them. It is particularly tragic that many of
these injuries are caused by assault or are related to
alcohol consumption and are therefore theoretically
preventable.
This study garnered comprehensive data on facial
injuries occurring in the UK. It is not possible to
make direct extrapolations from these data to calcu-
late accurately the total number of facial injuries
occurring in the UK annually. However, comments
made by the participating oral and maxillofacial units
suggest that this week experienced an unusually low
incidence of facial injuries, possibly because of the
unique event of the funeral of Diana, Princess of
Wales in the preceding week. Despite the large num-
ber of facial injuries reported, it is likely therefore that
the figures for all facial injuries and for alcohol-
related injuries in this study are a significant underes-
timate. The data from this study suggest that, each
year, at least half a million patients in the UK suffer
facial injuries which are severe enough for them to
present to A&E departments.
In an attempt to reduce the burden of these injuries
on society, the BAOMS have planned a preliminary
educational campaign in secondary schools in the
UK targeting young adults and alerting them to the
dangers of excessive alcohol consumption outlined
above.
It is hoped that this campaign, in conjunction with
campaigns by the Health Education Council, will pre-
vent many of these unnecessary injuries.
Acknowledgements
We would like to thank the BAEEM, casualty consultants and all
their staff including receptionists, nurses and doctors. We also
thank all BAOMS consultants and their junior staff who
participated and collected data diligently. The junior medical and
secretarial staff at the Royal London, Liverpool Dental and Walton
Hospitals spent many hours entering data onto computers. Finally,
BAOMS and The Martha Redlich Oral Surgery Research Fund
supported this study financially.
The authors would like to acknowledge, with thanks, the par-
ticipation of the following maxillofacial units and their associated
A&E Departments: Weston Super Mare Hospital, Aberdeen Royal
Infirmary. Addenbrooke’s Hospital. Airedale General Hospital,
Arrowe Park Hospital, Barnsley District General Hospital,
Basildon and Thurrock General Hospital, Birmingham City
Hospital NHS Trust, Blackburn Royal Infirmary, Bristol Royal
Infirmary and Dental Hospital, Bromley NHS Trust, Canniesburn
Hospital: Carlisle City General Hospital, Central Middlesex Hos-
oital. Charinn Cross Hosoital. Charles Clifford Dental Hosuital.
Cheltenham General Hospital: Chesterfield and North Derbyshire
Royal Hospital, Countess of Chester Hospital, Crosshouse Hos-
pital, Derriford Hospital, Dumfries and Galloway Royal Infirmary,
Dundee Roval Infirmarv. Edinburgh Citv Hospital, Exeter and
North Devon Combined Maxillofacial Unit, Fairfield General
Hospital, Frenchay Hospital, Glan Clywd Hospital, Gloucester-
shire Royal Infirmary, Great Ormond Street Hospital for Children.
Greenwich District General Hospital, Grimsby Health NHS Trust,
Guy’s Hospital, Halifax General Hospital, Hereford County
Hospital. Hope Hospital, Ipswich Hospital, John Radcliffe
Hospital, Kent and Canterbury Hospital, Kettering General
Hospital, Kings Mill Centre, Leeds General Infirmary, Leicester
Royal Infirmary, Lincoln County Hospital, Luton and Dunstable
Hospital, Manchester Royal Infirmary, Middlesbrough General
Hospital, Monklands and Bellshill Hospitals Trust, Morriston
Hospital, Mount Vernon Hospital. Newcastle Dental Hospital.
Newcastle General Hospital, Norfolk and Norwich Hospital,
North Devon District Hospital, North Hampshire Hospital, North
Herts NHS Trust, North Manchester General Hospital, North
Staffs Hospital Trust. Northampton General Hospital, Northern
General Hospital Trust, Perth- Royal Infirmary, Peterborough
District Hospital, Pilgrim Hosoital. Pindert’ields Hosoitals NHS
Trust, Poole’HospitalTrust, Princess of Wales Hospual. Queen
Alexandra Hospital. Queen Elizabeth Hospital, Queen Margaret
Hospital NHS Trust, Queen Mary’s Hospital. Queen Mary’s
University Hospital. Queen’s Medical CentrelUniversity Hospital
Nottingham, Raigmore Hospital, Rotherham District General.
Royal
Berkshire Hospital, Royal Free Hospital, Royal Hospital
Gosport, Royal London Hospital, Royal Preston Hospital, Royal
Surrey Hospital. Salisbury District General Hospital, Southend
Hospital, Southmead Hospital, St George’s Hospital, St James’s
University Hospital, St John’s Hospital, St George’s Hospital, St
James’s University Hospital, St John’s Hospital, St Luke’s Hospital,
St Margaret’s Hospital, St Mary’s Hospital, St Richard’s Hospital,
Stafford District General Hospital, Stoke Mandeville Hospital,
Sunderland Royal Hospital, Taunton and Somerset NHS Trust.
Torbay Hospital. Ulster Hospital, University Dental Hospital of
Wales, University Hospital of South Manchester, Walton Hospital.
West Norwich Hospital. Wexham Park Hospital. Whipp’s Cross
Hospital. William Harvey Hospital. Worcester Royal Infirmary,
York District Hospital.
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The Authors
1. L. Hutchison
P. Magennis
J. P. Shepherd
A. E. Brown
C/o British Association of Oral & Maxillofacial Surgeons
Royal College of Surgeons of England
Lincolins Inn Fields
London WC2A 3PN
Correspondence and requests for offprints to 1. Hutchison
Paper received 6 December 1997
Accepted I2 December 1997
... 7 Consuming alcohol also increases the risk of a number of oral conditions, including oral and oropharyngeal cancers, as well as facial injuries and dental trauma. 8,9 Research has also shown that alcohol misuse is associated with periodontal disease, dental erosion, halitosis and tooth staining. 10,11,12,13,14 The current 'UK Chief Medical Officers' low risk drinking guidelines' state that it is safest not to drink more than 14 units of alcohol a week on a regular basis to keep health risks at a low level. ...
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Background The numerous health risks of excessive alcohol consumption are well documented. Individuals at risk of harm from alcohol consumption can be identified through alcohol screening tools; however, there is limited research regarding their use in general dental practices. Methods Data were collected as part of a feasibility trial evaluating delivery of brief alcohol advice in general dental practices in North London. Patient demographics and health-related behaviours were collected, and the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) tool was used to assess alcohol consumption patterns. Results The analytical sample comprised 552 dental patients, of whom approximately half (46%) were drinking alcohol at hazardous levels. Males, younger adults, those who consumed red meat weekly and smokers all had significantly increased risks of excessive alcohol consumption. Smokers were more likely to consume excessive levels of alcohol irrespective of smoking frequency. Notable sex differences in alcohol consumption were identified, with males being more likely to consume alcohol frequently and in larger quantities than females. Conclusion The AUDIT-C tool can be used in general dental practice to screen for harmful levels of alcohol consumption. Clear associations exist between patient demographics, health behaviours and excessive alcohol consumption.
... [4] British Association of Oral and Maxillofacial Surgery reported that children below the age of 15 account for 39% of all facial trauma cases presenting to ER departments in the UK. [5] Most epidemiological studies on maxillofacial trauma focus on facial fractures ignoring soft tissue injuries despite being more common than facial fractures. Other studies discuss the cosmetic outcomes comparing different treatment methods with no emphasis on epidemiological analyses. ...
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... [4] British Association of Oral and Maxillofacial Surgery reported that children below the age of 15 account for 39% of all facial trauma cases presenting to ER departments in the UK. [5] Most epidemiological studies on maxillofacial trauma focus on facial fractures ignoring soft tissue injuries despite being more common than facial fractures. Other studies discuss the cosmetic outcomes comparing different treatment methods with no emphasis on epidemiological analyses. ...
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ResearchGate has not been able to resolve any references for this publication.