Patterns and associated factors of traumatic dental injuries in children: a five-year retrospective study from a national paediatric referral centre in Thailand

Abstract

Background

Traumatic dental injuries (TDIs) are a frequent cause of dental emergencies in children and may lead to long-term functional and developmental consequences. Evidence from Southeast Asia remains limited, and no study has examined TDI patterns in a national paediatric referral centre in Thailand. This study aimed to describe the patterns and associated factors of TDIs in children treated over a five-year period.

Methods

A retrospective hospital-based study reviewed dental records of children aged 0–15 years who presented with TDIs at the Queen Sirikit National Institute of Child Health, Bangkok, between January 2020 and December 2024. Data collected included demographics, medical conditions, aetiology and injury location, time to consultation, dentition involved, injured teeth, injury type, and emergency management. Injuries were classified according to Andreasen’s criteria. Categorical variables were analysed using chi-square or Fisher’s exact tests, and odds ratios were calculated. Statistical significance was set at p < 0.05.

Results

Among 60,008 paediatric dental visits, 287 children sustained TDIs involving 436 injured teeth. The mean age was 5.33 ± 3.76 years, and 66.9% were boys. About one-fifth had underlying medical or developmental conditions. Falls were the leading cause of injury (76.5%), occurring most often in children aged 0–6 years. Most injuries occurred at home (53.2%). Primary teeth accounted for 59.2% of injured teeth, and maxillary central incisors were most frequently affected. Fracture injuries predominated overall (57.6%), whereas luxation injuries were significantly more common in primary teeth than in permanent teeth (χ² = 9.37, p = 0.002). Luxation injuries were more frequent in children aged 0–6 years than in those aged 7–15 years (OR 1.95, 95% CI 1.31–2.91). Delayed presentation (> 24 h) occurred in 66% of cases.

Conclusion

This five-year study provides updated epidemiological evidence on TDIs among Thai children at a national paediatric referral centre. Falls, younger age, and primary dentition were associated with a higher proportion of luxation injuries, and delayed care-seeking was common. Strengthening prevention, caregiver awareness, and pathways for timely emergency dental care—particularly for preschool-aged children and those with underlying medical conditions—may help reduce the burden of paediatric TDIs in similar hospital-based settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-026-06853-z.

Introduction

Traumatic dental injuries (TDIs) are increasingly recognised as an important global public health concern in children. Beyond the immediate pain and functional impairment, TDIs may result in long-term complications such as pulp necrosis, infection, tooth loss, and developmental disturbances in the permanent dentition. These consequences often require complex and costly treatment and may negatively affect a child’s quality of life and psychosocial well-being. More than one billion individuals worldwide are estimated to have experienced a TDI, highlighting the substantial burden of this condition [1].

The occurrence, causes, and severity of TDIs vary across countries and age groups, influenced by environmental, cultural, and behavioural factors. Falls are the most common cause among preschool children, while sports-related and traffic-related injuries become more frequent in older age groups [2–4]. Many studies report a higher frequency of TDIs in boys, often attributed to greater physical activity and risk-taking behaviours, although some research shows no significant sex differences when exposure levels are comparable [5–7]. Children with neurological or developmental conditions, such as epilepsy, cerebral palsy, or autism spectrum disorder, have been reported to be more frequently affected by TDIs, potentially due to impaired motor coordination, seizure activity, or self-injurious behaviour [8, 9]. Another challenge frequently reported is delayed presentation after trauma, which is commonly associated with limited parental awareness and barriers to accessing timely dental care, particularly in low- and middle-income settings [10].

Despite increasing international attention, epidemiologic data from Southeast Asia remain limited. Existing Thai studies have mainly been conducted in community or school settings [11, 12], and only one hospital-based report from a university dental hospital has been published [13]. However, there is no available study focusing on a national tertiary paediatric referral centre, where more complex and severe trauma cases are typically managed. The lack of such information limits the understanding of true injury patterns in Thai children and reduces opportunities for comparison with other countries that have similar healthcare systems or demographic characteristics.

This study aimed to describe the patterns and factors associated with TDIs among children aged 0–15 years treated at Thailand’s national tertiary paediatric hospital over a five-year period. The findings provide updated hospital-based evidence to support clinical practice, strengthen prevention strategies, and guide recommendations for caregivers, educators, and healthcare providers regarding timely management of dental trauma.

Methods

Study design and setting

This retrospective hospital-based study reviewed dental records of paediatric patients aged 0–15 years who presented with traumatic dental injuries (TDIs) at the Dental Department of the Queen Sirikit National Institute of Child Health (QSNICH), Bangkok, Thailand, between January 2020 and December 2024. QSNICH is a tertiary-level paediatric teaching hospital and the national referral centre for children across Thailand.

Eligibility criteria

Inclusion criteria were all patients aged up to 15 years with a documented diagnosis of TDI during the study period. Exclusion criteria were incomplete records on core variables (age, gender, or injury type), duplicate entries, or cases in which the trauma diagnosis could not be verified.

Data collection and definitions

Clinical data extracted from patient records included gender, age, underlying medical conditions, date of injury, cause and location of the accident, time elapsed from injury to consultation, type of dentition involved, number and identity of affected teeth, type of injury, and emergency management. Dental injuries were classified according to Andreasen’s criteria as recommended by the International Association of Dental Traumatology [14–16].

For comparative analyses, age was recorded using two groupings according to analytical purpose. The 0–6 vs. 7–15 years grouping was applied in the main epidemiological analyses to distinguish early childhood from school-aged children, whereas the 4–6 vs. 7–12 years grouping was used in selected analyses aligned with dentition stage and school attendance. Injury type was categorised into two groups (luxation vs. non-luxation) for odds ratio analyses. Tooth type was classified as primary or permanent. Cases with missing or unknown values were excluded pairwise in the relevant analyses.

For analytical purposes, child-level data were used for demographic characteristics, aetiology, injury location, and timing of presentation, whereas tooth-level data were used descriptively to characterise injury types and tooth distribution.

Statistical analysis

Statistical analyses were performed using IBM SPSS Statistics for Windows, Version 29.0 (IBM Corp., Armonk, NY, USA). Microsoft Excel (Microsoft Corp., Redmond, WA, USA) was used for data cleaning, descriptive summaries, and percentage calculations.

Descriptive statistics, including means, standard deviations, medians, ranges, and proportions, were used to summarise patient and injury characteristics. Categorical variables (such as injury type by dentition or age group) were compared using chi-square tests. Fisher’s exact test was applied when expected cell counts were less than five.

For selected binary outcomes, such as luxation versus non-luxation injuries across different age groups or tooth types, odds ratios (ORs) with 95% confidence intervals were calculated using 2 × 2 contingency tables. These ORs were derived from univariate analyses and are presented as unadjusted estimates. Injury type was also grouped into two categories (luxation vs. non-luxation) to facilitate OR analysis. Statistical significance was set at p < 0.05 for all comparisons. Analyses were conducted using complete-case analysis, whereby cases with missing data were excluded from the relevant analyses.

Results

Demographic characteristics and case distribution

Between January 2020 and December 2024, a total of 60,008 paediatric dental visits were recorded at the Queen Sirikit National Institute of Child Health. Of these, 21,225 visits (35.4%) involved children with an underlying medical condition. During the same period, 287 children aged 10 months to 14 years 10 months presented with traumatic dental injuries (TDIs), involving 436 traumatised teeth. The cohort included 192 boys (66.9%) and 95 girls (33.1%), with a mean age of 5.33 ± 3.76 years (median 5). Boys predominated across nearly all age groups (Fig. 1). The highest frequency occurred among children aged 0–3 years, followed by those aged 7–12 years. No significant sex difference in TDI distribution was observed (χ² = 2.13, p = 0.345).

Fig. 1.

Distribution of traumatic dental injury cases by age group and sex. The bar chart shows the number of traumatic dental injury (TDI) cases across age groups among children aged 0–15 years. Boys accounted for a higher number of cases than girls in most age groups. The highest number of TDIs was observed in the 0–3-year age group, with a decreasing trend in frequency as age increased

Annual TDI case numbers showed modest variation over the study period, with the highest number observed in 2023. Most affected children were medically healthy, while 60 (20.9%) had an underlying systemic condition, classified according to the primary diagnosis, most commonly neurological or developmental conditions (Table 1).

Table 1.

Annual number of TDI cases and medical conditions (2020–2024)

Year	TDI cases	Medically healthy	With systemic conditions	Cardio/ /Metabolic/ Hematologic	Neurological/ Developmental/ Behavioral	Respiratory/Allergy
2020	55	42	13	4	5	4
2021	56	43	13	3	6	4
2022	46	37	9	3	3	3
2023	78	66	12	3	5	4
2024	52	39	13	5	8	0
Total	287	227 (79.1%)	60 (20.9%)	18 (6.3%)	27 (9.4%)	15 (5.2%)

Although some children had multiple medical conditions, only the primary systemic diagnosis was used for categorisation in this analysis. Percentages are calculated based on the total number of children with traumatic dental injuries over the five-year study period (n = 287)

Aetiology, location, and timing of injury

Table 2 presents the distribution of causes of traumatic dental injuries among cases with available aetiological data (n = 230). Falls were the leading cause of injury. Aetiology differed significantly by age group (χ² = 18.79, p < 0.001). Falls predominated in children aged 0–6 years, whereas children aged ≥ 7 years presented with more diverse causes including sports- and vehicle-related trauma. No significant association was observed between aetiology and sex (χ² = 4.93, p = 0.085).

Table 2.

Distribution of causes of traumatic dental injuries by age group and sex (n = 230)

Cause of accident	Total (n, %)	Age 0–6 (n, %)	Age ≥ 7 (n, %)	Boys (n, %)	Girls (n, %)
Fall	176 (76.5)	122 (84.1)	54 (63.5)	117 (76.5)	59 (76.6)
Collision with person/object	25 (10.9)	13 (9.0)	12 (14.1)	14 (9.2)	11 (14.3)
Vehicle-related	17 (7.4)	7 (4.8)	10 (11.8)	13 (8.5)	4 (5.2)
Sports-related	6 (2.6)	1 (0.7)	5 (5.9)	5 (3.3)	1 (1.3)
Medical condition/ seizure-related	1 (0.4)	0 (0.0)	1 (1.2)	0 (0.0)	1 (1.3)
Other causes	5 (2.2)	2 (1.4)	3 (3.5)	4 (2.6)	1 (1.3)
Total	230 (100)	145 (100)	85 (100)	153 (100)	77 (100)

Percentages are calculated within each column. Data on injury aetiology were available for 230 children; cases with missing or undocumented causes of injury (n = 57) were excluded. Other causes included play-related (n = 3), object-related (n = 1), and biting/self-injury (n = 1)

Among cases with recorded accident locations, most injuries occurred at home (53.2%), followed by outdoor or road areas (26.6%) and schools (20.2%). Location of injury differed significantly by age (χ² = 31.31, p < 0.001), with younger children more frequently injured at home and older children more often injured at school or outdoors. No seasonal or sex-related differences were detected.

The interval between injury and dental consultation was recorded in 226 cases (78.7%). Most children (66%) presented more than 24 h after the injury, whereas 32.7% sought care within 24 h. Only a small proportion (1.3%) received dental attention within the first 60 min. Delayed presentation did not differ significantly between younger and older children, though younger children tended to delay more (OR 1.60, 95% CI 0.91–2.84).

Distribution of affected dentition and teeth

Traumatic injuries involved primary dentition in 55.7% of children, mixed dentition in 40.8%, and permanent dentition in 3.5%. Most children (55.4%) had a single injured tooth, while 38.7% had two teeth involved and 6% had three or more. Of the 436 injured teeth, 258 (59.2%) were primary and 178 (40.8%) were permanent. Maxillary central incisors were the most frequently affected in both dentitions, followed by lateral incisors, whereas posterior teeth injuries were rare (Table 3).

Table 3.

Distribution of affected teeth by dentition and tooth type (n = 436)

Tooth type	Primary dentition (n, %)	Permanent dentition (n, %)	Total (n, %)
Maxillary central incisor	212 (82.2)	143 (80.3)	355 (81.4)
Maxillary lateral incisor	25 (9.7)	21 (11.8)	46 (10.6)
Mandibular incisor	19 (7.4)	10 (5.6)	29 (6.6)
Canine	1 (0.4)	2 (1.1)	3 (0.7)
Molar	1 (0.4)	2 (1.1)	3 (0.7)
Total	258 (100)	178 (100)	436 (100)

Percentages are calculated based on the total number of injured teeth within each dentition

Injury types by dentition

Fracture injuries were the most common overall (57.6%), followed by luxation injuries (36.0%) and combined fracture–luxation injuries (6.4%). The distribution of injury categories differed significantly by dentition, with primary teeth showing a higher proportion of luxation injuries and permanent teeth showing a predominance of fracture injuries (χ² = 9.37, p = 0.002) (Table 4). Detailed distributions of fracture and luxation injury subtypes are provided in Supplementary Table S1.

Table 4.

Distribution of fracture and luxation injuries by dentition

Type of injury	Primary teeth n (%)	Permanent teeth n (%)	Total n (%)
Fracture injuries	150 (54.9)	129 (45.1)	251 (57.6)
Luxation injuries	125 (67.2)	60 (32.3)	157 (36.0)
Combined fracture–luxation injuries	15 (62.5)	9 (37.5)	24 (6.4)
Total	258 (59.2)	178 (40.8)	436 (100)

Percentages are calculated within each injury category. Combined fracture–luxation injuries were analysed separately. The distribution of injury categories differed significantly by dentition (χ² = 9.37, p = 0.002)

Age-related differences in injury pattern were evident. Children aged 0–6 years had significantly higher odds of sustaining luxation injuries compared with those aged 7–15 years (OR 1.95, 95% CI 1.31–2.91).

Management of traumatic dental injuries

Management procedures varied according to injury type and severity. Restorative treatment was the most common intervention (26.0%), followed by observation or advice (24.8%), extraction (21.6%), and pulp therapy (14.0%). Reimplantation or repositioning with stabilisation was performed in selected cases of luxation or avulsion (Table 5).

Table 5.

Management of traumatic dental injuries (n = 436 teeth)

Management category	n	%
Restoration only	113	26.0
Observation/advice ± medication	108	24.8
Extraction ± medication	94	21.6
Pulp therapy ± restoration	61	14.0
Reimplantation/Repositioning ± Stabilization	35	8.0
Soft-tissue management only	12	2.8
Referral/planned care	13	3.0
Total	436	100

Discussion

This five-year retrospective study provides updated evidence on the patterns and associated factors of traumatic dental injuries among Thai children treated at a national paediatric referral centre. The findings contribute to the limited literature from Southeast Asia and highlight age-related differences in injury patterns, dentition involvement, aetiology, and care-seeking behaviour.

The male predominance observed in this cohort aligns with most international reports, which often attribute higher rates of injury among boys to increased physical activity and greater participation in vigorous play [2, 10, 17–19]. However, some studies have reported minimal sex differences when exposure risks are similar, suggesting that behavioural and environmental factors may have stronger influence than biological sex alone [6, 20]. Age was also a significant determinant of injury characteristics, with peaks in preschool and early school-aged children, consistent with previous hospital-based studies [5, 11, 13]. This distribution likely reflects both developmental vulnerability and referral behaviour. It is possible that parents are more likely to seek care for younger children with visible injuries, whereas older children may present to general hospitals or private clinics, which could result in fewer adolescent cases being captured in this tertiary referral setting.

Falls were the most common cause of injury, particularly among preschool children. This pattern is consistent with reports from various regions and reflects developmental motor immaturity and environmental hazards within the home [3, 19, 21–24]. Thai data also show similar trends, with maxillary central incisors being the most frequently affected teeth [12]. In contrast, sports-related injuries were uncommon and bicycle-related events were rarely documented in this cohort, despite being more frequent in older children and in regions where bicycles are widely used for daily transport [6].

Age-related variation was also observed in injury locations. Younger children were primarily injured at home, whereas older children were more frequently injured during sports or road activities, consistent with previous studies [3, 4, 24]. These patterns reinforce the importance of age-specific prevention. For younger children, preventive strategies should emphasise safer home environments, attention to floor surfaces, removal of sharp furniture edges, and close parental supervision [11]. For older children, preventive efforts should focus on sports safety, including proper mouthguard use, adherence to rules, and adequate supervision [4, 14].

A seasonal pattern was observed, with slightly increased TDI occurrences during the rainy season (July-September). It is possible that indoor confinement and slippery surfaces during this period may increase fall risk among young children. This contrasts with countries with temperate climates, where TDI incidence often rises during warmer months due to outdoor recreational activities [2, 25, 26]. Environmental conditions during the study period may also have influenced trauma patterns. For example, periodic peaks in air pollution, particularly PM2.5, may have led to public health recommendations to limit outdoor activity and school sports, which could partially explain the relatively low number of sports-related injuries and the high proportion of indoor falls [27].

The study period also overlapped with the coronavirus disease 2019 pandemic. It is possible that lockdowns and school closures reduced outdoor activity and limited access to dental services. The relatively stable or lower counts of TDIs during 2020 to 2022 may reflect reduced exposure to high-risk environments and barriers to timely care. Caregivers may also have delayed or avoided treatment for mild injuries, consistent with previous reports describing increased indoor injuries and delayed presentations during lockdowns [28, 29].

The rise in cases in 2023 following the relaxation of restrictions may represent a return to pre-pandemic activity patterns and improved access to dental services. These interpretations should be considered as possible explanations rather than confirmed associations, as no direct analyses were performed to specifically assess the impact of the COVID-19 pandemic on injury occurrence or care-seeking behaviour.

Injury types differed markedly by dentition. Subluxation injuries were the most common in the primary dentition, whereas uncomplicated crown fractures were more frequent in permanent teeth, consistent with previous studies [19, 30]. These patterns can be explained by developmental differences. Younger children have more resilient and elastic alveolar bone and incomplete root development, making primary teeth more prone to displacement rather than fracture [31]. The higher susceptibility to luxation injuries observed in younger children further supports this biomechanical explanation. In addition, the relatively high proportion of complicated crown fractures observed in primary teeth in the present study may be influenced by referral patterns and case severity in a national tertiary-care paediatric referral centre, where more severe injuries are more commonly referred for specialised care.

As permanent incisors erupt and root length increases, older children become more susceptible to crown fractures, a trend widely reported in the literature. However, some studies have reported lateral luxation as the most common injury type in the primary dentition [3, 32]. The high frequency of maxillary central incisor involvement reflects their anterior position and limited soft-tissue protection.

Delayed presentation was common, with two-thirds of children seeking care more than 24 h after injury. This delay was longer than in high-income settings such as Australia, where most children receive care within 12 h [3], but comparable to other hospital-based studies in which more than half of patients presented late [10, 30, 33]. Limited parental awareness, transportation barriers, and underestimation of primary tooth injuries may contribute to delayed care-seeking [10, 22]. Parents often seek care only when symptoms such as swelling, discolouration, or pain develop. Delayed management may lead to pulpal necrosis or poorer outcomes, particularly in injuries requiring timely intervention [20, 30].

Approximately one-fifth of patients had medical or developmental conditions, consistent with previous reports describing a higher burden of TDI among children with special health care needs [9, 34]. Neurological disorders, including seizure disorders or developmental delays, may increase vulnerability to accidental injuries through impaired motor coordination, sudden movements, or self-injurious behaviour [8]. Although previous Thai studies have not specifically evaluated this subgroup, the present findings highlight the importance of recognising medically compromised children as a distinct population in both prevention and management strategies. Preventive efforts for this group should place particular emphasis on caregiver education, home safety modifications, and early dental assessment. Such educational initiatives should also incorporate structured first-aid training for caregivers, alongside emergency department–based training to enhance healthcare providers’ preparedness for the early management of dental trauma in medically compromised children. From a management perspective, effective care may require close collaboration among dental practitioners, paediatricians, neurologists, and caregivers to address underlying medical conditions, optimise safety measures, and facilitate timely and appropriate dental trauma management.

Anatomical characteristics such as increased overjet and inadequate lip coverage have been consistently associated with anterior trauma [35, 36]. Emerging evidence also suggests that anthropometric and behavioural characteristics may increase susceptibility. Overweight or taller children may have poorer balance and may fall with greater force, which could contribute to a higher occurrence of TDIs [37]. Studies have reported a higher prevalence of TDIs among obese preschoolers compared with their normal-weight peers [38]. Although these variables were not assessed in this study, future research should investigate how growth patterns, motor development, and craniofacial characteristics interact with injury patterns in children.

Our study found from the dental records that the most common management approach for traumatic dental injuries was conservative, with most children receiving simple restorations or observation when pulpal health was not compromised. This approach is consistent with recommendations for primary teeth, where conservative care is preferred to avoid disturbing the developing permanent tooth germ and because young children often have limited cooperation after trauma [39, 40]. These factors likely contributed to the high use of observation and minimal intervention even among referred cases.

Limitations

This study has several limitations. First, as traumatic dental injuries were diagnosed by multiple clinicians in a routine clinical setting, formal calibration or inter-examiner reliability assessment was not performed, which may have introduced some diagnostic variability. However, data extraction from dental records was performed by a single investigator to ensure consistency in data collection. Second, as a retrospective hospital-based study conducted at a national tertiary-care paediatric referral centre, the findings are subject to selection and referral bias and may not be generalisable to the broader paediatric population. This referral context likely contributed to the predominance of younger children, a higher proportion of more severe injuries, and delayed presentation, as less severe cases and older children may have been managed in primary or secondary care settings. Third, the reported associations are based on univariate analyses and represent unadjusted estimates; therefore, they may be subject to confounding. The analyses were limited to univariate methods because the sample size and missing data limited the feasibility of robust multivariable modelling to adjust for potential confounding. Future studies with larger sample sizes and more complete data may allow the application of multivariable models. In addition, although both child-level and tooth-level data were analysed, multiple injured teeth within individual children were treated as independent observations, as the study was not designed for clustering-adjusted analyses. Missing or incomplete documentation in routine clinical records also resulted in the exclusion of some cases from specific analyses. In addition, treatment outcomes and long-term clinical sequelae were not evaluated, as this retrospective study was limited to injury characteristics and initial management recorded in dental records.

At the system level, the absence of a national trauma recording form remains a limitation in Thailand. Variability in documentation across institutions leads to fragmented and non-comparable data, hindering effective surveillance and cross-centre collaboration [41]. Establishing a standardised trauma registry would improve data quality and support coordinated national monitoring. In addition, dental trauma is not widely recognised as a public health priority. Many caregivers lack awareness of appropriate first aid and the urgency of seeking care after a dental injury. Educational initiatives directed at parents, schools, and primary care providers are essential for promoting early recognition and appropriate response. A strengthened data system, combined with improved public education, would likely enhance early intervention and long-term outcomes.

Conclusion

This five-year hospital-based study provides epidemiologic evidence on traumatic dental injuries among Thai children. Luxation injuries predominated in younger age groups, whereas fractures were more common in the permanent dentition, reflecting clear developmental and biomechanical differences. Falls remained the principal cause of injury, and delayed care seeking was common. These findings highlight age-related and environmental factors associated with injury patterns that may inform targeted prevention strategies and caregiver education. Strengthening early recognition and timely management of traumatic dental injuries, particularly for preschool-aged children and those with underlying medical conditions, remains important. Public health measures that enhance parental awareness, improve first aid responses in schools, and facilitate timely access to emergency dental care may help reduce the burden and long-term impact of dental trauma, while recognising the hospital-based context of these data.

Abbreviations

TDI

Traumatic Dental Injury

QSNICH

Queen Sirikit National Institute of Child Health

Authors’ contributions

PB, PL, and PT conceived the study. PB collected and analysed the data, and drafted the manuscript. PL and PT contributed to critical revision. All authors contributed to the study and manuscript preparation and approved the final version.

Funding

Not applicable.

Data availability

The datasets used and/or analysed during the current study are not publicly available due to ethical and privacy restrictions but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Institutional Review Board of the Queen Sirikit National Institute of Child Health (Approval No. REC.025/2568). The study was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent to participate was obtained from the parents or legal guardians of all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.