JCTXXX10.

1177/2380084419894576JDR Clinical & TranslationalImpact of Oral Problems on the Social Behavior of Preschoolers
research-article2019

Vol. XX • Issue X Impact of Oral Problems on the Social Behavior of Preschoolers

Original Report: Epidemiologic Research

Self-Perceptions of the Impact of

Oral Problems on the Social Behavior
of Preschoolers
M.F. Perazzo1 , M.C. Gomes2, É.T.B. Neves2, R.T. Firmino1 , A.A. Barros2, L.C. Silva2, C.C. Martins1,
S.M. Paiva1, and A.F. Granville-Garcia2

Abstract: Introduction: Investigating the children for the determination of problems exerted an impact on the
preschool children’s social behaviors dental caries, traumatic dental injury social behavior of the preschoolers
and the association with oral health (TDI), malocclusion, and bruxism. analyzed, such as playing, sleeping,
variables helps to understand child Descriptive and Poisson regression and smiling.
development. Besides that, different analysis for complex samples with
Knowledge Transfer Statement: The
perceptions need to be explored robust variance was used to test the
results of the present study may help
regarding the impact of oral problems associations (α = 5%).
parents and clinicians to understand
on the social behavior between the Results: The variables associated better the association of oral problems with
child’s self-report and parent’s/ with difficulty sleeping were low the social behavior of preschool children.
caregiver’s proxy report. household income (confidence interval Moreover, this study shows the importance
Objective: To determine which [CI]: 1.40–3.01), number of untreated of listening to children in clinical
socioeconomic and oral factors are dental caries (CI, 1.02–1.04), dental decisions. These results also can help in the
associated with difficulty sleeping and pain (CI, 1.76–3.59), TDI (CI, 1.08– elaboration of oral health policies.
playing and the avoidance of smiling 2.11), and anterior open bite (CI,
Keywords: play and playthings, pre-
in preschoolers. 1.11–2.20). Difficulty playing also
school child, quality of life, sleep, smil-
was associated with the low household
Methods: A cross-sectional study ing, psychometrics
income (CI, 1.34–3.15), number of
was conducted with a representative
untreated dental caries (CI, 1.01–
random sample of 769 pairs of parents/ Introduction
1.04), dental pain (CI,1.42–3.61),
caregivers and 5-y-old preschoolers.
and TDI (CI, 1.13–2.33). The number
The preschoolers answered a Child development is a gradual
of untreated dental caries (CI, 1.02–
questionnaire on difficulty sleeping, unfolding of biologically determined
1.05), dental pain (CI, 1.03–2.88),
difficulty playing, and the avoidance characteristics that arise as a child
anterior open bite (CI, 1.30–3.26), and
of smiling for reasons related to oral learns from experience (Pem 2015).
not using dental services (CI, 1.13–
problems. The parents/caregivers Good development in childhood could
2.73) were determinant factors for the
answered a questionnaire addressing mean healthier adulthood in terms
avoidance of smiling.
socioeconomic characteristics as of better social, economic, physical,
well as the use of dental services. Conclusion: Socioeconomic, and cognitive aspects (Blair and Raver
Two calibrated dentists examined symptomatic, and/or oral esthetic 2012; Pem 2015). Factors that exert a

DOI: 10.1177/2380084419894576. 1Department of Pediatric Dentistry, Federal University of Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil; 2Postgraduate
Program in Dentistry, State University of Paraíba (UEPB), Campina Grande, Paraíba, Brazil. Corresponding author: A.F. Granville-Garcia, Postgraduate Program in Dentistry,
State University of Paraíba (UEPB), 351 Rua Baraúnas, Bairro Universitário, Campina Grande, 58429-500, Paraíba, Brazil. Email: anaflaviagg@gmail.com.

© International & American Associations for Dental Research 2019

1
 JDR Clinical & Translational Research
negative impact on sleeping, playing,
and smiling can affect the development
of preschoolers since these behaviors
have physiological and social importance
(Abanto et al. 2014; Perazzo et al. 2017).
A healthy smile and playing are important
components of self-esteem and interpersonal
relationships (Bönecker et al. 2012),
while sleep affects aspects of
neurobehavioral functioning (Maski
and Kothare 2013).
Oral problems can exert an impact
on aspects of daily living and the
development of preschoolers (Bönecker
et al. 2012; Clementino et al. 2015).
Perceptions regarding the impact of
oral problems on the social behavior of
preschoolers can differ between a child’s
self-report and a parent’s/caregiver’s
proxy report (Fernandes et al. 2015;
Perazzo et al. 2017). As young children
are dependent on others for their health
care needs, an inadequate perception on
the part of parents/caregivers can lead to
delays in seeking dental/psychological
treatment (da Silva et al. 2011).
Understanding a child’s self-perception
may help clarify the negative impact that
oral problems have on aspects of daily
living, especially in a phase when time is
divided between parents/caregivers and
preschool (Pahel et al. 2007; Fernandes
et al. 2015; Perazzo et al. 2017). To our
knowledge, no previous studies have
evaluated the effect of problems on
aspects of daily living, such as sleeping,
playing, and smiling, using the reports of
5-y-old children. Therefore, the purpose
of the present study was to determine if
sociodemographic, economic, and oral
factors could be associated with difficulty
sleeping, difficulty playing, and the
avoidance of smiling in a randomly selected
sample of preschoolers. The alternative
hypothesis is that these independents
variables have a negative impact on the
social behavior of preschoolers.
Methods
Sample Characteristics
This study was developed following
the Declaration of Helsinki and
received approval from the Human
2
Research Ethics Committee of the State
University of Paraiba, Brazil (certificate
number: 38937714.0.0000.5187), and
was conducted following the norms
of the Strengthening the Reporting of
Observational Studies in Epidemiology
(STROBE) statement. A preschool-based
cross-sectional study was conducted
with a sample of 769 pairs of parents/
caregivers and 5-y-old preschoolers
enrolled at preschools between
August and December 2015 in a city
in northeastern Brazil. This city has an
average income of US$110 per capita per
month, a Human Development Index
of 0.72, and a poverty rate of 58.88%
(Brazilian Institute of Geography and
Statistics 2018).
The sample was selected using
a 2-stage strategy to ensure
representativeness. In the first stage,
20 public preschools and 28 private
preschools were randomly selected
among 263 preschools in the 6
administrative districts of the city. In the
second stage, pairs of parents/caregivers
and children were randomly selected
from each preschool. For the calculation
of the sample size, a 50% prevalence rate
of the outcome was employed to provide
the largest possible number of subjects
and enhance the statistical power of the
study (Browner et al. 2007). Assuming
a 5% margin of error, a 95% confidence
level, and a correction factor of 1.6
to compensate for the design effect,
the sample size was estimated at 615
preschoolers, to which 20% was added
to compensate for possible dropouts,
leading to a total of 769 children aged
5 y. All parents/caregivers received
clarifications regarding the objectives
of the study and were invited to sign a
statement of informed consent.
Eligibility Criteria
The inclusion criteria were 5-y-old
children with no systematic diseases
(based on parents’ reports) enrolled
at preschools. The parents/caregivers
needed to be fluent in Brazilian
Portuguese and spend at least 12 h
per day with the child. Children with
permanent teeth and/or a history of
Month 2019
orthodontic treatment were excluded
from the study.
Training, Calibration
Exercise, and Pilot Study
The training and calibration exercise
was divided into 2 steps: theoretical
and clinical. In the first step, an
expert (pediatric dentist) discussed
the criteria for the diagnosis of dental
caries, traumatic dental injuries, and
malocclusion. In the second step,
2 dentists and the expert examined
40 children in a randomly selected
preschool. These participants were
not included in the main sample.
Interexaminer kappa coefficients were
0.80 to 0.90 for dental caries, 0.88 to
0.90 for traumatic dental injury, and
0.86 to 0.91 for malocclusion. After a
7-d interval, a second examination of
the same children was performed for
the determination of intraexaminer
agreement (kappa = 0.87–1.00 for dental
caries, 0.82–0.87 for traumatic dental
injury, and 0.94–1.00 for malocclusion).
A pilot study was conducted to test the
nonclinical and clinical data collection
methods. The participants in the pilot
study (n = 45) were not included in the
main sample. Based on the results of this
step, no changes to the data collection
process were deemed necessary.
Nonclinical Data Collection
Items were used to evaluate the
children’s self-perceptions regarding the
impact of oral problems on sleeping
(has it ever been hard for you to sleep
because of your teeth?), playing (has it
ever been hard for you to play because
of your teeth?), and the avoidance
of smiling (have you ever not smiled
because of how your teeth look?). Three
response options were offered (no =
0, a little = 1, a lot = 2) aided by an
explanation card with corresponding
faces (Tsakos et al. 2012; Abanto et al.
2013). The following socioeconomic
characteristics were also collected: child’s
gender, parent’s/caregiver’s age, monthly
household income (categorized based on
the median, which was equal to US$280),
and the use of dental services.
 Vol. XX • Issue X
Clinical Data Collection
The children’s teeth were brushed
to remove plaque and facilitate the
diagnosis. Oral examinations were
performed in the knee-to-knee position
with the aid of a portable lamp attached
to the examiner’s head (Petzl Zoom
headlamp; Petzl America). The dentists
used individual protection equipment,
a sterilized mouth mirror (PRISMA),
sterilized Williams probe (WHO-621,
Trinity; Campo Mourão), and gauze to
dry the teeth.
Dental caries was diagnosed using
the International Caries Detection and
Assessment System (ICDAS-II), which
is a scoring system ranging from 0
(absence of dental caries) to 6 points.
In the present study, the frequency
of cavitated carious lesions (code ≥3)
was investigated (Ismail et al. 2007).
Traumatic dental injury was diagnosed
based on the criteria proposed by
Andreasen et al. (2007) and recorded
as present when any traumatic dental
injury or tooth discoloration was found.
Malocclusion was recorded in the
presence of at least 1 of the following
conditions: increased overbite (>2 mm),
increased overjet (>2 mm), anterior open
bite, anterior crossbite, and posterior
crossbite (Foster and Hamilton 1969;
Grabowski et al. 2007). The diagnosis of
sleep bruxism was based on parental/
caregiver reports of the occurrence of
tooth grinding during sleep, as proposed
by the American Academy of Sleep
Medicine for preschoolers (Buysse
et al. 2003) and employed in a previous
study (Serra-Negra et al. 2013). Dental
pain at some time in the life of the child
was investigated through proxy reports
from parents/caregivers. Fluoride varnish
was applied to the teeth following the
examinations.
Statistical Analysis
Data organization and statistical
analysis were performed using the
Statistical Package for Social Sciences
(SPSS for Windows, version 25.0; SPSS,
Inc.). Poisson regression with robust
variance for complex samples was
Impact of Oral Problems on the Social Behavior of Preschoolers
performed considering the design effect
and sample selection weights. The
analysis was employed to correlate the
score of each dependent variable (impact
of oral problems on playing, sleeping,
and smiling) and the independent
variables (nonclinical and clinical data).
The stepwise backward procedure
was used for the selection of variables
with a P value <0.20 in the bivariate
analysis as well as variables considered
epidemiological determinants. Variables
with a P value <0.05 in the adjusted
analysis were maintained in the final
regression model. The goodness of
fit of the final regression models was
evaluated by the Akaike’s information
criterion (AIC), finite sample-corrected
Akaike’s information criterion (AICC),
and Bayesian information criterion (BIC)
statistics.
Results
A total of 769 pairs of preschoolers
and their parents/caregivers participated
in this study. The prevalence of
children’s reports of difficulty sleeping,
difficulty playing, and the avoidance of
smiling was 23.3%, 22.1%, and 17.8%,
respectively. Table 1 displays the clinical
characteristics of the children as well
as the socioeconomic characteristics of
the sample. Boys accounted for 52.4%
of the preschoolers. Most parents/
caregivers were 31 y of age or older
(56.1%) and had a monthly household
income of less than US$280 (50.3%). The
majority of children had never visited
a dentist (56.5%). The frequencies of
oral problems among the children were
23.8% for dental pain, 26.9% for sleep
bruxism, 52.8% for traumatic dental
injury, 57.7% for malocclusion, and 15.2%
specifically for anterior open bite. The
mean (SD) number of cavitated carious
lesions among the preschoolers was 14.6
(12.6) (median, 12; range, 66).
Table 2 displays the results of the
Poisson regression analyses for difficulty
sleeping, difficulty playing, and the
avoidance of smiling. In the adjusted
model, the variables associated with
difficulty sleeping were low monthly
household income (prevalence ratio
[PR] = 2.05; 95% confidence interval [CI],
1.40–3.01), number of untreated dental
caries (PR = 1.03; 95% CI, 1.02–1.04),
dental pain (PR = 2.51; 95% CI, 1.76–
3.59), traumatic dental injury (PR = 1.51;
95% CI, 1.08–2.11), and anterior open
bite (PR = 1.56; 95% CI, 1.11–2.20).
The variables associated with difficulty
playing were low household income
(PR = 2.05; 95% CI, 1.34–3.15), number
of untreated dental caries (PR = 1.03;
95% CI, 1.01–1.04), dental pain (PR =
2.26; 95% CI, 1.42–3.61), and traumatic
dental injury (PR = 1.62; 95% CI, 1.13–
2.33). The avoidance of smiling was
associated with the number of untreated
dental caries (PR = 1.03; 95% CI, 1.02–
1.05), dental pain (PR = 1.72; 95% CI,
1.03–2.88), anterior open bite (PR = 2.06;
95% CI, 1.30–3.26), and not using dental
services (PR = 1.75; 95% CI, 1.13–2.73).
Discussion
This study evaluated factors associated
with difficulty sleeping, difficulty playing,
and the avoidance of smiling among
preschoolers. Current evidence shows
that children aged 4 to 6 y are capable
of reliably reporting on the more
concrete domains of their general health
and quality of life (Tsakos et al. 2012;
Abanto et al. 2013). Moreover, parents/
caregivers may have limited knowledge
regarding their children’s due to their
working routine, social life outside
the home, and the time the child is at
preschool or daycare, making proxy
reports less accurate (Jokovic et al.
2004). The present findings demonstrate
the negative impacts of socioeconomic
factors and oral problems on sleeping,
playing, and smiling.
Difficulty sleeping (23.3%) was the
most reported negative impact by the
preschoolers, followed by difficulty
playing (22.1%) and the avoidance
of smiling (17.8%). The factors
associated with these negative impacts
varied mainly in terms of economic,
symptomatic, and esthetic aspects.
Socioeconomic status affects oral
conditions that are closely associated
3
 JDR Clinical & Translational Research Month 2019

Table 1. associations found between the number

Characterization of Sample. of untreated dental caries and traumatic
dental injury and both difficulty sleeping
Frequency and playing. However, a previous study
Variable n % involving the analysis of proxy reports
from parents/caregivers found that dental
Child’s sex caries exerted no impact on playing
 Female 366 47.6 (Abanto et al. 2014). It is likely that the
concerns of parents/caregivers are rather
 Male 403 52.4 different from those of their preschool
children and are focused more on other
Parent’s/caregiver’s age, y
functional aspects of daily living (Abanto
  <31 323 43.9 et al. 2014; Fernandes et al. 2015). Such
differences underscore the importance of
  ≥31 413 56.1
considering both children’s and parental
Monthly household income reports in studies involving preschoolers
(Abanto et al. 2015; Perazzo et al. 2017).
  ≤US$280 370 50.3
For a long time, it was believed
  >US$280 365 49.7 that most esthetic oral factors were
not an important aspect of the lives
Use of dental services of preschoolers (Tsakos et al. 2012).
 Yes 334 43.5 However, children’s reports of social
behavior have proved otherwise (Abanto
 No 434 56.5
et al. 2013; Granville-Garcia
Dental pain et al. 2016; Perazzo et al. 2017). Anterior
open bite can affect oral esthetics and
 Yes 180 23.8 was associated with difficulty sleeping
 No 576 76.2 and avoiding smiling. Functional
limitations related to anterior open
Sleep bruxism bite, such as pronouncing words,
 Yes 205 26.9
also could contribute to this negative
impact (Ramos-Jorge et al. 2015). A
 No 556 73.1 similar justification can be attributed to
the association between the number
Traumatic dental injury
of untreated dental caries and social
 Yes 406 52.8 aspects. Besides the functional limitation
caused mainly by dental pain, there is
 No 363 47.2
a negative impact on esthetics when
Malocclusion carious lesions are located on anterior
teeth (Clementino et al. 2015; Perazzo
 Yes 443 57.7
et al. 2017). Sleep bruxism was not
 No 325 42.3 associated with a negative impact,
probably because it was not severe
Anterior open bite enough to cause aesthetic problems or
 Yes 116 15.2 pain (Perazzo et al. 2017).
Parents/caregivers play an important
 No 648 84.8 role in seeking dental care for the oral
Mean (SD) Median (Range) conditions of their children (Granville-
Garcia et al. 2015; Perazzo et al. 2016).
Untreated dental caries 14.6 (12.6) 12 (66) Children who failed to use dental
services were more likely to avoid
with a negative impact on social Perazzo et al. 2017). In the present smiling. Not visiting the dentist regularly
behavior, especially when the problem study, the probable dental pain caused may increase children’s susceptibility to
is symptomatic (Abanto et al. 2014; by oral problems could explain the oral problems and their consequences

4
 Vol. XX • Issue X Impact of Oral Problems on the Social Behavior of Preschoolers

Table 2.
Poisson Regression Analyses of Independent Variables Associated with Difficulty Sleeping, Difficulty Playing, and Avoiding Smiling in
5-y-Old Children.

Difficulty Sleeping Difficulty Playing Avoidance of Smiling

PR Adjusted PR Adjusted PR Adjusted
Variables Mean (SD) (95% CI)a Mean (SD) (95% CI)b Mean (SD) (95% CI)c
Child’s sex
 Female 0.3 (0.6) 0.3 (0.6) 0.2 (0.5)

 Male 0.3 (0.6) 0.3 (0.7) 0.3 (0.6)

Parent’s/caregiver’s age, y
 <31 0.3 (0.6) 0.3 (0.6) 0.3 (0.6)

  ≥31 0.3 (0.7) 0.3 (0.6) 0.2 (0.6)

Monthly household income

 >US$280 0.2 (0.5) 1.00 0.2 (0.5) 1.00 0.2 (0.5) 1.00

  ≤US$280 0.4 (0.7) 2.05 (1.40–3.01) 0.4 (0.7) 2.05 (1.34–3.15) 0.3 (0.6) 1.60 (0.98–2.62)

Number of untreated 1.03 (1.02–1.04) 1.03 (1.01–1.04) 1.03 (1.02–1.05)

  dental caries
Dental pain
 Yes 0.6 (0.8) 2.51 (1.76–3.59) 0.5 (0.8) 2.26 (1.42–3.61) 0.4 (0.7) 1.72 (1.03–2.88)

 No 0.2 (0.6) 1.00 0.3 (0.6) 1.00 0.2 (0.5) 1.00

Sleep bruxism
 Yes 0.3 (0.6) 1.00 0.3 (0.6) 0.74 (0.46–1.20) 0.2 (0.5)

 No 0.4 (0.7) 1.49 (1.00–2.24) 0.3 (0.7) 1.00 0.3 (0.6)

Traumatic dental injury

 Yes 0.4 (0.7) 1.51 (1.08–2.11) 0.4 (0.7) 1.62 (1.13–2.33) 0.2 (0.5) 1.00

 No 0.3 (0.6) 1.00 0.3 (0.6) 1.00 0.2 (0.6) 0.85 (0.55–1.30)

Malocclusion
 Yes 0.3 (0.6) 0.33 (0.65) 0.3 (0.6)

 No 0.3 (0.7) 0.29 (0.61) 0.2 (0.5)

Anterior open bite

 No 0.3 (0.6) 1.00 0.3 (0.6) 1.00 0.2 (0.5) 1.00

 Yes 0.5 (0.8) 1.56 (1.11–2.20) 0.5 (0.7) 1.44 (0.96–2.17) 0.4 (0.7) 2.06 (1.30–3.26)

Use of dental services

 Yes 0.3 (0.6) 0.3 (0.6) 0.2 (0.5) 1.00

 No 0.3 (0.7) 0.3 (0.7) 0.3 (0.6) 1.75 (1.13–2.73)

PR, prevalence ratio.

a
Variables incorporated into multivariate model (P < 0.20): monthly household income, number of untreated dental caries, dental pain, sleep bruxism, traumatic
dental injury, and anterior open bite. Model fit: Akaike’s information criterion (AIC) = 18,380.463; finite sample-corrected Akaike’s information criterion (AICC) =
18,380.622; Bayesian information criterion (BIC) = 18,412.450.
b
Variables incorporated into multivariate model (P < 0.20): monthly household income, number of untreated dental caries, dental pain, sleep bruxism, traumatic
dental injury, and anterior open bite. Model fit: AIC = 19,567.400; AICC = 19,567.559; BIC = 19,599.386.
c
Variables incorporated into multivariate model (P < 0.20): monthly household income, number of untreated dental caries, dental pain, traumatic dental injury,
anterior open bite, and use of dental services. Model fit: AIC = 15,361.968; AICC = 15,362.126; BIC = 15,393.994.

5
 JDR Clinical & Translational Research
due to reduced access to oral health
preventive strategies. Furthermore, dental
pain was also associated with avoiding
smiling, contributing to explain the
association between lack of use of dental
services and avoiding smiling. However,
no association was found between the
other aspects of the child’s daily living
evaluated and the use of dental services
in this study.
The present investigation has the
limitations inherent to cross-sectional
studies using questionnaires, such as
memory bias. However, a pilot study
was executed to diminish possible biases
in the study. The items on difficulty
sleeping, difficulty playing, and the
avoidance of smiling have appropriate
psychometrics proprieties to be used
in studies evaluating the reports of
preschoolers (Abanto et al. 2013).
Moreover, Poisson regression analysis
may have led to overdispersion of data,
which is another limitation of the study.
Therefore, these findings show the
importance of considering the reports
of preschoolers regarding aspects that
involve social behaviors in clinical
interventions and public health
strategies. Parents/caregivers and dentists
should be aware of oral conditions and
aspects of the daily lives of children to
prevent future negative consequences.
Longitudinal studies are needed to clarify
the relationship of causality and allow
the establishment of public policies
aimed at encouraging early dental care.
Author Contributions
M.F. Perazzo, contributed to
design, data acquisition, analysis,
and interpretation, drafted and
critically revised the manuscript; M.C.
Gomes, É.T.B. Neves, contributed to
conception, data acquisition, analysis,
and interpretation, drafted and critically
revised the manuscript; R.T. Firmino,
C.C. Martins, contributed to design, data
analysis, and interpretation, drafted and
critically revised the manuscript; A.A.
Barros, L.C. Silva, contributed to design,
data acquisition, and interpretation,
drafted and critically revised the
manuscript; S.M. Paiva, A.F. Granville-
6
Garcia, contributed to conception,
design, data analysis, and interpretation,
drafted and critically revised the
manuscript. All authors gave final
approval and agree to be accountable for
all aspects of the work.
Acknowledgments
This study was supported by Paraíba
State University, State of Minas Gerais
Research Foundation (FAPEMIG),
Brazilian Coordination for the
Improvement of Higher Education
Personnel (CAPES)/Ministry of Education,
and the National Council for Scientific
and Technological Development (CNPq).
The authors declare no potential conflicts
of interest with respect to the authorship
and/or publication of this article.
ORCID iDs
M.F. Perazzo https://orcid.org/0000
-0003-1231-689X
R.T. Firmino https://orcid.org/0000
-0001-5581-0658
References
Abanto J, Tello G, Bonini GC, Oliveira LB,
Murakami C, Bönecker M. 2015. Impact of
traumatic dental injuries and malocclusions
on quality of life of preschool children: a
population-based study. Int J Paediatr Dent.
25(1):18–28.
Abanto J, Tsakos G, Paiva SM, Carvalho TS,
Raggio DP, Bönecker M. 2014. Impact of
dental caries and trauma on quality of life
among 5- to 6-year-old children: perceptions
of parents and children. Community Dent
Oral Epidemiol. 42(5):385–394.
Abanto J, Tsakos G, Paiva SM, Goursand D,
Raggio DP, Bönecker M. 2013. Cross-cultural
adaptation and psychometric properties of
the Brazilian version of the scale of oral
health outcomes for 5-year-old children
(SOHO-5). Health Qual Life Outcomes. 11:16.
Andreasen J, Andreasen F, Andersson L. 2007.
Textbook and color atlas of traumatic injuries
to the teeth. 4td ed. Copenhagen: Munskgaard.
Blair C, Raver CC. 2012. Child development
in the context of adversity: experiential
canalization of brain and behavior. Am
Psychol. 67(4):309–318.
Bönecker M, Abanto J, Tello G, Oliveira LB.
2012. Impact of dental caries on preschool
children’s quality of life: an update. Braz
Oral Res. 26(Suppl 1):103–107.
Month 2019
Brazilian Institute of Geography and Statistics.
2018. Paraíba: Campina Grande. [accessed
2019 Nov. 22]. https://cidades.ibge.gov.br/
brasil/pb/campina-grande/panorama.
Browner W, Newman T, Hulley S. 2007.
Estimating sample size and power:
applications and examples. In: Designing
clinical research. 3rd ed. Philadelphia:
Lippincott and Williams & Wilkins. p. 65–94.
Buysse DJ, Young T, Edinger JD, Carroll J,
Kotagal S. 2003. Clinicians’ use of the
International Classification of Sleep
Disorders: results of a national survey. Sleep.
26(1):48–51.
Clementino MA, Gomes MC, Pinto-Sarmento
TC de A, Martins CC, Granville-Garcia AF,
Paiva SM. 2015. Perceived impact of dental
pain on the quality of life of preschool
children and their families. PLoS One.
10(6):e0130602.
da Silva AN, Mendonça MH, Vettore MV. 2011.
The association between low-socioeconomic
status mother’s Sense of Coherence and their
child’s utilization of dental care. Community
Dent Oral Epidemiol. 39(2):115–126.
Fernandes IB, Ramos-Jorge J, Ramos-Jorge ML,
Bönecker M, Abanto J, Marques LS, Paiva SM.
2015. Correlation and comparative analysis
of discriminative validity of the Scale of Oral
Health Outcomes for Five-Year-Old Children
(SOHO-5) and the Early Childhood Oral
Health Impact Scale (ECOHIS) for dental
caries. BMC Oral Health. 15:29.
Foster TD, Hamilton MC. 1969. Occlusion in
the primary dentition: study of children at
2 and one-half to 3 years of age. Br Dent J.
126(2):76–79.
Grabowski R, Stahl F, Gaebel M, Kundt G. 2007.
Relationship between occlusal findings and
orofacial myofunctional status in primary
and mixed dentition. Part I: Prevalence
of malocclusions. J Orofac Orthop.
68(1):26–37.
Granville-Garcia AF, Clementino MA, Gomes
MC, Costa EM, Pinto-Sarmento TC, Paiva
SM. 2015. Influence of oral problems and
biopsychosocial factors on the utilization of
dental services by preschool children. J Dent
Child (Chic). 82(2):76–83.
Granville-Garcia AF, Gomes MC, Dantas LR,
Dantas LR, da Silva BR, Perazzo Mde F,
Siqueira MB. 2016. Parental influence on
children’s answers to an oral-health-related
quality of life questionnaire. Braz Oral Res.
30. pii: S1806-83242016000100230.
Ismail AI, Sohn W, Tellez M, Amaya A, Sen A,
Hasson H, Pitts NB. 2007. The International
Caries Detection and Assessment System
 Vol. XX • Issue X
(ICDAS): an integrated system for measuring
dental caries. Community Dent Oral
Epidemiol. 35(3):170–178.
Jokovic A, Locker D, Guyatt G. 2004. How
well do parents know their children?
Implications for proxy reporting of child
health-related quality of life. Qual Life Res.
13(7):1297–1307.
Maski KP, Kothare SV. 2013. Sleep deprivation
and neurobehavioral functioning in children.
Int J Psychophysiol. 89(2):259–264.
Pahel B, Rozier RG, Slade G. 2007. Parental
perceptions of children’s oral health: the
Early Childhood Oral Health Impact Scale
(ECOHIS). Health Qual Life Outcomes.
5:6.
Impact of Oral Problems on the Social Behavior of Preschoolers
Pem D. 2015. Factors affecting early childhood
growth and development: golden 1000 days.
Adv Practice Nurs 1:101.
Perazzo MF, Gomes MC, Neves ÉT, Martins
CC, Paiva SM, Costa EMM de B, Granville-
Garcia AF. 2017. Oral problems and
quality of life of preschool children:
self-reports of children and perception
of parents/caregivers. Eur J Oral Sci.
125(4):272–279.
Perazzo MF, Gomes MC, Neves ÉT, Martins
CC, Paiva SM, Granville-Garcia AF. 2016.
Oral health-related quality of life and sense
of coherence regarding the use of dental
services by preschool children. Int J Paediatr
Dent. 27(5):334–343.
Ramos-Jorge J, Motta T, Marques LS, Paiva SM,
Ramos-Jorge ML. 2015. Association between
anterior open bite and impact on quality of
life of preschool children. Braz Oral Res.
29:46.
Serra-Negra JM, Paiva SM, Abreu MH, Flores-
Mendoza CE, Pordeus IA. 2013. Relationship
between tasks performed, personality traits,
and sleep bruxism in Brazilian school
children—a population-based cross-sectional
study. PLoS One. 8(11):e80075.
Tsakos G, Blair YI, Yusuf H, Wright W, Watt RG,
Macpherson LMD. 2012. Developing a new
self-reported scale of oral health outcomes
for 5-year-old children (SOHO-5). Health
Qual Life Outcomes. 10:62.