S YS T E M AT I C R E V I E W P R O T O C O L

Obesity and dental caries in early childhood: a systematic

review protocol
Narendar Manohar 1  Andrew Hayen 2  Amit Arora 1,3,4,5
1
Campbelltown Campus, School of Science and Health, Western Sydney University, Penrith, Australia, 2Australian Centre for Public and Population
Health Research, Faculty of Health, University of Technology Sydney, Ultimo, Australia, 3Discipline of Child and Adolescent Health, Sydney Medical
School, Faculty of Medicine and Health, Westmead, Australia, 4Oral Health Services, Sydney Local Health District and Sydney Dental Hospital, Surry
Hills, Australia, and 5Translational Health Research Institute, Western Sydney University, Campbelltown, Australia

ABSTRACT
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Objective: The objectives of this review are to examine whether overweight/obese children experience more
dental caries compared with non-overweight/non-obese children, and to identify common risk factors associated
with both conditions.
Introduction: Systematic reviews have shown that any evidence on a link between overweight and/or obesity and
dental caries remains inconclusive. This relationship has not been assessed for children under six years of age with
primary dentition. Therefore, an updated systematic review of this topic is necessary as its findings will be important
for young children, clinicians, researchers and policy makers.
Inclusion criteria: Studies examining children under six years of age and with complete primary dentition at the
time of dental caries assessment will be included. The exposure of interest is the overweight and/or obesity status of
children under six years of age. The outcome is dental caries in children with complete primary dentition. There will
be no restriction on setting, date or language.
Methods: MEDLINE, Web of Science, Cochrane Central Register of Controlled Trials, Embase, PsycINFO, ProQuest
Central, Scopus, CINAHL, and Google Scholar will be searched for eligible studies. The electronic database search will
be supplemented by OpenGrey and Grey Literature Report databases, ProQuest Dissertations and Theses Global, and
the International Association for Dental Research conference websites. Two reviewers will independently screen and
select studies, assess methodological quality and extract data. Meta-analysis will be performed, if possible, and the
Grading of Recommendations Assessment Development and Evaluation (GRADE) Summary of Findings presented.
Systematic review registration number: PROSPERO CRD42018085292.
Keywords Childhood; dental caries; obesity; overweight
JBI Evid Synth 2020; 18(1):135–145.

Introduction or obese in 2016.2 The Global Burden of Disease

hildhood overweight and obesity are increas-
C ingly significant public health issues, and the
World Health Organization (WHO) has classified
both as key risk factors for chronic diseases such as
type 2 diabetes, cardiovascular disease, musculoskel-
etal disorders, certain cancers and psychological
comorbidities and subsequent mortality in adult-
hood.1-4 The WHO estimates that nearly 41 million
children under the age of five were either overweight
Correspondence: Narendar Manohar, drnarendar@gmail.com
The authors declare no conflict of interest.
DOI: 10.11124/JBISRIR-D-19-00058
Study examined the global, regional and national
prevalence of obesity in children from 1980 to 2013
and reported that the prevalence of obesity has
increased substantially in children from both devel-
oped and developing countries.5
Dental caries (i.e. tooth decay) is one of the most
common chronic diseases worldwide and presents a
persistent public health challenge for young chil-
dren.6-9 The consequences of untreated dental caries
can include severe pain, infection and abscesses, all
of which lead to repeat prescription of antibiotics,
distress and altered sleep patterns.10,11 Furthermore,
untreated dental caries can compromise children’s
growth and development, especially in relation to

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SYSTEMATIC REVIEW PROTOCOL
their poor dietary intake.7 There is also evidence that
decay in primary (i.e. baby) teeth is a strong risk
predictor of tooth decay in the permanent dentition.6
The causes of overweight and obesity, and dental
caries are multi-factorial, and share some common
risk factors including high-sugar diet, low socio-
economic status, limited use of health services and
low health literacy.12-14 The common risk factors for
these health conditions seem to increase the preva-
lence of both conditions and appear to be the most
accepted explanation for the relationship between
overweight and/or obesity, and dental caries.15 Sev-
eral researchers have postulated that overweight
and/or obesity may be a marker of dental car-
ies,16-18 but the evidence remains inconclusive. It
would be beneficial to clearly identify the common
risk factors that are associated with both of these
conditions. This will assist clinicians, researchers
and policy makers to implement health promotion
programs based on the common risk factor
approach, to reduce the burden of overweight
and/or obesity and dental caries in young chil-
dren.19,20
Multiple scoping searches of the literature were
conducted to assess previous systematic reviews on
overweight and/or obesity and dental caries. The
authors of this review also searched for registered
(e.g. PROSPERO)21 or published protocols of any
new or ongoing reviews. These searches revealed six
systematic reviews on this research topic. The assess-
ment of these reviews identified various knowledge
gaps. Most systematic reviews draw evidence pre-
dominantly from cross-sectional studies15,22-24
except for the reviews by Li et al.25 and Hooley
et al.,26 which reported evidence from multiple
observational study designs (i.e. cohort, nested
cross-sectional and case-control studies). However,
the literature search of Li et al.25 was limited to 2014,
and that of Hooley et al.26 was only until 2011, which
highlights the need for an updated review. Then, we
appraised the methodological quality of all previous
systematic reviews using the AMSTAR 2 tool27 and
all were rated as ‘‘critically low’’. None of the reviews
performed gray literature searches or contacted field
experts to gather information on ongoing and/or
unpublished studies.15,22-26 In addition, none of the
reviews identified the common risk factors for over-
weight and/or obesity and dental caries,15,22-26
which is the most accepted explanation for the
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N. Manohar et al.
inter-relationship12-14 between the two health condi-
tions. Furthermore, previous reviews searched the
evidence relating to both children and adolescents
(under 18 years of age),15,22-26 and the majority of
reviews did not distinguish the results specifically for
children under six years with primary (baby) denti-
tion,15,24-26 which highlights a need to focus on evi-
dence in early childhood (under six years), as the
health status at a young age is a strong predictor
for wide-ranging health outcomes later in life.28,29
Moreover, all reviews conducted the literature search
on limited databases,15,22-26 with some restricted to
English language only,23,25 which might lead to
missing important evidence and language bias,
respectively.30,31 Finally, none of the reviews distin-
guished the results depending on the design of
included studies15,23,24,26; they considered the evi-
dence drawn from cross-sectional, cohort and case-
control studies as equal rather than weighing the
evidence as per the levels of quality of evidence.32
These gaps identify a need for a high-quality system-
atic review to ascertain if overweight and/or obese
children are at increased risk for dental caries.
The objectives of this review are i) to identify
whether overweight/obese children aged under six
years experience increased dental caries compared to
non-overweight/non-obese children, and ii) to iden-
tify the common risk factors associated with over-
weight and/or obesity, and dental caries. Our
planned search strategy will include studies of over-
weight and/or obesity, and dental caries measures
reported, and will synthesize available evidence
using rigorous methods. The strengths of this review
is that the updated and high-quality evidence will be
based on a truly exhaustive literature search. Fur-
thermore, this review will also identify the common
risk factors for overweight and/or obesity, and den-
tal caries in early childhood to inform policy and
practice in health promotion.
Review questions
To what extent do overweight/obese children, aged
under six years, experience more dental caries com-
pared to non-overweight/non-obese children?
An additional review sub-question is: Are there
any common risk factors for both health conditions
(i.e. overweight and/or obesity and dental caries) in
the study population?
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SYSTEMATIC REVIEW PROTOCOL
Inclusion criteria
Participants
Studies examining children under six years of age
and with a complete primary dentition (baby teeth)
at the time of dental caries assessment will be
included. Studies comparing children with: normal
adiposity score, no dental caries, high adiposity
score and with dental caries, will be included regard-
less of sex, country of origin, ethnicity or socio-
economic status. Studies that include children with
other medical conditions will be excluded. If studies
report outcomes for children and adolescents, they
will only be included in this review if data for
children aged 72 months and younger are
reported separately.
Exposure
The exposure of interest is the overweight and/or
obesity (excluding birth weight) status of children
under six years of age. Various assessment measures
will be considered such as body mass index (BMI),
BMI z-score, BMI z-score for age, BMI percentile for
age, and weight-for-height z-score.33-35 These are
some of the most accurate measures for assessing
adiposity change in growing children.33 The adipos-
ity status will be clearly defined into categories of
normal weight, overweight and obese based on
widely recognized standardized criteria.35-37
Outcome
The outcome of interest is dental caries in children
under 72 months of age with complete primary
dentition. The outcome must be measured after
the exposure assessment. The American Association
of Pediatric Dentistry definition will be used for early
childhood caries, which is the presence of cavitated
or non-cavitated carious lesions in children under the
age of six years.38 Only validated measures of dental
caries will be considered39: dmft (number of
decayed, missing due to decay, and filled primary
teeth); dmfs (number of decayed, missing due to
decay, and filled primary teeth surfaces); deft (num-
ber of decayed, extracted due to caries, and filled
primary teeth); defs (number of decayed, extracted
due to caries, and filled primary teeth surfaces); dft
(number of decayed and filled primary teeth); dfs
(number of decayed and filled primary teeth surfa-
ces); the number of dmfs according to International
Caries Detection and Assessment System (ICDAS)
codes 1–2 (non-cavitated lesions), codes 3–6
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N. Manohar et al.
(cavitated lesions), or 1–6 (non-cavitated and cavi-
tated lesions).40
The outcome variables will be considered for
inclusion if dental caries is assessed by a minimum
of one qualified dental professional and/or profes-
sionally trained and calibrated non-dental examiner.
Studies using data on self-reported experience of
dental caries will be used carefully and study authors
will be contacted for clarity, if necessary. Studies will
be omitted if they only report on self-reported or
non-validated outcome measures.
The eruption of complete primary dentition will
be the eligible starting point for measuring the pri-
mary outcome. Birth cohort studies with a minimum
follow-up of three years will be considered to
account for the eruption of all primary teeth. Dental
caries assessments at follow-up time points after the
initial three-year examination will also be eligible.
There will be no restriction on the type of study
settings.
Types of studies
Only specific human observational study designs
will be included: longitudinal/cohort studies (pro-
spective and retrospective), cross-sectional studies
nested within cohort studies, and case-control stud-
ies. Cross-sectional studies, case series and case
reports will be excluded due to their low level of
scientific evidence.32 Randomized controlled trials
and quasi-experiments will also be excluded because
this review is not examining the role of any inter-
vention related to overweight/obesity and/or dental
caries outcomes.
Methods
This protocol will be reported based on the Preferred
Reporting Items for Systematic Reviews and Meta-
analysis Protocol (PRISMA-P) checklist41,42 and will
follow the JBI methodology for systematic reviews of
etiology and risk.43
Search strategy
The search strategy will aim to find both published
and unpublished studies. A combination of specific
medical subject headings (MeSH) terms and text
words related to overweight, obesity, dental caries,
and children under six years of age will be drafted
and pre-tested in the MEDLINE database. Two
reviewers (NM and AA), having experience in data-
base searching, with assistance from an expert health
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SYSTEMATIC REVIEW PROTOCOL
sciences librarian, will initially conduct a pilot search
on two databases. Thereafter, the same two
reviewers will independently complete all remaining
literature searches. A draft MEDLINE search strat-
egy is provided in Appendix I. Once the MEDLINE
strategy is finalized, it will be adapted to the syntax
and subject headings of all other databases.
Additionally, a manual search of the reference
lists of all the eligible studies (matching the inclusion
criteria) and previously published systematic reviews
will be performed. Furthermore, topic specialists and
experts identified by the review team will also be
contacted to obtain information on unknown and
ongoing research studies. If a response is not received
after three contact attempts, it will be considered
that the respective expert is unaware of any ongoing
and/or unpublished studies on the research topic. For
this review, we will include articles with no restric-
tion on language. Relevant non-English articles will
be translated into English.
Information sources
The following electronic databases will be searched,
without any restriction on publication date (i.e. from
the time of database inception to present), type,
language or region: MEDLINE (OVID), Web of
Science (ISI), Cochrane Central Register of Con-
trolled Trials (CENTRAL) (The Cochrane Library),
Embase (OVID), PsycINFO, ProQuest Central, Sco-
pus, Cumulative Index to Nursing and Allied Health
Literature (CINAHL) (EBSCO) and Google Scholar.
The electronic database search will be supplemented
by searching OpenGrey and Grey Literature Report
(1999–2016) databases for gray literature, and Pro-
Quest Dissertations and Theses Global, and the
International Association for Dental Research con-
ference website for unpublished studies.
Study selection
Studies identified through the electronic databases,
gray literature databases, theses, conference website,
and manual searches, will be uploaded into reference
manager software, EndNote X8 (Clarivate Analyt-
ics, PA, USA), and duplicates removed. Prior to the
formal screening and selection process, a calibration
exercise between the two reviewers (NM and AA)
will be performed on a pilot group of studies to refine
the screening questions and ensure consistency
across reviewers for screening and selecting eligible
studies. The titles and abstracts of the identified
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N. Manohar et al.
studies will be screened independently by two
reviewers (NM and AA). Articles that may meet
the inclusion criteria will be retrieved in full and
their details imported into the JBI System for the
Unified Management, Assessment and Review of
Information (JBI SUMARI; Joanna Briggs Institute,
Adelaide, Australia). Two reviewers (NM and AA)
will then independently assess the full-text articles
and decide whether these meet the eligibility criteria.
To resolve questions about eligibility, the study
authors will be contacted to seek additional infor-
mation. If disagreements arise, they will be resolved
through discussion including a third reviewer (AH).
If there are multiple reports published from a single
study, multiple reports from the same study will be
linked together. We will also record the reasons for
excluding studies. None of the review authors will be
blind to the journal titles, study authors or institu-
tions. Non-English studies will be translated into
English with assistance from translation services
and/or volunteers. We anticipate that the translation
process of non-English articles will be completed in a
period of four weeks. The study selection process
will be presented in the format of Preferred Report-
ing Items for Systematic Reviews and Meta-Analysis
(PRISMA) flow diagram.44
Assessment of methodological quality
The methodological quality of each paper selected
for retrieval will be assessed by two reviewers (NM
and AA) independently using standardized critical
appraisal instruments from JBI for the following
study types: cohort studies (retrospective and pro-
spective) and case-control studies.43 Any disagree-
ments will be resolved through discussion and
consensus with a third reviewer (AH). Study authors
will be contacted in the event of insufficient details to
confidently assess the methodological quality. If a
response is not received after three contact attempts,
we will assess the study based on its available infor-
mation. The results of JBI tool assessment will be
defined in a contextualized (descriptive) format by
indicating what issues of methodological quality are
present in each study and how these may influence
the interpretation of study evidence.
The risk of bias of observational studies (i.e.
cohort and case-control studies) will be assessed
by two reviewers (NM and AA) independently using
the Risk Of Bias In Non-randomized Studies of
Interventions (ROBINS-I) tool.45 The tool evaluates
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SYSTEMATIC REVIEW PROTOCOL
biases based on confounding, selection of partici-
pants into the studies, missing data, and the
measurement of outcomes. The adjustment of con-
founding variables will be considered during the
conduct of review and what potential for bias that
might bring. Any disagreements will be resolved
through discussion and/or consensus with a third
reviewer (AH). Study authors will be contacted in
the event of insufficient details to confidently assess
the risk of bias. If we do not receive a response after
three contact attempts, we will assess the study based
on its available information.
The purpose of using two different instruments is
to ensure a comprehensive critical appraisal of the
included studies, as the JBI tool will assess the
methodological quality of included studies whereas
the ROBINS-I tool will primarily assess overall the
risk of bias. All included studies will be narratively
reported in the review regardless of their methodo-
logical quality and risk of bias score.
Data extraction
A standardized data extraction form has been devel-
oped based on a checklist presented in the Cochrane
Handbook for Systematic Reviews of Interven-
tions.31 The data extraction form will be pilot tested
(on two studies), and subsequently refined to ensure
that we capture all relevant data (see Appendix II)
and a calibration exercise will be performed to
ensure consistency across reviewers. Data from each
included study will be extracted independently by
two reviewers (NM and AA), and any subsequent
discrepancies will be resolved through discussion
with a third reviewer (AH).
The data extracted will include information on
the study design and settings, participant demo-
graphic details, sample size, follow-up period,
methods used to measure overweight and/or obesity
and dental caries, statistical analysis employed, key
study findings, common risk factors identified for
both the health conditions, and study funding sour-
ces. We will record any additional information
considered to be relevant, and modify our data
extraction form accordingly. If such a situation
arises, it will be duly reported in the intended
systematic review manuscript. We anticipate that
data will be presented as text, tables and graphs,
and that numerical values will be mentioned within
the actual graphs for better understanding for the
readers. The study authors will be contacted in
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N. Manohar et al.
case of missing data and/or to resolve any uncer-
tainties.
In case of studies in non-English language, we
anticipate that a single translator will transcribe the
full-text article followed by the aforementioned data
extraction process. We anticipate that measures used
to assess overweight and/or obesity and dental caries
outcomes in children would differ across studies. If
so, we will caution readers on the impact of such
measures on the review evidence.
Data synthesis
Individual studies,46 where possible, will be pooled
in a meta-analysis using STATA v15 (StataCorp,
College Station, TX, USA). Some degree of hetero-
geneity is expected across the studies; therefore, the
random effects model for meta-analysis will be
applied. Furthermore, data from cohort studies
and case-control studies will not be pooled in a
single meta-analysis. Effect sizes will be expressed
as risk ratios or odds ratios or prevalence ratios (for
dichotomous data) and weighted (or standardized)
mean differences (for continuous data) and their
95% confidence intervals (CI) will be calculated
for analysis. Cohort estimates will be presented as
risk ratios/prevalence ratios with 95% CI, and case-
control estimates will be presented as odds ratios
with 95% CI. We anticipate using adjusted values
for the analysis; however, if not available, unad-
justed values will be considered and readers will
be cautioned on the review findings. The degree of
statistical heterogeneity will be assessed using stan-
dard I-squared statistics, with statistical significance
values based on the statistical guidelines of the
Cochrane Handbook for Systematic Reviews of
Interventions.31 Where statistical pooling is not pos-
sible and/or there is substantial heterogeneity,31 a
narrative synthesis of the study findings will be
provided. The sources of heterogeneity and reasons
for which it was inappropriate to pool the data will
be specified in the main systematic review.
Subgroup analysis will be performed when there
is sufficient data (if over 10 studies) as recommended
by the Cochrane Handbook for Systematic Reviews
of Interventions,31 based on the following:
 estimates (adjusted or crude) for the outcome
measure
 country classification based on income level
(high-income countries versus middle-and low-
income countries)
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SYSTEMATIC REVIEW PROTOCOL
 study design (cohort studies versus case-control
studies).
Sensitivity analyses will be performed in order to
explore the impact of risk of bias of included studies
on outcomes. Where statistical pooling is not possi-
ble, the findings will be presented narratively in the
form of text, tables and figures. The readers will be
cautioned about the interpretation of the results and
recommendations will be made for future research.
Publication bias will be assessed using a funnel
plot of all included studies (if over 10 studies).47 To
assess funnel plot asymmetry, the Egger test48 (for
continuous outcomes) and the Arcsine test49 (for
dichotomous outcomes) will be performed. Study
authors will be contacted via email for missing data
and a maximum of three attempts will be made to
acquire specific numerical data. If data are still
unavailable, a narrative description of these studies
will be provided, and the potential impact of these
studies will be elaborated on in the review.
Assessing certainty in the findings
The quality of evidence for all the outcomes will be
assessed using the Grading of Recommendations
Assessment, Development and Evaluation (GRADE)
approach,50 which may require some level of adap-
tation as our aim is to assess if overweight/obese
children are more at risk of dental caries compared
to non-overweight/non-obese children. Two
reviewers will perform this process independently
(NM and AA). Any unresolved disagreements will be
resolved through discussion and/or consensus with a
third reviewer (AH). The quality of the evidence will
be assessed based on risk of bias, indirectness, incon-
sistency, imprecision, and publication bias.
Acknowledgments
The authors would like to thank Professor Gregory
Kolt (School of Science and Health at Western
Sydney University), Mr. Paul Fahey (Western Sydney
University) and Ms. Katrina Chaudhary (School of
Science and Health Librarian at Western Sydney
University) for their support and aid in this review.
This study is being completed as part of Doctor of
Philosophy (PhD) for NM.
Funding
This study is financially supported by the Australian
National Health and Medical Research Council
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N. Manohar et al.
Grants (1033213, 1069861, 1134075) and Western
Sydney University. The University will also provide
services of an on-site librarian, access to commercial
databases to obtain relevant literature, and software
to manage or analyze data.
References
1. Sanders RH, Han A, Baker JS, Cobley S. Childhood obesity
and its physical and psychological co-morbidities: a system-
atic review of Australian children and adolescents. Eur J
Pediatr 2015;174(6):715–46.
2. World Health Organization. Overweight and obesity. Fact
sheet no. 311 [Internet]. 2018 [cited 10 May 2019]. Available
from: http://www.who.int/mediacentre/factsheets/fs311/en/
3. Australian Institute of Health and Welfare. A rising epidemic:
obesity in Australian children and adolescents. Canberra,
Australia: Australian Institute of Health and Welfare; 2004.
4. National Health and Medical Research Council. Clinical
practice guidelines for the management of overweight
and obesity in adults, adolescents and children in Australia.
Melbourne: National Health and Medical Research Council;
2013.
5. Ng M, Fleming T, Robinson M, Thomson B, Graetz N,
Margono C, et al. Global, regional, and national prevalence
of overweight and obesity in children and adults during
1980–2013: a systematic analysis for the Global Burden of
Disease Study 2013. Lancet 2014;384(9945):766–81.
6. Çolak H, Dülgergil ÇT, Dalli M, Hamidi MM. Early childhood
caries update: a review of causes, diagnosis, and treatments.
J Nat Sc Biol Med 2013;4(1):29–38.
7. Leong PM, Gussy MG, Barrow S-YL, de Silva-Sanigorski A,
Waters E. A systematic review of risk factors during first year
of life for early childhood caries. Int J Paediatr Dent
2013;23(4):235–50.
8. Kassebaum NJ, Bernabé E, Dahiya M, Bhandari B, Murray C,
Marcenes W. Global burden of untreated caries: a
systematic review and metaregression. J Dent Res 2015;
94(5):650–8.
9. Lagerweij MD, van Loveren C. Declining caries trends: are
we satisfied? Curr Oral Health Rep 2015;2(4):212–7.
10. Martins-Júnior PA, Vieira-Andrade RG, Corrêa-Faria P, Oli-
veira-Ferreira F, Marques LS, Ramos-Jorge ML. Impact of
early childhood caries on the oral health-related quality of
life of preschool children and their parents. Caries Res
2013;47(3):211–8.
11. Hong L, Ahmed A, McCunniff M, Overman P, Mathew M.
Obesity and dental caries in children aged 2–6 years in
the United States: National Health and Nutrition Examina-
tion Survey 1999–2002. J Public Health Dent 2008;68(4):
227–33.
12. Hooley M, Skouteris H, Millar L. The relationship between
childhood weight, dental caries and eating practices in
children aged 4–8 years in Australia, 2004–2008. Pediatr
Obes 2012;7(6):461–70.
ß 2020 THE JOANNA BRIGGS INSTITUTE 140
SYSTEMATIC REVIEW PROTOCOL
13. Arora A, Schwarz E, Blinkhorn AS. Risk factors for early
childhood caries in disadvantaged populations. J Investige
Clin Dent 2011;2(4):223–8.
14. Trikaliotis A, Boka V, Kotsanos N, Karagiannis V, Hassapidou
M. Dmfs and BMI in preschool Greek children. An epidemi-
ological study. Eur Arch Paediatr Dent 2011;12(3):176–8.
15. Silva AER, Menezes AMB, Demarco FF, Vargas-Ferreira F,
Peres MA. Obesity and dental caries: systematic review. Rev
Saude Publica 2013;47(4):799–812.
16. Yang F, Zhang Y, Yuan X, Yu J, Chen S, Chen Z, et al. Caries
experience and its association with weight status among
8-year-old children in Qingdao, China. J Int Soc Prev Com-
munity Dent 2015;5(1):52–8.
17. Abu El Qomsan MA, Alasqah MN, Alqahtani FA, Alobaydaa
MA, Alharbi MM, Kola Z. Intricate evaluation of association
between dental caries and obesity among the children in
Al-Kharj City, Saudi Arabia. J Contemp Dent Pract
2017;18(1):29–33.
18. Frias-Bulhosa J, Barbosa P, Gomes E, Vieira MR, Manso MC.
Association between body mass index and caries among
13-year-old population in Castelo de Paiva, Portugal. Por J
Stom Dent Med Surg Maxillo 2015;56(1):3–8.
19. Sheiham A, Watt RG. The common risk factor approach: a
rational basis for promoting oral health. Comm Dent Oral
Epidemiol 2000;28(6):399–406.
20. Watt RG, Sheiham A. Integrating the common risk factor
approach into a social determinants framework. Comm
Dent Oral Epidemiol 2012;40(4):289–96.
21. Booth A, Clarke M, Dooley G, Ghersi D, Moher D, Petticrew
M, et al. The nuts and bolts of PROSPERO: an international
prospective register of systematic reviews. Syst Rev 2012;1(1):2.
22. Chen D, Zhi Q, Zhou Y, Tao Y, Wu L, Lin H. Association
between dental caries and BMI in children: a systematic
review and meta-analysis. Caries Res 2018;52(3):230–45.
23. Hayden C, Bowler JO, Chambers S, Freeman R, Humphris G,
Richards D, et al. Obesity and dental caries in children: a
systematic review and meta-analysis. Comm Dent Oral
Epidemiol 2013;41(4):289–308.
24. Kantovitz KR, Pascon FM, Rontani RM, Gaviao MB. Obesity
and dental caries–a systematic review. Oral Health Prev
Dent 2006;4(2):137–44.
25. Li L-W, Wong HM, Peng S-M, McGrath CP. Anthropometric
measurements and dental caries in children: a systematic
review of longitudinal studies. Adv Nutr 2015;6(1):52–63.
26. Hooley M, Skouteris H, Boganin C, Satur J, Kilpatrick N. Body
mass index and dental caries in children and adolescents: a
systematic review of literature published 2004 to 2011. Syst
Rev 2012;1:57.
27. Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J,
et al. AMSTAR 2: a critical appraisal tool for systematic
reviews that include randomised or non-randomised stud-
ies of healthcare interventions, or both. BMJ 2017;358:j4008.
28. Biro FM, Wien M. Childhood obesity and adult morbidities.
Am J Clin Nutr 2010;91(5):1499S–505S.
JBI Evidence Synthesis
©2020 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
N. Manohar et al.
29. Jordan A, Becker N, Jöhren H, Zimmer S. Early childhood
caries and caries experience in permanent dentition: a 15-
year cohort study. Swiss Dent J 2016;126(2):114–9.
30. Faggion CM, Wu Y-C, Tu Y-K, Wasiak J. Quality of search
strategies reported in systematic reviews published in
stereotactic radiosurgery. Br J Radiol 2016;89(1062):
20150878.
31. Higgins JPT, Green S (editors). Cochrane Handbook for
Systematic Reviews of Interventions version 5.1.0 [Internet;
updated March 2011; cited 10 May 2019]. The Cochrane
Collaboration. Available from: http://handbook.cochra-
ne.org.
32. Burns PB, Rohrich RJ, Chung KC. The levels of evidence and
their role in evidence-based medicine. Plast Reconstr Surg
2011;128(1):305–10.
33. Cole T, Faith M, Pietrobelli A, Heo M. What is the best measure
of adiposity change in growing children: BMI, BMI%, BMI
z-score or BMI centile? Eur J Clin Nutr 2005;59(3):419–25.
34. Kim CH. Measurements of adiposity and body composition.
Korean J Obes 2016;25(3):115–20.
35. World Health Organization. WHO child growth standards:
length/height-for-age, weight-for-age, weight-for-length,
weight-for-height and body mass index-for-age: methods
and development [Internet]. 2006 [cited 10 May 2019].
Available from: https://apps.who.int/iris/handle/10665/
43413.
36. Centers for Disease Control Prevention. Surveillance for
dental caries, dental sealants, tooth retention, edentulism,
and enamel fluorosis: United States, 1988–1994 and 1999–
2002. Atlanta, GA: Centers for Disease Control and Preven-
tion; 2005.
37. Cole T, Bellizzi M, Flegal K, Dietz W. Establishing a standard
definition for child overweight and obesity worldwide:
international survey. BMJ 2000;320(7244):1240–3.
38. American Academy of Pediatric Dentistry. Policy on early
childhood caries (ECC): classifications, consequences, and
preventive strategies. Pediatr Dent 2016;38(6):52–4.
39. Palmer J, Anderson R, Downer M. Guidelines for prevalence
studies of dental caries. Comm Dent Heal 1984;1(1):55–66.
40. Ismail A, Sohn W, Tellez M, Amaya A, Sen A, Hasson H, et al.
The International Caries Detection and Assessment System
(ICDAS): an integrated system for measuring dental caries.
Comm Dent Oral Epidemiol 2007;35(3):170–8.
41. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A,
Petticrew M, et al. Preferred reporting items for systematic
review and meta-analysis protocols (PRISMA-P) 2015 state-
ment. Syst Rev 2015;4:1.
42. Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A,
Petticrew M, et al. Preferred reporting items for systematic
review and meta-analysis protocols (PRISMA-P) 2015: elab-
oration and explanation. BMJ 2015;349:g7647.
43. Moola S, Munn Z, Tufanaru C, Aromataris E, Sears K, Sfetcu R,
et al. Chapter 7: Systematic reviews of etiology and risk. In:
Aromataris E, Munn Z (editors). Joanna Briggs Institute
ß 2020 THE JOANNA BRIGGS INSTITUTE 141
SYSTEMATIC REVIEW PROTOCOL
Reviewer’s Manual [Internet]. Adelaide: Joanna Briggs Insti-
tute; 2017 [cited 10 May 2019]. Available from: https://
reviewersmanual.joannabriggs.org/.
44. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Pre-
ferred reporting items for systematic reviews and meta-
analyses: the PRISMA statement. PLoS Med 2009;6(7):
e1000097.
45. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND,
Viswanathan M, et al. ROBINS-I: a tool for assessing risk of
bias in non-randomized studies of interventions. BMJ
2016;355:i4919.
46. Valentine JC, Pigott TD, Rothstein HR. How many studies do
you need? A primer on statistical power for meta-analysis.
J Edu Behav Stat 2010;35(2):215–47.
JBI Evidence Synthesis
©2020 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
N. Manohar et al.
47. Sterne JA, Sutton AJ, Ioannidis JP, Terrin N, Jones DR, Lau J,
et al. Recommendations for examining and interpreting
funnel plot asymmetry in meta-analyses of randomised
controlled trials. BMJ 2011;343:d4002.
48. Egger M, Davey Smith G, Schneider M, Minder C. Bias in
meta-analysis detected by a simple, graphical test. BMJ
1997;315(7109):629–34.
49. Macaskill P, Walter SD, Irwig L. A comparison of methods to
detect publication bias in meta-analysis. Stat Med
2001;20(4):641–54.
50. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-
Coello P, et al. GRADE: an emerging consensus on rating
quality of evidence and strength of recommendations. BMJ
2008;336(7650):924–6.
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Appendix I: Search strategy for MEDLINE (Ovid)

MeSH terms Records retrieved

1. Obesity/ or Overweight/ or Obesity, Morbid/ or Body Mass Index/ 2049
2. Body Constitution/ or Anthropometry/ or Waist Circumference/ or Adipose 766
Tissue/ or Body Composition/
3. exp Body Mass Index/ or exp Obesity/ or obes.mp. 38,199
4. exp Body Weight/ 2377
5. 1 or 2 or 3 or 4 39,191
6. exp Dental Caries/ 139
7. exp Oral Health/ or early childhood caries.mp. 396
8. ECC.mp. 440
9. tooth decay.mp. 180
10. dental decay.mp. 72
11. dental health.mp. 694
12. dmf.mp. 2435
13. dmft.mp. 599
14. dmfs.mp. 346
15. Tooth, Deciduous/ 27
16. 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 4787
17. 5 and 16 56
18. Child/ or Child, Preschool/ or Infant/ 7578
19. toddler.mp. 640
20. early childhood.mp. 3160
21. young.mp. 60,158
22. 18 or 19 or 20 or 21 68,510
23. 17 and 22 12

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Appendix II: Data extraction

Data extraction form 1: Source and eligibility

Heading Description of information

Reviewer’s name State the name of reviewer.
Authors, title, year, journal and contact List authors’ names, title, publication year, journal and
corresponding author’s contact details.
Article source State the source from which article was retrieved, e.g.
database, gray literature, hand searching of reference lists,
etc.
Language of the article State in which language the article was published.
Eligibility of the article Confirm eligibility. If any article is not eligible, explain the
reason for exclusion.
Purpose State the objectives of the article.

Data extraction form 2: Methods, participants, exposures, and outcomes

Heading Description of information

Study design, duration,
date, and participant
selection
Study setting
Country and location
Characteristics of partici-
pants (sex, age, socio-
demographics) and sam-
ple size
Recruitment and inclu-
sion/exclusion criteria
Follow-up scheme
Blinding
Exposure
Example: prospective study conducted between 2010 and 2016 using a
random sampling technique for participant selection.
Example: hospitals, private clinics, schools, university clinics, etc.
State the country and the city where the study was conducted.
Example: normal weight (BMI < [value provided in the study]) group:
n ¼ 50 (25 boys and 25 girls) mean age 5.2  0.5 years
Example: overweight (BMI > [value provided in the study]) group: n ¼ 30
(20 boys and 10 girls) mean age 4.8  1 years
If indicated summarize the groups, e.g. number of children having dental
caries per BMI subcategory.
Example: participants aged < 6 years having a complete primary dentition
attending a pediatric dental clinic at a local public hospital.
Example: participants were recruited at birth and then follow-up performed
at three and six years of age.
State if the examiners and/or participants were blind towards the group
allocation.
State the total number of participants in overweight and/or obese groups.
For each exposure and comparator group of interest, report the following:
 measures (and their associated references) used to assess the exposure
 details of the assessor and the methods employed.

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(Continued)

Heading Description of information

Outcomes Outcome measures used for assessing the prevalence of dental caries, and
assessment time-points.
Outcome definition with diagnostic criteria.
Unit of measurement.
Examiner details.
Intra- and inter-examiner agreement percentages.
Results Participation rate and loss to follow-up.
Number of participants in each exposure group.
Prevalence of dental caries in each exposure group.
Summary data for each exposure group (2x2 table for dichotomous data;
means and SD for continuous data).
Estimate of effect with confidence interval; P value.
Compare the prevalence of dental caries between overweight and/or obese
children and normal weight/normal BMI children.
Report if the study has identified any common risk factors for both health
conditions (i.e. overweight/obesity and dental caries).
Funding Funding sources of the study.
BMI: body mass index; SD: standard deviation.

Data extraction form 3: Miscellaneous

Heading Description of information

Funding source State the funding sources of the study.
Key conclusions of study State the main conclusions by the authors of the study.
authors
Miscellaneous comments Describe the important comments stated by the study authors.
by study authors
References to other rele- List the references of other relevant studies that should be retrieved.
vant studies

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