Parental satisfaction and acceptance of silver diamine fluoride treatment for molar incisor hypomineralisation in pediatric dentistry: a cross-sectional study

The study aimed to investigate parental satisfaction and acceptance of silver diamine fluoride (SDF) treatment for permanent molars affected by molar incisor hypomineralisation (MIH). This study was conducted in the pediatric dental department at Damascus University, Syria. This study was performed at the period from Jan 2023 to April 2023. In this cross-sectional study, a validated questionnaire employing a 5-point Likert scale was used to evaluate esthetics, ease of application, pain perception, and taste acceptability. Participants included 100 parents or guardians of children aged 6–9 years who had received SDF treatment in the past year. The findings of this study revealed high satisfaction levels (77.5%) with the treatment. Parents expressed contentment with the appearance of their child's molars after SDF application (58% agreed or strongly agreed) and found the application process easy and pain-free (100% agreed or strongly agreed). However, taste acceptability posed a challenge, with over half of the parents (53%) finding it unacceptable. Regression analysis underscored the significant impact of esthetics, ease of application, pain perception, and taste on parental satisfaction. Moreover, parents with higher education levels (graduate or postgraduate) exhibited higher acceptance rates compared to those with lower education levels (63.1% vs. 33.6%). Notably, parental gender and age did not significantly influence SDF treatment acceptance. This study provides critical insights into parental satisfaction and acceptance of SDF treatment for MIH-affected permanent molars. Despite concerns about tooth discoloration, the high satisfaction levels suggest that SDF holds promise as an effective treatment option. Parental education significantly influenced acceptance rates. This research highlights the importance of considering parental perspectives and tailoring communication strategies in pediatric dentistry, ultimately contributing to improved care for young patients with MIH.


Sample size calculation
The sample size for this study was calculated using the formula: n = , a widely recommended method for determining sample size in descriptive cross-sectional studies 26 .In adherence to a 5% type I error rate, the standard normal variate (Z) was set at 1.96.The proportion of the population was derived from previous studies, specifically the mean value of parental satisfaction regarding SDF application, which was found to be 60%.To ensure precision in our estimates, the desired margin of error (d) was set at 0.1.Consequently, the sample size calculation indicated a requirement for 92 participants.To account for potential attrition or unforeseen circumstances, we recruited 100 parents for the study, thereby enhancing the robustness and reliability of our findings.This methodology was chosen to guarantee that the study had adequate statistical power to detect meaningful relationships between parental satisfaction and various factors.
It should be noted that the sample population for this study had previously participated in a randomized controlled trial (RCT) comparing the preventive efficacy of SDF and MI Varnish on molars affected by MIH in children 9 .A total of 100 participants met the eligibility criteria and consented to participate in the study.

Application protocol of SDF
The application of SDF in this study followed the University of California San Francisco (UCSF) Protocol 27 .The procedure commenced with a thorough cleaning of the affected teeth using gauze, creating a dry field that was maintained with the assistance of cotton rolls.A single drop of SDF (Advantage Arrest, USA) was dispensed into a disposable plastic dish.Subsequently, a microbrush applicator (MRG400, Henry Schein, USA) was employed to apply the SDF to the affected tooth.The application was conducted for a duration of one minute, ensuring thorough coverage.
To support the effectiveness of the SDF application, parents were provided with specific post-application instructions.Participants were advised to refrain from consuming food or hot beverages for a period of 1 h.This precautionary measure aimed to optimize the retention and efficacy of the applied SDF.

Questionnaire development
For this study, a questionnaire was employed to assess parental satisfaction and acceptance of SDF treatment.The questionnaire was originally developed in English by Clemens et al. 21, has since been validated and tested for reliability.This well-established questionnaire was selected for its comprehensive coverage of pertinent aspects.

Translation and adaptation
To ensure linguistic and cultural relevance, the English version of the questionnaire was translated into Arabic.This translation process involved collaboration with two professionals whose native language was Arabic.Each professional independently translated the questionnaire into Arabic.Subsequently, the two Arabic versions were meticulously compared, and the most linguistically and culturally appropriate translation version was selected.
A critical step in the translation process involved back-translating the chosen Arabic version into English which was done by two professionals whose native language was English.This back-translation allowed for a thorough examination and comparison between the original English version and the back-translated Arabic version to ensure semantic equivalence and cultural appropriateness.

Pre-testing and refinement
In the pre-testing stage, a convenient sample of 20 parents/guardians, selected based on the same criteria as in the main study (except that their data were not included in the study's results), were invited to participate.These individuals completed the questionnaire.During this phase, deviations and errors in translation were meticulously scrutinized, and any necessary adjustments were made to improve linguistic clarity and ensure that the target participants easily understood questions.

Content validity
Measuring content validity involves assessing items of a questionnaire by asking experts if each item reaches the main aim that, the questionnaire is designed to cover.Five experts (three professors in pediatric dentistry and two professors in psychology) were asked to assess the items.Lawshe formula was used to determine the content validity ratio (CVR) 28 .Therefore, we asked each expert to determine whether the information behind each item is "essential", "useful but not necessary" or "not necessary".
N e is the number of essentials for the item, N is the number of experts.
The content validity index CVI, which is the mean of CVR for all studied items, was 0.92 and this means that the questionnaire developed was with high content validity.

Test-retest reliability
It involves administering the same questionnaire to 20% of the sample under the same conditions after period of time.In this study, 20% of the total sample (20 Participants) were randomly selected to refill up the questionnaire once again after 10 days.
Test-rest reliability was estimated with correlations between the scores at time point 1 and those at time point 2. Correlation coefficient (r) of parental satisfaction scores between the two time points was 0.89.This means that the studied questionnaire has an excellent reliability.

Internal consistency reliability
Internal consistency concerns the extent to which items on the test or instrument are measuring the same thing.This can be measured by Cronbach's alpha statistics.Cronbach's alpha reliability coefficient was 0.95, which means that the studied questionnaire has an excellent internal consistency.

Data collection
In this study, parental satisfaction with SDF treatment for their children's molars affected by MIH was assessed using a 4-item questionnaire.The questionnaire employed a 5-point Likert scale, with responses ranging from "1: Strongly Disagree" to "5: Strongly Agree." Structured interviews were conducted with parents or guardians to gather data regarding their satisfaction and acceptance of SDF treatment.The questionnaire included the following Likert scale questions: 1. Esthetics: "You are comfortable with your child's esthetics after SDF placement."2. Ease of Application: "SDF application is an easy process." 3. Pain Perception: "SDF application is pain-free for your child." 4. Taste: "SDF taste is acceptable to your child." Each of these questions was answered on a 5-level Likert scale: Strongly Agree, Agree, Neutral, Disagree, and Strongly Disagree.

Statistical analysis
The statistical analysis for this study was conducted using the Statistical Package for the Social Sciences (SPSS).Descriptive statistics were utilized to summarize the demographic characteristics of the 100 participants, including age, gender, and education levels.
Chi-square tests were employed to analyze the association between parental education levels and the acceptance of silver diamine fluoride (SDF) treatment.
Regression analysis was performed to assess the impact of independent variables (Esthetics, Ease of Application, Pain Perception, and Taste) on the dependent variable, Parental Satisfaction.Beta coefficients were calculated to determine the strength and direction of these relationships, while P-values were used to establish the statistical significance of the relationships.

Ethics approval and consent to participate
The study was conducted in accordance with the ethical standards outlined in the Declaration of Helsinki.Ethical approval was obtained from the Institutional Review Board at Damascus university with the following number (NO.2984), and a signed informed consent was obtained from all participants.

Results
A total of one hundred parents participated in this study.The majority were mothers (n = 69), and aged between 31 and 40 years (n = 75).In addition, 42% of the participants were graduates, while 13% were post-graduates (Table 1).
Regarding parental satisfaction with the appearance of their child's molars after SDF application, the findings revealed that 7% of parents strongly disagreed, 20% disagreed, 15% were neutral, 30% agreed, and 28% strongly agreed with the results.www.nature.com/scientificreports/When assessing the ease of application, 100% of parents either strongly agreed (70%) or agreed (30%) that the procedure was easy.On the other hand, regarding pain perception during SDF application, all parents found it to be a pain-free procedure, with 65% strongly agreeing and 35% agreeing.
As for the acceptability of the SDF taste by the children, the majority of parents reported that their children did not find the taste acceptable, with 18% strongly disagreeing, 35% disagreeing, 20% being neutral, 20% agreeing, and 7% strongly agreeing.
Table 2 presents the percentage distribution of each point on the scale for each questionnaire item, along with the mean values for all responses to each item.The highest mean satisfaction value was observed for ease of application (4.7), followed by pain perception (4.65), and then esthetics, with a mean value of (3.52).The lowest mean satisfaction value was associated with taste acceptability (2.63).
The mean value of parental satisfaction regarding SDF application for all studied items was 3.875, which corresponds to 77.5%, indicating high satisfaction.
In the regression analysis, the impact of four independent variables (Esthetics, Ease of Application, Pain Perception, and Taste) on the dependent variable, Parental Satisfaction, was assessed.
The results demonstrated that all four independent variables had a statistically significant impact on Parental Satisfaction.With an Adjusted R-squared value of 0.632, these variables collectively explained a substantial portion of the variance in Parental Satisfaction, emphasizing their significance.Findings are presented in Table 3.
Moreover, a detailed analysis of the satisfaction of SDF treatment revealed that the Chi-square test showed that higher number of parents with higher education levels (graduate and postgraduate) accepted SDF treatment compared to lower education level groups significantly (Illiterate, primary school and high school) (63.1% vs. 33.6%,respectively, P < 0.005).However, parental gender and age had no significant association with acceptance of SDF treatment (Table 4).

Discussion
The present study employed a cross-sectional research design to assess parental satisfaction and acceptance of SDF treatment for permanent molars affected by MIH.This study adhered to STROBE guidelines for crosssectional studies, ensuring a structured and rigorous approach to data collection and analysis.The primary aim of this study was to explore parental acceptance and satisfaction regarding SDF treatment for MIH-affected molars, a topic that had not been comprehensively addressed in previous literature.To achieve this aim, a Likert scale questionnaire was selected as the most suitable instrument to gauge parental opinions and satisfaction levels.
The questionnaire, which was adapted from Clemens et al. 21, underwent a rigorous translation process to ensure its applicability to Arabic-speaking participants.The pre-testing phase, involving a sample of 20 parents/ guardians, helped identify and rectify any discrepancies in translation.
Regarding parental satisfaction, our findings indicate that a significant proportion of parents expressed satisfaction with the aesthetic outcomes of SDF treatment on their children's permanent molars.This aspect is crucial, as it addresses one of the primary concerns among parents-the potential for tooth discoloration following SDF application.The study's results suggest that, despite concerns about discoloration, the majority of parents remained satisfied with the aesthetic results of SDF treatment (77.5%).
Comparing the findings of this study with prior research investigating parental acceptance of SDF treatment on primary teeth, certain consistencies and distinctions emerge.Prior studies have highlighted concerns about the aesthetic implications of SDF application 22,29 , an issue that was confirmed in our study.Parents exhibited a statistically notable inclination towards accepting SDF treatment when administered to posterior teeth 30 .This trend is consistent with observations found in various studies involving other types of unesthetic restorations, including stainless-steel crowns.It is a well-established phenomenon that patients generally express a higher preference for aesthetic interventions, especially when the restoration is prominently visible 31 .
It is noteworthy that, to our knowledge, no prior research has systematically assessed parental acceptance of SDF treatment specifically on permanent molars affected by MIH.This study thus fills a significant gap in the literature by providing valuable insights into the factors influencing parental acceptance in this context.It is crucial to consider that MIH-affected molars often pose a more intricate set of challenges than primary teeth, further underscoring the importance of this investigation.
Furthermore, the results of this study provide valuable insights into the factors influencing parental satisfaction and acceptance of SDF treatment for molars affected by MIH.Two key findings deserve particular attention and can be compared to existing research in the field.
Firstly, one of the standout findings in our study was that all parents reported that their children found the SDF application to be pain-free.This result is highly encouraging, emphasizing the non-invasive and gentle Table 3. Regression analysis of independent variables on parental satisfaction with SDF treatment for MIHaffected permanent molars.*Statistically significant (P-value < 0.001).www.nature.com/scientificreports/nature of SDF treatment.The fact that 65% of parents strongly agreed with this statement, and an additional 35% agreed, underscores the consensus regarding the painless nature of the procedure.These findings closely align with previous research that has praised SDF for its minimal discomfort during application 30,32 .The pain-free aspect of SDF treatment is particularly beneficial in pediatric dentistry, where reducing anxiety and apprehension in young patients is a top priority.It also enhances the overall experience of dental care, potentially reducing dental anxiety in children and fostering positive attitudes toward oral health 33 .

Independent variable
Secondly, the link between the perceived ease of application of SDF and higher levels of parental satisfaction and acceptance aligns with broader principles of user experience and satisfaction.In healthcare, treatments perceived as less burdensome or invasive often lead to higher patient satisfaction and adherence rates 34 .
In the case of pediatric dentistry, where children's comfort and cooperation during treatment are paramount, a minimally invasive and straightforward application process can significantly influence parental decisions 35 .This result is consistent with the literature on healthcare acceptance, which highlights the importance of user-friendly procedures in promoting treatment success 30,36 .
Dental practitioners may find value in emphasizing the ease and convenience of SDF treatment when discussing it with parents, as this aspect appears to play a pivotal role in their acceptance 37,38 .Furthermore, the results of this study showed that taste acceptability emerged as a notable factor influencing parental satisfaction and acceptance of SDF treatment for MIH-affected molars.
The findings revealed a considerable divide in parental perceptions, with a majority reporting that their children did not find the taste of SDF treatment acceptable.This discrepancy in taste acceptability raises intriguing questions about the role of sensory experiences in treatment acceptance, especially among pediatric patients.While SDF's clinical efficacy is well-documented, the taste factor appears to be a noteworthy consideration, potentially influencing parental decisions and children's cooperation during treatment.
It should be emphasised that the acceptability of taste is subjective and can vary widely among individuals and cultural contexts.A recent systematic review showed that some studies have reported that children, in particular, may exhibit a range of responses to different tastes, influenced by factors such as age, previous experiences, and cultural backgrounds 20 .Therefore, while taste acceptability emerged as a notable concern in our study, it's essential to view this finding within the broader landscape of pediatric dental care.
One important aspect to consider is the potential trade-off between taste and treatment effectiveness.SDF has gained recognition for its remarkable ability to halt dental caries progression, and its taste, while a concern for some, is arguably a small price to pay for its non-invasiveness and effectiveness 21 .Previous studies have indicated that parents and children may prioritize treatment outcomes over taste-related discomfort 20 .Therefore, while taste concerns exist, they may not outweigh the clinical benefits of SDF treatment.
Another notable discovery that merits specific consideration and can be likened to previous research in this domain is the educational background of parents.The observation that parents with higher education levels tend to express greater satisfaction and acceptance of the treatment aligns with broader trends in healthcare decisionmaking 39 .Prior studies have often reported that individuals with higher educational backgrounds tend to seek out and engage more actively in healthcare information and decision processes.They are often more receptive to novel treatments and technologies due to their ability to access and comprehend relevant information 40,41 .
In the context of this study, parents with higher education levels may have had a better understanding of the benefits and limitations of SDF treatment, leading to increased satisfaction and acceptance.This finding was similar to previous research 42 , which underscores the importance of tailored educational strategies that consider the educational backgrounds of parents, particularly when introducing innovative treatments like SDF.
While this study contributes significantly to the understanding of parental satisfaction with SDF treatment for MIH-affected molars, certain limitations must be acknowledged.The cross-sectional design restricts our ability to establish causal relationships, warranting caution when interpreting the results.Additionally, the study's recruitment of participants from a specific geographic area may limit the generalizability of the findings.Furthermore, reliance on self-reported data introduces the possibility of response bias.

Conclusion
In conclusion, this study offers unique insights into parental satisfaction and acceptance of SDF treatment for MIH-affected permanent molars.The remarkably high satisfaction levels suggest that SDF holds promise as an effective treatment option, despite concerns about tooth discoloration.The influence of parental education on acceptance rates emphasizes the need for tailored communication strategies in dental practice.This research contributes to the growing body of knowledge in pediatric dentistry and underscores the importance of considering parental perspectives when formulating treatment strategies.

Testing the translated version of the questionnaire
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Table 1 .
Demographic characteristics of study participants.

Table 2 .
Questionnaire responses and mean satisfaction scores of SDF treatment for MIH-affected permanent molars.

Table 4 .
Association between parental satisfaction with SDF treatment and various independent variables, including age, sex, and education level.*Statistically significant (P-value < 0.05).