The Use of AI PROMs in CYP and Clinicians

The Use of AI PROMs in CYP and Clinicians | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Use of AI PROMs in CYP and Clinicians Jenan Altaher, Susan Parekh, Fiona Ryan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6904800/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background: Amelogenesis Imperfecta (AI) is a genetic enamel defect affecting both primary and permanent dentitions, often leading to functional, aesthetic, and psychosocial challenges. Patient Reported Outcome Measures (PROMs) are increasingly used in paediatric dentistry, including ones developed for AI. Aim: To explore the impact of AI on oral health-related quality of life in children and young persons’ using an AI-specific PROM, and to assess clinician use of the PROM in the UK. Methods: This single-centre retrospective service evaluation involved children with AI who completed a 9-question PROM pre- and mid-treatment. Responses were analysed by treatment stage, age group, and AI subtype. Clinician feedback of the AI PROM was obtained via an online survey administered via the electronic platform Qualtrics™. Results: A total of 68 completed AI PROMs, with ages ranging between 7-19 were analysed at pre-treatment and mid-treatment stages. Younger children (under 13 years) were more likely to report functional difficulties, such as pain and eating challenges, while adolescents (over 13 years) more frequently expressed psychosocial concerns including bullying and low self-confidence. Notably, satisfaction with dental appearance increased from 26% to 42% by the mid-treatment stage. In the clinician feedback survey regarding use and effectiveness of the AI PROM, 23 paediatric dentists responded from a mailing list of 78, representing a 29.5% response rate. Of the clinicians familiar with the AI PROM, 67% reported actively using it in their clinical practice. Most found the tool valuable for enhancing communication and supporting care planning, though some highlighted workflow constraints and difficulty interpreting subjective responses. Conclusion: The AI PROM, while non-validated, provided meaningful insights into patient experiences and supported more empathetic, patient-centred care. Incorporating clinician perspectives highlighted both its promise and areas for refinement. Further validation is needed to support broader clinical implementation. Amelogenesis Imperfecta PROMs Paediatric Dentistry Quality of Life Enamel Defects Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1 Introduction Amelogenesis Imperfecta (AI) is a hereditary enamel defect that can present as missing, thin, or discoloured enamel due to abnormalities in the quantity and/or quality of enamel formation. In addition to clinical challenges, AI can significantly affect a child’s oral function, appearance, and self-esteem, all of which contribute to a reduced oral health-related quality of life (OHRQoL) [ 1 , 2 , 3 ]. Children and adolescents with AI may experience sensitivity, pain, aesthetic concerns, and bullying, particularly during school years. To capture these subjective impacts, a condition-specific PROM for AI was developed, piloted, and implemented across four UK specialist paediatric centres. Overall, 60 children aged 5–17 years completed the PROM with 72% reported pain or sensitivity, and 76% expressed dissatisfaction with the appearance of their teeth. Notably, satisfaction improved with treatment stage—81% of post-treatment patients reported being happy with their teeth, compared to 33% at pre-treatment [ 4 ]. Although this PROM is not yet validated, it has demonstrated value in capturing patient concerns and guiding treatment planning. This study builds on that work by evaluating the AI-specific PROM in a clinical paediatric setting, analysing responses from children and young persons at two stages of treatment. Additionally, it incorporates clinician feedback to assess the tool’s perceived utility and feasibility in everyday clinical practice. 2 Methods This retrospective service evaluation was conducted at a UK specialist paediatric dental centre and was registered with the local clinical governance department. As a service evaluation using routinely collected data, formal ethical approval was not required. Records from children and young persons (CYP) with a confirmed diagnosis of Amelogenesis Imperfecta (AI) who attended specialist clinics between January 2022 and January 2024 were included. PROMs were completed as part of routine care and retrieved from electronic health records. Inclusion criteria required both a pre-treatment and mid-treatment PROM to be fully completed and available in the records. Data were extracted and recorded in Microsoft Excel™, including demographic details, AI subtype, and treatment history. Descriptive statistics were used to summarise PROM responses, and subgroup analyses explored patterns by age (< 13 vs. ≥13 years), AI phenotype, and treatment stage. To explore clinician perspectives on the AI PROM, a cross-sectional online survey was developed using Qualtrics™. Ethical approval for the survey was obtained via University College London’s Low-Risk Research Ethics Committee (ID: 26593/001). The 25-item survey included a mix of closed-ended (multiple choice and Likert scale) and open-ended questions and was structured around key themes: familiarity with the PROM, perceived content relevance, clinical utility, implementation challenges, and recommendations for improvement. Survey questions were informed by a literature review and refined in collaboration with the research team. The final version was piloted with paediatric dental staff and reviewed for readability [ 7 ]. The survey was distributed via email to 78 dentists through the Amelogenesis Imperfecta Clinical Excellence Network (AICEN). Use of this targeted mailing list ensured that respondents were clinicians who routinely manage children and young people with AI, thereby providing relevant and experienced feedback. Participation was voluntary, and confidentiality was maintained; no IP addresses or personally identifiable data were collected via the Qualtrics™ platform. A Participant Information Leaflet and electronic consent form were embedded at the start of the survey. Quantitative data were analysed descriptively within Qualtrics™ and Excel™, while qualitative responses were examined thematically using a content analysis approach. 3 Results Patient Reported Outcomes A total of 68 paired PROM responses (pre- and mid-treatment) were analysed. At pre-treatment, 78% of children reported that their teeth affected their confidence to smile (i.e., responded ‘Sometimes’ or ‘Often’), compared to 64% at mid-treatment ( Fig. 1 ) . Aesthetic dissatisfaction was particularly common among adolescents. Satisfaction with dental appearance improved from 26% at pre-treatment to 42% mid-treatment ( Fig. 3 ) . Pain and sensitivity responses showed mixed results: although some children reported improved comfort, the proportion reporting frequent pain increased slightly from 7–10% ( Fig. 2 ) . Brushing discomfort and school absences remained largely unchanged. Younger children (< 13 years) showed more noticeable improvements in functional areas such as eating and hygiene. Subgroup Trends Subgroup analysis by AI phenotype and age suggested general trends, although numbers were too small to do formal statistical analysis. Children with hypomature AI (72%) made up the largest subgroup and showed some improvements in satisfaction and confidence mid-treatment (Fig. 4 ). Those with hypocalcified AI (9%) experienced persistent sensitivity, while those with hypoplastic AI (13%) continued to report low confidence despite having had the majority of anterior restorations being done in that specific subgroup. Younger children (< 13 years) tended to report greater functional improvements ( Fig. 5 ) , whereas adolescents remained more affected by psychosocial factors. Treatment Modalities and Patient Perception Common treatments included tooth whitening (26%), fissure sealants (18%), and anterior composites (11%). Whitening was associated with increased confidence, particularly in adolescents with hypomature AI. Preventive measures such as fluoride varnish and desensitising toothpastes were used across all subtypes. Children who received a combination of aesthetic and functional treatments generally reported greater satisfaction at mid-treatment. Clinician Use and Perceptions of the AI PROM (Qualtrics™ Survey) A total of 23 paediatric clinicians consented to participate in the online survey. Of these, 82% (18/22) reported familiarity with the AI PROM, and among them, 67% (12/18) confirmed using it in their clinical unit. All respondents supported its use at the pre-treatment and review stages, while 67% also endorsed its use mid-treatment, particularly in longer or multi-phase care plans. Clinicians highlighted several benefits of the PROM. 64% reported that it improved communication with patients and families, and 56% felt it enhanced patient satisfaction with their treatment experience. Notably, 83% said it improved their understanding of the emotional and functional impact of AI on children’s lives. However, the average usefulness rating was modest—56 out of 100—suggesting room for refinement. Clinician Recommendations for Improvement Clinicians provided extensive qualitative feedback suggesting improvements to enhance the AI PROM’s clinical relevance and usability. Four key themes emerged from the content qualitative analysis (Table 1 ). Many respondents (44%) advocated expanding the PROM to capture broader treatment outcomes, including emotional and long-term effects. Others recommended streamlining question design, allowing mid-treatment assessments, and improving digital accessibility through mobile platforms or integration with electronic health records. Table 1 Clinician Recommendations to Improve the AI PROM Recommendation Theme Clinicians Mentioning (%) Example Quote Expand treatment outcomes 44% (n = 11) “Include questions about emotional impacts and long-term QoL.” Streamline question content design 36% (n = 9) “Focus on severity rather than frequency and reduce the number of questions.” Flexible timing for assessments 36% (n = 9) “Introduce mid-treatment assessments to monitor progress and adapt treatment plans.” Improved accessibility 28% (n = 7) “A mobile app or integration into EHRs would make it easier to use in a busy clinic.” 4. Discussion The AI PROM, though non-validated, provided valuable insights into the lived experiences of children with AI, revealing improvements in satisfaction and confidence during treatment—particularly among younger patients and those with hypomature AI. However, challenges such as persistent sensitivity, aesthetic dissatisfaction, and psychosocial impacts remained, especially in older children and those with hypocalcified AI. This could be because treatment for most patients was still on-going. Post-treatment PROM data were not collected, as children with AI often face a prolonged and complex treatment journey involving lifelong follow-up, staged interventions, and substantial care burdens [ 6 , 7 ]. The mid-treatment timepoint was therefore chosen to reflect early outcomes within the context of this ongoing, resource-intensive pathway. Clinician feedback reinforced the PROM’s clinical relevance, especially in opening conversations around appearance, bullying, and treatment anxieties. Most respondents valued its role in communication and care planning, though barriers such as time constraints, survey length, and limited digital integration were cited. Suggestions for improvement included streamlining the tool, expanding outcome domains, and embedding the PROM into digital platforms to enhance accessibility. This dual perspective—combining patient and clinician insights—strengthens the case for condition-specific PROMs in paediatric dental care. While broadly validated tools like COHIP and ECOHIS remain valuable, the AI PROM captures the unique burden and treatment outcomes associated with AI specifically. Its tailored focus highlights its promise as a developmental yet meaningful adjunct to routine care. Looking ahead, successful integration will rely on digital delivery, child-friendly design, psychometric testing, and continued refinement to ensure these tools are both practical and impactful in everyday practice. Importantly, plans are underway to administer the AI PROM post-treatment as well, enabling a more complete assessment of long-term outcomes and satisfaction. 5. Limitations This evaluation has several limitations. The small sample sizes—both in patient and clinician datasets—limit generalisability and precluded formal statistical comparisons, particularly within AI subgroups. As a retrospective study relying on self-reported data, responses may have been influenced by recall bias, mood, or parental input. The mid-treatment PROM timepoint was chosen due to the ongoing nature of AI care, which typically involves lifelong follow-up and staged interventions, making a definitive "post-treatment" stage difficult to define. The AI PROM was introduced recently, restricting longitudinal data collection and follow-up. Additionally, the clinician survey had a low response rate (29.5%), was UK-focused and excluded patient/parent perspectives, limiting its scope. Future studies should prioritise prospective, multi-centre designs and include diverse views to enhance robustness and relevance. 6. Conclusion Combining both patient and clinician perspectives, this evaluation highlights the emerging role of a condition-specific, non-validated AI PROM in paediatric dentistry. PROM responses revealed meaningful improvements in satisfaction and confidence, particularly in younger patients and those with hypomature AI, while also surfacing ongoing challenges like sensitivity and social anxiety—especially in hypocalcified cases. Clinicians valued the PROM’s ability to open conversations around hidden concerns, such as bullying and treatment-related anxiety [ 8 , 9 ], but cited implementation barriers including time constraints and the need for digital integration. This dual insight reinforces the PROM’s potential as a patient-centred communication tool, offering tailored information beyond routine clinical assessments. While broader validation is needed, the AI PROM complements established OHRQoL measures making it a promising adjunct for condition-specific care. Declarations Author Contribution J.A. conceptualised the study, led data collection and analysis, and drafted the main manuscript text. S.P. provided supervision, methodological guidance, and contributed to manuscript revisions. F.R. supported study design, reviewed data interpretation, and contributed to manuscript editing. All authors reviewed and approved the final manuscript. References Parekh S, Almehateb M, Cunningham SJ. How do children with amelogenesis imperfecta feel about their teeth?[1] Int J Paediatr Dent. 2014;24(5):326–35. Genderson MW, Sischo L, Markowitz K, Fine D, Broder HL. An overview of children's oral health-related quality of life assessment: from scale development to measuring outcomes [2]. Caries Res. 2013;47(Suppl 1):13–21. Jokovic A, Locker D, Stephens M, Kenny D, Tompson B, Guyatt G. Validity and reliability of a questionnaire for measuring child oral-health-related quality of life [3]. J Dent Res. 2002;81(7):459–63. Lyne A, Parekh S, Rodd H. Patient-reported outcome measure for children and young people with amelogenesis imperfecta. Br Dent J. 2021;231(6):411–6. Readable. Test your readability [Internet]. 2020 [cited 2025 Apr 12]. Available from: https://readable.com/ Patel M, McDonnell ST, Iram S, Chan MF. Amelogenesis imperfecta: lifelong management. Br Dent J . 2013;215(9):449–57. MacDonald S, Arkutu N, Malik K, Gadhia K, McKaig S. Managing the paediatric patient with amelogenesis imperfecta. Br Dent J. 2012;212(9):425–8. Coffield KD, Phillips C, Brady M, Roberts MW, Strauss RP, Wright JT. The psychosocial impact of developmental dental defects in people with hereditary amelogenesis imperfecta. J Am Dent Assoc. 2005;136(5):620–30. Hashem A, Kelly A, O’Connell B, O’Sullivan M. Impact of moderate and severe hypodontia and amelogenesis imperfecta on quality of life and self-esteem of adult patients. J Dent. 2013;41(8):689–94. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 01 Jul, 2025 Reviews received at journal 25 Jun, 2025 Reviews received at journal 22 Jun, 2025 Reviewers agreed at journal 19 Jun, 2025 Reviewers agreed at journal 17 Jun, 2025 Reviewers invited by journal 17 Jun, 2025 Editor assigned by journal 17 Jun, 2025 Submission checks completed at journal 17 Jun, 2025 First submitted to journal 16 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6904800","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":472670013,"identity":"d588606c-ff26-4f8c-8605-ed7b00ee6625","order_by":0,"name":"Jenan Altaher","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYBAC9gYwZcHAIAGkPgAxGzsBLYwQLRISIC2MM0BamEnRwswDYhPU0t578HNBjUQd/+zmY59tfm2T52NmYPzwMQePlp5zydIzjklISNw5ljw7t++2YRszA7PkzG14tMzIMZDmYQM67EaOMXNuz21GoBY2Zl58Wua/Mf7N809CQv5G/mdmy57b9gS1CM7gMZPmbZOQMLiRw8zM8ON2IkEt0jw5Zta8fRKSG2+kGTP2NtxObmNmbMbrFz72M8a3eb7Z8MvdSH7M8OPPbdv57c0HP3zEowXNZ21gsoFY9SDwhxTFo2AUjIJRMFIAAAkrSJINW1MDAAAAAElFTkSuQmCC","orcid":"","institution":"University College London (UCL)","correspondingAuthor":true,"prefix":"","firstName":"Jenan","middleName":"","lastName":"Altaher","suffix":""},{"id":472670014,"identity":"9c652f5a-36f5-4f8e-852c-d6fb4146f189","order_by":1,"name":"Susan Parekh","email":"","orcid":"","institution":"University College London (UCL)","correspondingAuthor":false,"prefix":"","firstName":"Susan","middleName":"","lastName":"Parekh","suffix":""},{"id":472670015,"identity":"0e7202bb-9840-4d10-b2d6-6a70d8f71127","order_by":2,"name":"Fiona Ryan","email":"","orcid":"","institution":"University College London (UCL)","correspondingAuthor":false,"prefix":"","firstName":"Fiona","middleName":"","lastName":"Ryan","suffix":""}],"badges":[],"createdAt":"2025-06-16 10:53:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6904800/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6904800/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85171498,"identity":"a1df5d15-e931-4e44-9a29-e487014494da","added_by":"auto","created_at":"2025-06-23 05:44:23","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":335892,"visible":true,"origin":"","legend":"\u003cp\u003eResponses to PROM Question 6: “Do your teeth affect your confidence to smile?” comparing pre-treatment and mid-treatment results.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6904800/v1/e17b7178a0dbfcbb4d8ae9e9.jpeg"},{"id":85171482,"identity":"57e9fb3d-e13c-43a8-a907-09fb0adddcfb","added_by":"auto","created_at":"2025-06-23 05:44:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":91974,"visible":true,"origin":"","legend":"\u003cp\u003eResponses to PROM Question 1: “Do your teeth cause you pain or sensitivity?” pre- vs. mid-treatment.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6904800/v1/eab7534271475ce8afa77d5c.png"},{"id":85171484,"identity":"75436408-809b-4962-81d0-dbd69523a76d","added_by":"auto","created_at":"2025-06-23 05:44:18","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":106209,"visible":true,"origin":"","legend":"\u003cp\u003eResponses to PROM Question 9: “Do you like the way your teeth look?” pre- vs. mid-treatment.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6904800/v1/09961ca4351d26025d9100a4.png"},{"id":85172301,"identity":"f9a546da-75f4-44a9-b8dc-7bf778f157a7","added_by":"auto","created_at":"2025-06-23 05:52:18","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":110369,"visible":true,"origin":"","legend":"\u003cp\u003ePatient responses to PROM Question 9 (“Are you happy with your teeth?”) stratified by AI phenotype (Hypomature, Hypocalcified, Hypoplastic) and treatment stage. Responses are shown across three categories (Often, Sometimes, Never) for both pre-treatment and mid-treatment stages.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-6904800/v1/d0f2afa3a42052bb02682e64.png"},{"id":85171488,"identity":"7fd29549-3d30-4288-9d75-2c402020eb52","added_by":"auto","created_at":"2025-06-23 05:44:18","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":96950,"visible":true,"origin":"","legend":"\u003cp\u003ePatient responses to PROM Question 9 (“Are you happy with your teeth?”) grouped by age (\u0026lt;13 vs. 13 and over) and treatment stage. The figure highlights differences in perception of satisfaction between age groups at pre- and mid-treatment timepoints.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-6904800/v1/70f3782a9f6dfd835aa0f23c.png"},{"id":85173286,"identity":"752506dd-fe29-4b3a-b9ec-96e4375112c9","added_by":"auto","created_at":"2025-06-23 06:00:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1087222,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6904800/v1/681982ee-393c-4041-bb1a-6e09b86f2bd7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe Use of AI PROMs in CYP and Clinicians\u003c/p\u003e","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eAmelogenesis Imperfecta (AI) is a hereditary enamel defect that can present as missing, thin, or discoloured enamel due to abnormalities in the quantity and/or quality of enamel formation. In addition to clinical challenges, AI can significantly affect a child\u0026rsquo;s oral function, appearance, and self-esteem, all of which contribute to a reduced oral health-related quality of life (OHRQoL) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Children and adolescents with AI may experience sensitivity, pain, aesthetic concerns, and bullying, particularly during school years.\u003c/p\u003e \u003cp\u003eTo capture these subjective impacts, a condition-specific PROM for AI was developed, piloted, and implemented across four UK specialist paediatric centres. Overall, 60 children aged 5\u0026ndash;17 years completed the PROM with 72% reported pain or sensitivity, and 76% expressed dissatisfaction with the appearance of their teeth. Notably, satisfaction improved with treatment stage\u0026mdash;81% of post-treatment patients reported being happy with their teeth, compared to 33% at pre-treatment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough this PROM is not yet validated, it has demonstrated value in capturing patient concerns and guiding treatment planning. This study builds on that work by evaluating the AI-specific PROM in a clinical paediatric setting, analysing responses from children and young persons at two stages of treatment. Additionally, it incorporates clinician feedback to assess the tool\u0026rsquo;s perceived utility and feasibility in everyday clinical practice.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cp\u003eThis retrospective service evaluation was conducted at a UK specialist paediatric dental centre and was registered with the local clinical governance department. As a service evaluation using routinely collected data, formal ethical approval was not required. Records from children and young persons (CYP) with a confirmed diagnosis of Amelogenesis Imperfecta (AI) who attended specialist clinics between January 2022 and January 2024 were included. PROMs were completed as part of routine care and retrieved from electronic health records. Inclusion criteria required both a pre-treatment and mid-treatment PROM to be fully completed and available in the records. Data were extracted and recorded in Microsoft Excel\u0026trade;, including demographic details, AI subtype, and treatment history. Descriptive statistics were used to summarise PROM responses, and subgroup analyses explored patterns by age (\u0026lt;\u0026thinsp;13 vs. \u0026ge;13 years), AI phenotype, and treatment stage.\u003c/p\u003e \u003cp\u003eTo explore clinician perspectives on the AI PROM, a cross-sectional online survey was developed using Qualtrics\u0026trade;. Ethical approval for the survey was obtained via University College London\u0026rsquo;s Low-Risk Research Ethics Committee (ID: 26593/001). The 25-item survey included a mix of closed-ended (multiple choice and Likert scale) and open-ended questions and was structured around key themes: familiarity with the PROM, perceived content relevance, clinical utility, implementation challenges, and recommendations for improvement. Survey questions were informed by a literature review and refined in collaboration with the research team. The final version was piloted with paediatric dental staff and reviewed for readability [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The survey was distributed via email to 78 dentists through the Amelogenesis Imperfecta Clinical Excellence Network (AICEN). Use of this targeted mailing list ensured that respondents were clinicians who routinely manage children and young people with AI, thereby providing relevant and experienced feedback. Participation was voluntary, and confidentiality was maintained; no IP addresses or personally identifiable data were collected via the Qualtrics\u0026trade; platform. A Participant Information Leaflet and electronic consent form were embedded at the start of the survey. Quantitative data were analysed descriptively within Qualtrics\u0026trade; and Excel\u0026trade;, while qualitative responses were examined thematically using a content analysis approach.\u003c/p\u003e"},{"header":"3 Results","content":"\u003cp\u003e \u003cb\u003ePatient Reported Outcomes\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA total of 68 paired PROM responses (pre- and mid-treatment) were analysed. At pre-treatment, 78% of children reported that their teeth affected their confidence to smile (i.e., responded \u0026lsquo;Sometimes\u0026rsquo; or \u0026lsquo;Often\u0026rsquo;), compared to 64% at mid-treatment \u003cem\u003e(\u003c/em\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e. Aesthetic dissatisfaction was particularly common among adolescents. Satisfaction with dental appearance improved from 26% at pre-treatment to 42% mid-treatment \u003cem\u003e(\u003c/em\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e. Pain and sensitivity responses showed mixed results: although some children reported improved comfort, the proportion reporting frequent pain increased slightly from 7\u0026ndash;10% \u003cem\u003e(\u003c/em\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e. Brushing discomfort and school absences remained largely unchanged. Younger children (\u0026lt;\u0026thinsp;13 years) showed more noticeable improvements in functional areas such as eating and hygiene.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubgroup Trends\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSubgroup analysis by AI phenotype and age suggested general trends, although numbers were too small to do formal statistical analysis. Children with hypomature AI (72%) made up the largest subgroup and showed some improvements in satisfaction and confidence mid-treatment (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Those with hypocalcified AI (9%) experienced persistent sensitivity, while those with hypoplastic AI (13%) continued to report low confidence despite having had the majority of anterior restorations being done in that specific subgroup. Younger children (\u0026lt;\u0026thinsp;13 years) tended to report greater functional improvements \u003cem\u003e(\u003c/em\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e, whereas adolescents remained more affected by psychosocial factors.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTreatment Modalities and Patient Perception\u003c/b\u003e \u003c/p\u003e \u003cp\u003eCommon treatments included tooth whitening (26%), fissure sealants (18%), and anterior composites (11%). Whitening was associated with increased confidence, particularly in adolescents with hypomature AI. Preventive measures such as fluoride varnish and desensitising toothpastes were used across all subtypes. Children who received a combination of aesthetic and functional treatments generally reported greater satisfaction at mid-treatment.\u003c/p\u003e \u003cp\u003e \u003cb\u003eClinician Use and Perceptions of the AI PROM (Qualtrics\u0026trade; Survey)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA total of 23 paediatric clinicians consented to participate in the online survey. Of these, 82% (18/22) reported familiarity with the AI PROM, and among them, 67% (12/18) confirmed using it in their clinical unit. All respondents supported its use at the pre-treatment and review stages, while 67% also endorsed its use mid-treatment, particularly in longer or multi-phase care plans.\u003c/p\u003e \u003cp\u003eClinicians highlighted several benefits of the PROM. 64% reported that it improved communication with patients and families, and 56% felt it enhanced patient satisfaction with their treatment experience. Notably, 83% said it improved their understanding of the emotional and functional impact of AI on children\u0026rsquo;s lives. However, the average usefulness rating was modest\u0026mdash;56 out of 100\u0026mdash;suggesting room for refinement.\u003c/p\u003e \u003cp\u003e \u003cb\u003eClinician Recommendations for Improvement\u003c/b\u003e \u003c/p\u003e \u003cp\u003eClinicians provided extensive qualitative feedback suggesting improvements to enhance the AI PROM\u0026rsquo;s clinical relevance and usability. Four key themes emerged from the content qualitative analysis (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Many respondents (44%) advocated expanding the PROM to capture broader treatment outcomes, including emotional and long-term effects. Others recommended streamlining question design, allowing mid-treatment assessments, and improving digital accessibility through mobile platforms or integration with electronic health records.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinician Recommendations to Improve the AI PROM\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecommendation Theme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinicians Mentioning (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExample Quote\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExpand treatment outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44% (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Include questions about emotional impacts and long-term QoL.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStreamline question content design\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36% (n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Focus on severity rather than frequency and reduce the number of questions.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlexible timing for assessments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36% (n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Introduce mid-treatment assessments to monitor progress and adapt treatment plans.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImproved accessibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28% (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;A mobile app or integration into EHRs would make it easier to use in a busy clinic.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe AI PROM, though non-validated, provided valuable insights into the lived experiences of children with AI, revealing improvements in satisfaction and confidence during treatment\u0026mdash;particularly among younger patients and those with hypomature AI. However, challenges such as persistent sensitivity, aesthetic dissatisfaction, and psychosocial impacts remained, especially in older children and those with hypocalcified AI. This could be because treatment for most patients was still on-going.\u003c/p\u003e \u003cp\u003ePost-treatment PROM data were not collected, as children with AI often face a prolonged and complex treatment journey involving lifelong follow-up, staged interventions, and substantial care burdens [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The mid-treatment timepoint was therefore chosen to reflect early outcomes within the context of this ongoing, resource-intensive pathway.\u003c/p\u003e \u003cp\u003eClinician feedback reinforced the PROM\u0026rsquo;s clinical relevance, especially in opening conversations around appearance, bullying, and treatment anxieties. Most respondents valued its role in communication and care planning, though barriers such as time constraints, survey length, and limited digital integration were cited. Suggestions for improvement included streamlining the tool, expanding outcome domains, and embedding the PROM into digital platforms to enhance accessibility.\u003c/p\u003e \u003cp\u003eThis dual perspective\u0026mdash;combining patient and clinician insights\u0026mdash;strengthens the case for condition-specific PROMs in paediatric dental care. While broadly validated tools like COHIP and ECOHIS remain valuable, the AI PROM captures the unique burden and treatment outcomes associated with AI specifically. Its tailored focus highlights its promise as a developmental yet meaningful adjunct to routine care. Looking ahead, successful integration will rely on digital delivery, child-friendly design, psychometric testing, and continued refinement to ensure these tools are both practical and impactful in everyday practice. Importantly, plans are underway to administer the AI PROM post-treatment as well, enabling a more complete assessment of long-term outcomes and satisfaction.\u003c/p\u003e"},{"header":"5. Limitations","content":"\u003cp\u003eThis evaluation has several limitations. The small sample sizes\u0026mdash;both in patient and clinician datasets\u0026mdash;limit generalisability and precluded formal statistical comparisons, particularly within AI subgroups. As a retrospective study relying on self-reported data, responses may have been influenced by recall bias, mood, or parental input. The mid-treatment PROM timepoint was chosen due to the ongoing nature of AI care, which typically involves lifelong follow-up and staged interventions, making a definitive \"post-treatment\" stage difficult to define. The AI PROM was introduced recently, restricting longitudinal data collection and follow-up. Additionally, the clinician survey had a low response rate (29.5%), was UK-focused and excluded patient/parent perspectives, limiting its scope. Future studies should prioritise prospective, multi-centre designs and include diverse views to enhance robustness and relevance.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eCombining both patient and clinician perspectives, this evaluation highlights the emerging role of a condition-specific, non-validated AI PROM in paediatric dentistry. PROM responses revealed meaningful improvements in satisfaction and confidence, particularly in younger patients and those with hypomature AI, while also surfacing ongoing challenges like sensitivity and social anxiety\u0026mdash;especially in hypocalcified cases. Clinicians valued the PROM\u0026rsquo;s ability to open conversations around hidden concerns, such as bullying and treatment-related anxiety [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], but cited implementation barriers including time constraints and the need for digital integration. This dual insight reinforces the PROM\u0026rsquo;s potential as a patient-centred communication tool, offering tailored information beyond routine clinical assessments. While broader validation is needed, the AI PROM complements established OHRQoL measures making it a promising adjunct for condition-specific care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJ.A. conceptualised the study, led data collection and analysis, and drafted the main manuscript text. S.P. provided supervision, methodological guidance, and contributed to manuscript revisions. F.R. supported study design, reviewed data interpretation, and contributed to manuscript editing. All authors reviewed and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eParekh S, Almehateb M, Cunningham SJ. How do children with amelogenesis imperfecta feel about their teeth?[1] \u003cem\u003eInt J Paediatr Dent.\u003c/em\u003e 2014;24(5):326\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGenderson MW, Sischo L, Markowitz K, Fine D, Broder HL. An overview of children's oral health-related quality of life assessment: from scale development to measuring outcomes [2]. \u003cem\u003eCaries Res.\u003c/em\u003e 2013;47(Suppl 1):13\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJokovic A, Locker D, Stephens M, Kenny D, Tompson B, Guyatt G. Validity and reliability of a questionnaire for measuring child oral-health-related quality of life [3]. \u003cem\u003eJ Dent Res.\u003c/em\u003e 2002;81(7):459\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLyne A, Parekh S, Rodd H. Patient-reported outcome measure for children and young people with amelogenesis imperfecta. \u003cem\u003eBr Dent J.\u003c/em\u003e 2021;231(6):411\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReadable. Test your readability [Internet]. 2020 [cited 2025 Apr 12]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://readable.com/\u003c/span\u003e\u003cspan address=\"https://readable.com/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel M, McDonnell ST, Iram S, Chan MF. Amelogenesis imperfecta: lifelong management. \u003cem\u003eBr Dent J\u003c/em\u003e. 2013;215(9):449\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacDonald S, Arkutu N, Malik K, Gadhia K, McKaig S. Managing the paediatric patient with amelogenesis imperfecta. \u003cem\u003eBr Dent J.\u003c/em\u003e 2012;212(9):425\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoffield KD, Phillips C, Brady M, Roberts MW, Strauss RP, Wright JT. The psychosocial impact of developmental dental defects in people with hereditary amelogenesis imperfecta. \u003cem\u003eJ Am Dent Assoc.\u003c/em\u003e 2005;136(5):620\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHashem A, Kelly A, O\u0026rsquo;Connell B, O\u0026rsquo;Sullivan M. Impact of moderate and severe hypodontia and amelogenesis imperfecta on quality of life and self-esteem of adult patients. \u003cem\u003eJ Dent.\u003c/em\u003e 2013;41(8):689\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-archives-of-paediatric-dentistry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"EAPD","sideBox":"Learn more about [European Archives of Paediatric Dentistry](https://link.springer.com/journal/40368)","snPcode":"40368","submissionUrl":"https://submission.springernature.com/new-submission/40368/3","title":"European Archives of Paediatric Dentistry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Amelogenesis Imperfecta, PROMs, Paediatric Dentistry, Quality of Life, Enamel Defects","lastPublishedDoi":"10.21203/rs.3.rs-6904800/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6904800/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003cbr\u003e\nAmelogenesis Imperfecta (AI) is a genetic enamel defect affecting both primary and permanent dentitions, often leading to functional, aesthetic, and psychosocial challenges. Patient Reported Outcome Measures (PROMs) are increasingly used in paediatric dentistry, including ones developed for AI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim:\u003cbr\u003e\n \u003c/strong\u003eTo explore the impact of AI on oral health-related quality of life in children and young persons’ using an AI-specific PROM, and to assess clinician use of the PROM in the UK.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003cbr\u003e\n \u003c/strong\u003eThis single-centre retrospective service evaluation involved children with AI who completed a 9-question PROM pre- and mid-treatment. Responses were analysed by treatment stage, age group, and AI subtype. Clinician feedback of the AI PROM was obtained via an online survey administered via the electronic platform Qualtrics™.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 68 completed AI PROMs, with ages ranging between 7-19 were analysed at pre-treatment and mid-treatment stages. Younger children (under 13 years) were more likely to report functional difficulties, such as pain and eating challenges, while adolescents (over 13 years) more frequently expressed psychosocial concerns including bullying and low self-confidence. Notably, satisfaction with dental appearance increased from 26% to 42% by the mid-treatment stage.\u003c/p\u003e\n\u003cp\u003eIn the clinician feedback survey regarding use and effectiveness of the AI PROM, 23 paediatric dentists responded from a mailing list of 78, representing a 29.5% response rate. Of the clinicians familiar with the AI PROM, \u003cstrong\u003e67% reported actively using it\u003c/strong\u003e in their clinical practice. Most found the tool valuable for enhancing communication and supporting care planning, though some highlighted workflow constraints and difficulty interpreting subjective responses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003cbr\u003e\n \u003c/strong\u003eThe AI PROM, while non-validated, provided meaningful insights into patient experiences and supported more empathetic, patient-centred care. Incorporating clinician perspectives highlighted both its promise and areas for refinement. Further validation is needed to support broader clinical implementation.\u003c/p\u003e","manuscriptTitle":"The Use of AI PROMs in CYP and Clinicians","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-23 05:44:13","doi":"10.21203/rs.3.rs-6904800/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-01T11:34:48+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-25T18:25:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-22T14:17:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"48722005535607926831452839577074967790","date":"2025-06-19T16:57:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"51246602282253013250511742950758509879","date":"2025-06-17T16:07:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-17T15:49:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-17T07:20:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-17T07:17:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Archives of Paediatric Dentistry","date":"2025-06-16T10:48:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-archives-of-paediatric-dentistry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"EAPD","sideBox":"Learn more about [European Archives of Paediatric Dentistry](https://link.springer.com/journal/40368)","snPcode":"40368","submissionUrl":"https://submission.springernature.com/new-submission/40368/3","title":"European Archives of Paediatric Dentistry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"d84274f8-09b5-4af0-a1ed-f35f0ee66665","owner":[],"postedDate":"June 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T03:38:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-23 05:44:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6904800","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6904800","identity":"rs-6904800","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}