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Did the March 2020 lockdown cause an increase in patients presenting to the emergency department with odontogenic pain and infection? A single centre, retrospective analysis

  • Author Footnotes
    1 Joint first authors.
    Emily Gray
    Correspondence
    Corresponding author at: Oral and Maxillofacial Department, Bristol Dental Hospital, Lower Maudlin Street, BS1 2LY, United Kingdom.
    Footnotes
    1 Joint first authors.
    Affiliations
    Bristol Dental Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Lower Maudlin Street, Bristol BS1 2LY, United Kingdom
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  • Author Footnotes
    1 Joint first authors.
    Constance Hardwick
    Footnotes
    1 Joint first authors.
    Affiliations
    Bristol Dental Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Lower Maudlin Street, Bristol BS1 2LY, United Kingdom

    Bristol Dental School, University of Bristol, Lower Maudlin Street, Bristol BS1 2LY, United Kingdom
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  • Nicola Gradwell
    Affiliations
    Bristol Dental Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Lower Maudlin Street, Bristol BS1 2LY, United Kingdom
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  • Annie Pellatt
    Affiliations
    Bristol Dental Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Lower Maudlin Street, Bristol BS1 2LY, United Kingdom
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  • Naomi Cassells
    Affiliations
    Dept. of Anaesthesia, University Hospitals Bristol and Weston NHS Foundation Trust, Lower Maudlin Street, Bristol BS1 2LY, United Kingdom
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  • Rachael Craven
    Affiliations
    Dept. of Anaesthesia, University Hospitals Bristol and Weston NHS Foundation Trust, Lower Maudlin Street, Bristol BS1 2LY, United Kingdom
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  • Author Footnotes
    2 Joint last authors.
    Jacqueline Cox
    Footnotes
    2 Joint last authors.
    Affiliations
    Bristol Dental Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Lower Maudlin Street, Bristol BS1 2LY, United Kingdom
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  • Author Footnotes
    2 Joint last authors.
    Tom Dudding
    Footnotes
    2 Joint last authors.
    Affiliations
    Bristol Dental Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Lower Maudlin Street, Bristol BS1 2LY, United Kingdom

    Bristol Dental School, University of Bristol, Lower Maudlin Street, Bristol BS1 2LY, United Kingdom

    MRC Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, United Kingdom
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      Abstract

      On the 25 March 2020 the Chief Dental Officer (CDO) published guidance to restrict the provision of routine dental care in England due to the rapid spread of the severe acute respiratory syndrome Coronavirus 2 (COVID-19). We analysed the impact of the pandemic on the number of patients presenting with odontogenic pain and infection to the emergency department (ED) of an urban-based teaching hospital, the Bristol Royal Infirmary (BRI). Furthermore, we investigated the severity of infection at first presentation to the ED. The study period encompassed three phases that represented the stages of pandemic restrictions: phase 1 prior to lockdown measures, with no restrictions to dental practice; phase 2 during the government lockdown, with the severest restrictions on dental practices; and phase 3 following the ease of lockdown measures, with return to limited dental services. Data were collected retrospectively from electronic patient records (EPR) regarding adult patients presenting to the ED with dental pain. The rate of presentations (per week) was calculated for each timepoint and compared. A severity score was assigned to each patient using a grading system based on signs of clinical infection and treatment modality. Patients' presentations were analysed at each phase of the pandemic. There was a 42.8% increase in attendance with oral facial pain and infection to ED from phases 1 to 3. The COVID-19 pandemic resulted in restrictions to routine primary dental care services, which were deemed necessary to reduce the spread of the virus. However, this increased demand on secondary care services, as patients increasingly struggled to access primary dental care to manage dental pain.

      Keywords

      Introduction

      COVID-19 created significant challenges for the National Health Service (NHS) and introduced significant limitations to dental services in both primary and secondary care. The World Health Organization declared COVID-19 a global pandemic on 11 March 2020.

      World Health Organisation. Director-General's opening remarks at the media briefing on COVID-19 11 March 2020; 2020. Available from URL: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020 [last accessed: 22/04/22].

      A nation-wide lockdown was enforced in the United Kingdom on 24 March 2020. Following this, the CDO published guidance to cease the practice of non-urgent and routine dental care in England on the 25 March 2020.

      Hurley S, Rooney E, Reece C. Issue 2 preparedness letter for primary dental care 20 March 2020. Available from URL: https://www.gdc-uk.org/docs/default-source/covid-19/issue-2-prepardness-letter-for-primary-dental-care-20-march-2020.pdf?sfvrsn=69d46d90_2 [last accessed: 22/04/22].

      This resulted in a shift from face-to-face clinical practice to a remote telephone triage service, focussed on offering ‘Advice, Analgesia and Antibiotics’ (AAA). Patients requiring urgent, face-to-face treatment had to fulfil strict criteria to be referred to an Urgent Dental Care Centre (UDCC) via their general dental practitioner (GDP) or NHS 111.

      Hurley S, Rooney E, Reece C. Issue 2 preparedness letter for primary dental care 20 March 2020. Available from URL: https://www.gdc-uk.org/docs/default-source/covid-19/issue-2-prepardness-letter-for-primary-dental-care-20-march-2020.pdf?sfvrsn=69d46d90_2 [last accessed: 22/04/22].

      These measures impacted access to primary dental care and left many patients with unresolved dental concerns. Studies have demonstrated an increase in the prescription of antibiotics for dental conditions which, under normal circumstances, could have been managed operatively in a primary care dental setting.
      • Shah S.
      • Wordley V.
      • Thompson W.
      How did COVID-19 impact on dental antibiotic prescribing across England.
      As a result, during the March 2020 lockdown, patients’ dental issues were not being resolved as efficiently.
      On the 8 June 2020, following the relaxation of lockdown measures, the CDO issued new guidance to restart face-to-face clinical practice in primary care, as part of a phased transition to the reopening of dental practices.

      Office of Chief Dental Officer England. Standard operating procedure: transition to recovery; 28th August 2020. Available from URL: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0575-dental-transition-to-recovery-SOP-4June.pdf [last accessed: 22/04/22].

      Implementation of enhanced infection prevention and control measures to reduce COVID-19 transmission generated changes in practice that increased costs and reduced the number of patient appointments available. To begin with, practices had to acquire their own adequate personal protective equipment (PPE), to comply with new infection control measures. This was made challenging by supply issues, which caused further delays in the initial opening of practices.

      NHS Business Services Authority. Guidance to support dental contract management arrangements for the 2020/21 – year-end reconciliation. Available from URL: https://www.nhsbsa.nhs.uk/sites/default/files/2020-12/2021%20YE%20CM%20guidance.v15.3_0.pdf [last accessed: 22/04/22].

      This improved with NHS practices ordering PPE from the government PPE portal. Additionally, ‘fallow time’ - the period of time a dental surgery must be left empty after the completion of an aerosol generating procedure (AGP) - was mandated, which resulted in longer appointments and compromised the total number of patients seen per day.
      A survey conducted by the Royal College of Surgeons Dental Faculty reported that only 40% of the surveyed NHS GDPs were performing AGPs from the 8 of June until September 2020, with many reporting large reductions in the number of patients seen per session compared to pre-pandemic sessions.

      Faculty of Dental Surgery. A resumption of dental services? Dental surgeons’ experiences of delivering care since 8 June 2020. Available from URL: https://www.rcseng.ac.uk/-/media/files/rcs/coronavirus/fds-report-resumption-of-dental-services-2-oct-2020.pdf [last accessed: 22/04/22].

      As a result of the lockdown, and COVID-19 risk management measures, dental services in the UK were severely truncated. An increase in patient presentations to secondary care ED services, which had limited resources and different skill sets than those needed to treat dental problems, was not appropriate in an already stretched resource. A study in Mid Yorkshire Hospital Trust showed that a reduction in access to primary care dentistry adversely affected the provision of early treatment for odontogenic infections, which resulted in an increased severity of disease presenting to their ED.
      • Long L.
      • Corsar K.
      The COVID-19 effect: number of patients presenting to The Mid Yorkshire Hospitals OMFS team with dental infections before and during the COVID-19 outbreak.
      The aim of this analysis was to explore the impact of the pandemic on the number of patients presenting to the ED at the BRI with odontogenic pain and infection. In addition, it assessed the severity of infection at first presentation to the ED both during primary dental care restrictions and after, when dental services re-opened with some restrictions.

      Material and methods

      Data were collected retrospectively from EPR regarding adult patients attending the ED of the BRI, from 1 January 2020 to 1 January 2021. Inclusion criteria were patients presenting with odontogenic pain and/or odontogenic infection. Dentoalveolar trauma was excluded. Data from the EPR were collected on patient demographics such as age and gender, details of their condition, indicators of infection severity, and details of treatment provided. A full list of recorded variables is shown in Table 1.
      Table 1Data collection for each presentation to the emergency department.
      VariableParameter
      Anonymous identifier
      Age
      SexMale/Female
      Referral sourceEmergency department/Bristol Dental Hospital
      Regular dental attenderYes/No/Unknown
      Previous general dental practitioner visit prior to emergency department attendanceYes/No
      Previous general medical practitioner visit prior to emergency department attendanceYes/No
      Previous antibiotic prescriptionYes/No

      Oral/IV
      ComorbiditiesDiabetes, smoking, immunocompromised
      MedicationSteroids, anticoagulants, immunosuppressants, other, none
      AllergiesYes/No
      Systemic involvementNone, lymphadenopathy, neck swelling, trismus, dysphonia/dysphagia, bilateral neck swelling/Ludwig’s angina
      Infection site
      Ludwig’s anginaYes/No
      Return to theatreYes/No
      ITU admissionYes/No
      Previous analgesic useParacetamol, ibuprofen, paracetamol and ibuprofen, codeine, codeine and paracetamol, other, none
      Previous dental treatmentNone, extirpation, temporary restoration, incision and drainage, extraction under local anaesthesia
      Sepsis six triggerYes/No
      Route of antibiotic prescribed in secondary careOral and discharge from emergency department, IV in emergency department and discharge, IV and admit
      TreatmentNo treatment, analgesic advice, discharge and dentist to treat, extraction under local anaesthesia, incision and drainage under local anaesthesia, treatment under general anaesthesia
      Patients were separated into three groups based on attendance date. The first group (phase 1) corresponded to 1 January to 24 March 2020, with no COVID-19 restrictions. The second group (phase 2) assessed 25 March to 7 June 2020 during closure of routine primary dental care. The third group (phase 3) covered 8 June 2020 to 1st January 2021, when primary dental care reopened, albeit with tight restrictions. As the relatively short duration of phase 2 meant numbers of attendance were low, phases 2 and 3 were combined in statistical analyses to create a post COVID-19 restriction phase. Each attendance was counted as a single event, even if the patient had attended previously. The number of patient attendances were calculated per day and per week during each phase (Table 2).
      Table 2Number of attendances to the emergency department for dental pain and or infection during the different phases of primary dental service restrictions due to COVID-19. Data are number.
      PhaseNumber of presentations seen at BRINumber of days in phaseNumber of weeks in phaseAverage number of presentations/weeksMean difference pre and post COVID-19 restrictions
      Phase 1

      Pre COVID-19 restrictions

      1 January to 24 March 2020
      1018411.88.5
      Phase 2

      25 March to 7 June 2020
      1177510.710.9
      Phase 3

      8 June 2020 to 1 January 2021
      36420829.812.2
      After COVID-19 restrictions

      Phases 2 and 3 combined
      48128340.511.83.07

      (0.35, 5.78)

      p=0.005
      Severity of the patient's condition was assessed by grading signs and symptoms and the management implemented. Scores for systemic features of infection, treatment, antibiotics, signs of sepsis, and intensive treatment unit (ITU) admission were assigned a numerical value (Table 3, column 2). Severity scores were combined to give an overall total severity score out of a maximum of 21. Subsequently this variable was dichotomised into Mild (score 0–4) and Moderate-Severe (5–21).
      Table 3Severity score/phase of COVID-19 restrictions to primary dental care. Data are No. (%).
      VariablesPhase 1Phase 2Phase 3Post COVID-19 restrictions (phases 2 and 3)Total
      Systemic score:
       No sign of systemic involvement (score = 0)82 (81.2)100 (85.5)298 (81.9)398 (82.7)480 (82.5)
       Lymphadenopathy (score = 1)03 (2.6)4 (1.1)7 (1.5)7 (1.2)
       Trismus (score = 2)12 (11.9)7 (5.9)44 (12.1)51 (10.6)63 (10.8)
       Major neck swelling (score = 3)00000
       Dysphagia/dysphonia (score = 4)7 (6.9)7 (5.9)15 (4.1)22 (4.6)29 (4.9)
       Bilateral neck swelling/Ludwig’s angina (score = 5)003(0.8)3 (0.6)3 (0.5)
       Total101117364481582
       Mean score0.510.380.460.440.45
      Treatment score:
       No treatment (score = 0)18 (17.8)8 (6.8)41 (11.2)49 (10.2)67 (11.5)
       Analgesic advice/GDP to treat/referral to BDH (score = 1)53 (52.5)79 (67.5)237 (65.1)316 (65.7)369 (63.4)
       Extraction with LA (score = 2)01 (0.9)01 (0.21 (0.2
       Incision and drainage LA (score = 3)15 (14.9)19 (16.2)52 (14.3)71 (14.8)86 (14.8)
       Treatment under GA (score = 4)15 (14.9)10 (8.6)34 (9.3)44 (9.1)59 (10.1)
       Total101117364481582
       Mean score1.561.521.451.471.49
      Antibiotic score:
       No antibiotics (score = 0)40 (39.6)50 (42.7)138 (37.9)188 (39.1)228 (39.2)
       Oral antibiotics and discharged (score = 1)33 (32.7)51 (43.6)149 (40.9)200 (41.6)233 (40.0)
       IV antibiotics and discharged (score = 2)7 (6.9)4 (3.4)34 (9.3)38 (7.9)45 (7.7)
       Admitted for IV antibiotics (score = 3)21 (20.8)12 (10.3)43 (11.8)55 (11.4)76 (13.1)
       Total101117364481‘582
       Mean score1.090.810.950.920.95
      Sepsis six pathway:
       No (score = 0)98 (97.0)115 (98.3)354 (97.3)469 (97.5)567 (97.4)
       Yes (score = 4)3 (2.9)2 (1.7)10 (2.8)12 (2.5)15 (2.6)
       Total101117364481582
       Mean score0.120.070.110.100.1
      ITU admittance:
       No admittance to ITU (score = 0)100 (99.0)116 (99.2)359 (98.6)475 (98.8)575 (98.8)
       Admitted to ITU (score = 5)1 (0.9)1 (0.9)5 (1.4)6 (1.2)7 (1.2)
       Total101117364481582
       Mean score0.050.040.070.060.06
      Total mean score3.342.823.042.993.05
      Low severity score total (0–4)76 (75.2)99 (84.6)295 (81.0)394 (81.9)470 (80.8)
      Chi-squared test comparing pre and post COVID-19 restrictions x2 = 2.8; p = 0.1; 1degree of freedom.
      Moderate-severe severity score total (5–21)25 (24.8)18 (15.4)69 (19.0)87 (18.1)112 (19.2)
      Chi-squared test comparing pre and post COVID-19 restrictions x2 = 2.8; p = 0.1; 1degree of freedom.
      Total101117364481582
      * Chi-squared test comparing pre and post COVID-19 restrictions x2 = 2.8; p = 0.1; 1degree of freedom.
      Approval for the study was sought and approved by the clinical governance committee at University Hospitals Bristol and Weston NHS Foundation Trust.
      Data was anonymised and statistical analysis performed using StataMP17. A paired 2-sided t-test was used to assess for evidence of a difference between the mean number of ED attendances prior to (phase 1), and after COVID-19 restrictions on routine primary dental care (phases 2 and 3 combined). A chi squared test with one degree of freedom was used to compare severity scores prior to and after implementation of COVID-19 dental restrictions (Table 3).

      Results

      Change in attendance

      A total of 582 patients attended the ED during the study period 1 January 2020 to 1 January 2021 with odontogenic pain, with or without infection. In phase 1, prior to COVID-19 restrictions to primary care dental services, 101 patients attended the ED. A total of 117 patients attended in phase 2 and 364 in phase 3 (Table 3). The number of presentations to the ED per week are shown in Table 2. Attendance increased by 27.8% in phase 2. This increased by a further 11.7% in phase 3. The difference in mean ED attendances per week between phase 1, and phases 2 and 3 combined was 3.1, with 95% confidence interval (CI): 0.3–5.7; p = 0.005. Overall, there was a 42.8% attendance increase to ED from phases 1–3 (Table 2).
      Of the patients seen in phase 1, 57.4% (n = 58) did not see a GDP prior to attending the ED. This increased to 70.9% (n = 83) in phase 2 and 70.0% (n = 255) in phase 3. General medical practitioner (GMP) advice regarding dental concerns, was sought by 7.9% (n = 8) in phase 1 which increased only minimally to 8.5% in phase 3.
      A total of 104 patients (17.8%) received dental care prior to attending the ED - distribution and type of treatment are shown in Fig. 3. The majority (n = 74) of these patients, having already sought advice from a GDP, had no systemic features and received no further treatment from the ED.

      Severity of infections across time

      The majority of patients presented with low severity scores, increasing only slightly across the phases, 75.2% (phase 1), 84.6% (phase 2) and 81.0% (phase 3) (Table 3). Only 19.2% of presentations scored Moderate-Severe across the study. 82.0% (n = 480) of patient presentations had no clinical systemic involvement. Three patients (0.8%) presented with severe bilateral neck swelling. Fig. 1 shows the total severity scores across each phase: two patients scored 21, both in phase 3. Severity score total was dichotomised into Mild (Score 0–4) and Moderate-Severe (Score 5–21). A total of 80.8% (n = 470) of presentations were classified as Mild and 19.2% (n = 112) of presentations fell into the Moderate-Severe category (Fig. 2). There was a slightly lower proportion of Moderate-Severe presentations post COVID-19 restrictions however there was no statistical evidence for a difference ( = 2.8, d.f = 1, p = 0.1) shown in Fig. 3.
      Figure thumbnail gr1
      Fig. 1Total Severity Score at each phase of primary dental care closure due to COVID-19 restrictions.
      Figure thumbnail gr2
      Fig. 2Total severity score across the Phase 1, 2 and 3 separated into Mild and Moderate-Severe Severity.
      Figure thumbnail gr3
      Fig. 3Bar chart to show pre admittance dental treatment across the study period.
      Antibiotic prescription prior to attending ED occurred in 28.7% (n = 29) of presentations, with an additional 2.0% (n = 2) having multiple courses for the same dental concern.
      Presentations to the ED were largely an inappropriate use of secondary care resources, as 63.0% (n = 367) of patients were discharged from the ED to see a GDP for treatment or given advice regarding analgesia. A total of 40.0% of patients (n = 233) were given oral antibiotics and discharged, with a further 30.0% (n = 175) discharged without a prescription.
      When dental infections are severe, however, this creates substantial burden on the NHS due to requirements for admission, surgical management, and the potential need for ITU support. The predominance of patients required no acute emergency treatment: 63.0% (n = 367) were discharged with advice and 40.0% were discharged with oral antibiotics. Of the patients who required admission (13.0%), 59 (78.0%) required surgical intervention in combination with IV antibiotics, with seven patients necessitating ITU admission. The mean (range) ITU stay was 4.12 (2–17) days.

      Discussion

      This study provides evidence that COVID-19 pandemic-related restrictions to dental care caused an increase in patients presenting with dental pain and infection to ED. This has been corroborated by other single-centre studies in the UK.
      • Long L.
      • Corsar K.
      The COVID-19 effect: number of patients presenting to The Mid Yorkshire Hospitals OMFS team with dental infections before and during the COVID-19 outbreak.
      • Puglia F.A.
      • Ubhi H.
      • Dawoud B.
      • et al.
      Management of odontogenic cervicofacial infections presenting to oral and maxillofacial units during the first wave of the COVID-19 pandemic in the United Kingdom.
      For the duration of the study, most patients who attended the ED with dental problems presented with low severity conditions and required little input from secondary care. The results show a 14.0% increase in patients attending the ED without prior consultation with a dentist following lockdown measures. It is postulated that many of these patients could have accessed a primary care dentist had there been no restrictions. However, a conflicting observation from the data is that over half of the patients had not sought help from a dentist before the COVID-19 dental restriction implementation. This rose to over 70.0% during phases 2 and 3. This highlights a pre-existing lack of access to NHS dental care, which was exacerbated by pandemic restrictions, when the delivery of courses of dental treatment decreased by 68.7%, during the 12-month period prior to March 2021.

      NHS. NHS dental statistics for England – 2020-21 annual report; 26th August 2021. Available from URL: https://digital.nhs.uk/data-and-information/publications/statistical/nhs-dental-statistics/2020-21-annual-report# [last accessed: 22/04/22].

      A number of patients, ranging from 8 to 31 during phases 1 to 3, respectively, sought help for their dental problems from a GMP prior to attending the ED, which is not appropriate or the responsibility for GMPs to manage. This predates the COVID-19 crisis, equating to approximately 380,000 GMP consultations for dental concerns annually in the UK.
      • Cope A.L.
      • Chestnutt I.G.
      • Wood F.
      • et al.
      Dental consultations in UK general practice and antibiotic prescribing rates: a retrospective cohort study.
      Phase 2, when routine dentistry was suspended but a ‘AAA’ telephone triage service was adopted, saw an increase in ED attendances from phase 1 by 27.8%. Although the ‘AAA’ strategy can easily and quickly be implemented at a national scale, it has several limitations especially for conditions that do not respond to antibiotics, such as pulpitis. Antibiotic prescribing from April to July 2020 was 25.0% higher than the previous year.
      • Shah S.
      • Wordley V.
      • Thompson W.
      How did COVID-19 impact on dental antibiotic prescribing across England.
      However, in our study, the number of patients receiving antibiotics prior to their ED attendance did not increase but remained at similar levels prior to and during COVID-19 dental restrictions, with 30.0% in phase 1, 31.0% in phase 2, and 26.0% in phase 3.
      The number of patients with dental infections requiring ITU input and triggering a sepsis six pathway, an indication of severe spreading infection, increased after implementation of the pandemic restrictions. The results demonstrated that the most severe infections were observed in phase 3; five patients were admitted to ITU out of a total of seven across the study period. The data suggest that the restrictions in routine primary dental care services contributed to an increase in the emergence of number of patients requiring ITU treatment because of odontogenic infections.
      During the study period, six patients reattended the ED for the same dental complaint. Four of these required subsequent admittance for GA and two were referred to the dental hospital for treatment as they were unable to access their own GDP after initial advice and treatment in the ED. Of the six patients who re-attended, one patient required three subsequent incision and drainage procedures under GA due to the severity of the dental infection and one patient, on their second re-attendance required ITU admission. This highlights the impact on patients of not being able to attend a GDP despite not requiring treatment at the initial ED attendance.

      Conclusion

      This study investigated the impact of COVID-19 related restrictions to dental care on the number of patients presenting to ED with dental pain and infection. It has demonstrated an increase in presentations to ED regarding dental pain and infection following the CDO restrictions on primary dental care since 25 March 2020. It was suggested that due to a lack of availability in primary care dentistry, the severity of infections would increase following lockdown. The results show the most severe cases requiring ITU admission occurred following lockdown measures and restricted access to dental care. It can be inferred from the data that this was a direct result of patients being unable to access primary dental care. However, the majority of presentations were deemed to be of low severity, and did not require secondary care input, which placed an unnecessary burden on an already stretched ED resource.
      It was demonstrated that many patients coming to the ED with dental problems had not seen a dentist first, even if their presenting complaint did not require secondary care input. This inappropriate use of ED services highlights a pre-existing limitation of primary dental care provision in the UK, which has been exacerbated by COVID-19 public health measures.
      The COVID-19 pandemic brought many restrictions to primary care health services, which were deemed necessary to prevent the spread of the virus. However, the collateral damage to dental care services in the UK has far reaching implications for both patients and dental practices.

      Conflict of interest

      We have no conflicts of interest.

      Acknowledgements

      The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health.

      Funding

      The authors received no financial support

      Ethics statement/confirmation of patients’ permission

      None.

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