Influence of Digital Behavior and Sleep Quality on Periodontal Status in Adolescents: A Cross-Sectional Study

Influence of Digital Behavior and Sleep Quality on Periodontal Status in Adolescents: A Cross-Sectional 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 Research Article Influence of Digital Behavior and Sleep Quality on Periodontal Status in Adolescents: A Cross-Sectional Study Nurcan Aksaka, Selin Şahinkaya, Ekin Yay This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6776154/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Aug, 2025 Read the published version in BMC Oral Health → Version 1 posted 11 You are reading this latest preprint version Abstract Background Internet addiction and poor sleep quality are increasingly recognized as behavioral risk factors that may influence adolescents’ overall and oral health. This study aimed to evaluate the association between internet addiction, sleep quality, and clinical periodontal parameters among adolescents. Methods This cross-sectional study included 100 systemically healthy adolescents (aged 12–18 years). The sample consisted of both male (47%) and female (53%) participants, predominantly of Turkish ethnicity, representing middle socioeconomic backgrounds. Data on internet use patterns and sleep quality were collected using the Young Internet Addiction Test (IAT) and the Pittsburgh Sleep Quality Index (PSQI), respectively. Clinical periodontal parameters, including Gingival Index (GI), Plaque Index (PI), Probing Pocket Depth (PPD), and Bleeding on Probing (BoP), were measured by a calibrated examiner. Results Adolescents with poor sleep quality exhibited significantly higher GI and PI scores (p = 0.025 and p = 0.024, respectively). Additionally, the mean IAT score was significantly higher in adolescents with poor sleep quality (p = 0.032). A high frequency of internet use (> 28 hours/week) was more prevalent in this group (p = 0.020). Conclusions The findings suggest that poor sleep quality and excessive internet use may negatively influence periodontal health in adolescents. These results emphasize the importance of considering behavioral factors such as digital media exposure and sleep patterns in the clinical assessment and prevention of periodontal diseases during adolescence. Adolescent internet addiction periodontal health plaque index sleep quality Background Sleep is essential for maintaining systemic balance, including immune responses, hormone regulation, cardiovascular stability, and mental functioning. 1 In adolescents, who are undergoing critical physical and psychological development, adequate and good quality sleep is particularly essential. However, modern lifestyles—especially those involving prolonged screen exposure and digital media engagement—have led to a growing prevalence of sleep disturbances in this age group. 2,3 One of the behavioral patterns increasingly associated with poor sleep quality is excessive internet use. Internet addiction (IA), characterized by an inability to control one’s internet use despite negative consequences, has been linked to disrupted circadian rhythms, reduced sleep duration, and increased daytime dysfunction. 4,5 According to national reports, internet usage among adolescents continues to rise sharply. For instance, the Turkish Statistical Institute reported that the rate of internet use in individuals aged 16–24 was 84.3% in 2016, increased to 90.8% in 2019, and reached 96.8% by 2022, highlighting a rapid and ongoing increase in digital media engagement among young people. 6,7 Importantly, insufficient and poor-quality sleep may also impair self-care behaviors, including oral hygiene practices, dietary routines, and attention to health-related habits. Inadequate sleep has been associated with higher levels of systemic inflammation and may indirectly affect periodontal tissues, making adolescents more susceptible to gingival inflammation and plaque accumulation. 8–10 Furthermore, internet addiction may compound these effects by encouraging sedentary behaviors, delaying meal times, and reducing attention to daily routines such as tooth brushing or dental check-ups. 11,12 Although a few studies have explored the relationship between digital behavior and oral health, most relied on self-reported oral health indicators rather than clinical periodontal assessments. To address this gap, the present study aimed to evaluate the relationship between sleep quality, internet addiction, and periodontal health among adolescents using objective clinical measurements. Methods This cross-sectional study was conducted at the department of periodontology between the dates of September 2019 and September 2024. The study population consisted of adolescents aged 12–18 years living in Istanbul, Türkiye, primarily of Turkish ethnicity. The present study was granted ethical approval by institutional ethics committee in accordance with applicable national regulations and conducted in accordance with the guidelines of the Helsinki Declaration of 1975, as revised in 2008. All participants and their parents or legal guardians were informed both verbally and in writing about purpose of the study and their written consent was obtained. Systemically healthy participants who did not use antibiotics in the last 6 months, did not smoke, and had at least 20 teeth in their mouth were included in this study. The sample size of 100 adolescents (50 with poor sleep quality and 50 with good sleep quality) was determined based on the number of eligible participants who met the inclusion criteria and consented to participate during the study period. Data were collected using a structured questionnaire divided into three sections: sociodemographic information, the Young Internet Addiction Test (IAT), and the Pittsburgh Sleep Quality Index (PSQI). Face-to-face interviews were conducted by trained researchers. Participants’ general characteristics including age, gender, height/weight, grade were obtained. Perceived family economic status and perceived academic achievement were assessed with responses classified into “high,” “middle,” and “low”. Questions were asked about internet access, such as “do you have a computer?”, “do you have internet access at home?”, and “weekly internet usage hours.” In addition, the purposes for which the participants used the internet and how often they used it were assessed with a 5-point Likert-type question, “never,” “rarely,” “sometimes,” “often,” and “always.” In order to assess the participants’ oral hygiene habits, they were asked about their frequency of brushing their teeth, using dental floss or interdental brushes, their use of mouthwash, and the time they last visited the dentist. Developed by Young, 13 the Internet Addiction Test (IAT) comprises 20 questions designed to evaluate the frequency of internet-related behaviors. Each item is rated on a 6-point Likert scale, with options ranging from ‘never’ to ‘always.’ The total possible score spans from 0 to 100, with higher values indicating greater severity of internet use problems. Scores between 20 and 49 are classified as “average internet user (non-risky user)”, scores between 50 and 79 as “internet user who rarely has problems (risky user)”, and scores between 80 and 100 as “internet user who often has problems (addicted user)”. The Turkish version of the scale was previously applied among adolescents by Bayraktar and Gün, who reported a Cronbach’s alpha reliability coefficient exceeding 0.80. 14 The PSQI is a self-reported instrument that evaluates sleep characteristics and disruptions over a one-month period. The questionnaire contains 24 items in total, with 19 addressed by the respondent and 5 completed by a parent or roommate. Of these, 18 contribute to the final score. Seven distinct domains are scored from 0 to 3, and the cumulative score is calculated by summing the domain scores. A score of 5 or below reflects good sleep quality, while scores above 5 suggest poor sleep quality. The Turkish validity-reliability study of the scale was conducted by Ağargün et al. and Cronbach's alpha internal consistency coefficient was calculated as 0.80. 16 Clinical periodontal parameters were assessed by a single calibrated examiner who was blinded to the questionnaire data. To determine the periodontal status, the following indices were recorded: Plaque Index (PI), Gingival Index (GI), Probing Pocket Depth (PPD), and Bleeding on Probing (BoP). Measurements were obtained from six sites per tooth for all present teeth. PI was used to determine the oral hygiene level of all individuals. The gingival index was used to assess inflammation, ranging from 0 for healthy gingiva to 3 for severe inflammation with spontaneous bleeding. PPD is measured by placing the Williams periodontal probe parallel to the long axis of the tooth into the sulcus and is expressed in millimeters. Following the measurement of PPD, the presence of bleeding at the site was recorded as BoP (+). Data were analyzed with IBM SPSS V23. The Kolmogorov-Smirnov test was used to examine the conformity of the data to normal distribution. Mann Whitney U test was used to analyze the data that did not follow normal distribution in two groups. Independent samples t test was used to analyze the data that followed normal distribution in two groups. Fisher's Exact test, Pearson chi-square, Yates correction and Fisher-Freeman-Halton Test were used to examine the relationship between categorical data. The significance level was taken as p < 0.05. Results There was no statistically significant relationship between gender and the groups (p = 1.000). In the poor sleep quality group, 52% of participants were female and 48% were male. In the good sleep quality group, 54% of participants were female and 46% were male. The mean age, weight, and height of all participants were 15.6 ± 1.72 years, 57.9 ± 14.5 kg, and 165.2 ± 11.01 cm, respectively. There were no statistically significant differences between groups in terms of age, weight, and height. (Table 1 ) Table 1 Comparison of participants’ demographic characteristics by groups Group Total (n = 100) p* Poor sleep quality (n = 50) Good sleep quality (n = 50) Sex, n (%) Female 26(52) 27(54) 53(53) 1,000 † Male 24(46) 23(46) 47(47) Age, years (mean ± SD) 15.86 ± 1.71 15.5 ± 1.73 15.6 ± 1.72 0,242* Weight, kg (mean ± SD) 59 ± 14.1 56.8 ± 14.9 57.9 ± 14.5 0,446* Height, cm (mean ± SD) 166,6 ± 11,3 163,9 ± 10,7 165.2 ± 11.01 0,233** † Yates’s correction, *Mann Whitney U test, median(min-max)**Independent sample t testi, SD: standard deviation There was no statistically significant relationship between the groups in terms of tooth brushing, interdental brushing, last dentist visit, gingival bleeding report, smoking, socioeconomic status, and academic success (p = 0.363), (p = 1.000), (p = 0.678), (p = 0.266), (p = 0,059), (p = 0,940), (p = 0,603). (Table 2 ) Table 2 Relationship between sleep quality and oral health behaviors, dental attendance, smoking, socioeconomic status, and academic performance Group Test statistic p Poor Sleep Good Sleep Total Tooth brushing None 5 (10) 2 (4) 7 (7) 3,859 0,363** 1 19 (38) 18 (36) 37 (37) 2 or more 13 (26) 20 (40) 33 (33) Irregular 13 (26) 10 (20) 23 (23) Interdental brushing No 47 (94) 48 (96) 95 (95) - 1,000* Yes 3 (6) 2 (4) 5 (5) Last dental visit None 5 (10) 3 (6) 8 (8) 2,314 0,678** 6 months ago 30 (60) 28 (56) 58 (58) 1 year ago 9 (18) 8 (16) 17 (17) 2 year ago 4 (8) 6 (12) 10 (10) 5 year or more 2 (4) 5 (10) 7 (7) Gingival bleeding No 18 (36) 25 (50) 43 (43) 1,469 0,266*** Yes 32 (64) 25 (50) 57 (57) Smoking No 43 (86) 49 (98) 92 (92) - 0,059* Yes 7 (14) 1 (2) 8 (8) Socioeconomic status Low 5 (10) 4 (8) 9 (9) 0,124 0,940** Middle 39 (78) 40 (80) 79 (79) High 6 (12) 6 (12) 12 (12) Academic performance Low 2 (4) 2 (4) 4 (4) 1,011 0,603** Middle 40 (80) 36 (72) 76 (76) High 8 (16) 12 (24) 20 (20) *Fisher’s exact test; **Pearson chi-square test ; *** Yates’s correction There is no statistically significant relationship between the groups and whether there is a computer at home, the frequency of internet access, and the age of internet use (p = 1.000), (p = 0.809), (p = 0.224). There is a statistically significant relationship between the groups and the weekly internet use hours (p = 0.020). The rate of those who use the internet more than 28 hours per week in the poor sleep group is 30% and the rate of those who use the internet more than 28 hours per week in the good sleep group is 6%. When the multiple comparison results of the rates are examined, this difference is due to the difference in the rates according to the groups that use the internet more than 28 hours per week. (Table 3 ) Table 3 Comparison of internet access and usage characteristics beween groups Group Test statistic p Poor Sleep Good Sleep Total Availability of a home computer No 13 (26) 13 (26) 26 (26) 0,000 1,000* Yes 37 (74) 37 (74) 74 (74) Frequency of internet access Always 40 (80) 38 (76) 78 (78) 0,058 0,809* Occasionally 10 (20) 12 (24) 22 (22) Age at first internet use < 12 years 32 (64) 26 (52) 58 (58) 1,026 0,224* ≥ 12 years 18 (36) 24 (48) 42 (42) Total weekly internet usage time 1–2 hours 2 (4) 7 (14) 9 (9) 11,622 0,020 ** 2–7 hours 13 (26) 14 (28) 27 (27) 7–14 hours 12 (24) 15 (30) 27 (27) 21–28 hours 8 (16) 11 (22) 19 (19) > 28 hours 15 (30) a 3 (6) b 18 (18) * Yates’s correction Fisher-Freeman-Halton Test a−b There is no difference between groups with the same letter. When the total IAT score average value of the participants was compared with their sleep quality, there was a significant difference. Accordingly, the IAT scores of the participants with poor sleep quality were found to be statistically significantly higher than those with good sleep quality (p = 0.032). Total IAT score categorical variable does not differ according to the groups (p = 0.074). While 26.5% of the participants with poor sleep quality were found to be addicted, 5% of the participants with good sleep quality were found to be addicted to the internet. (Table 4 ) Table 4 Comparison of total IAT scores by groups Poor Sleep Good Sleep Test statistic p Total IAT Scores 36,2 ± 19,5 28,2 ± 16,8 2,179 0,032 * Non-risky user 12 (24,5) 19 (38) 5,207 0,074 ** Risky user 24 (49) 26 (52) Addicted user 13 (26,5) 5 (10) * Independent samples t-test, mean ± standard deviation, ** Pearson chi-square test When clinical periodontal parameters were compared between the groups, GI and PI scores were found to be statistically significantly higher in participants with poor sleep quality (p = 0.025, p = 0.024). There was no difference between the groups in terms of BoP and PPD mean values. (Table 5 ) Table 5 Comparison of clinical periodontal parameters according to groups Variables (mean ± SD) Poor Sleep Good Sleep Test statistic p* GI 1,25 ± 0.52 1,03 ± 0.42 2,276 0,025 PI 1,34 ± 0,41 1,14 ± 0,44 2,294 0,024 PPD 1,81 ± 0,33 1,74 ± 0,27 1,207 0,230 BoP 40,62 ± 21,95 33,24 ± 16,94 1,882 0,063 *Independent samples t-test, SD: standard deviation Discussion In this cross-sectional study, we evaluated the relationship between internet use, sleep quality, and periodontal health among adolescents. Our findings demonstrated that poor sleep quality is significantly associated with higher scores of GI and PI, as well as elevated IAT scores and longer weekly internet usage. These findings contribute to the growing body of literature indicating that lifestyle habits influenced by excessive internet use may indirectly impact oral health outcomes. Our study revealed that adolescents with poor sleep quality spent significantly more time on the internet, with 30% exceeding 28 hours per week, compared to only 6% in the good sleep quality group. This aligns with a study conducted in 2023, which found a link between social media use and poor sleep quality among adolescents. 17 Furthermore, participants with poor sleep had higher mean IAT scores, indicating a greater risk of problematic internet use or addiction. These findings are consistent with prior research suggesting a bidirectional relationship between sleep disorders and internet addiction, particularly among adolescents. 18 In support of these findings, Do and Lee demonstrated both direct and indirect associations among problematic internet use, sleep disturbances, and oral health problems through logistic regression analysis. 19 Their findings reinforce the interconnected impact of digital behavior on adolescent well-being, highlighting how impaired sleep may serve as a mediating factor between internet use and deteriorating oral health. Research suggests that adequate sleep contributes to the regulation of the immune system and inflammatory pathways, including those affecting oral tissues. When sleep is disrupted, the body may produce higher levels of inflammation-related molecules, potentially contributing to the development of periodontal diseases. 1 Our findings support this biological plausibility, as participants with poor sleep quality showed significantly higher levels of GI and PI, reflecting increased gingival inflammation and plaque accumulation. Consistent with our results, a nationally representative U.S. study by Alkhodair et al. found that adults who slept more than seven hours per night were significantly less likely to exhibit severe periodontitis. 20 Notably, this relationship was stronger in individuals with diabetes, indicating that sleep duration may modulate systemic inflammation pathways that impact periodontal health. Although the differences in PPD and BoP were not statistically significant, it is possible that as age increases, periodontal inflammation may progress, potentially leading to alveolar bone destraction and more pronounced differences in these parameters over time. Interestingly, while the present study did not find statistically significant differences in oral hygiene behaviors such as brushing frequency or interdental cleaning between groups, previous literature indicates a possible association between excessive internet use and deterioration in oral health habits. For instance, Do et al., in a large-scale national survey of Korean adolescents, found that those with high internet use were significantly less likely to engage in preventive oral hygiene behaviors, including post-lunch tooth brushing. 21 Supporting this, a study by Al-Ansari et al. demonstrated that problematic internet use was associated with reduced tooth brushing frequency and poorer self-perceived oral health among young adults. 22 One possible explanation for this discrepancy may lie in the behavioral patterns associated with excessive internet use, particularly the increased desire to return to social media platforms. This digital engagement may lead to more hurried or less effective tooth brushing routines. Although no statistically significant differences were observed in tooth brushing frequency between groups, we observed significantly higher GI and PI scores in the poor sleep quality group, which may reflect the quality or thoroughness of oral hygiene practices. These discrepancies may also stem from differences in sample characteristics, cultural practices, or how oral hygiene behaviors are operationalized across studies. Moreover, our findings may suggest that while overt hygiene behaviors such as brushing frequency appear unaffected, other mediating factors—such as psychological stress, behavioral regulation difficulties, sleep disruption, or immune dysregulation—could play a more pivotal role in influencing periodontal outcomes. The lack of significant differences in socioeconomic status, academic achievement, and smoking status between groups strengthens the argument that internet use and sleep quality themselves are likely the major contributing factors in the observed differences in periodontal health. These findings also highlight the importance of multidisciplinary approaches, integrating dental, psychological, and behavioral assessments when addressing adolescent health. A notable strength of our study lies in the use of clinical periodontal examination rather than relying solely on self-reported measures. This enables a more objective assessment of oral health status, filling a notable gap in the current literature. Previous studies evaluating internet addiction and oral health often lack clinical verification of periodontal status, thereby limiting the accuracy of their findings. 18 Conclusion In conclusion, our findings suggest a meaningful relationship between internet usage, sleep quality, and periodontal health in adolescents. Poor sleep quality, associated with higher internet usage and internet addiction risk, correlates with poorer periodontal outcomes. These results underscore the need for awareness and preventive strategies targeting digital behavior and oral hygiene in adolescents as part of comprehensive oral health promotion efforts. This study has certain limitations. As it was designed cross-sectionally, it precludes the ability to determine causal relationships. Additionally, factors that might influence periodontal health -such as stress, dietary habits, and physical activity- were not assessed. Future longitudinal and multi-centered studies including broader behavioral assessments are recommended to confirm and expand upon these results. Declarations Ethics approval and consent to participate: This study was approved by the Istanbul Medipol University Ethics Committee (approval no: 679, approval date: 25.09.2019). Written informed consent was obtained from all participants included in the study. In the case of participants under the age of 16, informed consent was obtained from their parents or legal guardians. All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Clinical trial number: Not applicable. Consent for publication: Not applicable Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Requests for data access should be directed to Dr. Nurcan Aksaka (Istanbul Medipol University, School of Dentistry, Department of Periodontology, TEM Avrupa Otoyolu Göztepe Çıkışı No. 1, 34214 Bağcılar, Istanbul, Turkey; email: [ [email protected] ]). Competing interests: The authors declare that they have no competing interests. Funding: None Authors’ contributions: N.A. contributed to conceptualization, investigation, methodology, and writing (original draft and review & editing). S.Ş. contributed to conceptualization and investigation. E.Y. contributed to methodology and writing (review & editing). All authors have read and approved the final version of the manuscript. Acknowledgements: The authors have no individuals or organizations to acknowledge for this study. References Irwin MR. Why sleep is important for health: A psychoneuroimmunology perspective. Annual Review of Psychology. 2015;66:143–72. https://doi.org/10.1146/annurev-psych-010213-115205 Brautsch LAS, Lund L, Andersen MM, Jennum PJ. Digital media use and sleep in late adolescence and young adulthood: A systematic review. Sleep Medicine Reviews. 2022;68:101742. https://doi.org/10.1016/j.smrv.2022.101742 Açıkgöz A, Açıkgöz B, Açıkgöz O. The effect of internet addiction and smartphone addiction on sleep quality among Turkish adolescents. 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Cite Share Download PDF Status: Published Journal Publication published 26 Aug, 2025 Read the published version in BMC Oral Health → Version 1 posted Editorial decision: Revision requested 16 Jul, 2025 Reviews received at journal 12 Jul, 2025 Reviews received at journal 30 Jun, 2025 Reviewers agreed at journal 29 Jun, 2025 Reviewers agreed at journal 27 Jun, 2025 Reviewers agreed at journal 10 Jun, 2025 Reviewers invited by journal 10 Jun, 2025 Editor invited by journal 05 Jun, 2025 Editor assigned by journal 05 Jun, 2025 Submission checks completed at journal 04 Jun, 2025 First submitted to journal 04 Jun, 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-6776154","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":469978841,"identity":"6456709b-b87d-46c4-abc9-3a166de8e449","order_by":0,"name":"Nurcan Aksaka","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYFAC5gYgYQPEiUBGAZA+QFALYyNQaRpUiwFYC2MDEVoOAxkJDMRpMWc/2P7gx5/z0fzsyW0PPhgwyPHdSGB/XIFHi2VPYmNjb9vt3Jk9D9sNZxgwGEveSGBsPINHi8GBxMYG3obbuRtuJLZJ8xgwJG4AacHnMoPzDxsb//w5l7sfqqWesJYbiY3NPGwHcjdIQLQkGBDW8rBxtmxbcu6MM2C/SBjOPPOwcSZ+hyUf+Pjmj11uf3v6swcfKmzk+Y4DRfBpQQZsQCwBxIRiEk3LKBgFo2AUjAJMAABruVpsmzlN0QAAAABJRU5ErkJggg==","orcid":"","institution":"Istanbul Medipol University","correspondingAuthor":true,"prefix":"","firstName":"Nurcan","middleName":"","lastName":"Aksaka","suffix":""},{"id":469978842,"identity":"98e3c819-d131-42fc-b5ff-da9da1b22ca8","order_by":1,"name":"Selin Şahinkaya","email":"","orcid":"","institution":"Private Dental Clinic","correspondingAuthor":false,"prefix":"","firstName":"Selin","middleName":"","lastName":"Şahinkaya","suffix":""},{"id":469978845,"identity":"23f9ab4b-4e67-49ae-a11d-fe774fa9ccae","order_by":2,"name":"Ekin Yay","email":"","orcid":"","institution":"University of Birmingham","correspondingAuthor":false,"prefix":"","firstName":"Ekin","middleName":"","lastName":"Yay","suffix":""}],"badges":[],"createdAt":"2025-05-29 11:38:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6776154/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6776154/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-025-06749-x","type":"published","date":"2025-08-26T15:56:57+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90344827,"identity":"eda79e08-e591-446e-a18e-e0169eedd33e","added_by":"auto","created_at":"2025-09-01 16:04:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":641620,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6776154/v1/020e969f-7986-4d6d-841e-c856200ae8ca.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Influence of Digital Behavior and Sleep Quality on Periodontal Status in Adolescents: A Cross-Sectional Study","fulltext":[{"header":"Background","content":"\u003cp\u003eSleep is essential for maintaining systemic balance, including immune responses, hormone regulation, cardiovascular stability, and mental functioning.\u003csup\u003e1\u003c/sup\u003e In adolescents, who are undergoing critical physical and psychological development, adequate and good quality sleep is particularly essential. However, modern lifestyles\u0026mdash;especially those involving prolonged screen exposure and digital media engagement\u0026mdash;have led to a growing prevalence of sleep disturbances in this age group.\u003csup\u003e2,3\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOne of the behavioral patterns increasingly associated with poor sleep quality is excessive internet use. Internet addiction (IA), characterized by an inability to control one\u0026rsquo;s internet use despite negative consequences, has been linked to disrupted circadian rhythms, reduced sleep duration, and increased daytime dysfunction.\u003csup\u003e4,5\u003c/sup\u003e According to national reports, internet usage among adolescents continues to rise sharply. For instance, the Turkish Statistical Institute reported that the rate of internet use in individuals aged 16\u0026ndash;24 was 84.3% in 2016, increased to 90.8% in 2019, and reached 96.8% by 2022, highlighting a rapid and ongoing increase in digital media engagement among young people.\u003csup\u003e6,7\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eImportantly, insufficient and poor-quality sleep may also impair self-care behaviors, including oral hygiene practices, dietary routines, and attention to health-related habits. Inadequate sleep has been associated with higher levels of systemic inflammation and may indirectly affect periodontal tissues, making adolescents more susceptible to gingival inflammation and plaque accumulation.\u003csup\u003e8\u0026ndash;10\u003c/sup\u003e Furthermore, internet addiction may compound these effects by encouraging sedentary behaviors, delaying meal times, and reducing attention to daily routines such as tooth brushing or dental check-ups.\u003csup\u003e11,12\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlthough a few studies have explored the relationship between digital behavior and oral health, most relied on self-reported oral health indicators rather than clinical periodontal assessments. To address this gap, the present study aimed to evaluate the relationship between sleep quality, internet addiction, and periodontal health among adolescents using objective clinical measurements.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis cross-sectional study was conducted at the department of periodontology between the dates of September 2019 and September 2024. The study population consisted of adolescents aged 12\u0026ndash;18 years living in Istanbul, T\u0026uuml;rkiye, primarily of Turkish ethnicity. The present study was granted ethical approval by institutional ethics committee in accordance with applicable national regulations and conducted in accordance with the guidelines of the Helsinki Declaration of 1975, as revised in 2008. All participants and their parents or legal guardians were informed both verbally and in writing about purpose of the study and their written consent was obtained. Systemically healthy participants who did not use antibiotics in the last 6 months, did not smoke, and had at least 20 teeth in their mouth were included in this study. The sample size of 100 adolescents (50 with poor sleep quality and 50 with good sleep quality) was determined based on the number of eligible participants who met the inclusion criteria and consented to participate during the study period.\u003c/p\u003e \u003cp\u003eData were collected using a structured questionnaire divided into three sections: sociodemographic information, the Young Internet Addiction Test (IAT), and the Pittsburgh Sleep Quality Index (PSQI). Face-to-face interviews were conducted by trained researchers. Participants\u0026rsquo; general characteristics including age, gender, height/weight, grade were obtained. Perceived family economic status and perceived academic achievement were assessed with responses classified into \u0026ldquo;high,\u0026rdquo; \u0026ldquo;middle,\u0026rdquo; and \u0026ldquo;low\u0026rdquo;. Questions were asked about internet access, such as \u0026ldquo;do you have a computer?\u0026rdquo;, \u0026ldquo;do you have internet access at home?\u0026rdquo;, and \u0026ldquo;weekly internet usage hours.\u0026rdquo; In addition, the purposes for which the participants used the internet and how often they used it were assessed with a 5-point Likert-type question, \u0026ldquo;never,\u0026rdquo; \u0026ldquo;rarely,\u0026rdquo; \u0026ldquo;sometimes,\u0026rdquo; \u0026ldquo;often,\u0026rdquo; and \u0026ldquo;always.\u0026rdquo; In order to assess the participants\u0026rsquo; oral hygiene habits, they were asked about their frequency of brushing their teeth, using dental floss or interdental brushes, their use of mouthwash, and the time they last visited the dentist.\u003c/p\u003e \u003cp\u003eDeveloped by Young,\u003csup\u003e13\u003c/sup\u003e the Internet Addiction Test (IAT) comprises 20 questions designed to evaluate the frequency of internet-related behaviors. Each item is rated on a 6-point Likert scale, with options ranging from \u0026lsquo;never\u0026rsquo; to \u0026lsquo;always.\u0026rsquo; The total possible score spans from 0 to 100, with higher values indicating greater severity of internet use problems. Scores between 20 and 49 are classified as \u0026ldquo;average internet user (non-risky user)\u0026rdquo;, scores between 50 and 79 as \u0026ldquo;internet user who rarely has problems (risky user)\u0026rdquo;, and scores between 80 and 100 as \u0026ldquo;internet user who often has problems (addicted user)\u0026rdquo;. The Turkish version of the scale was previously applied among adolescents by Bayraktar and G\u0026uuml;n, who reported a Cronbach\u0026rsquo;s alpha reliability coefficient exceeding 0.80. \u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe PSQI is a self-reported instrument that evaluates sleep characteristics and disruptions over a one-month period. The questionnaire contains 24 items in total, with 19 addressed by the respondent and 5 completed by a parent or roommate. Of these, 18 contribute to the final score. Seven distinct domains are scored from 0 to 3, and the cumulative score is calculated by summing the domain scores. A score of 5 or below reflects good sleep quality, while scores above 5 suggest poor sleep quality. The Turkish validity-reliability study of the scale was conducted by Ağarg\u0026uuml;n et al. and Cronbach's alpha internal consistency coefficient was calculated as 0.80.\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eClinical periodontal parameters were assessed by a single calibrated examiner who was blinded to the questionnaire data. To determine the periodontal status, the following indices were recorded: Plaque Index (PI), Gingival Index (GI), Probing Pocket Depth (PPD), and Bleeding on Probing (BoP). Measurements were obtained from six sites per tooth for all present teeth. PI was used to determine the oral hygiene level of all individuals. The gingival index was used to assess inflammation, ranging from 0 for healthy gingiva to 3 for severe inflammation with spontaneous bleeding. PPD is measured by placing the Williams periodontal probe parallel to the long axis of the tooth into the sulcus and is expressed in millimeters. Following the measurement of PPD, the presence of bleeding at the site was recorded as BoP (+).\u003c/p\u003e \u003cp\u003eData were analyzed with IBM SPSS V23. The Kolmogorov-Smirnov test was used to examine the conformity of the data to normal distribution. Mann Whitney U test was used to analyze the data that did not follow normal distribution in two groups. Independent samples t test was used to analyze the data that followed normal distribution in two groups. Fisher's Exact test, Pearson chi-square, Yates correction and Fisher-Freeman-Halton Test were used to examine the relationship between categorical data. The significance level was taken as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThere was no statistically significant relationship between gender and the groups (p\u0026thinsp;=\u0026thinsp;1.000). In the poor sleep quality group, 52% of participants were female and 48% were male. In the good sleep quality group, 54% of participants were female and 46% were male. The mean age, weight, and height of all participants were 15.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.72 years, 57.9\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5 kg, and 165.2\u0026thinsp;\u0026plusmn;\u0026thinsp;11.01 cm, respectively. There were no statistically significant differences between groups in terms of age, weight, and height. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of participants\u0026rsquo; demographic characteristics by groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor sleep quality (n\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood sleep quality (n\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26(52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53(53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1,000\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24(46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23(46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47(47)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,242*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight, kg (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59\u0026thinsp;\u0026plusmn;\u0026thinsp;14.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.8\u0026thinsp;\u0026plusmn;\u0026thinsp;14.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57.9\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,446*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight, cm (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e166,6\u0026thinsp;\u0026plusmn;\u0026thinsp;11,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e163,9\u0026thinsp;\u0026plusmn;\u0026thinsp;10,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e165.2\u0026thinsp;\u0026plusmn;\u0026thinsp;11.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,233**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003eYates\u0026rsquo;s correction, *Mann Whitney U test, median(min-max)**Independent sample t testi, SD: standard deviation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003eThere was no statistically significant relationship between the groups in terms of tooth brushing, interdental brushing, last dentist visit, gingival bleeding report, smoking, socioeconomic status, and academic success (p\u0026thinsp;=\u0026thinsp;0.363), (p\u0026thinsp;=\u0026thinsp;1.000), (p\u0026thinsp;=\u0026thinsp;0.678), (p\u0026thinsp;=\u0026thinsp;0.266), (p\u0026thinsp;=\u0026thinsp;0,059), (p\u0026thinsp;=\u0026thinsp;0,940), (p\u0026thinsp;=\u0026thinsp;0,603). (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eRelationship between sleep quality and oral health behaviors, dental attendance, smoking, socioeconomic status, and academic performance\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eTest statistic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"\"\u003e\n \u003cp\u003ePoor Sleep\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eGood Sleep\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eTooth brushing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e5 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e2 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e7 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e3,859\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e0,363**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e19 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e18 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e37 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e2 or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e13 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e20 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e33 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eIrregular\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e13 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e10 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e23 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eInterdental brushing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e47 (94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e48 (96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e95 (95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e1,000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e3 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e2 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e5 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eLast dental visit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e5 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e3 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e8 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003e2,314\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003e0,678**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e6 months ago\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e30 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e28 (56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e58 (58)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e1 year ago\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e9 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e8 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e17 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e2 year ago\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e4 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e6 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e10 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e5 year or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e2 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e5 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e7 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eGingival bleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e18 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e25 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e43 (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e1,469\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0,266***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e32 (64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e25 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e57 (57)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSmoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e43 (86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e49 (98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e92 (92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\" rowspan=\"2\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0,059*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e7 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e8 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSocioeconomic status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e5 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e4 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e9 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\" rowspan=\"3\"\u003e\n \u003cp\u003e0,124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e0,940**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMiddle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e39 (78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e40 (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e79 (79)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e6 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e6 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e12 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcademic performance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e2 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e2 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e4 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\" rowspan=\"3\"\u003e\n \u003cp\u003e1,011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e0,603**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMiddle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e40 (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e36 (72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e76 (76)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e8 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e12 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"\"\u003e\n \u003cp\u003e20 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e*Fisher\u0026rsquo;s exact test; **Pearson chi-square test ; *** Yates\u0026rsquo;s correction\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\u003cp\u003eThere is no statistically significant relationship between the groups and whether there is a computer at home, the frequency of internet access, and the age of internet use (p\u0026thinsp;=\u0026thinsp;1.000), (p\u0026thinsp;=\u0026thinsp;0.809), (p\u0026thinsp;=\u0026thinsp;0.224). There is a statistically significant relationship between the groups and the weekly internet use hours (p\u0026thinsp;=\u0026thinsp;0.020). The rate of those who use the internet more than 28 hours per week in the poor sleep group is 30% and the rate of those who use the internet more than 28 hours per week in the good sleep group is 6%. When the multiple comparison results of the rates are examined, this difference is due to the difference in the rates according to the groups that use the internet more than 28 hours per week. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of internet access and usage characteristics beween groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTest statistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor Sleep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood Sleep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvailability of a home computer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1,000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e74 (74)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of internet access\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78 (78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,809*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccasionally\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at first internet use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;12 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58 (58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1,026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,224*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;12 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42 (42)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal weekly internet usage time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e11,622\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003e0,020\u003c/b\u003e**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;7 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (27)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u0026ndash;14 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (27)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u0026ndash;28 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (19)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;28 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (30)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* Yates\u0026rsquo;s correction Fisher-Freeman-Halton Test \u003csup\u003ea\u0026minus;b\u003c/sup\u003e There is no difference between groups with the same letter.\u003c/p\u003e \u003cp\u003eWhen the total IAT score average value of the participants was compared with their sleep quality, there was a significant difference. Accordingly, the IAT scores of the participants with poor sleep quality were found to be statistically significantly higher than those with good sleep quality (p\u0026thinsp;=\u0026thinsp;0.032). Total IAT score categorical variable does not differ according to the groups (p\u0026thinsp;=\u0026thinsp;0.074). While 26.5% of the participants with poor sleep quality were found to be addicted, 5% of the participants with good sleep quality were found to be addicted to the internet. (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of total IAT scores by groups\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" style=\"width: 6.2568%;\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" style=\"width: 4.2991%;\"\u003e\n \u003cp\u003ePoor Sleep\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" style=\"width: 4.5678%;\"\u003e\n \u003cp\u003eGood Sleep\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 6.0265%;\"\u003e\n \u003cp\u003eTest statistic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\" style=\"width: 3.1092%;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.2568%;\"\u003e\n \u003cp\u003eTotal IAT Scores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 4.2991%;\"\u003e\n \u003cp\u003e36,2\u0026thinsp;\u0026plusmn;\u0026thinsp;19,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 4.5678%;\"\u003e\n \u003cp\u003e28,2\u0026thinsp;\u0026plusmn;\u0026thinsp;16,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.0265%;\"\u003e\n \u003cp\u003e2,179\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" style=\"width: 3.1092%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,032\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.2568%;\"\u003e\n \u003cp\u003eNon-risky user\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.2991%;\"\u003e\n \u003cp\u003e12 (24,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 4.5678%;\"\u003e\n \u003cp\u003e19 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.9517%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\" style=\"width: 2.188%;\"\u003e\n \u003cp\u003e5,207\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"3\" style=\"width: 1.996%;\"\u003e\n \u003cp\u003e0,074\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.2568%;\"\u003e\n \u003cp\u003eRisky user\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.2991%;\"\u003e\n \u003cp\u003e24 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 4.5678%;\"\u003e\n \u003cp\u003e26 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.9517%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.2568%;\"\u003e\n \u003cp\u003eAddicted user\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.2991%;\"\u003e\n \u003cp\u003e13 (26,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 4.5678%;\"\u003e\n \u003cp\u003e5 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.9517%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"12\" style=\"width: 25.7181%;\"\u003e* Independent samples t-test, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, ** Pearson chi-square test\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\u003cp\u003eWhen clinical periodontal parameters were compared between the groups, GI and PI scores were found to be statistically significantly higher in participants with poor sleep quality (p\u0026thinsp;=\u0026thinsp;0.025, p\u0026thinsp;=\u0026thinsp;0.024). There was no difference between the groups in terms of BoP and PPD mean values. (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of clinical periodontal parameters according to groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003cp\u003e(mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor Sleep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood Sleep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTest statistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,03\u0026thinsp;\u0026plusmn;\u0026thinsp;0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2,276\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0,025\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,34\u0026thinsp;\u0026plusmn;\u0026thinsp;0,41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,14\u0026thinsp;\u0026plusmn;\u0026thinsp;0,44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2,294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0,024\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,81\u0026thinsp;\u0026plusmn;\u0026thinsp;0,33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,74\u0026thinsp;\u0026plusmn;\u0026thinsp;0,27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,207\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,230\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40,62\u0026thinsp;\u0026plusmn;\u0026thinsp;21,95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33,24\u0026thinsp;\u0026plusmn;\u0026thinsp;16,94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,882\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,063\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Independent samples t-test, SD: standard deviation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this cross-sectional study, we evaluated the relationship between internet use, sleep quality, and periodontal health among adolescents. Our findings demonstrated that poor sleep quality is significantly associated with higher scores of GI and PI, as well as elevated IAT scores and longer weekly internet usage. These findings contribute to the growing body of literature indicating that lifestyle habits influenced by excessive internet use may indirectly impact oral health outcomes.\u003c/p\u003e \u003cp\u003eOur study revealed that adolescents with poor sleep quality spent significantly more time on the internet, with 30% exceeding 28 hours per week, compared to only 6% in the good sleep quality group. This aligns with a study conducted in 2023, which found a link between social media use and poor sleep quality among adolescents.\u003csup\u003e17\u003c/sup\u003e Furthermore, participants with poor sleep had higher mean IAT scores, indicating a greater risk of problematic internet use or addiction. These findings are consistent with prior research suggesting a bidirectional relationship between sleep disorders and internet addiction, particularly among adolescents.\u003csup\u003e18\u003c/sup\u003e In support of these findings, Do and Lee demonstrated both direct and indirect associations among problematic internet use, sleep disturbances, and oral health problems through logistic regression analysis.\u003csup\u003e19\u003c/sup\u003e Their findings reinforce the interconnected impact of digital behavior on adolescent well-being, highlighting how impaired sleep may serve as a mediating factor between internet use and deteriorating oral health.\u003c/p\u003e \u003cp\u003eResearch suggests that adequate sleep contributes to the regulation of the immune system and inflammatory pathways, including those affecting oral tissues. When sleep is disrupted, the body may produce higher levels of inflammation-related molecules, potentially contributing to the development of periodontal diseases.\u003csup\u003e1\u003c/sup\u003e Our findings support this biological plausibility, as participants with poor sleep quality showed significantly higher levels of GI and PI, reflecting increased gingival inflammation and plaque accumulation. Consistent with our results, a nationally representative U.S. study by Alkhodair et al. found that adults who slept more than seven hours per night were significantly less likely to exhibit severe periodontitis.\u003csup\u003e20\u003c/sup\u003e Notably, this relationship was stronger in individuals with diabetes, indicating that sleep duration may modulate systemic inflammation pathways that impact periodontal health. Although the differences in PPD and BoP were not statistically significant, it is possible that as age increases, periodontal inflammation may progress, potentially leading to alveolar bone destraction and more pronounced differences in these parameters over time.\u003c/p\u003e \u003cp\u003e Interestingly, while the present study did not find statistically significant differences in oral hygiene behaviors such as brushing frequency or interdental cleaning between groups, previous literature indicates a possible association between excessive internet use and deterioration in oral health habits. For instance, Do et al., in a large-scale national survey of Korean adolescents, found that those with high internet use were significantly less likely to engage in preventive oral hygiene behaviors, including post-lunch tooth brushing.\u003csup\u003e21\u003c/sup\u003e Supporting this, a study by Al-Ansari et al. demonstrated that problematic internet use was associated with reduced tooth brushing frequency and poorer self-perceived oral health among young adults.\u003csup\u003e22\u003c/sup\u003e One possible explanation for this discrepancy may lie in the behavioral patterns associated with excessive internet use, particularly the increased desire to return to social media platforms. This digital engagement may lead to more hurried or less effective tooth brushing routines. Although no statistically significant differences were observed in tooth brushing frequency between groups, we observed significantly higher GI and PI scores in the poor sleep quality group, which may reflect the quality or thoroughness of oral hygiene practices. These discrepancies may also stem from differences in sample characteristics, cultural practices, or how oral hygiene behaviors are operationalized across studies. Moreover, our findings may suggest that while overt hygiene behaviors such as brushing frequency appear unaffected, other mediating factors\u0026mdash;such as psychological stress, behavioral regulation difficulties, sleep disruption, or immune dysregulation\u0026mdash;could play a more pivotal role in influencing periodontal outcomes.\u003c/p\u003e \u003cp\u003eThe lack of significant differences in socioeconomic status, academic achievement, and smoking status between groups strengthens the argument that internet use and sleep quality themselves are likely the major contributing factors in the observed differences in periodontal health. These findings also highlight the importance of multidisciplinary approaches, integrating dental, psychological, and behavioral assessments when addressing adolescent health. A notable strength of our study lies in the use of clinical periodontal examination rather than relying solely on self-reported measures. This enables a more objective assessment of oral health status, filling a notable gap in the current literature. Previous studies evaluating internet addiction and oral health often lack clinical verification of periodontal status, thereby limiting the accuracy of their findings.\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, our findings suggest a meaningful relationship between internet usage, sleep quality, and periodontal health in adolescents. Poor sleep quality, associated with higher internet usage and internet addiction risk, correlates with poorer periodontal outcomes. These results underscore the need for awareness and preventive strategies targeting digital behavior and oral hygiene in adolescents as part of comprehensive oral health promotion efforts.\u003c/p\u003e \u003cp\u003eThis study has certain limitations. As it was designed cross-sectionally, it precludes the ability to determine causal relationships. Additionally, factors that might influence periodontal health -such as stress, dietary habits, and physical activity- were not assessed. Future longitudinal and multi-centered studies including broader behavioral assessments are recommended to confirm and expand upon these results.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: This study was approved by the Istanbul Medipol University Ethics Committee (approval no: 679, approval date: 25.09.2019). Written informed consent was obtained from all participants included in the study. In the case of participants under the age of 16, informed consent was obtained from their parents or legal guardians. All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003eClinical trial number: Not applicable.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Requests for data access should be directed to Dr. Nurcan Aksaka (Istanbul Medipol University, School of Dentistry, Department of Periodontology, TEM Avrupa Otoyolu G\u0026ouml;ztepe \u0026Ccedil;ıkışı No. 1, 34214 Bağcılar, Istanbul, Turkey; email: [[email protected]]).\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding: None\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions: N.A. contributed to conceptualization, investigation, methodology, and writing (original draft and review \u0026amp; editing). S.Ş. contributed to conceptualization and investigation. E.Y. contributed to methodology and writing (review \u0026amp; editing). All authors have read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: The authors have no individuals or organizations to acknowledge for this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eIrwin MR. Why sleep is important for health: A psychoneuroimmunology perspective. Annual Review of Psychology. 2015;66:143\u0026ndash;72. https://doi.org/10.1146/annurev-psych-010213-115205\u003c/li\u003e\n\u003cli\u003eBrautsch LAS, Lund L, Andersen MM, Jennum PJ. Digital media use and sleep in late adolescence and young adulthood: A systematic review. Sleep Medicine Reviews. 2022;68:101742. https://doi.org/10.1016/j.smrv.2022.101742 \u003c/li\u003e\n\u003cli\u003eA\u0026ccedil;ıkg\u0026ouml;z A, A\u0026ccedil;ıkg\u0026ouml;z B, A\u0026ccedil;ıkg\u0026ouml;z O. The effect of internet addiction and smartphone addiction on sleep quality among Turkish adolescents. 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Sleep Health: Journal of the National Sleep Foundation.2023;9(4):444-52. https://doi.org/10.1016/j.sleh.2023.01.005 \u003c/li\u003e\n\u003cli\u003eLam LT. Internet Gaming Addiction, Problematic Use of the Internet, and Sleep Problems: A Systematic Review. Curr Psychiatry Rep. 2014;16:444. https://doi.org/10.1007/s11920-014-0444-1\u003c/li\u003e\n\u003cli\u003eDo KY, Lee KS. Relationship between problematic internet use, sleep problems, and oral health in Korean adolescents: A national survey. Int. J. Environ. Res. Public Health. 2018; 15(9):1870. https://doi.org/10.3390/ijerph15091870 \u003c/li\u003e\n\u003cli\u003eAlqaderi H, Goodson JM, Agaku I. Association between sleep and severe periodontitis in a nationally representative adult US population. Journal of Periodontology. 2020;91(6): 767\u0026ndash;74. https://doi.org/10.1002/JPER.19-0105 \u003c/li\u003e\n\u003cli\u003eDo KY, Lee ES, Lee KS. Association between excessive Internet use and oral health behaviors of Korean adolescents: A 2015 national survey. Community Dental Health. 2017;34(3):183\u0026ndash;89. https://doi.org/10.1922/CDH_4107Do07 \u003c/li\u003e\n\u003cli\u003eAl-Ansari A, El Tantawi M, AlMadan N, Nazir M, Gaffar B, Al-Khalifa K, AlBaty A. Internet addiction, oral health practices, clinical outcomes, and self-perceived oral health in young Saudi adults. Scientific World Journal. 2020;1\u0026ndash;7. https://doi.org/10.1155/2020/7987356\u003c/li\u003e\n\u003c/ol\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":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescent, internet addiction, periodontal health, plaque index, sleep quality","lastPublishedDoi":"10.21203/rs.3.rs-6776154/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6776154/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eInternet addiction and poor sleep quality are increasingly recognized as behavioral risk factors that may influence adolescents\u0026rsquo; overall and oral health. This study aimed to evaluate the association between internet addiction, sleep quality, and clinical periodontal parameters among adolescents.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis cross-sectional study included 100 systemically healthy adolescents (aged 12\u0026ndash;18 years). The sample consisted of both male (47%) and female (53%) participants, predominantly of Turkish ethnicity, representing middle socioeconomic backgrounds. Data on internet use patterns and sleep quality were collected using the Young Internet Addiction Test (IAT) and the Pittsburgh Sleep Quality Index (PSQI), respectively. Clinical periodontal parameters, including Gingival Index (GI), Plaque Index (PI), Probing Pocket Depth (PPD), and Bleeding on Probing (BoP), were measured by a calibrated examiner.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAdolescents with poor sleep quality exhibited significantly higher GI and PI scores (p\u0026thinsp;=\u0026thinsp;0.025 and p\u0026thinsp;=\u0026thinsp;0.024, respectively). Additionally, the mean IAT score was significantly higher in adolescents with poor sleep quality (p\u0026thinsp;=\u0026thinsp;0.032). A high frequency of internet use (\u0026gt;\u0026thinsp;28 hours/week) was more prevalent in this group (p\u0026thinsp;=\u0026thinsp;0.020).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe findings suggest that poor sleep quality and excessive internet use may negatively influence periodontal health in adolescents. These results emphasize the importance of considering behavioral factors such as digital media exposure and sleep patterns in the clinical assessment and prevention of periodontal diseases during adolescence.\u003c/p\u003e","manuscriptTitle":"Influence of Digital Behavior and Sleep Quality on Periodontal Status in Adolescents: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-12 10:50:47","doi":"10.21203/rs.3.rs-6776154/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-16T06:49:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-12T08:53:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-30T12:54:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2621069526923929727285015402280437698","date":"2025-06-29T17:09:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150024625061326018650358928832279795113","date":"2025-06-27T12:00:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2621069526923929727285015402280437698","date":"2025-06-10T15:42:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-10T14:03:45+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-05T08:15:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-05T08:03:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-04T08:15:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-06-04T08:13:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e3412249-f6e8-41b9-a93b-572baa34227b","owner":[],"postedDate":"June 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-01T15:58:59+00:00","versionOfRecord":{"articleIdentity":"rs-6776154","link":"https://doi.org/10.1186/s12903-025-06749-x","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2025-08-26 15:56:57","publishedOnDateReadable":"August 26th, 2025"},"versionCreatedAt":"2025-06-12 10:50:47","video":"","vorDoi":"10.1186/s12903-025-06749-x","vorDoiUrl":"https://doi.org/10.1186/s12903-025-06749-x","workflowStages":[]},"version":"v1","identity":"rs-6776154","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6776154","identity":"rs-6776154","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}