Sir, whilst there has been a significant decrease in attendance to Emergency Departments during the COVID-19 pandemic,1 the Paediatric Emergency Department (PED) at Alder Hey Children's Hospital has observed little change in the number of dental attendances. We compared the characteristics of attendances in March, April 2020 to the same months in 2019 with three key findings to consider in the months ahead, as we resume dental services.

Firstly, the number of children attending the PED with traumatic dental injuries (TDIs) increased in the COVID-19 affected period. This may be due to decreased availability of primary care dental services in the region. Additionally, with more children undertaking exercise and activities at home with school closures, more accidental injuries may occur. It is also important to consider the possibility of TDIs related to non-accidental injury during lockdown, with children living in violent or dysfunctional families having limited access to safe spaces, friends, teachers and support outside the home in this period, leading to an increase in domestic violence and abuse.2 On presentation, it is important to take a thorough history and examination, identifying any discrepancies which may raise suspicion.3,4The BSPD have published excellent guidelines to aid us with the management and follow up of TDIs during the COVID-19 pandemic.5

Secondly, we found that the number of admitted patients decreased, suggesting that conditions of lower severity were presenting to the PED. This may also be attributable to a lack of alternatively available dental services.

Finally, as a result of the pandemic, thousands of children nationally have experienced cancellation of dental general anaesthetics (GA), with cases being prioritised as per national guidelines.6 Subsequently, thousands of children have been left in pain, taking regular analgesics and sometimes requiring multiple courses of antibiotics. Indeed, the number of children receiving repeat courses of antibiotics from the PED increased in the COVID affected period.

With GDPs reopening and reaching a 'new normal', the emergency management of TDIs and children in pain should be considered a priority in paediatric primary care triage to reduce the subsequent burden on tertiary services, which carries increased expense to the NHS.