This study identified significant age-specific vulnerability patterns in paediatric dental emergencies during the COVID-19 lockdown, with very young children (0–3 years) demonstrating unique emergency needs and treatment outcomes. Despite an overall 40.2% reduction in paediatric dental emergencies during lockdown, the decrease was less pronounced in the youngest age group (35.7%) compared to older children, especially the 10–12 age group (52.0%). This pattern aligns with findings from similar studies worldwide (Alzahrani et al. 2021; Eggmann et al. 2021; Fux-Noy et al. 2021).

The significant drop in mean age of patients seeking emergency dental care during lockdown (from 7.1 to 6.2 years) confirms younger children's particular vulnerability during healthcare disruptions. This finding is consistent with research from Switzerland (Eggmann et al. 2021), Saudi Arabia (Alzahrani et al. 2021), and Argentina (Rodriguez et al. 2022), suggesting a consistent pattern across different healthcare systems.

The observed age gradient in emergency visit reduction, with older children (10–12 years) showing the most substantial decrease (52.0%) while the youngest age group (0–3 years) showed the smallest reduction (35.7%), suggests age-specific differences in care-seeking behavior during the crisis. This pattern may reflect several factors: parents may perceive dental problems in younger children as more urgent and requiring immediate attention regardless of external circumstances (Samuel et al. 2021); older children may be better able to tolerate or communicate about mild to moderate dental discomfort, allowing parents to defer care during lockdown (Goswami et al. 2021); and older children typically have fewer developmental dental issues requiring emergency intervention (Masri et al. 2021). Additionally, the anatomical structure of primary teeth in younger children, with thinner enamel and larger pulp chambers, allows for more rapid progression of dental pathology (Luzzi et al. 2021), potentially creating more urgent situations that families felt unable to postpone despite pandemic restrictions. These findings reinforce the particular vulnerability of very young children in dental emergency contexts during healthcare crises (Sudri et al. 2024) and highlight the need for age-tailored approaches in emergency dental service planning (Whyte et al. 2023).

A concerning finding was the increased proportion of emergency visits due to dental pain (51.2%) and swelling/abscess (24.8%) among 0–3-year-olds during lockdown compared to pre-COVID levels (42.1% and 19.5%, respectively). This pattern mirrors previous research, which reported a higher prevalence of pulpal pathology emergencies among younger children during lockdown (Goswami et al. 2021; Kumar et al. 2021). Several factors likely explain this increased prevalence of pulpal pathology. First, dental care for very young children was often considered non-urgent pre-pandemic, with many practitioners opting for watchful waiting of early carious lesions (Luzzi et al. 2021). During lockdown, this approach resulted in rapid progression to symptomatic disease, particularly in primary teeth with their larger pulp chambers and thinner enamel. Second, pandemic-related changes in diet and oral hygiene routines may have accelerated caries development, with families reporting increased consumption of cariogenic snacks and disrupted oral hygiene supervision during home confinement (Goswami et al. 2021). Finally, pandemic-related stress and altered sleep patterns in young children may have exacerbated bruxism and other parafunctional habits, potentially accelerating pulpal involvement in teeth with pre-existing conditions (Samuel et al. 2019).

The dramatic reduction in trauma-related visits across all age groups, but particularly in the 0–3 group (from 12.4 to 5.2%), was expected due to reduced physical activity during lockdown and corroborates findings from multiple studies (Olszewska et al. 2021; Üstün et al. 2021; Yang and Yoon 2023).

The most concerning finding was the significant increase in invasive treatments in the 0–3 age group during lockdown. The proportion of extractions rose from 18.4% pre-COVID to 24.8% during lockdown (p = 0.03), while pulp extirpations increased from 12.2% to 19.7% (p = 0.003). The interaction effect identified in our multivariate model (OR = 1.38, 95% CI: 1.12–1.68, p = 0.008) suggests very young children had a disproportionately greater likelihood of requiring invasive treatments during lockdown. Similar patterns have been observed in other studies, including increased rates of pulp therapy and extractions among young children in Germany (Masri et al. 2021) and increased abscess drainages in Poland (Olszewska et al. 2021).

The observed steady increase in permanent restorations with age (from 7.7% in the 0–3 age group to 16.7% in the 10–12 age group) reflects important developmental and clinical considerations in paediatric dental practice. This pattern likely stems from multiple factors: the greater structural integrity of teeth in older children making them more suitable candidates for definitive restorations; the increased cooperative capacity of older children allowing for more technique-sensitive procedures; and the longer remaining lifespan of permanent teeth in older children justifying more definitive interventions (Goswami et al. 2021; Luzzi et al. 2021). Conversely, the lower rates of permanent restorations in the youngest age group highlight another dimension of their vulnerability during emergencies—not only did they experience more severe conditions requiring intervention, but they were also less likely to receive definitive restorative treatments that might prevent future emergencies, potentially creating a cycle of repeated emergency visits.

The age-related gradient in treatment invasiveness provides further insight into this vulnerability pattern. The weaker negative relationship between age and likelihood of invasive treatment during lockdown (β = − 0.06) compared to pre-COVID (β = − 0.14) and post-lockdown periods (β = − 0.13) demonstrates how the healthcare crisis intensified age-based disparities in treatment needs.

The continued decline in pharmaceutical-only management for the 0–3 age group even after lockdown restrictions were lifted (from 43.1% pre-COVID to 15.6% post-lockdown) may represent a lasting effect of the pandemic on paediatric dental practice. While this pattern could suggest a shift in treatment philosophy, alternative explanations should be considered, including changes in case severity, evolving clinical guidelines, or methodological factors. Longer-term follow-up studies would be needed to confirm whether this represents a permanent change in clinical practice. Several factors might explain this lasting change: dental practitioners may have observed better outcomes with more definitive interventions during the lockdown period; the experience of uncertainty about future care access may have permanently altered risk assessment calculations; or the pandemic may have accelerated an existing trend toward more definitive management of dental emergencies in very young children (Luzzi et al. 2021; Masri et al. 2021). Regardless of the underlying cause, this finding indicates that certain aspects of crisis-induced changes in clinical decision-making may have longer-term impacts on treatment patterns, outlasting the immediate conditions that prompted them.

Several factors likely contribute to very young children's unique vulnerability pattern. The anatomical structure of primary teeth, characterized by thinner enamel and wider root canals, allows more rapid progression of dental caries (Luzzi et al. 2021). Limited ability to communicate pain severity often leads to delayed recognition of dental problems until they become severe (Goswami et al. 2021; Samuel et al. 2019). Additionally, different immune responses in very young children may lead to faster progression of dental infections (Sudri et al. 2024). During lockdown, these factors were likely exacerbated by heightened parental concerns about virus exposure (Cagetti et al. 2021; Remmani et al. 2023).

Our findings have important implications for both crisis response and routine dental care. The unique vulnerability patterns observed in very young children (0–3 years) during the pandemic highlight characteristics that remain relevant in normal circumstances: anatomical features predisposing primary teeth to rapid caries progression (Luzzi et al. 2021), limited communication abilities hampering timely pain reporting (Samuel et al. 2019), and developmental challenges in treatment cooperation (Goswami et al. 2021). While many dental conditions could be deferred during healthcare crises, the disproportionate impact on the youngest age group indicates this population requires special consideration in emergency planning (Dave et al. 2020; Whyte et al. 2023). These findings suggest dental care systems should restructure preventive protocols to place greater emphasis on early childhood, with more frequent recall intervals and prioritized access to specialist services (Masri et al. 2021). The consistently high proportion of pulpal pain and abscess presentations in very young children points to potential gaps in preventive dental care for this age group (Choi et al. 2024).

Implementing age-specific pathways that acknowledge the distinctive needs of very young children could reduce emergency presentations and invasive treatments even during non-crisis periods, improving both oral health outcomes and resource utilization.

Several limitations should be considered when interpreting these findings. First, the retrospective design limits our ability to establish causality between lockdown measures and observed changes in emergency presentations. Second, data from a single healthcare provider, though serving approximately 25% of Israel's population, may limit generalizability. Third, we lacked detailed information on socioeconomic factors, parental education, and home oral hygiene practices, which could influence pre-existing conditions and care-seeking behaviours (Choi et al. 2024; Siboro et al. 2023). Fourth, our study focused exclusively on emergency visits and did not capture potential long-term consequences of delayed routine care. Finally, we lack information about emergency dental visits to private clinics or those managed through teledentistry during lockdown (Hung et al. 2022). Finally, the study also has limitations in its ability to assess the impact of socioeconomic, cultural, and social factors on emergency visit patterns. While the data include basic geographic and demographic information, detailed information about socioeconomic status, parental education, and social determinants of health that could influence care-seeking behavior during the pandemic is lacking. Additionally, the study does not capture information about specific barriers that prevented families from seeking care, such as transportation difficulties, financial constraints, or health-related concerns about COVID-19 exposure.

Future research should focus on several key areas. Longitudinal studies following children who received emergency dental treatment during lockdown would provide valuable insights into the long-term consequences of delayed care and invasive treatments in the youngest age group. Investigation of age-specific risk factors for severe dental emergencies, combining clinical data with detailed demographic and behavioural information, could help identify modifiable risk factors and develop targeted preventive strategies. More granular analysis of age-specific vulnerability patterns would be particularly valuable. While our study categorized children into broad age groups, even within the 0–3 years category, there likely exist meaningful developmental differences affecting both disease progression and care-seeking behaviour. For instance, children aged 2–3 years, who have more developed communication abilities, may better articulate dental pain compared to infants and very young toddlers, potentially leading to earlier intervention. Similarly, the presence of a complete primary dentition versus a partially erupted one may influence both caries patterns and treatment approaches. Future studies with larger sample sizes should consider more refined age categorizations (e.g., 0–12, 13–24, 25–36 months) to better characterize vulnerability periods and inform age-specific preventive protocols. Also, they should incorporate comprehensive socioeconomic and behavioral data to better understand the intersection between social determinants of health and age-specific vulnerabilities in pediatric dental emergencies. Research examining the role of parental education, household income, insurance coverage, and cultural factors in care-seeking behavior during healthcare crises would provide valuable insights for developing targeted interventions.

The effectiveness of alternative care delivery models, such as teledentistry triage, should be evaluated specifically for different paediatric age groups. While such approaches showed promise during the pandemic, their effectiveness for managing dental emergencies in very young children requires further investigation. Finally, comparative studies across different healthcare systems would enhance understanding of how system-level factors influence age-specific vulnerability patterns in paediatric dental emergencies.