Introduction

Dental caries is the world’s most common disease with 60-90% of school children worldwide having experienced dental caries.^1,2

In Scotland, significant improvements in the oral health of children have been achieved in recent years with nearly three-quarters of P1 children (4-7 years old) and 82% of P7 children (10-13 years old) now having no obvious decay experience.^3,4 However, in high deprivation areas 41% of P1 children and 28% of P7 children do have obvious caries experience. Similar patterns of falling disease levels but with a higher burden of disease in children from more deprived areas are seen in England and Wales.^5,6 Untreated dental caries can result in pain and infection impacting on quality of life, school performance and development.^7,8 In the UK, dental extraction remains one of the most common reasons for a child to undergo an elective hospital admission for general anaesthetic.   

Dental caries is largely preventable. Effective, evidence-based strategies are available for caries prevention and also for management of the disease. This guidance deals with clinical interventions that are focussed on the individual child, rather than population-based measures, including water fluoridation.⁹

All members of the dental team play a vital role in both preventing and managing caries in children. These efforts need to be supported in two ways. Firstly by broader action to address the wider social determinants of health through wider multidisciplinary working.¹⁰ Secondly, as dietary risk factors for caries are shared by a number of other chronic diseases, adopting a collaborative approach in prevention with other health professionals (known as the common risk factor approach) is more rational than one that is disease specific.¹¹ Therefore, the dental team needs to work collaboratively with other health professional agencies and third sector organisations to protect children’s health and wellbeing,¹² which requires effective lines of communication to be in place. 

In Scotland, the national GIRFEC (Getting it right for every child) policy supports this multiagency early year’s approach and is discussed further in Providing additional support. GIRFEC is founded on the United Nations Convention on the Rights of the Child (UNCRC), an international human rights treaty that grants all children and young people (aged 17 and under) a comprehensive set of rights.¹³ Ratified in the UK in 1991, UNCRC became a statutory requirement in Scotland in 2024, aiming to deliver a proactive culture of everyday accountability for children’s rights across public services.¹⁴ It requires all of Scotland’s public authorities to take proactive steps to protect children’s rights in their decision-making and service delivery in line with the UNCRC requirements. When providing oral health care for children, this includes ensuring that children and young people have a voice in decisions that affect them, having a child-friendly complaints process and providing information in child-friendly formats.

Childsmile is a national programme for improving children’s oral health in Scotland. It has been developed to deliver multidisciplinary primary caries prevention, anticipatory care and supports appropriate management of dental caries via NHS dental services and other settings. Working alongside Childsmile, this guidance was first published in 2010, and updated in 2018, with the aim of presenting clear and consistent advice to support dental professionals to deliver preventive care and, where necessary, to manage caries in children. This third edition brings this advice up to date with the most recent research evidence, national policy and legislation. 

Although this guidance has been developed to support improvements in the oral health care and oral health of children in Scotland, these recommendations are likely to be relevant in other countries, taking local differences in the organisation of dental services into consideration. Other programmes in the UK aimed at improving oral health in children, include Designed to Smile in Wales, Happy Smiles in Northern Ireland and Starting Well: A Smile4Life Initiative in England. Public Health England has also published Delivering Better Oral Health - an evidence based toolkit for prevention guidance for health professionals.

There is now a wealth of evidence to inform the prevention and management of dental caries in children. Consequently, many of the recommendations in this guidance are based on research evidence while others draw on the consensus view of expert and experienced practitioners. Each dental team member is encouraged to follow these recommendations as their standard practice for all their child patients. The evidence that underpins this guidance indicates that this will significantly benefit both children’s oral health and experience of dental care. 

Realistic Medicine is the Scottish Government’s approach to delivering values-based health and care that aims to put the patient at the centre of decisions made about their care.^15-17 Realistic Medicine is of relevance within all healthcare disciplines, including dentistry, and has six principles: Shared Decision Making, Personalised Approach to Care, Reduce Harm and Waste, Reduce Unwarranted Variation, Manage Risk Better, Become Improvers and Innovators.

Adopting the Realistic Medicine approach aligns with environmental considerations and efforts to achieve more sustainable healthcare. Climate change represents a major threat to both human health and the health of our planet. The need to minimise the impact we have on the environment is widely acknowledged and National Health Services in the UK are committed to reducing greenhouse gases, the cause of climate change.^18-20

Through the evidence-based recommendations and advice within this edition of the Prevention and Management of Dental Caries in Children, this guidance:

• Encourages shared decision making and provides strategies for the dental team to support and empower children (and/or their parents/carers) to take an active role in maintaining their own oral health.
• Promotes the prevention of dental caries and encourages the early identification and treatment of disease, which underpins achieving value in health and care, and treatment choice for the best outcomes. Recognised as a fundamental pillar of sustainable healthcare, disease prevention avoids the need for more complex care, which has associated environmental and health costs. Similarly, early intervention aims to minimise the need for more complex treatment.^21,22
• Advocates risk-based personalised care, which underpins planning of appointments at intervals tailored to clinical need, thereby minimising travel to attend and unnecessary use of resources.
• Gives practical advice on how to efficiently deliver care that is effective in maintaining and improving children’s oral health.
• Advises against interventions that are not supported by evidence, thereby avoiding unnecessary, and therefore wasteful, care.

Consequently, this guidance supports the application of Realistic Medicine within children’s oral health care. By following the recommendations and clinical advice, dental professionals will contribute to reducing their environmental/carbon footprint.

For more general advice on other strategies the dental team can follow towards achieving more sustainable healthcare, refer to the SDCEP Practice Support Manual.

Prevention and Management of Dental Caries in Children is designed to assist and support primary care practitioners and their teams in improving and maintaining the oral health of their young patients from birth up to the age of 18 years. It includes advice on:

• assessing the child and family
• helping the family manage dental care
• delivery of preventive care based on caries risk
• choosing from the range of caries management options available
• delivery of restorative care, including how to carry out specific treatments
• referral and recall
• management of suspected dental neglect 
• working with other agencies to support and safeguard the wellbeing of children and young people

The complete dental management of children with bleeding disorders, or who are immunocompromised and those at increased risk from infection, is outside the remit of this guidance. However, there are few children for whom preventive care cannot be managed within primary care practice. Similarly, for children with additional needs, such as those with a significant behavioural or learning difficulty, preventive care should be provided in primary care practice. However, as an individual child’s ability to cope with dental treatment can vary, it is recognised that in some circumstances a child with additional needs might have to be referred for specific items of treatment. Other important aspects of children’s oral health, including monitoring the developing occlusion and the management of dental trauma, are also outside the remit of this guidance and are not discussed.

Many parts of the guidance remain unchanged within this third edition. Updates are focused on specific aspects of the guidance to reflect new evidence or other recent developments. The main changes in this edition are:

• reference to values-based care/Realistic Dentistry and sustainability (see above)
• amendment to the recommendation about preventive fissure sealants (see Caries prevention)
• creation of a ‘Professionally-delivered interventions’ section based on previous separate sections on topical fluoride and fissure sealants 
• inclusion of silver diamine fluoride (SDF) application as a caries management option for primary teeth
• wider application of vital pulp therapy in permanent teeth including a new key recommendation about pulpotomy for treatment of pulpitis with irreversible symptoms (see Caries management in permanent teeth)
• inclusion of sealant/infiltration as a management option for moderate lesions in permanent teeth
• alignment of advice on the management of first permanent molars of poor prognosis with the Royal College of Surgeons of England guideline
• advice on providing additional support updated to reflect current child protection guidelines, citing and aligning with UNCRC

This guidance is directed towards all members of the primary care dental team involved in providing oral health care for children in general practice and the Public Dental Service or Community Dental Service. This includes trainee and qualified dentists, dental hygienists, dental therapists, dental nurses, dental health support workers and oral health educators. It is also of relevance to the Hospital Dental Service, dental educationalists and those involved in dental and wider public health.

Evidence-based practice makes use of the best current research evidence, taking into account clinical expertise and the preferences of the patient, to inform decisions about patient care. The recommendations in this guidance have been developed to assist in clinical decision making and are based on critical evaluation of the available body of evidence and expert opinion. Each recommendation is considered important for the provision of high-quality dental care. 

The guidance is presented in several sections. The main sections each address a specific aspect of the prevention and management of dental caries in children. Additional action to improve and support children’s wellbeing that includes collaborative working is discussed in Providing additional support. Recommendations for quality improvement and future research are briefly discussed in QI and research. Further details about the development of the recommendations in this guidance can be found in Methodology and in the accompanying Guidance Update Methodology documents.

Throughout the text, specific types of information are included as follows. 

Key recommendations - communicate the core messages in the guidance and are only included in those sections specifically devoted to the prevention and management of dental caries (Caries prevention, Caries management in primary teeth, Caries management in permanent teeth). The strength of each key recommendation is stated directly after the recommendation with a brief justification in the accompanying text. A strong recommendation is one where it is considered, based on all the available information and weighing up the balance of benefits versus risk, that almost all individual patients would choose this option. A conditional recommendation is one where there is a finer balance between the options and it is likely that the majority but not all would choose the recommended option. In the case of a conditional recommendation, the dental practitioner should expect to spend more time discussing the treatment management options so that the patient/carer can make an informed decision.

Basis for this recommendation - an overview of the evidence which informs the recommendations within the prevention and management of caries sections.

Other clinical practice advice in this guidance is based on consensus, expert opinion and existing best practice as identified in the accompanying text. These advice points are indicated with ‘molar’ bullet points (see below).

Key recommendation and molar bullet symbols

In Caries prevention, Standard Prevention actions for all children are presented under amber headings, with Enhanced Prevention actions for those children assessed as at increased risk of developing caries under red headings. 

How caries is measured, described and managed is an evolving area, with no consensus on the preferred approach. Consequently, for the purposes of this guidance a system of classifying carious lesions based on how they can be managed has been created for both primary and permanent teeth (see Lesion classification). A formal tooth notation system has not been used because it has not been necessary to specify individual teeth. 

Further details about the Scottish Dental Clinical Effectiveness Programme (SDCEP) and the development of this guidance are given in Guidance development and Methodology.

Child
The word ‘child’ is used in this guidance to describe infants, children and young people up to the age of 18 years.

Family
The word ‘family’ is used in this guidance to describe individuals who are close to a child and who may have a role in their care. It is acknowledged that the care arrangements of children vary considerably and that in this context the family might include unrelated individuals.

Clinician
Throughout the guidance, the term ‘clinician’ is used to mean any suitably trained dentist or dental care professional with clinical responsibility for the oral health care of the child.

Pulpotomy
Pulp therapy in which the instrumentation is confined to the coronal pulp chamber.

Pulpectomy
Pulp therapy in which the instrumentation is extended to include the root canal system. Pulpectomy is carried out as part of root canal therapy (RCT) leading to a permanent restoration and in this guidance the term pulpectomy/root canal therapy (or pulpectomy/RCT) is used to denote this.

Root canal therapy (RCT)
Instrumentation of the root canal system (pulpectomy) plus permanent restoration of the root canals and crown.

Other resources to support the implementation of the guidance can be found in Supporting tools. Narrative versions of these resources are included to aid accessibility.

Resources include:

• a flowchart to assist with the diagnosis and management of dental pain or infection 
• flowcharts to assist in decision making about management of carious lesions in primary and permanent teeth 
• tables that illustrate the options for management of carious lesions in primary and permanent teeth 
• a flowchart for assessing management options when considering referral for sedation or GA

A downloadable version of the Guidance in Brief, which includes the flowcharts and tables noted above, is also available.

This guidance has resulted from careful consideration of the available evidence, expert opinion, current legislation and professional regulations. It should be taken into account when making decisions regarding treatment in discussion with the patient and/or parent or carer. 

As guidance, the information presented here does not override the clinician’s right, and duty, to make decisions appropriate to each patient with the patient's valid consent. It is advised that significant departures from this guidance, and the reasons for this, are fully documented in the patient’s clinical record.