Table 2.

Themes and data categorization

Themes	Subthemes	Definition	Exemplary quotations
Predisposing oral dysfunction	Eating problems	Difficulty in chewing and swallowing	“He could swallow it, but only shallowly and then only once or twice, there was still a lot of food in his mouth. In addition, there remained the problem with choking.” (FG 1-3) “Even with soft foods like bananas, he doesn’t chew, rather he sucks it in his mouth before swallowing. Chewing is virtually impossible.” (FG 2-2)
	Abnormal diet and increased caries risk	Food impaction	“What I’m most concerned about is that despite cutting food into a small size for her, the food becomes stuck between her teeth. We can floss or pick the teeth, but, she cannot tell us what’s bothering her. The food will be there for days; and eventually she will be ended up having cavities.” (FG 2-3)
		Sugar uptake	“These kids are mostly on a liquid diet and I’m afraid that it is high in sugar.” (FG 2-4)
	Deteriorated deciduous dentition	Congenital defects	“When her teeth first came out, they were all black and rotten. I’ve heard that it might be something to do with the medicine she was taking at that time.” (FG 2-3)
		Baby bottle tooth decay	“She started having regular meals when she turned four. Before then, she was biting the milk bottle all the time.” (Int 1)
Home care challenges	Physical adversities	Rinsing and spitting	“When brushing teeth, it is natural that we hold the water in our mouth, but, for her, it’s not easy. She just swallows all of the toothpaste foam.” (FG 1-2) “When I finish his brushing, the toothpaste foam is completely gone; he ate it all.” (FG 1-3)
	Behavioral rejection	Dislike of untasteful objects	“The bristles go into the mouth and touch it where she doesn’t want to be touched. She has never got used to the feeling, even with brushes having thin, fine bristles.” (FG 1-4) “There may be differences as to the degree, but the truth is they all hate the tooth brush.” (FG 1-1) “Once I used a toothpaste which was not what I usually did, and he threw up all he had eaten… Kids on a liquid diet have a weak stomach.” (FG 2-2)
	Deficit of self-care	Caregiver responsibility	“Tooth brushing is much harder than washing his body. Giving him a bath is way easier.” (FG 1-3) “We let him brush by himself first, then to ensure that all spots are reached. We go over it again. He can’t do it properly—just a few quick swipes…” (Int 5) “I imagine it would be difficult for volunteer workers or school faculty to master it (toothbrushing), because our family finds it hard as well… I usually do it because his father feels pressured with me watching next to him.” (FG 1-1)
Professional treatment barriers	Cognitive impairment	Communicative limitation	“Because of the medication, he is insensitive to any types of pain and, of course when it does hurt, he doesn’t cry about it, just bear it. The fact that he can’t express what he’s feeling…, well, as a parent, I’m extremely sensitive about it.” (FG 2-2)
		Lack of understanding	“At the dental office, he saw many sharp looking instruments, and suddenly he was afraid that he’s going to get pinched and freaked out. We had to return home without doing anything.” (Int 5)
	Fear and resistance	Noise, smell, needles, mouth opening, physical restraint	“The sound of scratching is the most terrifying. Even me, I’m scared of it.” (Int 4) “The thought of opening his mouth and being tied down by force. Not to mention the frightening sounds.” (FG 2-1) “They hate opening their mouths. When they walk in the office, the first thing they see is people lying down, all with mouths gaping wide.” (FG 2-3) “An enormous fear of needles…, when he had to get shots, ah… I could write a book about it.” (Int 5)
	Rejection by and unwillingness of professionals	Attitude and rejection	“A volunteer doctor was there, he was somewhat disrespectful, played fast and loose, I didn’t want to go there again… We are extremely conscious about how our children are treated.” (FG 1-1) “(at the clinic) she behaved in an uncontrollable way, and the doctor refused to…” (FG 1-3)
		Concerns about clinical conditions	“Most local clinics cannot possibly manage these children.” (Int 2) “The staff were extremely anxious and recommended that we seek treatment at some other place.” (FG 2-4)
	Financial burdens	Cost	“Costs are the main issue. Most mothers are concerned and asking me about it” (Int 1)
			“(In dental care) the most desperate thing is… money.” (Int #4)
		Insurance coverage	“What I wish for most, … is financial support, and better insurance coverage. Then, the kids can come seek treatment as soon as they show the first sign of cavities” (Int 6)
	Emotional aspects of caregivers	Awareness	“Many children don’t visit the dental clinic at all. Their mothers take a glimpse at their teeth, and believe the teeth are fine, then the children don’t see the dentist.” (FG 2-4)
		Empathy	“There are kids who intensely, aggressively show signs of their dislike… the mothers are uncomfortable in such situations and feeling apprehensive about it…, I have never had such a heavy heart as when going to the dentist with him” (Int 3)