Introduction

Dental caries management has changed over time and is now founded on a better understanding of the mechanism of disease development. Since the publication of the first policy statement on minimal intervention dentistry (MID), the approach to caries lesions has developed to include noninvasive, micro invasive, and minimally invasive strategies that aim to preserve tooth structure that can be remineralized (WHO 2016). The minimally invasive procedures (also known as minimal intervention procedures) (MIPs) recommended in the guidelines and policies for caries lesions management include the application of silver diamine fluoride (SDF) in cavitated lesions, fissure and pit sealants, non-restorative approaches, and restorations using different techniques and materials, such as atraumatic restorative treatment (ART) with glass ionomer cement, and the Hall Technique (HT) (Corrêa-Faria et al. 2020).

The efficacy of MID-based procedures has been investigated in an increasing number of clinical studies and reviews (BaniHani et al. 2022). An umbrella review evaluated 18 systematic reviews on the management of caries lesions in primary teeth using these procedures and confirmed the efficacy of SDF application, selective removal of carious tissue, and HT and ART techniques in halting the progression of lesions (BaniHani et al. 2022). Results on the effectiveness of MID-based procedures are important for making decisions regarding treatment options and should be considered together with the professional’s experience (Rønneberg et al. 2017), and the preference, values and needs of the patient and his family (Jayaraman and Mallineni 2022). However, the number of studies on parents’/caregivers’ perception toward MIPs for caries lesion management in children is still limited.

The evaluation of caries lesion treatment options by patients/caregivers, and their involvement in the decision-making process is an emerging need in pediatric dentistry (Ladewig et al. 2018). Patient-reported outcome measures (PROMS), or outcomes reported by the children’s caregivers, are increasingly sought in clinical trials because they allow related therapies to be evaluated by the people with the greatest interest in the treatment (Mendes et al. 2020). Outcomes, such as parent/caregiver acceptance and preference for a certain MIP, have recently been investigated in clinical trials and observational studies, and the results have been summarized in both scoping (Magno et al. 2019) and systematic reviews (Sabbagh et al. 2020; Hu et al. 2022). These reviews have evaluated what guides the acceptance of SDF in primary teeth (Magno et al. 2019; Sabbagh et al. 2020), as well as HT (Hu et al. 2022). The literature has a gap regarding parent/caregiver acceptance of other MIPs and offers a synthesis allowing a comparative evaluation of the acceptance of these procedures, indicated for managing caries lesions in children.

To map and synthesize the scientific evidence on the acceptance of the different MPIs it is desirable to conduct a scoping review. This type of review differs from the systematic one in that it allows the elaboration of a broader question related to heterogeneous topics (Tricco et al. 2018; Munn et al. 2018). From this design, it will be possible to verify and synthesize the literature on the different MIPs.

The aim of this study was to use a scoping review to map and synthesize the evidence on parents’ and caregivers’ acceptability of MIPs for managing cavitated caries lesions in children and to identify the variables that may affect acceptability.

Material and methods

The scoping review was reported following PRISMA guidelines (Tricco et al. 2018). The study involved the following steps: (1) formulation of the research question; (2) identification of relevant studies; (3) selection of studies; (4) data mapping; (5) grouping, synthesis and reporting of results (Levac et al. 2010). The protocol was registered at the Open Science Framework in December 2022 (https://osf.io/ujdk3https://doi.org/10.17605/OSF.IO/4XNCQ).

The CoCoPop (condition, context and population) acronym was used to formulate the research question: “To what extent do parents/caregivers accept MIPs for managing cavitated caries lesions in children?” The condition investigated was the use of MIPs to manage cavitated caries lesions in deciduous teeth. The context was the acceptance of MIPs by parents/caregivers, who constituted the population in reference.

Relevant studies on the subject were searched in PubMed, Lilacs, Cochrane Library, OpenGrey through the Dans Easy Archive and Google Scholar electronic databases. The search strategy was developed using terms indexed in the Medical Subject Heading (MeSH) and synonyms and was adapted to each electronic database (Table 1). The search made no restriction to date or language of publication of the studies. The reference lists of the included articles were consulted to identify relevant studies.

Table 1 Search strategy
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The references were managed using Rayyan software (Rayyan—Intelligent Systematic Review) (Ouzzani et al. 2016). Duplicate articles were removed, and the others were evaluated by three researchers, independently and in two stages. In the first stage, the title and abstract of each article were read, and the eligibility criteria, applied. Next, the full text of the articles included in the previous stage was read and evaluated on the inclusion and exclusion criteria. Disagreements among the evaluators were resolved by consensus. The inclusion criteria of the articles were: observational studies (cross-sectional, case–control and cohort) and intervention studies (clinical trials) that investigated the acceptance of parents/caregivers toward the MIPs indicated for managing cavitated carious lesions in deciduous teeth. Guidelines, editorials, case reports, qualitative studies, reviews, animal studies, and in vitro studies were excluded.

Information was extracted from the included articles and then synthesized in a table and text. Details about the study (authors, year, and country of publication), method (study design), participants (number of participants, relationship with the child, age of the children), the MIPs investigated, method of evaluation of acceptance, results on acceptance, associated factors, and conclusion were extracted. When relevant information was not available in the articles, it was requested from the authors by email.

Results

Study selection

The search in the electronic databases resulted in 952 articles and was conducted in January 2023. After the removal of the duplicates, 920 were submitted to the title and abstract evaluation stage. A total of 869 documents were excluded because they did not evaluate the caregivers’ acceptance of MIPs for caries lesion management in primary teeth, and 51 were read in full. Of these, 16 were included in the scoping review. A consultation of the reference list of the articles identified 9 documents, 3 of which were included. In the end, 19 articles were included (Fig. 1).

Fig. 1
figure 1

PRISMA 2020 flow diagram for updated systematic reviews which included searches of databases, registers and other sources

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Study characteristics

The studies were conducted in the United Arab Emirates (1), Pakistan (1), Syria (1), Saudi Arabia (4), India (4), Singapore (1), the United States (4), Egypt (2) and Brazil (1). The cross-sectional design was the most frequent (n = 12), followed by clinical trials (n = 6) and longitudinal studies (n = 1). The number of participants ranged from 26 in a longitudinal study (Chaurasiya and Gojanur 2021) to 546 in a cross-sectional study (Kumar et al. 2019). In the clinical trials, the number of participants ranged from 30 (Clemens et al. 2018) to 100 (El-Ghandour et al. 2021). The interventions compared in these trials were ART versus application of SDF (El-Ghandour et al. 2021; Ali et al. 2021), ART versus HT (Araújo et al. 2020), HT versus restoration with resin-modified glass ionomer cement (Thakkar and Jawdekar 2022), and SDF versus conventional restoration (Cleary et al. 2022).

Parent/caregiver acceptance of MIPs was assessed mainly by using a 4- to 5-point Likert scale (Ali et al. 2021; Alshammari et al. 2019; Asif and Guranathan 2020; Bagher et al. 2019; Bassam et al. 2022; Clemens et al. 2018; El-Ghandour et al. 2021; Hu et al. 2020; Thakkar and Jawdekar 2022; Walia et al. 2022). In most studies on the acceptance of SDF application, parents/caregivers were questioned after observing photographs of treated teeth that evidenced the blackening of the tooth structure (Akshita et al. 2022; Alshammari et al. 2019; Asif and Gurunathan 2020; Bagher et al. 2019; Crystal et al. 2017; Salim et al. 2021), and a video (Hu et al. 2020). In 3 cross-sectional studies, parents/caregivers were presented with different scenarios related to the management of the child’s behavior toward dental care (Crystal et al. 2017; Akshitha et al. 2022; Walia et al. 2022).

In 7 clinical trials (Clemens et al. 2018; El-Ghandour et al. 2021; Araujo et al. 2020; Ali et al. 2021; Chaurasiya and Gojanur 2021; Bassam et al. 2022; Cleary et al. 2022), acceptance was assessed immediately after treatment (Araujo et al. 2020; Bassam et al. 2022) or in follow-up sessions at 2-week (Clemens et al. 2018; El-Ghandour et al. 2021; Ali et al. 2021) to 12-month intervals (Cleary et al. 2022). The acceptance of parents/caregivers was based on criteria related to the child, such as comfort (Ali et al. 2021), discomfort caused by the procedure (Araújo et al. 2021), pain caused by the procedure (Clemens et al. 2018; Asif and Gurunathan 2020), duration of the session (Ali et al. 2021), aesthetic aspect (Alshammari et al. 2019; Ali et al. 2021; Cleary et al. 2022; El-Ghandour et al. 2021; Almarwan et al. 2021; Akshitha et al. 2022; Asif and Gurunathan 2020; Bassam et al. 2022), ease in performing the procedure (Clemens et al. 2018; Asif and Gurunathan 2020), taste of the product (Clemens et al. 2018; El-Ghandour et al. 2021), how well the restoration could protect the tooth (Araújo et al. 2020), and understanding why treatment is needed (Araújo et al. 2020).

The percentage of acceptance of MIPs ranged from 1.4% (Walia et al. 2022) to 100% (Chaurasiya and Gojanur 2021). In the studies that evaluated SDF application, the acceptance of parents was investigated according to the location of the teeth (Almarwan et al. 2021; Bagher et al. 2019; Bassam et al. 2022; Crystal et al. 2017; Salim et al. 2021; Wajahat et al. 2022; Walia et al. 2022), and to the behavior of the children (Akshitha et al. 2022; Ali et al. 2021; Bagher et al. 2019; Walia et al. 2022). The acceptance of SDF application to anterior teeth ranged from 28.7% (Akshitha et al. 2022) to 57.5% (Ali et al. 2021), versus 55.2% (Almarwan et al. 2021) to 97.5% (Ali et al. 2021) for posterior teeth. In one study, more than 90% of the participants considered SDF application unacceptable for either anterior or posterior teeth (Alshammari et al. 2019).

Acceptance of SDF application was associated with behavioral management problems (Bagher et al. 2019; Hu et al. 2020; Ali et al. 2021; Akshitha et al. 2022), pharmacological techniques indicated for behavior management (Chaurasiya and Gojanur 2021; Akshitha et al. 2022), and location of the teeth to be treated (Akshitha et al. 2022). Socioeconomic factors such as educational level (Crystal et al. 2017; Asif and Gurunathan 2020; Walia et al. 2022), income (Crystal et al. 2017; Asif and Gurunathan 2020), and treatment costs (Hu et al. 2020) were associated with the acceptance of SDF application.

When SDF was compared with ART, there was better acceptance for SDF regarding treatment duration and comfort (Ali et al. 2021). Acceptance in relation to the aesthetic aspect was similar for both treatments (Ali et al. 2021). In contrast, there was better acceptance of ART in relation to aesthetics than HT (Araújo et al. 2020). HT was investigated in only two of the 19 studies included (Araujo et al. 2020; Thakkar and Jawdekar 2022). When HT was compared with restorations using resin-modified glass ionomer cement, the mean acceptance rate for HT was higher (Thakkar and Jawdekar 2022). The information extracted from the articles has been summarized in Table 2.

Table 2 Summary of the results of the articles
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Discussion

The objective of the scoping review was to synthesize the evidence on parent acceptance of MIPs for caries lesion management in children. There are a growing number of investigations on MIPs related especially to efficacy (BaniHani et al. 2022). Little is addressed concerning patient-reported outcomes (PRO), despite the emerging need for pertinent information (Ladewig et al. 2018).

The selected studies evaluated the acceptance of parents mainly toward using SDF. Only a few studies investigated the acceptance of ART (Araújo et al. 2020; El-Ghandour et al. 2021; Ali et al. 2021) and HT (Araújo et al. 2020; Thakkar and Jawdekar 2022). The reason is that acceptance of these techniques by parents/caregivers is mostly affected by their aesthetic perception. Specifically, the aesthetic aspect is more questionable in relation to SDF than other MIPs. This hypothesis is strengthened by the observation that parental acceptance was related to the aesthetic aspect in practically all the studies investigated.

The definitive change in tooth color impacted the acceptance of the parents even after clarifications were given about the benefits and efficacy of SDF in the paralysis of caries lesions. The highest acceptance rate was observed when the treatment context involved problems of managing the child’s behavior at the dentist. This result corroborates that observed in a systematic review published in 2020 (Sabbagh et al. 2020). However, this review included only eight studies that addressed the acceptance of SDF. Other MIPs were not investigated or compared.

The aesthetic perception was mentioned in the evaluations of HT acceptance. Although HT treatment is performed on posterior teeth, which are less visible than anterior teeth, the appearance of the HT outcome bothered the parents of Brazilian children, who accepted glass ionomer cement or composite resin restorations better (Araújo et al. 2020). In contrast, HT was better accepted than resin-modified glass ionomer cement restorations by parents of Indian children (Thakkar and Jawdekar 2022). In the last cited study, the question used to evaluate treatment acceptance was not detailed, thus precluding any indication of what factors caused parents to better accept HT. When comparing the acceptance means of HT versus ART, it can be observed that the numerical difference was not clinically relevant, hence leading to the conclusion that the acceptance of treatments was similar (Thakkar and Jawdekar 2022).

Acceptance of the MIP was assessed considering the parents’ perception of images, videos, and observation of their child’s teeth after treatment (Ali et al. 2021). In the post-treatment periods, the aspects evaluated included treatment duration (Ali et al. 2021), aesthetics/appearance (Araújo et al. 2020; El-Ghandour et al. 2021; Ali et al. 2021; Cleary et al. 2022), child comfort/discomfort (Clemens et al. 2018; Araújo et al. 2020; Ali et al. 2021), understanding why the treatment is needed (Araújo et al. 2020), taste (El-Ghandour et al. 2021) and pain (Cleary et al. 2022). Evaluation of acceptance after the procedure aroused doubts about the concept of acceptance adopted in the studies. According to the Health Sciences Descriptors (DECS) 2017, acceptance refers to the willingness to receive health services. Thus, it is expected that acceptance will be evaluated prior to the performance of the dental procedure. However, when considering that the study design involved clinical trials, an a posteriori evaluation would be a warranted avenue of investigation, justified by the need to maintain randomization and avoid interference of the parents’/caregivers’ preference in the allocation of children to the intervention groups. Perhaps, it would be more appropriate to evaluate satisfaction in these studies.

There are some limitations in the present scoping review. Participants in the studies included in the scoping review were approached in dental school clinics or in specialized services. The external validity of the findings of the primary studies was compromised since it did not represent other children who had dental needs and/or were treated with MIPs in private services or others. Another limitation involved the difficulty of comparing the concept of acceptance by parents of children from different countries and cultures. Cultural differences may affect the acceptance of treatment and the aesthetic perception of parents/caregivers. In future studies, it is recommended that primary studies be grouped according to geographic location and cultural similarity.

Evaluating the acceptance of MIPs by parents/caregivers is an important part of the decision-making process for pediatric dental treatment. However, this scoping review revealed that there is still little information available on the acceptance of these procedures and that the studies investigated tended to evaluate the acceptance mostly of SDF.

Conclusion

In general, it was observed that the application of silver diamine fluoride, Hall Technique and atraumatic restorative treatment are acceptable procedures for carious lesion management in children, although the evidence is still limited. A gap remains in the literature regarding the acceptance of other procedures. Therefore, further studies in this area will contribute toward a better understanding of the opinion of parents/caregivers, and thus improve caries lesion management in children.