Eleven interviews were conducted, each with one of 11 parent/child dyads. The 11 parent participants comprised three fathers, seven mothers and one grandmother. All children were regular dental attenders and of the 11 children, 55% were boys. The age of child participants ranged from six-year-olds or younger (n=4), seven to nine year-olds (n=3) and over nine years-olds (n=4). Interviews were from 15 to 25 minutes in length.
Children’s previous dental experience
The previous dental experience of children varied, but all of those interviewed had received dental oral health assessments (“check-ups”). For two of the children, the only intervention had been the placement of fissure sealants. Five children had undergone GA for multiple primary tooth extractions. One had received dental extractions with local analgesia. Three children had received restorations, one of whom had endodontic treatment for a permanent tooth. Three had received a crown placed using the Hall Technique (HT) and two children had previously received SDF treatment at DDH&S.
Parents whose children had undergone multiple tooth extractions under GA described the experience as traumatic for both themselves and their child. In addition, they suggested that they felt that an excessive number of teeth had been extracted during the procedure. Children who could recall their GA experience, reported it to be very distressing.
“I was angry, I was angry, I was angry, ‘cause he, he was sitting there crying for mum and dad and we were there and there’s nothing I could’ve done er, he didn’t want put to sleep. The, the nurses, give the nurses their due, they tried everything, give him a gas until he fell asleep. It’s when he woke up was when the pain kicked in, and to see a child going through a lot of pain after this being done, getting them all taken out”
(Parent I, father to a 10 year-old boy)
Parents of children who received a HT crown, reported satisfaction with this treatment approach, despite it being slightly uncomfortable for the child. However, they did not consider the HT to be a straightforward procedure as it was time-consuming to choose the crown dimension and to carry out the placement of the crown. Children who had been treated with the HT suggested that having the crown fitted was acceptable though they experienced some discomfort.
“…so I went and got the crown. It didn’t really hurt, it only hurt, like, a tiny bit because he really hard pushed on my tooth to stick it on, but it never really hurt”
(Child E, girl aged 9 years old)
Parents’ views of SDF
The two following overarching themes emerged from the interviews with parents: ‘perceptions of SDF’ and ‘factors influencing decision-making’ (Table 1).
Perceptions of SDF
While many acknowledged the advantages, they also identified disadvantages. The two sub-themes that emerged were ‘perceived advantages of SDF’ and ‘aesthetics’.
Perceived advantages of SDF
Some parents believed that SDF treatment could be particularly useful for children where their anxiety or inability to co-operate with or tolerate some treatments may limit other interventions. Parents perceived SDF to be a non-invasive procedure that children would not find stressful and moreover beneficial to introduce children to the dental environment.
“I think it’s a great treatment for kids, especially young kids that are apprehensive about coming to the dentist or the dentist sort of, er, looking in their mouth and things like that”
(Parent J, father to a 5 year-old boy)
Parents felt further advantages were the delay or avoidance of treatment under GA and in promoting good oral health.
“it made a massive difference to Jack when he got that put on. He was kind of scared to brush his teeth because he was in that much pain, and then after that product was put on, he could brush his teeth. It helped him help his other teeth that were going to be staying”
(Parent G, father to a 10 year-old boy)
Aesthetics
There were concerns about lesion staining, especially of anterior teeth. It was stated that an SDF treated tooth could look worse than the original untreated carious tooth.
“I guess it looks worse to me, it doesn’t look like there’s been a problem solved but obviously there is”
(Parent B, mother to a 5 year-old boy)
Parents suggested that developing a way to minimise the black staining would improve SDF acceptability.
Factors influencing decision-making
Parents did not appear to have a clear opinion about choosing SDF for their child. There were many factors influencing decision-making. The sub-themes identified within this theme were ‘perception of others’, relative visibility of the tooth’, ‘self-consciousness’, ‘longevity of the tooth’, ‘relative merits of alternative approaches’, ‘preferences and recommendations of others involved in treatment’, ‘financial considerations’ and ‘child tolerance’.
Perceptions of others
Some parents believed that the discolouration, especially of anterior teeth could result in the child feeling uncomfortable or anxious when they spoke or smiled and may make them a focus for bullying. Of note, the school culture seemed to be influential in that if the school reported endemic problems with bullying, the parents were more hesitant to consent to SDF treatment for their child.
“then the next thing, a kid’s at school with black teeth… I think I’m all about the anti-bullying, and this to me would lead to bullying”
(Parent E, grandmother to a 9 year-old girl)
Black-stained teeth were associated with drug abuse in adults and there was concern this may be reflected towards children too. Fear of what ‘others would think’ and a feeling that parents may be judged by others as neglecting their child’s health if their child had black-stained teeth. This was also because they thought a blackened tooth appeared similar to an untreated carious lesion and people may not be able to differentiate. Parents believed they would rather have the teeth extracted as they would be less likely to be judged by others, with people assuming the teeth had exfoliated earlier than normal.
Parents believed SDF could be a more acceptable if people had greater awareness of it. With greater awareness there may be less chance of being judged by others and therefore, parents would be less apprehensive about choosing SDF for their child.
“Maybe more to the future, once it’s been around a while, people know more about it, they’d maybe understand what it was and they maybe wouldn’t judge so much, you know?”
(Parent H, mother to a 7 year-old boy)
Relative visibility of the tooth
The SDF-treated carious lesion’s visibility seemed to be the most influential factor on parents’ decision and more acceptable on their child’s posterior teeth since it would not be as visible. Some parents commented that the arrested carious lesions may not look any worse than amalgam fillings:
“if it is in a back tooth, a back molar, then it’s the equivalent of one of the old iron or dark fillings”
Parent D, mother to a 6 year-old girl
The staining caused by SDF on anterior teeth was unacceptable for many parents.
“Hmm, it looks awful! It looks awful. …. certainly on a front tooth, I wouldn’t want that on my child”
Parent F, mother to a 10 year-old boy
However, the size of the lesion was of importance with SDF a possible option if the lesion was relatively small and not very noticeable.
Some parents said that they would not mind the appearance if SDF would stop the lesion progressing and avoid any further intervention.
Self-consciousness
Younger children were considered less self-conscious than older children and may not mind the staining, therefore SDF-related discolouration may be less of a barrier for them. But with older children, parents were more concerned with the possibility of bullying.
“It wouldn’t have bothered me before, now that he is at school, it would worry me that other children might pick up on that and that might be an issue, only because of children’s behaviour. Yeah”
(Parent B, mother to a 5 year-old boy)
Gender did not appear to influence parents’ decision-making regarding the use of SDF for their child.
Longevity of the tooth
Parents had conflicting opinions about how the length of time until the tooth was expected to exfoliate might affect their decision. Some thought that if the teeth were to be lost within a short period of time i.e. less than six months, they would consider SDF treatment. Conversely, some believed that if the tooth to receive the SDF treatment would fall out in few months, they would rather just take the tooth out and if the tooth was likely to last longer, they would opt for SDF.
“If she was on the crust of her new teeth coming through and it would only be, like, two or three months, I would say, “Och, yeah, take them out then.” What’s the problem? Young kids at that age do lose their teeth anyway. But if it was going to be a longer period of time, six months plus without teeth, I would say, “Nah, get this treatment done”
Parent E, grandmother to a 9 year-old girl
Relative merits of alternative approaches
Parents took alternative treatment options to SDF into consideration. Some parents who were less accepting of SDF showed more flexibility if SDF was the last resort that could save the anterior teeth from extraction believing that a black-stained tooth was better than not having the tooth at all.
Some parents would choose SDF, albeit hesitantly, if it avoided the child undergoing GA because of its associated risks. Even if the other option was treatment under inhalation sedation, parents tended to prefer SDF.
“Mhm. I wouldn’t want her put to sleep for her teeth to be filled or treated. I’d rather that she had that, the SDF because there’s such a risk with general anaesthetic. Well, not a massive risk but there’s still a risk with GAs isn’t there”
Parent A, mother to a 5 year-old girl
In contrast, several parents insisted that they would never choose SDF for their child’s anterior teeth and considered the outcome unacceptable with extractions more acceptable than a visible, black-stained tooth.
“Yeah, that’s awful. I would rather he got put to sleep and them taken out, yeah. I would rather not have them”
Parent H, mother to a 7 year-old boy
Parents were asked about their preferences between HT or SDF for their child, since both techniques share some clinical indications. Some preferred the SDF option because aesthetically, the crowns were silver, cover the whole tooth and also not very aesthetic whereas SDF only affected part of the tooth. Furthermore, they thought applying SDF was simpler and more acceptable for the child.
“If I remember rightly it was a little bit uncomfortable when they were pushing it on, trying to fit it, so I mean, this would be a lot simpler. You know, the back teeth, getting that stuff on, it would probably be a better option”
Parent H, mother to a 7 year-old boy
Preferences and recommendations of others involved in treatment
Some parents took their child’s treatment preferences into account not wishing to force their child to receive treatment.
“I think as a, as a parent yeah, I mean it would obviously depend on… because it’s work to be done to the child, so I would want to have their opinion on it, and I would never force something”
Parent J, mother to a 9 year-old girl
Others suggested that the dentist was the expert and they reported having full trust in them. They were happy to choose whatever treatment the dentist believed to be the best option for the child.
Financial considerations
Some parents also considered the cost of treatment to the NHS. If there were two management options with similar success rates, they would prefer the more cost-effective treatment approach.
“Um, and also I am interested in what it costs um, the NHS and, and things like that because that’s something I think that we do need to be responsible citizens and if there are treatment options that are going to be more cost effective for the NHS then I do think um, that it’s, that it’s our duty to consider those”
Parent J, mother to a 9 year-old girl
Child tolerance
Parents suggested that some children with sensitivity issues towards new or strong smells or tastes may not tolerate SDF because of the taste.
“The only thing he has a problem with, he’s got, like, sensory things, you don’t like tastes and smells and things. So, if it’s certain varnishes and the coatings and things that they’re using, if they taste funny or smell funny, he’s like, “No!” He’s more frightened of that than anything else”
(Parent H, mother to a 7 year-old boy)
Children’s views of SDF
Younger children were shy and generally less talkative than older children, especially at the beginning of the interview. They tended to be more responsive to yes and no questions than open questions probing for more expansive responses. Children were shown pictures of SDF treated teeth as part of the interview and they described them as “rotten”, “weird”, “silly”, “ugly” or “disgusting”. One overarching theme, ‘child’s acceptability of SDF’ emerged from the interviews with children.
Child’s acceptability of SDF
Factors influencing children’s views could be categorised into three sub-themes: ‘relative visibility of the tooth’, ‘peers’ perception’ and ‘previous experience’ (Table 1).
Relative visibility of the tooth
When asked how they felt about having similar treatments on their teeth, some children seemed more accepting of black staining on their posterior teeth, believing that others would not see it.
“Um, on the back, that’s okay, kind of. I don’t mind to have [it] because people wouldn’t really, like, see it when, like, um, like, when I’m like, talking or anything, because it’s in my, like, one of my back teeth, so they wouldn’t really see it”
(Child E, girl aged 9 years old)
However, most children were not keen on SDF staining being visible on their anterior teeth as they thought it looked like a rotten tooth.
Similar to parents, if the lesion was fairly small however, there was less opposition.
“Um, if they were at the front, I wouldn’t really like it. If it was just a little at the front, then that would be okay, like that one”
(Child F, boy aged 10 years old)
Peers’ perceptions
Children worried others would comment on their appearance and they may be picked upon by their peers. One child who had previously suffered from bullying at school commented:
“Oh, the front teeth, no, no ….. Absolutely not because they look not that nice. I wouldn’t like that because it will look silly, because I think I’ll get bullied. And then people will just go, like, “Amy, what are your teeth like? They look ugly.” I think they’ll say that”
(Child E, girl aged 9 years old)
Some children reported that they would be unwilling to accept SDF treatment, preferring to have their teeth extracted. The children’s responses indicated that older children were more aware of the staining and how that could lead to being picked on, than younger children. It was suggested that younger children may be less self-conscious or worried about the implication or reaction from others of having black staining of their teeth.
“If they see them and they think it’s rotten then I think they’d possibly laugh if they’re in like the older classes, but otherwise if it was friends they would try and support them”
(Child J, girl aged 9 years old)
Overall, boys and girls did not appear to have different opinions about having their teeth treated with SDF, with both reporting similar perceptions.
Previous experience
Previous dental experience appeared to influence children’s opinions in relation to future dental treatment. Most of the children interviewed had experienced multiple tooth extractions under GA and described the experience as very distressful. They stated that they would choose SDF treatment if it could avoid a further GA.
“Yes, I would prefer that one. Yeah, ‘cause getting all those teeth pulled out I couldn’t go through all that pain again, oh, that was so sore”
(Child I, boy aged 10 years old)
Conversely, one child appeared less concerned about undergoing GA and reported that they would prefer a GA again rather than SDF treatment. This child participant had also previously had crowns fitted with the Hall Technique applied and said they would prefer this to SDF. A possible explanation is fear of SDF as unknown.