Parents in Brazil accept silver diamine fluoride staining on back teeth

Parents attending a paediatric dentistry clinic in Brasília, Brazil, were far more willing to accept the permanent black staining caused by silver diamine fluoride when it affected back teeth than front teeth, according to a cross-sectional study published on 28 September 2026 in the journal Discover Pediatrics. Of 103 parents or legal guardians who took part, 62.1% rated staining on posterior primary teeth as acceptable, while only 27.2% accepted staining on anterior teeth. The paired difference was statistically significant, with a McNemar chi-square value of 34.11 and a p value below 0.001.

The study was led by Brenda de Castro Novaes, with Ingrid Quaresma Diniz de Queiroz, José Carlos Pettorossi Imparato and Érica Torres de Almeida Piovesan as co-authors. It was conducted between January and May 2025 at a postgraduate paediatric dentistry clinic of a dental school in Brasília, a clinic that provides dental care to children from infancy through 14 years of age. Participants were eligible if their child had previous caries experience, if they could understand Portuguese, and if they voluntarily agreed to take part. All eligible parents or guardians attending the clinic during the study period were invited consecutively, and recruitment continued until 103 complete interviews had been obtained. The number of individuals who declined participation was not formally recorded, and no financial compensation was offered.

Silver diamine fluoride is a colourless alkaline solution containing silver and fluoride ions stabilised by ammonia, commonly used at a concentration of 38%. Its caries-arresting action has been attributed to the antibacterial activity of silver ions, the inhibition of demineralisation, the promotion of enamel and dentine remineralisation, and the protection of dentine collagen from degradation. Because its application is simple and non-invasive, it is considered a useful option for children and for settings where conventional restorative care may be difficult to provide. The trade-off is aesthetic: the agent causes permanent black staining of carious dental tissues through the precipitation of silver-containing compounds, and this discolouration may negatively affect parental acceptance, particularly when anterior teeth are involved.

Each participant received a standardised explanation in Portuguese before the acceptance questions were administered. They were told that dental caries is caused by microorganisms that produce acids, that a liquid could be applied to a carious lesion to prevent it from progressing, and that the treated lesion would become darker, with the darkening indicating that the treatment had been effective. Participants then evaluated printed reproductions of the complete photographic set published with the original questionnaire by Crystal and colleagues, showing primary anterior and posterior teeth before and after SDF application. The post-treatment photographs showed marked black staining of decalcified enamel and carious dentine displayed alongside photographs of the same teeth before treatment, and the same photographs and presentation format were used for everyone.

Acceptability was rated on a four-point scale ranging from unacceptable to acceptable, with responses of unacceptable and somewhat unacceptable classified as unacceptable and responses of somewhat acceptable and acceptable classified as acceptable. Because each participant evaluated both tooth locations, the paired binary responses were compared using McNemar’s test. Acceptance of staining in anterior teeth was treated as the primary outcome because of the greater visibility and aesthetic relevance of front teeth, while acceptance of posterior tooth staining was a secondary outcome. In total, 72.8% of participants considered staining in anterior teeth unacceptable.

The researchers also fitted an exploratory multivariable binary logistic regression model to examine whether educational level and monthly family income were associated with acceptance of anterior tooth staining. Participants with incomplete higher education had significantly lower odds of accepting anterior staining than those with postgraduate education, with an odds ratio of 0.04 and a 95% confidence interval of 0.003 to 0.67 (p = 0.024). Participants with secondary education or less also showed lower odds, but the association did not reach statistical significance (OR = 0.16; 95% CI 0.02–1.16; p = 0.070), and participants with completed higher education did not differ from the postgraduate reference group (OR = 0.91; 95% CI 0.19–4.44; p = 0.909). No monthly family income category was significantly associated with acceptance. Although participants earning R$2000–2999 had higher estimated odds than those earning R$7000 or more, the confidence interval was wide and included the null value (OR = 6.73; 95% CI 0.95–47.53; p = 0.056).

The authors urge caution in interpreting the educational finding. Only one participant in the incomplete higher education category accepted staining in anterior teeth, producing a small odds ratio and a wide confidence interval, and no consistent educational gradient was observed across the categories. The overall likelihood-ratio test for the model was statistically significant (chi-square of 14.76 with seven degrees of freedom; p = 0.039), but several estimates had wide confidence intervals reflecting the limited number of participants who accepted anterior staining and sparse observations in some categories. Because only 28 participants considered anterior tooth staining acceptable, the regression analysis was considered exploratory, and the association with incomplete higher education should be regarded as hypothesis-generating rather than confirmatory.

The sample was predominantly composed of mothers, who made up 57.3% of respondents, followed by fathers at 25.2% and other legal guardians at 17.5%. The most frequent age group was 31 to 40 years, accounting for 39.8% of participants. Most participants lived in areas surrounding Brasília (79.6%), while 14.6% lived in the central Plano Piloto district and 5.8% lived in rural areas. Regarding education, 43.7% had completed secondary education or less, 13.6% had incomplete higher education, and 42.7% had completed higher education or postgraduate studies. Monthly family income varied across categories, with 67.0% of participants reporting an income of R$3000 or more.

The study protocol was approved by the Research Ethics Committee of the São Leopoldo Mandic Faculty and conducted in accordance with the Declaration of Helsinki and its later amendments, with written informed consent obtained from all participants. The questionnaire, adapted from the instrument developed by Crystal and colleagues, was translated into Portuguese and reviewed by a second paediatric dentist for conceptual equivalence, but it was not subjected to formal psychometric validation and no pilot study was conducted. The recruitment target was based on the a priori sample size calculation reported in the original photographic study, which indicated that at least 94 participants were required, rather than on an independent calculation for the outcomes examined here.

Several further limitations shape how the findings should be read. Participants were recruited from a single postgraduate paediatric dentistry clinic, which may limit generalisability to other clinical settings and regions of Brazil. Aesthetic perception was evaluated using standardised photographs rather than actual treatment decisions, and stated acceptance may not fully correspond to the choices parents make when a child requires treatment. The individual ages of the children were not recorded, so parental perceptions may have varied with the child’s age, dentition stage, treatment needs, previous dental experience and ability to cooperate with conventional restorative procedures. Previous knowledge of SDF and prior exposure to the treatment were not assessed. The authors note that acceptance may depend on clinical circumstances: parents who initially consider staining unacceptable may reconsider when conventional restorative care is difficult, when the child is unable to cooperate, or when more advanced behavioural or pharmacological management would otherwise be required. They conclude that clinicians should clearly explain before application that SDF causes permanent dark staining of carious tissue, likely to be more noticeable in anterior teeth, and that representative clinical photographs, individualised communication and shared decision-making are important when SDF is considered for paediatric caries management.

Subject of Research: Parental acceptance of silver diamine fluoride staining on anterior and posterior primary teeth in Brazil

Article Title: Parental acceptance of silver diamine fluoride staining in anterior and posterior teeth in Brazil

Article References: de Castro Novaes, B., de Queiroz, I. Q. D., Imparato, J. C. P., & de Almeida Piovesan, É. T. (2026). Parental acceptance of silver diamine fluoride staining in anterior and posterior teeth in Brazil. Discover Pediatrics, 1(1), Article 7. https://doi.org/10.1007/s44571-026-00008-2

Image Credits: AI Generated

DOI: 10.1007/s44571-026-00008-2

Keywords: silver diamine fluoride, dental caries, parental acceptance, primary teeth, tooth staining, paediatric dentistry, Brasília, cross-sectional study, aesthetic perception, shared decision-making, oral health, caries management