Unhealthy Dietary Habits and Sedentary Behavior Drive Untreated Dental Caries among Adolescents: A Population-Based Study

Unhealthy Dietary Habits and Sedentary Behavior Drive Untreated Dental Caries among Adolescents: A Population-Based Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Unhealthy Dietary Habits and Sedentary Behavior Drive Untreated Dental Caries among Adolescents: A Population-Based Study Leticia Barros, Luiza Grieleitow, Rafael Bomfim This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6404590/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Oct, 2025 Read the published version in Scientific Reports → Version 1 posted 10 You are reading this latest preprint version Abstract Untreated dental caries remains a significant public health challenge, particularly among adolescents, where it can compromise well-being and quality of life. This population-based study investigates the factors associated with untreated dental caries in 12-year-olds across the five most populous cities (each with >80,000 inhabitants) in the state of Mato Grosso do Sul, Brazil. Using WHO criteria, clinical oral examinations and self-reported behavioral data were collected. Guided by a social determinants of health framework, we conducted univariable and multilevel logistic regression analyses to explore associations between untreated dental caries and individual, behavioral, and contextual factors. The prevalence of untreated dental caries was 25.3% (95% CI: 18.8–33.1). Protective factors included household income above the poverty line [OR = 0.55 (95% CI: 0.33–0.91)], exposure to fluoridated water [OR = 0.58 (95% CI: 0.28–0.99)], and brushing more than twice daily [OR = 0.54 (95% CI: 0.32–0.91)]. In contrast, adolescents reporting frequent consumption of unhealthy foods [OR = 5.00 (95% CI: 2.21–11.62)] and sedentary behavior [OR = 1.56 (95% CI: 1.00–2.52)] were more likely to present untreated caries. Our findings highlight the interplay between socioeconomic context, lifestyle behaviors, and access to preventive measures. To reduce the burden of untreated dental caries in adolescence, oral health interventions must adopt a transdisciplinary approach that addresses broader social and behavioral determinants—promoting healthier diets, reducing sedentary time, and ensuring access to fluoridated water. Health sciences/Health care/Dentistry/Preventive dentistry/Fluoridation Health sciences/Health care Health sciences/Health care/Nutrition Dental caries Oral health Adolescents Social determinants Machine learning Public health Brazil Introduction Dental caries has historically been recognized as one of the greatest global public health challenges, affecting populations of all ages and social backgrounds. It is one of the leading non-communicable chronic diseases, with impacts that go beyond oral health, affecting overall well-being, learning ability, and even the social integration of affected individuals[1]. The condition is multifactorial in nature, influenced by several elements such as diet composition, access to oral healthcare, and education on oral hygiene[2]. Adolescents with severe dental caries report negative impacts on their self-esteem, such as difficulties in social interactions, particularly in the school environment. This underscores the importance of disease prevention and the promotion of self-care for oral health in this age group[3]. In Brazil, the situation is also concerning. Data from the latest national oral health survey, SB Brasil, indicate that over 80% of Brazilian adolescents have had at least one tooth affected by caries[4]. Although the country has implemented oral health policies focused on prevention and treatment, such as the “Brasil Sorridente” Program, many young people still face difficulties accessing quality dental services. Factors such as social inequality, lack of resources in rural or underserved areas, and parents' low educational levels directly affect the oral health of adolescents[4]. Studies show that the distribution of dental caries among adolescents is heterogeneous, with the disease being more severe in socially disadvantaged classes. Furthermore, variables such as the Municipal Human Development Index (MHDI) and the ratio of dentists to the population are also related to the number of decayed teeth. In regions with lower MHDI and a smaller proportion of dentists per capita, the prevalence of dental caries is higher[5]. Adolescence is a critical period in human development, marked by profound physical, emotional, and social changes. During this phase, many young people tend to neglect oral hygiene, either due to lack of proper information, peer influence, or reduced regular follow-up by an oral health professional[6]. Additionally, dietary choices—often rich in sugars and processed foods—increase the risk of dental caries. This context makes adolescence a particularly vulnerable stage for the onset and progression of caries, a condition that, if left untreated, can lead to serious complications such as intense pain, abscesses, and even tooth loss[7]. Systematic reviews[8] have found an association between screen time/TV viewing and the consumption of unhealthy foods among adolescents, showing that the presence of screens during meals increases the intake of sugar-rich foods and sugary beverages, which can lead to a higher prevalence of caries in this age group[8]. Thus, the high prevalence of untreated dental caries in adolescents highlights the need for a more integrated and comprehensive approach that considers not only individual behaviors but also the social and economic determinants that shape access to and the quality of oral health care [2]. The objective of this study was to analyze factors associated with untreated dental caries in 12-year-old adolescents living in the five largest cities (>80,000 inhabitants) in the state of Mato Grosso do Sul, Brazil. Specifically, the study aimed to: identify behavioral, socioeconomic and contextual factors influencing the prevalence of untreated dental caries in adolescents. Methods This is a cross-sectional, school- and population-based study derived from the SBMS 2018/2019 epidemiological survey, which was conducted in the five largest cities in the state of Mato Grosso do Sul with over 80,000 inhabitants: Campo Grande, Dourados, Três Lagoas, Corumbá, and Ponta Porã, between April 2018 and February 2019. These cities were selected because they are the most representative of the state’s four territorial macro-regions [9,10]. This study analyzed the factors associated with untreated dental caries in 12-year-old adolescents. Data were collected on caries experience according to the criteria of the World Health Organization (WHO), as well as behavioral data from the adolescents. The theoretical framework of the social determinants of oral health guided all analyses [9,10]. Sample Size To calculate the sample size for dental caries, a formula was used that considered the mean and standard deviation values of the DMFT index (Decayed, Missing, and Filled Teeth) for the Central-West region of Brazil, according to SBBrasil 2010 (n = final sample size; Z = significance level of 1.96 (corresponding to a 95% confidence level, i.e., α = 0.05);2 = variance of the sample mean, i.e., the square of the standard deviation of the variable (1.81);X = mean DMFT in the Central-West region, according to SBBrasil 2010 (mean = 2.63); ε = acceptable margin of error or tolerated error (ε = 0.10); deff = design effect (deff = 2.0); NRR = non-response rate (estimated at 30% refusal to participate). A probability sampling by clusters was adopted, conducted in two stages with probabilities proportional to size. The five cities were organized as Primary Sampling Units (PSUs), and the municipal public elementary schools in each city were considered Secondary Sampling Units (SSUs) [9,10]. Following the guidelines of the national epidemiological survey (SBBrasil 2010), data collection and interviews were planned in 32 schools in each of the two largest cities. If a city had fewer than 32 schools, all schools were included [9,10]. In 2018, the number of public elementary schools in each selected city was as follows: Campo Grande (86), Dourados (45), Corumbá (26), Três Lagoas (17), and Ponta Porã (8). Therefore, all schools in Corumbá, Ponta Porã, and Três Lagoas were included, and a random draw was conducted in Campo Grande and Dourados to select 32 schools each. Based on this, a total of 115 schools participated in the study[9,10]. Study Participants and Data Collection To select study participants, up to ten 12-year-old adolescents per classroom were selected, drawn from a list provided by the school administration. Students who had transferred to other schools or were not attending at the time of the study were excluded from the sample.Epidemiological data were collected through a questionnaire delivered by the local coordination team to the parents or guardians of the adolescents, which included sociodemographic questions. After returning the completed questionnaire at school, the adolescents answered another questionnaire about their dietary habits.Subsequently, each student underwent an intraoral examination, conducted by five dental teams in the selected cities. Each team consisted of a dentist and a recorder and received 32 hours of prior practical training [9,10]. Outcome The outcome variable was the Decayed teeth(D≥1), a component of DMFT (decayed missing and filling tetth, as recommended by the World Health Organization(WHO)[11]. A CPI probe was used for clinical caries examination on tooth surfaces, considering caries in the presence of a fissure, pit, or smooth surface of a tooth with a visible cavity or softened tissue at the base of the enamel, enamel discoloration, or a temporary restoration (except for glass ionomer). Descriptive proportion analyses were performed to establish associations between the independent variables and the outcome. Independent variables The variables were dichotomized: sex (female or male) and self-reported race/skin color (White, Brown/mixed-race, Asian, Black, or Indigenous). Per capita household income was categorized as below or equal/above the poverty line, considering the Brazilian economic context in 2018. Parental education level was subdivided into 1–4 years of schooling and more than 4 years [9,10]. For the weekly frequency of unhealthy food consumption, an instrument recommended by the Brazilian Ministry of Health was used, covering five food groups with the following options: (1) French fries, packaged chips, and fried snacks; (2) hamburgers and processed meats; (3) salty crackers or packaged savory snacks; (4) sweet cookies, filled cookies, candies, and chocolate (bars or bonbons); and (5) regular soda[12]. The average weekly frequency was obtained by summing and dividing by five, classifying unhealthy food consumption as: low (up to 2 times/week), moderate (2 to 4 times/week), and high (4 or more times/week)[10]. Sedentary behavior (more than 2 hours/day) was assessed using an instrument translated and validated Rey lopez et al[13] and validated to the Brazilian adolescents population[14] based on the total time adolescents spent in four sedentary domains: TV, video games, internet use, and remaining seated. Participants selected one of seven categories that described their daily routine (0 minutes; less than 30 minutes; 30 minutes to 1 hour; more than 1 hour to 2 hours; more than 2 hours to 3 hours; more than 3 hours to 4 hours; and more than 4 hours per day). Total hours spent in sedentary behavior during weekdays were multiplied by five, and weekend hours by two, then divided by seven (total days of the week) to obtain a weekly average[10]. To analyze toothbrushing frequency, responses were categorized as brushing two or more times/day versus once or not at all. The water fluoridation variable was based on measurements from the 2017 Vigiflúor survey[15], which provides the most up-to-date data on public water supply fluoridation in the state of Mato Grosso do Sul. Statistical Analysis Univariable and adjusted multilevel logistic regressions were performed to test the association between untreated dental caries and behavioral and sociodemographic factors. In the unadjusted models, the relationship of each variable with the presence of dental caries was examined. Variables included in the adjusted models were those with statistical significance or with p < 0.20. Ethical Aspects The study was approved by the Human Research Ethics Committee of the Federal University of Mato Grosso do Sul (CAAE number 85647518.4.0000.0021). All participants signed an informed assent form, and their guardians signed the informed consent form. Results The study population consisted of 615 twelve-year-old schoolchildren from 69 schools that agreed to participate in the study. The prevalence of untreated dental caries at age 12 was 25.3% (95% CI: 18.8–33.1). To facilitate the analysis, the following tables present the results obtained, addressing various factors associated with untreated dental caries in adolescents, including socioeconomic, behavioral, and public health determinants. Table 1 presents the descriptive characteristics and proportions for the state of Mato Grosso do Sul (SBMS Study 2018–19) among 12-year-old children and untreated dental caries. According to the variables analyzed, regarding ethnic groups, Black children (n=32) had the highest prevalence of untreated caries (57.9%) compared to White (n=270; 20.9%), Mixed-race (n=266; 28.3%), Asian (n=24; 23%), and Indigenous (n=6; 50%) children. Regarding sex, the prevalence of untreated caries was similar between groups: 24.2% in females (n=315) and 26.9% in males (n=300). Regarding per capita income, families above the poverty level (n=376) had a lower prevalence of caries (23.3%) than those below the poverty level (n=216; 32.4%). Concerning parental education, adolescents whose parents had more than four years of schooling (n=234) had a lower prevalence of caries (22.6%) compared to those whose parents had up to four years of schooling (n=381; 26.1%). A higher prevalence of caries was also observed among adolescents with high unhealthy food consumption (more than 4 times/week; n=217; 40.4%), followed by moderate consumption (2 to 4 times/week; n=197; 31.4%) and low consumption (up to 2 times/week; n=168; 9.4%). In terms of brushing frequency, adolescents who brushed their teeth only once a day or not at all (n=234) had a higher prevalence of dental caries (33.6%) compared to those who brushed two or more times a day (n=318; 18.7%). Regarding flossing, adolescents who reported not using dental floss (n=272) showed a higher prevalence of dental caries (32.4%) than those who did use it (n=280; 18.6%). Analysis of water fluoridation status—a contextual variable—showed that areas with access to fluoridated water had a lower prevalence of untreated caries (n=411; 21.6%) compared to areas without access (n=204; 42.3%). Additionally, adolescents with sedentary behavior (more than 2 hours/day using the internet, gaming, sitting, or watching TV) had a higher prevalence of caries (n=251; 44.6%) compared to those without such behavior (n=338; 25.7%). Table 2 below presents the multilevel logistic regression models for the prevalence of untreated caries according to covariates. In the adjusted models, sociodemographic characteristics such as income above the poverty level [OR = 0.55 (95% CI: 0.33–0.91)], access to fluoridated water [OR = 0.58 (95% CI: 0.28–0.99)], and brushing more than twice a day [OR = 0.54 (95% CI: 0.32–0.91)] were associated with untreated dental caries as protective factors. Risk factors included unhealthy food consumption [OR = 5.00 (95% CI: 2.21–11.62)] and sedentary behavior [OR = 1.56 (95% CI: 1.00–2.52)]. Unhealthy food consumption was a highly significant variable, increasing the likelihood of untreated caries by five times. Water fluoridation was significant, reducing the likelihood of untreated caries by 42%. Additionally, per capita income was significant, with a 45% protective effect. The ICC (Intraclass Correlation Coefficient) refers to the variance partition coefficient, indicating how much of the variation in caries prevalence is attributable to differences between cities. Thus, the context matters, with a 21.1% (95% CI: 11.7–35.2) variation in caries prevalence between municipalities Discussion This study highlights sedentary behavior and unhealthy food consumption as behavioral factors influencing the prevalence of untreated dental caries among Brazilian adolescents, emphasizing that caries remains a significant public health issue in this population. Its multifactorial etiology encompasses behavioral, socioeconomic and contextual components as access to water fluoridation. As a cross-sectional study, this research has inherent limitations, notably the inability to infer causality and the lack of data on residential mobility of participants, which could not be controlled. However, the use of validated instruments—both nationally and internationally—particularly for assessing sedentary behavior, enhances the reliability of our findings and supports their potential relevance for informing public policies [13,14]. A major strength of this study is its representativeness: it covered over half the population of Mato Grosso do Sul, a key Brazilian state in the Midwest region, significant for its agribusiness sector, which contributes around 25% to Brazil’s GDP. Unlike many previous studies that focus solely on screen time, this research assessed four dimensions of sedentary behavior using the HELENA study instrument, known for its internal reliability[13]. To our knowledge, this is the first complex oral health survey in Brazil to examine the association between sedentary behavior and dental caries, with unhealthy food consumption as a potential mediator [10]. Dietary data were collected using the SISVAN questionnaire, a validated tool from the Brazilian Ministry of Health [12]. Untreated dental caries is recognized as a socially determined disease. In this study, a high-sugar diet, inadequate oral hygiene practices, low socioeconomic status and water fluoridation 16 were central to its prevalence. A marked polarization of the disease was observed: while some adolescents had no signs of caries, others—particularly those in vulnerable conditions—were disproportionately affected, reflecting Brazil's deepening social inequalities. These findings underscore the need for integrated public health policies that address the social determinants of oral health. Adolescents from families below the poverty line showed greater disease burden, likely due to reduced dental visits and limited access to hygiene products such as toothbrushes, fluoridated toothpaste, and floss[10,17]. Issues such as obesity, stress, and adverse environments significantly influence oral health and should be considered in preventive strategies[18]. The association between obesity and caries reinforces the connection between behavioral risk factors and oral health. Sedentary adolescents—often with poor diets high in sugars and ultra-processed foods—exhibited greater untreated caries prevalence. These dietary patterns contribute both to obesity and oral disease and are consistent with studies linking poor nutrition in adolescents to increased caries susceptibility[18]. Moreover, Physical activity emerged as a protective factor. A 15% reduction in caries and periodontal issues was observed among adolescents engaged in sports clubs, possibly due to healthier lifestyles and lower consumption of sugary foods. Additionally, physical activity may boost immunity, offering further protection against oral disease[18].The data point to the need for integrated public health interventions promoting healthy eating, reduced sugar intake, and physical activity. School and government programs that combine sports promotion, oral hygiene education, and regular dental check-ups can enhance awareness and reduce reliance on complex, curative treatments. Education is another determinant. Lower educational levels correlate with poorer oral hygiene practices and reduced awareness of oral health's importance. Families with limited schooling are more exposed to oral health problems, indicating the value of educational interventions in promoting self-care[6]. Maternal education, in particular, appears protective, as more educated mothers are more likely to encourage preventive behaviors and ensure regular dental care for their children[19,20]. Inadequate hygiene—such as infrequent brushing and flossing—was also strongly linked to caries prevalence. This reinforces the need for robust educational strategies targeting adolescents and families, especially in low-income communities, where knowledge and use of preventive measures may be limited[17]. Untreated caries affects not only oral health but also adolescents’ quality of life. It can cause pain, impair self-esteem, hinder eating, concentration, and communication, and negatively affect academic performance. Additionally, limited access to dental care in low-income settings can lead to long-term oral and general health consequences[21]. An integrated approach is necessary for caries prevention—one that considers individual behaviors and structural conditions, such as access to fluoridated water. The lack of access to fluoridation was linked to higher caries prevalence and severity, reaffirming its importance as a cost-effective public health measure, especially for vulnerable groups[6]. However, fluoridation alone is insufficient. Broader strategies are needed to address social inequalities. Adolescents in underserved regions often face inadequate access to education and healthcare, which heightens their risk of oral disease. Equitable policies that combine oral health education and the fair distribution of resources are crucial[6]. Research from Brazil on the Family Health Strategy (ESF-SB) showed that greater coverage of oral health teams increases oral health services use among adolescents[9]. Disparities were also evident in service access: wealthier, white adolescents are more likely to use private services for prevention, while lower-income and non-white adolescents often access public services only for treatment. Strategies such as expanding preventive oral health coverage in public schools and health education campaigns are essential to close this gap and promote equitable access[9]. Similar findings appear in studies linking sedentary behavior, unhealthy diets, and caries in 12-year-olds. Excess screen time and frequent consumption of snacks and sugary drinks were associated with higher DMFT scores. Once again, water fluoridation proved protective[10,16]. A further study showed that income trajectory influences lifetime caries progression. Adolescents from high income families had better oral health, while those from low-income households had more untreated caries, despite universal healthcare. This illustrates how income inequality affects access and outcomes, underscoring the need for equitable distribution of dental resources[22].Even within Brazil’s Unified Health System (SUS), disparities persist. Higher-income families access preventive and curative services more easily, often through private care. In contrast, low-income families may only seek public care in emergencies, leading to more extractions and poorer long-term outcomes. Strengthening prevention and ensuring equitable access from early childhood is essential to address this[22]. Longitudinal studies show that childhood caries is a strong predictor of adult caries, reinforcing the need for prevention strategies that extend beyond adolescence[23]. In conclusion, this study confirms that dental caries in adolescents is shaped by multiple, intersecting determinants. Socioeconomic status, access to healthcare, poor hygiene habits, and sugar-rich diets significantly influence caries prevalence. Socially vulnerable adolescents are disproportionately affected, demanding public policies that expand access to care and incorporate preventive strategies such as water fluoridation. Oral health teams must adopt interdisciplinary approaches, promoting healthy diets and physical activity alongside oral hygiene. Socioeconomic indicators like family income and education level demonstrate that oral health is not merely a biological issue but a reflection of broader social conditions. School performance is linked to caries prevalence and severity, further emphasizing education’s role in fostering self-care. Declarations Funding: This study was partially funded by the Federal University of Mato Grosso do Sul (UFMS). Competing Interests: none Ethics Approval: The study was approved by the Human Research Ethics Committee of the Federal University of Mato Grosso do Sul (CAAE number 85647518.4.0000.0021). Informed Consent: all adolescents and their families gave informed consent Data Availability Statement: The datasets generated and/or analysed during the current study are not publicly available due to ethical and legal restrictions related to participant confidentiality and data protection agreements, but are available from the corresponding author on reasonable request. Acknowledgements: RAB has a productivity (PQ) fellowship from Fundect/CNPq Contribution Statement: LPB contributed to the conception and design, data interpretation, and critically drafted and revised the manuscript. LCG contributed to the conception and design, data interpretation, and critically drafted and revised the manuscript. RAB contributed to the conception and design, conducted all statistical analyses and data interpretation, and critically drafted and revised the manuscript. References Organization WH. Global report on the status of oral health towards universal oral health coverage by 2030. Geneva2022. 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Impact of water fluoridation on dental caries decline across racial and income subgroups of Brazilian adolescents. Epidemiol Health. 2022;44:e2022007. doi: 10.4178/epih.e2022007. Epub 2022 Jan 3. PMID: 34990530; PMCID: PMC9016390. Cruz RKS, Freitas YNL, Mendes TCO, Silva JVD, Machado FCA, Rodrigues MP, et al. Spatial inequality of dental caries in the Brazilian territory. Braz Oral Res. 2020;33:e122. Schmidt J, Vogel M, Poulain T, Kiess W, Hirsch C, Ziebolz D, et al. Association of Oral Health Conditions in Adolescents with Social Factors and Obesity. Int J Environ Res Public Health. 2022;19(5). Meira GF, Knorst JK, Maroneze MC, Ortiz FR, Ardenghi TM. Effect of dental caries and socioeconomic status on social capital throughout adolescence: a 6-year follow-up. Braz Oral Res. 2020;34:e104. Elamin A, Garemo M, Mulder A. Determinants of dental caries in children in the Middle East and North Africa region: a systematic review based on literature published from 2000 to 2019. BMC Oral Health. 2021;21(1):237. Lembacher S, Hofer V, Bekes K. The Impact of Dental Pain on the Oral Health-Related Quality of Life (OHRQoL) of Preschool Children in Austria. J Clin Med. 2023;12(18). Peres MA, Liu P, Demarco FF, Silva AER, Wehrmeister FC, Menezes AM, et al. Income trajectories affect treatment of dental caries from childhood to young adulthood: a birth cohort study. Braz Oral Res. 2018;32:e36. Broadbent JM, Foster Page LA, Thomson WM, Poulton R. Permanent dentition caries through the first half of life. Br Dent J. 2013;215(7):E12. Tables Table 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files tablesOdontology.docx Cite Share Download PDF Status: Published Journal Publication published 01 Oct, 2025 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 11 Jun, 2025 Reviews received at journal 06 Jun, 2025 Reviewers agreed at journal 26 May, 2025 Reviewers agreed at journal 26 May, 2025 Reviews received at journal 08 May, 2025 Reviewers agreed at journal 03 May, 2025 Reviewers invited by journal 01 May, 2025 Editor assigned by journal 28 Apr, 2025 Submission checks completed at journal 24 Apr, 2025 First submitted to journal 24 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6404590","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":451492288,"identity":"ceb8b0c6-871c-4e93-acf6-99413e5fb595","order_by":0,"name":"Leticia Barros","email":"","orcid":"","institution":"Federal University of Mato Grosso do Sul","correspondingAuthor":false,"prefix":"","firstName":"Leticia","middleName":"","lastName":"Barros","suffix":""},{"id":451492289,"identity":"332591fc-620c-4549-84a1-f4ec7f464818","order_by":1,"name":"Luiza Grieleitow","email":"","orcid":"","institution":"Federal University of Mato Grosso do Sul","correspondingAuthor":false,"prefix":"","firstName":"Luiza","middleName":"","lastName":"Grieleitow","suffix":""},{"id":451492290,"identity":"5b795496-cdd9-4e0c-bcd0-bfc75824bc4a","order_by":2,"name":"Rafael Bomfim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIie2QsYoCMRCGJwTWZmHbVPoKEUE48E2uSR4gXHFNCpVUa+MDWIi+wtlsPRLINYIPcMXFN9jutjS7gtis4bqDy1cMP8N8ZCYAicRfhAJB3wUE8LoN1MQUQNGGLFRxajskosCjIss2RZRiRRGFhreipBcvd4vXYhWURle9CrOZwLDPy8ZlEy6rT7WxxJD16av/GZtzDPtw+DZTJiunTFAoKfuVkS3qThm5wU8jt07tYwq3OXQKd/kUpJmrj5gythkPtzA+dvk7Ew7VISjHZ7cMz/biaz3jQzc41PV8qXZne/SNfnL+DXb/ja5ibP6R5W+GE4lE4p9wBX6cXnnRqOfSAAAAAElFTkSuQmCC","orcid":"","institution":"Federal University of Mato Grosso do Sul","correspondingAuthor":true,"prefix":"","firstName":"Rafael","middleName":"","lastName":"Bomfim","suffix":""}],"badges":[],"createdAt":"2025-04-08 15:08:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6404590/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6404590/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-16230-y","type":"published","date":"2025-10-01T15:58:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":92883882,"identity":"4d13516e-68c3-4452-8913-d41825979e65","added_by":"auto","created_at":"2025-10-06 16:10:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":387611,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6404590/v1/2aab59a6-9f1f-4f0f-84af-464950518494.pdf"},{"id":82079176,"identity":"614aff53-cb77-4c37-9f24-7641562832ad","added_by":"auto","created_at":"2025-05-06 14:11:24","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":26585,"visible":true,"origin":"","legend":"","description":"","filename":"tablesOdontology.docx","url":"https://assets-eu.researchsquare.com/files/rs-6404590/v1/2cd28da1e7ef1ee5e3abf8c1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Unhealthy Dietary Habits and Sedentary Behavior Drive Untreated Dental Caries among Adolescents: A Population-Based Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDental caries has historically been recognized as one of the greatest global public health challenges, affecting populations of all ages and social backgrounds. It is one of the leading non-communicable chronic diseases, with impacts that go beyond oral health, affecting overall well-being, learning ability, and even the social integration of affected individuals[1]. The condition is multifactorial in nature, influenced by several elements such as diet composition, access to oral healthcare, and education on oral hygiene[2]. Adolescents with severe dental caries report negative impacts on their self-esteem, such as difficulties in social interactions, particularly in the school environment. This underscores the importance of disease prevention and the promotion of self-care for oral health in this age group[3].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn Brazil, the situation is also concerning. Data from the latest national oral health survey, SB Brasil, indicate that over 80% of Brazilian adolescents have had at least one tooth affected by caries[4]. Although the country has implemented oral health policies focused on prevention and treatment, such as the \u0026ldquo;Brasil Sorridente\u0026rdquo; Program, many young people still face difficulties accessing quality dental services. Factors such as social inequality, lack of resources in rural or underserved areas, and parents\u0026apos; low educational levels directly affect the oral health of adolescents[4].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStudies show that the distribution of dental caries among adolescents is heterogeneous, with the disease being more severe in socially disadvantaged classes. Furthermore, variables such as the Municipal Human Development Index (MHDI) and the ratio of dentists to the population are also related to the number of decayed teeth. In regions with lower MHDI and a smaller proportion of dentists per capita, the prevalence of dental caries is higher[5]. Adolescence is a critical period in human development, marked by profound physical, emotional, and social changes. During this phase, many young people tend to neglect oral hygiene, either due to lack of proper information, peer influence, or reduced regular follow-up by an oral health professional[6].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdditionally, dietary choices\u0026mdash;often rich in sugars and processed foods\u0026mdash;increase the risk of dental caries. This context makes adolescence a particularly vulnerable stage for the onset and progression of caries, a condition that, if left untreated, can lead to serious complications such as intense pain, abscesses, and even tooth loss[7]. Systematic reviews[8] have found an association between screen time/TV viewing and the consumption of unhealthy foods among adolescents, showing that the presence of screens during meals increases the intake of sugar-rich foods and sugary beverages, which can lead to a higher prevalence of caries in this age group[8]. Thus, the high prevalence of untreated dental caries in adolescents highlights the need for a more integrated and comprehensive approach that considers not only individual behaviors but also the social and economic determinants that shape access to and the quality of oral health care [2].\u003c/p\u003e\n\u003cp\u003eThe objective of this study was to analyze factors associated with untreated dental caries in 12-year-old adolescents living in the five largest cities (\u0026gt;80,000 inhabitants) in the state of Mato Grosso do Sul, Brazil. Specifically, the study aimed to: identify behavioral, socioeconomic and contextual factors influencing the prevalence of untreated dental caries in adolescents.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is a cross-sectional, school- and population-based study derived from the SBMS 2018/2019 epidemiological survey, which was conducted in the five largest cities in the state of Mato Grosso do Sul with over 80,000 inhabitants: Campo Grande, Dourados, Tr\u0026ecirc;s Lagoas, Corumb\u0026aacute;, and Ponta Por\u0026atilde;, between April 2018 and February 2019. These cities were selected because they are the most representative of the state\u0026rsquo;s four territorial macro-regions [9,10].\u003c/p\u003e\n\u003cp\u003eThis study analyzed the factors associated with untreated dental caries in 12-year-old adolescents. Data were collected on caries experience according to the criteria of the World Health Organization (WHO), as well as behavioral data from the adolescents. The theoretical framework of the social determinants of oral health guided all analyses [9,10].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample Size\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo calculate the sample size for dental caries, a formula was used that considered the mean and standard deviation values of the DMFT index (Decayed, Missing, and Filled Teeth) for the Central-West region of Brazil, according to SBBrasil 2010 (n = final sample size; Z = significance level of 1.96 (corresponding to a 95% confidence level, i.e., \u0026alpha; = 0.05);2 = variance of the sample mean, i.e., the square of the standard deviation of the variable (1.81);X = mean DMFT in the Central-West region, according to SBBrasil 2010 (mean = 2.63); \u0026epsilon; = acceptable margin of error or tolerated error (\u0026epsilon; = 0.10); deff = design effect (deff = 2.0); NRR = non-response rate (estimated at 30% refusal to participate).\u003c/p\u003e\n\u003cp\u003eA probability sampling by clusters was adopted, conducted in two stages with probabilities proportional to size. The five cities were organized as Primary Sampling Units (PSUs), and the municipal public elementary schools in each city were considered Secondary Sampling Units (SSUs)\u0026nbsp;[9,10].\u003c/p\u003e\n\u003cp\u003eFollowing the guidelines of the national epidemiological survey (SBBrasil 2010), data collection and interviews were planned in 32 schools in each of the two largest cities. If a city had fewer than 32 schools, all schools were included [9,10].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn 2018, the number of public elementary schools in each selected city was as follows: Campo Grande (86), Dourados (45), Corumb\u0026aacute; (26), Tr\u0026ecirc;s Lagoas (17), and Ponta Por\u0026atilde; (8). Therefore, all schools in Corumb\u0026aacute;, Ponta Por\u0026atilde;, and Tr\u0026ecirc;s Lagoas were included, and a random draw was conducted in Campo Grande and Dourados to select 32 schools each. Based on this, a total of 115 schools participated in the study[9,10].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Participants and Data Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo select study participants, up to ten 12-year-old adolescents per classroom were selected, drawn from a list provided by the school administration. Students who had transferred to other schools or were not attending at the time of the study were excluded from the sample.Epidemiological data were collected through a questionnaire delivered by the local coordination team to the parents or guardians of the adolescents, which included sociodemographic questions. After returning the completed questionnaire at school, the adolescents answered another questionnaire about their dietary habits.Subsequently, each student underwent an intraoral examination, conducted by five dental teams in the selected cities. Each team consisted of a dentist and a recorder and received 32 hours of prior practical training [9,10].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe outcome variable was the Decayed teeth(D\u0026ge;1), a component of DMFT (decayed missing and filling tetth, as recommended by the World Health Organization(WHO)[11]. A CPI probe was used for clinical caries examination on tooth surfaces, considering caries in the presence of a fissure, pit, or smooth surface of a tooth with a visible cavity or softened tissue at the base of the enamel, enamel discoloration, or a temporary restoration (except for glass ionomer). Descriptive proportion analyses were performed to establish associations between the independent variables and the outcome.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIndependent variables\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe variables were dichotomized: sex (female or male) and self-reported race/skin color (White, Brown/mixed-race, Asian, Black, or Indigenous). Per capita household income was categorized as below or equal/above the poverty line, considering the Brazilian economic context in 2018. Parental education level was subdivided into 1\u0026ndash;4 years of schooling and more than 4 years [9,10].\u003c/p\u003e\n\u003cp\u003eFor the weekly frequency of unhealthy food consumption, an instrument recommended by the Brazilian Ministry of Health was used, covering five food groups with the following options: (1) French fries, packaged chips, and fried snacks; (2) hamburgers and processed meats; (3) salty crackers or packaged savory snacks; (4) sweet cookies, filled cookies, candies, and chocolate (bars or bonbons); and (5) regular soda[12]. The average weekly frequency was obtained by summing and dividing by five, classifying unhealthy food consumption as: low (up to 2 times/week), moderate (2 to 4 times/week), and high (4 or more times/week)[10].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSedentary behavior (more than 2 hours/day) was assessed using an instrument translated and validated Rey lopez et al[13] and validated to the Brazilian adolescents population[14] based on the total time adolescents spent in four sedentary domains: TV, video games, internet use, and remaining seated. Participants selected one of seven categories that described their daily routine (0 minutes; less than 30 minutes; 30 minutes to 1 hour; more than 1 hour to 2 hours; more than 2 hours to 3 hours; more than 3 hours to 4 hours; and more than 4 hours per day). Total hours spent in sedentary behavior during weekdays were multiplied by five, and weekend hours by two, then divided by seven (total days of the week) to obtain a weekly average[10]. To analyze toothbrushing frequency, responses were categorized as brushing two or more times/day versus once or not at all. The water fluoridation variable was based on measurements from the 2017 Vigifl\u0026uacute;or survey[15], which provides the most up-to-date data on public water supply fluoridation in the state of Mato Grosso do Sul.\u003c/p\u003e\n\u003cp\u003eStatistical Analysis\u003c/p\u003e\n\u003cp\u003eUnivariable and adjusted multilevel logistic regressions were performed to test the association between untreated dental caries and behavioral and sociodemographic factors. In the unadjusted models, the relationship of each variable with the presence of dental caries was examined. Variables included in the adjusted models were those with statistical significance or with p \u0026lt; 0.20.\u003c/p\u003e\n\u003cp\u003eEthical Aspects\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Human Research Ethics Committee of the Federal University of Mato Grosso do Sul (CAAE number 85647518.4.0000.0021). All participants signed an informed assent form, and their guardians signed the informed consent form.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study population consisted of 615 twelve-year-old schoolchildren from 69 schools that agreed to participate in the study. The prevalence of untreated dental caries at age 12 was 25.3% (95% CI: 18.8\u0026ndash;33.1). To facilitate the analysis, the following tables present the results obtained, addressing various factors associated with untreated dental caries in adolescents, including socioeconomic, behavioral, and public health determinants. Table 1 presents the descriptive characteristics and proportions for the state of Mato Grosso do Sul (SBMS Study 2018\u0026ndash;19) among 12-year-old children and untreated dental caries. According to the variables analyzed, regarding ethnic groups, Black children (n=32) had the highest prevalence of untreated caries (57.9%) compared to White (n=270; 20.9%), Mixed-race (n=266; 28.3%), Asian (n=24; 23%), and Indigenous (n=6; 50%) children.\u003c/p\u003e\n\u003cp\u003eRegarding sex, the prevalence of untreated caries was similar between groups: 24.2% in females (n=315) and 26.9% in males (n=300). Regarding per capita income, families above the poverty level (n=376) had a lower prevalence of caries (23.3%) than those below the poverty level (n=216; 32.4%). Concerning parental education, adolescents whose parents had more than four years of schooling (n=234) had a lower prevalence of caries (22.6%) compared to those whose parents had up to four years of schooling (n=381; 26.1%). A higher prevalence of caries was also observed among adolescents with high unhealthy food consumption (more than 4 times/week; n=217; 40.4%), followed by moderate consumption (2 to 4 times/week; n=197; 31.4%) and low consumption (up to 2 times/week; n=168; 9.4%). In terms of brushing frequency, adolescents who brushed their teeth only once a day or not at all (n=234) had a higher prevalence of dental caries (33.6%) compared to those who brushed two or more times a day (n=318; 18.7%). Regarding flossing, adolescents who reported not using dental floss (n=272) showed a higher prevalence of dental caries (32.4%) than those who did use it (n=280; 18.6%).\u003c/p\u003e\n\u003cp\u003eAnalysis of water fluoridation status\u0026mdash;a contextual variable\u0026mdash;showed that areas with access to fluoridated water had a lower prevalence of untreated caries (n=411; 21.6%) compared to areas without access (n=204; 42.3%). Additionally, adolescents with sedentary behavior (more than 2 hours/day using the internet, gaming, sitting, or watching TV) had a higher prevalence of caries (n=251; 44.6%) compared to those without such behavior (n=338; 25.7%). Table 2 below presents the multilevel logistic regression models for the prevalence of untreated caries according to covariates.\u003c/p\u003e\n\u003cp\u003eIn the adjusted models, sociodemographic characteristics such as income above the poverty level [OR = 0.55 (95% CI: 0.33\u0026ndash;0.91)], access to fluoridated water [OR = 0.58 (95% CI: 0.28\u0026ndash;0.99)], and brushing more than twice a day [OR = 0.54 (95% CI: 0.32\u0026ndash;0.91)] were associated with untreated dental caries as protective factors.\u003c/p\u003e\n\u003cp\u003eRisk factors included unhealthy food consumption [OR = 5.00 (95% CI: 2.21\u0026ndash;11.62)] and sedentary behavior [OR = 1.56 (95% CI: 1.00\u0026ndash;2.52)]. Unhealthy food consumption was a highly significant variable, increasing the likelihood of untreated caries by five times. Water fluoridation was significant, reducing the likelihood of untreated caries by 42%. Additionally, per capita income was significant, with a 45% protective effect. The ICC (Intraclass Correlation Coefficient) refers to the variance partition coefficient, indicating how much of the variation in caries prevalence is attributable to differences between cities. Thus, the context matters, with a 21.1% (95% CI: 11.7\u0026ndash;35.2) variation in caries prevalence between municipalities\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study highlights sedentary behavior and unhealthy food consumption as \u0026nbsp;behavioral factors influencing the prevalence of untreated dental caries among Brazilian adolescents, emphasizing that caries remains a significant public health issue in this population. Its multifactorial etiology encompasses behavioral, socioeconomic and contextual components as access to water fluoridation.\u003c/p\u003e\n\u003cp\u003eAs a cross-sectional study, this research has inherent limitations, notably the inability to infer causality and the lack of data on residential mobility of participants, which could not be controlled. However, the use of validated instruments\u0026mdash;both nationally and internationally\u0026mdash;particularly for assessing sedentary behavior, enhances the reliability of our findings and supports their potential relevance for informing public policies [13,14]. A major strength of this study is its representativeness: it covered over half the population of Mato Grosso do Sul, a key Brazilian state in the Midwest region, significant for its agribusiness sector, which contributes around 25% to Brazil\u0026rsquo;s GDP. Unlike many previous studies that focus solely on screen time, this research assessed four dimensions of sedentary behavior using the HELENA study instrument, known for its internal reliability[13]. To our knowledge, this is the first complex oral health survey in Brazil to examine the association between sedentary behavior and dental caries, with unhealthy food consumption as a potential mediator [10]. Dietary data were collected using the SISVAN questionnaire, a validated tool from the Brazilian Ministry of Health [12].\u003c/p\u003e\n\u003cp\u003eUntreated dental caries is recognized as a socially determined disease. In this study, a high-sugar diet, inadequate oral hygiene practices, low socioeconomic status and water fluoridation\u003csup\u003e16\u003c/sup\u003e were central to its prevalence. A marked polarization of the disease was observed: while some adolescents had no signs of caries, others\u0026mdash;particularly those in vulnerable conditions\u0026mdash;were disproportionately affected, reflecting Brazil\u0026apos;s deepening social inequalities. These findings underscore the need for integrated public health policies that address the social determinants of oral health. Adolescents from families below the poverty line showed greater disease burden, likely due to reduced dental visits and limited access to hygiene products such as toothbrushes, fluoridated toothpaste, and floss[10,17].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Issues such as obesity, stress, and adverse environments significantly influence oral health and should be considered in preventive strategies[18]. The association between obesity and caries reinforces the connection between behavioral risk factors and oral health. Sedentary adolescents\u0026mdash;often with poor diets high in sugars and ultra-processed foods\u0026mdash;exhibited greater untreated caries prevalence. These dietary patterns contribute both to obesity and oral disease and are consistent with studies linking poor nutrition in adolescents to increased caries susceptibility[18]. Moreover, Physical activity emerged as a protective factor. A 15% reduction in caries and periodontal issues was observed among adolescents engaged in sports clubs, possibly due to healthier lifestyles and lower consumption of sugary foods. Additionally, physical activity may boost immunity, offering further protection against oral disease[18].The data point to the need for integrated public health interventions promoting healthy eating, reduced sugar intake, and physical activity. School and government programs that combine sports promotion, oral hygiene education, and regular dental check-ups can enhance awareness and reduce reliance on complex, curative treatments.\u003c/p\u003e\n\u003cp\u003eEducation is another determinant. Lower educational levels correlate with poorer oral hygiene practices and reduced awareness of oral health\u0026apos;s importance. Families with limited schooling are more exposed to oral health problems, indicating the value of educational interventions in promoting self-care[6]. Maternal education, in particular, appears protective, as more educated mothers are more likely to encourage preventive behaviors and ensure regular dental care for their children[19,20].\u003c/p\u003e\n\u003cp\u003eInadequate hygiene\u0026mdash;such as infrequent brushing and flossing\u0026mdash;was also strongly linked to caries prevalence. This reinforces the need for robust educational strategies targeting adolescents and families, especially in low-income communities, where knowledge and use of preventive measures may be limited[17]. Untreated caries affects not only oral health but also adolescents\u0026rsquo; quality of life. It can cause pain, impair self-esteem, hinder eating, concentration, and communication, and negatively affect academic performance. Additionally, limited access to dental care in low-income settings can lead to long-term oral and general health consequences[21].\u003c/p\u003e\n\u003cp\u003eAn integrated approach is necessary for caries prevention\u0026mdash;one that considers individual behaviors and structural conditions, such as access to fluoridated water. The lack of access to fluoridation was linked to higher caries prevalence and severity, reaffirming its importance as a cost-effective public health measure, especially for vulnerable groups[6]. However, fluoridation alone is insufficient. Broader strategies are needed to address social inequalities. Adolescents in underserved regions often face inadequate access to education and healthcare, which heightens their risk of oral disease. Equitable policies that combine oral health education and the fair distribution of resources are crucial[6].\u003c/p\u003e\n\u003cp\u003eResearch from Brazil on the Family Health Strategy (ESF-SB) showed that greater coverage of oral health teams increases oral health services use among adolescents[9]. Disparities were also evident in service access: wealthier, white adolescents are more likely to use private services for prevention, while lower-income and non-white adolescents often access public services only for treatment. Strategies such as expanding preventive oral health coverage in public schools and health education campaigns are essential to close this gap and promote equitable access[9]. Similar findings appear in studies linking sedentary behavior, unhealthy diets, and caries in 12-year-olds. Excess screen time and frequent consumption of snacks and sugary drinks were associated with higher DMFT scores. Once again, water fluoridation proved protective[10,16].\u003c/p\u003e\n\u003cp\u003eA further study showed that income trajectory influences lifetime caries progression. Adolescents from high income families had better oral health, while those from low-income households had more untreated caries, despite universal healthcare. This illustrates how income inequality affects access and outcomes, underscoring the need for equitable distribution of dental resources[22].Even within Brazil\u0026rsquo;s Unified Health System (SUS), disparities persist. Higher-income families access preventive and curative services more easily, often through private care. In contrast, low-income families may only seek public care in emergencies, leading to more extractions and poorer long-term outcomes. Strengthening prevention and ensuring equitable access from early childhood is essential to address this[22]. Longitudinal studies show that childhood caries is a strong predictor of adult caries, reinforcing the need for prevention strategies that extend beyond adolescence[23].\u003c/p\u003e\n\u003cp\u003eIn conclusion, this study confirms that dental caries in adolescents is shaped by multiple, intersecting determinants. Socioeconomic status, access to healthcare, poor hygiene habits, and sugar-rich diets significantly influence caries prevalence. Socially vulnerable adolescents are disproportionately affected, demanding public policies that expand access to care and incorporate preventive strategies such as water fluoridation. Oral health teams must adopt interdisciplinary approaches, promoting healthy diets and physical activity alongside oral hygiene.\u003c/p\u003e\n\u003cp\u003eSocioeconomic indicators like family income and education level demonstrate that oral health is not merely a biological issue but a reflection of broader social conditions. School performance is linked to caries prevalence and severity, further emphasizing education\u0026rsquo;s role in fostering self-care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study was partially funded by the Federal University of Mato Grosso do Sul (UFMS).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e none\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval:\u003c/strong\u003e The study was approved by the Human Research Ethics Committee of the Federal University of Mato Grosso do Sul (CAAE number 85647518.4.0000.0021).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent:\u003c/strong\u003e all adolescents and their families gave informed consent\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e The datasets generated and/or analysed during the current study are not publicly available due to ethical and legal restrictions related to participant confidentiality and data protection agreements, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eRAB has a productivity (PQ) fellowship from Fundect/CNPq\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContribution Statement:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;LPB contributed to the conception and design, data interpretation, and critically drafted and revised the manuscript.\u003cbr\u003e\u0026nbsp;LCG contributed to the conception and design, data interpretation, and critically drafted and revised the manuscript.\u003cbr\u003e\u0026nbsp;RAB contributed to the conception and design, conducted all statistical analyses and data interpretation, and critically drafted and revised the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOrganization WH. Global report on the status of oral health towards universal oral health coverage by 2030. Geneva2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCascaes AM, Silva NRJD, Fernandez MDS, Bomfim RA, Vaz JDS. Ultra-processed food consumption and dental caries in children and adolescents: a systematic review and meta-analysis. Br J Nutr. 2022 Jul 27:1\u0026ndash;10. doi: 10.1017/S0007114522002409. Epub ahead of print. PMID: 35894293.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChimbinha \u0026Iacute;, Ferreira BNC, Miranda GP, Guedes RS. Oral-health-related quality of life in adolescents: umbrella review. BMC Public Health. 2023;23(1):1603.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrasil. SB Brasil 2010: Pesquisa Nacional de Sa\u0026uacute;de Bucal: resultados principais/ Minist\u0026eacute;rio da Sa\u0026uacute;de. Bras\u0026iacute;lia2010. p. 116.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePedroso CLM, Roberto LL, De Paula AMB, Haikal DSa. Contextual and Individual Factors Associated with Dental Caries among Brazilian Adolescents: A Multilevel Study. Dent Res Oral Health. 2022;5(4):94\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorr\u0026ecirc;a LLG, Sousa MDLR, Frias AC, Antunes JLF. Factors associated with dental caries in adolescents: a cross-sectional study, S\u0026atilde;o Paulo State, Brazil, 2015. Epidemiol Serv Saude. 2020;29(5):e2019523.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLunardelli SE, Traebert E, Lunardelli AN, Martins LGT, Traebert J. Autoestima e c\u0026aacute;rie dent\u0026aacute;ria em adolescentes: um estudo seccional. Revista de Odontologia da UNESP. 2016:332-8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShqair AQ, Pauli LA, Costa VPP, Cenci M, Goettems ML. Screen time, dietary patterns and intake of potentially cariogenic food in children: A systematic review. Journal of Dentistry. 2019;86:17\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartinelli DLF, Cascaes AM, Frias AC, Souza LB, Bomfim RA. Oral health coverage in the Family Health Strategy and use of dental services in adolescents in Mato Grosso do Sul, Brazil, 2019: cross-sectional study. Epidemiol Serv Saude. 2021;30(4):e20201140.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBomfim RA, Frias AC, Cascaes AM, Mazzilli LEN, Souza LB, Carrer FCA, et al. Sedentary behavior, unhealthy food consumption and dental caries in 12-year-old schoolchildren: a population-based study. Braz Oral Res. 2021;35:e041.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Oral health surveys: basic methods \u0026minus;\u0026thinsp;5th edition\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinist\u0026eacute;rio da Sa\u0026uacute;de [homepage]. Protocolos do sistema de vigil\u0026acirc;ncia alimentar e nutricional SISVAN. Bras\u0026iacute;lia(DF) 2008 : Minist\u0026eacute;rio da Sa\u0026uacute;de ; 2017 [cited 2017 Nov 27]. Available from: \u0026lt;http://189.28.128.100/dab/docs/portaldab/publicacoes/protocolo_sisvan.pdf \u0026gt;.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRey-Lopez JP, Ruiz JR, Ortega FB, Verloigne M, Vicente-Rodriguez G, Gracia-Marco L, et al. Reliability and validity of a screen time-based sedentary behaviour questionnaire for adolescents: The HELENA study. Eur J Public Health. 2012 Jun;22(3):373-7. doi: 10.1093/eurpub/ckr040.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerreira RW, Rombaldi AJ, Ricardo LI, Hallal PC, Azevedo MR. 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Impact of water fluoridation on dental caries decline across racial and income subgroups of Brazilian adolescents. Epidemiol Health. 2022;44:e2022007. doi: 10.4178/epih.e2022007. Epub 2022 Jan 3. PMID: 34990530; PMCID: PMC9016390.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCruz RKS, Freitas YNL, Mendes TCO, Silva JVD, Machado FCA, Rodrigues MP, et al. Spatial inequality of dental caries in the Brazilian territory. Braz Oral Res. 2020;33:e122.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchmidt J, Vogel M, Poulain T, Kiess W, Hirsch C, Ziebolz D, et al. Association of Oral Health Conditions in Adolescents with Social Factors and Obesity. Int J Environ Res Public Health. 2022;19(5).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeira GF, Knorst JK, Maroneze MC, Ortiz FR, Ardenghi TM. Effect of dental caries and socioeconomic status on social capital throughout adolescence: a 6-year follow-up. Braz Oral Res. 2020;34:e104.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElamin A, Garemo M, Mulder A. Determinants of dental caries in children in the Middle East and North Africa region: a systematic review based on literature published from 2000 to 2019. BMC Oral Health. 2021;21(1):237.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLembacher S, Hofer V, Bekes K. The Impact of Dental Pain on the Oral Health-Related Quality of Life (OHRQoL) of Preschool Children in Austria. J Clin Med. 2023;12(18).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeres MA, Liu P, Demarco FF, Silva AER, Wehrmeister FC, Menezes AM, et al. Income trajectories affect treatment of dental caries from childhood to young adulthood: a birth cohort study. Braz Oral Res. 2018;32:e36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBroadbent JM, Foster Page LA, Thomson WM, Poulton R. Permanent dentition caries through the first half of life. Br Dent J. 2013;215(7):E12.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Dental caries, Oral health, Adolescents, Social determinants, Machine learning, Public health, Brazil","lastPublishedDoi":"10.21203/rs.3.rs-6404590/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6404590/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Untreated dental caries remains a significant public health challenge, particularly among adolescents, where it can compromise well-being and quality of life. This population-based study investigates the factors associated with untreated dental caries in 12-year-olds across the five most populous cities (each with \u003e80,000 inhabitants) in the state of Mato Grosso do Sul, Brazil. Using WHO criteria, clinical oral examinations and self-reported behavioral data were collected. Guided by a social determinants of health framework, we conducted univariable and multilevel logistic regression analyses to explore associations between untreated dental caries and individual, behavioral, and contextual factors. The prevalence of untreated dental caries was 25.3% (95% CI: 18.8–33.1). Protective factors included household income above the poverty line [OR = 0.55 (95% CI: 0.33–0.91)], exposure to fluoridated water [OR = 0.58 (95% CI: 0.28–0.99)], and brushing more than twice daily [OR = 0.54 (95% CI: 0.32–0.91)]. In contrast, adolescents reporting frequent consumption of unhealthy foods [OR = 5.00 (95% CI: 2.21–11.62)] and sedentary behavior [OR = 1.56 (95% CI: 1.00–2.52)] were more likely to present untreated caries. Our findings highlight the interplay between socioeconomic context, lifestyle behaviors, and access to preventive measures. To reduce the burden of untreated dental caries in adolescence, oral health interventions must adopt a transdisciplinary approach that addresses broader social and behavioral determinants—promoting healthier diets, reducing sedentary time, and ensuring access to fluoridated water.","manuscriptTitle":"Unhealthy Dietary Habits and Sedentary Behavior Drive Untreated Dental Caries among Adolescents: A Population-Based Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 14:11:19","doi":"10.21203/rs.3.rs-6404590/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-11T09:16:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-06T17:32:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165218354792052308242876347757441161746","date":"2025-05-26T20:10:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"335237066612461037816520647713422758863","date":"2025-05-26T13:39:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-08T17:16:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120459552851617498814185956233392109041","date":"2025-05-03T15:45:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-01T08:27:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-28T12:38:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-24T14:25:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-04-24T14:24:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f394ab38-6178-4fd9-939d-af0397034cd2","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":48029924,"name":"Health sciences/Health care/Dentistry/Preventive dentistry/Fluoridation"},{"id":48029925,"name":"Health sciences/Health care"},{"id":48029926,"name":"Health sciences/Health care/Nutrition"}],"tags":[],"updatedAt":"2025-10-06T16:04:18+00:00","versionOfRecord":{"articleIdentity":"rs-6404590","link":"https://doi.org/10.1038/s41598-025-16230-y","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-10-01 15:58:06","publishedOnDateReadable":"October 1st, 2025"},"versionCreatedAt":"2025-05-06 14:11:19","video":"","vorDoi":"10.1038/s41598-025-16230-y","vorDoiUrl":"https://doi.org/10.1038/s41598-025-16230-y","workflowStages":[]},"version":"v1","identity":"rs-6404590","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6404590","identity":"rs-6404590","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}