RESEARCH

Received f

*Adjunc

yUnder zPostgr xReside kOral a

{Adjun This re

cional de

de Pesqui

2017 and

UPE 2017-

Do Type of Helmet and Alcohol Use Increase Facial Trauma Severity?

Gabriela Granja Porto, PhD,* Ladyanne Pav~ao de Menezes, DMD,y Darlan Kelton Ferreira Cavalcante, DMD,z Rosa Rayanne Lins de Souza, DMD,x

Suzana C�elia de Aguiar Soares Carneiro, PhD,k and Antonio Azoubel Antunes, PhD{

Purpose: Facial trauma caused by motorcycle accidents has become a major issue because of its high

prevalence and morbidity, causing death and esthetic and functional sequelae in many individuals. This

work evaluated helmet and alcohol use and severity of facial fractures in motorcyclists treated at public

hospitals in Pernambuco, Brazil.

Patients andMethods: This prospective studywas conducted fromDecember 2016 to December 2018

and submitted to statistical and descriptive analysis. Variables such as gender, age, helmet use and type,

previous accidents, and duration of hospitalization were collected. The Facial Injury Severity Scale was

used to classify the facial fractures. The Alcohol Use Disorders Identification Test was used to verify alcohol dependence.

Results: The sample was composed of 455 patients. Most were male patients (90.8%) and were aged 18

to 29 years (54.5%). Of the patients, 36.5% reported no helmet use and 31.6% reported wearing an open helmet. Alcohol use was reported in 38.7% of the group. In 79.8% of the sample, alcohol use was classified

as low risk. There was a greater likelihood of having severe facial trauma if patients were aged between 30

and 39 years and had harmful or at-risk alcohol use. These patients also tended to remain hospitalized for

more than 10 days. No statistically significant relationship was found with the type of helmet.

Conclusions: The individuals most affected by facial trauma were young male patients (aged 18 to

29 years). Patients aged 30 to 39 years with high-risk use and dependence on alcohol were more likely

to have more complex facial trauma. The type of helmet used was not effective in reducing the severity

of facial fractures.

� 2019 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 78:797.e1-797.e8, 2020

Traffic accidents have become an epidemic in modern- day society.1 The data are even more alarming when

one observes motorcycle accident rates. Among the

types of damage caused in patients who survive these

accidents, motor, psychological, and mutilation

sequelae may be emphasized.2 Lesions in the head

and face region tend to be more complex owing to

rom University of Pernambuco, Camaragibe, Brazil.

t Professor, Master in Forensic Sciences.

graduate Student, Faculty of Dentistry.

aduate Student, Master in Forensic Sciences.

nt, Restauraç~ao Hospital.

nd Maxillofacial Surgeon, Restauraç~ao Hospital.

ct Professor, Master in Forensic Sciences.

search received financial support from Programa Institu-

Bolsas de Iniciaç~ao Cientifica (PIBIC)/Conselho Nacional

sa (CNPq)/Universidade de Pernambuco (UPE) 2016-

Programa Institucional de Apoio a Extens~ao (PIAEXT)/

2018.

797.e

the peculiarities of their anatomic structures, such as the complex vascularization, nervous system, bones,

muscles, and cartilage.3

These injuries also play an important role in phys-

ical, esthetic, functional, and mental sequelae.4 Thus,

they definitively compromise the life of the individual

and, when poorly treated, may leave sequelae,

Conflict of Interest Disclosures: None of the authors have any

relevant financial relationship(s) with a commercial interest.

Address correspondence and reprint requests to Dr Porto: Uni-

versity of Pernambuco/Faculty of Dentistry of Pernambuco, Av Gen-

eral Newton Cavalcanti, 1650, 54753-220 Camaragibe, PE, Brazil;

e-mail: [email protected]

Received September 12 2019

Accepted December 2 2019

� 2019 American Association of Oral and Maxillofacial Surgeons

0278-2391/19/31368-0

https://doi.org/10.1016/j.joms.2019.12.004

1

797.e2 FACIAL TRAUMA SEVERITY IN MOTORCYCLISTS

marginalizing the individual from social interaction,

generating incapacity for work, and condemning the

individual to economic segregation.2

The causes of trauma injuries may vary from country

to country because of different local, cultural, and

social factors.1 Worldwide, especially in developing

countries, the most frequent cause of fractures and

serious facial injuries are traffic accidents, especially those involving motorcycles. Such accidents may

become more serious when associated with alcohol

use.5 This substance has proved to be an aggravating

factor and is a cause of concern for road safety around

the world, given the role of alcohol in reducing an

individual’s reflexes and concentration, directly

interfering with his or her driving ability.6

In many countries, motorcycles have been used as the main means of transport. They can be purchased

at low cost and are associated with the increase in

the speed of traffic, being important factors in their

use in professional activities.7 Indeed, motorcycles

play an important role in transportation, especially

for the working class that uses them for various

services.8 For this reason, accidents involving motor-

cycles have increased in many countries, with major repercussions on the public health system.

Much work needs to be performed to prevent these

accidents involving motorcyclists. Prevention is the

most important way to reduce this public health

problem. In this respect, actions focused on the

primary prevention level may minimize accidents

initially, generating changes in motorcyclists’

behavior.2 Therefore, obtaining recent epidemiologic data on facial trauma may help in planning strategies for

the prevention of traffic accidents.

In many countries, there are laws that oblige motor-

cyclists to wear helmets and forbid them to drive after

drinking alcohol. However, they do not specify the

most appropriate type of helmet that could lead to

fewer serious injuries.9 Furthermore, it is still

unknown whether the use of alcohol increases trauma severity, and there are no studies in the literature

correlating alcohol and helmet use with the severity

of facial injuries. Thus, the main purpose of this study

was to evaluate the helmets used and the use or

nonuse of alcohol in relation to the types of facial

injuries in a Brazilian population of motorcyclists.

Patients and Methods

The study was approved by the university’s ethics

committee (No. 57061115.9.0000.5207) and followed

the Declaration of Helsinki on medical protocol and ethics. It was conducted from March 2016 to

December 2018 at the main emergency hospitals in

the state of Pernambuco, Brazil: Restauraç~ao Hospital

and Regional do Agreste Hospital.

The study comprised all patients of both genders

at any age with trauma in the oral and maxillofacial

region due to motorcycle accidents who agreed to

participate in the study after reading the informed

consent form. For data collection, an evaluation

form was elaborated containing information such

as age, gender, address, type of motorcycle, helmet

use and type (open or closed), alcohol consumption before the accident, purpose of motorcycle use,

type and severity of trauma, and length of hospi-

talization.

The Facial Injury Severity Scale (FISS), designed by

Bagheri et al10 (2006) was used to calculate the

severity of facial injury. The FISS is represented as a

numerical value according to the sum of all facial in-

juries, with a higher score indicating greater severity. On this scale, the face is divided into horizontal thirds

for bony injuries: mandible, midface, and upper face.

In addition, the total length of all facial lacerations is

included in the scale.

To verify the risk of alcohol dependence, the

Alcohol Use Disorders Identification Test (AUDIT)

questionnaire was applied. This questionnaire, con-

sisting of 10 questions, is widely used in several coun- tries because it is straightforward and inexpensive to

apply.11 The total score ranges from 0 to 40 points,

making it possible to identify 4 patterns of alcohol

use or risk zones: 1) low-risk use, 0 to 7 points; 2)

at-risk use, 8 to 15 points; 3) harmful use, 16 to 19

points; and 4) probable dependence, 20 or

more points.

Data were analyzed descriptively using absolute and percentage distributions for categorical variables and

statistical measurements—mean, standard deviation,

and median—for the numerical variables age and

FISS score. To evaluate the occurrence of a bivariate as-

sociation between the FISS score (#5 vs $6) and the

other variables in the study, we used the Pearson c2

test or, in situations in which the conditions for the

c2 test were not verified, the Fisher exact test. The Mann-Whitney test was used in the comparison of 2

categories. The Kruskal-Wallis test was used to

compare the categories of the variables (>2) in relation

to the numerical variable (FISS score). In the case of

significant differences, multiple comparisons tests

were used.

It should be noted that the choice of the Mann-

Whitney and Kruskal-Wallis tests was made because of the absence of data normality in at least 1 of the cat-

egories. The verification of normality was performed

by the Shapiro-Wilk test.

To estimate the probability of a patient having a

score of at least 6 on the FISS, a multivariate logistic

regression model was fitted with variables that

showed a significant association of up to 20%

(P < .20) in the bivariate study. In the bivariate study,

Table 1. EVALUATION OF DURATION OF HOSPITALI- ZATION, FRACTURE LOCATION AND COMPLEXITY, AND AUDIT CLASSIFICATION

Variable n %

Total 455 100.0

No. of days hospitalized

#10 321 70.5

>10 134 29.5

AUDIT classification I

Low-risk use (0-7 points) 363 79.8

At-risk use (8-15 points) 88 19.3

Harmful use (16-19 points) 3 0.7

Probable dependence ($20 points) 1 9.2

AUDIT classification II

Low-risk use 363 79.8

At-risk use, harmful use, and

probable dependence

92 20.2

FISS classification I

#5 411 90.3

$6 44 9.7

FISS classification II

0-1 (slight) 133 29.2

2-5 (moderate) 278 61.1

$6 (severe) 44 9.7

Abbreviations: AUDIT, Alcohol Use Disorders Identification Test; FISS, Facial Injury Severity Scale.

Porto et al. Facial Trauma Severity in Motorcyclists. J Oral Maxillo-

fac Surg 2020.

PORTO ET AL 797.e3

the values of significance for each variable, as well as

the odds ratio and confidence interval for each cate- gory, were obtained in relation to the FISS score

($6). In the multivariate logistic regression model,

the same parameters were obtained.

The margin of error used in statistical testing was

5%, and intervals of confidence of 95% were obtained.

The datawere entered into an Excel worksheet (Micro-

soft, Redmond, WA), and the IBM SPSS program

(version 23; IBM, Armonk, NY) was used to obtain the statistical calculations.

Results

The sample comprised 455 patients who were

injured during motorcycle accidents in which they

were the driver. The mean age was

31.19 � 11.36 years (minimum, 15 years;

maximum, 72 years).

Most patients were male patients (90.8%). More

than half (54.5%) were aged 15 to 29 years. The

percentage of patients who reported using alcohol was 38.7%. The purpose of motorcycle use was for

work in 36.3%. Table 1 shows the evaluation of the

duration of hospitalization, fracture location and

complexity, and AUDIT classification.

Table 2 presents the FISS classification in relation to

the use and type of helmet, motor power, duration of

hospitalization, alcohol use, and AUDIT classification.

Significant associations were found between the FISS

score and age group, days of hospitalization, and

AUDIT classification. For these variables, it is empha-

sized that the percentage of patients with FISS scores

of at least 6 was lower in the 18- to 29-year-old group (7.3%) and higher in the 30- to 39-year-old group

(16.4%); it increased with the number of days hospital-

ized and was higher among patients classified by the

AUDIT as having at-risk or harmful use of alcohol

than in those with low-risk use (17.4% vs 7.7%).

Table 3 shows significant differences between age,

gender, helmet use, number of days hospitalized,

AUDIT classification, and FISS score. For these vari- ables, it is evident that the mean FISS score was higher

in male patients than in female patients (P = .029). It

was also higher with significant differences in patients

aged 30 to 39 years (P < .001), those who were not

wearing a helmet (P = .026), and those classified by

the AUDIT as having at-risk or harmful use of alcohol

(P = .014). Patients who had a high FISS score

remained in the hospital for more than 10 days (P < .001).

Table 4 presents the bivariate and multivariate lo-

gistic regression results for the patients classified

with FISS scores of at least 6 according to the inde-

pendent variables that presented P < .20 in the bivar-

iate study. The following variables were included in

the multivariate logistic regression model: age, motor

power, length of stay, and AUDIT classification. Of these 4 variables, only motor power was not signifi-

cant at 5%. On the basis of the odds ratios for the 3

significant variables, it is estimated that the likelihood

of a patient being classified as having a score of at

least 6 on the FISS increases if the patient is 30 to

39 years old, hospitalized for more than 10 days,

and classified by the AUDIT as having at-risk or harm-

ful use of alcohol. The results of other models indi- cated acceptance of our model (P < .001), an

adequate fit to the data (P = .353 using the

Hosmer-Lemeshow test), and correct classification

of 86.4% of the data.

Discussion

Motorcycle accidents are one of the leading causes

of death in traffic all over the world. Among road

deaths worldwide, accidents involving motorcyclists

accounted for 9% of deaths in Europe, 20% in the

United States, and 34% in the countries of the Western Pacific and Southeast Asia.12 Therefore, studies must

be carried out so that prevention and education cam-

paigns in transit can be designed in such a way to

reduce these numbers. This study evaluated whether

Table 2. EVALUATION OF FACIAL SEVERITY ACCORDING TO AGE, GENDER, HELMET USE AND TYPE, MOTOR POWER, DURATION OF HOSPITALIZATION, ALCOHOL USE, AND AUDIT CLASSIFICATION

Variable

FISS Score

P Value OR (95% CI)

$6 #5 Total

n % n % n %

Total group 44 9.7 411 90.3 455 100.0

Age group .023*,y

18-29 yr 18 7.3 230 92.7 248 100.0 1.00

30-39 yr 18 16.4 92 83.6 110 100.0 2.50 (1.25-5.02)

40-72 yr 8 8.2 89 91.8 97 100.0 1.15 (0.48-2.74)

Gender .105z

Male 43 10.4 370 89.6 413 100.0 —

Female 1 2.4 41 97.6 42 100.0 —

Helmet use .521y

Yes 26 9.0 263 91.0 289 100.0 1.00

No 18 10.8 148 89.2 166 100.0 1.23 (0.65-2.32)

Helmet type .236y

No helmet 18 10.8 148 89.2 166 100.0 1.82 (0.79-4.20)

Closed 17 11.7 128 88.3 145 100.0 1.99 (0.86-4.63)

Open 9 6.3 135 93.8 144 100.0 1.00

Motorcycle power .105z

>50 cm3 43 10.4 370 89.6 413 100.0 —

<50 cm3 1 2.4 41 97.6 42 100.0 —

Days of hospitalization <.001*,y

1-10 13 4.0 308 96.0 321 100.0 1.00

>10 31 23.1 103 76.9 134 100.0 7.13 (3.59-14.15)

Alcohol use .519y

Yes 19 10.8 157 89.2 176 100.0 1.23 (0.66-2.31)

No 25 9.0 254 91.0 279 100.0 1.00

AUDIT classification .005*,y

Low-risk use 28 7.7 335 92.3 363 100.0 1.00

At-risk use or harmful use 16 17.4 76 82.6 92 100.0 2.52 (1.30-4.89)

Abbreviations: AUDIT, Alcohol Use Disorders Identification Test; CI, confidence interval; FISS, Facial Injury Severity Scale; OR, odds ratio. * Significant association at the 5.0% level. y Pearson c2 test. z Fisher exact test.

Porto et al. Facial Trauma Severity in Motorcyclists. J Oral Maxillofac Surg 2020.

797.e4 FACIAL TRAUMA SEVERITY IN MOTORCYCLISTS

the type of helmet and alcohol consumption increased

facial trauma severity in motorcyclists.

When assessing the distribution of patients accord-

ing to gender, we observed a predominance of male

patients (90.8%), corroborating the results of other studies in the literature.13 This finding can be

explained by the greater involvement of men in out-

door activities and their greater exposure to violent

actions.14 It also should be noted that male drivers

outnumber female drivers.15 It is interesting to note,

however, that a study by Zhou et al16 (2015) in China

found that women in the 11- to 20-year-old groupwere

more associated with facial trauma than were men. This finding indicates that female individuals tend to

take an early active role in society and is associated

with the greater participation of women in extra-

community activities, bringing them closer to men in

risk groups in some countries.16,17

Ours showed that the most prevalent age groupwas

the 18- to 29-year-old group (54.5%), similarly to the

study of Yu et al18 (2011), in which 51.5% of the patients were young persons aged between 18 and

35 years. The prevalence of facial trauma in this age

group can be attributed to the fact that this group

engages in dangerous sports, besides using means of

transportation at a high rate of speed.16 We expected

that this age group would have a greater severity of

facial trauma. However, this was not confirmed in

our study, with all age groups having mild facial trauma (a score between 2 and 3 on the FISS). We found a

greater likelihood of patients aged 30 to 39 years hav-

ing more complex trauma.

Table 3. FISS STATISTICS ACCORDING TO CHARACTERISTICS INCLUDING HELMET USE AND TYPE, MOTORCYCLE POWER, USE OF ALCOHOL, AND AUDIT CLASSIFICATION

Variable

Statistics

P ValueMean � SD Median Minimum Maximum

Total 2.76 � 1.97 2.00 0.00 12.00

Age <.001*,y

18-29 yr 2.81 � 1.74A 2.00 0.00 11.00

30-39 yr 3.05 � 2.23A 2.00 0.00 10.00

$40 yr 2.31 � 2.15B 2.00 0.00 12.00

Gender .029*,z

Male 2.82 � 1.99 2.00 0.00 12.00

Female 2.19 � 1.63 2.00 1.00 10.00

Helmet use .026*,z

Yes 2.63 � 1.89 2.00 0.00 11.00

No 3.00 � 2.09 2.00 0.00 12.00

Helmet type .083y

No helmet 3.00 � 2.09 2.00 0.00 12.00

Closed 2.73 � 2.11 2.00 0.00 11.00

Open 2.52 � 1.63 2.00 0.00 10.00

Motorcycle power .209z

>50 cm3 2.81 � 2.02 2.00 0.00 12.00

50 cm3 2.29 � 1.33 2.00 0.00 6.00

Days of hospitalization <.001*,z

1-10 2.38 � 1.53 2.00 0.00 10.00

>10 3.67 � 2.53 3.00 1.00 12.00

Alcohol use .909z

Yes 2.78 � 2.01 2.00 0.00 12.00

No 2.75 � 1.95 2.00 0.00 11.00

AUDIT classification .014*,z

Low-risk use 2.64 � 1.88 2.00 0.00 12.00

At-risk use or harmful use 3.25 � 2.23 3.00 0.00 11.00

Note: Regarding age, if the superscript letters are different, there is a significant difference between groups. Abbreviations: AUDIT, Alcohol Use Disorders Identification Test; FISS, Facial Injury Severity Scale; SD, standard deviation. * Significant at 5.0%. y Mann-Whitney test. z Kruskal-Wallis test.

Porto et al. Facial Trauma Severity in Motorcyclists. J Oral Maxillofac Surg 2020.

PORTO ET AL 797.e5

In this study, nearly one third (28%) of the inter-

viewees reported involvement in previous motor-

cycle accidents. In a study by Veronese and de

Oliveira19 (2006), 51% of the sample had already

had more than 1 accident and 8% had already had

more than 10 accidents. It may be that the use of

alcohol contributes to this behavior because patients

either lose their fear or momentarily forget about their previous accidents after alcohol intake20; in

our study, alcohol use was reported in 38.7% of

the sample.

A recent study by Roccia et al21 (2019) in Italy found

a progressive reduction in the incidence of maxillofa-

cial fractures over a period of 17 years. They attributed

these results precisely to the implementation, applica-

tion, and observance of road-safety policies, which

was reflected in low percentages of patients reporting

alcohol abuse while driving and high percentages of

helmet use. Thus, in this regard, it was to be expected

that people would not drink alcohol at all because the

act of drinking and driving any vehicle is forbidden by

a Brazilian law; this law, implemented in 2008 and

reinforced in 2012 through a resolution, prohibited

driving under the influence of any amount of alcohol.6

However, it is worth mentioning that the number of

patients who used alcohol before an accident may be

underestimated. Fearing legal proceedings, patients

may claim that they did not use alcohol before driving,

which would constitute a crime according to the Bra-

zilian Traffic Code.6 This bias may be repeated

regarding the nonuse of a helmet at the time of the

accident because, by law, a helmet constitutes

Table 4. LOGISTIC REGRESSION RESULTS FOR FACIAL TRAUMA PREVALENCE FOR LESIONS CLASSIFIED AS 6 OR GREATER USING FISS SCORE

Variable

Bivariate Analysis Adjusted Multivariate Analysis

n %y OR (95% CI) P Value OR (95% CI) P Value

Age .021* .012*

18-29 yr (n = 182) 17 9.3 1.00 1.00

30-39 yr (n = 77) 17 22.1 2.75 (1.32-5.73) 3.16 (1.43-6.98) .005*

40-72 yr (n = 50) 8 16.0 1.85 (0.75-4.57) 2.63 (0.98-7.05) .055

Motorcycle power

>50 cm3 (n = 281) 41 14.6 4.61 (0.61-34.88) .147 5.49 (0.69-44.08) .109

50 cm3 (n = 28) 1 3.6 1.00 1.00

Days of hospitalization

1-10 (n = 195) 12 6.2 1.00 <.001* 1.00 <.001*

>10 (n = 114) 30 26.3 5.45 (2.66-11.16) 5.43 (2.59-11.42)

AUDIT classification

Low-risk use (n = 232) 26 11.2 1.00 .034* 1.00 .038*

At-risk use or harmful use

(n = 77)

16 20.8 2.08 (1.05-4.12) 2.22 (1.05-4.72)

Abbreviations: AUDIT, Alcohol Use Disorders Identification Test; CI, confidence interval; FISS, Facial Injury Severity Scale; OR, odds ratio. * Significant at 5.0%. y Percentage obtained from total group in each category.

Porto et al. Facial Trauma Severity in Motorcyclists. J Oral Maxillofac Surg 2020.

797.e6 FACIAL TRAUMA SEVERITY IN MOTORCYCLISTS

mandatory protection equipment. According to

Soares-Carneiro et al22 (2016), an objective method

of confirming whether the patient was drunk before

the trauma would be to perform an intoxication test

at the time of his or her arrival at the hospital.

Thus, alcohol use and a previous accident reported

by a large number of the motorcyclists may suggest

that the ingestion of an alcoholic beverage may inter- fere with a driver’s cognitive and motor responses, im-

pairing control of the motorcycle.23 These data are

relevant because a considerable number of patients

in this study reported being recidivists in traffic acci-

dents, which increases the state’s expenditure on

emergency services and treatment of possible

sequelae. Moreover, drivers classified as harmful

alcohol users were about twice as likely to have more complex fractures (FISS score $ 6) compared

with low-risk users.

Most of the patients in this study reported driving a

motorcycle with a horsepower greater than 50 cm3

(90.8%), which is in accordance with the work of

Hidalgo-Fuentes and Sospedra-Baeza (2019),17 in

which the mortality rate of motorcycle drivers who

had an accident while driving at excessive speed was much higher than in those involved in a traffic acci-

dent at a low speed. Thus, it was expected that pa-

tients who were driving more powerful motorcycles

would have more severe facial injuries compared

with patients who were not. However, this was not

confirmed in our study, maybe because the sample

was not large enough to make such comparisons.

Regarding helmet use, 63.5% of patients stated that

they were wearing one at the time of the trauma, a

percentage lower than that of Kuo et al24 (2017),

who reported a frequency of 86.3%. This value should be close to 100% when taking into account mandatory

helmet use since the current Brazilian Traffic Code

came into force in 1997.9

Regarding the types of helmets used in this study,

the type with the highest frequency was the closed

type, worn in approximately 31.9% of patients; this

is a piece of equipment that is expected to offer

adequate face protection. In addition, among the 63.5% of patients who reported wearing a helmet,

31.6% were using an open helmet, which is not

expected to provide adequate protection in case of

facial trauma. Thus, it can be considered that

68.1% of the total patient group was not using

adequate protection for the bones of the face at

the time of the motorcycle accident. However, con-

trary to our expectations and the literature con- sulted,15 we did not find any significant differences

when comparing facial severity with types

of helmets.

PORTO ET AL 797.e7

However, similar percentages of facial trauma with

higher scores on the FISS (characterizing more severe

injuries) were found, both in individuals who used

open helmets and in those who did not wear a helmet

at all. Thus, even though no significant differences

were found between type of helmet and trauma

severity, there was a tendency for finding more

complex trauma in patients wearing an open helmet or wearing no helmet at all. These data are in agree-

ment with the systematic review developed by Liu

et al25 (2008), in which the evidence indicated that

the use of closed helmet affords greater protection

against head injuries when compared with the

absence of helmet use, but no evidence was found

to support the claim that the use of an open helmet of-

fers less protection against facial injuries than the use of a closed one. The authors concluded that, at pre-

sent, no conclusive evidence exists on the effect of

motorcycle helmets on neck or facial injuries.25 To

substantiate this supposition, a greater sample size

should be included in a multicenter study, considering

other variables such as correct size of the helmet and

whether it was attached to the neck, as well as impact

energy and direction of the accident. According to the BrazilianMinistry of Health and the

National Mortality Information System,26 in 2016,

traffic accidents in Brazil caused 180,443 hospitaliza-

tions, generating a total cost of US $65.7 million. In

our study, most motorcyclists (36.9%) were in the hos-

pital for more than 10 days, which generates direct and

indirect hospital costs (treatment sequelae, social

security, and interruption of production, among others). Moreover, a statistically significant relation-

ship was observed between drivers who had an inpa-

tient period of more than 10 days and a lesion

severity degree as high as 6 or above. This result may

be directly related to the fact that patients with more

severe lesions may need care for edema regression,

and stabilization of vital signs, as well as other evalua-

tions by other specialists, so that the ideal treatment is attained, which requires more days of hospitalization.

Moreover, the FISS score, as proposed by Bagheri

et al10 (2006), was an indicator of the duration of hos-

pital stay of patients with facial trauma.27 This variable

is worth studying to see whether there are any signifi-

cant differences in the expenses incurred by patients

with more complex fractures.

These results, confirmed by the bivariate and multi- variate logistic regression findings, indicate that the

chances of a patient presenting with a lesion with an

elevated FISS score (ie, lesions of greater severity)

increase if the patient is aged between 30 and 39 years,

presents at-risk or harmful alcohol use according to

the AUDIT, and is hospitalized for more than 10 days.

The results are, therefore, in agreement with the liter-

ature that indicates alcohol use as an inducer of

euphoria and self-confidence, generating driver inat-

tention and favoring the abuse of speed

limits.22 These factors, in association with inadequate

protection, may be paramount in determining the frac-

tures incurred. Our data are even more relevant in that

there are no studies in the literature comparing the

severity of facial trauma, alcohol abuse, and use and

type of helmet at the time of the motorcycle accident. The individuals most affected by facial trauma in this

study were young patients (18 to 29 years) and partic-

ularly male patients. Patients aged 30 to 39 years with

high-risk use and dependence on alcohol were more

likely to have more complex facial trauma. In addition,

these patients tended to stay hospitalized for more

than 10 days. The type of helmet used was not effec-

tive in reducing the severity of facial fractures.

References

1. Maduakonam DE, Miriam DU, Arthur N: Retrospections on road traffic injuries as a social burden: The role of public health edu- cation initiatives in a developing country. Niger J Med 24:169, 2015

2. Jack JM, Stewart DH, Rinker BD, et al: Modern surgical treatment of complex facial fractures: A 6-year review. J Craniofac Surg 16: 726, 2005

3. Wulkan M, Parreira Junior JG, Botter DA: Epidemiology of facial trauma. Rev Assoc Med Bras 51:290, 2005

4. World Health Organization. Helmets: A Road Safety Manual for Decision-Makers and Practitioners. Geneva, Switzerland, World Health Organization, 2006

5. Rao SG, Paramesh RC, Bansal A, et al: A prospective computed tomography study of maxillofacial injuries in patients with head injury [published online ahead of print March 12, 2019]. Eur J Trauma Emerg Surg. https://doi.org/10.1007/s00068-019- 01099-0

6. Al-Abdallat IM, Al Ali R, Hudaib AA, et al: The prevalence of alcohol and psychotropic drugs in fatalities of road-traffic acci- dents in Jordan during 2008-2014. J Forensic Leg Med 39:130, 2016

7. Vlahogianni EI, Yannis G, Golias JC: Overview of critical risk fac- tors in power-two-wheeler safety. Accid Anal Prev 49:12, 2012

8. Dos Anjos KC, de Rezende MR, Mattar R: Social and hospital costs of patients admitted to a university hospital in Brazil due to motorcycle crashes. Traffic Inj Prev 8:585, 2017

9. Departamento Nacional de Trânsito (DENATRAN). Lei no 12.760/ 12, de 21 deDezembro de 2012. Brası́lia, Brasil, C�odigo de Trânsito Brasileiro, 1997. Available at: http://www.planalto.gov.br/ccivil_ 03/_Ato2011-2014/2012/Lei/L12760.htm. Accessed August 13, 2019

10. Bagheri SC, Dierks EJ, Kademani D, et al: Application of a facial injury severity scale in craniomaxillofacial trauma. J Oral Maxil- lofac Surg 64:408, 2006

11. Babor TF, Higgins-Biddle JC: Brief intervention for hazardous and harmful drinking. A manual for use in primary care. Geneva, Switzerland, Department of Mental Health and Substance Dependence, World Health Organization, 2001

12. World Health Organization: Global status report on road safety 2015. Available at: http://www.who.int/violence_injury_ prevention/road_safety_status/2015/GSRRS2015_Summary_EN_ final2.pdf?ua=1. Accessed August 13, 2019

13. WaseemM, Ahmed A, Saeed TU: Factors affecting motorcyclists’ injury severities: An empirical assessment using random param- eters logit model with heterogeneity inmeans and variances. Ac- cid Anal Prev 123:12, 2019

14. Al-Khateeb T, Abdullah FM: Craniomaxillofacial injuries in the United Arab Emirates: A retrospective study. J Oral Maxillofac Surg 65:1094, 2007

797.e8 FACIAL TRAUMA SEVERITY IN MOTORCYCLISTS

15. Lopes Albuquerque CE, Nogueira Arcanjo FP, Cristino-Filho G, et al: How safe is your motorcycle helmet? J Oral Maxillofac Surg 72:542, 2014

16. Zhou HH, Liu Q, Yang RT, et al: Maxillofacial fractures in women and men: A 10-year retrospective study. J Oral Maxillofac Surg 73:2181, 2015

17. Hidalgo-Fuentes S, Sospedra-Baeza MJ: Gender and age distribu- tion of motorcycle crashes in Spain. Int J Inj Contr Saf Promot 26:108, 2019

18. Yu WY, Chen CY, Chiu WT, Lin MR: Effectiveness of different types of motorcycle helmets and effects of their improper use on head injuries. Int J Epidemiol 40:794, 2011

19. Veronese AM, de Oliveira DLLC: Traffic accidents from the motorcycle couriers’ perspective: Feedback for health promo- tion. Cad Saude Publica 22:2717, 2006

20. Chandra Shekar BR, Reddy CVK: A five-year retrospective sta- tistical analysis of maxillofacial injuries in patients admitted and treated at two hospitals of Mysore city. Indian J Dent Res 19:304, 2008

21. Roccia F, Sotong J, Savoini M, et al: Maxillofacial injuries due to traffic accidents. J Craniofac Surg 30:e288, 2019

22. Soares-Carneiro SC, Vasconcelos BC, Matos da-Silva GS, et al: Alcohol abusive use increases facial trauma? Med Oral Patol Oral Cir Bucal 21:547, 2016

23. Jayaraj R, Whitty M, Thomas M, et al: Prevention of Alcohol- Related Crime and Trauma (PACT): Brief interventions in routine care pathway—Astudyprotocol. BMCPublicHealth 13:49, 2013

24. Kuo SCH, Kuo PJ, Rau CS, et al: The protective effect of helmet use in motorcycle and bicycle accidents: A propensity score–matched study based on a trauma registry system. BMC Public Health 17:639, 2017

25. Liu BC, Ivers R, Norton R, et al: Helmets for preventing injury in motorcycle riders. Cochrane Database of Syst Rev CD004333, 2008

26. da Sa�ude Minist�erio: Departamento de Inform�atica do Sistema �Unico de Sa�ude–DATASUS. Sistema Nacional de Informaç~ao so- bre Mortalidade. Available at: http://www.2datasus.gov.br/ DATASUS/index.php?area=060701. Accessed August 13, 2019

27. Aita TG, Pereira Stabile CL, Dezan Garbelini CC, Vitti Stabile GA: Can a facial injury severity scale be used to predict the need for surgical intervention and time of hospitalization? J Oral Maxillo- fac Surg 76:1280, 2018