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European Annals of Dental Sciences
Official Publication of Ankara University, Faculty of Dentistry
E A
D S
EADS, 2024, 51 (2), 74–78
e-ISSN : 2757-6744
doi : 10.52037/eads.2024.001
Article Received/Accepted : June, 5 2024 / August, 13 2024
Ethical Committee No : 2023/217
ORIGINAL RESEARCH ARTICLE
Evaluation of Bedtime Oral Hygiene Behavior and
Dietary Habits in Children
Sabiha Ceren İlisulu ID *, Edmon Sakız ID and Mustafa Küçük ID
Altınbaş University, Faculty ofDentistry, Department of Pediatric Dentistry, Istanbul, Turkey
*Corresponding Author; ceren.ilisulu@altinbas.edu.tr
Abstract
Purpose: The purpose of this study was to assess the effect of bedtime oral hygiene and dietary behaviors on dental health in
children.
Materials and Methods: For this study, 83 parents with children aged 6 to 8 years participated. All participants who agreed to take
part in the study were called on their mobile phones for 7 days (weekdays and weekend) for collecting data of bedtime routine
activities of children including oral hygiene behaviors and dietary habits 1 hour before bedtime. Children’s clinical oral examination
was carried out by trained and calibrated pediatric dentist following WHO guideline 2013. IBM SPSS Statistics (version 22.0) was
used for all statistical analyses, including the Mann Whitney U test, the Kruskal Wallis test, and the Kolmogorov-Smirnov test.
Results: The dmft score of children who were allowed to eat or drink 1 hour before bedtime was statistically significantly higher
than those who were not allowed (p=0.014; p<0.05). Although the dmft score of children who consumed snacks or drinks other
than water or unflavored milk 1 hour before bedtime were higher than those who consumed only water or unflavored milk, this
difference was not statistically significant (p>0.05).
Conclusions: The present study highlighted bedtime dietary habits affect the dental health of children. Establishing optimal
bedtime routines, including oral hygiene practices and dietary habits, is essential for proper oral hygiene and the well-being and
development of children.
Key words: Bedtime; Children; Diet; Oral hygiene
Introduction
About 60% of children globally are estimated to be affected by den-
tal caries, one of the most common diseases in children.
1
It is a
multifactorial disease in which the development and progression
of dental caries are affected by the oral bacterial flora, and environ-
mental and genetic factors including diet, oral hygiene routines,
composition of saliva and tooth structure play an essential role.
2
As
per the findings of the Turkey Oral and Dental Health Profile 2018
survey, there was at least one dental caries in 64.4% of children
aged 5 years, 46.6% of children aged 12 years, and 58.3% of chil-
dren aged 15 years.
3
Children with dental caries have discomfort,
pain, difficulty sleeping, difficulty chewing, learning disabilities,
psychological development problems (e.g. low self-esteem), and
missed days of school that lead to a decline in school performance
all of which have a detrimental impact on their quality of life. 4,5
Bedtime routines are defined as a regular, dynamic, and shared
series of activities that occur approximately one hour prior to chil-
dren going to bed.
6
These routines include brushing teeth, avoid-
ing electronics such as TVs, avoiding snacks and drinks other than
water or unflavored milk, reading books or storytelling between
parent and child, as well as other activities that encourage positive
interaction between parents and children.
7,8
Prior research per-
taining to bedtime routines has demonstrated the significance of
these practices with respect to sleep quality, dental health, academic
achievement, psycho-social and mental growth, general function-
ing of families, and stress for parents and self-assurance.9,10
Bedtime is especially crucial time for both diet and preventative
practices in terms of oral health.
11
Consuming food or beverages,
particularly those high in free sugars, right before bed increases
the risk of dental caries because it causes salivary flow to dimin-
ish and shifts the scales in favor of demineralization rather than
remineralization.
12
Several clinical guidelines have recommended
avoiding foods and beverages containing free sugars and brushing
the teeth twice a day at bedtime with fluoride toothpaste under
parental supervision.
13,14
Establishing and maintaining healthy
family routines is essential for controlling free sugar consumption,
particularly before bedtime, and for brushing twice a day.15
There is currently a lack of knowledge regarding the features
of children’s bedtime routines in relation to oral hygiene behaviors
How to cite: Ilisulu SC, Sakiz E, Kucuk M. Evaluation of Bedtime Oral Hygiene Behavior and Dietary Habits in Children. EADS.
2024;51(2): 74-78
Bed time oral hygiene behavior and dietary habits |75
and dietary habits. Thus, the main purpose of this study is to gain
a better understanding of the impact of bedtime oral hygiene and
dietary behaviors on dental health in children.
Material and Methods
This cross-sectional study was approved by Research Ethical Board
of Altınbaş University (2023/217). Participants were approached
during dental examination in Altınbaş University Pediatric Den-
tistry Clinic between January 2024 – April 2024. All participants
gave written informed consent in accordance with the Helsinki Dec-
laration before the study, and they were all informed of the study’s
purpose. Inclusion criteria consisted of I) ability in reading and
speaking Turkish, II) having access to working mobile phone and
III) having children between the ages of 6 and 8. In all, 83 parents
of children between the ages of 6 and 8 took part in presentstudy.
During children’s examination, sociodemographic data, includ-
ing the age and gender of the parents and children, family income,
and number of children, were obtained. Children’s clinical oral
examination was carried out by trained and calibrated pediatric
dentist (S.C.İ) following WHO guideline 2013.
16
All participants
who accepted to take part in the study were called on their mobile
phones for 7 days (weekdays and weekend) to collect data on bed-
time routine activities of children. Specific questions were asked
regarding the oral hygiene behaviors of the children (e.g., did they
brush their teeth that evening, and if so, by whom), as well as their
dietary habits before bed. Parents were asked whether they allowed
their children to eat or drink 1 hour before going to bed at night
and, if yes, what they ate. Two postgraduate students (E.S and M.K)
noted data of bedtime routine activities of children.
Statistical Analysis
Data were analyzed with the Statistical Package for Social Sciences
version 22.0 software (IBM Corp.; Armonk, NY, USA). Using the
Kolmogorov-Smirnov test, the parameters’ suitability for a normal
distribution was assessed, and it was found that the parameters
did not exhibit a normal distribution. When analyzing the data,
the Kruskal-Wallis testwas utilized for parameter comparisons be-
tween more than two groups in quantitative data comparisons, and
the Mann-Whitney U test was employed for comparisons between
two groups. Descriptive statistical methods such as minimum, max-
imum, mean, standard deviation, median, and frequency were used
as well. The statistical significance was accepted as p<0.05.
Results
In total, 83 parents and their children participated in the study. An
overview of the sample characteristics is given in Table 1, which
includes the number of children, the age and gender of the parents
and children, and the family’s income level. The mean age of the
parents was 39.05 (SD=3.98), and only 23 male parents participated
in the study. The majority of the parents were female. Only three
families had more than 3 children, compared to the majority of
families with 2 (n=35). 53% of the children in the study were female
and 47% were male, and their ages ranged from 5 to 8. Most of the
income level of the families (92.9%) was above minimum wage.
Regarding whom was brushing the children’s teeth, majority
of the children (81.9%, n=68) brushed their teeth on their own
with no assistance, 13.3% of them were brushed by parents. 59%
of parents (n=49) stated thatthey brushed their children’s teeth
every night of the week. 77.1% of parents (n=64) allowed children
food or drink 1 hour before bedtime. While 20.3% of parents who
allowed to eat or drink before bedtime, only allowed to drink water
or unflavored milk, 79.7% allowed snacks or drinks other than
water or unflavored milk. Of the 51 parents who allowed snacks and
Table 1. Sociodemographic characteristics
Min-Max Mean±SD
Age of parents 30-50 39.05±3.98
Age of child 5-8 7.12±0.85
Number of children (median) 1-6 1.83±0.93 (2)
n %
Gender of parents
Female
60 72.3
Male
23 27.7
Gender of child
Female
44 53.0
Male
39 47.0
Family income
Medium
6 7.2
High
77 92.9
SD: Standard Deviation, Min: Minimum, Max: Maximum
drinks other than water or unflavored milk, 76.5% allowed them
on Saturdays and 59.8% on Sundays. While 38.6% of the children
did not consume snacks at all, 27.7% consumed snacks less than
3 days a week, 24.1% consumed snacks more than 3 days a week
and 9.6% consumed snacks every day (Table 2). Foods and drinks
consumed by children 1 hour before bedtime according to days are
shown in Table 3.
The mean dmft and DMFT scores of children are shown in Table
4. The dmft score of children who were allowed to eat or drink
1 hour before bedtime was statistically significantly higher than
those who were not allowed (p=0.014; p<0.05). Although the dmft
score of children who consumed snacks or drinks other than water
or unflavored milk 1 hour before bedtime was higher than those
who consumed only water or unflavored milk, this difference was
not statistically significant (p>0.05) (Table 5).
Discussion
In this study, the dental health of children was investigated regard-
ing the oral hygiene behaviors and dietary habits of children 1 hour
before bedtime. The findings of this study, in consistent with pre-
vious studies
17–19
has demonstrated the significance of bedtime
dietary habits and oral hygiene behaviors for oral health of children.
The study’s findings indicate that allowing a child to eat or drink
one hour prior to bedtime and the child’s dmft score were signifi-
cantly associated. There is strong evidence that dietary habits have
a negative impact on oral health from a physiological and biological
standpoint, and that avoiding free sugars in general is important.
17
The natural sugars in unflavored milk have minimal effects on
oral health. Nevertheless, free sugars—that is, naturally occurring
sugars that have broken down along with sugar added within food
and beverages—have been shown to negatively impact oral health
because of their cariogenic load.
19
In present study, for children
allowed to eat or drink one hour before bedtime, there was no sig-
nificant difference in dmfs between those who consumed water or
unflavored milk and those who had snacks or beverages. In contrast
to our study, a recent study has reported a significant positive corre-
lation between the dmft score and consumption of snacks or drinks
before bedtime.
5
Additionally, a previous study has indicated that
the majority of parents permitted snacks or drinks other than water
or unflavored milk similar to our study, leading to their children
developing unhealthy eating habits. 10
In present study, allowing eat or drink before bedtime was more
common on Saturday (76.5%) and Sunday (60.8%) than week-
days. Kitsaras et al.
10
described this situation as the “weekend
effect” and has indicated that parents maybehave differently on
weekdays compared to weekends. Additionally, just identifying
certain evenings as school nights and others as weekend nights can
be enough to explain the development of behavioral and practical
changes in children as well as changed expectations about what is
and isn’t appropriate for them to be doing.
Brushing teeth is an important bedtime routine activity for chil-
76 |Ilisulu et al.
Table 2. Bed time oral hygiene behaviors and dietary habits ofchildren
n %
A person who brush
child’s teeth
Child 68 81.9
Parents 11 13.3
Parents + Child 4 4.8
Frequency of
tooth brushing
Less than %50 15 18.1
More than %50 19 22.9
Every day 49 59.0
Toothpaste containing
flouride
Yes 36 43.4
No 47 56.6
Allowing the child to eat or
drink 1 hour before bedtime
Yes 64 77.1
No 19 22.9
If it is allowed
(n=64)
Only water or unflavored milk 13 20.3
Snack or drinks other than water or unflavored milk 51 79.7
The days allowed
(n=51)
Monday 28 54.9
Tuesday 28 54.9
Wednesday 29 56.9
Thursday 28 54.9
Friday 28 54.9
Saturday 39 76.5
Sunday 31 60.8
Frequency of
snacks or drinks
Never 32 38,6
Less than 3 days 23 27.7
More than 3 days 20 24.1
Every day 8 9.6
Table 3. Food and drink consumed by children 1 hour before bedtime by day
Monday
n (%)
Tuesday
n (%)
Wednesday
n (%)
Thursday
n (%)
Friday
n (%)
Saturday
n (%)
Sunday
n (%)
Absent 5 (%9.8) 7 (%13.7) 13 (%25.5) 11 (%21.6) 10 (%19.6) 6 (%11.8) 13 (%25.5)
Flavored Milk 2 (%4) 2 (%4) 2 (%4) 1 (%2) 1 (%2) 1 (%2) 1 (%2)
Crips 4 (%7.8) 1 (%2) 2 (%3.9) 2 (%3.9) 2 (%3.9) 11 (%21.6) 7 (%13.7)
Cookie 2 (%3.9) - - 2 (%3.9) - 1 (%2) 2 (%3.9)
Chocolate 4 (%7.8) 8 (%15.7) 4 (%7.8) 6 (%11.8) 5 (%9.8) 7 (%13.7) 3 (%5.9)
Fruit 13 (%25.5) 12 (%23.5) 18 (%35.3) 13 (%25.5) 14 (%27.5) 9 (%17.6) 10 (%19.6)
Fruit Juice 1 (%2) 1 (%2) - - 2 (%3.9) 1 (%2) -
Coke - 2 (%3.9) - - - - -
Nut - 1 (%2) - - - - -
Popcorn 1 (%2) - 1 (%2) 2 (%3,9) 1 (%2) 4 (%7.8) 4 (%7.8)
Water 18 (%35.3) 13 (%25.5) 8 (%15.7) 10 (%19.6) 10 (%19.6) 5 (%9.8) 5 (%9.8)
Unflavored
milk
- 3 (%5.9) 1 (%2) 2 (%3.9) 3 (%5.9) 1 (%2) 2 (%3.9)
Dessert - - 1 (%2) 1 (%2) 2 (%4) 4 (%7.8) 3 (%5.9)
Yogurt 1 (%2) 1 (%2) 1 (%2) 1 (%2) 1 (%2) 1 (%2) 1 (%2)
Table 4. DMFT and dmft scores of children
Min-Max Mean±SD Median
dmft 0-12 3.75±3.59 3
DMFT 0-7 0.81±1.61 0
SD: Standard Deviation, Min: Minimum, Max: Maximum
dren to highlight. The recommendations state that parentsshould
supervise and brush their children’s teeth until they are ten years
old.
20
However, the present study has reported that only 13.3% of
parents brushed their children’s teeth. A significant number of
children brush their teeth unsupervised by an adult, which can be
detrimental to their dental health even though current guidelines
indicate contrary. In terms of frequency of brushing, while 59% of
participants brushed teeth every night in present study, Kitsaras et
al.10 found that 53% of parents did so.
Based on the existing research on bedtime routines, children
and their families can benefit much in the long run from success-
fully and regularly executing the appropriate bedtime routine. Prior
research has demonstrated that children who followed robust rou-
tines, such as brushing their teeth and not eating late atnight, had
lower dental caries and generally improved oral health.
15
Eliminat-
ing dental problems at an earlyage can therefore not only benefita
child’s general development by reducing the risk oftooth extrac-
tions, dental pain, sleep disturbances but also contribute to public
finances by reducing financial expenses.
4
Other than dental health,
good dietary habits one hour before bedtime have been demon-
strated to have significant reduction in obesity rates. 21
The repetitive aspect of bedtime routines and the earlyemphasis
on routines can facilitate children’s rapid adoption and long-term
maintenance of positive behaviors.
5
Furthermore, the psychologi-
cal and emotional wellbeing of parents and children has been con-
nected to bedtime routines. Compared to other children, those who
have irregular bedtime routines have greater behavioral issues on a
regular basis, while parents who follow an ideal bedtime routine
report feeling less stressed, irritated, and tired.15,22
The most significant potential limitation ofthis study is most
likely the risk of bias, particularly desirability bias. Since the par-
ticipant is required to answer honestly and accurately, there is no
way to ensure that their responses are accurate, which makes it
challenging to control for the impacts of this kind of bias in self-
reported measures. Contacting the parents at different times (on
the same day for each patient) without prior notice and learning
about their bedtime routines could help provide more objective
findings. Another limitation of this study is that it focused solely to
bedtime routines, without evaluating dietary habits throughout the
Bed time oral hygiene behavior and dietary habits |77
Table 5. Comparison of oral hygiene behaviors and dietary habits 1 hour before bedtime and dmft/DMFT scores
dmft DMFT
Mean±SD (median) Mean±SD (median)
Frequency of tooth brushing
Less than 50% 5.67±4.78 (5) 1.73±2.22 (0)
More than 50% 3.21±2.74 (3) 0.58±1.02 (0)
Every day 3.37±3.35 (3) 0.61±1.51 (0)
p10.263 0.122
Toothpaste containing flouride
Yes 3.97±3.49 (3) 0.92±1.57 (0)
No 3.57±3.7 (3) 0.72±1.65 (0)
p20.551 0.306
A person who brush child’s teeth
Child 3.60±3.42 (3) 0.90±1.69 (0)
Parents 4.73±4.94 (3) 0.36±1.21 (0)
Parents + Child 3.50±2.65 (4) 0.50±1.0 (0)
p10.918 0.490
Allowing the child to eat or
drink 1 hour before bedtime
Yes 4.22±3.61 (4) 0.8±1.6 (0)
No 2.16±3.15 (1) 0.84±1.71 (0)
p20.014* 0.862
If it is allowed
Only water or unflavored milk 2.77±3.52 (2) 0.23±0.6 (0)
Snack or drinks other than
water or unflavored milk 4.59±3.57 (4) 0.94±1.74 (0)
p20.068 0.267
1Kruskal Wallis test 2Mann Whitney U Test*p<0.05 SD: Standard Deviation, Min: Minimum, Max: Maximum
day, and drawing conclusions within a short period. A more compre-
hensive assessment of both daily dietary habits in conjunction with
bedtime routines, conducted over a longer duration, would likely
provide a healthier understanding of the relationship between dmft
and DMFT values and dietary routines.
Conclusion
This study provided evidence that children’s dietary habits before
bedtime have an impact on their oral health. A critical initial point
for excellent short-and long-term oral health outcomes, alongwith
the wellbeing and development of children, is the promotion, cre-
ation, and maintenance of optimum bedtime routine activities, in-
cluding appropriate dental hygiene behaviors and dietary habits
before bedtime.
Author Contributions
Idea/Concept: S.C.İ; Design: S.C.İ, E.S, M.K; Control/Supervision:
S.C.İ, E.S, M.K; Data Collection and/or Processing: S.C.İ, E.S, M.K;
Analysis and/or Interpretation: S.C.İ; Literature Review: S.C.İ, E.S,
M.K; Writing the Article: S.C.İ, E.S, M.K; Critical Review: S.C.İ, E.S,
M.K.
Conflict of Interest
The authors declare that they have no conflict of interest.
Authors’ ORCID(s)
S.C.I. 0000-0003-3679-4001
E.S. 0009-0002-0386-0025
M.K. 0009-0000-1583-3820
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