Sir, the paper by Kearney-Mitchell et al.1 seems at first sight once again to challenge the desirability of a restorative option in the care of the primary dentition. Interestingly, or perhaps tellingly, the authors note that 'restorative care is becoming less of a priority for primary dental care practitioners in the UK'. As ever, we are faced with the puzzle of which came first, a change of heart or a change of priority? Be that as it may, I am much more concerned about the care implications of their colleague's exclusion of 'caries in the deciduous dentition' as a reason for referral than in any question of 'to fill or not to fill'.

Donaldson, in his research summary in the same edition, questions whether 'referral would be appropriate for preventive interventions'. I agree; when a preventive approach is so passionately advocated by some,2 and promoted by such an august body as the British Society of Paediatric Dentistry3 it is surely important that children at dental risk are put in the way of such support.

Secondly, would this exclusion be mirrored elsewhere in the UK? The North West seems to have carried more than its share of being 'questionnaired' to date. Would a similar view be held in other parts of the country? Does the availability of facilities have a bearing here; 'I will recommend what is possible, not necessarily what is ideal'?

However, all this is still of relatively little importance by comparison with the lost opportunity to help to protect a child against neglect and possible further abuse.

'Neglect is the persistent failure to meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development, such as failing to provide adequate food, shelter and clothing, or neglect of, or unresponsiveness to, a child's basic emotional needs'.4

At the BDA conference in 1997 I asked the question: 'Dental caries in childhood: are neglect and abuse part of the problem?' I argued there that if we define abuse as the repeating of an action which we know to be harmful then both the inappropriate supply of sugars to children, and the failure of a dental professional to act in the presence of the resulting decay could be seen to be abusive. I didn't get very far!

In the USA, the position is much clearer; widespread tooth decay is seen as a clear part of the spectrum of child abuse. I can do no better than to quote:

'Dental neglect, as defined by the American Academy of Pediatric Dentistry, is the “wilful failure of parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection.

“Some children who first present for dental care have severe early childhood caries (formerly termed 'baby bottle' or 'nursing' caries); caregivers with adequate knowledge and wilful failure to seek care must be differentiated from caregivers without knowledge or awareness of their child's need for dental care in determining the need to report such cases to child protective services.”

'The point at which to consider a parent negligent and to begin intervention occurs after the parent has been properly alerted by a health care professional about the nature and extent of the child's condition, the specific treatment needed, and the mechanism of accessing that treatment.

'Because many families face challenges in their attempts to access dental care or insurance for their children, the clinician should determine whether dental services are readily available and accessible to the child when considering whether negligence has occurred.

'The physician or dentist should be certain that the caregivers understand the explanation of the disease a nd its implications and, when barriers to the needed care exist, attempt to assist the families in finding financial aid, transportation, or public facilities for needed services.

'If, despite these efforts, the parents fail to obtain therapy, the case should be reported to the appropriate child protective services agency'.5

Should the UK be very different from this? In the light of these careful statements, are the authors comfortable with their consensus that a 'Child with caries in the deciduous [sic] dentition' should not prompt a referral, or even an 'attempt to assist the families' by the examining dentist?