Impact of parental knowledge on prevention risk of caries in Seville children between 6 and 14 years old, applying the CAMBRA Protocol

Academic Editor: Ziad D. Baghdadi Received: 28 May 2025 Revised: 18 June 2025 Accepted: 19 June 2025 Published: 23 June 2025 Citation: Pérez de Mora, E.; Barrera-Mora, J.M.; Arenas-González, M.; Mendoza-Mendoza, A.; Ribas-Pérez, D. Impact of Parental Knowledge on Prevention Risk of Caries in Seville Children Between 6 and 14 Years Old, Applying the CAMBRA Protocol. Children 2025,12, 824. https://doi.org/10.3390/ children12070824 Copyright: © 2025 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/ licenses/by/4.0/). Article Impact of Parental Knowledge on Prevention Risk of Caries in Seville Children Between 6 and 14 Years Old, Applying the CAMBRA Protocol Esther Pérez de Mora 1, José María Barrera-Mora 2, Marcela Arenas-González 3,* , Asunción Mendoza-Mendoza 3and David Ribas-Pérez 3 1Paediatric Dentistry, Faculty of Dentistry, Complutense University of Madrid, 28040 Madrid, Spain; [email protected] 2Orthodontics, Faculty of Dentistry, University of Seville, 41009 Seville, Spain; [email protected] 3Paediatric Dentistry, Faculty of Dentistry, University of Seville, 41009 Seville, Spain; [email protected] (A.M.-M.); [email protected] (D.R.-P.) *Correspondence: mar[email protected] Abstract Background/Objectives: To explore the association between parental knowledge on dental caries prevention and the risk of caries in pediatric patients aged 6 to 14 years who reside in the province of Seville, using the CAMBRA preventive protocol as an assessment tool. Methods: After the approval granted by the Ethics Committee, a descriptive and analytical observational study was conducted. Caries risk was established using the CAMBRA Questionnaire, pH measurement, and salivary flow rate. To assess the socioeconomic background of the patients and their hygiene and dietary habits, parents completed two surveys: the first about the quality of the patient’s diet, and the second directly related to the CAMBRA questionnaire used and validated by the University of Seville. Results: The final study sample consisted of 300 pediatric patients, aged 6 to 14 years, of whom 54% were boys and 46% were girls. The caries risk distribution was as follows: 33% low, 7% moderate, 48.6% high, and 11.3%. A total of 61.7% of the participants live in urban areas, while 38.3% are from peri-urban regions. There is a statistically significant association between socioeconomic status and family circumstances in children with a risk of caries. Furthermore, an association was established between caries risk, dietary habits, and oral hygiene. Conclusions: Parental knowledge about dental caries prevention and caries risk in children was found to have a strong association with reduced caries risk in children. Keywords: CAMBRA; dental caries; environment; parents; pH; prevention; risk of dental caries; sialometry 1. Introduction Historically, caries has been considered an infectious, chronic, transmissible, and dynamic disease caused by microorganisms. It is located in the hard tissues of the teeth and begins with demineralization of the enamel, caused by organic acids produced by certain oral bacteria when carbohydrates are metabolized in our diet. However, today, the concept of caries encompasses both the disease itself and its clinical manifestations. This condition involves dysbiosis in the normal oral biofilm, which reacts dynamically to sugar-rich diets, generating acids that cause caries lesions [1–3]. Children 2025,12, 824 https://doi.org/10.3390/children12070824 Children 2025,12, 824 2 of 20 Dental caries is, therefore, a microbial disease that arises from an imbalance in the oral microbiome. This imbalance results in a shift in bacterial species, favoring those that produce or tolerate acids, increasing the risk and activity of caries. The current definition of caries establishes that it is a dynamic, chronic, non-communicable process mediated by bacteria and influenced by diet, which manifests clinically as the loss of minerals in the hard tissues of the tooth [4–6]. Preventive strategies focus on addressing each of the factors involved in the etiology of caries: the agent, the host, and the substrate. The dentist must select the most appropriate preventive measures for each situation, with the goal of preventing the development of caries and its potential consequences [1,4]. The primary objective of any caries intervention is to preserve healthy teeth and prevent the disease from developing; that is, to achieve primary prevention in the prepathogenic phase of the disease. However, this is not always possible due to the high prevalence of caries and the numerous sequelae associated with this pathology. Therefore, it is essential to develop guidelines for global risk assessment [ 7 , 8 ]. Risk factors play a crucial role in the etiology of caries; their presence directly increases the likelihood of disease development, while their absence or elimination decreases this probability [7,9]. The diagnosis of dental caries in children involves not only the identification and monitoring of carious lesions but also a variety of factors. This includes assessing caries risk, analyzing the natural history of caries progression, assessing and reassessing disease activity, evaluating the results of previous treatments, and parental expectations and preferences. Multiple tools have been developed to assess caries risk, including the CAMBRA protocol, the subject of this study [7,10]. The CAMBRA protocol, promoted by the California Dental Association (CDA) in 2002, is a procedure that analyzes a patient’s caries risk based on their age, assessing the type and amount of dental plaque present. The original model includes four risk levels: low, moderate, high, and extremely high. This questionnaire assesses the caries lesion and proposes action protocols based on risk level [7,10,11]. CAMBRA allows patients to be classified according to their risk assessment, considering caries prevalence, and establishes treatment protocols that offer an individualized approach for each risk group. This facilitates treatment focused on caries-related protective factors. Additionally, it plays a preventive and interceptive role in the disease, covering the entire population; even those considered low-risk can benefit from prevention recommendations [7,10–12]. However, the effectiveness of these individualized preventive strategies is closely related to behaviors established within the family environment. The caries risk outcome obtained through the CAMBRA protocol in pediatric patients largely depends on the daily habits promoted at home [13–15]. Parents play a crucial role in the behavior of a child in the pediatric dentist [ 13 – 15 ]. Recently, different parenting styles have gained great interest since parents, as primary caregivers, exert a significant influence on the development of their children’s present and future emotional health, personality, character, well-being, social and cognitive development, and academic performance. This is transferred to the dental office, affecting the interaction with the dentist [ 13 ]. Parenting styles also influence children’s health. Childhood obesity and sugar consumption are increasing among children, and this is a concern for children’s oral and general health [ 13 , 14 ]. Therefore, understanding the level of knowledge and the practices of parents and caregivers plays an important role in the advancement of intervention programs aimed at modifying behavior and promoting the improvement of oral health of child patients [14,15]. Children 2025,12, 824 3 of 20 Prevention and treatment of childhood caries require a comprehensive approach that combines individualized clinical strategies, such as the CAMBRA protocol, with the essential role of the family in adopting healthy habits and shaping behaviors that promote good oral health from the early years [7,10,14,15]. 2. Materials and Methods 2.1. Study Type and Settings This cross-sectional, observational, and analytical study was approved by the Research Ethics Committee of the University of Seville. The sample consisted of 300 children who had no known allergies to any of the products used in the study. The sample size was calculated based on a risk of error ( α ) with a 95% confidence interval (CI) and a risk of error ( β ). Patients who underwent orthodontic treatment, systemic pathologies, or daily medication were excluded. The guardians consented to the use of their records and personal data for scientific purposes. Various types of data were collected. 2.2. CAMBRA Assessment Questionnaire First, CAMBRA questionnaires were applied to obtain the caries risk of pediatric patients according to the CAMBRA protocol. Saliva samples were taken to measure pH, buffering capacity, and salivary flow rate. The four original levels of caries risk (low, moderate, high, and extreme) were considered, and based on these data, a dental education program on oral hygiene was implemented, and a diet analysis was performed to make the necessary recommendations about the foods that could promote the appearance of caries at a young age [7]. 2.3. Clinical Examination As part of the clinical assessment, the presence of bacterial plaque on dental surfaces was examined to determine the state of oral hygiene. The presence or absence of bacterial plaque on dental surfaces was evaluated using the modified Quigley–Hein plaque index as a reference. The measurement focused on the third gingival layer of the buccal and lingual dental surfaces of all erupted teeth [ 6 ]. The average index was obtained by dividing the sum of the total surface score by the number of surfaces examined. A score of 0 to 1 corresponded to low amounts of bacterial plaque, and 2 or more was associated with high plaque scores [16]. 2.4. Saliva Analysis To evaluate the salivary characteristics of the patients, specific tests were performed to measure salivary flow rate and pH. A sialometry test was performed by stimulation with paraffin chewing gum to measure salivary flow rate (SFV) in patients [ 17 ]. The result of this collection was expressed as milliliters per minute and was obtained by dividing the salivary volume by the number of minutes elapsed. A salivary flow rate of less than 1 mL/min in 5 min was considered hyposalivation [ 17 , 18 ]. Regarding salivary pH measurement, the pH scale was taken into account, which includes values between 0 and 14, through which the acidity or alkalinity of saliva was estimated. In the case of the salivary sample studied, which is composed of 99% water and 1% organic and inorganic molecules, the normal pH has a value between 6.7 and 7.4. That is, it is relatively neutral [ 18 – 20 ]. The value legend included in the GC Europe Saliva Check Buffer pack, which was the set purchased for sialometry and salivary pH measurement, was used as a reference. Children 2025,12, 824 4 of 20 2.5. Socioeconomic Data Collection To assess parents’ knowledge and children’s socioeconomic background on dental caries prevention, parents completed two surveys. The first was to assess dietary habits using the Diet Quality Questionnaire of the Spanish Society of Dietetics and Food Sciences (SEDCA), which has been validated and used in previous studies with the Spanish pediatric population (Appendix A). This questionnaire has good internal consistency and sensitivity to identify dietary patterns that could influence oral health. This survey is validated for the Spanish child population and can produce three possible results: a good diet, a diet with room for improvement, and a poor diet [21]. The second survey was conducted to analyze knowledge and practices related to oral hygiene habits to prevent dental caries. This questionnaire was adapted from the CAMBRA protocol, but it underwent an additional validation process that included a pilot test with a representative sample of parents to assess the clarity of the questions. The questionnaires were administered by the same interviewer to minimize bias and ensure uniformity in data collection. Regarding socioeconomic background, data were collected on: age, gender, educational level, and nationality of parents, whether the child patients selected for the study were only children or not, whether their parents were separated, and whether the pediatric patients lived in an urban or peri-urban environment. In addition, 14 questions were included in their knowledge of dental caries prevention (Appendix B). 2.6. Radiographic Exam All patient examination radiographs were obtained digitally following standardof-care procedures. It is the standard of care to obtain caries detection radiographs if no diagnostic-quality radiographs have been available in the past year, according to the AAPD [ 22 ]. The principal investigator clinically and radiographically evaluated the patients, classifying the various pathology into different types: enamel caries, dentin caries, and pulpal caries. The gold standard for inter-operator agreement was Dr. Asunción Mendoza-Mendoza, Professor of Pediatric Dentistry at the University of Seville, who has extensive experience in conducting studies of this nature. 2.7. Statistical Analysis and Validation Regarding the database, a data collection sheet was used using Microsoft Excel, in which patient codes, full names, and values of the variables analyzed were recorded. To ensure the anonymity of the patients included in the study, each was assigned a numerical code. Only the principal investigator of this study had access to these data. A table was designed to record all data using SPSS v. 29 for analysis. To validate the collected data, a detailed verification process was conducted to ensure that all entries were correctly coded and that the information was complete and consistent. Incomplete or incorrect data were identified and removed from the database to avoid potential biases in the results. Subsequently, a comprehensive descriptive analysis was performed to characterize the sample based on the main sociodemographic and clinical variables. In addition, a more in-depth analysis was performed, including the application of multivariate models to identify significant associations between the variables studied and the risk of caries. This approach allowed for more robust results and allowed for adjustment for potential confounding factors. 3. Results Within the sample, 162 patients were boys (54%) and 138 girls (46%). The age distribution shows a fairly uniform spread across the range from 6 to 14 years old, with slight Children 2025,12, 824 5 of 20 variations between genders. In particular, younger age groups (6 to 8 years) had a higher proportion of boys compared to girls, while in some middle age groups (9 to 11 years), the proportion of girls was slightly higher or similar to boys. In older age groups (12 to 14 years), the numbers tend to level out again, with small differences between boys and girls. Overall, the data suggest that there was no significant gender skew in the sample across the age range studied, indicating a balanced representation for further analysis. To determine whether the quantitative variables met the normality criteria, the Kolmogorov–Smirnov test with Lilliefors correction was performed; the assumption of normality was rejected based on the results obtained. Medians, percentiles, and interquartile ranges for all these variables were calculated, producing a median of 9 for age, with an interquartile range of 4. For stimulated salivary flow, the median was 8, with an interquartile range of 4. For salivary pH, the median was 7, with an interquartile range of 0.4. The frequencies and percentages of all the quantitative variables collected in the study were calculated (Tables 1–4). The variables were divided into 4 tables, based on the grouping selected for each one. Table 1. Frequencies and percentages of qualitative variables related to the risk of caries in children. Variable Boys Girls Total Frequency (%) Frequency (%) Frequency (%) Gender 162 (54) 138 (46) 300 (100) Risk of caries CAMBRA Low 52 (32.1) 47 (34.1) 99 (33) Moderate 11 (6.8) 10 (7.2) 21 (7) High 81 (50) 65 (12.3) 146 (48.7) Extreme 17 (10.5) 17 (5.7) 34 (11.3) Modified Quigley–Hein plaque index 0 22 (13.6) 30 (21.7) 52 (119) 1 60 (37) 59 (42.8) 119 (39.7) 2 62 (38.3) 40 (29) 102 (34) 3 18 (11.1) 9 (6.5) 27 (9) 4 0 (0) 0 (0) 0 (0) 5 0 (0) 0 (0) 0 (0) Diet Quality Survey Good 61 (37.7) 56 (40.6) 117 (39) Improvable 93 (57.7) 79 (57.2) 172 (54.3) Bad 8 (4.9) 3 (2.2) 11 (3.7) Sugar consumption more than 3 times/day Yes 116 (71.6) 99 (71.7) 215 (71.7) No 46 (28.4) 39 (28.3) 85 (28.3) The Table 1shows the qualitative variables related to the risk of caries in the patients selected for the study. The table presents information on the following variables: caries risk determined by the CAMBRA questionnaire, the modified Quigley–Hein plaque index, diet quality, and sugar consumption more than three times a day. These results are divided in the table by gender of the selected sample (Table 1). Sixty percent of children are at high or extreme risk for caries. Similar results were obtained for the variables used to determine the risk of caries, determined by CAMBRA. Almost 83% of children have some level of dental plaque. Although only 3.7% have a “poor” diet, 54.3% have a diet that could be improved. More than 70% of the children consumed excessive sugar (Table 1). Children 2025,12, 824 6 of 20 Table 2. Frequencies and percentages of variables on the family situation or the environment of children. Variable Boys Girls Total Frequency (%) Yes/No Frequency (%) Yes/No Frequency (%) Yes/No Frequency (%) Yes/No Single child 33 (20.4) 29 (21) 62 (20.7) 300 (100) 129 (79.6) 109 (79) 238 (79.3) Separated parents 18 (11) 10 (7.2) 28 (9.3) 300 (100) 144 (88.9) 128 (92.8) 272 (90.7) Place of residence 92 (56.8) 93 (67.4) 185 (61.7) 300 (100) 70 (43.2) 45 (32.6) 115 (38.3) Table 3. Frequencies and percentages of variables in the survey to determine the knowledge of children’s parents about dental caries prevention. Variable Boys Girls Total Frequency (%) Yes/No Frequency (%) Yes/No Frequency (%) Yes/No Frequency (%) Yes/No 1. Has the mother or primary caregiver had cavities in the past year? 51 (17)/111 (37) 56 (18.7)/82 (27.3) 107 (35.7)/193 (64.7) 300 (100) 2. Has your child had fillings in the past year? 61 (20.3)/101 (33.7) 62 (20.7)/76 (25.3) 123 (41)/177 (59) 300 (100) 3. Has your child had dental visits in the last year? 138 (46)/24 (8) 120 (40)/18 (6) 258 (86) 42 (14) 300 (100) 4. Does your child eat snacks or drink sugary drinks between meals more than three times a day? 25 (8.3)/136 (45.3) 25 (8.3)/113 (37.7) 50 (16.6)/249 (83) 299 (100) 5. Does your child regularly drink other beverages than water? 55 (18.3)/107 (35.7) 38 (12.7)/100 (33.3) 93 (31)/207 (69) 300 (100) 6. Does your child sleep in with a bottle or breastfeed on demand while sleeping between the ages of 2 and 6? 3 (1)/159 (53) 2 (0.7)/136 (45.3) 5 (1.7)/295 (98.3) 300 (100) 7. Do you know the purpose of fluoride? 118 (39.3)/44 (14.7) 104 (34.7)/34 (11.3) 222 (26)/78 (74) 300 (100) 8. Does your child brush their teeth with 1450 ppm fluoride toothpaste daily? 131 (43.7)/31 (10.3) 115 (38.3)/23 (7.7) 246 (82)/54 (18) 300 (100) 9. Does your child brush their teeth three times a day? 44 (14.7)/118 (39.3) 44 (14.7)/94 (31.3) 88 (29.3)/212 (70.7) 300 (100) 10. Did your child brush their teeth three times a day before the age of 6? 38 (12.7)/124 (41.3) 38 (12.7)/100 (33.3) 76 (25.3)/224 (74.7) 300 (100) Children 2025,12, 824 7 of 20 Table 3. Cont. Variable Boys Girls Total Frequency (%) Yes/No Frequency (%) Yes/No Frequency (%) Yes/No Frequency (%) Yes/No 11. Do you check your child’s brushing at least once a day? 87 (29)/75 (25) 63 (21)/75 (25) 150 (50)/150 (50) 300 (100) 12. Did you check your child’s brushing at least once a day before age 6? 58 (19.3)/104 (34.7) 42 (14)/96 (32) 100 (33.3)/200 (66.7) 300 (100) 13. Does your child use fluoride mouthwash or rinse? 44 (14.7)/118 (39.3) 39 (13)/99 (33) 83 (27.7)/217 (72.3) 300 (100) 14. Does your child use a manual toothbrush? 128 (42.7)/34 (11.3) 112 (37.3)/26 (8.7) 240 (80)/60 (20) 300 (100) Table 4. Chi-square analysis evaluating the association between parental knowledge of prevention (based on survey data) and qualitative variables related to children’s caries risk. Question Modified Quigley–Hein Plaque Index Caries Risk CAMBRA Diet Quality Survey Sugar Consumption Greater Than 3 Times/Day 1. Has the mother or primary caregiver had cavities in the past year? 0.155 0.003 * 0.001 * 0.001 * 2. Has your child had fillings in the past year? 0.001 * 0.001 * 0.016 * 0.005 * 3. Has your child had dental visits in the last year? 0.148 0.027 * 0.001 * 0.001 * 4. Does your child eat snacks or have sugary drinks between meals more than three times a day? 0.214 0.002 * 0.001 * 0.013 * 5. Does your child regularly drink other beverages than water? 0.001 * 0.003 * 0.001 * 0.001 * 7. Do you know the purpose of fluoride? 0.538 0.001 * 0.132 0.038 * 8. Does your child brush their teeth with 1450 ppm fluoride toothpaste daily? 0.162 0.015 * 0.003 * 0.015 * 11. Do you check your child’s brushing at least once a day? 0.299 0.009 * 0.305 0.898 *pvalue < 0.05 means statistical significance. The following table presents information on the family situation or environment of the children included in the study. The qualitative variables selected were as follows: whether or not they were single children, the parents’ marital status (whether the parents Children 2025,12, 824 8 of 20 were separated or not), and the children’s primary residence.,Seville, an urban area, or a periurban area (Table 2). The vast majority, 79.3%, of the children had siblings. Therefore, 20.7% of the children were single children. Only 9.3% of the children had separated parents. 61.7% lived in the city of Seville, while 38.3% lived in peri-urban areas (Table 2). Figure 1shows information on the socioeconomic background of the 300 participants, determined by the age, educational level, and nationality of the parents. Most of the fathers were over 35 years old, with an almost equal distribution between the 35–45 age groups (45.7%) and those over 45 years old (46%). Regarding the mothers of the patients, most were between 35 and 45 years of age (52.7%), slightly younger than the fathers on average. Regarding the educational level, 54% of fathers and 55% of mothers had higher education. Children 2025, 12, x FOR PEER REVIEW 6 of 23 The vast majority, 79.3%, of the children had siblings. Therefore, 20.7% of the children were single children. Only 9.3% of the children had separated parents. 61.7% lived in the city of Seville, while 38.3% lived in peri-urban areas (Table 2). Table 2. Frequencies and percentages of variables on the family situation or the environment of children. Variable Boys Girls Total Frequency (%) Yes/No Frequency (%) Yes/No Frequency (%) Yes/No Frequency (%) Yes/No Single child 33 (20.4) 29 (21) 62 (20.7) 300 (100) 129 (79.6) 109 (79) 238 (79.3) Separated parents 18 (11) 10 (7.2) 28 (9.3) 300 (100) 144 (88.9) 128 (92.8) 272 (90.7) Place of residence 92 (56.8) 93 (67.4) 185 (61.7) 300 (100) 70 (43.2) 45 (32.6) 115 (38.3) Figure 1 shows information on the socioeconomic background of the 300 participants, determined by the age, educational level, and nationality of the parents. Most of the fathers were over 35 years old, with an almost equal distribution between the 35–45 age groups (45.7%) and those over 45 years old (46%). Regarding the mothers of the patients, most were between 35 and 45 years of age (52.7%), slightly younger than the fathers on average. Regarding the educational level, 54% of fathers and 55% of mothers had higher education. Figure 1. Frequencies and percentages of relevant qualitative variables referring to the socioeconomic environment of children. However, a small percentage of mothers had primary education (14.3%). Regarding the nationality of the parents, most of the two sexes were Spanish (approximately 90%). Figure 1. Frequencies and percentages of relevant qualitative variables referring to the socioeconomic environment of children. However, a small percentage of mothers had primary education (14.3%). Regarding the nationality of the parents, most of the two sexes were Spanish (approximately 90%). The following table shows the frequencies and percentages of responses that were included, as previously mentioned, in the survey of parents to determine their knowledge about dental caries prevention habits (Appendix B) (Table 3). In general, high rates of affirmative responses were obtained, such as in Question 3 (86%) and Question 14 (80%). It should be noted that in Question 6, the majority of parents responded “No,” with 98.3%. In Question 11, the responses were split exactly 50/50 (Table 3). In general, the proportion of responses does not vary significantly between boys and girls. However, we note that in Question 5, more parents of boys answered “Yes” (18.3%) compared to parents of girls (12.7%). However, in Question 12, the difference is also notable: More parents of boys (19.3%) answered “Yes” compared to parents of girls (14%) (Table 3). Pearson’s chi-square test was performed to test the significance among categorical variables. Subsequently, we describe the significance of each categorical independent variable relative to the other categorical dependent variables. Caries risk (CAMBRA) is Children 2025,12, 824 9 of 20 observed to be the indicator with the most statistically significant associations, especially with a history of cavities in caregivers, the presence of cavities in the child, the frequency of dental visits, frequent sugar consumption, and fluoride use, indicating that these factors are key determinants of caries risk. Daily sugar consumption also shows significant associations with most variables related to diet and fluoride use. In contrast, the plaque index was only significantly associated with the consumption of beverages other than water (Table 4). The remaining results obtained from the Chi-square test for the independent variables did not show any significant association with the dependent variables. In the following, we detail the significance of the association between each categorical dependent variable and the other categorical dependent variables. The educational level of both parents, father, and mother, is the sociodemographic factor with the highest number of statistically significant associations with children’s oral health habits. It is primarily related to frequent sugar consumption, knowledge of fluoride, and the use of fluoride toothpaste. Some significant associations are also observed with the parents’ nationality and, to a lesser extent, with their age, especially in aspects such as supervising tooth brushing and the consumption of sugary drinks (Tables 5and 6). The variables in which statistically significant results were obtained have been included in Tables 4–6. It is highlighted, for example, that there were no relevant results regarding the type of brush used by the patients. Because the sample did not have a normal distribution, nonparametric statistical tests were applied, in this case, the Wilcoxon test for related samples. In the following, we detail the significance of the numerical independent variable (age) with the other numerically dependent variables (stimulated salivary flow and salivary pH). Both results showed a statistically significant relationship (p= 0.001). There was a significant association between the numerically dependent variables since the pvalue was less than 0.05 (p= 0.026). Logistic regression analysis was used to identify variables significantly associated with the likelihood of the event of interest. This approach allows exploring how different factors contribute to the occurrence of the phenomenon studied, facilitating a better understanding of the collected data. The numerical variables were grouped into three groups: age, divided into three groups according to the type of dentition (young children with mixed dentition, phase 1: between 6 and 9 years; middle-aged children with mixed dentition, phase 2: between 10 and 12 years; older children with permanent dentition: between 13 and 14 years). Regarding the salivary pH variable, values were grouped into two intervals based on the type of pH (acidic pH, between 6.2 and 7; basic pH, between 7.2 and 7.8). Regarding the values of the stimulated salivary flow variable, they have been grouped into two ranges: values less than 5 mL/min are associated with hyposalivation, while values greater than 5 mL/min are associated with normal salivation. In the following, with respect to age, using the oldest group (13–14 years) as a reference, significant associations were observed with the educational level of the father (secondary and high school) and with the responses to the preventive knowledge questions (questions 1 and 7) in the 6to 9-year-old group. For children aged 10–12 years, significant associations were found with the educational level of the father (secondary and higher education), the age of the mother (26–35 years), and the responses to question 9 on brush frequency. Salivary pH, taking the basic pH group as a reference, with the other categorical variables showed significance with the patient’s gender (p= 0.039 and OR = 0.560), the modified Quigley–Hein plaque index, variable 0 (p= 0.044 and OR = 0.082), the Patient’s Diet Quality Survey, good (p< 0.001 and OR = 2.065 × 10 −9 ) and place of residence (p= 0.024 and OR = 2.019). Children 2025,12, 824 16 of 20 E.P.d.M.; investigation, E.P.d.M.; resources, E.P.d.M.; data curation, E.P.d.M., D.R.-P.; writing— original draft preparation, E.P.d.M.; writing—review and editing, E.P.d.M., M.A.-G.; visualization, E.P.d.M., A.M.-M., D.R.-P.; supervision, A.M.-M.; project administration, E.P.d.M., J.M.B.-M.; funding acquisition, E.P.d.M. All authors have read and agreed to the published version of the manuscript. Funding: This research did not receive external funding. Institutional Review Board Statement: The study was carried out in accordance with the Declaration of Helsinki and approved by the Ethics Committee of UNIVERSIDAD DE SEVILLA (protocol code 0930-N23 and date of 31 January 2024). Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. Data Availability Statement: Original contributions presented in this study are included in the article and Supplementary Materials. Further inquiries can be directed to the corresponding author. Conflicts of Interest: The authors declare that they have no conflicts of interest. Appendix A. Validated Survey on Diet Quality by the Spanish Society of Dietetics and Food Sciences DIET QUALITY SURVEY (SEDCA) QUESTION YES NO 1. Do you consume at least 2 to 3 servings of fresh fruit every day? 2. Do you regularly include a full serving of vegetables and greens in both lunch and dinner (making up about 1/3 to 1/2 of the plate)? 3. Do you consume at least 2–3 servings of legumes per week? 4. Do you regularly include raw or roasted (not fried or salted) nuts or raw or roasted seeds (such as chia, flaxseed, sesame, sunflower, pumpkin. . .) in your diet several times a week? 5. When you eat breakfast cereals, bread, pasta, or flour products, do you choose whole grain versions instead of white or refined ones? 6. Do you consume at least 3–4 servings of fish per week (including canned fish), with some of them being oily fish? 7. Do you regularly eat sugary breakfast cereals, cookies, pastries, or sweets (more than 3 times a week on average)? 8. Do you drink soft drinks, whether sugary or in their light/zero versions, several times a week (more than 2 soft drinks per week)? 9. When buying packaged foods, do you read the nutrition label to choose the best options (no added sugars, quality fats, lower in salt, whole grain flours. . .)? 10. Do you consume more than 4–5 servings of meat and processed meat products (cold cuts, sausages, meat preparations. . .) per week? Children 2025,12, 824 17 of 20 DIET QUALITY SURVEY (SEDCA) QUESTION YES NO 11. Do your breakfasts usually include sugary cereals, cookies, commercial jams, sweetened cocoa powder, sugar, pastries. . .? 12. Do you usually add sugar to foods such as coffee or yogurt, or choose their pre-sweetened versions? 13. Do you often use refined oils (such as sunflower, palm, palm kernel. . .) for cooking or frequently buy products that contain those (precooked meals, cookies, breakfast cereals. . .)? 14. Do you often skip meals to reduce your calorie intake, eat as little as possible, or follow very restrictive diets to the point of feeling very hungry at the next meal, experiencing food anxiety, or feeling unwell? 15. Do you skip meals or snack on anything between meals to avoid taking a break at work or due to a lack of time to prepare proper meals? 16. Do you often resort to quick dinners made with low-nutritional-quality processed foods, order fast food, or eat cold cuts, cookies with milk, or similar (2 or more times per week)? If your score is: • Between 11 and 16 points: The quality of the diet is quite good. It is important to support an active lifestyle and exercise. • Between 6 and 10 points: The quality of the diet could be improved. Some of the points should be reviewed for improvement, and alternatives should be sought to improve them. • Between 0 and 5 points: The quality of the diet needs to be improved. It is important to review the recommendations that are not being followed and to try to gradually introduce improvements to the diet. Appendix B. Validated Survey on Daily Dietary Habits of Pediatric Patients PARENTAL SURVEY ON ORAL HEALTH PREVENTION This survey is a response to research being conducted at the University of Seville to determine the knowledge of parents of pediatric patients regarding hygiene and caries prevention measures. Age of 1st parent: ◦Under 25 years old ◦Between 25 and 35 years old ◦Between 35 and 45 years old ◦Over 45 years old Age of 2nd parent: ◦Under 25 years old ◦Between 25 and 35 years old ◦Between 35 and 45 years old ◦Over 45 years old Children 2025,12, 824 18 of 20 PARENTAL SURVEY ON ORAL HEALTH PREVENTION Gender of 1st parent: ◦Female ◦Male ◦Other Gender of 2nd parent: ◦Female ◦Male ◦Other Educational level of 1st parent: ◦Primary education ◦Secondary education ◦Higher education ◦Don’t know, no answer (DK/NA) Educational level of 2nd parent: ◦Primary education ◦Secondary education ◦Higher education ◦Don’t know, no answer (DK/NA) Nationality of 1st parent: Nationality of 2nd parent: Is the patient an single child? NO YES Are the patient’s parents separated/divorced? NO YES Does the patient live in an urban setting? NO YES 1. Has the mother or primary caregiver had cavities in the past year? NO YES 2. Has your child had fillings in the past year? NO YES 3. Has your child visited the dentist in the past year? NO YES 4. Does your child eat snacks or sugary drinks between meals more than three times a day? NO YES 5. Does your child regularly drink other beverages than water? NO YES 6. Does your child sleep with a bottle or breastfeed on demand while sleeping between the ages of 2 and 6? NO YES 7. Do you know the purpose of fluoride? NO YES 8. Does your child brush their teeth with 1450 ppm fluoride toothpaste daily? NO YES 9. Does your child brush their teeth three times a day? NO YES 10. Did your child brush their teeth three times a day before the age of 6? NO YES 11. Do you review your child’s brushing habits at least once a day? NO YES 12. Did you review your child’s brushing habits at least once a day before age 6? NO YES 13. Does your child use fluoride-free mouthwash or rinse? NO YES 14. Does your child use a manual toothbrush? NO YES References 1. Boj, J.R.; Catalá, M.; García-Ballesta, C.; Mendoza, A.; Planells, P. 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