In this series, we’re exploring how we can adapt our practice to meet the needs of different groups of patients. This time we’re looking at the issues to consider when treating children and teenagers.

One of the best things about being a dental professional is having the chance to make a difference and this is certainly true for your young patients. As well as escaping the pain and misery of toothache, fillings and extractions, good oral health in childhood has been linked to improved long-term physical development, higher levels of wellbeing and confidence and even better educational performance.

Regular check-ups from an early age will help ensure your patients have the best start so it’s important to make the experience positive and unthreatening. That includes being able to navigate potentially tricky dento-legal areas like consent, confidentiality, compliance and child protection that might otherwise jeopardise your professional relationship.

In this article, we’ll advise you on the best way to handle five situations that often prompt calls to the DDU.

1. Assessing Gillick competence

Although children are generally considered capable of making decisions about their health from the age of 16, younger patients can also give valid consent, depending on their maturity and the nature of the decision.

This legal principle is commonly referred to as ‘Gillick competence,’ after a landmark 1985 court judgement that healthcare professionals could assess a child's capacity on a case-by-case basis. In addition, The Children (Scotland) Act 1995 suggests children are mature enough to have a view on their treatment from the age of 12, and under case law, a parent might not be able to overrule a competent young person's decision.

To assess if your young patient is ‘Gillick competent,’ you should be satisfied that they can:

Understand what the proposed decision involves, its consequences and the alternatives (including the option of no treatment).
Retain that information.
Use or weigh up that information in making a decision.
Communicate that decision.

If a patient is able to consent, take care to communicate all the information they need to make an informed decision in a way they can understand and ensure they have the chance to ask questions. Record all these conversations in the patient’s notes.

Even if a young patient is unable to consent at an appointment, things could easily have changed by the next time you see them so make a fresh assessment each time. You should also bear in mind that young patients may reach maturity during their course of treatment especially with orthodontics which usually starts when a patient has just started senior school and can continue until they are ready to take their exams. It’s important to use your judgement and involve these patients as soon as they meet the criteria for Gillick competence.

2. Obtaining parental authority

If young children don’t have capacity, you will need to obtain consent from an adult with parental responsibility under the Children Act 1989. This would generally be:

The biological mother and father (if they are named on the birth certificate). Be aware that this does not change in the event of separation or divorce, even if one parent is granted custody - parental responsibility can only be removed by the family court.
Same-sex parents who were civil partners at the time of the insemination treatment or where the second parent has applied for parental responsibility, become a civil partner of the other parent and make a parental responsibility agreement, or jointly registered the birth.
Stepparents who have acquired parental responsibility with the agreement of both parents or by court order.
A person who ‘has care’, such as a grandparent, can do what is reasonable to safeguard the child’s welfare. This doesn’t need to be confirmed by parent in writing but this makes it easier for all parties.
Adoptive parents who are named on the adoption certificate.
The local authority in cases where a child is the subject of a care order (rather than being looked after on a voluntary basis). The order does not deprive the child's parents of responsibility or the ability to authorise treatment but the local authority's responsibility may override that of the parents, where this is necessary for the child's welfare.

While the person who accompanied the child to their appointment will usually have the necessary authority, you should confirm their identity if you’re unsure. Ideally, you will have the name and contact details for the child’s next of kin on the patient management system.

It’s reasonable to rely on the authority of just one person with parental responsibility but there can sometimes be disagreements over treatment decisions typically when the parents are no longer together. If this happens it might be possible to discuss the matter with both sides and reach agreement in the patient’s best interests but avoid getting dragged into family disputes. If you’re not sure what to do, speak with your supervisor or get advice from the DDU.

3. Respecting patient confidentiality

Parents might expect to be kept informed about their child’s treatment, especially if they are paying. However, if the patient is over 16 or ‘Gillick competent’, you have a duty of confidentiality and should seek consent to disclose this information, even to a parent.

It’s often a good idea for young patients to involve their parents in decision-making and you can encourage this but if they refuse, you should respect their wishes unless you have reason to be concerned about their welfare (see our child protection advice below). Call the DDU if you’re unsure whether to disclose patient information.

4. Managing an unwilling patient

Even if you think dental treatment is clinically necessary and you have parental authority, forcing this on a child is not practical and likely to cause them distress, as well as damaging their trust in the dental profession. If your patient can’t be persuaded to cooperate or has specific needs, consider a referral to the community dental service or specialist paediatric dentist who would be better placed to manage their anxiety.

On the other hand, you don’t have to carry out treatment at the request of a Gillick competent patient or someone with parental authority if you don’t think it’s clinically appropriate or in their best interests. And despite their popularity with younger adults, tooth whitening procedures that use a higher concentration than 0.1% hydrogen peroxide are only lawful for patients over 18.

5. Raising concerns about dental neglect and child protection

Of course, your first concern when you see a child in poor dental health should be addressing their immediate care needs with a treatment plan including referral for specialist care if appropriate. In many cases, it will then be possible to work with the family to improve the child’s oral health through dietary advice, setting up regular appointments and showing them how to care for their teeth and gums. It’s important to provide support in a non-judgmental way, in line with GDC guidance which says patients must be treated “with dignity and respect at all times.” (Standards for the Dental Team, para 1.2).

The British Society of Paediatric Dentistry (BSPD) defines dental neglect as “the persistent failure to meet a child's basic oral health needs, likely to result in the serious impairment of the child's oral or general health or development”. In its 2023 policy document the BSPD advises dental professionals how to assess patients if you suspect dental neglect, taking into account factors like the prevalence of dental decay in the wider population, how much parents understand about oral health and their access to dental care. Obvious disease which has gone untreated despite clear evidence that it’s causing pain and distress would usually be a cause for concern but seek advice from an experienced colleague or paediatric dentist if you aren’t sure.

You must act promptly if you believe that dental neglect is causing significant harm or notice other signs of mistreatment such as unexplained injuries or where the child seems fearful of their parents. The GDC expects you to “raise any concerns you may have about the possible abuse or neglect of children or vulnerable adults” (Standards for the Dental Team, para 8.5.1).

If you have concerns, talk to your safeguarding lead and decide whether to refer the child to local social services. You should usually inform the family unless this would put the child at greater risk. Be sure to document your findings and discussions.

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The state of our children’s teeth has become a major talking point in the UK in recent years with official data now revealing that around a fifth of five-year olds in England have experienced dental decay. While the Government is attempting to address problems in the dental service which are outside the control of ordinary dental professionals, we can still make a positive difference for our young patients by earning their trust and confidence at each appointment.

Further resources

For more background reading on this patient group, try the following:

British Society of Paediatric Dentistry

Safeguarding in general dental practice: A toolkit for dental teams.

Dental consent and young patients – The DDU

[Read part one - Treating elderly patients]

Next time – treating anxious patients/patients with special needs

The DDU is here for you as a student and throughout your dental career. Visit the join DDU pages to explore the benefits of membership now and beyond graduation.

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Student members can contact our dento-legal advisers for support or call us on 0800 374 626 between 8am and 6pm Monday to Friday

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