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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 283-287

Satisfaction of primary caregiver with the dental treatment by silver diammine fluoride during COVID-19 pandemic


1 Department of Pediatric and Preventive Dentistry, Dr. Ziauddin Ahmad Dental College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
2 I.T.S Center for Dental Study and Research, Ghaziabad, Uttar Pradesh, India

Date of Submission02-Aug-2021
Date of Decision13-Aug-2021
Date of Acceptance25-Aug-2021
Date of Web Publication20-Dec-2021

Correspondence Address:
Faraha Javed
Department of Pediatric and Preventive Dentistry, Dr. Ziauddin Ahmad Dental College, Aligarh Muslim University, Aligarh, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrr.jdrr_135_21

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  Abstract 


Context: Silver diammine fluoride (SDF) is a neoteric preventive measure that effectively arrests caries at an early stage and prevents its further progression. Aim: SDF (38%) is an evidence-based nonrestorative treatment for carious lesions of both dentitions causing permanent black staining. The aim of this study was to find out primary caregiver's satisfaction with SDF treatment and factors affecting it during the COVID-19 pandemic. Subjects and Methods: Eighty-nine parents were contacted after 6 months of the application of SDF to their child's teeth through telephone and were asked questions related to SDF. Statistical Analysis Used: For statistical analysis, predictive modeling through machine learning algorithms by random tree and Chi-square Automatic Interaction Detection (CHAID) model was done and accuracy was also checked. Results: In 92.1% of the cases, the primary caregiver was the mother. Only 19.1% reported esthetic concern related to black discoloration. Random tree and CHAID model showed chief complaint redressal as the main variable governing the satisfaction of primary caregiver. Random tree was a better model predictor with 96.6% accuracy against 82% of CHAID. Conclusions: Parents accepted SDF treatment for their child, especially in the ongoing COVID-19 pandemic, and would go for its use in future as a treatment modality.

Keywords: Black discoloration, carious lesions, COVID-19, machine learning, primary caregiver, satisfaction, silver diammine fluoride


How to cite this article:
Javed F, Khan SY, Sharma MK. Satisfaction of primary caregiver with the dental treatment by silver diammine fluoride during COVID-19 pandemic. J Dent Res Rev 2021;8:283-7

How to cite this URL:
Javed F, Khan SY, Sharma MK. Satisfaction of primary caregiver with the dental treatment by silver diammine fluoride during COVID-19 pandemic. J Dent Res Rev [serial online] 2021 [cited 2022 May 23];8:283-7. Available from: https://www.jdrr.org/text.asp?2021/8/4/283/332921




  Introduction Top


One of the most prevalent diseases of childhood is dental caries which affects all the strata of society. On the basis of caries risk, a population can be divided into low and high risk. The level of caries risk can be restrained by several factors, namely diet, education status, socioeconomic status, and other demographic factors. Dental caries is of universal concern, which is why it requires an effectual solution. Treatment and prevention are said to be two modus operandi; the former consists of drilling and filling and later depends on arresting caries initiation at the earliest. Prevention seems to be a better option reasonably.[1]

Silver diammine fluoride (SDF) is a neoteric preventive measure which effectively arrests caries at an early stage and prevents its further progression. SDF has been authenticated by systematic reviews of randomized controlled trials of humans as an inexpensive, minimally invasive therapy which is easily applied, does not require any caries removal, and is least risky for patients.[2] It is time saving and requires minimum efforts from the dental team as well as the family.[1] The American Academy of Pediatric Dentistry has lately issued an evidence-based guideline which encourages SDF use in arresting cavitated carious lesions in deciduous teeth.[3] A systematic review has been carried out by the American Dental Association which issued a clinical recommendation based on evidence for nonrestorative treatment of caries lesions in both deciduous and permanent teeth with SDF.[4] SDF forms a squamous layer on dentin which is exposed and plugs the dentinal tubules partially. Silver compounds interfere with the biofilm-forming ability of pathogens on SDF-treated surfaces, hence arresting dentinal caries. It also advocates remineralization by forming fluorapatite from hydroxyapatite crystals.[5]

However, SDF has its drawbacks too, of which the most significant is black staining of carious enamel and dentin. This can be a major obstacle in its utilization as it affects esthetics which is of prime importance for most. Besides, the most commonly reported barrier to SDF's use is parental acceptance (91.8%). Some clinical trials have shown a low parental concern regarding staining (<7%),[2] while others indicated a different level of tolerance.[1]

Since SDF treatment is noninvasive, it was especially preferred in the COVID-19 pandemic period. The present study was conducted with the aim to assess the level of primary caregiver's satisfaction and whether it is affected by age, gender, primary caregiver, educational status of primary caregiver, tooth position, and chief complaint redressal.


  Subjects and Methods Top


The study was approved by the Institutional Ethical Committee D. No. 257/FM dated May 11, 2019, which was according to the World Medical Association Declaration of Helsinki. The study has been registered with Clinical Trials Registry – India (CTRI) having registration number CTRI/2020/01/022794 for this trial. A hundred parents of registered pediatric patients in the age group of 3–7 years were contacted for this study, out of which six gave no response and five dropped out from the study. Hence, the study was conducted on the remaining 89 parents, who had given verbal consent for the use of SDF on their child's teeth to arrest/prevent caries development through telephone during COVID-19. Written mandatory consent was also taken before the start of the treatment. SDF was applied only on those teeth having DIAGNOdent reading between 13 and 34 and no history of pain. After 6 months of the application of SDF, the parents/caregivers were contacted again through telephone to collect data about their satisfaction. For collecting the data, a purposeful questionnaire was designed that was tested for clarity, ease of completion, and timing. To test the face validity, a total of ten participants were asked the questions from the questionnaire and were inquired if they faced any trouble understanding or answering any of the questions. The questionnaire consisted of closed-ended questions. The telephonic interview was performed by a trained pedodontist. The first section of the questionnaire included sociodemographic data such as age, gender, primary caregiver, and educational status of primary caregiver. The other section included the clinical questions like if they are satisfied with the treatment done, whether SDF was able to address their chief complaint, treatment was done on which tooth, and regarding any esthetic concern they might have.

Statistical analysis

The collected data were tabulated and analyzed statistically using predictive modeling through machine learning algorithms by random tree and Chi-square Automatic Interaction Detection (CHAID) model. The accuracy of the abovementioned models was also checked. Multiple logistic regression analysis was performed too.


  Results Top


Out of 100 parents of registered pediatric patients contacted for the study, 89 parents responded. The children were 3–7 years old. Maximum children were 3 years old (31.5%). Female children were slightly more in number (51.7%). The primary caregiver in more than 90% of the cases was the mother. About 38.2% of the primary caregivers were graduates, 29.2% were postgraduates, and only 2.20% were just literates. The sociodemographic data of the participating subjects are represented in [Table 1].
Table 1: Sociodemographic characteristics of participating subjects

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92.1% of the parents were satisfied with the treatment of SDF. The percentage of parents who reported that their chief complaint was addressed was again 92.1%. The treatment was done mostly on posterior teeth (in 51.7% of the cases). Only 19.1% reported some kind of esthetic concerns related to black discoloration, otherwise the majority of the parents (80.9%) had no esthetic concerns. Around 88.8% of the parents were satisfied with the oral health status of their child after treatment done by SDF. The data of clinical questions are represented in [Table 2].
Table 2: Clinical questions

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Multiple logistic regression analysis revealed three variables to be statistically significant: primary caregiver, SDF ability to address the chief complaint of the patient, and parents' satisfaction with the oral health status of their child after treatment [Table 3]. For multiple logistic regression, predictive modeling through a machine learning algorithm was performed to find which variable determined the satisfaction of parents the most. The accuracy of both the models was also checked.
Table 3: Multiple logistic regression analysis for finding independent association of variables with primary caregiver's satisfaction

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The CHAID model, from [Figure 1], showed that 92.135% of the parents were satisfied with the ability of SDF to address the chief complaint of their children. The random tree predicting model, from [Figure 2], showed the prediction importance of different factors. It was found that the primary caregiver's satisfaction highly depended upon the fact that SDF was able to address the chief complaint. In terms of accuracy, random tree was more accurate with 96.6% accuracy against 82% accuracy of the CHAID model [Table 4].
Figure 1: The Chi-square Automatic Interaction Detection model showed that 92.135% of the parents were satisfied with the ability of silver diammine fluoride to address the chief complaint of their children

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Figure 2: The random tree predicting model showed prediction importance of different factors. It was found that primary caregiver's satisfaction highly depended upon the fact that silver diammine fluoride was able to address the chief complaint

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Table 4: In terms of accuracy, random tree was more accurate with 96.6% against 82% of Chi-square Automatic Interaction Detection model

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  Discussion Top


To the best of our knowledge, ours is a novel study conducted in the COVID-19 pandemic focusing on parental acceptance of SDF and comparing different variables and their association with parental satisfaction of SDF treatment. It is neoteric in using predictive modeling through machine learning algorithms for statistical analysis.

Evidence-based dentistry suggests SDF as an effective anticaries agent. It can be used in the pediatric population, especially in very young children, and has no imminent risk or harm.[6] The main barrier to its use in clinical practice is the black discoloration it causes,[7],[8] when applied to a demineralized tooth, which is permanent. Hence, it is indispensable to envisage parental concern regarding SDF treatment.[2] One of the outcomes for medical care is parent's satisfaction which affects their decision regarding health care.[9] For decision-making in children, parental satisfaction is important.[10] Focusing on outcomes that are patient-centered has a long-term and greater impact in achieving oral as well as overall health.[3]

A total of 100 parents of registered pediatric patients were contacted, 89 responded. Primary caregivers were mostly mothers (92.1%), which was statistically significant. This is similar to the study done by Crystal et al.[2] and Alshammari et al.[1] According to them, there is a difference between the male and female perception of esthetics, and the decision about the treatment is made by the one who takes the child to dental appointments. Primary caregivers' satisfaction with the treatment was 92.1%. Similar results were reported by Clemens et al.[11]

With increase in education level, acceptance of SDF treatment increased in our study. This is similar to the study done by Alshammari et al.[1] In contrast to this, a study done by Crystal et al.[2] reported acceptance to be more among parents having lower education. Increased acceptance in our study might be due to the fact that in the pandemic period, parents, especially those with higher education, understood the risks of invasive treatments and thus preferred noninvasive.

In our study, a significant association was seen between parental acceptance and chief complaint redressal (P = 0.00). Around 92.1% of the parents reported that their chief complaint was addressed by SDF treatment. This is the first study to measure the ability of SDF to address the chief complaint of the patient.

51.7% of the teeth treated were posteriors, which is slightly more than the anteriors. Similar results were reported by other studies too.[1],[2],[5],[12],[13] The reason might be the fact that staining is much less visible on posteriors in comparison to the anterior teeth. Crystal et al.[3] deduced an esthetic-driven nature of the society which entails the clinician to specifically emphasize the benefits of SDF treatment over other modalities to the parents so that they choose the treatment that is best suited for their child based on its effectivity rather than just esthetics. Following the recommendation, parents were explained the significance of the treatment. While about 80.9% of the parents reported no esthetic concerns with the treatment, only 19.1% were esthetically concerned. It is similar to the study done by Huebner et al.[4] who reported that most of the parents (73%) were not bothered by the discoloration. Other studies have also supported our result.[11],[14],[15] However, one study done in Hong Kong has reported dissatisfaction of parents with the esthetic outcome of SDF therapy.[16]

Nearly 88.2% of the parents were satisfied with the oral health status of their child after treatment, whereas about 11.2% were not satisfied. The reason for satisfaction might be the effective caries arrest by SDF. Similar findings have been reported by a study done by Jiang et al.[17] who reported an increase in the mean parental satisfaction score regarding their child's dental health status after 6 months of SDF application (P < 0.001) from 2.2 ± 0.7 to 2.8 ± 1.0.

No association was found between the primary caregiver's satisfaction and the gender of the child. Similar results were reported by Sultan et al.[18] Contrary to this, Alshammari et al.[1] found that parents of female children were more reluctant toward SDF treatment.

The strengths of this study were the interviewer-administered survey that provides the opportunity for probing and follow-up questions in contrast to self-administered or anonymous surveys. The possibility of recall bias was diminished as the survey was conducted on only those patients who had received the SDF application. Parents' acceptance was evaluated based on their experience with the SDF treatment and not merely on the basis of the pictures of before and after treatment. The use of predictive modeling through machine learning algorithms has set this study apart from the rest. Multiple logistic regression revealed three variables to be statistically significant: primary caregiver, SDF's ability to address the chief complaint of the patient, and primary caregiver's satisfaction with the oral health status of their child after treatment. However, according to random tree and CHAID, primary caregiver's satisfaction highly depended only on one variable, i.e. the ability of SDF to address the chief complaint. Machine learning models are designed to make the most accurate predictions possible. This is one of the key highlights of our study.


  Conclusions Top


Parents accepted SDF treatment for their child, especially owing to the ongoing COVID-19 pandemic, and would most likely prefer it in future as well as a treatment modality since their child's chief complaint was primarily addressed by the SDF application. Although few parents showed concern regarding black discoloration, most of them understood the risk of alternative treatment chiefly in these extraordinary circumstances.

Ethical clearance

The study was approved by the institutional Ethics Committee of the Faculty of Medicine, Aligarh Muslim University with Draft No 257/FM.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Alshammari AF, Almuqrin AA, Aldakhil AM, Alshammari BH, Lopez JNJ. Parental perceptions and acceptance of silver diamine fluoride treatment in Kingdom of Saudi Arabia. Int J Health Sci (Qassim) 2019;13:25-9.  Back to cited text no. 1
    
2.
Crystal YO, Janal MN, Hamilton DS, Niederman R. Parental perceptions and acceptance of silver diamine fluoride staining. J Am Dent Assoc 2017;148:510-8.e4.  Back to cited text no. 2
    
3.
Crystal YO, Kreider B, Raveis VH. Parental expressed concerns about silver diamine fluoride (SDF) treatment. J Clin Pediatr Dent 2019;43:155-60.  Back to cited text no. 3
    
4.
Huebner CE, Milgrom P, Cunha-Cruz J, Scott J, Spiekerman C, Ludwig S, et al. Parents' satisfaction with silver diamine fluoride treatment of carious lesions in children. J Dent Child (Chic) 2020;87:4-11.  Back to cited text no. 4
    
5.
Bagher SM, Sabbagh HJ, AlJohani SM, Alharbi G, Aldajani M, Elkhodary H. Parental acceptance of the utilization of silver diamine fluoride on their child's primary and permanent teeth. Patient Prefer Adherence 2019;13:829-35.  Back to cited text no. 5
    
6.
Gao SS, Zhao IS, Hiraishi N, Duangthip D, Mei ML, Lo EC, et al. Clinical trials of silver diamine fluoride in arresting caries among children: A systematic review. JDR Clin Trans Res 2016;1:201-10.  Back to cited text no. 6
    
7.
Chu CH, Lo EC, Lin HC. Effectiveness of silver diamine fluoride and sodium fluoride varnish in arresting dentin caries in Chinese pre-school children. J Dent Res 2002;81:767-70.  Back to cited text no. 7
    
8.
Yee R, Holmgren C, Mulder J, Lama D, Walker D, van Palenstein Helderman W. Efficacy of silver diamine fluoride for arresting caries treatment. J Dent Res 2009;88:644-7.  Back to cited text no. 8
    
9.
McMillan JR. Measuring consumer satisfaction to improve quality of care. Health Prog 1987;68:54-5, 76-80.  Back to cited text no. 9
    
10.
Kittiprawong R, Kitsahawong K, Pitiphat W, Dasanayake A, Pungchanchaikul P. Parent-Child Satisfaction and Safety of Silver Diamine Fluoride and Fluoride Varnish Treatment. Conference: The 13th International Conference of Asian Academy of Preventive Dentistry. Vol. 14; 2018. p. 52-63.  Back to cited text no. 10
    
11.
Clemens J, Gold J, Chaffin J. Effect and acceptance of silver diamine fluoride treatment on dental caries in primary teeth. J Public Health Dent 2018;78:63-8.  Back to cited text no. 11
    
12.
Gordon NB. Silver diamine fluoride staining is acceptable for posterior primary teeth and is preferred over advanced pharmacologic behavior management by many parents. J Evid Based Dent Pract 2018;18:94-7.  Back to cited text no. 12
    
13.
Sabbagh H, Othman M, Khogeer L, Al-Harbi H, Al Harthi A, Abdulgader Yaseen Abdulgader A. Parental acceptance of silver diamine fluoride application on primary dentition: A systematic review and meta-analysis. BMC Oral Health 2020;20:227.  Back to cited text no. 13
    
14.
Hu S, Meyer B, Duggal M. A silver renaissance in dentistry. Eur Arch Paediatr Dent 2018;19:221-7.  Back to cited text no. 14
    
15.
Triches TC, Cordeiro MM, Souza JC, Saltori EK, França BH. Parental acceptance of the use of diamine silver fluoride in children aged 0 to 3 years in the city of Cascavel, PR, Brazil. Braz Res Pediatr Dent Integr Clin 2009;9;265-9.  Back to cited text no. 15
    
16.
Jiang M, Xie Q, Wong MC, Chu CH, Lo EC. SDF Treatment and Parental Satisfaction with Aesthetics of Child's Teeth. The 96th General Session and Exhibition of the International Association for Dental Research (IADR) and IADR Pan European Regional (PER) Congress, London, UK. Vol. 97; 2018. p. 1883.  Back to cited text no. 16
    
17.
Jiang M, Wong MC, Chu CH, Dai L, Lo EC. Effects of restoring SDF-treated and untreated dentine caries lesions on parental satisfaction and oral health related quality of life of preschool children. J Dent 2019;88:103171.  Back to cited text no. 17
    
18.
Sultan A, Mehta A, Juneja A, Siddiqui M. Evaluating parental acceptance for silver diamine fluoride therapy- A pilot study. RSBO 2020;17:226-9.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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