Overview of the participants
Two groups of participants were invited to participate in this study. There were eight children (M/F= 5/3) and ten caregivers (M/F=2/8) in the patient group. All these patients, demographic data of which are shown in Table 3, received comprehensive dental restorative treatments in multiple outpatient department (OPD) appointments, and one of the patients received another surgical removal of mesiodens under general anaesthesia. There were ten dentists (M/F=6/4; clinical experience means=26.9 years, minimum=16 years) in the dentist group. Seven of the dentists received their degrees from other countries. Seven dentists worked in both medical centres and private practice. Two dentists practised only in medical centres, and one dentist practised only in private practice.
Overview of the results
The themes from the patients who reversed their caries risk were mainly related to patient aspects rather than dentist aspects and were especially related to parent aspects according to both dentist and patient participants. Most of our dentist participants stated that the resilience of caries conditions depends on patient factors because dentists treated all their patients in the same way, but only a small proportion of patients were able to reverse their caries risk or condition. Most of the dentists could clearly describe similar ideas and characteristics among the resilient patients, which were similar to the features of the included patient participants.
[Doctor #8] I feel tiger moms who prefer to take control are more prone to be successful, but this is because these parents would keep on bringing their children back. They are not necessarily tiger moms. They care about dental things more. … I feel the ratio between dentists and parents is 3 to 7. Thirty percent relies on dentists, and 70% relies on parents. … It is the parents who must accomplish things. They may not be control freaks. They may be determined. … Dentists provide solutions, but not all parents adopt the solutions.
[Doctor #7] Moms knew the 'Achilles' tendon' of their children. Their children's Achilles tendon was attacked, and then the children became compliant. … We originally thought dentists, parents, and children are a triangle, but it can be a linear relationship… Don't put the responsibility of controlling children on dentists…. You (dentists) need to persuade the parents to be willing to control their children.
[Doctor #9] The resilient patients who improve have parents who accept things very quickly.… When dentists tell them what to do, they (parents) just accept, and their habits change with your suggestions. Hence, the habit will be maintained after treatments, which means that these patients need only the first-round treatment. The refractory group has parents who have difficulties influencing their children. Children have caries in mixed dentition, and these children are not resilient.
In the analysis, four essential themes were identified from the similar descriptions provided by dentist and patient participants: dental things/teeth as their priority, normalising, tiger parenting/conscientiousness, and trust. The subthemes and illustrative quotes in these four main themes are outlined in Table 4.
Main theme 1: dental things/teeth are their priority
All the participants in both the dentist and patient groups thought that compliant patients who reversed their caries risk considered teeth to be the first priority. Compliant parents valued or appreciated the importance of dental health and the severity of the dental conditions of their children. They always remembered to visit their dentist regularly and were willing to take a day off to take their children to a dental appointment. Parents might obtain this attitude from their own experience, but they perhaps did not make their own teeth a priority.
[Researcher] …Is it inconvenient to keep asking for days off for dental treatments?
[Casper's female caretaker] Nope, I feel (dental) health is more important than work. I must do what needs to be done.
[Cindy's female caretaker] In addition, because my teeth are not well, I think teeth are very important.
These parents valued dental treatment rather than their children's dental experiences. Although their children cried or fought during treatment procedures, behaviour management techniques or mild physical restraints were acceptable for them. None of our patient participants received restorative treatments under general anaesthesia or sedation. They understood that successful treatment outcomes might not come in an easy way.
[Conan's female caretaker] Crying and fighting severely on the dental chair are normal responses of children. When they mentioned general anaethesia, I denied and wanted to have it step by step.
[Researcher] So you didn't want to have general anaethesia?
[Conan's female caretaker] No. I wanted him to get used to it.
[Researcher] Is it inconvenient or difficult to come so many times?
[Conan's female caretaker] It's OK. We must be cooperative.
[Doctor #8] The chance for retreats is higher for TCI (a kind of sedation) children. … If the patient disappears, it is because of the attitude of parents. Usually, when they come back, you will notice that it (caries severity) is the same for several years. Therefore, this is because of the attitude of parents. The second thing is how seriously do they think about using fluoride. … Patients of TCI, honestly, are just the same of the study of GA. The record of the GA study shows a higher recurrent caries rate. If you do not perform behaviour management, after the treatment of TCI patients, they are still afraid of visiting dentists. After TCI, you can't train them for a while. Parents of these (refractory) patients hope that their children can visit dentists happily. When they know that you finish TCI, they will not let you touch their kids. In your mind, you will have a long window period. You cannot do complete treatment.
Parents with a higher socioeconomic status had more resources to take better care of their children's teeth. Nevertheless, it was the parents who were responsible for these children reversing their caries conditions, who recognised the importance of their children's dental health, and who were compliant with dentists making their children's teeth better.
[Doctor #6] I don't think socioeconomic status is the absolute factor. How do parents value it (dental health) is more important. Very rich parents do not necessarily value it. An average family (with parents as office workers) might value it. However, among parents with high socioeconomic status, the ratio of this kind of people seems to be higher.
[Celine's female caretaker] I am the kind of person who gets a good thing and then promotes it. My friends (refractory parents) did not keep (visiting the dentist). I don't know what they were doing. They live truly close in an expensive area in the Capital and 10 minutes away from the dental clinic. … and these two moms did not need to work.
Main theme 2: normalising
It was normal or routine for all these compliant patients and parents to practise oral health behaviours, such as brushing teeth or dental visits. They, especially children, might not engage in health behaviours for any specific reason or motivation, such as making themselves healthier. They might maintain oral health behaviours because they got used to keep on doing it or do it subconsciously. They might also feel weird not doing it. Those oral hygiene behaviours became their habits might be the reason that their oral health was maintained, and the effect could be long term.
[Cindy's female caretaker] I just tell her that you take good care of your teeth. It is for her own good, not for me.
[Cindy] … Because I have got used to keeping on coming back, it is a part of my routines. I don't think anything special about the dental visit.
[Che's female caretaker] Do you brush your teeth more seriously before you go to bed, Che?
[Che] I don't know. I would just brush my teeth.
[Researcher] What do you mean by 'OK'? Do you take a bath or exercise because you benefit from them? Or, do you worry that if you don't do these things, something bad will happen? Or, you simply think that you should listen to me or your mom.
[Conan] I just want to follow you.
[Conan's female caretaker] You should be afraid of being blamed? I do snap checks.
[Researcher] Therefore, you don't think that my teeth will become better because I do these?
[Researcher] You totally worry that you don't meet our requirement from both of us. Does health education in the school teach you how to take care of your teeth?
[Conan's female caretaker] Yes. They also distribute mouthwash and teach kids how to use it.
[Researcher] Does this make you want to take care of your teeth?
[Researcher] Do you worry that your teeth will be rotten if you don't follow the rules?
[Researcher] Don't you think your teeth will be broken?
[Conan] No, I don't think so.
[Researcher] You know that, if you don't take care of your teeth, they will be ruined. Don't you think this occurs to you? Or, you think that's something far away in the future?
[Conan] Too far away in the future.
Main theme 3: tiger parenting/conscientious
Many parents were tiger parents. They were determined, not caring whether their children could receive treatment cooperatively or calmy. They decided that their children should go through the treatments and followed the dentists' suggestions. They remembered to come back regularly. They remembered the details of the dentists' suggestions and their children's daily dental behaviours. Hence, they can confirm these with their dentists in latter appointments to ensure they have achieved dentists' suggestions. Nevertheless, these parents and their children might not have a clear goal. They just followed the dentists' orders.
[Celine's female caretaker] Only a tiger mom can make a child of this age follow the rules. Otherwise, when you tell her thoroughly, she will not understand.
[Researcher] … What's the difference? … Because you believe that she has the ability to achieve it, and you trust her that she can do it when you ask, so you do this. Or, you don't think about it. You just set the rules and she has to make it. …
[Celine's male caretaker] Because you dentists make the rules, I think that I should cooperate. … In addition, she likes you. She did not resist you at all. The first or second appointment did not count because you were strangers. She is OK afterwards.
[Dentist #5] (Resilient) parents always come back. They must know how to take care of their children. They always know what happens to their children. They even ask me whether they should change to electric toothbrushes. Parents use all kinds of means to change their children's behaviours and to make this (dental thing) work. These parents return every three months, sharing their experience and feedback with the dentists. So, I know that they are serious.
Most parents liked to achieve something or be praised by their dentists, feeling guilty or bad when they knew that they had not yet done enough. They would find ways to manage their children to follow the dentists' orders. Nevertheless, they might not want to be the best or flawless. They just did not like failing.
[Cole's male caretaker] … (About their experience in previous dental clinics) After the examination, the dentist condemned us (parents). He said that these were parents' fault. … I felt sorry for my child. I wanted to find solutions when I was blamed. … After I was condemned then, I felt sad for a long time. I felt that I ignored these things and then made his teeth like this. Many people said, 'It's OK. It's just caries'. However, I felt depressed, and how come we didn't notice this.
Main theme 4: trust
Most parents mentioned that they trusted or respected dentists. Thus, instead of following what was shared by their friends or websites, they would believe what was instructed by dentists. Some of the parents even stated that it was fate to meet the dentist.
[Chas's female caretaker] Someone suggested you (the dentist). Serendipity. I quite believe in fate. If it felt right, I had confidence in the dentist. Then, the trust would be there.
[Celine's female caretaker] I am not that keen on (googling the information). However, I absolutely believe in the profession. Yes, I trust in the dentist's profession, and my kid likes the dentist. I can arrange and come to the dental appointment, (so) why not?
[Casper's female caretaker] Yes, the previous dentist (in your clinic) was very patient, so I felt quite good. Then, I met you (dentist). I thought you trustworthy, and we just followed you step by step.
These parents also had trust in their children, and they believed their children could succeed. These parents usually had good relationships with their children and did not force them to do things. Therefore, they can cooperate well with their children and then follow dentists' instructions together.
[Doctor #9] Yes, resilient parents trust both their dentists and children. As long as we do this, everybody will get better together, and things will get better. … I did not feel these parents force their children. I felt the resilient children usually had a good family relationship. …The mom and child both felt these dental things were what should be done together. The mom got a new concept, and the child accepted and did what was asked. The resilient parents did not force their children. Then, they happily came every three months for fluoride varnish. I feel this is the characteristic of resilience. … Parents who need to force their children, their caries severity did not improve.