Record-low decay masks a widening social gradient in Scottish children
Scottish children have reached their best recorded oral health on paper, but the headline figure does not tell the full story. Public Health Scotland’s 2026 National Dental Inspection Programme found that 76% of Primary 1 pupils had no obvious tooth decay, the highest level ever recorded in the programme. Average decay experience also fell to a record low of 0.92 affected, missing or filled teeth per child, a sign that the overall burden is easing.
The improvement is real. So is the inequality.
Among children living in the most deprived areas, only 62% had no obvious decay, compared with 87.3% in the most affluent areas. Geography also tracked with a visible gap: decay-free rates ranged from 72% in Fife to 90% in Shetland. Those differences are large enough to shape the daily work of paediatric dental teams, school health programmes, and primary care services far beyond the numbers themselves.
The pandemic hangover still sits inside the data
The latest results suggest progress has slowed after several years of improvement. Previous reports recorded decay levels at 73.2% and 73.5%, and the newest figure has edged higher rather than leapt forward. Edinburgh dentist and City Dental Care owner Hamza Al Haddad said the pattern looks like stalled recovery, with much of the current disease burden representing treatment delayed during the pandemic.
The biological and behavioural logic is straightforward. If prevention stalls during the years when first permanent habits are formed, disease accumulates quietly and appears later as filled, missing, or decayed teeth. In younger children, that loss of momentum can translate into lesions that might have been prevented with earlier fluoride exposure, supervised brushing, or better access to routine dental review. Once those opportunities are missed, the catch-up is slow.
School-based prevention remains part of the answer, but coverage has not fully recovered. Supervised toothbrushing now runs in 58% of primary schools, below the 65.9% seen before the pandemic. A programme that slips by several percentage points can look modest on paper and still affect thousands of children across a national system. In preventive dentistry, those small percentage shifts matter because they change the number of children who receive a daily reinforcement of fluoride, technique, and routine.
Prevention needs to start before damage becomes entrenched
The report points toward age six as a particularly important prevention window. Public Health Scotland has repeatedly indicated that the pattern of decay supports greater use of fissure sealants, while fluoride varnish is recommended for every child from age two at least twice yearly. The age profile matters because early decay often clusters before school age, when families are still establishing brushing routines and deciding whether a child needs regular dental supervision.
Registration with an NHS dentist also appears to be slipping in the youngest children. In September 2025, 42.1% of children aged zero to two were registered with an NHS dentist, down from 47.4% in September 2019. That drop may seem small at first glance, but it points to a narrower prevention pipeline at exactly the stage when advice on diet, fluoride, bottle-feeding habits, and brushing support can have the biggest effect.
A child who is not in the dental system early is less likely to receive preventive guidance before the first lesion appears.
Funding prevention is not the same as measuring it
One of the more important policy issues raised by the current system concerns how prevention is recorded. Since the November 2023 payment reform, varnish, brushing instruction, and diet advice have been claimed together under one preventive item. That approach may reward a broader preventive encounter, but it also means national data no longer show whether varnish was actually delivered on a given visit.
From a public health perspective, the accounting problem is not trivial. If the system only records one bundled preventive code, decision-makers lose visibility into whether the intervention most strongly linked to caries prevention is reaching children consistently. PHS has welcomed payment for prevention, but has also said it would welcome more detail on what the item delivers. Better measurement would allow policymakers to separate activity from impact, and to see whether the intended preventive package is being delivered in full or only in part.
Water fluoridation remains an unresolved structural issue
The report also returns to an old but persistent question: why should fluoride exposure depend so heavily on individual behaviour and local access when a population-wide approach is available? No public water supply in Scotland is fluoridated. Dr Al Haddad argued that the next practical step should be to fund health boards to carry out feasibility studies, echoing the position taken by BDA Scotland.
Water fluoridation is not a quick fix, and it is not a substitute for brushing, diet change, or routine dental care. It does, however, shift part of the prevention burden from families and clinicians to a universal system that reaches children regardless of postcode, appointment attendance, or parental knowledge. In a country where decay rates differ sharply by deprivation and region, that kind of universal exposure has obvious appeal.
The current report leaves Scotland in a familiar place: oral health is improving, but not evenly, and not quickly enough to close the gap between rich and poor children. The strongest gains are being recorded where risk is already lowest, while the children most likely to need preventive support continue to carry the heaviest burden. The next challenge is not proving that prevention works. It is deciding whether the system will deliver enough of it, early enough, to change the distribution of disease rather than merely its average.