Every year, 31,165 children aged 5–9 are admitted to hospital for tooth decay treatment under general anaesthetic, costing the NHS £40.7 million. Tooth decay is the most common childhood disease globally, yet the care pathways children follow to get treatment vary wildly across England. No one knows which pathway—from a general dentist to a specialist, with or without sedation—produces the best outcomes for children, or which costs the NHS least. This matters because 29.3% of five-year-olds already have decay, and children in deprived areas are 2.5 times more likely to be affected. The problem is almost entirely preventable, but the system for treating it is unexamined. This study will map every care pathway in England, then follow 240 children through four diverse routes, tracking clinical outcomes, costs, and environmental impacts. It will also survey 352 families to find out what they value most in a pathway. If successful, the research will produce a clear, evidence-based recommendation for how the NHS should restructure children’s dental services—saving money, reducing greenhouse gas emissions from anaesthetics and patient travel, cutting waiting lists, and reinvesting savings into prevention.
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Dental caries (tooth decay) is the most common disease to affect children globally, and has significant impacts on children's quality of life.2-4 In England, 29.3% of five-year-old children have caries, with children from the most deprived areas being 2.5 times more likely to have caries.5 Caries experience is significantly higher in minority ethnic groups.5 Caries is almost entirely preventable. Many children with caries are treated by General Dental Practitioners, yet a large proportion are referred on to secondary/tertiary care services to access treatment under inhalation sedation (IHS) or dental general anaesthetic (DGA). The care pathways that children follow to receive treatment vary substantially across the country, but it remains unknown whether these pathways result in different oral health outcomes for children. Treatment of caries remains the leading cause of hospital admission for children aged 5-9 years,6 with 31,165 DGAs undertaken in 2023/24 at a cost of £40.7 million.6 NHS Standards state each child undergoing a DGA should be assessed by a specialist or consultant in paediatric dentistry, yet the workforce is insufficient.7-9 Interestingly, there is no evidence to demonstrate the impact of specialist input for children treated for caries. Both DGA and the alternative, IHS, produce greenhouse gas emissions, whilst treatment involves a range of single-use plastic products. Furthermore, patient travel can be extensive, contributing to the NHS carbon footprint. There is a lack of data to inform modelling of the carbon footprint of dental services for children. The NHS has committed to a Plastic Reduction Pledge and a Net Zero 2040 target.10 The proposed study would facilitate a triple bottom line analysis of different care pathways for children with caries. Through identification of the optimal approach, it aims to inform future restructuring of care pathways for children with caries in England. WP1 - geographical mapping Care pathways and services across England will be mapped. WP2 - longitudinal study (n=240) Four diverse care pathways from WP1 will be selected. Children will be followed through their care pathway from diagnosis, until 6 months after treatment. A range of clinician-, child- and parent/carer-reported outcomes, costs and environmental impacts will be collected at different timepoints. A cost-utility analysis will be undertaken. WP3 - qualitative interviews (Up to 30 interviews (up to 20 child-parent dyads and up to 10 clinicians)) A sub-sample from WP2 will be purposively sampled to explore child and parent/carer experiences. Clinicians' experiences will also be explored. WP4 - economic and environmental modelling The findings from the economic evaluation undertaken in WP2 will be extrapolated over a longer time horizon, and potential uncertainty around the parameters explored. Carbon footprinting will be undertaken. WP5 - preference elicitation (n=352) Preference elicitation surveys will be undertaken to identify which attributes of a care pathway matter most to children/parents. WP6 - co-design of recommendations for policy makers on the optimal care pathway for children with caries Implementation of more efficient care pathways nationally will improve outcomes for children, reduce inequalities in care and reduce waiting times, whilst NHS cost-savings can be reinvested in preventive care.
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