Comparison of perceived stress and oral health status using perceived stress scale and DMFT index between healthy, undiagnosed hypertensive, and known hypertensive dental patients

Saira Atif; Uffaq Syed; Musarat Rafiq; Ateeb Fatima; Sadia Rana; Madiha Tariq

doi:10.1371/journal.pone.0311645

Peer Review History

Original SubmissionJuly 22, 2024
19 Aug 2024 Decision Letter - Hadi Ghasemi, Editor PONE-D-24-30378Comparison of perceived stress and oral health status between healthy, suspected hypertensive, and known hypertensive dental patientsPLOS ONE Dear Dr. Atif, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Oct 03 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly Reviewer #2: Partly Reviewer #3: Yes Reviewer #4: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: I Don't Know Reviewer #3: No Reviewer #4: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: No Reviewer #3: Yes Reviewer #4: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Article is good in writing and structure. However the relevance of the topic to the disease described is not clearly referred to and it is only the health behavior which is addressed . Suggestion is to edit the title accordingly. Reviewer #2: This study examines the association between oral health status, perceived stress, and hypertension among dental patients. Conducted at the CMH Lahore Medical College & Institute of Dentistry in Pakistan, the research involved 108 participants, divided into three groups: healthy, suspected hypertensive, and known hypertensive patients. Using the Decayed, Missing, and Filled Teeth (DMFT) index and the Perceived Stress Scale (PSS-10), the study found significant correlations between elevated blood pressure, higher perceived stress, and deteriorated oral health. The study emphasizes the potential role of dentists in identifying undiagnosed hypertension through routine screenings during dental visits. Critique: 1. Sample Size and Generalizability: The study's relatively small sample size and its focus on a single institution limit the generalizability of the findings. A larger, multi-center study would provide more robust and widely applicable results. 2. Sampling Method: The use of purposive sampling rather than random sampling introduces potential bias, which could affect the study’s validity. Random sampling would have enhanced the representativeness of the sample. 3. Lack of Control for Confounding Variables: The study does not account for potential confounding factors such as socioeconomic status, lifestyle factors (like diet and exercise), and other health conditions that could influence both stress and oral health. This omission weakens the conclusions drawn about the direct relationship between hypertension, stress, and oral health. 4. Measurement Tools: While the DMFT index and PSS-10 are established tools, the study could benefit from a broader assessment of oral health and stress. Including measures like periodontal health or using more detailed psychological assessments might offer a more comprehensive understanding of the relationships explored. 5. Limited Discussion on Mechanisms: The discussion touches on possible links between hypertension and oral health but lacks a deeper exploration of the biological or behavioral mechanisms that might explain these relationships. Providing more context from existing literature would strengthen the study’s theoretical foundation. 6. Short Study Duration: The study was conducted over just two months, which may not adequately capture the variations in stress and oral health that can occur over longer periods. Longitudinal studies would be better suited to observe the long-term effects of stress and hypertension on oral health. 7. Absence of Longitudinal Data: The cross-sectional design limits the ability to draw causal inferences. Future research could benefit from a longitudinal approach to better establish the temporal relationship between hypertension, stress, and oral health deterioration. Overall, while the study offers valuable insights into the potential role of dentists in early hypertension detection, addressing these limitations in future research would enhance the reliability and impact of the findings. Reviewer #3: The paper evaluated the perceived stress (by PSS-10 questionnaire) and oral health status (by using DMFT index) between patients with hypertension. The respected Authors categorized patients into healthy, suspected hypertensive, and known hypertensive dental patients. Overall, the article is well-written and has used validated questionnaires for obtaining the needed metrics. Since the association was examined using Chi-square test and correlation, the yielded links could be a result some variables that have not been adjusted for. Although important studies have been conducted on the association of perceived stress and oral hygiene care separately, the novelty of the present study is to conduct the present study on patients into healthy, suspected hypertensive, and known hypertensive patients. Additionally, there are some issues that I would like address. 1. The respected authors have used the term “suspected hypertension” which is not quit right. Based on the explained method, this includes patients with two times SBPs >130 or DBP>90. This would translate to undiagnosed HTN rather than suspects. This change would also mandate some revisions for the rationales stated for the rate of oral health status in this population in the discussion section. 2. I recommend using “patients with hypertension” instead of “hypertensive patients” across the manuscript as it has negative burden. 3. Please provide the exact purposive sampling method in line 85 as it can result in selection bias. 4. Lines 114- 117 are repeated and can be removed. 5. The reference for validation of perceived stress, is based on age 19-30 years. As older population exist in the current study, I suggest elaborating it as A limitation of the study. 6. In method section, were the continuous variables normally distributed? I’d suggest providing the appropriate statistical metrics for them. 7. Table 1 and 2 have the duplicate data due to the gender of the population in the study. 8. In table 1 and result section, I’d highly recommend to add three extra columns reporting the characteristics based on the hypertension groups and incorporating them accordingly to the discussion section, as well. 9. Caution should be used when definitive association or equivalent terms are used in the result or discussion section, as the probable role of other possible co variates was not accounted for in this article. So, if possible, conducting a regression, with adjusting for confounding variables could significantly improve the conclusions of the study. 10. In line 197, please provide more detail to compare your finding with other studies. Reviewer #4: The manuscript is an important one and is well written. However, 1. Reference is needed for line 44. 2. One or more references should be included in Page 3 line 60, page 7 line 214 since studies were mentioned. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: Ghassem Ansari Reviewer #2: No Reviewer #3: Yes: Fatemeh Farshad Reviewer #4: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0311645.r001
Revision 1
10 Sep 2024 Author Response We have incorporated the suggestions into the revised manuscript. Thank you for your valuable comments and suggestions. A detailed response and the changes incorporated are given below: Suggestions by Academic Editor: Thank you for highlighting a very important aspect related to anonymity of the data. We have removed age column from the data. Comments 1-4: We thank the reviewers for their valuable time and for constructive feedback which has undoubtedly improved the revised manuscript. Comment 5: For Reviewer 1: We thank you for your review. For minor grammatical errors, these have been corrected on page 6, 7, 15, 17 and 18. Kindly let me know if there is anything specific that I might have missed. For Reviewers 2,3,4: We are thankful for your valuable suggestions and comments working on which have undoubtedly improved the manuscript. We would highly appreciate if you could go through the revised manuscript and guide further if more corrections are needed. The following corrections are done: Reviewer’s suggestion Reviewer 1: Article is good in writing and structure. However, the relevance of the topic to the disease described is not clearly referred to and it is only the health behavior which is addressed. Suggestion is to edit the title accordingly A: The title of the manuscript has been revised. Please let us know if the revised title is appropriate. Page 1 and 2 Reviewer 2: 1. Small sample size and its focus on a single institution limit the generalizability of the findings. A larger, multi-center study would provide more robust and widely applicable results. A: This has been added in the last paragraph of discussion as the limitation of this study. line 285-297 2. The use of purposive sampling rather than random sampling introduces potential bias, which could affect the study’s validity. Random sampling would have enhanced the representativeness of the sample. A: It has been incorporated as study limitation line 288-291 3. Lack of control for confounding variables. The study does not account for potential confounding factors such as socioeconomic status, lifestyle factors (like diet and exercise), and other health conditions that could influence both stress and oral health. This omission weakens the conclusions drawn about the direct relationship between hypertension, stress, and oral health. A: We have added table 6 for binary logistic regression analysis which accounts for the adjustment of possible confounders. Other limitations were mentioned in the last paragraph of discussion. Thank you for your valuable suggestions. line 156-158 4. Measurement Tools: While the DMFT index and PSS-10 are established tools, the study could benefit from a broader assessment of oral health and stress. Including measures like periodontal health or using more detailed psychological assessments might offer a more comprehensive understanding of the relationships explored. A: It went beyond our study scope. However, we have included the suggestions in limitations and future recommendations line 294-297 5. Limited Discussion on Mechanisms: The discussion touches on possible links between hypertension and oral health but lacks a deeper exploration of the biological or behavioral mechanisms that might explain these relationships. Providing more context from existing literature would strengthen the study’s theoretical foundation. A: We have added more details in discussion session about possible link between hypertension, stress and oral health. line 274-276 6. Short Study Duration: The study was conducted over just two months, which may not adequately capture the variations in stress and oral health that can occur over longer periods. Longitudinal studies would be better suited to observe the long-term effects of stress and hypertension on oral health. A: We have included this as limitation. line 294-297 7. Absence of Longitudinal Data: The cross-sectional design limits the ability to draw causal inferences. Future research could benefit from a longitudinal approach to better establish the temporal relationship between hypertension, stress, and oral health deterioration. A: We have included this as limitation and future recommendations line 294-297 Reviewer 3 1. The respected authors have used the term “suspected hypertension” which is not quit right. Based on the explained method, this includes patients with two times SBPs >130 or DBP>90. This would translate to undiagnosed HTN rather than suspects. This change would also mandate some revisions for the rationales stated for the rate of oral health status in this population in the discussion section. A: We used suspected hypertension as we being dentists were not able to diagnose hypertension on our own and were in a position to refer such patients for proper diagnosis form a medical specialist. We have rephrased suspected hypertension with undiagnosed hypertension across the manuscript. All 2. I recommend using “patients with hypertension” instead of “hypertensive patients” across the manuscript as it has negative burden. A: Thank you for your valuable input. It has been corrected across the manuscript. All 3. Please provide the exact purposive sampling method in line 85 as it can result in selection bias. A: It is added. Line 91-94 4. Lines 114-117 are repeated and can be removed. A: It has been rephrased and repetition removed. Line 119 5. The reference for validation of perceived stress, is based on age 19-30 years. As older population exist in the current study, I suggest elaborating it as A limitation of the study A: We have added another reference for perceived stress in comparative age of 18-69 years. Thank you for highlighting this. line 129 6. In method section, were the continuous variables normally distributed? I’d suggest providing the appropriate statistical metrics for them. A: It has been added that continuous variables were not normally distributed as per Shapiro Wilk’s test. Hence, non-parametric Kruskal Wallis test was used for comparison. line 149-152 7. Table 1 and 2 have the duplicate data due to the gender of the population in the study. A: Sex from table 1 has been removed. Table 1 page 7 8. In table 1 and result section, I’d highly recommend to add three extra columns reporting the characteristics based on the hypertension groups and incorporating them accordingly to the discussion section, as well. A: Table has been modified and relevant discussion added. Table 1 page 7, line 216-225 9. Caution should be used when definitive association or equivalent terms are used in the result or discussion section, as the probable role of other possible co variates was not accounted for in this article. So, if possible, conducting a regression, with adjusting for confounding variables could significantly improve the conclusions of the study. A: We have conducted binary regression analysis and have included it in results and discussion. line 198-205, Table 6, 255-266 10. In line 197, please provide more detail to compare your finding with other studies. A: We have included another reference. line 225, 258-259 Reviewer 4 1. Reference is needed for line 44. A: Thank you for highlighting very important point. Reference is added. line 47 2. One or more references should be included in Page 3 line 60, page 7 line 214 since studies were mentioned. A: References are added. line 64, 243 Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0311645.r002
24 Sep 2024 Decision Letter - Hadi Ghasemi, Editor Comparison of perceived stress and oral health status using Perceived Stress Scale and DMFT index between healthy, undiagnosed hypertensive, and known hypertensive dental patients PONE-D-24-30378R1 Dear Dr. Saira Atif We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. 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If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #3: All comments have been addressed Reviewer #4: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #3: Yes Reviewer #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #3: Yes Reviewer #4: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #3: Yes Reviewer #4: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #3: Yes Reviewer #4: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #3: I read the paper entitled “Comparison of perceived stress and oral health status using Perceived Stress Scale and DMFT index between healthy, undiagnosed hypertensive, and known hypertensive dental patients” with great interest and congratulate the honorable authors for their excellent work. The article is well-written and has a meticulously answered all previous comments. Just I have to mentioned that Table 6 does not have any title. Please consider that as well. Reviewer #4: All comments have been addressed. The manuscript is technically sound and data analysis good. The manuscript is written in standard English. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #3: Yes: Fatemeh Farshad Reviewer #4: No ******** https://doi.org/10.1371/journal.pone.0311645.r003
Formally Accepted
1 Oct 2024 Acceptance Letter - Hadi Ghasemi, Editor PONE-D-24-30378R1 PLOS ONE Dear Dr. Atif, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Hadi Ghasemi Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0311645.r004

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