Purpose

This clinical standard sets out a structured, level-based model of oral healthcare for children and young people.

It defines national expectations for assessing complexity, allocating care, referral and triage, anxiety management, sedation and general anaesthetic pathways, safeguarding, governance, and the leadership role of paediatric managed clinical networks.

It supersedes the 2018 NHS England clinical standard for paediatric dentistry.

Scope: providers covered

The standard applies to all providers involved in the oral healthcare of children and young people, including primary dental care, community dental services, hospital dental services and tertiary paediatric centres, across both general and specialist dental care.

It covers care from birth to age 16. The upper age boundary can extend to 25 for individuals with special educational needs and disabilities or long-term medical conditions requiring continuity of specialist care.

Who should use the standard

This standard is for professionals involved in the oral healthcare of children and young people, including:

• general dental practitioners and dental care professionals
• level 2 paediatric dental practitioners
• specialists and consultants in paediatric dentistry
• community dental service and hospital dental teams
• integrated care board (ICB) commissioners and public health teams
• managed clinical network chairs and system leaders (for example local dental network and managed clinical network clinical leads, provider clinical directors and ICB clinical leads for children and young people)

It will also be useful for other professionals working with children and young people, including health visitors, school nurses, paediatricians, midwives, safeguarding teams and education providers.

How services are currently organised

Most dental care for children and young people is provided in primary care by general dental services. Community dental services provide general dental services to children with additional needs and specialist paediatric dental services through specialist or consultant-led teams. Specialist centres are traditionally hospital-based but increasingly operate in a community dental service setting. Dental treatment under general anaesthetic must be provided in a hospital setting, as part of a specialist-led service. Managed clinical networks in paediatric dentistry provide clinical leadership to local oral health systems, working with local dental networks to ensure quality and equitable access.

Local oral health systems must be designed in partnership with ICBs, public health teams, maternity services, health visiting, early years providers and families, adopting Core20PLUS5 children and young people principles. Across all settings, healthcare professionals should incorporate brief, person-centred oral health advice in line with the ‘Making every contact count’ principles.

Within this standard, a specialist-led paediatric dental service is defined as dental care in which assessment, treatment planning and overall clinical responsibility rest with a General Dental Council-registered specialist or consultant in paediatric dentistry, working within a multidisciplinary team and delivering care in accordance with national clinical standards, including for treatment under general anaesthetic where required.

1. Core expectations

1.1 Integration with neighbourhood health services

Paediatric dental services should be planned and delivered in alignment with the neighbourhood health direction set out by NHS England, working as part of integrated neighbourhood teams to support holistic management of children and young people in the community. This includes coordinated working with health visiting, school nursing, dietetics and nutrition, early years providers, GP practices, paediatrics, social care and safeguarding leads, ensuring that prevention, dietary advice, behaviour change support, and identification of wider need sit within a joined-up local offer rather than in dental services alone.

1.2 Escalation and information sharing

Where dental presentation indicates a wider clinical or safeguarding concern (for example, severe untreated caries in a young child, repeated ‘was not brought’ episodes, unexplained dental injury, or co-occurring nutritional, behavioural or social risk), the dental team must communicate proactively with the child’s GP, named safeguarding professional, health visitor, school nurse and, where relevant, social care and child and adolescent mental health services, in line with national information-sharing guidance and local multi-agency safeguarding arrangements. This applies across all levels of care. Specific safeguarding governance requirements are set out in Section 5.4.

1.3 Domiciliary and home-based care

A small but important group of children and young people cannot attend a dental setting due to severe disability, complex medical need, palliative status or end-of-life care. Domiciliary dental assessment and care for these patients is normally delivered through community dental services, with appropriate equipment, infection prevention, safeguarding and lone-working arrangements, and with specialist or consultant paediatric dental support as needed. Commissioners and managed clinical networks should ensure domiciliary capacity is identified within local pathways, recognising that this care often forms part of wider shared management with paediatric, palliative, social care and family teams.

1.4 NHS care in pregnancy and early childhood

These standards assume that people are able to access NHS dental care during pregnancy, and that children are brought into care within the first year of life for anticipatory guidance and preventive support.

1.5 Free at the point of care

NHS dental services for children and young people are free at the point of care.

2. Standard principles

All members of the dental workforce share responsibility for prevention, early identification and appropriate management of oral disease in children and young people. They must discharge this responsibility within their competence and with clear pathways for escalation. The following principles apply across all levels of service provision.

2.1 Inclusive, child- and family-centred care

• child‑ and family‑centred care is defined as an approach that places the child, together with their family, at the heart of planning and delivery of care, emphasising shared decision‑making, respect for family strengths, culture and preferences, and partnership working
• clinicians must act in line with national guidance that care and treatment for children and young people must always be in their best interests
• the child’s best interests must remain central to all decision‑making, with their views heard and given weight in line with their age, maturity and understanding
• planned care should be timely, proportionate to the child’s needs, and based on the best available evidence, including National Institute for Health and Care Excellence (NICE) guidance and other recognised clinical standards
• communication must be developmentally appropriate and inclusive of parents or carers, including those with additional needs, communication difficulties or whose first language is not English
• clinicians must follow national guidance on decision‑making and consent, and apply current legal and professional frameworks governing consent, assent, parental responsibility and capacity for children and young people
• safeguarding requirements, including information‑sharing and escalation where there are concerns about a child’s welfare, are set out in Section 5.4

2.2 Provision of care closer to home

• services should provide care in the least complex, most accessible setting appropriate for the child.
• systems should ensure effective first-time referral to the most appropriate setting
• shared-care arrangements, supported by clear referral and communication pathways, should enable stabilisation and continuity of care prior to, during and following specialist intervention where appropriate
• virtual advice and guidance pathways, including consultant- or specialist-led remote paediatric dentistry advice clinics, should be used to support local teams to deliver care closer to home, particularly in remote or underserved areas
• hub‑and‑spoke models and consultants working within community dental services can further extend specialist input into local settings, reducing travel and reliance on hospital‑based care

2.3 Reasonable adjustments

• children and young people with special educational needs and disabilities may need adapted communications, protocols to help them acclimatise, changes to the environment or adjustments to procedures
• practices must comply with the Equality Act 2010 and make reasonable adjustments
• visual support (for example, the Picture Exchange Communication System), behaviour guidance strategies and extended appointment times should be available as needed
• the Reasonable Adjustment Flag should be recorded in patient records, where possible

2.4 Prevention and evidence-based clinical care

Clinical care for children and young people should be grounded in minimally invasive, outcomes-focused principles, prioritising tissue preservation, early intervention, and child-centred approaches that support long-term oral health and minimise the need for operative dentistry.

• prevention-focused care must be embedded across all levels, following the Delivering Better Oral Health guidance and the Scottish Dental Clinical Effectiveness Programme’s (SDCEP’s) Prevention and management of dental caries in children guidance
• care plans should incorporate structured caries and periodontal risk assessment, with risk-based recall intervals in line with the NICE CG19 guidance.
• clinical management should be timely and proportionate, using interventions that are evidence-based and consistent with national guidance and recognised clinical standards.
• every dental contact should include short, structured, person-centred behaviour change support – such as advice on toothbrushing, fluoride use, diet and sugar intake, and tobacco or alcohol, where relevant – matched to the individual’s needs.

3. Levels of care and treatment complexity

A structured, level-based framework ensures children and young people receive dental care in settings configured to meet their clinical, behavioural and medical needs. Determination of care level is based on the complexity of the child’s needs, the skills and competencies of the workforce, and the capabilities of the provider service.

The framework sets out which children should be managed at each level, the workforce requirements and expected competencies, and the service features necessary to deliver equitable, safe and consistent care through defined referral, escalation and review processes. It is aligned with NHS England service-level descriptors, General Dental Council standards, and current paediatric dentistry training and accreditation pathways.

Determining complexity

The level of care appropriate for a child or young person is determined by 2 complementary dimensions of complexity, considered together:

1. Patient complexity assessed using the British Dental Association case mix tool (2019) across its 6 domains: ability to communicate, ability to cooperate, medical status, oral risk factors, access to oral care, and legal and ethical barriers to care. Patient complexity reflects the modifying factors that affect how care must be delivered.
2. Procedural (dental-specific) complexity, reflecting the clinical nature of the condition or treatment itself, irrespective of patient-level modifying factors. It is described in this standard through condition- and treatment-specific pathways, including dental trauma (Section 4.4) and developmental anomalies, as well as other condition-specific descriptors set out in Appendix 2. Examples include severe dento-alveolar trauma, amelogenesis or dentinogenesis imperfecta, severe molar incisor hypomineralisation (MIH), severe hypodontia and complex restorative or surgical needs.

Service-level factors (facilities, skill mix, sedation and general anaesthetic capacity, multidisciplinary team access) and workforce capability determine which provider can deliver care at the required level. The level of care required for an individual child is determined by the higher of patient and procedural complexity. A medically well, cooperative child with a complicated crown-root fracture, for example, may score at the lowest band on all 6 British Dental Association domains yet require Level 2 or 3a care on procedural grounds alone.

Below provides a summary of the levels of care, associated settings and typical complexity profiles for children and young people requiring dental services. Each level reflects increasing clinical, behavioural and medical complexity and the corresponding need for enhanced skills, facilities and multidisciplinary input.

Summary of levels of care

Level 1a – General Dental Practitioner Primary Care

Typical setting: General dental practice

Complexity profile: Low complexity; minimal modifying factors

Level 1b – Enhanced Primary Care

Typical setting: General dental practice (child-friendly and focused dental practice or equivalent scheme, enhanced skill mix)

Complexity profile: Low-to-moderate; acute dental disease without significant modifying factors

Level 2 – Intermediate Complexity Care

Typical setting: Primary care (where commissioned), community or hospital dental services

Complexity profile: Moderate complexity; some modifying factors; enhanced behaviour management needs

Level 3a – Specialist-led Care

Typical setting: Community or hospital dental services

Complexity profile: High complexity; significant modifying factors; complex medical or behavioural needs

Level 3b – Consultant-led or Tertiary Care

Typical setting: Tertiary centres and community or hospital dental services

Complexity profile: Very high complexity; rare conditions; general anaesthetic-dependent care

3.1 clinical standards by level of care

Local commissioners and managed clinical networks should determine which levels of paediatric dental care (Level 1a, Level 1b, and/or Level 2) are required and feasible within their area, tailoring the service model to the needs, complexity, and distribution of their local child population.

Children and young people should receive care at the least specialist level appropriate to their needs, with Level 1 primary care as the starting point and onward referral only where clinical complexity, behaviour, or wider factors indicate this is necessary.

3.1.1 Standards by level

Detailed descriptors of activity at each level are set out in appendix 2, with a summary at-a-glance in appendix 1.

Level 1a — General dental practitioner primary care

• children and young people with no significant modifying factors and manageable dental disease.
• care is delivered in general dental practice using full dental care professional skill mix.
• prevention follows Delivering better oral health guidance; recall follows NICE CG19 and the Scottish Dental Clinical Effectiveness Programme (SDCEP) Prevention and management of dental caries in children guidance.
• non-pharmacological behaviour management applies; children requiring sedation or general anaesthetic should be escalated.
• clear, managed clinical network-agreed referral criteria define escalation to higher levels.

Level 1b — Enhanced primary care (‘child-focused dental practice’)

In addition to Level 1a, Level 1b serves children and young people with acute dental disease (predominantly caries) who would otherwise be referred to community or hospital dental services, but who do not have significant medical, behavioural or social modifying factors. Care is delivered in a child-focused dental practice (CFDP) by general dental practitioners, dental therapists and teams with enhanced training (for example, this CFDP programme or equivalent).

Anxiety management, including use of non‑pharmacological techniques and inhalation sedation with nitrous oxide where appropriate, should follow the national Clinical guide for dental anxiety management and the Intercollegiate Advisory Committee for Sedation in Dentistry Standards for conscious sedation in the provision of dental care (IACSD 2020), with care provided only by trained practitioners in suitably equipped practices with robust governance arrangements.

Treatment under intravenous sedation or general anaesthesia, complex trauma management and management of significant medical comorbidity are excluded from Level 1b and should be provided at higher levels of care.

Level 1b services should be embedded within managed clinical network referral pathways, with regular specialist or consultant peer review, and clear criteria for escalation where modifying factors emerge, intravenous sedation is required, or overall complexity exceeds the scope of this level.

Level 2 — Intermediate complexity care

In addition to Levels 1a and 1b, Level 2 serves children and young people with moderate complexity and some modifying factors requiring enhanced behaviour management or sedation. Care may be delivered in primary care by accredited practitioners, community or hospital dental services with facilities proportionate to the case mix (inhalation sedation capability, intra-oral and panoramic radiography, positioning aids, paediatric resuscitation equipment, communication aids). Conscious sedation follows IACSD (2020) standards. Delivering better oral health prevention is embedded with shared-care stabilisation pathways to avoid unnecessary general anaesthetic. General anaesthetic-dependent care is escalated to Level 3.

The expectation of Level 2 workforce competency in community dental services is implied, with organisations supporting upskilling through continuing professional development, mentorship and regional training programmes. Experience and competence gained in community dental services can contribute to a practitioner’s portfolio when seeking Level 2 accreditation in other settings.  In primary care, formal accreditation through local accreditation panels is mandatory (see Section 3.3.2). British Dental Association case mix tool which supports caseload benchmarking; procedural complexity is recorded against the descriptors in Appendix 2, and activity coding aligns with Getting It Right First Time (GIRFT) Community Dental Services recommendations. Managed clinical network (MCN)-defined criteria govern escalation and referral to Level 3 specialist care.

Level 3a — Specialist-led care

In addition to care defined at levels 1a, 1b and 2, Level 3a serves children and young people with high complexity, multiple modifying factors, complex trauma, developmental anomalies, cleft lip or palate under regional multidisciplinary team, and those requiring care under general anaesthetic. Care is led by a specialist in paediatric dentistry in community or hospital dental services. Facilities include all level 2 equipment plus dental laboratory, cone beam computed tomography (CBCT), and general anaesthetic or advanced sedation facilities in line with the Royal College of Anaesthetists’ Guidelines for the provision of anaesthesia services and IACSD (2020). Providers host and supervise specialty trainees and contribute to research and audit. Step up to Level 3b for very high complexity, rare conditions or multidisciplinary team dependent care.

Tooth whitening for children and young people with intrinsic tooth discolouration related to dental trauma or developmental conditions may be considered at Level 3a, where there is a clear disease-related aesthetic or psychosocial impact, and where it provides a less invasive alternative to restorative treatment.

All care must comply with current UK legislation and professional guidance. This includes the requirements set out in the General Dental Council guidance on tooth whitening in under-18s, and the relevant UK regulations on the use of hydrogen peroxide.

Treatment should be planned and delivered within an appropriate specialist-led framework in line with these standards.

Level 3b — Consultant-led or tertiary care

In addition to Level 3a, Level 3b serves children and young people with very high complexity, rare conditions, complex cranio-facial conditions requiring multidisciplinary team and general anaesthetic-dependent care. The conditions are defined by appendix 1 and 2 of the Specialised surgery in children service specification (E02/S/a).

Care is led by a consultant in paediatric dentistry. Extended multidisciplinary team in line with staffing requirements, with 2 to 4 individuals per staff group for service resilience where feasible and necessary. Facilities include all Level 3a equipment, plus an operating theatre with paediatric critical care, digital radiography (fixed and mobile), outpatient or inpatient sedation infrastructure, and, ideally, low-level laser therapy and a microscope.

In some regions, elements of the Level 3b pathway are delivered within community dental services, supported by appropriate consultant leadership, workforce and facilities, in line with the relevant specialised service specification. Commissioning arrangements should recognise and align with this model, using the appropriate clinical and contracting frameworks where specialised care is provided in a community dental service setting.

Governance includes compliance with the Specialised surgery in children service specification (E02/S/a); participation in surgery in children clinical networks; Specialised Services Quality Dashboard reporting; mandatory Morbidity and Mortality (M and M) meeting reporting to Trust governance; engagement in national registries, National Consultant Information Programme as part of the Model Health System, and research. Dual consultant operating is recommended for complex or infrequent procedures on a case-by-case basis when high-risk.

Shared care principles (level 3a and 3b):

• care with relevant specialties (orthodontics, restorative, oral and maxillofacial surgery, special care dentistry, oncology) as indicated
• shared care and step-down to Level 1 and Level 2 providers for prevention and maintenance when safe and appropriate
• surgical and general anaesthetic lists apply national prioritisation guidance for children (sepsis, trauma, high-risk medical cohorts)
• specialist dentists embedded into multidisciplinary teams for high-risk medical groups (oncology, congenital heart disease, cleft lip and palate, diabetes)

3.2 Modifying factors for allocation and escalation

When applying the complexity framework, the following modifying factors may increase the required care level:

• disease severity or urgency: rapidly progressing caries, acute infection, significant trauma
• cooperation or anxiety: previous failed attempts, need for sedation or general anaesthetic, severe anxiety
• medical status: chronic disease, immunocompromise, oncology pathways, conditions where oral infection impacts systemic health. (See the British Society of Paediatric Dentistry’s Oral health pathway for children and young people with a new cancer diagnosis)
• disability or social factors: learning disability, autism, safeguarding concerns, deprivation, language barriers
• access barriers: transport difficulties, clinic accessibility, family capacity or health literacy
• legal or ethical factors: consent issues, parental responsibility, safeguarding thresholds

3.3 Workforce

3.3.1 Minimum workforce composition by level

Staffing must ensure safe skill mix, safeguarding competence, supervision and compliance with sedation or general anaesthetic requirements. Workforce modelling should be informed by case-mix data and local epidemiology. Managed clinical networks play a key role in ensuring regional alignment and equity of provision.

Summary of levels of care

Level 1a

Core clinical team: General dental practitioner; dental care professionals including therapists, hygienists and dental nurses with extended duties

Additional roles: Health visitor or early years links; safeguarding lead; translation or advocacy support

Governance and links: Risk-based recall (NICE/SDCEP); Delivering better oral health prevention; safeguarding per General Dental Council and Care Quality Commission; audit or quality improvement

Level 1b

Core clinical team: General dental practitioners and dental therapists with enhanced training; dental nurses (including extended duties)

Additional roles: Access to specialist or consultant peer review through managed clinical network

Governance and links: As Level 1a plus embedded in managed clinical network referral pathways; proportionate outcome recording

Level 2

Core clinical team: Practitioner with Level 2 competency; enhanced dental care professional skill mix

Additional roles: Access to consultant or specialist advice through managed clinical network or local commissioned pathways

Governance and links: As Level 1 plus embedded in managed clinical network referral pathways; formal managed clinical network governance; escalation protocols; outcome reporting; activity coding

Level 3a

Core clinical team: Specialist in paediatric dentistry (General Dental Council Specialist Register); community or hospital team; paediatric anaesthetists

Additional roles: Multidisciplinary team with oral and maxillofacial surgery, restorative, orthodontics, paediatrics, oral medicine, oral surgery, special care; speech and language therapy, dietetics or psychology as needed

Governance and links: As Level 1 and 2 plus tertiary pathways; multidisciplinary team boards; prioritisation standards; training to General Dental Council curriculum; hosting specialty trainees

Level 3b

Core clinical team: Consultant in paediatric dentistry (certificate of completion of secondary training); consultant orthodontists; consultant anaesthetists; dental therapists; dental radiographers; registered children’s nurses; healthcare play specialists; care coordinators

Additional roles: As 3a plus paediatric diagnostic radiologists; physiotherapists (musculoskeletal or temporomandibular joint (TMJ)); paediatric clinical psychologists; formal access to oral and maxillofacial surgery

Governance and links: As 3a plus Specialised surgery in children service specification (E02/S/a) compliance; Specialised Services Quality Dashboard reporting; Morbidity and Mortality (M and M) meetings; Surgery in Children Clinical Networks; National Children’s Improvement Programme and national registry engagement

Dental therapists may deliver treatment within their scope of practice under general anaesthetic, in line with the Joint statement on dental therapists in general anaesthetic settings (2026) (signed by the British Society of Paediatric Dentistry, British Association of Dental Therapists, British Society for Special Care Dentistry, and the Society for the Advancement of Anaesthesia in Dentistry) and the General Dental Council’s Scope of Practice guidance and the Safe Practitioner Framework. 

Procedures under general anaesthetic include restorative care, extraction of primary teeth, and placement of preformed crowns in scope.

Complex procedures — including surgical extractions involving bone removal, endodontic treatment in permanent teeth, and advanced radiographic interpretation — remain the responsibility of dentists.

Dental therapists working in general anaesthetic settings require immediate and close supervision (supervisor physically present in theatre or immediately available in an adjacent theatre), and must have completed training in general anaesthetic protocols, immediate life support, consent processes, and airway management awareness, demonstration of competence through workplace-based assessments, logbooks and general anaesthetic-focused entrustable professional activities (EPAs) is recommended.

Services must ensure appropriate clinical governance; audit, and indemnity arrangements are in place.

3.3.2 Training and accreditation pathways

Level 1b enhanced training

Description: Short-term, skills-focused training (for example a ‘child-focused dental practice’ e-learning programme, digital handbook, webinars). Participation in specialist or consultant-led peer review through the managed clinical network.

Accreditation or governance: No formal accreditation required. Local services and managed clinical networks should support engagement and monitor participation.

Level 2 competency in community dental services

Description: Level 2 competency is expected for relevant community dental service clinicians. Community providers are responsible for ensuring staff meet and maintain Level 2 standards through continuing professional development, mentorship and regional training programmes.

Accreditation or governance: Formal accreditation panels are not required for community dental service staff. Providers must have internal processes to evidence competence, ongoing continuing professional development and supervision.

Level 2 accreditation in primary care

Description: Regions may operate structured 24-month Level 2 training pathways (for example, the Yorkshire and Humber programme) including: fortnightly specialist supervision, portfolio (clinical logbook, 8–10 case studies, 24 work-based assessments made up of 8 case-based discussions, 10 direct observations of clinical skills, 6 mini-clinical evaluation exercises, and multi-source feedback), 10 study days, a clinical governance project, and the final review.

Accreditation or governance: Formal accreditation required through local accreditation panels in line with the NHS England Accreditation Framework.

Specialist and consultant training

Description: Follows the General Dental Council Paediatric Dentistry Specialty Training Curriculum, with supporting materials and assessment processes through Royal College of Surgeons or the Intercollegiate Surgical Curriculum Programme.

Accreditation or governance: Nationally approved specialty training and accreditation processes apply (deanery or NHS England Workforce, Education and Training programmes, Annual Review of Competence Progression, specialty examination, specialist list entry).

3.4 Illustrative allocation examples

Early childhood caries, no comorbidities

Typical allocation: Level 1a or 1b

Notes: Prevention-first; Hall crowns or pulp therapy as indicated; escalate if cooperation fails or disease rapidly progresses

Acute caries in primary dentition

Typical allocation: Level 1b

Notes: Suitable for enhanced primary care; avoids unnecessary community dental services or secondary care referral

Severe caries with learning disability (manageable with enhanced behaviour management or sedation)

Typical allocation: Level 2

Notes: Stabilisation or treatment using enhanced techniques +/- sedation

Complex dental trauma (luxation or crown-root fractures)

Typical allocation: Level 3a or 3b

Notes: Specialist or consultant-led care with imaging, endodontic or trauma protocols

Developmental anomalies (for example, amelogenesis imperfecta (AI) or molar incisor hypomineralisation (MIH) or hypodontia)

Typical allocation: Level 3a or 3b

Notes: Multidisciplinary team with restorative, orthodontic or oral and maxillofacial surgery; shared care back to Level 1–2 for prevention or maintenance

Oncology or long-term medical conditions

Typical allocation: Level 3b

Notes: Tertiary acceptance criteria; close liaison with medical teams; often requiring care under general anaesthetic, aligning with medical treatment requirements and time-critical management

4. Referral management, urgent care, trauma and clinical pathways

This section sets out the requirements for referral management, urgent and unscheduled dental care, anxiety management pathways, sedation and general anaesthetic pathways and trauma care.

4.1 Principles for referral and triage

All paediatric dental referrals should be managed through a standardised NHS electronic referral management system (E-RMS) operating at ICB level. Regions must work towards this as a minimum standard.

Requirements for referral systems:

• consistency across the ICB: every provider must use the same E-RMS to ensure equitable, transparent referral processes
• access for all providers: all paediatric dentistry teams must have full access to facilitate seamless movement of referrals
• managed clinical network oversight: managed clinical networks should work with commissioning teams to agree service specifications (inclusion or exclusion criteria) for each part of the system; provide clinical governance of referral processes; ensure equity of access; monitor waiting times and support triage
• single point of referral. Wherever possible, a standardised triage at one central location should exist within each ICB, ensuring every child is triaged for complexity, urgency and appropriate level
• referrals should be accepted from: members of the oral healthcare team, aligned with national protocol; health and social care professionals; medical teams and self-referral

Minimum referral dataset

Each referral into Level 2 or Level 3 services must include:

Data elements

Patient demographics

Name, date of birth, NHS number, address, contact details

GP and dental provider

Name of referring dentist; general dental practitioner or community or hospital dental services provider

Reason for referral

Summary of presenting complaint and clinical concern

Relevant medical history

Active conditions, medications, allergies, American Society of Anesthesiologists grade, where relevant

Dental history

Treatment history, cooperation history, previous sedation or general anaesthetic

Current dental status

Clinical and radiographic findings; caries, trauma or anomalies

British Dental Association case mix

Domains and overall complexity rating (where available)

Safeguarding, social history and reasonable adjustments

‘Was not brought’ history, ‘looked after child’ status, safeguarding concerns, relevant social factors, details of parental responsibility or legal guardian, and required reasonable adjustments, including other key professionals involved in the child’s care

Urgency

Routine, urgent or emergency, as defined in the Clinical guidance on unscheduled urgent and non-urgent dental care (section 4.4)

Preferred level of care

Level 1b, Level 2, Level 3a or Level 3b

Referrer commitment to ongoing care

Confirmation that the referrer will provide routine and shared care, including preventive follow up, where appropriate, even when the child is accepted for higher levels of care.

4.2 Anxiety management and sedation pathways

Services should provide a clear, graduated approach to anxiety management, progressing from non‑pharmacological strategies to pharmacological options in line with the Clinical standard for dental anxiety management and relevant paediatric guidance. This section summarises how those pathways apply within paediatric dental care across all complexity levels.

Non-pharmacological anxiety management

Non-pharmacological anxiety management

All levels

Tell-show-do, modelling, distraction, guided imagery; consistent team approach; acclimatisation; adapted communication for special education needs and disabilities

Level 1b onwards

Enhanced techniques (for example cognitive behavioural therapy-informed approaches, structured acclimatisation, parental coaching) in line with the Prevention and management of dental caries in children (SDCEP) guidance and Royal College of Surgeons’ and British Society of Paediatric Dentistry guidance on anxiety management and sedation.

Pharmacological anxiety management and sedation

Inhalation sedation (Nitrous oxide)

Applicable level: Level 1b (where trained); Level 2; Level 3a or 3b

Key standards: IACSD (2020): appropriately trained and experienced operator-sedationist, dedicated trained sedation nurse, appropriate monitoring, suitably equipped facility, and written protocols for patient selection, monitoring, recovery and discharge

Intravenous sedation

Applicable level: Level 2 (typically children and young people aged 12 and over, where trained and commissioned, in line with IACSD 2020 and local pathway agreements); Level 3a or 3b

Key standards: IACSD (2020): consultant or specialist oversight; age-appropriate protocols; trained team and recovery facilities

Advanced sedation techniques

Applicable level: Level 3a or 3b only

Key standards: IACSD (2020) and the Guidelines for the provision of anaesthesia services; delivered in hospital or specialist environment with anaesthetic support

Governance requirements for sedation:

• all sedation services must be registered with and meet the Care Quality Commission standards.
• minimum sedation training, equipment and monitoring standards must meet the standards of Intercollegiate Advisory Committee for Sedation in Dentistry (2020)
• sedation must not be used as a substitute for addressing the underlying cause of dental anxiety
• regular audit of sedation activity, outcomes and complications should be completed

4.3 General anaesthetic pathways

General anaesthetic for dental treatment in children and young people must only be performed in a hospital setting with appropriate paediatric facilities, staffing and governance. This section provides the authoritative framework for general anaesthetic pathways (and is aligned with the Royal College of Anaesthetists’ Guidelines for the provision of anaesthetic services). The standards at Levels 3a and 3b (Section 3.1.1) reference this section.

Core principles

• general anaesthetic is a last resort and should only be used when all reasonable non-general anaesthetic alternatives have been explored
• the decision for general anaesthetic must be clearly documented, with evidence that non- general anaesthetic options were considered, discussed with the family, and found to be inappropriate or not feasible
• all children and young people referred for dental general anaesthetic must have a comprehensive treatment plan that maximises the benefit of the single general anaesthetic episode, reducing repeat general anaesthetic risk
• pre-operative assessment should be conducted in line with Royal College of Anaesthetists’ Guidelines for the provision of anaesthetic services and Association of Paediatric Anaesthetists of Great Britain and Ireland’s guidance

Operational requirements

• dedicated paediatric dental general anaesthetic lists must take place with appropriate anaesthetic, nursing and dental staffing
• pre-operative assessment should take place in line with national guidance and within a child-friendly environment
• access to paediatric high-dependency or critical care as required by case complexity should be available.
• families must be provided with clear post-operative instructions, including pain management, diet advice and follow-up
• post-general anaesthetic follow-up should be arranged within 3-6 months either in the general anaesthetic service or an appropriate primary/community setting, with subsequent recall on a risk-based interval in line with NICE CG19

Prevention integration

• every dental general anaesthetic episode must include a structured preventive intervention (for example fluoride varnish, fissure sealants where indicated, and a written prevention plan), with the agreed preventive pathway clearly documented in the discharge letter back to the Level 1 provider
• post-general anaesthetic follow-up and delivery of ongoing preventive care should then be led by the primary care dental team (Level 1a, 1b or 2), in line with local recall and risk-based pathways

4.4 Urgent and emergency care or trauma

General principles

• all children and young people presenting with dental emergencies should receive timely assessment and management, irrespective of any existing care relationship with a dental team
• urgent and emergency dental care for children should operate within the wider unscheduled care system (including NHS 111, urgent dental care services and emergency departments) and be consistent with the national Clinical guidance on unscheduled urgent and non-urgent dental care, which should be referred to for definitions of emergency, urgent and non‑urgent unscheduled care and the associated response times.
• management of dental trauma in children should follow the International Association of Dental Traumatology guidelines and the Dental trauma guide, with prompt access to appropriately trained paediatric dental or maxillofacial teams for complex injuries.

Trauma pathways

This framework describes the typical level of service at which different severities of dental trauma should be managed.

Dental trauma management

Uncomplicated (subluxation, uncomplicated crown fractures)

Management level: Level 1a or 1b

Key actions: Immediate assessment, simple splinting of minor injuries where indicated (for example short-term flexible splints for uncomplicated luxation injuries); conservative restoration or temporisation of uncomplicated crown fractures (for example, smoothing sharp edges, bandage or temporary dressings or simple composite build ups); soft diet advice, follow-up and referral if complexity exceeds Level 1.

Moderate complexity (complicated crown fractures, uncomplicated root fractures, post-avulsion follow-up of uncomplicated cases)

Management level: Level 2

Key actions: Specialist-directed care, including repositioning, definitive splinting, pulp therapy, and structured follow-up according to trauma guidelines, taking into account the stage of root development (for example, immature versus mature permanent teeth). Cases with complications, multi-tooth involvement or risk of failing teeth should be followed up at Level 3a/3b.

High complexity (severe luxation, multi-tooth injuries, alveolar fractures)

Management level: Level 3a or 3b

Key actions: Specialist or consultant-led multidisciplinary team care in hospital or specialist settings, advanced imaging, surgical management and complex splinting as part of comprehensive trauma care.

At Level 1, splinting is limited to simple cases in cooperative children that fall within the expected scope of a general dental practitioner; more complex or prolonged splinting, and higher-risk trauma presentations, should be managed at Levels 2 or 3 in appropriate specialist or hospital settings. Where high-complexity trauma is initially managed at Level 3a or 3b, structured follow-up should also be delivered at that level until the dentition is stable, given the volume-dependent nature of follow-up assessment and the frequent need for multidisciplinary team input where failing teeth are identified.

4.5 Transition and cross-specialty pathways

Transition into adult services

Young people should transition to adult services in line with NICE NG43. Transition must include:

• early planning: beginning well before the young person’s 16th birthday
• co-produced plans: young people and families involved in planning
• joint care models: joint appointments between paediatric and adult services where available
• defined adult pathways: clarity on receiving adult providers and referral criteria
• equity and continuity: no gaps in care, particularly for medically complex young people or those with special educational needs or disabilities

Cross-specialty pathways

The pathways below are illustrative of common cross-specialty interactions in paediatric dental care; they are not an exhaustive list. Children with conditions not specifically listed should be managed using the same shared-care principles, with input from the relevant medical and social care teams.

Medically complex pathways

Oncology or haematology

Pre-treatment dental assessment and optimisation; oral health monitoring during treatment; post-treatment rehabilitation; shared protocols with oncology multidisciplinary team

Congenital heart disease

Dental fitness assessment prior to cardiac surgery; prevention-focused management; coordinated care with cardiology team

Cleft lip and palate

Dental care within regional cleft multidisciplinary team hub-and-spoke model; shared care with Level 1 or 2 for routine prevention

Organ transplant or renal

Pre-transplant dental assessment to identify and stabilise sources of oral infection before immunosuppression; ongoing immunosuppression-aware dental management post-transplant

Diabetes or endocrine

Periodontal monitoring; coordinated recall with medical review

Mental health or eating disorders

Awareness of dental erosion and oral manifestations; liaison with child and adolescent mental health services (CAMHS) where indicated

Bleeding disorders (for example haemophilia, von Willebrand)

Shared protocols with haemophilia centre; pre-procedural factor cover or local haemostatic measures; coordinated planning for extractions and surgical procedures

Antiresorptive or bisphosphonate therapy

Medication-related osteonecrosis of the jaw (MRONJ) risk awareness; pre-treatment dental optimisation before initiation where possible; shared protocols with prescribing paediatric team

‘Looked after’ children and care-experienced young people

Statutory dental health assessment within initial health assessment; flexible appointment models; close liaison with corporate parent and social worker; continuity of care across placement changes

5. Governance, managed clinical networks and service configuration

5.1 Clinical governance standards

All providers of paediatric dental services must maintain clinical governance systems that ensure:

• safe, effective, evidence-based, person-centred care in line with General Dental Council standards and Care Quality Commission requirements
• incident reporting, learning and action
• regular clinical audit and quality improvement
• compliance with infection prevention and control standards
• evidence-based prescribing and radiation exposure management (IRMER)

For Level 3b services, additional governance requirements are set out in the Specialised surgery in children service specification (E02/S/a), including Specialised Services Quality Dashboard reporting and mandatory Morbidity and Mortality (M and M) meetings.

5.2 Role of paediatric dental managed clinical networks

Every ICB should have access to a paediatric dental managed clinical network that provides:

• clinical leadership and quality assurance across all levels
• oversight of referral systems, triage standards and waiting times
• support for workforce planning, training and accreditation
• facilitation of shared care, step-down and cross-level coordination
• engagement with commissioners, public health teams and wider system partners
• monitoring of access, equity and outcomes across the network
• Managed clinical networks should include representation from primary care, community dental service, hospital services, specialist or consultant paediatric dentistry, commissioners and patient or public voice.

5.3 Service models and hub-and-spoke arrangements

Paediatric dental services should be configured on a hub-and-spoke basis, with tertiary or specialist hubs providing expertise, training and governance support to spoke services at Levels 1 and 2. Configuration should ensure:

• equitable geographic access across the ICB footprint
• sufficient capacity at each level based on epidemiological need
• clear pathways between levels with defined escalation and step-down criteria
• consideration of outreach, virtual consultation and teledentistry to support care closer to home
• integration with wider children’s services (health visiting, school nursing, CAMHS, paediatrics)

5.4 Safeguarding leadership

This section consolidates all safeguarding requirements. Safeguarding is a statutory, ethical and clinical duty for all dental professionals across every level of care.

Universal requirements (all levels)

• dental teams must identify, document and respond to concerns about neglect, abuse or vulnerability
• missed appointments must be recorded as ‘was not brought’ and considered a potential safeguarding concern
• all staff must meet mandatory safeguarding training requirements per their role
• services must follow national safeguarding guidance, including Working Together to Safeguard Children 2026, maintain updated policies, engage in multi-agency safeguarding arrangements, and comply with General Dental Council and Care Quality Commission requirements
• dental teams should be aware of Operation Encompass (now a statutory duty under the 2026 guidance), which enables schools to notify relevant professionals when a child has been exposed to domestic abuse; children may present with unexplained facial or dental injuries following such incidents

Enhanced requirements (Level 2 and above):

• named safeguarding lead (and deputy) with strategic oversight
• safeguarding supervision embedded within the service
• staff delivering clinical services to under-18s should complete Level 3 paediatric and Level 3 adult safeguarding training
• appropriately resourced to participate in local safeguarding arrangements and facilitate child protection referrals

Where safeguarding concerns are identified through dental presentation, the dental team must share information with the child’s GP, named safeguarding professional, health visitor, school nurse and other relevant agencies, in line with the integration principles set out in the wider system context, integration and accountability section.

6. Quality, outcomes and data

6.1 Quality domains

Quality monitoring should be organised across the domains of access, activity, clinical outcomes, patient experience, and safety. The following combined indicator set provides the recommended framework for outcome recording and performance monitoring.

6.2 Recommended indicators and performance monitoring

Quality and performance indicators

Access – Waiting time for assessment (Levels 3a and 3b)

Frequency: Monthly

Standard or target: 92% within 18 weeks; 0% over 52 weeks (NHS Constitution referral to treatment standard)

Access – Waiting time for assessment (Level 2)

Frequency: Monthly

Standard or target: 18-week aspiration (NHS England community dental service guidance, August 2025); 0% over 52 weeks

Access – Waiting time for treatment (Levels 3a and 3b)

Frequency: Monthly

Standard or target: 92% within 18 weeks; 0% over 52 weeks (NHS Constitution referral to treatment standard)

Access – Waiting time for treatment (Level 2)

Frequency: Monthly

Standard or target: 18-week aspiration; 0% over 52 weeks

Access – Number waiting for assessment and treatment (Levels 2, 3a and 3b)

Frequency: Monthly

Standard or target: Reported for transparency; trajectory improvement where above 18-week threshold

Access – Time from referral to treatment for trauma: avulsion or luxation (all levels)

Frequency: Monthly

Standard or target: Same day or within 24 hours

Access – Time from referral to treatment for trauma: crown or root fracture with pulp exposure (all levels)

Frequency: Monthly

Standard or target: Within 48 hours

Access – Time from referral to treatment for trauma: uncomplicated or sub-acute (all levels)

Frequency: Monthly

Standard or target: Within 2 weeks

Activity – Number seen for assessment (Levels 2, 3a and 3b)

Frequency: Monthly

Standard or target: Locally agreed activity plan

Activity – Number seen for treatment (Levels 2, 3a and 3b)

Frequency: Monthly

Standard or target: Locally agreed activity plan

Activity – New-to-follow-up ratio by performer (Levels 2, 3a and 3b)

Frequency: Monthly

Standard or target: Managed clinical network-agreed benchmark; variation triggers peer review

Activity – Number assessed and accepted for Level 3 care (Levels 3a and 3b)

Frequency: Monthly

Standard or target: Reported for capacity planning

Activity – Number discharged complete (Levels 2, 3a and 3b)

Frequency: Monthly

Standard or target: Step-down trajectory monitored by managed clinical network

Activity – Proportion of children seen receiving fluoride varnish application in line with Delivering better oral health (all levels)

Frequency: Quarterly

Standard or target: Reported for transparency; benchmarked at managed clinical network level; supports prevention monitoring across the system

Outcome – Repeat general anaesthetic rate, with case-level review of avoidability (Levels 3a and 3b)

Frequency: Quarterly

Standard or target: Local audit identifying preventable vs clinically indicated repeat episodes; benchmarking against national or managed clinical network distribution; where a service is a national outlier, a reduction trajectory is expected

Outcome – Patient reported outcome measures (for example, ‘CARIES-QC’) (Levels 2, 3a and 3b)

Frequency: Quarterly

Standard or target: Baseline to be established; improvement trajectory

Outcome – Patient reported experience measures (Levels 2, 3a and 3b)

Frequency: Quarterly

Standard or target: Minimum 85% positive experience (aspirational)

Safety – ‘Was not brought’ (WNB) rate, with case-level safeguarding review of repeat WNB (all levels)

Frequency: Monthly

Standard or target: Every WNB triggers review per safeguarding policy; rates reported and benchmarked stratified by deprivation, special educational needs and disabilities and ‘looked after child’ status; unexplained variation reviewed by managed clinical network

Safety – Cancellation rate by provider (Levels 2, 3a and 3b)

Frequency: Monthly

Standard or target: Less than 5% provider-initiated cancellation, excluding cancellations on clinical safety grounds (for example child unwell, sedation contraindication identified at pre-op check)

Safety – Safeguarding referral activity (all levels)

Frequency: Quarterly

Standard or target: Reported for governance; unexplained variation reviewed by managed clinical network

Equity – Data stratified by deprivation, ethnicity, special educational needs and disabilities or learning disabilities, ‘looked after child’ status (all levels)

Frequency: Quarterly

Standard or target: No statistically significant unexplained variation in access or outcomes, while recognising that some positive variation may occur where resources have been deliberately targeted to reduce inequalities

6.3 Datasets and reporting

Providers must submit activity and outcome data using national NHS datasets and any additional fields specified in local commissioning arrangements. Where systems are not yet in place to collect all of the indicators in Section 6.2, providers must agree a phased implementation plan with their commissioner and managed clinical network, prioritising indicators already captured and agreeing how and when the remainder will be brought into routine reporting.

Providers should report transparently against what they can collect and flag indicators still in development, rather than submit incomplete or unreliable data. Once an indicator is established within agreed local arrangements, persistent failure to submit complete and accurate data may trigger contractual performance review and remedial action.

Managed clinical networks should aggregate and benchmark data across providers to identify unwarranted variation, monitor equity of access and outcomes, and drive quality improvement. The managed clinical network chair should produce an annual report summarising network performance, key trends and agreed improvement actions for commissioners and provider organisations.

7. Implementation and review

7.1 Implementation support

Commissioners, managed clinical networks and providers should use this standard when updating service specifications and pathways. Where services are not yet meeting these clinical standards, implementation should be phased, with an agreed timeline and trajectories for achieving full compliance.

Local implementation should involve:

• co-production with patients, families and community representatives
• alignment with ICB dental commissioning strategies
• managed clinical network leadership in pathway redesign and quality assurance

7.2 Review cycle

This standard will be reviewed every 5 years, or earlier if required by national policy changes.

7.3 Relationship with local commissioning

This clinical standard informs the development of local service specifications, which should also reflect regional priorities, resources, and models of care. The standard provides the national framework; local specifications provide the operational detail.

Appendix 1: Treatment categories by level of care

This appendix provides a summary at-a-glance of how the main categories of paediatric dental care map across levels. It is intended as a quick reference for clinicians, commissioners and managed clinical networks. The detailed descriptors of activity at each level — including the specific procedures, conditions and patient groups managed — are set out in appendix 2.

Each level escalates by patient complexity, behaviour or sedation requirements, setting, and need for multidisciplinary input or general anaesthetic.

Clinical activity by category and level

General and preventive

Level 1 (1a or 1b): Evidence-based prevention and risk-based recall; behaviour management and acclimatisation; topical fluoride varnish; silver diamine fluoride (SDF); sports mouthguards

Level 2: As Level 1 for children with added complexity using enhanced behaviour support and/or sedation

Level 3 (3a or 3b): Consultant-led preventive care within managed clinical network or general anaesthetic pathways

Restorative or prosthodontic

Level 1 (1a or 1b): Management of ‘making every contact count’ and limited disease; direct restorations; preformed metal crowns (Hall or conventional)

Level 2: Moderate treatment needs suitable for local anaesthetic or sedation; deliver parts of complex plans under specialist direction

Level 3 (3a or 3b): Specialist or consultant-level restorative planning and delivery including developmental defects; comprehensive care under general anaesthetic

Endodontics

Level 1 (1a or 1b): Pulp therapy in primary teeth; simple endodontics in permanent teeth with closed apices

Level 2: Simple endodontics in immature permanent teeth; emergency pulpal management beyond Level 1

Level 3 (3a or 3b): Specialist or consultant endodontic care for non-vital immature teeth, complex access, general anaesthetic or multidisciplinary team

Periodontal

Level 1 (1a or 1b): Routine periodontal assessment; oral hygiene instruction; non-surgical management

Level 2: As Level 1 for children with additional complexities

Level 3 (3a or 3b): Specialist or consultant periodontal care within multidisciplinary team and/or general anaesthetic pathways

Oral pathology or surgery

Level 1 (1a or 1b): Routine extractions under local anaesthetic; incision and drainage; identification and referral of oral lesions

Level 2: Extractions where complexity or cooperation exceeds Level 1; minor soft tissue lesion management; sedation-supported care

Level 3 (3a or 3b): Comprehensive general anaesthetic surgical care; joint procedures with other surgical specialties

Trauma

Level 1 (1a or 1b): Emergency care for subluxation or mild luxation and uncomplicated crown fractures; reimplantation in emergency; arrange follow-up

Level 2: Complicated crown fractures; uncomplicated root fractures; repositioning and splinting; follow-up of single-tooth and uncomplicated multi-tooth injuries within Level 2 scope

Level 3 (3a or 3b): Moderate-severe luxation; avulsions with complications; complex surgical intervention; autotransplantation; structured follow-up of complicated multi-tooth trauma, including identification and multidisciplinary planning of failing teeth (orthodontic, restorative and surgical input as required)

Developmental anomalies

Level 1 (1a or 1b): Identification and monitoring; fissure sealants for molar incisor hypomineralisation (MIH); referral of complex anomalies

Level 2: Intermediate management of MIH and enamel defects amenable to sedation-supported care where appropriate

Level 3 (3a or 3b): Specialist or consultant-led multidisciplinary team care for complex developmental anomalies (for example amelogenesis imperfecta (AI), dentinogenesis imperfecta (DI), severe MIH, severe hypodontia), including transition planning to adult restorative care and shared care prevention and maintenance; may include planning and delivery of tooth whitening of intrinsically discoloured teeth using peroxide-based agents where indicated as treatment of disease rather than cosmetic whitening, in line with UK law, General Dental Council guidance and local governance.

Developing dentition

Level 1 (1a or 1b): Monitoring and management of eruption problems; simple space maintenance; referral for complex orthodontic issues

Level 2: Interceptive management of developing dentition where enhanced cooperation support is needed

Level 3 (3a or 3b): Specialist or consultant management including surgical exposure or removal, comprehensive management within multidisciplinary team or general anaesthetic pathways

Appendix 2: Treatment complexity levels

This appendix sets out the detailed descriptors of activity at each level of care, complementing the summary in appendix 1.

Where appendix 1 maps care categories across levels, appendix 2 describes the specific procedures, conditions and patient groups managed at each level. Both appendices should be read together.

Level 1a

The conditions and treatments at Level 1a are those that can be performed or managed by a dentist whose competence is commensurate with the Curriculum for Dental Foundation Training or its equivalent, and include:

• oral health assessment of need and circumstances, oral health review, risk screening and treatment planning including appropriate referral, where necessary, for all children
• evidence-based preventive care, advice and interventions
• restorations of primary and permanent teeth with the use of local anaesthesia where appropriate, including pulp therapies of primary molars and pre-formed metal crowns where appropriate
• uncomplicated endodontic treatment of permanent teeth
• simple partial dentures and removable space maintainers
• routine extraction of primary and permanent teeth under local anaesthesia
• emergency and urgent treatment and management of pain, infection and dento-alveolar trauma, including immediate management of avulsion injuries in line with International Association of Dental Traumatology guidelines
• timely identification and referral of significant developmental defects of the dental tissues and disturbances of the developing dentition
• management of dento-alveolar traumatic injuries to the primary and permanent dentition (for example subluxation and mild luxation injuries of primary and permanent teeth; uncomplicated crown fracture of primary or permanent incisors)
• appropriate referral of children requiring more complex treatment that is Level 2, 3a or 3b

Level 1b – Enhanced primary care (‘child-focused dental practice’)

Conditions appropriate for management in child-focused dental practice by clinicians with enhanced training, embedded within managed clinical network referral pathways.

Level 1b includes:

• the management of localised or moderately extensive caries in cooperative children, including multi-surface restorations in primary and permanent teeth where care can be delivered under local anaesthesia, with or without inhalation sedation
• pulp therapy and preformed metal crowns for primary molars in children whose behavioural and medical profile does not require Level 2 or 3 care
• completion of simple treatment plans for early childhood caries where disease can be stabilised and restored in primary care without the need for intravenous sedation or general anaesthetic
• management of mild dental anxiety using communication techniques, tell-show-do and, where indicated, inhalation sedation in line with the IACSD standards
• first-line management of uncomplicated dento-alveolar trauma that falls within Level 1 (for example subluxation, minor luxation, uncomplicated crown fractures), where the child can cooperate in a primary care setting
• ongoing preventive care and caries-risk-based recall for children who have completed care in Level 2 or 3 services and can safely be maintained in enhanced primary care
• stabilisation and interim care (for example caries control, temporary restorations, extractions under local anaesthetic) for children awaiting specialist review, where there are no significant medical, behavioural or social modifying factors
• delivery of care for children and young people with low-level additional needs (for example, mild learning difficulty, mild autism spectrum disorder or attention deficit hyperactivity disorder with good support) where behaviour is predictable and safely manageable with reasonable adjustments in a general dental practitioner or child-focused dental practice environment

Level 2

This level of care involves complex clinical needs or patient factors and must be delivered by a clinician with enhanced skills and experience, whether or not they are on a specialist register.

This care may require additional equipment or environment standards but can usually be provided in the community dental services and primary care when part of a formally accredited programme.

Level 2 covers:

• the management of complicated crown fracture of permanent teeth
• the management of complicated primary tooth trauma, including luxation and intrusion injuries, and injuries with potential impact on the developing permanent successor (for example risk of enamel hypoplasia, eruption disturbance, or damage to the successor tooth germ)
• root and crown-root fractures of permanent teeth without features requiring multidisciplinary or surgical management (for example, extensive subcrestal fracture, severe displacement, combined periodontal or orthodontic needs)
• post-emergency follow-up of multi-tooth injuries in the permanent dentition without features suggesting risk of failing teeth or need for multidisciplinary planning; cases with such features should be followed up at Level 3a or 3b
• emergency management of injuries to primary and permanent teeth where the required assessment or treatment (for example, complex splinting, repositioning, pulp therapy or management of multiple injuries) lies beyond Level 1
• management of hard-tissue dental defects and disturbances of the developing dentition not requiring specialist or multidisciplinary management for example early permanent tooth surface loss, developmental defects of primary or permanent teeth amenable to and stabilised by simple restoration
• management of more complex problems affecting the developing dentition or dental hard tissues under the direction of a specialist or consultant in paediatric dentistry
• extraction of teeth under general anaesthesia in line with a specialist‑ or consultant‑led treatment plan, including operative care and immediate post‑operative follow‑up where the overall complexity remains within Level 2
• management of children with routine oral health surveillance or treatment needs but where behavioural or psychological development or significant anxiety increases the complexity of delivery of care such as those requiring sedation
• management of children with routine oral health surveillance or treatment needs but where medical comorbidity or disability increases the complexity of delivery of care
• inhalation sedation where appropriate for all ages of children and intravenous sedation for children aged 12 and above
• management of children with extensive caries or early childhood caries amenable to care under local anaesthesia or with sedation as described above, as an adjunct
• assessment and management (or referral to a higher level, as appropriate) of children subject to a child protection plan or looked after by the local authority (usually in foster or residential care) who either have no current arrangement for ongoing oral health review with the general dental service or who are identified to have unmet dental needs

Level 3a

The conditions, care and procedures at Level 3a are those that should be performed or managed by a dentist recognised by the General Dental Council as a specialist in paediatric dentistry.

These include:

• severe early childhood caries or unstable or extensive caries especially where treatment under general anaesthesia may be necessary
• moderate to severe tooth surface loss in the permanent dentition
• molar incisor hypomineralisation (MIH), amelogenesis imperfecta, dentinogenesis imperfecta, mild to moderate hypodontia
• supernumerary teeth and or delayed eruption of permanent teeth not requiring complex surgical or multidisciplinary management
• restorative and exodontia treatments for children with cleft lip and or palate being managed under the direction of a regional multidisciplinary team. Routine restorative and exodontia treatment is delivered at Level 3a; advanced rehabilitative care is delivered at Level 3b (see below)
• avulsion injuries and post-avulsion management, especially where complications have developed.
• management of injuries to immature permanent incisors where endodontic management is required.
• moderate-to-severe luxation injuries, especially when complications have developed
• injuries involving significant damage to multiple teeth
• aggressive periodontitis or other less common periodontal or gingival conditions.
• uncomplicated dento-alveolar surgical interventions
• dental care of children with significant anxiety and or behavioural disturbance
• treatment planning, support, and follow-up for children requiring extractions under general anaesthesia
• treatment planning and delivery of comprehensive dental care under general anaesthesia, including more difficult surgical or restorative procedures within the scope of Level 3a
• oral health surveillance and treatment needs where significant medical comorbidity, or disability increases the complexity and risks of delivery of care. Such care may be shared with a consultant and many of these children will be under the ongoing care of a paediatrician.  Examples of comorbidities include, but are not limited to: significant cardiovascular disease, significant abnormalities of haemostasis, children undergoing treatment for haematological or organ malignancies, children with significant disability or learning difficulties and children with significant behavioural problems or communication disorders (autism).

Level 3b

The distinction between Level 3a and Level 3b is primarily clinical, reflecting whether overall responsibility for a child’s care rests with a specialist (3a) or a consultant (3b) in paediatric dentistry. The level designation refers to the model of care and clinical leadership required, not to the setting in which care is delivered or to a fixed allocation of procedures.

Level 3b activity may therefore be delivered in either hospital dental services or community dental services, provided the service has appropriate consultant leadership, workforce, facilities and governance arrangements in line with the relevant specialised service specification. Equally, Level 3b services routinely deliver Level 3a activity as part of their broader caseload, and some activity described at Level 3b may, depending on workforce configuration, be delivered within a Level 3a service that has consultant input. Local commissioners and managed clinical networks should agree how levels are configured within their geography to ensure children receive care led by clinicians with the appropriate skills, recognising that workforce distribution and service models will vary.

The bullets below describe the categories of clinical activity delivered at Level 3b. The specific in-scope conditions are set out in appendix 3 and align with the specialised surgery in children service specification (E02/S/a).

Care should be delivered by a dentist recognised as a consultant in paediatric dentistry.

Level 3b covers the assessment and management of complex dental or cranio-facial conditions that require multidisciplinary team input to treatment planning and care. It also covers situations where the management of a disturbance in dental development is complicated by features requiring input or active treatment by other dental specialties.

Examples include:

• moderate to severe hypodontia, and significant dental hard-tissue developmental defects, especially during transition into orthodontic and definitive adult restorative management and treatment
• traumatic dento-alveolar injuries where significant complications have arisen, especially where multidisciplinary planning and care is required (including tooth autotransplantation)
• patients requiring obturators or advanced intermediate restorative management as part of cleft, craniofacial or post-oncology rehabilitation pathways, delivered within the relevant multidisciplinary team
• patients with complex presentations of tooth morphology (macrodontia, double teeth, dens-in-dente, talon teeth)
• assessment and management of oral pathology or oral medical conditions
• assessment, surveillance and treatment of children with significant co-morbidity being managed by other paediatric specialities (for example, oncology, cardiology, haematology, hepatology, nephrology, endocrinology). For example, this may include providing urgent dental treatment prior to open heart surgery, organ transplant, or prior to commencing chemotherapy
• assessment and management of children with significant disability, complex comorbidity or severe behavioural disturbance whose dental care requires tertiary-level multidisciplinary work-up, hospital admission, or delivery alongside other paediatric or surgical specialties (for example, joint anaesthetic planning with paediatric cardiology or intensive care, or care coordinated within an inpatient admission)
• treatment planning and delivery of dental care under general anaesthesia where the child is undergoing joint procedures with another surgical specialty, or where perioperative management requires tertiary-level paediatric medical or anaesthetic input
• acute dental emergencies in children otherwise meeting Level 3b criteria, including those requiring inpatient management or care alongside other paediatric specialties

Appendix 3: Conditions within Level 3b’s scope (E02/S/a)

The specialised surgery in children service specification (E02/S/a) defines the conditions for which specialist paediatric dental services are expected. This list is not exhaustive.

Conditions requiring specialist or consultant-led care

Congenital and acquired conditions associated with abnormal tooth and jaw development

Ectodermal dysplasia, cleidocranial dysplasia, Williams syndrome, Treacher Collins syndrome, osteogenesis imperfecta, X-linked hypophosphataemia, genetic and endocrine disorders

Conditions where mouth opening is limited or restricted

TMJ disorders, juvenile idiopathic arthritis, craniofacial syndromes, neuromuscular conditions, orofacial burns and scarring, mucopolysaccharidosis, scleroderma

Conditions predisposing to salivary abnormalities

Reduced salivary gland function, salivary gland aplasia, drug complications, ectodermal dysplasia

Oral soft tissue and periodontal conditions associated with systemic disease

Gingival fibromatosis, Behçet’s disease, oral Crohn’s disease, anaemias, connective tissue diseases, gingival overgrowth, epidermolysis bullosa

Acute and chronic destructive periodontal conditions associated with systemic disease

Papillon–Lefèvre syndrome, Langerhans cell histiocytosis, hypophosphatasia, glycogen storage disorders, Ehlers–Danlos syndrome, neutropenia

Vascular and lymphatic malformations of the face and mouth

Lymphangiomatosis, haemangiomas

Oral conditions in newborns

Neonatal teeth, congenital epulis

Orthodontic abnormalities in children and young people with complex health conditions and neurodevelopmental conditions

Maxillary protrusion or deficiency, vertical skeletal excess, alignment problems, posterior crossbite

Complex dental or cranio-facial conditions requiring multidisciplinary team input

Severe hypodontia in ectodermal dysplasia, cleidocranial dysplasia, macrodontia, microdontia, complex presentations of tooth morphology

Severe traumatic oral injury requiring acute management and complex rehabilitation

Injuries arising from significant disability, severe epilepsy, self-mutilating behaviours, hereditary sensory neuropathies, Lesch–Nyhan syndrome

Paediatric oral pathology and oral medicine conditions

Oral ulcerative conditions, polyps and growths, mucoceles

Complex comorbidities influencing dental management or perioperative care

Oncology, cardiac surgery, organ transplant, chemotherapy, stem cell transplant pathways

Acute and chronic oral health conditions arising in long-term hospital admissions

Dental disease or oral infection impacting on systemic health

Appendix 4: Related standards and guidance

You should read this clinical standard alongside the following publications, which set out the evidence base, pathways and requirements relevant to oral health and dental care for children and young people.

Prevention and recall

Delivering better oral health (Department of Health and Social Care and NHS England): Prevention toolkit for all levels of care

Dental checks: intervals between oral health reviews (National Institute for Health and Care Excellence CG19): Risk-based recall intervals

Prevention and management of dental caries in children (Scottish Dental Clinical Effectiveness Programme (SDCEP)): Caries management pathways

Sedation and anaesthesia

• Standards for conscious sedation in the provision of dental care (Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD)): standards for conscious sedation (levels 1b, 2 and 3)
• Guidelines for the provision of anaesthetic services – paediatric anaesthesia, chapter 10, (Royal College of Anaesthetists): General anaesthetic provision (levels 3a and 3b)

Workforce standards and skills

• Accreditation of performers of Level 2 complexity care (NHS England): Level 2 accreditation and curriculum
• Paediatric dentistry specialty training curriculum (General Dental Council, 2023): Specialist and consultant training
• Standards for the dental team (General Dental Council): Professional standards and safeguarding requirements
• Joint statement on dental therapists in general anaesthetic settings (2026): defines dental therapists’ role, supervision requirements and governance in GA services

Service design, specifications and monitoring tools

• Specialised surgery in children service specification (NHS England E02/S/a): Level 3b conditions, workforce, facilities and governance
• Case mix 2019 (British Dental Association): Complexity assessment and allocation
• Specialist services quality dashboard (NHS England): Quality outcomes and metrics at Level 3b
• GIRFT Hospital dentistry or community dental services supplement (NHS England, Getting It Right First Time (GIRFT)): Service configuration, data quality and referral management
• Working together to safeguard children 2026 (UK Government): Safeguarding framework
• Clinical standards for dental anxiety management (NHS England): Anxiety management pathways
• Iterative pathway process map (British Society of Paediatric Dentistry): Flow diagram of paediatric dental care within an ICB
• Oral health pathway for children and young people with a new cancer diagnosis (British Society of Paediatric Dentistry): The dental assessment, prevention and treatment needed before, during and after cancer care for children and young people.

Development of this standard

This standard was developed by the British Society of Paediatric Dentistry for NHS England with input from paediatric dentistry specialists, consultants, commissioners, managed clinical network chairs, community dental services, primary care practitioners and patient representatives.

Publication reference: PRN02162