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Mediating effect of eating pattern on the relationship between television

exposure and caries in children

Article in Brazilian Oral Research · July 2023

DOI: 10.1590/1807-3107bor-2023.vol37.0075

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 Original Research
Paediatric Dentistry

Mediating effect of eating pattern on

the relationship between television
exposure and caries in children

Ayah Qassem SHQAIR(a) Abstract: Behavioral characteristics may also take part in the etiology
Matheus dos Santos FERNANDEZ(b)
of dental caries. Sedentary behavior, especially watching television, is
Francine dos Santos COSTA(c)
Karen JANSEN(d) associated with increased intake of foods high in fat or free sugar, which
Janaína Vieira dos Santos MOTTA(e) could influence the occurrence of dental caries. The aim of this study
Ricardo Azevedo da SILVA(d) was to assess the mediating effect of eating pattern on the relationship
Vanessa Polina da COSTA(c)
between television exposure time and the presence of dental caries in
Marília Leão GOETTEMS(c)
children. A cross-sectional study was conducted with a representative
sample of 580 parent-child dyads with children aged 7 to 8 years in
(a)
Arab American University, Department of
Dental Sciences, Jenin, Palestine. 20 public schools in Pelotas, Brazil. Parents or legal guardians were
interviewed and provided information on demographic/socioeconomic
(b)
Universidade Federal de Pelotas – UFPel,
School of Dentistry, Pelotas, RS, Brazil. data, children’s daily television exposure time, and answered the
Biological Rhythms Interview for Assessment in Neuropsychiatry for
(c)
Universidade Federal de Pelotas – UFPel,
Graduate Program in Dentistry, Pelotas, Kids (BRIAN-K-eating pattern domain). Caries was evaluated through
RS, Brazil. clinical examination. The mediating effect of eating pattern on the
(d)
Universidade Católica de Pelotas – UCPEL, relationship between television exposure and presence of dental caries
Graduate Program in Health and Behavior, was estimated using the parametric g-formula. Prevalence of dental
Pelotas, RS, Brazil. caries was 63%, and 22% of children watched TV 4 or more hours
(e)
Universidade Federal de Pelotas – UFPel, per day. Television exposure had no direct effect on the dental caries
Graduate Program in Epidemiology, Pelotas, experience [odds ratio (OR): 1.05 (95% confidence interval (95%CI):
RS, Brazil.
0.92–1.19)]. Nevertheless, difficulty maintaining regular eating pattern
mediated the natural indirect effect of television exposure time (≥ 4
Declaration of Interests: The authors
hours/day) on dental caries experience [OR: 1.07 (95%CI): 1.01–1.14)]. The
certify that they have no commercial or
associative interest that represents a conflict results of this study confirm the indirect pathway between television
of interest in connection with the manuscript. viewing and dental caries and the role of disordered eating patterns in
this association.

Corresponding Author:
Keywords: Cross-Sectional Studies; Child; Television; Diet; Dental
Marília Leão Goettems Caries.
E-mail: [email protected]

Introduction
https://doi.org/10.1590/1807-3107bor-2023.vol37.0075
Dental caries is the most common non-communicable disease and
is considered an international public health challenge, especially
in children.1 The prevalence of caries in deciduous and permanent
teeth in children was estimated to be 46.2% and 53.8%, respectively.2
Submitted: May 26, 2022
Consequences of the disease can include poor food intake, deficient
Accepted for publication: February 27, 2023
Last revision: April 13, 2023 school performance, and presence of mental health disorders, which
can affect the quality of life of children and their families. 3 Caries

Braz. Oral Res. 2023:37:e075 1

 Mediating effect of eating pattern on the relationship between television exposure and caries in children

originates from the complex interaction of socio- biological rhythm.15 Recently, an instrument to
economic risk factors (e.g., low parental educational measure the degree of difficulty and maintenance of
level and low household income) with low access the biological rhythm of circadian system, including
to and low use of preventive health services, which eating patterns, was validated for Brazilian children.
increase the likelihood of risky behaviors such as The eating domain of the Biological Rhythm
high consumption of cariogenic foods and irregular Interview of Assessment in Neuropsychiatry
oral hygiene.4 for Kids (BRIAN-K) identifies the disruption of
The increasing consumption of cariogenic foods children’s eating patterns considering their difficulty
(i.e., those rich in fermentable carbohydrates, such in maintaining mealtimes, maintaining the same
as ultra-processed foods – UPF), in particular, is amount of food eaten regularly, and their difficulty
a well-established contributing factor on caries to consume moderately stimulating foods or sweets.16
development in children. 5 This consumption So far, few studies have verified the association
pattern frequently exposes teeth to an acidic between television viewing and dental caries,11 and
plaque environment for extended periods of time they have mainly examined the effect of food intake
, which promotes enamel demineralization and aspects in this relationship.17,18 Silva et al.17 have
causes dental caries.6 Indeed, a recent meta-analysis investigated the role of cariogenic food intake while
study concluded that children and adolescents who watching television on caries experience in Brazilian
consume UPF foods (e.g., snacks, fast foods, junk children aged 10 to 12 years. The authors observed
foods, sugar-sweetened beverages, sugary cereals, that children who consume cariogenic foods while
chocolate, and others) have a higher probability of watching television and those who are exposed to
having their teeth affected by caries.7 In childhood, television for prolonged periods of the day were more
UPF consumption during television viewing likely to have dental caries lesions than those who
is common, which can alter energy intake by do not ingest these foods and watch television daily
delaying satiation and reducing satiety signals from for a shorter period (< 90 minutes/day).17
previously consumed foods. This relationship can Although these epidemiological findings
be explained by children’s exposure to television contribute to the understanding of the multifactorial
advertisements for unhealthy foods high saturated etiology of caries, the interpretation and analytical
fats, trans fat, and free sugars, which may increase approach do not usually imply the investigation of
their cravings for these products.8.9 a causal effect. The G-computation is one approach
Therefore, it is suggested that dietary changes to causal-effect estimation. The parameters in a
related to sedentary habits, such as watching G-formulation approach are estimated similarly to a
television, may act as modifying factors in the perfectly randomized controlled trial, under certain
development of dental caries.10 This could be due assumptions that allow for causal interpretation.
to the influence of this sedentary activity on the The G-computation procedure has some advantages
dietary habits of children during this period, over traditional regression analysis, including the
which may favor the absence of a regular eating decoupling of confounding adjustment and effect
pattern regarding frequency, quality, and quantity estimation, which can provide an explanation
of meals.9,11 Eating patten is a broad term that for the mechanisms underlying the association
encompasses food choices and motives, feeding between an exposure of interest (e.g., television
practices, dieting behaviors, and eating-related exposure) and a specified outcome (e.g., dental
problems.12 Within the context of behavioral caries in children), considering a mediator (e.g.,
medicine, research on diet practices focuses on eating pattern).19 Therefore, this study investigated
the impact of promoting healthy eating patterns the mediating effect of eating pattern on the
on the management and prevention of dental (e.g., relationship between television exposure and dental
dental caries) and medical (e.g., obesity and diabetes) caries in children using the parametric g-formula
conditions,13,14 as well as seeks the relationship with mediation analysis.

2 Braz. Oral Res. 2023:37:e075

 Shqair AQ, Fernandez MS, Costa FS, Jansen K, Motta JVS, Silva RA, et al.

Methodology the contact details of their respective parents/

guardians. Firstly, all parents/guardians were
Study design contacted via telephone and home visits were
This cross-sectional study was performed with scheduled. In the meetings, the researchers presented
school children aged 7 to 8 years in Pelotas, Rio the objective and methodology of the study and
Grande do Sul, Brazil. The report of this study was requested authorization to include the children and
performed according to the guidelines of the the family in the sample. Subsequently, the children
Strengthening the Reporting of Observational Studies were invited to participate and, upon acceptance,
in Epidemiology checklist. child-parent dyads were considered for inclusion
in the study.
Ethical aspects Since the final sample comprised 580 children
Ethical approval for this study was obtained from and considering a prevalence of caries of 62% in
the Human Research Ethics Committee of the Catholic the unexposed group (< 4 hours per day/TV), the
University of Pelotas (UCPel) (#843526). All parents/ study achieved a power of 80% to detect a risk ratio
caregivers also received an information letter and of 1.20 or greater as significant, with a 95% level
signed written informed consent, authorizing their of confidence.
children’s participation in the study. Children were
asked for their consent to participate in the study. Study logistics and data collection
Initially, the researchers contacted school officials
Sample and, with the authorization of the institutions,
Th is st udy is part of a mult idiscipli nar y requested that an informative booklet be sent to
e pide m iolog ic a l s u r ve y e nt it le d “He a lt hy the children to give to their parents/guardians. The
Childhood in Context”, which evaluated children booklet contained information about the general
enrolled in public schools in Pelotas, Brazil. objective and execution of the project, as well
More information can be found elsewhere. The as a detachable section with blanks for parents/
municipality is in the extreme south of Brazil and guardians to indicate their interest in participating
has approximately 344,385 inhabitants. According in the research and to provide their telephone
to the latest government data, the Municipal number and current home address; the detachable
Human Development Index of Pelotas was 0.739 section was to be given to the teacher in charge after
(2022), the Gross Domestic Product per capita was completion. Subsequently, all parents/guardians
R$25,884.35 Brazilian Reais (2022) (U$D 4,961.54 were contacted by telephone and an in-person
- converted on 26 December 2022), and the Gini meeting at the family home was scheduled. In case
Index was 0.5596 (2010). of non-response during the day of data collection,
The probability sampling method was used to another attempt was made before excluding the
select the schools. The Municipal Secretariat of household/family. At the home meeting, all the
Education of Pelotas provided a list with the location children’s parents/guardians were again briefed
and contact information of all primary schools of on the objectives of the study and those who
the public education network and authorized the agreed to participate completed the consent form.
participation of the units in the research. All 40 Data collection started in August (2015) and was
institutions described in the list were contacted completed in November (2016), respecting the
and invited to participate in the study (acceptance annual school calendar, which is divided into two
rate: 100%). The public schools were coded (1-40), semesters (March-June; August-November). The
and a total of 20 institutions were randomly selected protocol of this study was not published in part
through an online tool (www.randomizer.org). or in full prior to data collection.
The institutions provided a list identifying all 7- The interviews with parents/guardians were
and 8-year-old children enrolled in grade 3 and carried out in the children’s home by a team of

Braz. Oral Res. 2023:37:e075 3

 Mediating effect of eating pattern on the relationship between television exposure and caries in children

interviewers composed of psychology students, completed years of study of the participants (up
while the clinical examination of the children was to 11 years; 12 years or more).
carried out in the schools by a previously trained Parents/guardians were asked to indicate the
and calibrated graduate student in Paediatric child’s total number of hours per day of television
Dentistry (UFPel). The psychology undergraduate viewing on weekdays (5/7) and weekends (2/7).
students were trained in two stages: a) theoretical: According to the methodology adopted in previous
presentation and interpretation of all items of the studies, the weighted mean number of hours of
research questionnaire; b) practical: application of television watching per week was calculated as
the questionnaire in the pilot study. The training follows: [(hours of television on weekdays × 5) +
included classes on psychopathology, how to (hours of television on weekend days × 2)] / 7].21
conduct clinical interview, and application of the Self-report methods of quantifying screen time have
other instruments. In addition to applying the been shown to have acceptable reliability and validity
instruments during training, the students applied in children.22 For descriptive statistics, television
the instruments in the pilot study, doubts were viewing time was dichotomized based on the cutoff
discussed, and then we started data collection. point in the average number of hours of television
The pilot study was carried out in two schools that exposure,21 classifying the sample into children with
were not selected for the study. Furthermore, a low and with high exposure time (“low”: < 4 hours
calibration was performed comparing the results of per day; “high”: ≥ 4 hours per day).
the examination of 15 children with those of a gold The BRIAN-K was used to measure the degree
standard examiner (PhD in Paediatric Dentistry). of difficulty maintaining the biological rhythm.16
Inter-examiner agreement with the gold standard BRIAN-K consists of 20 items, of which 17 were
examiner was high for dental caries (kappa test = added to generate a quantitative measure, with
0.80; 95%CI: 0.69–0.86). higher scores indicating greater biological rhythm
disruption. The final score can also be divided into
Non-clinical data collection four domains: sleep, social rhythm, eating pattern,
The following sociodemographic and economic and overall activities. In the present study, only the
variables were collected: sex (female; male), family eating pattern domain (items 14 to 17) was used. Items
socioeconomic status, and parents/guardians’ on the subscale assess how difficult is for the child
education (in complete years). Socioeconomic to maintain mealtimes (breakfast, lunch, snack, and
status was assessed using the National Economic dinner), difficulty in making all meals (breakfast,
Indicator, which is based on the accumulation lunch, snack, and dinner); difficulty to maintain the
of material goods and the schooling of the head same amount of food eaten regularly, and difficulty
of the household.20 Family socioeconomic status to consume moderately stimulants (such as chocolate
was based on cut-off points in the sample tertiles, and cola flavored soda) or sweets. The score ranges
classifying families as lower, middle, and upper from 0 to 3 on a Likert scale (0 = not at all; 1 = just a
socioeconomic status; in this study, families were little; 2 = quite a bit; and 3 = very much); scores for
identified as lower/middle or upper socioeconomic the global BRIAN-K scale and eating pattern domain
status. Initially, caregiver education was obtained range from 0 to 51 and 0 to 12, respectively - higher
through a question about the number of years scores indicating greater difficulty in maintaining
studied during elementary and high school and a regular pattern.16
during college and/or graduate school. The number
of years of study completed was calculated from Clinical data collection
the sum of the values reported by the participants The children’s Body Mass Index (BMI) was
at each educational level. For statistical analysis obtained using the World Health Organization
purposes, educational level was dichotomized (WHO) formula [weight (kg)/height2 (m)]. Children
based on the cut-off point in the mean number of were weighed barefoot, standing erect, facing the

4 Braz. Oral Res. 2023:37:e075

 Shqair AQ, Fernandez MS, Costa FS, Jansen K, Motta JVS, Silva RA, et al.

mechanical scale, with arms stretched and feet apart. author ([email protected]), according
The mechanical platform scale has a precision of 0.1 to FAIR Data Principles (www.force11.org/group/
grams and was placed on a flat, firm and smooth fairgroup/fairprinciples).
surface. Height was measured using a stadiometer Dental caries experience was the main outcome
attached to the scale. To do so, the children stood of this study. The following exposure variables were
barefoot, with their backs to the scale, arms stretched, included: ‘sex’, ‘socioeconomic status’, ‘parents/
and feet together. Both scales were calibrated and guardians’ education’, ‘body weight classification’,
evaluated by INMETRO (National Institute of ‘television exposure time’ and ‘BRIAN-K’ (eating
Metrology, Standardization and Industrial Quality). pattern domain). Descriptive analysis of variables
All anthropometric evaluations were performed by was performed using absolute numbers and relative
a properly trained graduate student in a reserved frequencies, central tendency (mean), and variability
room and only in the presence of the child. Body (standard deviation - SD). Chi-square test was used for
weight was classified using the intercepts of the the bivariate analysis of categorical variables, while
WHO z-score percentile table, in which the columns the analysis of continuous variables was performed
contain BMI (kg/m 2) values and the lines contain with the unequal T-test.
age (years) and according to sex (boys and girls, To assess the mediating effect of eating pattern
respectively): underweight (≥ -3 and < -2), normal on the relationship between television exposure
weight (≥ -2 and ≤ +1), overweight (≥+1 and ≤ 2), and time and presence of dental caries, the parametric
obesity (≥ +2 and ≤ +3).23 g-formula (mediation option) was applied to estimate
Dental caries experience (outcome) was assessed the total effect, the natural direct/indirect effects,
using the Decayed, Missing and Filled teeth (dmft/ and the controlled direct effect. The total effect
DMFT) for the deciduous and permanent dentition, is the difference between the potential outcome
according to the WHO criteria.24 This index measures if all individuals were counterfactually exposed
the individual number of decayed teeth requiring and unexposed. The natural direct effect is the
filling or extraction, lost teeth that have been removed difference between two potential outcomes: the
as a result of caries, and filled/restored teeth. In first is the potential outcome if in the counterfactual
the oral examination, children were seated on an scenario all individuals were exposed, keeping
ordinary chair in the school and with their heads the mediators to their potential values under no
facing a source of natural light. The examiner was exposure; the second is the potential outcome if all
seated in front of them and performed the exam using individuals were unexposed in the counterfactual
gauze, mirror, and examination probe. For analyses, scenario. The natural indirect effect is the difference
the variable was dichotomized as dmft/DMFT ≥ 1, between the total effect and the direct effect. Finally,
if children had at least one primary or permanent the controlled direct effect is a comparison of the
decayed, missing or filled tooth, or dmft/DMFT = 0. expected outcome while keeping the value of the
Parents of children with the need of treatment were mediators fixed (M = 0). Body weight classification
advised to seek dental care in the public health system (overweight) was used as a post-confounder. The
and at the clinic of the School of Dentistry (UFPel). Monte Carlo approach was used to estimate the
effects. For a simulated hypothetical cohort, we used
Data analysis a sample size of 10.000, where these samples were
Data were double-entered in EpiData® software drawn from a known probability distribution (e.g.,
(Version 3.1) (The EpiData Association, Odense, normal). The Bootstrap method was used to estimate
Denmark). Statistical analyses were performed using the standard errors as well as the confidence interval
Stata Statistical Package (Version 14.0) (Stata Corp, of the estimated effects. For the later estimation, we
College Station, USA). The database of this study used 1.000 resamples with the size of 10.000. The
is not available in any open repository, but can be results of G-computation analysis are presented in
accessed by request via email to the corresponding OR, 95%CI, and standard error (SE).

Braz. Oral Res. 2023:37:e075 5

 Mediating effect of eating pattern on the relationship between television exposure and caries in children

Results family socioeconomic status (p = 0.034), parents/

guardians education (p = 0.005), and mean score on
A total of 723 children were eligible to participate the BRIAN-K eating pattern domain (p = 0.050) in
in this study. Of these, 34 (5%) did not attend school the bivariate analysis (Table 1).
on the evaluation days and 80 (11%) parents did not The parametric g-formula analysis showed
consent to their children’s participation. A total 596 that television viewing had no direct effect on the
caregivers completed the assessment and 13 (2%) presence of dental caries [ORTCE: 1.05 (95%CI: 0.92–1.19);
were not located. Of the 596 children, 18 did not p = 0.484]. Nevertheless, the difficulty in maintaining
complete the oral clinical examination. Thus, 580 a regular eating pattern mediated the natural indirect
dyads were included in the analysis. effect of television exposure time (≥ 4 hours/day) on
More than half of the sample had low/middle dental caries experience [ORNIE: 1.07 (95CI%: 1.01–1.14);
socioeconomic status (67%), and the majority of p = 0.022] (Table 2) (Figure).
caregivers (85%) had up to 11 years of education.
Twenty-two percent of children watched more than Discussion
four hours of television per day; the mean daily
screen time for the sample was 4.06 (SD 1.02) hours. The relationship between television viewing and
The global mean score on the BRIAN-K eating dental caries has not been sufficiently investigated in
pattern subscale was 2.44 (SD 2.66). The prevalence the literature. In particular, the effect of a non-regular
of dental caries was 63% and was associated with eating pattern on this relationship is still unclear.

Table 1. Sample distribution according to presence of dental caries in schoolchildren (n = 580).

Variables Total sample dmft/DMFT = 0 dmft/DMFT ≥1 p-value

Sex – n (%)

Female 284 (48.97) 105 (36.97) 179 (63.03)

0.962*
Male 296 (51.03) 110 (37.16) 186 (62.84)

Socioeconomic status – n (%)

Lower/intermediate 379 (66.73) 128 (33.77) 251 (66.23)

0.034*
Upper 189 (33.27) 81 (42.86) 108 (57.14)

Parents/guardians education - n (%)

Up to 11 years 478 (84.75) 164 (34.31) 314 (65.69)

0.005*
12 years or more 86 (15.25) 43 (50.00) 43 (50.00)

Body weight classification – n (%)

Normal weight 315 (54.78) 111 (35.24) 204 (64.76)

Overweight 121 (21.04) 46 (38.02) 75 (61.98) 0.572*

Obese 139 (24.17) 56 (40.29) 83 (59.71)

Television exposure time – n (%)

<4 hours per day 437 (77.76) 164 (37.53) 273 (62.47)
0.422*
≥4 hours per day 125 (22.24) 42 (33.60) 83 (66.40)

BRIAN-K – mean (SD)

Eating pattern 2.44 (2.66) 2.16 (2.44) 2.61 (2.79) 0.050**

Total 580 (100) 215 (37.07) 365 (62.93)

Note: *Chi-square test; **unequal T-test; SD: standard deviation.

6 Braz. Oral Res. 2023:37:e075

 Shqair AQ, Fernandez MS, Costa FS, Jansen K, Motta JVS, Silva RA, et al.

Table 2. G-computation analysis of the eating pattern domain (BRIAN-K) as mediator in the association between television exposure
and dental caries (n = 580).
G-computation Estimate
Exposure-mediator-outcome Bootstrap (SE) p-value
(OR) 95% CI
TCE 1.05 0.92, 1.19 0.0666084 0.484
NDE 0.98 0.85, 1.12 0.0696435 0.750
NIE 1.07 1.01, 1.14 0.0301322 0.022
CDE 0.96 0.90, 1.20 0.0717883 0.599
Note: TCE: total causal effect; NDE: natural direct effect; CDE: controlled direct effect; NIE: natural indirect effect; SE: standard error; OR: odds
ratio; 95% CI: 95% confidence interval.

Socioeconomic status
Television viewing Eating pattern Dental caries
Caregiver education

Nutritional status

Figure. Mediation analysis model with total causal effect and natural indirect effect. Pelotas, RS, Brazil (n = 580).

Thus, the present study investigated the mediating difficulty consuming moderately stimulating foods
effect of eating pattern on the relationship between or sweets, may mediate the relationship between
television exposure time and the presence of television exposure time and caries experience. Thus,
dental caries in children using the g-formula. For we understand that the effect of the difficulty in
the best of our knowledge, this is the first study maintaining the eating pattern does not correspond
investigating this relationship using the g-formula. only to the ingestion of foods potentially related to
This analytical approach is of relevance for studying dental caries, but also to the absence of a healthy
the effects of exposures that cannot be allocated eating routine, such as eating schedules (frequency
in randomized clinical trials for ethical reasons. of ingestion) and quantity and quality of the foods
The use of the parametric g-formula allowed us consumed. Unfortunately, the comparison of our
to test the association between television viewing findings is strongly limited by the absence of similar
and dental caries using a counterfactual approach. studies; however, additional information related to
This statistical method uses models for the outcome food consumption during television viewing and
and the mediator, which produces more efficient dental caries may provide interesting insights into
estimates (with narrower confidence intervals) than this relationship.
the weighting approaches that use models for the One systematic review examined the associations
mediator and/or the exposure.25 between television viewing during a meal or snack
In general, our results confirm that aspects and the quality of children’s diet and showed that
of children’s eating pattern, such as difficulty eating whilst watching television reduces diet
maintaining or taking all meals, difficulty maintaining quality and increases consumption of high-fat,
the same amount of food eaten regularly, and high-sugar foods and sugar-sweetened beverages

Braz. Oral Res. 2023:37:e075 7

 Mediating effect of eating pattern on the relationship between television exposure and caries in children

and decreases intake of fruits and vegetables.9 present study investigated only the association with
Also, a cross-sectional study with more than 10,000 television. However, further studies could investigate
children aged 6–9 years from five European countries the association with other media, including cell
shows that each additional hour of screen time was phones, which are becoming more easily available.
associated with increased consumption of high- Also in this context, international associations
fat/high-sugar foods including sugar-sweetened recommend that the use of screen-based devices by
drinks, candy bars or chocolate, and pizza, chips children under 18 months should be avoided, except
or hamburgers and decreased consumption of for video chatting, whereas in children aged 2-5 years,
vegetables and fresh fruits.21 In this context, the the use of screen-based devices should be limited to
uncontrolled intake of these foods during television 1 h/day of quality programming. For children/youth
viewing may justify the absence of a healthy eating aged 5-12 years, it is recommended that recreational
pattern, as snack consumption was associated sedentary screen time be limited to no more than
with an increased odds ratio of meal skipping in 2 hours per day.32,33 In this study, children aged 7-8
children. 25 Therefore, we hypothesized that the years were exposed to a mean screen time of 4.06
eating pattern resulting from the difficulty in hours per day. This value is double the sedentary time
maintaining a healthy eating routine associated with specified in international recommendations for this
the frequent consumption of potentially cariogenic age group and contrasts with other investigations
foods during television viewing predisposes that observed a lower average screen time in samples
children to experience caries. It is recommended that of Brazilian, Portuguese, and North American
interventions be directed at parents to limit screen children.34,35 These data largely argue for policies
time, particularly whilst eating, and to encourage to limit abusive screen use by children, because
family meals without television. Special attention there is evidence of health harms in a wide range of
must be paid to children from lower socioeconomic health domains that go far beyond the oral aspects,
backgrounds,9 considering that they are exposed but also the impact of this behavior on physical and
to more risk factors than children from higher biopsychosocial dimensions.36
socioeconomic conditions.26 Policymakers should A recent systematic review investigated the
consider the effects that sedentary habits may have content of television advertising during children’s
on lifelong eating habits. viewing time, focusing on the number of cariogenic
In the literature, the relationship between food advertisements, and confirmed that the most
skipping meals or snacking out of meal time and frequently advertised foods during children’s
the consumptions of refined carbohydrate or programming are foods that are potentially harmful
sugar has been already established. Bonotto et al.27 to dental health, with a large amount of hidden
showed that limiting snacks is a protection factor sugars. 37 Following the trend of more specific
against untreated dental caries. It is clear that the regulation of food advertising in Brazil, the National
availability of snacks leads to the establishment Health Surveillance Agency published in June 2010
of inadequate eating patterns and good dietary the Resolution RDC no. 24, which requires that the
habits promotes oral health. 28 Thus, raising the advertisement for foods high in sugar, fat, and
awareness of parents/caregiver about good habits sodium, as well as for nutrient-poor beverages,
such as eating breakfast daily and limiting snacks include warnings about the possible health risks in
between meals could be important. the case of over-consumption. For now, this resolution
Among the various types of screens, television is suspended. Nowadays, there is no law in Brazil
is the most popular form of media used by young that regulates the advice on cariogenic foods. It
children,29 due to easy access, and by low-income seems that policy-makers need to review and revise
populat ion s. 30 The most releva nt sedenta r y regulations on child-targeted food advertisements to
behavior, in terms of the effect on food and beverage promote health habits, especially those that support
consumption, is television watching. 31 Thus, the healthier eating patterns.

8 Braz. Oral Res. 2023:37:e075

 Shqair AQ, Fernandez MS, Costa FS, Jansen K, Motta JVS, Silva RA, et al.

Socioeconomic factors were associated with outcome variables. The use of data self-reported by
dental caries, which confirmed in our hypothesis. parents/guardians can also be listed as a limitation
It is known that parental educational background of the study as it may lead to social causality bias
frequently determines income, which affect access in the perception and reporting of aspects related
to personal or professional preventive means such as to the children’s behaviors and biological rhythm.
toothpaste, dental floss, low calorie, sugar-reduced The frequency (i.e., number of times per day and
diets, and dental treatments.38 Besides, educational duration of television exposure) and type of food/
background can also affect other characteristics beverages (i.e., natural foods or ultra-processed foods)
such as health behavior, including dietary and consumed by children while watching television
tooth brushing habits, or health service utilization could help understand the association between these
frequency.39 Of note, differences were confirmed variables and dental caries, but unfortunately this
despite the fact that all children were attending information was not collected in this investigation.
public schools. Therefore, further longitudinal investigations using
This study has some strengths that should be recognized methods to assess diet, exposure to TV
highlighted. First, the results presented fill an or screen devices, and the overall spectrum of dental
under-explored gap in the literature and reinforce caries in representative samples of this population
that television viewing may play an indirect role should be conducted.
in the progression of dental caries. This makes
the harmful effects of excessive television viewing Conclusion
on general and oral health particularly clear. The
number of sampling points of this study ensured The results of this study confirm the indirect
external variability, making it representative of the pathway between television viewing and dental caries
public-school population of Pelotas, RS, Brazil. in children and the role of eating pattern disruption
Furthermore, according to the local education in this association. These findings are useful in
authority, all children in urban areas are enrolled supporting the behavioral and dietary guidelines
in the schools included in the process of sample provided by dentists to parents and children during
randomization. The internal validity of the study was clinical care and to guide new integrated health care
ensured, as the dentist was trained and calibrated policies for this population.
and interviewers were previously trained.
Some limitations of this st udy should be Acknowledgment
considered when interpreting the results. The This study was financed in part by the Coordenação
exclusion of private schools limits the reproducibility de Aperfeiçoamento de Pessoal de Nível Superior -
and comparison of the findings to only children Brasil (CAPES) - Financial Code 001/2016. Matheus
from public schools. Despite our large population dos Santos Fernandez has a scientific initiation
sample, some of the associations tested could have CNPq/CAPES scholarship for undergraduate
been affected by lack of statistical power. The students at Federal University of Pelotas in the
cross-sectional design of the study does not allow EPIBucal group (Acronym in Portuguese for “Grupo
the inference of causality between exposures and de Estudos em Epidemiologia da Saúde Bucal”).

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