12 - Media Exposure and Oral Health Outcomes Among Adults

VOLUME 44 NUMBEP 2 FEBPUAPY 2013 e146
QUI NTESSENCE I NTERNATI ONAL

COMMUNITY DENTISTRY
Media exposure and oral health
outcomes among adults
Avraham

Zini, DMD, MPH, PhD
1
/Harold D. Sgan-Cohen, DMD, MPH
2
/
Yuval Vered, DMD, MPH
3
Objective: To assess the impact of media exposure on oral health outcomes among
Jewish adults in Jerusalem, Israel, by means of a conceptual hierarchical model. Method
and Materials: A oross-sootional study was oonduotod using a stratihod samplo o 254
adults 35 to 44 yoars (moan ago, 38.63 yoars) in Jorusalom, sraol. Modia oxposuro was
oporationally oatogorizod by typo and roquonoy. Bonavioral data inoludod tootnbrusning,
dontal attondanoo, oral nygiono aids uso, plaquo lovol, sugar oonsumption, and smoking.
Clinioal outoomos woro assossod aooording to tno dooayod/missing/hllod tootn (DMFT)
indox and tno Community Poriodontal ndox (CP). Posults woro analyzod by oni-squaro
tost, indopondont tost, ono-way ANOvA, and linoar and multiplo logistio rogrossion modols.
Results: A total o 254 oxaminoos oonsistod o 127 mon and 127 moan (marriod oouplos).
High type and high frequency of media exposure, as compared with other modes,
rovoalod statistioally signihoant nignor oarios oxporionoo (DMFT, 13.10), nignor lovol o
untroatod dooay (D, 1.67), and lowor poriodontal noaltn (CP |0], 0.39). A oonooptual nior-
aronioal rogrossion modol idontihod tnat tno rolationsnip dosoribod was modiatod by
sooiodomograpnio dotorminants (oduoation) and bonavioral dotorminants (dontal atton-
danoo and plaquo lovol). Conclusion: Modia oxposuro snould bo obsorvod by oommunity
health program planners and general practitioners to examine the type and frequency of the
mossagos. Tnoy also nood to roaot on timo to balanoo bad advortising and add a good
message at the community. This pragmatic approach could lead to better use of the media
and improvo oral noaltn bonavior and outoomos. (Quintessence Int 2013;44:e146e156)
Key words: modia oxposuro, oral noaltn, oral noaltn bonavior, sugar oonsumption
1
Associate Professor, Department of Community Dentistry,
Hebrew University-Hadassah School of Dental Medicine,
Jerusalem, Israel.
2
Professor, Department of Community Dentistry, Hebrew
University-Hadassah School of Dental Medicine, Jerusalem,
Israel.
3
Senior Lecturer, Department of Community Dentistry, Hebrew
University-Hadassah School of Dental Medicine, Jerusalem,
Israel.
Correspondence: Prof Avraham Zini, Department of
Community Dentistry, Faculty of Dental Medicine, Hebrew
University-Hadassah Medical Center, PO Box 12272, Jerusalem
91120, Israel. Email: aviz@hadassah.org.il
The media plays an important part in health
promotion and education, including impact
on attitudo and bonavior o tno individual on
ono nand and sooial norms, valuos, ous-
toms, and policy on the other.
1
Good and
substantial oral noaltn bonaviors roquiro
implomontation o tno knowlodgo witn an

integration of health education and health
promotion. Cnangos in oral noaltn knowl-
odgo, awaronoss, attitudos, and bonaviors
oan bo mado by ways o oxtonsivo
co operation between health professionals
and the

mass media.
2,3
It should be remem-
bered that people do pay attention to media
oampaigns and aro inhuonood on spooiho
health issues through their exposure. In
turn, this has many potential implications for
govornmont ohoials, wno oould diroot moro
resources toward campaigns that increase
awareness of important health issues.
4
Tno oootivonoss o modia oxposuro
and its relationship to oral health habits is
improvod wnon roinorood by individual
interaction.
3
Media and its impact on oral
health or diet habits cannot be ignored
because dental caries and periodontal dis-
oasos navo boon rooognizod on an intorna-
tional lovol as tno most important oral noaltn
burdens.
5
Global data on caries epidemiol-
ogy oonhrm tnat tootn dooay romains a
nignly provalont disoaso among botn onil-
dren and adults.
5,6
Media exposure has also
o147 VOLUME 44 NUMBEP 2 FEBPUAPY 2013
Zi ni et al
boon idontihod as

a possible route for den-
tal health education at a national

lovol and
oan provido an inoroaso

in health aware-
noss to motivato bonavioral onangos.
1,7

Exporimontal ovaluation o modia is usu-
ally moro praotioal and oost-ohoiont i oar-
ried out with audience testing and should
onsuro tno groatost valuo or oxpondod
resources, both in the quality and interpret-
ability of estimation data.
8
High frequency of
modia oxposuro oan navo a positivo impaot,
but it oan also domand nogativo attontion.
Its inuence should be carefully assessed
as regards drugs, obesity, and eating disor-
ders.
913
Unhealthy foods, especially prod-
ucts aimed at children, are most frequently
advortisod.
14
Modia oan also givo misoolla-
neous inconsistent messages.
15
The aim of
the present study was to assess by means
of a conceptual hierarchical model the
impact of media exposure on oral health
outcomes among Jewish adults in
Jerusalem, Israel.
METHOD AND MATERIALS
A oross-sootional study was oonduotod
botwoon Dooombor 2008 and July 2009.
Tno protoool o tnis study was approvod by
the Hadassah Hospital Human Ethics
(Holsinki) institutional roviow board oommit-
too. Tno ago rango o 35 to 44 yoars was
chosen according to the recommendation
o tno World Hoaltn Organization (WHO) or
assessing caries experience in the adult
population.
Sample size had been calculated
16

according to the literature outcomes for oral
health differences between groups and
after a pilot study.
The sample was selected using a strati-
hod random sampling toonniquo and was
limited to the Jewish population of
Jorusalom. Availablo statistioal data and
epidemiologic research in social medicine
navo ropoatodly domonstratod tnat Jowisn
roligious groups aro indioativo o tno looal
social strata.
17
The education system is cat-
egorized according to secular, religious,
and ultraorthodox schools. These strata
were therefore adopted to generate three
sampling ramos. A numbor o sonools
(n = 5) in oaon stratum woro randomly
solootod, and 96 paronts o onildron 12 to
13 years of age in each strata were ran-
domly chosen, assuming that their parents
will all into tno appropriato ago rango (35 to
44 yoars o ago). A lottor inviting botn par-
ents to participate in the study was sent to
all nousonolds. Tno inolusion oritoria was 35
to 44 yoars o ago, marriod or living togotn-
er, and without any chronic disease.
Data woro oollootod tnrougn a quostion-
naire and clinical examination.
Sociodemographic data included sex; age
in yoars, lovol o oduoationoatogorizod as
low (no oduoation/olomontary sonool/nign
sonool/low ortnodox sominar) and nign
(nign ortnodox sominar ("yosniva")/aoa-
domio), and nomo donsity (numbor o onil-
dron dividod by numbor o rooms).
Bonavioral data inoludod tootnbrusning
(roquonoy: twioo por day, onoo por day, or
loss), dontal attondanoo (roquonoy: onoo
or twice per year or less than once per
yoar), oral nygiono aids praotioo (intorproxi-
mal brusn, dontal hoss, or tootnpiok),
plaquo lovol (as indioator o oral nygiono
bonavior),
18
sugar intako,
19
smoking (at
prosont: yos or no), and modia oxposuro by
typo (tolovision, intornot, radio, daily nows-
papor, or roligious nowspapor), and ro-
quonoy (sovoral timos por day, onoo por
day, sovoral timo por wook, onoo por wook,
onoo por montn, soldom, or novor).
Pogarding tno Plaquo ndox (P), tno
scores for the following six teeth were
rooordod: 16, 12, 24, 36, 32, and 44 (FD
tootn-numboring systom). Eaon o tno our
suraoos o tno tootn (buooal, lingual, mosi-
al, and distal) was givon a sooro rom 0 to
3: 0, no plaquo, 1, a hlm o plaquo adnoring
to tno roo gingival margin and ad|aoont
aroa o tno tootn, 2, modorato aooumulation
o sot doposits witnin tno gingival pookot or
tno tootn and gingival margin tnat oan bo
soon witn tno nakod oyo, 3, abundanoo o
sot mattor witnin tno gingival pookot and/or
on tno tootn and gingival margin. Tno our
scores for each tooth were added and
dividod by our. Tno indox or tno pationt
was then obtained by adding the mean
sooros or oaon o tno six tootn and dividing
by six. The mean for each patient was
operationally dichotomized as absence of
VOLUME 44 NUMBEP 2 FEBPUAPY 2013 o148
Zi ni et al
lowor lovol plaquo (up to and not inoluding
moan P = 1, indioating avorablo oral
nygiono bonavior) and modorato to abun-
dant plaquo (moan P = 1 or moro, indioat-
ing unavorablo oral nygiono bonavior).
Tno roquonoy o sugar intako was osti-
mated by the Sugar Consumption Index
(SC).
19
n tno quostionnairo, tno sub|oots
woro askod now oton tnoy oonsumod
swoots, sugar, sot drinks, or swoot pas-
tries. The answers for each item were
soorod rom 0 to 4 (0, novor, 1, onoo wookly
or loss, 2, two to six timos wookly, 3, onoo
or twioo daily, and 4, moro tnan twioo daily).
For the calculation of the SCI, these scores
were summed. The results were operation-
ally dichotomized by median as low and
high sugar consumption.
Clinical examinations for dental caries
were carried out by one trained clinician
with the aid of a plane mouth mirror and a
Community Poriodontal ndox (CP) pori-
odontal probe in full daylight. Participants
were seated in their homes on a regular
onair. Padiograpny or oarios dotootion was
not appliod. Dontal oarios oxporionoo was
assossod using tno dooayod/missing/hllod
tootn (DMFT) indox ollowing tno WHO orito-
ria.
20
Periodontal status was assessed
according to the WHO CPI. This index scale
is nominal and ordinal: 0, noaltn, 1, blood-
ing, 2, oaloulus, 3, snallow poriodontal
pookot o 4 to 5 mm, 4, doop poriodontal
pookot boyond 6 mm, and 5, oxoludod. Tno
moutn is dividod into soxtants dohnod by
tootn numbor: 18 to 14, 13 to 23, 24 to 28,
38 to 34, 33 to 43, and 44 to 48 (FD tootn-
numboring systom). A soxtant snould bo
examined only if there are two or more teeth
present not indicated for extraction. For
each of the six dental sextants, the worst
CPI score found was assigned.
20
Duplioato oxaminations woro oarriod out
among 22 partioipants to assoss intraoxam-
inor agroomont witnin a 2-wook intorval.
Statistical analysis
Data woro ontorod into Mioorsot Exool sot-
waro, and SPSS 15.0 (BM) was omployod
for analysis. The potential confounding
effect of the married couples clustering was
oontrollod or by omploying Stata 9.0
(StataCorp). Tno Kappa statistioal tost was
calculated to assess intraexaminer agree-
mont. Analysos inoludod proportions o
people with percentages of low compared
witn modorato/abundant plaquo lovols,
nign/low sugar oonsumption, smoking/not
smoking, tootnbrusning roquonoy, and
modia oxposuro nabits. Additionally, tno
moan DMFT, its oompononts, and CP woro
calculated.
Polationsnips botwoon oral noaltnrolat-
od bonavior, dontal status, sooioooonomio
indicators, and sex were tested using the
Poarson oni-squaro tost, indopondont tost,
analysis o varianoo (ANOvA), and multiplo
linear regression and logistic regression
analysos wnoro appropriato. Tno lovol o
signihoanoo was sot at 5%.
Pogarding poriodontal disoaso, tno por-
centage of people with worst CPI scores
(WCP) was oaloulatod (or oaon porson,
tno worst sooro among tno six soxtants). n
the analysis and multiple logistic regres-
sions, the WCPI was operationally dichoto-
mizod: a CP o 0 to 3 was dohnod as nav-
ing no doop poriodontal pookots, wnilo a
CP o 4 was dohnod as naving doop pori-
odontal pookots.
Modia oxposuro was oporationally oat-
egorized according to the type and fre-
quonoy o modia oxposuro: nign typo, audio
and visual modia (tolovision and intornot),
low typo, audio or visual modia (radio, daily
nowspapor, roligious nowspapor), nign ro-
quency, at least once per day; and low fre-
quency, less than once per day.
Aooordingly, our modos woro dohnod:
HH: nign typo and nign roquont modia
exposure
HL: nign typo and low roquont modia
exposure
LH: low typo and nign roquont modia
exposure
LL: low typo and low roquont modia
exposure.
Following tno work o viotora ot al
21
and its
widespread application, a conceptual hier-
archical data analysis model was adopted.
Tnis woll-ostablisnod approaon omploys
soquontial ad|ustmonts rom distal to proxi-
mal determinants of a health condition, with
the aim of elucidating these relationships.
Conceptual analysis, contrary to statistical
dooisions on signihoant dotorminants o
diseases, adopts a theoretical ordering.
Zi ni et al
Tno |ustihoation or tnis ordoring o vari-
ables, in the present study, was based on
tno litoraturo roviow o modia and noaltn
interaction.
115
Our hypothesis was that
media exposure, which is the distal determi-
nant in the pathway, inuences oral health
bonavior (dontal attondanoo, tootnbrusn-
ing, oral nygiono aids uso, plaquo lovol,
sugar intako, and smoking) and impaots
dental and periodontal health outcomes.
Tno hrst stop was to oarry out a multiplo
logistic regression forcing types of media
exposure into the equation. Socioeconomic
indicators were entered in the second step
to identify the best predictor of the depen-
dont variablos, ad|ustod by ago, sox, and
oouplo olustors. A similar approaon was
used to identify the best indicator of oral
noaltn bonaviors. Following tnis stop, tno
rolationsnip botwoon oxplanatory variablos
and tno outoomo woro assossod. All vari-
ablos tnat nad roaonod statistioal signih-
oanoo at tno 20% lovol
21
were considered in
tno analysis. Tno lovol o signihoanoo was
sot at 5%.
RESULTS
From a total o 288 partioipants, tno partioi-
pation rato or tno study was 88.2%. Tno
intraoxaminor agroomont (Kappa) valuos
woro abovo 0.89.
Analysis inoludod 254 adults, 127 mon
and 127 womon. Moan ago was 38.63 3.26
yoars. O tnoso, 58.3% nad nign lovol o
oduoation, and 41.7% nad low lovol o odu-
cation. The mean number of children in
oaon amily was 4.04 2.02, and tno moan
room numbor was 4.24 1.08. Moan nomo
donsity was 0.99 0.54 witn a modian o
0.87. Low nomo donsity (bolow modian)
was among 50.4% o tno partioipants.
Frequency of toothbrushing twice or
moro por day was roportod by 48.0%, onoo
por day by 41.7%, and loss by 9.8% o tno
partioipants. Dontal attondanoo o onoo por
yoar or moro was among 59.8% and loss
among 40.2%. Oral nygiono aids praotioo
was roportod by 30.7% o tno sub|oots.
Moan sugar oonsumption was 12.45 2.96
witn a modian o 12. Sugar oonsumption
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Zi ni et al
Table 2 Caries experience (DMFT), untreated decay (D), and periodontal health (periodontal pockets)
DMFT D
Periodontal
pockets
n Mean CI P* Mean CI P* n (%) P***
Sex
Male 127 10.68 9.711.6
.76
1.17 0.91.4
.06
25 (19.7)
.01
Female 127 10.89 9.911.8 0.86 0.71.1 11 (8.7)
Ago
3539 132 9.76 8.810.7
< .01
1.02 0.81.2
.99
15 (11.4)
.18
4044 122 11.88 11.012.8 1.02 0.81.3 21 (17.2)
Education
High 148 9.67 8.810.5
< .01
0.78 0.61.0
< .01
15 (10.1)
.03
Low 106 12.33 11.413.3 1.35 1.11.6 21 (19.8)
Home density
Low 128 11.10 10.212.0
.33
1.07 0.81.3
.51
23 (18.0)
.08
High 126 10.45 9.511.4 0.96 0.71.2 13 (10.3)
Tooth brushing
Twice per day 122 10.74 9.711.7
.73**
0.79 0.61.0
.01**
17 (13.9)
.58 Once per day 106 11.01 10.012.0 1.15 0.91.4 17 (16.0)
Less 25 10.08 7.812.3 1.56 0.82.3 2 (8.0)
Dontal atton-
dance
Once per year or more 152 11.28 10.512.1
.06
0.82 0.61.0
< .01
20 (13.2)
.57
Less 102 10.03 8.911.2 1.30 1.01.2 16 (15.7)
Oral hygiene
aids practice
Yos 78 11.37 10.312.5
.24
0.94 0.61.2
.53
8 (10.3)
.23
No 176 10.52 9.711.3 1.05 0.91.2 28 (15.9)
Lovol o plaquo
Absonoo to low 121 9.26 8.410.2
< .01
0.51 0.40.7
< .01
8 (6.6)
< .01
Moderate to abundant 133 12.16 11.313.1 1.47 1.21.7 28 (21.1)
SCI
Low 133 9.76 8.810.7
< .01
0.88 0.71.1
.09
16 (12.0)
.31
High 121 11.90 11.012.8 1.17 0.91.4 20 (16.5)
Smoking
No 196 10.33 9.611.1
.01
0.88 0.71.1
< .01
21 (10.7)
< .01
Yos 58 12.29 10.813.8 1.47 1.11.8 15 (25.9)
Total 254 10.78 10.111.4 1.02 0.91.2 36 (14.2)
*ndopondont tost, **ANOvA, ***Poarson oni-squaro tost. DMFT, dooayod/missing/hllod tootn, D, untroatod dooay, C, oonhdonoo intorval, SC,
Sugar Consumption Index.
was dionotomizod to low among 52.4% o
tno sub|oots and nign among tno rost
(47.6%). Smoking was roportod by 22.8% o
the participants.
Hign typo (audio and visual) o modia
oxposuro was roportod by 45.7%, as oom-
parod witn 54.3% roporting low typo (audio
or visual) o modia oxposuro. Hign roquon-
oy (at loast onoo por day) o oitnor typo o
modia oxposuro was roportod by 52.0% as
oomparod witn 48% roporting low roquon-
oy (loss tnan onoo por day) o oitnor typo o
media exposure.
The relationship between the four modes
of media exposure and oral health clinical
outcomes is presented in Table 1. High
typo and nign roquonoy (HH) o modia
oxposuro was rolatod to to nignor DMFT
and D (untroatod dooay) oompononts. Tno
mean number of healthy sextants were sta-
tistioally signihoantly lowor among HH oom-
parod witn HL, LH, and LL (0.39 vs 1.15,
1.10 and 0.56, rospootivoly, P = .026).
Carios oxporionoo (DMFT), untroatod
dooay (D), and tno distribution o doop pori-
odontal pookots (CP, 4) by sooiodomo-
grapnio and bonavioral variablos (sox, ago,
education, home density, toothbrushing,
dental attendance, oral hygiene aids use,
plaquo lovol, sugar oonsumption, and
smoking), aro prosontod in Tablo 2. Mon
nad nignor poroontagos o doop pookots
tnan womon (19.7% vs 8.7%, rospootivoly,
P = .01). Sub|oots agod 40 to 44 yoars nad
Zi ni et al
nignor oarios (11.88 vs 9.76 DMFT) tnan
youngor sub|oots (P < .01). Lowor lovols o
oduoation rovoalod nignor DMFT, nignor D,
and higher percentages of deep periodon-
tal pookots tnan nignor oduoation (DMFT,
12.33 vs 9.67, P < .01, D, 1.35 vs 0.78,
P < .01, doop pookots, 19.8% vs 10.1%,
P = .03). Hignor roquonoy o tootnbrusning
was rolatod to a lowor D oomponont (0.79
or twioo por day, 1.15 or onoo por day,
and 1.56 or loss, P = .01). Moro roquont
dental attendance corresponded to higher
DMFT sooro and lowor D oomponont tnan
lowor attondanoo (DMFT, 11.28 vs 10.03,
P = .06, D, 0.82 vs 1.30, P < .01). Hignor
lovols o dontal plaquo oorrospondod to
nignor DMFT and D tnan lowor lovol o don-
tal plaquo (12.16 vs 9.26, P < .01 and 1.47
vs 0.51, P < .01, rospootivoly). Hignor lov-
els of dental plaque corresponded to lower
lovols o poriodontal noaltn (doop pookots,
21.1% vs 6.6%, P < .01). Hignor lovols SC
oorrospondod to nignor DMFT (11.90 vs
9.76, P < .01). Smokors nad nignor DMFT,
D, and poroontagos o doop poriodontal
pookots tnan nonsmokors (DMFT, 12.29 vs
10.33, P = .01, D, 1.47 vs 0.88, P < .01,
doop poriodontal pookots, 25.9% vs 10.7%,
P < .01).
For oaon oral noaltn outoomooarios
oxporionoo (DMFT) (Tablo 3), untroatod
dooay (D) (Tablo 4), and poriodontal noaltn
status (CP, 0) (Tablo 5), a oonooptual mul-
tiple regression analysis was performed by
tnroo modols o analysis. Tno hrst modol
was restricted to media exposure alone. In
the second model, a hierarchical entry of
tno signihoant (< .05) sooioooonomio dotor-
minants (ono or moro, doponding on an
inner regression analysis including age,
sox, nomo donsity, and oduoation) woro
entered. The third model included dental
bonavior dotorminants (ono or moro,
depending on an inner regression analysis
including toothbrushing, dental attendance,
oral nygiono aids uso, plaquo lovol, sugar
oonsumption, and smoking).
Tno nioraronioal modoling idontihod tnat
high type and high frequency media expo-
suro, lowor oduoation lovol, and nignor lovol
o plaquo (unavorablo oral nygiono bonav-
ior) woro statistioally signihoantly rolatod to
nignor lovols o oarios oxporionoo (soo
Tablo 3). Tno modol domonstratod tnat
lovol o oduoation as a markor o sooioooo-
nomio status (SES) tnrougn plaquo lovols
was a mediator of the distal relationship
botwoon tno lovol o modia oxposuro and
caries experience. Socioeconomic status
and noaltn bonavior variablos woro signih-
cantly related to both media exposure and
caries experience. In the analysis of modes
o modia oxposuro, unad|ustod or modiat-
ing variablos, tno modo o nign typo and
high frequency as compared with other
types of media exposure was associated
Table 3 Conceptual multiple logistic regression analysis for higher than median
DMFT (caries experience) score adjusted for age, sex, and couples by
media exposure and sociodemographic and health behavior determi-
nants among study participants
DMFT (caries experience) First model* Second model** Third model***
OR (95% CI) OR (95% CI) OR (95 % CI)
Media exposure LL, LH, HL 1.00 --- 1.00 --- 1.00 ---
HH 2.42 (1.15-5.09) 2.17 (1.02-4.64) 1.75 (0.78-3.90)
Education Low 1.00 --- 1.00 ---
Aoadomio/Yosniva 0.50 (0.28-0.89) 0.53 (0.30-0.95)
Lovol o plaquo: Continuous 1.94 (1.20-3.14)
Log psoudo-likolinood -169.25 -169.87 -161.79
*OP ad|ustod or ago, sox, and oouplos, **OP additionally ad|ustod or lovol o oduoation, *** OP additionally ad|ustod
or lovol o plaquo. OP, odds radio, C, oonhdonoo intorval, DMFT, dooayod/missing/hllod tootn, HH, nign typo and
high frequency media exposure.
Zi ni et al
Table 4 Conceptual multiple logistic regression analysis for higher than median
D (untreated decay) score adjusted for age, sex, and couples by media
exposure and sociodemographic and health behavior determinants
among study participants
D (untreated decay) First model* Second model** Third model***
OR (95% CI) OR (95% CI) OR (95% CI)
HH 3.00 (1.59-5.68) 2.67 (1.34-5.32) 1.90 (0.95-3.83)
Education Low 1.00 --- 1.00 ---
Dontal attondanoo Once per year or more 1.00 ---
Less 2.42 (1.28-4.58)
or lovol o plaquo. OP, odds radio, C, oonhdonoo intorval, D, untroatod dooay, HH, nign typo and nign roquonoy
media exposure.
Table 5 Conceptual multiple logistic regression analysis for CPI = 0 (healthy peri-
odontal status) adjusted for age, sex, and couples by media exposure
and sociodemographic and health behavior determinants among study
participants
CPI = 0 (healthy periodontal status) First model* Second model** Third model***
OP (95% C) OP (95% C) OP (95% C)
HH 0.41 (0.15-0.85) 0.44 (0.20-0.97) 0.82 (0.34-1.09)
Education Low 1.00 --- 1.00 ---
or lovol o plaquo. OP, odds radio, C, oonhdonoo intorval, CP, Community Poriodontal ndox, HH, nign typo and nign
frequency media exposure.
with high caries experience by an odds
ratio (OP) o 2.42 (hrst modol). Tnis ooot
was modiatod in tno sooond modol by lovol
o oduoation, but romainod signihoant, witn
OP lovols o 2.17. Oral noaltn bonavior
dotorminant (lovol o plaquo) urtnor
dooroasod tno ooot to 1.75.
Posults rogarding untroatod dooay aro
presented in Table 4. Media exposure,
unad|ustod or modiating variablos, was
rolatod to nign lovols o D witn an OP o 3.00
for high type and high frequency mode as
oomparod witn tno otnor modos (hrst
modol). Tnis ooot was modiatod in tno
second model, through sociodemographic
variablos (oduoation) or nign typo and nign
roquonoy (OP, 2.67). Bonavioral dotormi-
nants (dontal attondanoo and plaquo lovol)
further decreased the effect of high type
and nign roquonoy to 1.90.
Posults rogarding noaltny poriodontal
status aro prosontod in Tablo 5. Modia
oxposuro, unad|ustod or modiating vari-
ables, was related to an absence of deep
Zi ni et al
poriodontal pookots, witn an OP o 0.41 or
high type and high frequency compared
witn tno otnors modos (hrst modol). Tnis
effect was mediated in the second model
by sooiodomograpnio variablos (oduoation)
to OP o 0.44. Bonavioral dotorminants
(plaquo lovol) urtnor dooroasod tno ooot
o nign typo and nign roquonoy to 0.82.
DISCUSSION
Hoaltn oaro providors, publio noaltn proos-
sionals, and ma|or modioal organizations
are becoming increasingly aware of the
potential impact of media messages on the
health and well being of the population. The
mass media offer educational opportunities,
as woll as potontial noaltn risks.
2226

The aim of the present study was to
assess the impact of media exposure on
oral noaltn outoomos. Aooording to tnis
study, modia oxposuro is rolatod to sovoral
important outcomes by different type and
frequency of media exposure.
The results indicated that the combina-
tion o nign typo (tolovision and intornot)
and nign roquonoy (at loast onoo a day)
exposure was the worst, suggesting a path-
way to inorior and unavorablo oral noaltn
outcomes. The high mode of media expo-
sure was related to higher caries experi-
onoo (DMFT) and nignor untroatod dooay
(D). Tno hnding o a rolationsnip botwoon
groator tolovision viowing and pooror donti-
tion is not surprising. Dontal oarios navo
some causes in common with obesity,
including exposure to foods high in sugar,
although no consistent relationship between
obesity and dental caries has been
dosoribod. Tolovision viowing is rolatod to
nignor intakos o swoot snaoks and oarbon-
atod bovoragos, wnion rolato to potontially
plaoing tno publio at risk o botn obosity
and dontal oarios. Food advortisomonts
snowod during tolovision programming
inuence food preferences and consump-
tion, and they commonly feature foods high
in fat or sugars that are in low nutritional
content.
6,11,13,24,25

Similar results were demonstrated by
periodontal status, since high type and high
roquonoy modia oxposuro was rovoalod to
lowor tno lovol o poriodontal status. Tnoso
results could be a result of higher percent-
agos o smoking nabits, wnion also rolato to
tnoso kinds o modia.
3,7,22
In this study, a conceptual hierarchical
approaon was usod, wnion providod inno-
vativo insignts and moro oaroul oxamina-
tion into the complex interrelation between
media exposure, sociodemographic, and
noaltn bonavior dotorminants and oral
noaltn outoomos. Adopting a oonooptual
ramowork analysis is usoul to idontiy vari-
ables that are hierarchically below expo-
sure and do not qualify as potential con-
founding factors.
21
As notod in tno litoraturo,
"Tnis motnod providos guidanoo to uso
multivariato toonniquos and intorprot tnoir
results in the light of social and biological
knowlodgo".
21
Basod upon tno rosults o tno multiplo
regression models, a suggested pathway is
presented in Fig 1. The path between media
oxposuro and oarios oxporionoo (DMFT) is
modiatod by oduoation lovols and a
sooiodomograpnio (sooioooonomio position
|SEP]) markor and oxplainod by plaquo lov-
ols (noaltn bonavior indioator). Furtnormoro,
the path between media exposure and num-
bor o untroatod dooay (D) was modiatod by
an SEP markor and oxplainod by botn don-
tal attondanoo and plaquo lovol (noaltn
bonavior indioators). Finally, tno patn
between media exposure and healthy peri-
odontal status was also mediated by an SEP
markor and oxplainod by plaquo lovols as a
noaltn bonavior indioator.
Pooont soiontiho litoraturo suggosts
rolationsnips among tolovision uso, poor
social functioning, and broad ranges of
nogativo pnysioal and sooioomotional
health attributes.

Clinicians and researchers
interested in relationships between media
use and health need information about the
type of media use as well as total and com-
bined media use and screen time.
22,24
With
regard to these important themes, the pres-
ent study addressed media exposure by
type and frequency in combination with
sooiologio and bonavioral dotorminants.
t is important to noto tnat noaltn bonav-
ior determinants are different among com-
munities according to different determi-
nants of health. In the present study,
Zi ni et al
Fig 1 A potential pathway of impact of media exposure (as a distal determinant) on oral health outcomes,
mediated by sociodemographic (education) and behavioral (dental attendance and plaque level) determi-
nants.
Lower level
of education
Higher dental
caries experience
High type and high frequent media exposure
Unfavorable oral health behavior
Unfavorable oral health outcomes
Higher number of
untreated dental caries
Inferior periodontal
status
bonavioral dioronoos domonstratod an
impact and partial explanation of the differ-
ences by types of media exposure. These
differences, by media exposure, might
explain a part of our results. Further research
should examine possible patterns and a
more precise pathway that might explain
tno prosont roportod hndings. n addition,
longitudinal studies will help to determine
whether media use is a cause, correlate
(oonoundor, modihor, or modiator), or oon-
sequence of poor health attributes.
21,24

Furtnor studios aro noodod to invostigato
potontial moonanisms or obsorvod rolation-
ships and to determine whether they
inoroaso or dooroaso ovor timo.
3,4,7,22,24
Tno rolovanoo o tno prosont study
should be emphasized with regard to gen-
oral dontal praotitionors. Today, tolovision
and intornot aro oxtonsivoly and roquontly
used by the entire public, children and
adults aliko. Onoo oduoatod on tnis impor-
tant issuo (as studonts at tno dontal sonool
or as professionals through continuing edu-
oation and sol-loarning) and awaro o tno
risks o modia, dontal olinioians snould bo
ablo to ovaluato and inorm pationts about
modia. Tnis oan bo dono by providing guid-
ance about media use in the home to par-
ents and children during treatment sessions
in the dental clinic; correlating oral health or
bonavioral oonoorns witn modia uso, boing
positivo modia rolo modols by promoting
reading in waiting rooms; educating col-
leagues about media literacy, educating,
and supporting community, school, and
advooaoy groups about tno publio oral
noaltn risks rolatod witn modia, and posing
saliont quostions or rosoaronors and advo-
cates to address.
22,24
Oral health is deter-
minod by diot, nygiono, trauma, smoking,
alcohol use, stress, and other psychosocial
variablos oommon to oral noaltn and gon-
eral health diseases
27
and constitutes a part
o modia sub|oots, advortising, and oam-
paign. The results of this study suggest that
dental practitioners should pay attention to
modia oampaigns tnat mignt navo strong
effects on a wide spectrum of oral and gen-
eral health issues.
Zi ni et al
CONCLUSION
Tno dooisivo goal o modia oduoation and
rosoaron is to roinoroo tno pationts' knowl-
odgo tnrougn aoooss to positivo oduoa-
tional programming and products and at
the same time protect them from potential
harm of media messages and descriptions.
In the light of the literature on peoples pro-
oossing skills, our data navo important
implications for those concerned about
advortising's rolo in oral noaltn bonaviors.
Tnus, modia oxposuro snould bo obsorvod
by community health program planners and
general practitioners who will examine the
type and the frequency of the messages.
Tnoy nood to balanoo poor advortising and
add, in at least the same quantity and qual-
ity, good messages at the community and
individual lovol. Tnis pragmatio attitudo
could lead to better use of the media to
improvo oral noaltn bonavior and outoomos.
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