Background <p>An earlier study in Kampala, Uganda reported that a proportion of 0.9 children with dental caries remain untreated. A lack of comprehensive data about oral health in Uganda has been identified. However, the limited information available indicates an increasing prevalence of dental caries among adolescents. A recent survey conducted in Kampala revealed that over 75% of adolescents were affected by dental caries.</p> <p><?noindent??>There was limited data about the oral health status among children in Buhweju District of rural Southwestern Uganda. This study sought to establish the prevalence, predictors and treatment needs of dental caries among primary school children in Buhweju district. </p> Methods <p>In a descriptive cross-sectional study design, 433 primary school children aged 5-17 years were enrolled from March to April 2025. Clinical oral examinations were performed in a private room at school under natural light. Every tooth visible in the mouth was examined by use of plain disposable mouth mirror and dental probe. Carious teeth and spaces (if a tooth was removed due to caries) were scored and reported as Decayed, Missing and Filled Teeth (DMFT) due to caries for permanent or Decayed and Filled teeth (dft) for primary dentition. The dental caries treatment needs were captured during clinical examination when there was decay or missing tooth. </p> Results <p>Overall, 274(63.3%) had dental caries with median DMFT of 0 (IQR=1) and median dft of 0 (IQR=2). Caries was more prevalent among females (64.7%) than males (62.1%). The prevalence of false teeth extraction among the permanent dentition was 72 (16.6%). Some 192 (44.3%) of the study participants needed Prompt treatment (including scaling, and fillings). At bivariate analysis, several variables met the inclusion criterion for multivariate analysis (p&lt;0.25), including age 5–11 years, Bakiga ethnicity, belief that dental caries is not preventable, history of tooth removal, brushing after every meal, never eating cassava, previous dental clinic visits, and lack of oral health information through school career guidance. In the multivariate logistic regression model, two factors remained independently associated with dental caries. Children who had ever visited a dental clinic were twice as likely to have dental caries compared to those who had never visited a clinic (aOR=2.1, 95% CI: 1.2–3.4; p=0.005). Additionally, children who had never consumed cassava had 2.5 times higher odds of dental caries compared to those who consumed cassava monthly (aOR=2.5, 95% CI: 1.1–6.0; p=0.037).</p> Conclusion <p>The study found a high prevalence of dental caries, mainly in permanent teeth, driven by limited dental health education, dietary factors, and unmet treatment needs. </p> Recommendation <p>The study recommends strengthening school oral health programs through teacher training and three to six months oral health checkups as this ensures early detection of hygiene issues. </p>