Introduction and aims Children with Down syndrome (DS) face increased oral health risks and barriers to dental care. Understanding caregivers’ perceptions about their child’s dental care is key to better outcomes. This study aimed to investigate primary caregivers’ perceptions of the dental and orthodontic care of children with DS, and the association with cooperation in encounters involving the child and dental professionals. Methods A cross-sectional study was conducted using an online questionnaire completed by 77 primary caregivers, mostly mothers, of children with DS aged 6 to 17 years. Descriptive statistics and logistic regression were used to analyse the data. Results Children with DS often needed support with toothbrushing, but were frequently reported as cooperative during home care and dental visits. Many children used alternative communication methods and had difficulty being understood. About half of the caregivers discussed their child’s needs with dental professionals in a premeeting. Fewer than half of the professionals were reported as communicating effectively with the children. Children who were perceived by their primary caregivers as cooperative during toothbrushing at home were significantly more likely to be cooperative during dental visits ( P < .05). Additionally, being referred for an orthodontic assessment was statistically associated with higher levels of cooperation during dental appointments, according to the primary caregivers ( P < .05). Conclusion Despite communication challenges, many children showed cooperation during home care and dental visits. Perceived cooperation during toothbrushing at home and being referred for an orthodontic assessment were associated with higher cooperation during dental appointments for children with DS. Enhancing dental professionals’ communication skills and using personalised care approaches may improve dental outcomes and experiences for children with DS. Clinical relevance These findings underscore the importance of tailored dental care approaches and improved communication techniques to foster active participation and better dental outcomes for children with DS.