In the present study, parental knowledge regarding children's oral health-related habits, and their preferences regarding treatment of primary teeth were assessed in an attempt to provide insights into the factors affecting parental decision-making. Results showed increased knowledge of oral health and a high acceptance of the importance of primary teeth, although oral hygiene and dietary habits were not ideal. Regarding dental treatment, in most cases parents would accept the clinician’s recommendations, while the duration of the appointment, the tooth exfoliation time, cost of the treatment, and aesthetics were the factors directly affecting their final decision.

From the study sample, almost half of the children brushed their teeth twice daily with a manual toothbrush and fluoridated toothpaste. In a previous Greek study of preschool children, it was reported that 51% of the children brushed only once daily and 48% brushed alone (Agouropoulos et al. 2013). Supervision of tooth brushing was reported in only 21% of the present study sample, with 20% of children younger than 6.5 years brushing their teeth alone. This might mean that parents in Greece may not consider or insist on supervising their children during tooth brushing. Data from other countries present great variation with low (Nagaveni et al. 2011) or high percentages (Al-Batayneh et al. 2019) for twice daily brushing, while supervised toothbrushing has been reported as relatively high (Gibi et al. 2020; Al-Batayneh et al. 2019).

These differences can be attributed to the variability of the samples and the specific characteristics of the participants. More specifically, Nagaveni et al. (2011) did not report parental characteristics or the age of the children for whom the answers were given, which, as mentioned above, may directly influence the children's habits and therefore reported answers. Al-Batayneh et al. (2019) reported that three-quarters of children brush twice daily, with the high percentage being probably attributed to the higher education level overall of the majority of participants. Parental education level can affect their perception of oral hygiene and consequently children's performance of oral hygiene.

Regarding dietary habits, results from the present study reported that 38% of children consumed sugary snacks on a daily basis, which is lower than the corresponding percentages reported previously for Greece. Kavvadia et al. (2012), found that 83% of children ate more than three sugary snacks per day. The difference can be probably attributed to the difference in age groups of the two studies. In children, for whom decisions are not independent, principal risk factors for caries development, such as diet and oral hygiene, are determined by factors related to family values and lifestyles. These factors in turn are related to parental culture and socio-economic background. Parental education level has been found to be negatively correlated with the consumption of sugary foods (Flores-Barrantes et al. 2022). This was confirmed in our study, as children of parents with primary education had a higher intake of sugary foods compared to their counterparts of higher education.

Most of the respondents considered primary teeth to be very important (72%), with corresponding results from the literature being controversial. Some studies reported similar (Vittoba Setty and Srinivasan 2016; Hussein et al. 2013) and others different results (Al-Batayneh et al. 2019; Nagaveni et al. 2011). Cultural differences, personal beliefs and socioeconomic background are factors that can directly affect this perception and justify the reported variance (Casamassimo 2003). The high rate of acknowledging the importance of primary teeth can be underlined by the increased percentage of responders identifying the importance of the connection between oral and general health, which has been previously documented in Greek parents (Agouropoulos 2012).

The majority of the participants reported that would accept the dentist’s recommendation for the proposed treatment plan, which is in accordance with the literature where it is widely reported that patients prefer the final decision to be made by the dentist (Murdoch et al. 2023; Benecke et al. 2020; Al-Batayneh et al. 2019; Popoola et al. 2013; Tickle et al. 2003; Adewumi et al. 2001). Lack of clinical knowledge makes patients and parents feel uncertain about their decisions, and they prefer to share the responsibility with their doctor (Alsulamy et al. 2021; Schooten et al. 2003), although patient participation in the decision-making process is of great importance for the outcome of the treatment plan. Knowledge of parental concerns and priorities regarding dental treatment and their perception of various aspects of health, helps clinicians to focus on patients’ needs and provide them with adequate information. This is in accordance with the widely accepted approach of shared decision-making in the medical field (Alsulamy et al. 2021).

According to the results of this study, parents prioritize their child's cooperation and potential sense of pain over cost when choosing a treatment option. The School of Dentistry (NKUA) provides dental care to all children at a low cost, making it accessible to families of all socioeconomic backgrounds. This may explain why cost wasn't considered as such an important factor. The results might have been different if the sample had originated from private dental practices. This can be also highlighted in countries where public or private insurances cover part or the total cost of treatment, and therefore patients might choose treatments beyond defined needs (Felgner and Henschke 2023). Previous studies have reported cost, long duration and fear as the main factors parents consider before deciding upon treatment, with some reporting on the effect in regard to prevention and caries treatment (Felgner et al. 2022; Schwendicke and Göstemeyer 2016).

The vast majority of the parents reported that they would have an asymptomatic tooth restored, even if there was no obvious cavity or pain, which is consistent with the high recognition of the importance of primary teeth recorded in the present study. This is in accordance with the study by Al-Batayneh et al. (2019) but different when compared with the results of Sheetal et al. (2022), where a high percentage of parents preferred to deny treatment or wait until pain symptoms appeared. Tickle et al. (2003) reported that nearly one-third of parents chose to monitor and not treat an asymptomatic carious tooth. This non-interventional approach for the treatment of carious primary teeth either indicates a tendency for a reluctance to intervene for "minor symptomless elements" or that dentists may be adopting a more conservative approach to care, with parents accepting this philosophy. The authors clearly stated that neither socio-economic status, reported attendance patterns nor the children’s anxiety levels seemed to significantly affect the decision on treatment. It is worth mentioning that in the same study parents whose children had previously undergone dental treatment, were more likely to express a preference for restorative care.

In the case of the symptomatic primary tooth, although most of the parents would seek treatment, there were four who would not. This can only be attributed to the low socioeconomic status related to these cases. An even higher percentage of refusal (16,8%) has been reported previously in Northern Jordan, where more than half of parents stated that as primary teeth will be replaced there is no need to treat them (Al-Batayneh et al. 2019). Pain is one of the factors that influence oral health-related quality of life in children (Clementino et al. 2015) and it is surprising that the parents would leave painful teeth untreated.

Regarding treatment options, although there were no statistically significant differences according to parental and children’s characteristics, there was a slight preference for restoration compared to extraction. Results in the literature are controversial, with studies indicating a clear preference for extraction over more conservative and less painful procedures due to the immediate pain relief (Gibi et al. 2020; Al-Batayneh et al. 2019; Bozorgmehr et al. 2013; Thakare et al. 2012). Extractions were more likely to be chosen by parents whose children were irregular attenders and who present to the dentist only when in pain, attitudes correlated to low socioeconomic backgrounds (Tickle et al. 2003).

Finally, acceptance of SDF applications reached 56% while in most studies this exceeds 60% (Wajahat et al. 2022; Kumar et al. 2019; Crystal et al. 2017). This could be attributed to the fact that, in Greece, parents and clinicians have limited knowledge and experience in the use of the material. Although very few parents prioritized esthetics when it comes to their children's treatment, it is interesting that 43% preferred a "white filling" probably because of the color after SDF application. Parents of boys were significantly more positive for SDF, which has also been reported previously (Asif and Gurunathan 2020) and may reflect the greater concern of parents about appearance in girls than in boys. It should be noted though, that the results might have been different if the option of “smart technique” had been introduced.

Current dental public systems inevitably face the great problem of contemporary lifestyles that affect oral health and alleviation of dental problem through the unnecessary removal of tooth structure is inevitable. The restorative approach for dental caries management is failing to improve oral health outcomes for many patients. Lately, clinicians endeavor to implement minimally invasive techniques which continue to grow despite some significant challenges that they present they continue to grow. This is well supported by the overall acceptance of parents/guardians, although there is an urgent need to undertake research to assess the cost-effectiveness of this approach and their continual application by clinicians.

The high acceptance of these techniques can be utilized for the planning of new policies towards their adoption them for controlling caries progression. These techniques which are easily applicable and do not require special equipment or training might be the basis for supporting efficacious prevention and early intervention of the disease process. Given that dental caries despite being a highly prevalent disease is now considered an ecological and non-communicable disease, these techniques may find great applicability in the public sector.