CRANIO®

The Journal of Craniomandibular & Sleep Practice

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Lifestyle and oral facial disorders associated with

sleep bruxism in children

Nashalie Andrade de Alencar , Alline Birra Nolasco Fernandes , Margareth

Maria Gomes de Souza , Ronir Raggio Luiz , Andréa Fonseca-Gonçalves &
Lucianne Cople Maia

To cite this article: Nashalie Andrade de Alencar , Alline Birra Nolasco Fernandes , Margareth
Maria Gomes de Souza , Ronir Raggio Luiz , Andréa Fonseca-Gonçalves & Lucianne Cople Maia
(2017) Lifestyle and oral facial disorders associated with sleep bruxism in children, CRANIO®, 35:3,
168-174, DOI: 10.1080/08869634.2016.1196865

To link to this article: http://dx.doi.org/10.1080/08869634.2016.1196865

Published online: 22 Jun 2016.

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 Sleep
Lifestyle and oral facial disorders associated
with sleep bruxism in children
Nashalie Andrade de Alencar DDS, MSD1, Alline Birra Nolasco Fernandes DDS,
MSD1, Margareth Maria Gomes de Souza DDS, MSD, PhD1, Ronir Raggio Luiz
MSc, PhD2, Andréa Fonseca-Gonçalves DDS, MSD, PhD1, Lucianne Cople Maia
DDS, MSD, PhD1
1
Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Universidade Federal do Rio de
Janeiro, Rio de Janeiro, Brazil, 2Institute of Public Health Studies, Universidade Federal do Rio de Janeiro, Rio
de Janeiro, Brazil
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Objective: The aim of the study was to investigate the routine, sleep history, and orofacial disorders associated
with children aged 3–7 years with nocturnal bruxism.
Methods: Children (n = 66) were divided into groups of parent reported nocturnal bruxism (n = 34) and those
without the disorder (n = 32). Data about the child’s routine during the day, during sleep and awakening, headache
frequency, temporomandibular joint (TMJ), and hearing impairments were obtained through interviews with
parents/caregivers. Electromyography examination was used to assess the activity of facial muscles. Multiple
logistic regression (MLR), chi-square test, and t-test analyses were performed.
Results: MLR revealed association of nightmares (p = 0.002; OR = 18.09) and snoring (p = 0.013; OR = 0.14)
with bruxism. Variables related to awakening revealed an association with bruxism (p < 0.05). Parents of the
main group (children with nocturnal bruxism) reported more complaints of orofacial pain, facial appearance,
and headache occurrence (p < 0.05). Auditory and muscle disorders were not significant variables (p > 0.05).
Conclusion: Nightmares and snoring are associated with nocturnal bruxism in children. Bruxism in children
elicits consequences such as headache, orofacial pain, and pain related to awakening.
Keywords:  Bruxism, Children, Routine, Oral facial pain, Sleep, Electromyography

Introduction hyperactivity, attention deficit, sleepiness, and poor school

Bruxism is a parafunction with repetitive involuntary jaw
muscle activity characterized by clenching or grinding
of teeth and/or by bracing or thrusting of the mandible.1,2
It can occur during sleep (nocturnal bruxism) or during
wakefulness (awake bruxism). It is more common in chil-
dren than in adults and less common in older adults, since
it tends to decrease with age.3,4 According to Manfredini
et al.,4 the prevalence of the disorder in children ranges
from 3.5 to 40.6%, and no gender preference has been
reported. Although bruxism is considered a multifactorial
parafunction5 with complex and controversial etiology,6 it
is assumed to be mainly regulated by the central nervous
system, not peripherally. emotional factors, high anxiety
levels, and stress,7 among other factors such as oral hab-
its,8 malocclusions and occlusal interferences,9 extensive
caries,9 and genetic predisposition10 play a role in the
occurrence of bruxism. In addition, bruxism in children
has also been associated with behavioral problems such as
Correspondence to: Lucianne Cople Maia, Caixa Postal: 68066, Cidade
Universitária, CCS, CEP: 21941-971, Rio de Janeiro, RJ, Brazil. Email:
rorefa@terra.com.br
performance.11,12 The diagnosis of nocturnal bruxism must
be based on the conjunction of signs, symptoms, and trig-
gering factors due to its multifactorial nature.13 However,
nocturnal bruxism is not only related to a specific symp-
tom.14 Some associated signs and symptoms like tem-
poromandibular disorders,15 breathing disorders during
sleep,16–18 headache,19 buccal mucosa riding,19 and exces-
sive jaw muscle activity20–22 must be assessed to assist
dentists in a more accurate diagnosis of this parafunction.
Therefore, there is a need for more studies addressing
interactions between bruxism and possible predictor fac-
tors, signs, and symptoms.
Studies investigating the association between brux-
ism and a child’s routine during the day, oral facial pain,
masseter muscle activity, auditory disorders, sleep dis-
orders, and awakening have not been found in literature.
Therefore, this study aimed to investigate the association
between a child’s routine, sleep history, and oral facial dis-
orders with bruxism. The null hypothesis was that there is
no causality between these factors and nocturnal bruxism.

© 2016 Informa UK Limited, trading as Taylor & Francis Group

168 DOI 10.1080/08869634.2016.1196865 CRANIO® : The Journal of Craniomandibular & Sleep Practice  2017  VOL. 35   NO. 3

Methods
Study design, setting, and sample selection
The present study was approved by the local ethics
committee (protocol number: 108/107) of the Federal
University of Rio de Janeiro (UFRJ), Brazil. Parents/
caregivers signed an informed consent form. This study
was performed with a sample of children who were
searching for treatment in a pediatric dental clinic of
UFRJ from March 2012 to March 2013. The present
study was developed in two phases. First, a cross-sec-
tional study was carried out to estimate the prevalence
of nocturnal bruxism in children aged 3–7 years. In the
second phase, the study was developed to identify the
association of nocturnal bruxism in children with the
following variables: sociodemographic information,
lifestyle features, oral facial disorders, and masseter
muscle activity.
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The diagnosis of nocturnal bruxism was performed
using the classification of the American Academy of Sleep
Medicine (AASM): parents indicating the occurrence of
audible teeth grinding at night, no other medical or men-
tal disorders (sleep-related epilepsy, abnormal movement
while sleeping), and no other reported sleep disorders
(obstructive sleep apnea syndrome).23 Moreover, to be
included in this study, participants had to have complete
primary or mixed dentition. Children were examined by
a trained dentist, and those with dental caries, dental ero-
sion, malocclusions (crossbite, openbite and dental crowd-
ing), gingivo-periodontal sickness, orthodontic device, or
with some dental anomalies, and those making use of
medications that could interfere with the central nervous
system were excluded.
The prevalence of bruxism in this population was eval-
uated, after which a convenience sample (n = 66) was
selected.
After application of the eligibility criteria, children
were divided into main and control groups. Overall, 34
healthy children with parent/caregiver’s report of noc-
turnal bruxism (exposition) aged 3–7 years and with
complete primary or mixed dentition were selected to
participate in the main group. The control group (n = 32)
was composed of children without bruxism paired by
gender and age.
Data collection instruments
General questions
Data were collected by complete anamnesis performed
by a trained examiner through interviews with parents/
caregivers to confirm sociodemographic data such as
child gender, age, and parental/caregiver education. In
addition, information about family economic status was
collected.24
CRANIO® : The Journal of Craniomandibular & Sleep Practice  2017  VOL. 35   NO.
Alencar et al.  Bruxism associated with lifestyle and facial disorders
Child’s routine, sleep history
Information about lifestyle features such as the child’s
routine and physical activities, and the awakening and
sleep history (parasomnias) were also collected through
interviews with parents/caregivers.
Oral facial disorders
Oral facial disorders were evaluated by means of the mas-
seter muscle activity, as well as the consequences of brux-
ism to the temporomandibular joint and auditory system.
Masseter muscle activity
The masseter muscle activity was evaluated by electro-
myography examination (EMG) conducted in both groups
with an electromyography apparatus (EMG System 500®,
São José dos Campos, Brazil). The authors used surface
electrode stickers (3M ® model 2223BR – 3M Brazil
Ltda) appropriate for children. During examination of
EMG signs, subjects were placed sitting upright in a
chair with back straight and looking at the horizon, with
the Frankfurt horizontal plane parallel to the ground and
hands on the legs, as performed in previous studies.25,26
The reference electrode was placed on the palm of the
hand between thumb and forefinger, on the interdigital
space, which comprises a reference area of easy location.
The remaining electrodes were placed on the region of
the greatest activity of the masseter muscle.27 For such
identification, the authors requested that patients simulate
a voluntary maximum bite force in a load cell. The results
of EMG examinations were expressed by the mean value
(Kgf).
Temporomandibular joint, headache, and auditory
parameters
A modification in the Research Diagnostic Criteria for
Temporomandibular Disorders (RDC/TMD) Axis II
Questionnaire28 was performed in order to evaluate the
possible consequences of bruxism to the temporomandib-
ular joint (TMJ) of children. Only questions about pain
applicable to children were included in this questionnaire,
which was applied by a trained examiner through inter-
views directed to parents/caregivers. The same methodol-
ogy was used to detect the presence or absence of headache
and auditory disorders such as earache, plugged ear, ear
thumping sound, ear buzzing sound, and ear infection.
Statistical analysis
Statistical analysis was performed using the SPSS sta-
tistical software (version 20.0, Chicago IL, USA). The
independent categorical variables (gender, daily awak-
ening, headache, TMJ, and auditory consequences) were
analyzed by the chi-square test. The family economic sta-
tus was analyzed by Mann–Whitney test, and EMG mean
3 169
 Alencar et al.  Bruxism associated with lifestyle and facial disorders

Table 1  Values obtained from the multiple logistic regression for the selection of variables (p<0.20): possible risk factors
during the day, and possible parasomnias associated with bruxism.

Selection of variables (p<0.20) Final model variables Coefficient of determination

Variable OR (odds ratio) p value R2
Time of playing a
0.53 0.250 0.028
Time of computer useb 1.28 0.743 0.003
Time of videogame useb 1.22 0.806 0.002
Scheduled athletic/artistic activityc 1.20 0.728 0.002
Time of extracurricular activityd 0.71 0.602 0.006
Nightmares 18.09 0.002* 0.363
Drooling 1.37 0.739 0.041
Snoring 0.14 0.013* 0.289
Sleeptalking 1.33 0.722 0.096
Awakening 0.46 0.306 0.118
Sleepwalking 0.20 0.207 0.102
Nocturnal enuresis – – –
a
“Only weekends” or “any time outside the school”;
b
“No use” or “daily use of 30 min or more”;
c
“Yes” or “no”;
d
“None and 2 h or less” or “more than 2 h”. Means that the variable was eliminated because p value was > 0.20;
*
Demonstrated association on the final model. R2 summarizes the proportion of variance in the dependent variable associated with the
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predictor (independent) variables, with larger R2 values indicating that more of the variation is explained by the model.

values were analyzed by the t-test. A multiple logistic
regression (MLR) model was performed to test associ-
ations between bruxism (as the dependent variable) and
possible factors during the day and during sleep (independ-
ent variables). The variables included had p value < 0.20.
The inclusion of variables was made one by one, where
only those with significance level of p < 0.05 were kept
in the final model. The final significance level was set at
5%. In addition, the child’s routine during the day was
interpreted with respect to the time into ‘only weekends’
(less leisure time) or ‘any time outside of school’ (more
leisure time). Moreover, the independent variable ‘time
of computer/videogames’ was investigated, considering
the following options: ‘no use’ or ‘daily use of 30 min or
more.’ Also, the independent variable ‘scheduled athletic/
artistic activity’ was carried out, considering the following
answer options: ‘yes’ or ‘no.’ In addition, the independent
variable ‘time of extracurricular activity’ was assessed,
considering the following options: ‘none or 2 h or less’
or ‘more than 2 h.’
Results
The authors evaluated 839 children aged 0–16 years. Of
these, 420 were 3–7 years old, and 138 had parental report
of teeth grinding (32.8%). Thus, the prevalence of brux-
ism was 32.8% for children aged 3–7 years. After the
application of the eligibility criteria to 420 children, 66
composed the final sample, in which 51.5% (n = 34) had
parental report of teeth grinding. The mean age of children
was 5.33 (±1.10), and 59.1% were female. Of the 66 sub-
jects selected for this study, 72.7% had medium-low social
economic status. Multiple logistic regression did not show
any association between potential risk factors during the
day and bruxism. All these variables were eliminated
from the model because the p value was > 0.20 (Table
1). On the other hand, considering the possible paras-
omnias associated with bruxism during sleep, backward
stepwise logistic regression revealed that nightmares and
snoring (variables that demonstrated association on the
final model) have great probability of being associated
with bruxism. Actually, nightmares increase the chance
of the child having bruxism by 18 times. On the other
hand, drooling, sleep talking, awakening, sleepwalking,
and nocturnal enuresis did not demonstrate association on
the final model (Table 1).
Multiple logistic regression revealed that children with
bruxism have poorer consequences in their awakening and
to TMJ (‘Child wakes up looking tired,’ ‘Child has diffi-
culty getting out of bed,’ ‘Child wakes up in bad mood,’
‘Child feels tired or has painful jaw in the morning’) com-
pared to children without bruxism (p < 0.05) (Table 2).
However, children with bruxism have more headaches and
facial pain, and consequently, a sad appearance (p < 0.05)
(Table 3). The variables included in the MLR model, such
as ‘facial pain limited chewing,’ ‘drinking,’ ‘playing,’ ‘eat-
ing hard or soft foods,’ ‘smiling,’ ‘brushing teeth,’ ‘yawn-
ing,’ ‘swallowing,’ and ‘talking’ did not demonstrate any
association with the presence of bruxism (Table 3).
Considering the auditory consequences of bruxism, no
difference was observed between groups (p > 0.05) (Table
3), nor was any difference detected between children with
bruxism and those without the disorder, considering the
EMG results (Table 4).
Discussion
There are several theories in literature that attempt to
uncover the real risk factors associated with the trigger-
ing of bruxism in children.7,9,19,29,30 Additionally, there are

170 CRANIO® : The Journal of Craniomandibular & Sleep Practice  2017  VOL. 35   NO. 3
 Alencar et al.  Bruxism associated with lifestyle and facial disorders

Table 2  Consequences of bruxism in daily awakening.

Bruxism
p value χ2
Possible consequences in daily awakening No (n = 32) Yes (n = 34) Odds ratio (confidence interval 95%) test
Child feels tired or has painful jaw in the morning 1.17 (1.02–1.34) 0.031*
 Yes 0 5
 No 32 29
Child wakes up in bad mood 0.31 (0.10–0.92) 0.029*
 Yes 7 16
 No 25 18
Child has difficulty getting out of bed 0.28 (0.09–0.82) 0.016*
 Yes 7 17
 No 25 17
Child wakes up looking tired 0.33 (0.10–1.01) 0.042*
 Yes 6 14
 No 26 20

Values that demonstrated association.

*

many signs and symptoms that can be observed with the variances, further studies are needed mainly to evaluate
persistence of this habit.7 Based on these findings, the the association of bruxism and the child’s routine related
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authors sought to investigate the possible risk factors
that trigger bruxism and the possible symptoms of this
parafunction in children. The authors studied activities
related to the child’s routine during the day involved with
leisure, playing, and practice of physical activities. Only
one study in the literature31 investigated the association
between tooth grinding and sports activities. They did
not find any correlations, and suggested the performance
of further studies. Thus, the authors decided to investi-
gate this topic and considered the time of playing and
physical practice by children an important variable to be
explored. Moreover, according to Dowling et al.,32 people
who frequently play electronic games are often associ-
ated with high levels of depression, anxiety, and other
psychological disorders.32 Based on the fact that brux-
ism is strongly associated with anxiety,19,29,33 the authors
supposed that the use of computer/videogames by chil-
dren could be a triggering factor for bruxism. Therefore,
considering the present results, the factors related to the
child’s routine during the day did not present association
with bruxism (Table 1). The sample of the present research
was composed of very young subjects who, so far, do not
demand much of themselves in respect to their activities.
Moreover, the author’s questions about the child’s routine
during the day were related to the time of practice of lei-
sure activities, which probably do not negatively affect the
child’s emotional aspects. Serra-Negra et al.31 observed
association between the tasks performed by children and
bruxism. However, unlike results of the present study,
these authors31 investigated tasks not only related to lei-
sure, but also those involved in household chores such
as making up the bed, sweeping, cleaning the house, and
caring for younger brothers and sisters. Thus, these chil-
dren probably suffer greater pressure from their families
to become more responsible in their daily tasks, different
from younger children in the present study. Given these
to both sense of duty and leisure.
Regarding the events that occurred during the child’s
sleep, Weideman et al.34 reported a strong possibility that
common sleep disorders are involved with the trigger-
ing of bruxism. Other studies16–18,35 found an association
between snoring and bruxism. This relationship may occur
because snoring is caused by increased airway resistance,
which is one of the typical symptoms of obstructive sleep
apnea, which induces masticatory muscle activity that in
turn may trigger bruxism.35 Carra et al.21 also reported
that children with bruxism complain about sleep disor-
ders; however, they did not find any connection between
nightmares, snoring and bruxism. In the present study,
children who snore and have nightmares were more likely
to gnash their teeth compared to those without this habit.
Thus, nightmares contributed to a probability of eight-
een times greater for triggering bruxism in children. The
authors speculated that these unpleasant experiences dur-
ing sleep not only change the way children sleep, but may
also be involved with the neurophysiologic mechanisms
related to the triggering of bruxism. These results have to
be interpreted with caution because of the observed low
values of the coefficient of determination (Table 1). These
values indicate that although the variables are significant,
only a small portion of the variability is explained by
the model. Thus, the authors suggest further studies to
elucidate these findings.
Although there are limitations related to this con-
venience sample, to the best of the authors’ knowledge,
this is the first study that investigated the possible wak-
ing up consequences due to the presence of bruxism in
children under seven years of age. The authors found
more awakening alterations such as bad mood, pain or
fatigue in the jaw, and difficulty getting out of bed in
these children (Table 2). The authors consider that these
symptoms represent a warning sign for the presence of

CRANIO® : The Journal of Craniomandibular & Sleep Practice  2017  VOL. 35   NO. 3 171
 Alencar et al.  Bruxism associated with lifestyle and facial disorders

Table 3  Consequences of bruxism for TMJ, headache, and ear disorders.

Bruxism
Odds ratio (confidence
Possible Consequences on TMJ No (n = 32) Yes (n = 34) interval 95%) p value χ2 test
Child had recent facial pain 1.21(1.03–1.41) 0.015*
 Yes 0 6
 No 320 28
Facial pain limited chewing 0 3 1.09(0.98–1.21) 0.131
 Yes 32 31
 No
Facial pain limited drinking 1.03 (0.97–1.09) 0.515
 Yes 0 1
 No 32 33
Facial pain limited playing – –
 Yes 0 0
 No 32 34
Facial pain limited eating hard or soft foods 1.03(0.97–1.09) 0.515
 Yes 0 2
 No 32 32
Facial pain limited smiling 1.06 (0.97–1.15) 0.262
 Yes 0 2
 No 32 32
Facial pain limited brushing teeth 1.06 (0.97–1.15) 0.262
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 Yes 0 2
 No 32 32
Facial pain limited yawning – –
 Yes 0 0
 No 32 34
Facial pain limited swallowing – –
 Yes 0 0
 No 32 34
Facial pain limited talking 1.09(0.98–1.21) 0.131
 Yes 0 3
 No 32 31
Facial pain causes sad appearance 1.17(1.02–1.34) 0.031*
 Yes 0 5
 No 32 29
Headaches 0.17 (0.06–0.52) 0.001*
 Yes 13 27
 No 19 7
Possible auditive consequences Bruxism Odds ratio (confidence p value χ2 test
No (n = 32) Yes (n = 34) interval 95%)
Plugged ear 0.24 (0.02–2.29) 0.197
 Yes 1 4
 No 31 30
Ear thumping sound 1.03 (0.97–1.09) 0.515
 Yes 0 1
 No 32 33
Ear buzzing sound 1.13 (1.00 1.28) 0.064
 Yes 0 4
 No 32 30
Earache 2.45 (0.87–6.87) 0.071
 Yes 15 9
 No 17 25
Ear infection 0.73 (0.20–2.03) 0.369
 Yes 10 13
 No 22 21

Values demonstrating association.

*

bruxism and should be included in the dentist’s anamne-
sis to support the diagnosis of this parafunction in chil-
dren. In agreement with results of the present study, Carra
et al.21 reported a significantly higher frequency of day-
time sleepiness, feeling tired in the morning, and difficulty
in waking up in the morning in a population aged 7–17
years with bruxism.
The authors observed a high frequency of headache
and temporomandibular consequences such as ‛recent
facial pain’ and ‛sad appearance due to facial pain’ in
the sample composed of children with bruxism (Table 3).
Some studies corroborate the results of the present study
in respect to the high prevalence of headache in children
with bruxism.19,36 On the other hand, the association of
bruxism and temporomandibular disorders still remains
a controversial topic in literature,37 since bruxism could
be considered as a consequence of the masticatory neu-
romuscular system immaturity.37 Based on the above, the

172 CRANIO® : The Journal of Craniomandibular & Sleep Practice  2017  VOL. 35   NO. 3
 Alencar et al.  Bruxism associated with lifestyle and facial disorders

Table 4  Mean (± SD) scores of electromyography analyses for children with and without bruxism (kgf)

Bruxism
Yes (n = 30) No (n = 29)
Electromyography analyses (kgf) Mean (±SD) Mean (±SD) p value (Mann–Whitney test)
Right side
Bite force −18.34(±9.26) −18.87(±9.77) 0.620
Right masseter 4.14(±0.74) 4.35(±0.70) 0.480
Left masseter 6.97 (±0.71) 7.15 (±0.55) 0.136
Left Side
Bite force −17.79 (±11.05) −17.31 (±9.94) 0.632
Right masseter 4.15 (±0.69) 4.24 (±0.56) 0.561
Left masseter 7.07 (±1.13) 7.07 (±0.59) 0.130

authors believe that the results of the temporomandibu-
lar consequences could also be interpreted as transitory
consequences arising from the presence of bruxism in a
person still young and immature and not fully developed.
Moreover, bruxism is a parafuncional habit, which tends
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not only in their daily routines, but also in their com-
plaints of orofacial and head pain, and in their morning
appearance.
Author’s contributions

to reduce its prevalence with advancing age; thus, brux-
ism in these children was not long and severe enough
to trigger temporomandibular disorder (TMD). Cheifetz
et al.5 did not find association between bruxism and TMD.
In addition, Serra-Negra et al.38 explained that there are
few evidences about the future triggering of TMD in chil-
dren with bruxism. Accordingly, further studies should be
carried out to investigate the association of bruxism and
TMD in children.
In the present study, although children with bruxism
did not present auditory alterations when compared to
controls, the results of the present research (‘ear buzzing
sound’ and ‘earache’ – Table 3) indicate that there is a
tendency for this association. Future studies with larger
samples are needed to better understand this associa-
tion. Supported by the fact that bruxism occurs during
movements of the parafunctional masticatory system,
some authors believe that this habit may be related to
changes in the masticatory muscles.39 In a preliminary
study40 that monitored alterations in the movements of
the voluntary muscle, the authors observed differences in
EMG results between children with and without bruxism.
The EMG results of the present study demonstrated no
difference between groups. Although the authors did not
evaluate the activity of the masseter muscle during vol-
untary movements (only in bite force movement), they
presume that the divergent results of the present study
can be explained by the low age of children included in
the present research, in which alterations in the orofacial
musculature are difficult to identify, since young children
are in constant change.
Conclusion
The presence of nightmares and snoring were parasom-
nias associated with bruxism in children. In addition,
bruxism elicits consequences for the children’s lives,
Nashalie Andrade de Alencar contributed to design the
study, with the acquisition of data, to analyze data and to
draft the initial manuscript.
Alline Birra Nolasco Fernandes was responsible for the
electromyography analyses of all selected subjects from
both groups.
Margareth Maria Gomes de Souza conducted the sta-
tistical analyses and approved the final manuscript as
submitted.
Ronir Raggio Luiz conducted the statistical analyses,
reviewed and revised the manuscript, and approved the
final manuscript as submitted.
Andréa Fonseca-Gonçalves designed the study, critically
reviewed manuscript, analyzed data, and approved the
final manuscript as submitted.
Lucianne Cople Maia made substantial contributions to
conception and design the study, critically reviewed and
revised the manuscript and approved the final manuscript
as submitted.
Conflict of interest
All authors declare no conflicts of interest.
Acknowledgments
All authors are very grateful to the children and their par-
ents/caregivers for their participation in the study. This
study composes the master degree thesis of the first author.
Funding
This work was supported by FAPERJ and CAPES.
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