Supplementary Material for: The Mediation Pathway Linking Dental Caries and Academic Performance in Children.

Introduction. There is little discussion in the literature on the pathway linking oral health problems and academic performance in children. This study investigated the hypothesis that the influence of dental caries on academic performance is mediated through toothache and impacted sleep and study activities.
Methods. This cross-sectional study on children aged 12-14 years collected data on the exposure (decayed tooth index), outcome (school examination results), and mediator (school absence due to toothache, and oral health impact on sleep and study performance using the Child Oral Impact on Daily Performance instrument) variables. It used mediation analysis to examine the indirect effects of a single and two serial-mediators using Model 4 (caries  mediator  AP) and Model 6 (caries  mediator 1  mediator 2  AP), respectively, in PROCESS macro add-on software in IBM SPSS v24. Analyses were carried out separately for boys and girls at a 5% significance level.
Results. In Model 4, school absence due to toothache (boys: 95%CI: 0.42, 1.01; girls: 95%CI: 0.58, 0.98), and impacted sleep (95%CI: 0.13, 0.41; 95%CI: 2.17, 13.03), and study (95%CI:0.05, 0.42; 95%CI: 0.54, 0.94) performance were significant single mediators in both sexes. In Model 6, school absence due to toothache and impacted sleep activity (boys: 95%CI: 0.02, 0.29 and girls: 95%CI 1.37, 12.81), and school absence due to toothache and impacted study activity (girls: 95%CI 1.37, 12.81) were significant two serial mediators.
Conclusion. This study provides empirical evidence showing that dental caries and toothache can impact academic performance as they disrupt sleep and study performances to influence the learning and cognition process. The finding bridges the understanding of the mechanism underpinning the relationship and thus, further emphasises the importance of caries prevention in children with high caries risk for improving their health outcomes and educational experience.