Are Children with Early Childhood Caries and Their Families Stigmatized? Perceptions and Practices of Dental Professionals: A Qualitative Study

Are Children with Early Childhood Caries and Their Families Stigmatized? 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Perceptions and Practices of Dental Professionals: A Qualitative Study Guillemette Lienhart, Manon Verroul, Pierre Farge, Anne-Marie Schott-pethelaz, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7648443/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Despite recommendations emphasizing individualized prevention and patient-centered communication, studies show that preventive care is often under-delivered in routine dental practice. Parents are sometimes identified by dentists as a major barrier to caries prevention, due to perceived lack of parenting skills. Existing literature suggests that negative stereotypes may influence the quality of care provided to these families. This study aims to explore health professionals’ perceptions of children with early childhood caries (ECC) and how these perceptions may shape clinical practice. Method : This qualitative study was based on semi-structured interviews conducted with French general dental practitioners, with thematic analysis of the data. Results : Interviews were conducted with a mixed sample of 15 general dental practitioners, (varying in age, gender, geographic location, practice setting, and the number of children treated per week). Thematic analysis identified four main themes: 1/ Parents portrayed as guilty of neglecting their child’s oral health 2/ Ambivalent emotional perceptions of the child with severe dental caries 3/ Behavior change perceived as a major challenge 4/ Caries prevention perceived as a public health issue with systemic causes. Conclusion : The findings of this qualitative study suggest that children with severe dental caries and their parents may be exposed to a dual form of stigma. On one hand, children are perceived as too difficult or unpleasant to treat; on the other, their oral condition is often associated with stereotypes of parental neglect and exclusive responsibility for illness. These perceptions may undermine the quality of the patient–provider relationship and act as a barrier to accessing care. Trial registration number : NCT05284279, registered on 2022-03-17 Dental caries children attitude of health personnel social stigma qualitative study BACKGROUND Dental caries remains one of the most common chronic diseases in early childhood. According to global estimates from 2017, untreated carious lesions in primary teeth affected approximately 8% of children worldwide ( 1 ). In France, the situation appears even more concerning, with national data suggesting that the prevalence of untreated caries in deciduous teeth may reach up to 30% of the pediatric population ( 2 ). These figures are alarming given the well-documented impacts of dental caries on children's quality of life ( 3 , 4 ) and long-term oral health trajectories ( 5 , 6 ). Dental caries is a chronic, non-communicable, and multifactorial disease, resulting from complex interactions between genetic, biochemical, anatomical, social, and behavioral factors ( 7 , 8 ). The most recent guidelines for caries management emphasize the importance of a personalized approach based on the patient's specific caries risk ( 9 ). While traditional individual preventive measures, such as the use of fluoride and the application of fissure sealants, remain central, increasing attention is now being paid to behavioral barriers. Featherstone et al. have even drawn parallels between the role of the dentist and that of “health coaches and behavioral interventionists,” whose mission is to support patients in adopting positive oral health behaviors in their everyday lives. This coaching role is particularly relevant, as it implies the development of specific skills that extend clinical procedures to include patient-centered communication, active listening, and the ability to build a trust-based relationship and provide long-term support. Ideally, this is the role dentists are expected to fulfill; however, in practice, their involvement in prevention appears to be more limited. Studies have shown that preventive care, particularly in primary prevention, is not strongly emphasized in routine dental, with dentists reporting that they spend limited time on patient education, which typically consists of brief, generic advice rather than individualized behavioral support ( 10 – 12 ). Our recent systematic review of the literature highlights that oral health professionals identify multiple contributing factors to the limited implementation of preventive strategies ( 13 ). Among these factors, many are linked to systemic issues within the healthcare system. However, parents are also commonly perceived as a barrier to effective caries prevention, due to their lack of knowledge, parenting skills, health literacy, or even their inability to prioritize their child’s oral health. These negative perceptions warrant closer examination considering other research on weight stigma in healthcare. Studies in that field have shown that health professionals’ negative judgments can compromise the quality of care, leading to shorter medical encounters, less respectful communication, and a reduced focus on patient-centered approaches ( 14 ). In oral health care, these phenomena remain largely unexplored, although some findings are cause for concern. A 2017 survey of 700 general dentists found that 58% chose not to provide interproximal hygiene advice when they assumed the patient would not comply ( 15 ). Additionally, a qualitative investigation reported that some parents experienced negative or guilt-inducing communication from dental staff ( 16 ), while another study suggested that parents of caries-free children were more likely to receive comprehensive oral health information ( 17 ). It is therefore crucial to further investigate the perceptions associated with children affected by severe dental caries and their parents, and to examine how these perceptions may influence the quality of care of these families. This issue is particularly significant in a context where dental caries tends to be more prevalent among populations with low socioeconomic status ( 18 ). Indeed, these groups are already exposed to multiple forms of vulnerability (low income, limited education, complex family structures, language barriers…) and should receive greater support from healthcare professionals. This study aims to conduct an exploratory study on how dental professionals perceive and interact with children affected by early childhood caries and their parents. In this context, "perceptions" refer to the stereotypes that may be associated with these families. Stereotypes can be defined as implicit personality theories shared collectively by members of a group concerning members of another group ( 19 ). The study explores dentists’ perceptions and attitudes toward these families hrough two central questions: 1/ What perceptions do health professionals hold about children with severe dental caries and their families? 2/ To what extent might these perceptions influence the quality of care delivered, particularly in the field of oral health prevention? We hypothesize that some practitioners may hold negative views toward children with severe dental caries and their parents, which could in turn affect preventive care practices. METHOD This qualitative study was reported in accordance with the COREQ criteria (see Supplementary File 1). It was based on semi-structured interviews conducted with dentists, general practitioners, and pediatricians. The study protocol, detailing the methodology, was published in 2022 and strictly followed in the present work ( 20 ). Two minor deviations from the original protocol should be noted: the interview guide was revised after a pilot phase (the final version is provided in Supplementary File 2), and data were analyzed using Atlas.ti, a qualitative data analysis software, rather than NVivo, as initially planned. These modifications did not require seeking a new ethical opinion from an IRB. The interviews were conducted and analyzed by GL and MV. Interviews with dentists, pediatricians and general practitioners were analyzed separately. This article focuses exclusively on the interviews and data collected from dentists. RESULTS • Participant selection and data collection Participants were recruited using a purposive sampling strategy. Although the sample was not randomly selected, it was built through professional networks, with the support of individuals identified as well-connected within the field. Several key informants facilitated access to a diverse pool of potential participants. To ensure maximum variation, the selection process considered participants’ age, gender, geographic location, mode of practice, and the number of children they treated each week. Initial contact was made by email or phone, and in most cases, two follow-up messages were needed to receive a response. Sixteen dentists were contacted and invited to participate; only one declined, stating they did not feel sufficiently qualified to speak on the topic. Ultimately, 15 dentists were interviewed as part of this qualitative study. Demographic characteristics of the participants are presented in Table 1 . Table 1 Demographic and professional characteristics of participants Demographic information Number of participants GENDER Male Female 9 6 AGE Between 30 and 39 years Between 40 and 49 years Over 50 years 7 6 2 YEARS OF EXPERIENCE Between 1 and 10 years Between 11 and 20 years More than 20 years 6 6 3 PRACTICE LOCATION Urban Semi-urban Rural 6 5 4 PRACTICE LOCATION Group private practice Solo private practice Hospital-based practice Mixed practice (group private and hospital-based) 8 3 1 3 PEDIATRIC PATIENTS More than 20 per week Between 10 and 20 per week Between 5 and 10 per week Fewer than 5 per week None 2 2 3 4 4 Interviews were conducted over a six-month period, from December 2022 to May 2023. Two interviews were held in person at the investigator's workplace. The remaining thirteen interviews were conducted via videoconference. All interviews were conducted by a social psychologist (MV), and no other individuals were present during the sessions. The interviews lasted between 35 and 75 minutes, depending on the participant, with an average duration of 50 minutes. All interviews were systematically audio-recorded to ensure accurate verbatim transcription, and the interviewer also took field notes to document nonverbal cues (e.g., posture, attitudes, facial expressions, intonation). After transcription, each interview was sent back to the participant for review. None of the participants requested any modifications or additions. Data collection continued until data saturation was reached during thematic analysis. We applied the code meaning approach to saturation, as defined by Hennink and Kaiser in their systematic review, meaning that data collection continued until no new aspects, dimensions, or nuances emerged for each identified theme ( 21 ). Each interview was coded independently by two investigators (GL, MV) and subsequently discussed collectively to reach consensus. Similar codes were then grouped into coherent themes, defined as meaning-based patterns. Theme development drew on researchers’ subjectivity (knowledge, theoretical assumptions, etc.), as the aim was to provide an interpretation of the dataset rather than summarize it.” • Thematic analyses Four main themes were identified following the thematic analysis. Theme 1: Parents portrayed as guilty of neglecting their child’s oral health (Table 2 ) Table 2 Theme 1 - Parents portrayed as guilty of neglecting their child’s oral health 1/ PARENTS PORTRAYED AS GUILTY OF NEGLECTING THEIR CHILD’S ORAL HEALTH 1.1/ THE FAMILY'S SOCIAL ENVIRONMENT NEGATIVELY INFLUENCES HEALTH BEHAVIORS 1.2/ PARENTAL INDIVIDUAL RESPONSIBILITY 1.3/ A WEAK PARENTING FRAMEWORK 1.1.1/ Unfavorable health beliefs 1.1.2/ Family circumstances limiting parental engagement in oral health A/ An environment that normalizes dental caries “His brother had caries, his sister had caries...caries run in the family. So for them, it’s just normal, and […] in the end, living with that is not seen as something unusual in the family culture.” D02 B/ Oral health as a low priority in the context of everyday difficulties “Given […] how complicated their daily life is, oral hygiene is really, really not a priority. ” D15 C/ A curative perception of health leads to delayed care “ You’ve got those who don’t take care of their kids, who only bring them in when they’re screaming and keeping them up at night—because all they want is to sleep.” D11 “And unfortunately, it was only when […] the front teeth were affected that parents brought their children in. Even though there were just as many cavities in the back. But it was only when it impacted aesthetics that they decided to take the child to the dentist.” D03 A/ Precarity “For people who are really struggling—I don’t know, socioeconomically or things like that—we know that… well, when people don’t have much, in general […] a lack of resources often goes along with a diet that’s too sugary, highly processed, things like that, because it’s the simplest and the cheapest option .” D01 B/ Single parenthood “There’s the profile of parents from single-parent families—that is, young, divorced parents who work, who don’t necessarily have time to properly take care of their children, and who end up letting them kind of manage on their own.” D12 C/ Large families “These are big families—some of them have five, six kids… so they don’t really have time to take care of everyone.” D14 A/ Limited cognitive abilities “They’re really slow on the uptake — I mean, they've got the brains of a pony. We’re not going to make them any smarter. They just don’t have any sense of hygiene, or of what poor hygiene even means.” D15 B/ A lack of knowledge about oral health “There are those who don’t understand why their children have so many dental problems, because they haven’t made the link with sugar, for example. So really, it’s just due to a lack of knowledge — it’s not out of neglect or malice.” D11 C/ A lack of motivation and interest in the child’s oral health “For them, it’s kind of… well, to put it bluntly, it’s a hassle. That’s how it is for a lot of parents. I get the feeling they do it, but that it really annoys them to have to deal with it.” D06 A/ Parents are not a good role model for the child “There are parents who are just bad examples—they don’t take care of themselves, so how can they teach their children the right habits? “ D04 B/ Parents do not sufficiently oppose their child • Out of love “Because people think that […] it’s a sign of love—not saying no, or offering sugary food or several meals a day.” D02 • Out of convenience “And then, when parents… well, they just don’t have time. So as soon as the child screams, they give them something to eat or a bit of… fruit juice. “ D08 C/ Parents do not take responsibility for their role “Parents blame the child, when it’s not the child’s fault—it’s the parents who buy the sodas, the candy, and all that.” D05 Parents were held responsible for the poor oral condition of their children. The respondents explained what they perceived as a parental inability to care for their child through various factors. First, parents were described as evolving within an environment that promotes unfavorable health norms . More specifically, this environment was said to normalize caries, to deprioritize dental care, and to encourage a curative rather than preventive approach to health. Within this context, it was frequently reported that parents only sought dental care when caries had already caused pain or visible aesthetic damage. The family context was identified as another factor that could negatively affect parental involvement. Situations of socioeconomic hardship, single parenthood, or large families were frequently perceived as making it more difficult for parents to provide the conditions necessary for maintaining their child’s oral health. Parental individual responsibility was also called into question, with parents described as lacking knowledge, motivation, and sometimes even intellectual capacity. Finally, the child’s poor oral health was frequently attributed to a weak educational framework established by the parents. In this regard, parents were seen as poor role models for their children, and their lack of authority was often emphasized. According to the respondents, parents did not sufficiently oppose their child’s demands—either out of love or out of convenience. Theme 2: Ambivalent emotional perceptions of the child with severe dental caries (Table 3 ) Table 3 Theme 2 - Ambivalent emotional perceptions of the child with severe dental caries 2/ AMBIVALENT EMOTIONAL PERCEPTIONS OF THE CHILD WITH SEVERE DENTAL CARIES 2.1/ DENTISTS EXPRESS EMPATHY FOR THE CHILD WITH SEVERE CARIES... 2.2/ …BUT FIND IT UNPLEASANT TO TREAT THEM 2.1.1/ The child is perceived as a victim 2.1.2/ The child suffers the negative consequences of caries 2.2.1/ Children are difficult to treat 2.2.2/ This aversion negatively impacts children’s access to dental care A/ Victim of parental incompetence “I think the child is very innocent—they’re the ones who suffer, in a way. They suffer from their parents’ incompetence, more than anything else. “ D06 B/Victim of a failing healthcare system “I feel a bit desperate sometimes, when they show up in that kind of state at age six, and it’s clearly not something new. Sometimes it’s been going on for two years—these families have been medically wandering, unable to find someone to take care of them. And the situations just get worse. “ D01 A/ Pain and functional limitations “So the patient—the child—ends up being uncomfortable, even disabled in their daily life because of it. Whether it’s aesthetic, functional, or just due to pain.” D01 B/ Impaired social life “Well, yes, I think it has a psychological impact, because we all know how mean kids can be to each other (laughs). So yes, they’ll get comments—whether in the schoolyard, from their parents, their family, or even strangers on the street. Like, if they go grocery shopping with their parents, the cashier will see that, well, when the kid smiles… it’s not a great sight.” D12 A/ Care is challenging from both a technical and behavioral standpoint “For me, before age six, there’s a real issue with cooperation. Like, I’ll say ‘open your mouth,’ I blow some air, and then I ask, ‘does that hurt?’—but the child can’t really tell me whether it does or not.” D13 B/ Treating children requires a specific approach “It’s not that simple—because it requires a much more significant psychological approach than when treating adults, and that’s something many people aren’t comfortable with.” D01 C/ Pediatric dentistry is not a profitable or efficient practice “Actually, most of them don’t do it because it’s not well paid, because just talking like that can take up an hour. And if you do that with two or three kids, it can easily take an hour—just to talk, really.” D13 A/ Few dentists are willing to treat children “Well, there’s also the fact that I didn’t like treating children. I like kids, they don’t bother me, but I just don’t like treating them.” D04 B/ Dentists who do treat children often restrict their access to care “We only schedule children on Wednesday afternoons—just for a couple of hours, maybe two or three at most.” D08 “I used to take in the children of my regular patients—but I didn’t take others.” D13 During the interviews, dentists expressed a highly ambivalent view of children with severe dental caries. On the one hand, many professionals conveyed a strong sense of empathy toward these children. They were not seen as responsible for their condition, but rather as innocent and unfortunate patients suffering from the multiple negative consequences of dental decay. These children were portrayed as victims—both of their parents’ inability to provide adequate care and of systemic failures within the healthcare system. Despite the strong expression of empathy, dentists also reported significant challenges in treating these children, making their care burdensome or even unpleasant . The difficulties mentioned included technical obstacles (such as limited mouth opening or a restless child), behavioral issues (manifestations of anxiety, disturbance or refusal of care), the lack of financial profitability, and the need to adopt a specific, adapted approach. These various factors were seen as contributing to the fact that many dentists either refuse to treat young children altogether or restrict their access to care by imposing selective admission criteria. Theme 3: Behavior change perceived as a challenge (Table 4) Table 4 Theme 3 -Behavior change perceived as a challenge3/ BEHAVIOR CHANGE PERCEIVED AS A CHALLENGE Table 4: Theme 3 -Behavior change perceived as a challenge 3.1/ RAISING PARENTAL AWARENESS AS A KEY OBJECTIVE 3.2 / VARIOUS STRATEGIES TO RAISE PARENTAL AWARENESS 3.3/ A DIFFICULT PROCESS GENERATING NEGATIVE EMOTIONS 3.2.1/ Providing information as the dominant strategy 3.2.2/ Authoritative approach as a common strategy 3.2.3/ Strategies tempered by a more understanding approach 3.3.1/ Barriers to parental awareness 3.3.2/ Situations generating negative emotions A/ Raising awareness that caries are preventable “I try to explain that it’s not inevitable—just because their older sibling had cavities doesn’t mean they have to as well.” D02 B/ Raising awareness of inappropriate family health behaviors “Some parents just aren’t aware of how much sugar their child consumes. So sometimes I’d tell them: let’s keep a food diary—a kind of consumption log for their child […] and often, the parents would realize that, yes, actually, there was something every hour.” D03 C/ Raising awareness that parents are the key agents of change “It’s really the parents we have to win over. If we don’t win over the parents, it’s no good—we’ll never get anywhere” D05 “I always use the first consultation to avoid doing any actual treatment. I might do X-rays, explain things to them, show them, and then spend 30 minutes going over what they should eat, when, not snacking… I take the time to explain all of that. And then I do a little summary on how to brush, how much toothpaste to use, and which kind of toothpaste to buy.” D14 A/ Guilt-inducing discourse “Well, there are parents to whom I say: it’s not normal to bring your kid in at five years old with 15 cavities. Where were you? I mean, you don’t have to be a dentist to ask your kid to open their mouth and see that there are several cavities!” D13 B/ Paternalistic stance “So, to make it work, we do add a little touch of severity. Yeah. Like with a child.” D10 C/ Physical or verbal violence “So the choice we made was, yes, we were going to make him suffer—hoping that it would lead to a change in behavior, both on his part and on the part of his family. Mainly the family, because they’re the ones who buy the sodas.” D10 A/ Empowering rather than blaming “Being moralizing and judgmental doesn’t work. That creates conflictual relationships. That’s not how you build a relationship.” D01 “I really try to involve the child—even when they’re very young—so they understand it’s not just their parents being annoying, but that it’s actually important for them.” D09 B/ Collaborative approach “ You have to manage to create a discourse that works, one that brings people into the care process—because otherwise it doesn’t work either. They need to feel like they’re active participants, that they’re capable of doing it.” D01 A/ Deeply ingrained habits “It’s that mom and dad have to change their habits for the child to change his. But are mom and dad really ready to change their habits?” D14 B/ Language barrier “There are families from immigrant backgrounds who maybe don’t take in what we’re saying—because of the language barrier, I mean.” D12 C/ Parental sensitivity to judgment “The message doesn’t get through […] because people feel judged […]. There’s this… how can I say? Again, I think it’s this sensitivity you see in certain social groups.” D13 A/ Powerlessness “It’s like… sometimes you feel like you’re just […] preaching in the desert. And that the caries are progressing faster than I can do anything. So yeah […] that’s really hard. It honestly feels like a real failure.” D02 B/ Discouragement “I always try, of course, but when I really feel like I can’t get through, or when it just doesn’t feel right… I have to admit, there are times when I feel really discouraged.” D09 The issue of behavior change was widely addressed by the participants, who viewed it as one of the most challenging aspects of care. They reported significant difficulty in identifying effective levers for initiating change. To encourage behavior change within families, dentists aim to raise awareness among parents. More specifically, their goal is to help parents understand that dental caries is preventable, that their own behaviors contribute to the disease, and that their involvement is essential in preventing it. To achieve this goal, participants described a range of strategies. The dominant strategy, strongly favored by dentists, consists in informing the patient through explanations or demonstrations (eg. teeth brushing). In addition, the interviewed professionals often reported using approaches grounded in an authoritarian and paternalistic stance. Among these, guilt-inducing discourse was frequently mentioned as a lever for change, and, to a lesser extent, the use of physical or verbal violence to trigger behavior change. These insights are nonetheless tempered by a recurring idea: the importance of empowering parents rather than blaming them. In this context, guilt-inducing strategies were described by some participants as ineffective, or even counterproductive. Convincing and engaging parents to change their behavior is thus a complex process, hindered by various factors such as deeply rooted family habits, language barriers, or the sensitivity of some parents, which makes the subject difficult to address. In such circumstances, practitioners often face situations of failure, which can generate feelings of powerlessness, discouragement, or frustration. Theme 4: Caries prevention as a public health issue with systemic causes (Table 5 ) Table 5 Theme 4 - Caries prevention as a public health issue with systemic causes 4/ CARIES PREVENTION AS A PUBLIC HEALTH ISSUE WITH SYSTEMIC CAUSES 4.1/ A SOCIAL AND HEALTHCARE CONTEXT UNFAVORABLE TO CARIES PREVENTION 4.2/ INSUFFICIENT INTERPROFESSIONAL COORDINATION AROUND CHILD ORAL HEALTH 4.1.1/ The pervasive marketing of sugary products 4.1.2/ A healthcare system built around a curative approach 4.1.3/ The need for new public health measures 4.2.1/ Lack of involvement from physicians 4.2.2/ The need for new actors in caries prevention “They’re bombarded with ads for candy, chocolate, and so on. How are we supposed to compete with that? We’re only here occasionally, and there’s an entire system pushing them to eat junk.” D11 “We keep giving contradictory messages: ‘Eat five fruits a day,’ and then we show them four ads for cakes. […] It’s a schizophrenic model, in a way—‘Look, but don’t taste,’ ‘Taste, but don’t enjoy.’ Constant paradoxes. And well, some of them fall into the trap.” D11 “ In France, the healthcare system isn’t set up to support prevention, to make it possible to avoid caries before they happen. […] Health promotion isn’t valued, codified, paid for, or carried out.” D04 A/ Starting prevention as early as possible “The health insurance system has set up free check-ups—you know, people get letters at age 3, 6, 9, and so on. […] But in my opinion, it should start at 6 months, when the teeth first come in. That’s when it should begin.” D06 B/ Developing school-based prevention “I think there are structural reforms that would actually be easier to implement. Like, clearly, […] if everyone brushed their teeth at school—morning and night, or even at lunchtime—that would be a sort of safety net. Even if it’s not done at home, it’s done at school.” D04 C/ Implementing collective prevention policies led by the State “Like they say, ‘alcohol abuse is dangerous,’ well maybe we could say: sugar abuse may also be harmful for a child under six. ” D05 “They tell you: you have to see the dentist once a year. […] If you do, and the dentist gives you a good rating—basically meaning you followed the rules—it’s fully covered by the State. But if you miss a visit or don’t comply, well, that’s it […] it’s no longer covered, and you have to pay for everything yourself or through private insurance” D13 “Doctors rarely refer children, even when they’ve got cavities all over their mouths. When kids have caries, they don’t care—they check the tonsils, the adenoids, but they don’t look at the teeth. The teeth are ignored, and the kids end up with lots of cavities, abscesses…” D05 A/ Delegating preventive care “You can entrust that to personnel with intermediate qualifications. […] It would be much more efficient. You don’t call in a neurosurgeon to stitch up a thumb, do you? So, same thing—you don’t necessarily need a pediatric dentist to give advice to a family.” D04 B/ Involving other professionals “There should be two types of support staff: […] someone like a hygienist, and also someone kind of between psychology and nutrition—that would really be ideal.” D11 “You can easily refer people to a nutritionist to help restore dietary balance—I mean, there are plenty of levers available.” D12 The dentists who participated in the study reframed caries prevention as a broader, systemic issue involving multiple levels of the healthcare system. At the societal level, they criticized the omnipresence of sugar, which they saw as incompatible with the development of a true and global “prevention culture”. At the level of the healthcare system, they described an organization that remained structured around a curative approach to care, which hinders the implementation of preventive practices in professional settings. Finally, at the level of healthcare professionals, dentists expressed frustration over the lack of involvement of general practitioners and pediatricians in monitoring children’s oral health. In response to these systemic shortcomings, several solutions were proposed by participants to strengthen caries prevention in society: introducing educational interventions from the earliest months of a child’s life, organizing school-based prevention programs, and implementing collective prevention measures aimed at countering the influence of the sugar industry and encouraging regular follow-up among patients. Ultimately, they expressed a desire to reinforce interprofessional collaboration—not only with physicians, but also with other paramedical or social professionals—who could contribute to caries prevention or even take full responsibility for it. DISCUSSION • Interpreting the Results Through the Health Stigma and discrimination Framework As previously outlined in our study protocol ( 20 ), this section applies the Health Stigma and Discrimination Framework as a lens to synthesize and interpret both our findings and key insights from the existing literature. The framework offers a comprehensive, multi-level model for understanding how health-related stigma operates. It outlines the drivers and facilitators that initiate stigma, the processes through which individuals or groups become "marked," and the various ways in which stigma is experienced and enacted ( 22 ). We argue that severe early childhood caries can be understood as a condition subject to stigma marking, similar to other health conditions previously analyzed through this framework (HIV, obesity, mental health...) In the context of early childhood caries, one of the primary stigma drivers appears to be the widespread and strong belief that parents are individually responsible for neglecting their child’s oral health. This perception places durable emphasis on parental responsibility and portrays parents as the root cause of the condition. As a result, they are frequently associated with negative stereotypes of the “failing parent”, perceived as lacking knowledge, motivation, authority, and as poor role models. This judgment of parenting practices aligns with a substantial body of literature that similarly highlights the stigmatizing discourse surrounding parental blame in child oral healthcare ( 13 , 23 ). The predominance of a biomedical and individualized approach to dental caries may act as a facilitating factor in oral health-related stigma. Current prevention and care strategies are largely based on a risk factor model, with interventions primarily targeting families’ lifestyles. While these approaches are undoubtedly important for understanding and managing dental caries, they often overlook the structural social determinants that underpin inequalities in oral health. This perspective, based on the implicit assumption that behaviors are freely chosen and therefore easily modifiable through patient education and information, overemphasizes individual responsibility while minimizing the influence of broader social, economic, and institutional conditions ( 24 ). It also tends to ignore the existence of a well-documented social gradient in oral health ( 18 , 25 ). In doing so, it contributes to reinforcing parental blame and moral judgment, thereby facilitating stigma. Yet, the work of social science researchers has shown that, from early childhood onward, individual behaviors are deeply shaped by the social environments in which people are born, grow, and live ( 26 , 27 ). In our study, we observed that children with severe early childhood caries may also be subject to intersecting forms of stigma , particularly related to their young age. Some dental professionals described treating very young children as challenging or even unpleasant, which may lead to practices that limit children's access to dental care, such as declining to treat them or offering fewer appointment options. While age does not appear to be a significant barrier to dental care in some countries ( 28 ), this form of discrimination has been reported in places such as France and Croatia, where 18 to 25% of general dentists do not accept children due to the perception that they are generally uncooperative and difficult to treat ( 29 – 31 ). Although it is true that managing some pediatric patients can be complex, the generalization of this perception to all children contributes to turning age itself into a stigmatizing factor. The findings of our study indicate that oral health-related stigma manifests within the care setting through a weakened therapeutic relationship. While dental professionals frequently express a strong sense of empathy towards children, this was never extended to parents in our analysis. This lack of empathy may help explain why some practitioners adopt negatively framed preventive strategies toward these families. Such strategies often take the form of a paternalistic and top-down approach, accompanied by guilt-inducing communication, and in some cases, even verbal aggression or physical aggression in one case. These findings are highly consistent with existing literature on weight-related stigma. Several studies have shown that stigma scores tend to be higher when the condition is perceived as controllable by the individual ( 32 – 34 ). Conversely, when it is attributed to genetic or biological factors, stereotypes surrounding personal responsibility are weakened, leading to a reduction in weight-related stigma. While our study focuses on the practices of dental professionals, the manifestations of stigma can also be explored through the lens of patients’ lived experiences . Little is known about how families affected by severe early childhood caries experience stigma firsthand. Patient perspectives on access to dental care and their experiences within dental settings remain underexplored. However, two qualitative studies report that some parents described guilt-inducing communication from dental professionals and expressed the fear of being reprimanded during medical appointments ( 16 , 35 ). These experiences highlight an important area for further investigation, as evidence from obesity-related research shows that similar interactions can directly contribute to decreased self-esteem, reduced motivation, and ultimately, avoidance of healthcare services ( 36 ). Like other authors ( 37 , 38 ), we postulate that manifestations of oral health-related stigma influence a range of outcomes for affected populations, including access to care, the acceptability of healthcare services, adherence to treatment, and delays in diagnosis and care. Over time, these consequences of stigma may lead to numerous negative impacts for children and families affected by poor oral health, such as reduced quality of life, experiences of bullying or teasing, lower self-esteem, academic difficulties, and social isolation ( 39 ). At a broader societal level, by sustaining and exacerbating health problems, the stigmatization of these patients could contribute to reinforcing and perpetuating social inequalities in health, by limiting access to care, worsening disadvantaged health trajectories, and maintaining lower social status among affected families. • Limitations: One methodological limitation to consider in this study is the potential for social desirability bias. This bias is particularly relevant when participants are asked to discuss sensitive topics such as discrimination, which can lead to discomfort or self-censorship. It is therefore plausible that some respondents may have, consciously or unconsciously, polished their discourse to make it more socially acceptable. However, several measures were taken to minimize this risk ( 40 ). All interviews were conducted by a social psychologist (MV), who was external to the field of dentistry, rather than by GL, a pediatric dentist whose professional identity could be easily found online. The perception of the interviewer as outside the respondents’ professional sphere likely encouraged greater openness. In addition, the topic was introduced in a deliberately broad and neutral manner, without judgment and with a genuine intention to understand their practices. Discrimination was not mentioned explicitly, and follow-up questions were carefully worded to avoid leading responses. Anonymity was guaranteed in the information sheet and consent form, helping to create a safe space for participants. Finally, we opted exclusively for individual interviews rather than focus groups to limit peer influence and reduce the social pressures. Although Table 2 confirms a wide diversity of profiles among the dentists interviewed, it should be noted that many participants practice in private settings and group practices. This overrepresentation may represent a limitation, as it partially restricts the maximum variation principle. However, this distribution remains consistent with the national characteristics of the profession, with nearly 80% of dentists in France working in private practice and a strong trend toward professional grouping over the past decade ( 41 ). Moreover, our sample shows substantial heterogeneity across other dimensions (age, gender, geographical location, type of patient population), which nonetheless helps ensure a plurality of perspectives and professional experiences within the corpus analyzed. • Areas for future research: Research on oral health-related stigma is still in its early stages, and the field is only beginning to develop a coherent theoretical framework. The publication by Doughty et al. in 2023 marked an important milestone by proposing a first working definition of this phenomenon ( 37 ). In their narrative review, the authors emphasize that oral health-related stigma stems from societal perceptions of what constitutes good or poor oral health. These perceptions are often tied to moral judgments about personal neglect, social status, and failure to adhere to sociocultural norms of hygiene. Individuals with poor oral health may thus be seen as responsible for their condition and subjected to blame, mockery, or discrimination, whether in interpersonal interactions or within institutional settings. In this regard, our study aligns with this emerging theoretical framework by providing empirical evidence of differential treatment based on perceived oral health. More specifically, it is among the first to investigate how such perceptions and stereotypes are constructed and expressed by oral health professionals, particularly in relation to patients affected by severe dental caries. This work represents a necessary first step by helping to identify the underlying components of such stigma (drivers, facilitators, markers, and manifestations). However, further research is needed to complement this approach, particularly studies focused on patients' lived experiences and the impact of stigma on their health, well-being, and access to care. A promising avenue to deepen our findings would also be the development of standardized measurement tools to quantitatively assess stereotypes toward individuals with severe caries. Such instruments already exist in fields such as weight and mental health stigma ( 42 , 43 ), and could serve as useful tools for estimating the prevalence and intensity of these stereotypes within oral health settings. Another strength of our study is that it is, to our knowledge, the first to investigate oral health-related stigma in pediatric populations, approached through the lens of the family unit. As in other contexts, such as aging ( 38 ), our findings suggest that different forms of stigma can intersect (in this case, related to both age and oral health), generating distinct experiences of stigmatization and discrimination for affected families. These complex dynamics warrant further investigation, particularly through the theoretical framework of intersectionality. To date, oral health research has paid limited attention to how overlapping social identities (including gender, age, ethnicity, socio-economic status, etc.) shape the experience of stigma. In the case of families with children affected by severe dental caries, several stigma markers may converge: parents may be perceived as neglectful, children as uncooperative or difficult to treat, and these assumptions may also be entangled with social judgments related to poverty or cultural difference, reinforced by language barriers. An intersectional approach to oral health-related stigma would offer valuable insights into how these markers interact, leading to layered disadvantages for already vulnerable populations ( 44 ). CONCLUSION The findings of this qualitative study suggest that children with severe dental caries and their parents may experience a dual form of stigma. First, the children are often perceived as challenging or unpleasant to treat. Second, their oral condition tends to be associated with negative assumptions about parental neglect and sole responsibility for the disease. Such perceptions may compromise the quality of the patient–provider relationship and create barriers to care. Considering the efforts to improve clinical practice and ensure more equitable access to oral healthcare, further investigation into these forms of discrimination is warranted, particularly through quantitative research and the application of social science frameworks. Declarations Ethical approval Ethical approval was obtained from the research ethics committee of the Department of Family Medicine at University Lyon (approval number: 2021-09-09-03). Consent for publication Not applicable Competing interests The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Authors’ information At the time of the study, GL was a public health PhD student and worked as a lecturer in the pediatric dentist department at the University of Lyon 1. She was trained in qualitative methodology during her doctoral studies, and this project is her first qualitative research. MV is a social psychologist and was trained in qualitative methods during her graduate studies. She has served as principal investigator on several qualitative studies. MC holds a PhD in public health and is a member of the Department of General Practice at the University of Lyon 1. He has experience conducting qualitative research and has contributed to the publication of several qualitative studies. All other members of the research team have expertise either in pediatric dentistry or in qualitative research methods. Funding This work is supported by 2 grants, one from the French Ministry of Health [RESP-IR 2021, grant number: RESPIR-21-005] and another from the Hospices Civils de Lyon [Junior investigator award 2021]. Author Contribution All authors contributed to the design of the study. GL is the principal investigator, responsible for coordinating the study and analyzing the data. MV conducted all the dentists’ interviews. The data analysis was carried out by GL and MV. MC acted as supervisor and oversaw the entire process. GL is the lead author of this manuscript, and all authors contributed to its review and approved the final version. Acknowledgement Not applicable Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References GBD 2017 Oral Disorders Collaborators, Bernabe E, Marcenes W, Hernandez CR, Bailey J, Abreu LG, et al. Global, Regional, and National Levels and Trends in Burden of Oral Conditions from 1990 to 2017: A Systematic Analysis for the Global Burden of Disease 2017 Study. J Dent Res. 2020;99(4):362–73. Kassebaum NJ, Bernabé E, Dahiya M, Bhandari B, Murray CJL, Marcenes W. Global burden of untreated caries: a systematic review and metaregression. 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Garg S, Rubin T, Jasek J, Weinstein J, Helburn L, Kaye K. How willing are dentists to treat young children? a survey of dentists affiliated with Medicaid managed care in New York City, 2010. J Am Dent Assoc 1939 avr. 2013;144(4):416–25. Gavić L, Nikolić I, Sidhu SK, Jerković D, Tadin A. The Attitude of the General Dentist in the Republic of Croatia toward Treating Children. Child 1 déc. 2022;9(12):1888. Dominici G, Muller-Bolla M. L’activité pédiatrique des chirurgiens-dentistes généralistes en France. Rev Francoph Odontol Pediatr. 2018;13(1):1–6. Muller-Bolla M, Clauss F, Davit-Béal T, Manière M, Sixou J, Vital S. Prise en charge bucco-dentaire des enfants et des adolescents. CDF. 2018;1806–1807:1–5. O’Keeffe M, Flint SW, Watts K, Rubino F. Knowledge gaps and weight stigma shape attitudes toward obesity. Lancet Diabetes Endocrinol 1 mai. 2020;8(5):363–5. Hilbert A. Weight Stigma Reduction and Genetic Determinism. PLoS ONE. 2016;11(9):e0162993. Jeong SH. Effects of news about genetics and obesity on controllability attribution and helping behavior. Health Commun. 2007;22(3):221–8. Naidu R, Nunn J, Forde M. Oral healthcare of preschool children in Trinidad: a qualitative study of parents and caregivers. BMC Oral Health. 2012;12(1):27. Alberga AS, Edache IY, Forhan M, Russell-Mayhew S. Weight bias and health care utilization: a scoping review. Prim Health Care Res Dev. 2019;20(e116):1–14. Doughty J, Macdonald ME, Muirhead V, Freeman R. Oral health-related stigma: Describing and defining a ubiquitous phenomenon. Community Dent Oral Epidemiol. 2023;51(6):1078–83. Slack-Smith L, Ng T, Macdonald ME, Durey A. Rethinking Oral Health in Aging: Ecosocial Theory and Intersectionality. J Dent Res juill. 2023;102(8):844–8. Seehra J, Newton JT, DiBiase AT. Bullying in schoolchildren – its relationship to dental appearance and psychosocial implications: an update for GDPs. Br Dent J mai. 2011;210(9):411–5. Bispo JP. Social desirability bias in qualitative health research. Rev Saúde Pública 18 nov. 2022;56:101. Bergeat M, Vergier N, Verger P. Quatre médecins généralistes sur dix exercent dans un cabinet pluriprofessionnel en 2022. DREE, Etudes et Résultats. 2022;(1244). Bacon J, Scheltema K, Robinson B. Fat phobia scale revisited: the short form. Int J Obes. 2001;25(2):252–7. Kassam A, Papish A, Modgill G, Patten S. The development and psychometric properties of a new scale to measure mental illness related stigma by health care providers: the Opening Minds Scale for Health Care Providers (OMS-HC). BMC Psychiatry. 2012;12:62. Elaine Muirhead V, Milner A, Freeman R, Doughty J, Macdonald ME. What is intersectionality and why is it important in oral health research? Community Dent Oral Epidemiol. déc. 2020;48(6):464–70. Additional Declarations No competing interests reported. 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Perceptions and Practices of Dental Professionals: A Qualitative Study","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eDental caries remains one of the most common chronic diseases in early childhood. According to global estimates from 2017, untreated carious lesions in primary teeth affected approximately 8% of children worldwide (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In France, the situation appears even more concerning, with national data suggesting that the prevalence of untreated caries in deciduous teeth may reach up to 30% of the pediatric population (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). These figures are alarming given the well-documented impacts of dental caries on children's quality of life (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and long-term oral health trajectories (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDental caries is a chronic, non-communicable, and multifactorial disease, resulting from complex interactions between genetic, biochemical, anatomical, social, and behavioral factors (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The most recent guidelines for caries management emphasize the importance of a personalized approach based on the patient's specific caries risk (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). While traditional individual preventive measures, such as the use of fluoride and the application of fissure sealants, remain central, increasing attention is now being paid to behavioral barriers. Featherstone et al. have even drawn parallels between the role of the dentist and that of \u0026ldquo;health coaches and behavioral interventionists,\u0026rdquo; whose mission is to support patients in adopting positive oral health behaviors in their everyday lives. This coaching role is particularly relevant, as it implies the development of specific skills that extend clinical procedures to include patient-centered communication, active listening, and the ability to build a trust-based relationship and provide long-term support. Ideally, this is the role dentists are expected to fulfill; however, in practice, their involvement in prevention appears to be more limited. Studies have shown that preventive care, particularly in primary prevention, is not strongly emphasized in routine dental, with dentists reporting that they spend limited time on patient education, which typically consists of brief, generic advice rather than individualized behavioral support (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur recent systematic review of the literature highlights that oral health professionals identify multiple contributing factors to the limited implementation of preventive strategies (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Among these factors, many are linked to systemic issues within the healthcare system. However, parents are also commonly perceived as a barrier to effective caries prevention, due to their lack of knowledge, parenting skills, health literacy, or even their inability to prioritize their child\u0026rsquo;s oral health. These negative perceptions warrant closer examination considering other research on weight stigma in healthcare. Studies in that field have shown that health professionals\u0026rsquo; negative judgments can compromise the quality of care, leading to shorter medical encounters, less respectful communication, and a reduced focus on patient-centered approaches (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In oral health care, these phenomena remain largely unexplored, although some findings are cause for concern. A 2017 survey of 700 general dentists found that 58% chose not to provide interproximal hygiene advice when they assumed the patient would not comply (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Additionally, a qualitative investigation reported that some parents experienced negative or guilt-inducing communication from dental staff (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), while another study suggested that parents of caries-free children were more likely to receive comprehensive oral health information (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). It is therefore crucial to further investigate the perceptions associated with children affected by severe dental caries and their parents, and to examine how these perceptions may influence the quality of care of these families. This issue is particularly significant in a context where dental caries tends to be more prevalent among populations with low socioeconomic status (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Indeed, these groups are already exposed to multiple forms of vulnerability (low income, limited education, complex family structures, language barriers\u0026hellip;) and should receive greater support from healthcare professionals.\u003c/p\u003e\u003cp\u003eThis study aims to conduct an exploratory study on how dental professionals perceive and interact with children affected by early childhood caries and their parents. In this context, \"perceptions\" refer to the stereotypes that may be associated with these families. Stereotypes can be defined as implicit personality theories shared collectively by members of a group concerning members of another group (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The study explores dentists\u0026rsquo; perceptions and attitudes toward these families hrough two central questions: 1/ What perceptions do health professionals hold about children with severe dental caries and their families? 2/ To what extent might these perceptions influence the quality of care delivered, particularly in the field of oral health prevention? We hypothesize that some practitioners may hold negative views toward children with severe dental caries and their parents, which could in turn affect preventive care practices.\u003c/p\u003e"},{"header":"METHOD","content":"\u003cp\u003eThis qualitative study was reported in accordance with the COREQ criteria (see Supplementary File 1). It was based on semi-structured interviews conducted with dentists, general practitioners, and pediatricians. The study protocol, detailing the methodology, was published in 2022 and strictly followed in the present work (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Two minor deviations from the original protocol should be noted: the interview guide was revised after a pilot phase (the final version is provided in Supplementary File 2), and data were analyzed using Atlas.ti, a qualitative data analysis software, rather than NVivo, as initially planned. These modifications did not require seeking a new ethical opinion from an IRB.\u003c/p\u003e\u003cp\u003eThe interviews were conducted and analyzed by GL and MV. Interviews with dentists, pediatricians and general practitioners were analyzed separately.\u003c/p\u003e\u003cp\u003eThis article focuses exclusively on the interviews and data collected from dentists.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003e\u0026bull; Participant selection and data collection\u003c/h2\u003e\n \u003cp\u003eParticipants were recruited using a purposive sampling strategy. Although the sample was not randomly selected, it was built through professional networks, with the support of individuals identified as well-connected within the field. Several key informants facilitated access to a diverse pool of potential participants. To ensure maximum variation, the selection process considered participants\u0026rsquo; age, gender, geographic location, mode of practice, and the number of children they treated each week. Initial contact was made by email or phone, and in most cases, two follow-up messages were needed to receive a response. Sixteen dentists were contacted and invited to participate; only one declined, stating they did not feel sufficiently qualified to speak on the topic. Ultimately, 15 dentists were interviewed as part of this qualitative study. Demographic characteristics of the participants are presented in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" style=\"width: 431px;\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic and professional characteristics of participants\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth style=\"width: 276.329px;\" align=\"left\"\u003e\n \u003cp\u003eDemographic information\u003c/p\u003e\n \u003c/th\u003e\n \u003cth style=\"width: 141.671px;\" align=\"left\"\u003e\n \u003cp\u003eNumber of participants\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth style=\"width: 276.329px;\" align=\"left\"\u003e\n \u003cp\u003eGENDER\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/th\u003e\n \u003cth style=\"width: 141.671px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth style=\"width: 276.329px;\" align=\"left\"\u003e\n \u003cp\u003eAGE\u003c/p\u003e\n \u003cp\u003eBetween 30 and 39 years\u003c/p\u003e\n \u003cp\u003eBetween 40 and 49 years\u003c/p\u003e\n \u003cp\u003eOver 50 years\u003c/p\u003e\n \u003c/th\u003e\n \u003cth style=\"width: 141.671px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276.329px;\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eYEARS OF EXPERIENCE\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eBetween 1 and 10 years\u003c/p\u003e\n \u003cp\u003eBetween 11 and 20 years\u003c/p\u003e\n \u003cp\u003eMore than 20 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141.671px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276.329px;\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePRACTICE LOCATION\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003cp\u003eSemi-urban\u003c/p\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141.671px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276.329px;\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePRACTICE LOCATION\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eGroup private practice\u003c/p\u003e\n \u003cp\u003eSolo private practice\u003c/p\u003e\n \u003cp\u003eHospital-based practice\u003c/p\u003e\n \u003cp\u003eMixed practice (group private and hospital-based)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141.671px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276.329px;\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePEDIATRIC PATIENTS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMore than 20 per week\u003c/p\u003e\n \u003cp\u003eBetween 10 and 20 per week\u003c/p\u003e\n \u003cp\u003eBetween 5 and 10 per week\u003c/p\u003e\n \u003cp\u003eFewer than 5 per week\u003c/p\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141.671px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eInterviews were conducted over a six-month period, from December 2022 to May 2023. Two interviews were held in person at the investigator\u0026apos;s workplace. The remaining thirteen interviews were conducted via videoconference. All interviews were conducted by a social psychologist (MV), and no other individuals were present during the sessions. The interviews lasted between 35 and 75 minutes, depending on the participant, with an average duration of 50 minutes. All interviews were systematically audio-recorded to ensure accurate verbatim transcription, and the interviewer also took field notes to document nonverbal cues (e.g., posture, attitudes, facial expressions, intonation). After transcription, each interview was sent back to the participant for review. None of the participants requested any modifications or additions.\u003c/p\u003e\n \u003cp\u003eData collection continued until data saturation was reached during thematic analysis. We applied the \u003cem\u003ecode meaning\u003c/em\u003e approach to saturation, as defined by Hennink and Kaiser in their systematic review, meaning that data collection continued until no new aspects, dimensions, or nuances emerged for each identified theme (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e). Each interview was coded independently by two investigators (GL, MV) and subsequently discussed collectively to reach consensus. Similar codes were then grouped into coherent themes, defined as meaning-based patterns. Theme development drew on researchers\u0026rsquo; subjectivity (knowledge, theoretical assumptions, etc.), as the aim was to provide an interpretation of the dataset rather than summarize it.\u0026rdquo;\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003e\u0026bull; Thematic analyses\u003c/h3\u003e\n\u003cp\u003eFour main themes were identified following the thematic analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1: Parents portrayed as guilty of neglecting their child\u0026rsquo;s oral health\u003c/strong\u003e (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTheme 1 - Parents portrayed as guilty of neglecting their child\u0026rsquo;s oral health\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003e1/ PARENTS PORTRAYED AS GUILTY OF NEGLECTING THEIR CHILD\u0026rsquo;S ORAL HEALTH\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e1.1/ THE FAMILY\u0026apos;S SOCIAL ENVIRONMENT NEGATIVELY INFLUENCES HEALTH BEHAVIORS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e1.2/ PARENTAL INDIVIDUAL RESPONSIBILITY\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e1.3/ A WEAK PARENTING FRAMEWORK\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.1.1/ Unfavorable health beliefs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.1.2/ Family circumstances limiting parental engagement in oral health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eA/ An environment that normalizes dental caries\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;His brother had caries, his sister had caries...caries run in the family. So for them, it\u0026rsquo;s just normal, and [\u0026hellip;] in the end, living with that is not seen as something unusual in the family culture.\u0026rdquo;\u003c/em\u003e D02\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eB/ Oral health as a low priority in the context of everyday difficulties\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Given [\u0026hellip;] how complicated their daily life is, oral hygiene is really, really not a priority. \u0026rdquo;\u003c/em\u003e D15\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eC/ A curative perception of health leads to delayed care\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026nbsp;You\u0026rsquo;ve got those who don\u0026rsquo;t take care of their kids, who only bring them in when they\u0026rsquo;re screaming and keeping them up at night\u0026mdash;because all they want is to sleep.\u0026rdquo;\u003c/em\u003e D11\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;And unfortunately, it was only when [\u0026hellip;] the front teeth were affected that parents brought their children in. Even though there were just as many cavities in the back. But it was only when it impacted aesthetics that they decided to take the child to the dentist.\u0026rdquo;\u003c/em\u003e D03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eA/ Precarity\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;For people who are really struggling\u0026mdash;I don\u0026rsquo;t know, socioeconomically or things like that\u0026mdash;we know that\u0026hellip; well, when people don\u0026rsquo;t have much, in general [\u0026hellip;] a lack of resources often goes along with a diet that\u0026rsquo;s too sugary, highly processed, things like that, because it\u0026rsquo;s the simplest and the cheapest option\u003c/em\u003e.\u0026rdquo; D01\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eB/ Single parenthood\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;There\u0026rsquo;s the profile of parents from single-parent families\u0026mdash;that is, young, divorced parents who work, who don\u0026rsquo;t necessarily have time to properly take care of their children, and who end up letting them kind of manage on their own.\u0026rdquo;\u003c/em\u003e D12\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eC/ Large families\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;These are big families\u0026mdash;some of them have five, six kids\u0026hellip; so they don\u0026rsquo;t really have time to take care of everyone.\u0026rdquo;\u003c/em\u003e D14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eA/ Limited cognitive abilities\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;They\u0026rsquo;re really slow on the uptake \u0026mdash; I mean, they\u0026apos;ve got the brains of a pony. We\u0026rsquo;re not going to make them any smarter. They just don\u0026rsquo;t have any sense of hygiene, or of what poor hygiene even means.\u0026rdquo;\u003c/em\u003e D15\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eB/ A lack of knowledge about oral health\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;There are those who don\u0026rsquo;t understand why their children have so many dental problems, because they haven\u0026rsquo;t made the link with sugar, for example. So really, it\u0026rsquo;s just due to a lack of knowledge \u0026mdash; it\u0026rsquo;s not out of neglect or malice.\u0026rdquo;\u003c/em\u003e D11\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eC/ A lack of motivation and interest in the child\u0026rsquo;s oral health\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;For them, it\u0026rsquo;s kind of\u0026hellip; well, to put it bluntly, it\u0026rsquo;s a hassle. That\u0026rsquo;s how it is for a lot of parents. I get the feeling they do it, but that it really annoys them to have to deal with it.\u0026rdquo;\u003c/em\u003e D06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eA/ Parents are not a good role model for the child\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;There are parents who are just bad examples\u0026mdash;they don\u0026rsquo;t take care of themselves, so how can they teach their children the right habits? \u0026ldquo;\u003c/em\u003e D04\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eB/ Parents do not sufficiently oppose their child\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026bull; Out of love\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Because people think that [\u0026hellip;] it\u0026rsquo;s a sign of love\u0026mdash;not saying no, or offering sugary food or several meals a day.\u0026rdquo;\u003c/em\u003e D02\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026bull; Out of convenience\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;And then, when parents\u0026hellip; well, they just don\u0026rsquo;t have time. So as soon as the child screams, they give them something to eat or a bit of\u0026hellip; fruit juice. \u0026ldquo;\u003c/em\u003e D08\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eC/ Parents do not take responsibility for their role\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Parents blame the child, when it\u0026rsquo;s not the child\u0026rsquo;s fault\u0026mdash;it\u0026rsquo;s the parents who buy the sodas, the candy, and all that.\u0026rdquo;\u003c/em\u003e D05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eParents were held responsible for the poor oral condition of their children. The respondents explained what they perceived as a parental inability to care for their child through various factors.\u003c/p\u003e\n\u003cp\u003eFirst, parents were described as evolving within an \u003cstrong\u003eenvironment that promotes unfavorable health norms\u003c/strong\u003e. More specifically, this environment was said to normalize caries, to deprioritize dental care, and to encourage a curative rather than preventive approach to health. Within this context, it was frequently reported that parents only sought dental care when caries had already caused pain or visible aesthetic damage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe family context\u003c/strong\u003e was identified as another factor that could negatively affect parental involvement. Situations of socioeconomic hardship, single parenthood, or large families were frequently perceived as making it more difficult for parents to provide the conditions necessary for maintaining their child\u0026rsquo;s oral health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParental individual responsibility\u003c/strong\u003e was also called into question, with parents described as lacking knowledge, motivation, and sometimes even intellectual capacity. Finally, the child\u0026rsquo;s poor oral health was frequently attributed to a weak educational framework established by the parents. In this regard, parents were seen as poor role models for their children, and their lack of authority was often emphasized. According to the respondents, parents did not sufficiently oppose their child\u0026rsquo;s demands\u0026mdash;either out of love or out of convenience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2: Ambivalent emotional perceptions of the child with severe dental caries\u003c/strong\u003e (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTheme 2 - Ambivalent emotional perceptions of the child with severe dental caries\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003e2/ AMBIVALENT EMOTIONAL PERCEPTIONS OF THE CHILD WITH SEVERE DENTAL CARIES\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e2.1/ DENTISTS EXPRESS EMPATHY FOR THE CHILD WITH SEVERE CARIES...\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e2.2/ \u0026hellip;BUT FIND IT UNPLEASANT TO TREAT THEM\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.1.1/ The child is perceived as a victim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.1.2/ The child suffers the negative consequences of caries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.2.1/ Children are difficult to treat\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.2.2/ This aversion negatively impacts children\u0026rsquo;s access to dental care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eA/ Victim of parental incompetence\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I think the child is very innocent\u0026mdash;they\u0026rsquo;re the ones who suffer, in a way. They suffer from their parents\u0026rsquo; incompetence, more than anything else. \u0026ldquo;\u003c/em\u003e D06\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eB/Victim of a failing healthcare system\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I feel a bit desperate sometimes, when they show up in that kind of state at age six, and it\u0026rsquo;s clearly not something new. Sometimes it\u0026rsquo;s been going on for two years\u0026mdash;these families have been medically wandering, unable to find someone to take care of them. And the situations just get worse. \u0026ldquo;\u003c/em\u003e D01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eA/ Pain and functional limitations\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;So the patient\u0026mdash;the child\u0026mdash;ends up being uncomfortable, even disabled in their daily life because of it. Whether it\u0026rsquo;s aesthetic, functional, or just due to pain.\u0026rdquo;\u003c/em\u003e D01\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eB/ Impaired social life\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Well, yes, I think it has a psychological impact, because we all know how mean kids can be to each other (laughs). So yes, they\u0026rsquo;ll get comments\u0026mdash;whether in the schoolyard, from their parents, their family, or even strangers on the street. Like, if they go grocery shopping with their parents, the cashier will see that, well, when the kid smiles\u0026hellip; it\u0026rsquo;s not a great sight.\u0026rdquo;\u003c/em\u003e D12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eA/ Care is challenging from both a technical and behavioral standpoint\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;For me, before age six, there\u0026rsquo;s a real issue with cooperation. Like, I\u0026rsquo;ll say \u0026lsquo;open your mouth,\u0026rsquo; I blow some air, and then I ask, \u0026lsquo;does that hurt?\u0026rsquo;\u0026mdash;but the child can\u0026rsquo;t really tell me whether it does or not.\u0026rdquo;\u003c/em\u003e D13\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eB/ Treating children requires a specific approach\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s not that simple\u0026mdash;because it requires a much more significant psychological approach than when treating adults, and that\u0026rsquo;s something many people aren\u0026rsquo;t comfortable with.\u0026rdquo;\u003c/em\u003e D01\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eC/ Pediatric dentistry is not a profitable or efficient practice\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Actually, most of them don\u0026rsquo;t do it because it\u0026rsquo;s not well paid, because just talking like that can take up an hour. And if you do that with two or three kids, it can easily take an hour\u0026mdash;just to talk, really.\u0026rdquo;\u003c/em\u003e D13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eA/ Few dentists are willing to treat children\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Well, there\u0026rsquo;s also the fact that I didn\u0026rsquo;t like treating children. I like kids, they don\u0026rsquo;t bother me, but I just don\u0026rsquo;t like treating them.\u0026rdquo;\u003c/em\u003e D04\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eB/ Dentists who do treat children often restrict their access to care\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;We only schedule children on Wednesday afternoons\u0026mdash;just for a couple of hours, maybe two or three at most.\u0026rdquo;\u003c/em\u003e D08\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I used to take in the children of my regular patients\u0026mdash;but I didn\u0026rsquo;t take others.\u0026rdquo;\u003c/em\u003e D13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eDuring the interviews, dentists expressed a highly ambivalent view of children with severe dental caries. On the one hand, many professionals conveyed a strong sense of \u003cstrong\u003eempathy\u003c/strong\u003e toward these children. They were not seen as responsible for their condition, but rather as innocent and unfortunate patients suffering from the multiple negative consequences of dental decay. These children were portrayed as victims\u0026mdash;both of their parents\u0026rsquo; inability to provide adequate care and of systemic failures within the healthcare system.\u003c/p\u003e\n\u003cp\u003eDespite the strong expression of empathy, dentists also reported significant challenges in treating these children, making their care \u003cstrong\u003eburdensome\u003c/strong\u003e or even \u003cstrong\u003eunpleasant\u003c/strong\u003e. The difficulties mentioned included technical obstacles (such as limited mouth opening or a restless child), behavioral issues (manifestations of anxiety, disturbance or refusal of care), the lack of financial profitability, and the need to adopt a specific, adapted approach. These various factors were seen as contributing to the fact that many dentists either refuse to treat young children altogether or restrict their access to care by imposing selective admission criteria.\u003c/p\u003e\n\u003ch3\u003eTheme 3: Behavior change perceived as a challenge (Table 4)\u003c/h3\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTheme 3 -Behavior change perceived as a challenge3/ BEHAVIOR CHANGE PERCEIVED AS A CHALLENGE Table 4: Theme 3 -Behavior change perceived as a challenge\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.1/ RAISING PARENTAL AWARENESS AS A KEY OBJECTIVE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.2 / VARIOUS STRATEGIES TO RAISE PARENTAL AWARENESS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.3/ A DIFFICULT PROCESS GENERATING NEGATIVE EMOTIONS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.2.1/ Providing information as the dominant strategy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.2.2/ Authoritative approach as a common strategy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.2.3/ Strategies tempered by a more understanding approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.3.1/ Barriers to parental awareness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.3.2/ Situations generating negative emotions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eA/ Raising awareness that caries are preventable\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I try to explain that it\u0026rsquo;s not inevitable\u0026mdash;just because their older sibling had cavities doesn\u0026rsquo;t mean they have to as well.\u0026rdquo;\u003c/em\u003e D02\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eB/ Raising awareness of inappropriate family health behaviors\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Some parents just aren\u0026rsquo;t aware of how much sugar their child consumes. So sometimes I\u0026rsquo;d tell them: let\u0026rsquo;s keep a food diary\u0026mdash;a kind of consumption log for their child [\u0026hellip;] and often, the parents would realize that, yes, actually, there was something every hour.\u0026rdquo;\u003c/em\u003e D03\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eC/ Raising awareness that parents are the key agents of change\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s really the parents we have to win over. If we don\u0026rsquo;t win over the parents, it\u0026rsquo;s no good\u0026mdash;we\u0026rsquo;ll never get anywhere\u0026rdquo;\u003c/em\u003e D05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I always use the first consultation to avoid doing any actual treatment. I might do X-rays, explain things to them, show them, and then spend 30 minutes going over what they should eat, when, not snacking\u0026hellip; I take the time to explain all of that. And then I do a little summary on how to brush, how much toothpaste to use, and which kind of toothpaste to buy.\u0026rdquo;\u003c/em\u003e D14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eA/ Guilt-inducing discourse\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Well, there are parents to whom I say: it\u0026rsquo;s not normal to bring your kid in at five years old with 15 cavities. Where were you? I mean, you don\u0026rsquo;t have to be a dentist to ask your kid to open their mouth and see that there are several cavities!\u0026rdquo;\u003c/em\u003e D13\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eB/ Paternalistic stance\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;So, to make it work, we do add a little touch of severity. Yeah. Like with a child.\u0026rdquo;\u003c/em\u003e D10\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eC/ Physical or verbal violence\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;So the choice we made was, yes, we were going to make him suffer\u0026mdash;hoping that it would lead to a change in behavior, both on his part and on the part of his family. Mainly the family, because they\u0026rsquo;re the ones who buy the sodas.\u0026rdquo;\u003c/em\u003e D10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eA/ Empowering rather than blaming\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Being moralizing and judgmental doesn\u0026rsquo;t work. That creates conflictual relationships. That\u0026rsquo;s not how you build a relationship.\u0026rdquo;\u003c/em\u003e D01\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I really try to involve the child\u0026mdash;even when they\u0026rsquo;re very young\u0026mdash;so they understand it\u0026rsquo;s not just their parents being annoying, but that it\u0026rsquo;s actually important for them.\u0026rdquo; D09\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eB/\u003c/strong\u003e \u003cstrong\u003eCollaborative approach\u003c/strong\u003e \u003cstrong\u003e\u0026ldquo;\u003c/strong\u003e\u003cem\u003eYou have to manage to create a discourse that works, one that brings people into the care process\u0026mdash;because otherwise it doesn\u0026rsquo;t work either. They need to feel like they\u0026rsquo;re active participants, that they\u0026rsquo;re capable of doing it.\u0026rdquo; D01\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eA/ Deeply ingrained habits\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s that mom and dad have to change their habits for the child to change his. But are mom and dad really ready to change their habits?\u0026rdquo; D14\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eB/ Language barrier\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;There are families from immigrant backgrounds who maybe don\u0026rsquo;t take in what we\u0026rsquo;re saying\u0026mdash;because of the language barrier, I mean.\u0026rdquo; D12\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eC/ Parental sensitivity to judgment\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The message doesn\u0026rsquo;t get through [\u0026hellip;] because people feel judged [\u0026hellip;]. There\u0026rsquo;s this\u0026hellip; how can I say? Again, I think it\u0026rsquo;s this sensitivity you see in certain social groups.\u0026rdquo;\u003c/em\u003e D13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eA/ Powerlessness\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s like\u0026hellip; sometimes you feel like you\u0026rsquo;re just [\u0026hellip;] preaching in the desert. And that the caries are progressing faster than I can do anything. So yeah [\u0026hellip;] that\u0026rsquo;s really hard. It honestly feels like a real failure.\u0026rdquo; D02\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eB/ Discouragement\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I always try, of course, but when I really feel like I can\u0026rsquo;t get through, or when it just doesn\u0026rsquo;t feel right\u0026hellip; I have to admit, there are times when I feel really discouraged.\u0026rdquo;\u003c/em\u003e D09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe issue of behavior change was widely addressed by the participants, who viewed it as one of the most challenging aspects of care. They reported significant difficulty in identifying effective levers for initiating change. To encourage behavior change within families, dentists aim to raise awareness among parents. More specifically, their goal is to help parents understand that dental caries is preventable, that their own behaviors contribute to the disease, and that their involvement is essential in preventing it. To achieve this goal, participants described a range of strategies. The dominant strategy, strongly favored by dentists, consists in informing the patient through explanations or demonstrations (eg. teeth brushing). In addition, the interviewed professionals often reported using approaches grounded in an authoritarian and paternalistic stance. Among these, guilt-inducing discourse was frequently mentioned as a lever for change, and, to a lesser extent, the use of physical or verbal violence to trigger behavior change. These insights are nonetheless tempered by a recurring idea: the importance of empowering parents rather than blaming them. In this context, guilt-inducing strategies were described by some participants as ineffective, or even counterproductive. Convincing and engaging parents to change their behavior is thus a complex process, hindered by various factors such as deeply rooted family habits, language barriers, or the sensitivity of some parents, which makes the subject difficult to address. In such circumstances, practitioners often face situations of failure, which can generate feelings of powerlessness, discouragement, or frustration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 4: Caries prevention as a public health issue with systemic causes\u003c/strong\u003e (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTheme 4 - Caries prevention as a public health issue with systemic causes\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth colspan=\"5\" align=\"left\"\u003e\n \u003cp\u003e4/ CARIES PREVENTION AS A PUBLIC HEALTH ISSUE WITH SYSTEMIC CAUSES\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e4.1/ A SOCIAL AND HEALTHCARE CONTEXT UNFAVORABLE TO CARIES PREVENTION\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e4.2/ INSUFFICIENT INTERPROFESSIONAL COORDINATION AROUND CHILD ORAL HEALTH\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.1.1/ The pervasive marketing of sugary products\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.1.2/ A healthcare system built around a curative approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.1.3/ The need for new public health measures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.2.1/ Lack of involvement from physicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.2.2/\u0026nbsp;The need for new actors in caries prevention\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;They\u0026rsquo;re bombarded with ads for candy, chocolate, and so on. How are we supposed to compete with that? We\u0026rsquo;re only here occasionally, and there\u0026rsquo;s an entire system pushing them to eat junk.\u0026rdquo;\u003c/em\u003e D11\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;We keep giving contradictory messages: \u0026lsquo;Eat five fruits a day,\u0026rsquo; and then we show them four ads for cakes. [\u0026hellip;] It\u0026rsquo;s a schizophrenic model, in a way\u0026mdash;\u0026lsquo;Look, but don\u0026rsquo;t taste,\u0026rsquo; \u0026lsquo;Taste, but don\u0026rsquo;t enjoy.\u0026rsquo; Constant paradoxes. And well, some of them fall into the trap.\u0026rdquo;\u003c/em\u003e D11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026nbsp;In France, the healthcare system isn\u0026rsquo;t set up to support prevention, to make it possible to avoid caries before they happen. [\u0026hellip;] Health promotion isn\u0026rsquo;t valued, codified, paid for, or carried out.\u0026rdquo;\u003c/em\u003e D04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eA/ Starting prevention as early as possible\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The health insurance system has set up free check-ups\u0026mdash;you know, people get letters at age 3, 6, 9, and so on. [\u0026hellip;] But in my opinion, it should start at 6 months, when the teeth first come in. That\u0026rsquo;s when it should begin.\u0026rdquo;\u003c/em\u003e D06\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eB/ Developing school-based prevention\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I think there are structural reforms that would actually be easier to implement. Like, clearly, [\u0026hellip;] if everyone brushed their teeth at school\u0026mdash;morning and night, or even at lunchtime\u0026mdash;that would be a sort of safety net. Even if it\u0026rsquo;s not done at home, it\u0026rsquo;s done at school.\u0026rdquo;\u003c/em\u003e D04\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eC/ Implementing collective prevention policies led by the State\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Like they say, \u0026lsquo;alcohol abuse is dangerous,\u0026rsquo; well maybe we could say: sugar abuse may also be harmful for a child under six.\u003c/em\u003e\u0026rdquo; D05\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;They tell you: you have to see the dentist once a year. [\u0026hellip;] If you do, and the dentist gives you a good rating\u0026mdash;basically meaning you followed the rules\u0026mdash;it\u0026rsquo;s fully covered by the State. But if you miss a visit or don\u0026rsquo;t comply, well, that\u0026rsquo;s it [\u0026hellip;] it\u0026rsquo;s no longer covered, and you have to pay for everything yourself or through private insurance\u0026rdquo;\u003c/em\u003e D13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Doctors rarely refer children, even when they\u0026rsquo;ve got cavities all over their mouths. When kids have caries, they don\u0026rsquo;t care\u0026mdash;they check the tonsils, the adenoids, but they don\u0026rsquo;t look at the teeth. The teeth are ignored, and the kids end up with lots of cavities, abscesses\u0026hellip;\u0026rdquo;\u003c/em\u003e D05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eA/ Delegating preventive care\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;You can entrust that to personnel with intermediate qualifications. [\u0026hellip;] It would be much more efficient. You don\u0026rsquo;t call in a neurosurgeon to stitch up a thumb, do you? So, same thing\u0026mdash;you don\u0026rsquo;t necessarily need a pediatric dentist to give advice to a family.\u0026rdquo;\u003c/em\u003e D04\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eB/ Involving other professionals\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;There should be two types of support staff: [\u0026hellip;] someone like a hygienist, and also someone kind of between psychology and nutrition\u0026mdash;that would really be ideal.\u0026rdquo;\u003c/em\u003e D11\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;You can easily refer people to a nutritionist to help restore dietary balance\u0026mdash;I mean, there are plenty of levers available.\u0026rdquo;\u003c/em\u003e D12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe dentists who participated in the study reframed caries prevention as a broader, systemic issue involving multiple levels of the healthcare system. At the societal level, they criticized the omnipresence of sugar, which they saw as incompatible with the development of a true and global \u0026ldquo;prevention culture\u0026rdquo;. At the level of the healthcare system, they described an organization that remained structured around a curative approach to care, which hinders the implementation of preventive practices in professional settings. Finally, at the level of healthcare professionals, dentists expressed frustration over the lack of involvement of general practitioners and pediatricians in monitoring children\u0026rsquo;s oral health. In response to these systemic shortcomings, several solutions were proposed by participants to strengthen caries prevention in society: introducing educational interventions from the earliest months of a child\u0026rsquo;s life, organizing school-based prevention programs, and implementing collective prevention measures aimed at countering the influence of the sugar industry and encouraging regular follow-up among patients. Ultimately, they expressed a desire to reinforce interprofessional collaboration\u0026mdash;not only with physicians, but also with other paramedical or social professionals\u0026mdash;who could contribute to caries prevention or even take full responsibility for it.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e\u0026bull; Interpreting the Results Through the Health Stigma and discrimination Framework\u003c/h2\u003e\u003cp\u003eAs previously outlined in our study protocol (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), this section applies the Health Stigma and Discrimination Framework as a lens to synthesize and interpret both our findings and key insights from the existing literature. The framework offers a comprehensive, multi-level model for understanding how health-related stigma operates. It outlines the drivers and facilitators that initiate stigma, the processes through which individuals or groups become \"marked,\" and the various ways in which stigma is experienced and enacted (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). We argue that severe early childhood caries can be understood as a condition subject to stigma marking, similar to other health conditions previously analyzed through this framework (HIV, obesity, mental health...)\u003c/p\u003e\u003cp\u003eIn the context of early childhood caries, one of the primary stigma \u003cb\u003edrivers\u003c/b\u003e appears to be the widespread and strong belief that parents are individually responsible for neglecting their child\u0026rsquo;s oral health. This perception places durable emphasis on parental responsibility and portrays parents as the root cause of the condition. As a result, they are frequently associated with negative stereotypes of the \u0026ldquo;failing parent\u0026rdquo;, perceived as lacking knowledge, motivation, authority, and as poor role models. This judgment of parenting practices aligns with a substantial body of literature that similarly highlights the stigmatizing discourse surrounding parental blame in child oral healthcare (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe predominance of a biomedical and individualized approach to dental caries may act as a \u003cb\u003efacilitating factor\u003c/b\u003e in oral health-related stigma. Current prevention and care strategies are largely based on a risk factor model, with interventions primarily targeting families\u0026rsquo; lifestyles. While these approaches are undoubtedly important for understanding and managing dental caries, they often overlook the structural social determinants that underpin inequalities in oral health. This perspective, based on the implicit assumption that behaviors are freely chosen and therefore easily modifiable through patient education and information, overemphasizes individual responsibility while minimizing the influence of broader social, economic, and institutional conditions (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). It also tends to ignore the existence of a well-documented social gradient in oral health (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). In doing so, it contributes to reinforcing parental blame and moral judgment, thereby facilitating stigma. Yet, the work of social science researchers has shown that, from early childhood onward, individual behaviors are deeply shaped by the social environments in which people are born, grow, and live (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn our study, we observed that children with severe early childhood caries may also be subject to \u003cb\u003eintersecting forms of stigma\u003c/b\u003e, particularly related to their young age. Some dental professionals described treating very young children as challenging or even unpleasant, which may lead to practices that limit children's access to dental care, such as declining to treat them or offering fewer appointment options. While age does not appear to be a significant barrier to dental care in some countries (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), this form of discrimination has been reported in places such as France and Croatia, where 18 to 25% of general dentists do not accept children due to the perception that they are generally uncooperative and difficult to treat (\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Although it is true that managing some pediatric patients can be complex, the generalization of this perception to all children contributes to turning age itself into a stigmatizing factor.\u003c/p\u003e\u003cp\u003eThe findings of our study indicate that oral health-related stigma \u003cb\u003emanifests\u003c/b\u003e within the care setting through a weakened therapeutic relationship. While dental professionals frequently express a strong sense of empathy towards children, this was never extended to parents in our analysis. This lack of empathy may help explain why some practitioners adopt negatively framed preventive strategies toward these families. Such strategies often take the form of a paternalistic and top-down approach, accompanied by guilt-inducing communication, and in some cases, even verbal aggression or physical aggression in one case. These findings are highly consistent with existing literature on weight-related stigma. Several studies have shown that stigma scores tend to be higher when the condition is perceived as controllable by the individual (\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Conversely, when it is attributed to genetic or biological factors, stereotypes surrounding personal responsibility are weakened, leading to a reduction in weight-related stigma.\u003c/p\u003e\u003cp\u003eWhile our study focuses on the practices of dental professionals, the manifestations of stigma can also be explored through the lens of \u003cb\u003epatients\u0026rsquo; lived experiences\u003c/b\u003e. Little is known about how families affected by severe early childhood caries experience stigma firsthand. Patient perspectives on access to dental care and their experiences within dental settings remain underexplored. However, two qualitative studies report that some parents described guilt-inducing communication from dental professionals and expressed the fear of being reprimanded during medical appointments (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). These experiences highlight an important area for further investigation, as evidence from obesity-related research shows that similar interactions can directly contribute to decreased self-esteem, reduced motivation, and ultimately, avoidance of healthcare services (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eLike other authors (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), we postulate that manifestations of oral health-related stigma influence a range of \u003cb\u003eoutcomes\u003c/b\u003e for affected populations, including access to care, the acceptability of healthcare services, adherence to treatment, and delays in diagnosis and care. Over time, these consequences of stigma may lead to numerous negative \u003cb\u003eimpacts\u003c/b\u003e for children and families affected by poor oral health, such as reduced quality of life, experiences of bullying or teasing, lower self-esteem, academic difficulties, and social isolation (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). At a broader societal level, by sustaining and exacerbating health problems, the stigmatization of these patients could contribute to reinforcing and perpetuating social inequalities in health, by limiting access to care, worsening disadvantaged health trajectories, and maintaining lower social status among affected families.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e• Limitations:\u003c/h3\u003e\n\u003cp\u003eOne methodological limitation to consider in this study is the potential for social desirability bias. This bias is particularly relevant when participants are asked to discuss sensitive topics such as discrimination, which can lead to discomfort or self-censorship. It is therefore plausible that some respondents may have, consciously or unconsciously, polished their discourse to make it more socially acceptable. However, several measures were taken to minimize this risk (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). All interviews were conducted by a social psychologist (MV), who was external to the field of dentistry, rather than by GL, a pediatric dentist whose professional identity could be easily found online. The perception of the interviewer as outside the respondents\u0026rsquo; professional sphere likely encouraged greater openness. In addition, the topic was introduced in a deliberately broad and neutral manner, without judgment and with a genuine intention to understand their practices. Discrimination was not mentioned explicitly, and follow-up questions were carefully worded to avoid leading responses. Anonymity was guaranteed in the information sheet and consent form, helping to create a safe space for participants. Finally, we opted exclusively for individual interviews rather than focus groups to limit peer influence and reduce the social pressures.\u003c/p\u003e\u003cp\u003eAlthough Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e confirms a wide diversity of profiles among the dentists interviewed, it should be noted that many participants practice in private settings and group practices. This overrepresentation may represent a limitation, as it partially restricts the maximum variation principle. However, this distribution remains consistent with the national characteristics of the profession, with nearly 80% of dentists in France working in private practice and a strong trend toward professional grouping over the past decade (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Moreover, our sample shows substantial heterogeneity across other dimensions (age, gender, geographical location, type of patient population), which nonetheless helps ensure a plurality of perspectives and professional experiences within the corpus analyzed.\u003c/p\u003e\n\u003ch3\u003e• Areas for future research:\u003c/h3\u003e\n\u003cp\u003eResearch on oral health-related stigma is still in its early stages, and the field is only beginning to develop a coherent theoretical framework. The publication by Doughty et al. in 2023 marked an important milestone by proposing a first working definition of this phenomenon (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). In their narrative review, the authors emphasize that oral health-related stigma stems from societal perceptions of what constitutes good or poor oral health. These perceptions are often tied to moral judgments about personal neglect, social status, and failure to adhere to sociocultural norms of hygiene. Individuals with poor oral health may thus be seen as responsible for their condition and subjected to blame, mockery, or discrimination, whether in interpersonal interactions or within institutional settings. In this regard, our study aligns with this emerging theoretical framework by providing empirical evidence of differential treatment based on perceived oral health. More specifically, it is among the first to investigate how such perceptions and stereotypes are constructed and expressed by oral health professionals, particularly in relation to patients affected by severe dental caries. This work represents a necessary first step by helping to identify the underlying components of such stigma (drivers, facilitators, markers, and manifestations). However, further research is needed to complement this approach, particularly studies focused on patients' lived experiences and the impact of stigma on their health, well-being, and access to care. A promising avenue to deepen our findings would also be the development of standardized measurement tools to quantitatively assess stereotypes toward individuals with severe caries. Such instruments already exist in fields such as weight and mental health stigma (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), and could serve as useful tools for estimating the prevalence and intensity of these stereotypes within oral health settings.\u003c/p\u003e\u003cp\u003eAnother strength of our study is that it is, to our knowledge, the first to investigate oral health-related stigma in pediatric populations, approached through the lens of the family unit. As in other contexts, such as aging (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), our findings suggest that different forms of stigma can intersect (in this case, related to both age and oral health), generating distinct experiences of stigmatization and discrimination for affected families. These complex dynamics warrant further investigation, particularly through the theoretical framework of intersectionality. To date, oral health research has paid limited attention to how overlapping social identities (including gender, age, ethnicity, socio-economic status, etc.) shape the experience of stigma. In the case of families with children affected by severe dental caries, several stigma markers may converge: parents may be perceived as neglectful, children as uncooperative or difficult to treat, and these assumptions may also be entangled with social judgments related to poverty or cultural difference, reinforced by language barriers. An intersectional approach to oral health-related stigma would offer valuable insights into how these markers interact, leading to layered disadvantages for already vulnerable populations (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe findings of this qualitative study suggest that children with severe dental caries and their parents may experience a dual form of stigma. First, the children are often perceived as challenging or unpleasant to treat. Second, their oral condition tends to be associated with negative assumptions about parental neglect and sole responsibility for the disease. Such perceptions may compromise the quality of the patient\u0026ndash;provider relationship and create barriers to care. Considering the efforts to improve clinical practice and ensure more equitable access to oral healthcare, further investigation into these forms of discrimination is warranted, particularly through quantitative research and the application of social science frameworks.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003cp\u003e Ethical approval was obtained from the research ethics committee of the Department of Family Medicine at University Lyon (approval number: 2021-09-09-03).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eAuthors\u0026rsquo; information\u003c/h2\u003e\u003cp\u003eAt the time of the study, GL was a public health PhD student and worked as a lecturer in the pediatric dentist department at the University of Lyon 1. She was trained in qualitative methodology during her doctoral studies, and this project is her first qualitative research. MV is a social psychologist and was trained in qualitative methods during her graduate studies. She has served as principal investigator on several qualitative studies. MC holds a PhD in public health and is a member of the Department of General Practice at the University of Lyon 1. He has experience conducting qualitative research and has contributed to the publication of several qualitative studies. All other members of the research team have expertise either in pediatric dentistry or in qualitative research methods.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis work is supported by 2 grants, one from the French Ministry of Health [RESP-IR 2021, grant number: RESPIR-21-005] and another from the Hospices Civils de Lyon [Junior investigator award 2021].\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the design of the study. GL is the principal investigator, responsible for coordinating the study and analyzing the data. MV conducted all the dentists\u0026rsquo; interviews. The data analysis was carried out by GL and MV. MC acted as supervisor and oversaw the entire process. GL is the lead author of this manuscript, and all authors contributed to its review and approved the final version.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGBD 2017 Oral Disorders Collaborators, Bernabe E, Marcenes W, Hernandez CR, Bailey J, Abreu LG, et al. Global, Regional, and National Levels and Trends in Burden of Oral Conditions from 1990 to 2017: A Systematic Analysis for the Global Burden of Disease 2017 Study. J Dent Res. 2020;99(4):362\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKassebaum NJ, Bernab\u0026eacute; E, Dahiya M, Bhandari B, Murray CJL, Marcenes W. Global burden of untreated caries: a systematic review and metaregression. J Dent Res mai. 2015;94(5):650\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZaror C, Matamala-Santander A, Ferrer M, Rivera-Mendoza F, Espinoza-Espinoza G, Mart\u0026iacute;nez-Zapata M. Impact of early childhood caries on oral health-related quality of life: A systematic review and meta-analysis. Int J Dent Hyg. 2022;20(1):120\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNora \u0026Acirc;D, Soares FZM, Braga MM, Lenzi TL. Is Caries Associated with Negative Impact on Oral Health-Related Quality of Life of Pre-school Children? A Systematic Review and Meta-Analysis. AAPD. 2018;40(7):9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi Y, Wang W. Predicting Caries in Permanent Teeth from Caries in Primary Teeth: An Eight-year Cohort Study. 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L\u0026rsquo;activit\u0026eacute; p\u0026eacute;diatrique des chirurgiens-dentistes g\u0026eacute;n\u0026eacute;ralistes en France. Rev Francoph Odontol Pediatr. 2018;13(1):1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMuller-Bolla M, Clauss F, Davit-B\u0026eacute;al T, Mani\u0026egrave;re M, Sixou J, Vital S. Prise en charge bucco-dentaire des enfants et des adolescents. CDF. 2018;1806\u0026ndash;1807:1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eO\u0026rsquo;Keeffe M, Flint SW, Watts K, Rubino F. Knowledge gaps and weight stigma shape attitudes toward obesity. Lancet Diabetes Endocrinol 1 mai. 2020;8(5):363\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHilbert A. Weight Stigma Reduction and Genetic Determinism. PLoS ONE. 2016;11(9):e0162993.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJeong SH. 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Rethinking Oral Health in Aging: Ecosocial Theory and Intersectionality. J Dent Res juill. 2023;102(8):844\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSeehra J, Newton JT, DiBiase AT. Bullying in schoolchildren \u0026ndash; its relationship to dental appearance and psychosocial implications: an update for GDPs. Br Dent J mai. 2011;210(9):411\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBispo JP. Social desirability bias in qualitative health research. Rev Sa\u0026uacute;de P\u0026uacute;blica 18 nov. 2022;56:101.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBergeat M, Vergier N, Verger P. Quatre m\u0026eacute;decins g\u0026eacute;n\u0026eacute;ralistes sur dix exercent dans un cabinet pluriprofessionnel en 2022. DREE, Etudes et R\u0026eacute;sultats. 2022;(1244).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBacon J, Scheltema K, Robinson B. Fat phobia scale revisited: the short form. Int J Obes. 2001;25(2):252\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKassam A, Papish A, Modgill G, Patten S. The development and psychometric properties of a new scale to measure mental illness related stigma by health care providers: the Opening Minds Scale for Health Care Providers (OMS-HC). BMC Psychiatry. 2012;12:62.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eElaine Muirhead V, Milner A, Freeman R, Doughty J, Macdonald ME. What is intersectionality and why is it important in oral health research? Community Dent Oral Epidemiol. d\u0026eacute;c. 2020;48(6):464\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Dental caries, children, attitude of health personnel, social stigma, qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-7648443/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7648443/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Despite recommendations emphasizing individualized prevention and patient-centered communication, studies show that preventive care is often under-delivered in routine dental practice. Parents are sometimes identified by dentists as a major barrier to caries prevention, due to perceived lack of parenting skills. Existing literature suggests that negative stereotypes may influence the quality of care provided to these families. This study aims to explore health professionals’ perceptions of children with early childhood caries (ECC) and how these perceptions may shape clinical practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e: This qualitative study was based on semi-structured interviews conducted with French general dental practitioners, with thematic analysis of the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Interviews were conducted with a mixed sample of 15 general dental practitioners, (varying in age, gender, geographic location, practice setting, and the number of children treated per week). Thematic analysis identified four main themes: 1/ Parents portrayed as guilty of neglecting their child’s oral health 2/ Ambivalent emotional perceptions of the child with severe dental caries 3/ Behavior change perceived as a major challenge 4/ Caries prevention perceived as a public health issue with systemic causes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: The findings of this qualitative study suggest that children with severe dental caries and their parents may be exposed to a dual form of stigma. On one hand, children are perceived as too difficult or unpleasant to treat; on the other, their oral condition is often associated with stereotypes of parental neglect and exclusive responsibility for illness. These perceptions may undermine the quality of the patient–provider relationship and act as a barrier to accessing care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration number : \u003c/strong\u003eNCT05284279, registered on 2022-03-17\u003c/p\u003e","manuscriptTitle":"Are Children with Early Childhood Caries and Their Families Stigmatized? Perceptions and Practices of Dental Professionals: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-08 17:58:56","doi":"10.21203/rs.3.rs-7648443/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b4daf4eb-c279-4661-b497-f65f6b9c49ca","owner":[],"postedDate":"October 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-31T12:54:03+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-08 17:58:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7648443","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7648443","identity":"rs-7648443","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}