PONE-D-19-35772

Implementation and impact of a dental preventive intervention conducted within a health promotion program on health inequalities: A retrospective study

PLOS ONE

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"The study is an epidemiological retrospective study with a clinical examination of the children at school. The clinical examination was conducted by calibrated dentists and was limited to a visual observation.

Ethical approvals were obtained from the local educational and health institutions. Schools were approached through local educational authorities. Data were recorded in a file registered within the ethical comity for data management (CNIL N° kpP1390145R). Explanatory letters and consent forms were sent to parents prior to the dental examinations and children whose parents returned written consent were examined."

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Reviewers' comments:

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: a) One major suggestion is that more input & discussion should be developed to contextualize the sentence

327/328 "the intervention was not effective enough to balance the influence of health determinants in socially deprived sectors characterized by high dental needs"

For example analysis should be more deep and address issues like: what are the alternatives that can be introduced to overcome this situation?

b) it would be useful to implement a revision & proof reading of the text since there are some inconsistencies like

line 55 A formation and a standardized - training instead of formation

line 138 Poisson model a used. - Poisson model was used.

line 151 f the children selected - something is missing

lines 227, 229, 230, 232, 234 - etc "dots" misplaced

line 241 punctuation misplaced

line 280 review syntax and grammar

Reviewer #2: Introduction l.6-7 : The authors mention the challenge : taking into acount oral health inequalities gradient when assessing public health interventions. It is very interesting and original to assess the impact of interventions on health inequalities additionaly to a usual global assessment.

P5 l.58 and followings : this challenge does not appear very clearly in the aim of the study. « The aim was also to appreciate the influence of the quality of the intervention (retention rates) on the one-year caries increment, while taking into account initial dental status, conditions of sealants placement and social determinants such as the region of origin. Indeed, in order to tackle health inequalities, a greater or at least equivalent quality of intervention is expected in socially deprived sectors with highest health needs compared to more favoured areas [3]. »

The number of subjects was properly calculated.

P6 l.78 : By « region size », do you mean « region population » ? Did you make a clusterred sample ?

The statistical analysis has a high quality level (normal distribution checking, consequent use of a 0-inflated Poisson model, interactions testings…) and thus is very trustable.

P8 l. 138 : change « thus 0-inflated Poisson model a used » to « thus a 0-inflated Poisson model was used »

P9 l151 : « f the children selected in the 2017 sample participated ». Something might be missing ?

P9 l54 : « Eighty-three percent (95%CI: 79.9%-86.2%) of the dental sealants were present after one year. Among them, 31.1% (27.8%-34.5%) were totally present and 51.9% (48.6%-55.1%) were partially present. » I would suggest to remove « among them ». You don’t mean 31.1% of 83% ? Right ?

P9 l 159 : « Dental status in 2016, as well as the number of sealants applied in 2016, did

not influence retention rates. » This protocol does not allow to proove causal relationships (« influence »). I’d advise to rather talk about « links » or « associations ».

p9 Fig 1 : Why is the total retention rate lower than the complete retention rate ??? There might be a mistake.

Additionnally, it would maybe be clearer to talk about « full retention rate » and « global retention » rate…

p10 Table 1 :

Iles -> Islands

Partial retention rate : 0.52. Wouldn’t it be better to say 52% ? Do you mean 52% of the children had their sealants partially removed ?

What is the statistical unit ? Or do you mean 52% of the sealants ?

If my unsdersanding is right, I’d suggest the following changes :

P7 l 109 : « For each child, the number of sealants applied in 2016 was compared with the number of sealants present during the 2017 examination. This allowed the calculation of the retention rates; total (totally or partially present), partial (partially present) and complete retention rate (totally present). »

� « For each child, the numbers of partially remaining sealants and full sealants were recorded. The number of sealants applied in 2016 was compared with the numbers of sealants present during the 2017 examination. This allowed the calculation of 3 retention rates for each child; the complete retention rate (based on fully present sealants), the partial retention rate (partially present) and the global retention rate (fully or partially present). »

If my understanding is right, this sentence seems false to me : as the 2016 number of sealants per child was not always the same, the global percentage is not equal to the mean rate.

P9 l54 « Eighty-three percent (95%CI: 79.9%-86.2%) of the dental sealants were present after one year. Among them, 31.1% (27.8%-34.5%) were totally present and 51.9% (48.6%-55.1%) were partially present. »

I would suggest to change this sentence to : « On average, the children had still 83% (95%CI: 79.9%-86.2%) of their dental sealants after one year. Thirty one point one percent (27.8%-34.5%) of their initial sealants were still totally present and 51.9% (48.6%-55.1%) were partially present. »

If you calculate the global percentage, you get 85%,32% and 53%.

P12 Table 2 : The last column is unreadable : numbers are supeimposed.

P13 : What does all the text lines 224-235 stand for ?

Fig 2 : The definition is low and thus the figure is hard to read. Please provide a more readable figure.

P14 l241 : « and that 80% of the dental sealants were present after one year. » Change to « and that on average, the chidren had 80% of their dental sealants present after one year »

P14 l 252 You calculated the mean retention rate per child and not the global retention rate. The global retention rate woylb even be lower. The studies you are comparing to did calculate the global retention rate.

Your method allows an equal weight of each child in your study.

P15 l 282 : « Hence, it was possible in our sample to show that a high total number of sealants made a decisive contribution to caries prevention, particularly in deprived areas. »

On which result do you ground this assertion ? I do not see a statically significant difference about the « number of sealants » in any of your tables or figures. Indeed (Fig 1) the number of sealants applied inislands is lower than un other regions but the difference is not statically significant.

P17 l 327 « Nevertheless, even with well-balanced participation and retention rates between

regions, the intervention was not effective enough to balance the influence of health determinants in socially deprived sectors characterized by high dental needs. »

« Nevertheless, even with well-balanced participation and retention rates between

regions, the intervention was not effective enough to totally balance the influence of health determinants and especially in socially deprived sectors characterized by high dental needs. »

My conclusion :

This study showed that such a global program neither reaches to totally counterbalance other factors (caries increment 0.12-0.51) nor to alleviate the oral health inequalities (caries increment significantly higher in islands).

Additionnally it showed that independant predicting factors of tooth decay increment seem to be region and full sealant retention. Acting on these two factors might enhance the efficiency of such a program.

Cost-effectiveness studies would be needed to support public health decisions.

This study is a valuable contribution in public health as it is assessing a global program in real life condition.

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Reviewer #1: No

Reviewer #2: Yes: Pr Valerie BERTAUD

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Implementation and impact of a dental preventive intervention conducted within a health promotion program on health inequalities: A retrospective study

PONE-D-19-35772R1

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Frédéric Denis, Ph.D.

Academic Editor

PLOS ONE

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