Factors associated with the use of dental services in older adults in Peru

Bryan Alexis Cossio-Alva; Rubén Espinoza Rojas; Miguel Angel Ruiz-Barrueto; Giancarlo Becerra Atoche; Christian R. Mejia; Ibraín Enrique Corrales-Reyes

doi:10.1371/journal.pone.0316651

Peer Review History

Original SubmissionAugust 9, 2024
25 Oct 2024 Decision Letter - Boyen Huang, Editor PONE-D-24-33797Factors associated with access to dental services in older adults in PeruPLOS ONE Dear Dr. Cossio-Alva, 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. In addition to adressing the two reviewers' comments, the editor asks the authors to re-think whether they want to focus on the access or utilization of dental services in this manuscript. The title, aims, study design, measures, and results should be consistent in the focus and terminology used. Please submit your revised manuscript by Dec 09 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. 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Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. If data are owned by a third party, please indicate how others may request data access. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. 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 #1: Partly Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: No ****** 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: 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 ****** 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: This study uses data on older adults in Peru to examine potential predictors of dental service use (termed as access to dental services). There are several major and minor issues that inhibit my enthusiasm for this study and must be clarified or addressed before moving forward. Major comments The gap this study is addressing is not clear to me. The authors state that previous work has identified these factors as being predictive of dental service utilization. How is this study building on this and contributing something new? The authors should provide more information and support for how this study offers new insights. There is very little information given on what the authors did for “quality control” of the data, yet it is noted as a strength of the study. More detail needs to be given on what quality control entailed. Please provide more detail about the ENDES. Is this meant to be a nationally-representative sample? How are the data for the ENDES collected? Are data collected annually, and are there linkages across years if someone is surveyed multiple times (or are these anonymized repeated cross-sectional data)? I am still unclear on how the outcome variable (access to dental services) was defined. It seems to be parameterized dichotomously, however the sentence describing it does not make clear the window of time for a “recent” visit; is there a threshold by which the most recent visit would not indicate someone has access to dental services? For example, if someone had a dental visit in July of 2018 and no other visits, are they considered to have access to dental services? This versus someone who has more frequent visits throughout a year may be an important distinction. More clarity is needed on how the outcome variable was defined. Related to the above, is there any information on the nature of the dental visits? Someone may have a single visit and reasonable considered as having access to dental services if they are just receiving a routine cleaning, however someone else may have a single visit and be in need of more significant dental work and be unable to access it due to financial constraints; would this person also be counted as having access to dental services? It would be helpful to more clearly differentiate the measures described in the methods. Specifically, the authors could consider creating subsections with headings for “outcome”, “predictors” and “covariates for adjustment” so it is clear to the reader which measures are of interest for their potential predictiveness and which are only for adjustment. Why were some covariates included to adjust the models but results not reported, while others were? Specifically, the authors mention education as a covariate but also include its regression estimates, while language and department are not. Language is examined using a bar chart instead, but not talked about in the discussion section of the manuscript. Why wasn’t language discussed? Minor comments How are the levels of the wealth index defined? Is wealth based solely on income, or are there other factors considered (assets, properties, etc.)? A one-sentence description of this would be helpful. Including the variable codes seems extraneous; it takes up a lot of space and makes it more difficult to read through the methods. I would remove them. The authors should, in clarifying their definition of the outcome, make clear that they are (or seem to be) using dental service utilization as a proxy for access (note that access and utilization are closely tied but not exactly the same). Please explain why some factors (i.e., age, region, and marital status) were not included in the multivariable model. Please change “multivariate” to “multivariable” as the former describes models with multiple outcomes, whereas the latter describes models with multiple covariates. Reviewer #2: The manuscript supposedly reports on factors associated with access to dental services in older adults in Peru. However, manuscript does not report on access to dental services, but reports on dental utilization (i.e., accessing dental services). Access to dental care services and using dental care services are quite different. I was disappointed to learn the manuscript was not about access to dental care services. Overall, the manuscript and analysis are underdeveloped and lacks justification. There are several areas that need improvement before the manuscript may be of interest to the readers of the journal. The title of the manuscript needs to be changed to reflect that the study determined factors associated with dental utilization. The definition of dental utilization (most recent dental visit <2 year or 2 or more years) needs explanation and justification. Why the cutoff at 2 years? Is visiting the dentist at least once every 2 years the recommended frequency in Peru? This cutoff is not likely to be comparable to research done in many other countries where the recommended frequency is higher, such at least 1 once, if not twice, per year. Given the large sample sizes, it seems it would be possible to consider more than 2 categories for dental utilization, such as within the last year, with 1-2 years, and more than 2 years. At least one could report more descriptive summaries about dental utilization. However, maybe dental utilization was only asked as a dichotomous response (<2 and 2+ years)? Either way it is not apparent that the authors gave the definition of the outcome much thought. Selection of the potential factors associated with dental utilization needs justification. Were these the only characteristics collected in the survey? Were there no measures of need of dental care or reasons for last dental visit? The description of the regression method is a bit vague, “a robust variance estimation [was used] to consider possible distortions in the data.” I would describe the method as “Crude and adjusted prevalence ratios were estimated using a modified Poisson regression with a robust standard error estimates to account for overdispersion.” Make it clear in the title for Table 2 that you are reporting on factors related to NOT accessing dental services. Also, Table 2 should report on the overall statistical significant of each variable, such as is done in Table 1. It is a bit perplexing that the authors do not comment on the difference between the crude prevalence ratio and adjusted prevalence ratio for type of residence (255% higher prevalence of not accessing dental care versus only a 5% higher prevalence of not accessing dental care). Is the reader to assume that the apparent lack of accessing dental care in rural areas compared urban areas is due to other factors, such as education and wealth. I.e., the access to dental is similar in rural and urban areas it is just that individuals in rural areas can’t afford dental care or don’t think it is important. A more likely explanation is that there are other strong correlations between the factors, besides the ones with region living in, that the authors need to consider. What about interactions between the factors? There is no mention that the authors considered interactions between the variables. Again, the analysis seems under developed. ****** 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: No Reviewer #2: 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. Attachments Attachment Submitted filename: PLOS One review.docx https://doi.org/10.1371/journal.pone.0316651.r001
Revision 1
5 Dec 2024 Author Response REVIEWER 1. It is unclear what gap this study is addressing. The authors state that previous studies have identified these factors as predictors of dental service utilization. To what extent does this study build on that and provide something new? The authors should provide more information and support on how this study contributes new insights. Response from the Authors: The reviewer's comment was taken into account and promptly addressed. REVIEWER 1. Very little information is provided regarding what the authors did for "data quality control," yet it is highlighted as a strength of the study. More details are needed on what the quality control process entailed. Response from the Authors: The reviewer's comment was taken into account and promptly addressed. REVIEWER 1. Provide more details about ENDES. Is it designed to be a nationally representative sample? How are the data collected in ENDES? Are the data collected annually, and are there links across years if the same individual is surveyed multiple times, or are they repeated cross-sectional and anonymous data? Response from the Authors: The reviewer's comment was taken into account and promptly addressed. REVIEWER 1. I still do not fully understand how the outcome variable (access to dental services) was defined. It seems to be parameterized dichotomously; however, the description does not clarify the time period for a "recent" visit. Is there a threshold beyond which the most recent visit would not indicate access to dental services? For instance, if someone had a dental visit in July 2018 and no further visits, would they be considered to have access to dental services? This contrasts with someone who has more frequent visits over a year, which could represent an important distinction. Greater clarity is needed on how the outcome variable was defined. Response from the Authors: The reviewer's comment was taken into account and promptly addressed. REVIEWER 1. In relation to the above, is there any information about the nature of the dental visits? For example, one person might have a single visit and reasonably be considered to have access to dental services if they are only receiving a routine cleaning. However, another individual might have a single visit and require more extensive dental work but be unable to access it due to financial limitations. Would this person also be considered as having access to dental services? Response from the Authors:Dear reviewer, the mentioned limitation has been added to the discussion. REVIEWER 1. It would be helpful to differentiate the measures described in the methods more clearly. Specifically, the authors could consider creating subsections with headings such as "Outcome," "Predictors," and "Covariates for Adjustment" to make it clear to the reader which measures are of interest for their predictive potential and which are only used for adjustment. Response from the Authors: The reviewer's comment was taken into account and promptly addressed. REVIEWER 1. Why were some covariates included to adjust the models but their results were not reported, while others were? Specifically, the authors mention education as a covariate and also include its regression estimates, whereas language and department are not reported. Language is analyzed through a bar chart, but it is not mentioned in the discussion section of the manuscript. Why was language not addressed? Response from the Authors: The exclusion of certain covariates, such as language, from the multivariable model and the discussion was primarily due to collinearity with other variables included in the analysis, such as geographic region and wealth index, which more broadly capture structural inequalities related to access to dental services. While language may play an important role in specific local contexts, its effect was not independent of these variables in preliminary analyses. Therefore, a methodological decision was made to prioritize variables that better represent the general sociodemographic dynamics of the country. However, we acknowledge that this decision may have limited the exploration of certain specific linguistic barriers, and we have highlighted this limitation in the discussion section as an area to address in future research. REVIEWER 1. How are the levels of the wealth index defined? Does wealth rely solely on income, or are other factors such as assets, properties, etc., taken into account? A concise description of this would be helpful. Response from the Authors: The reviewer's comment was taken into account and promptly addressed. REVIEWER 1. Including the variable codes seems unnecessary, takes up significant space, and makes the methods section harder to read. I would recommend removing them. Response from the Authors:The reviewer's comment was taken into account and promptly addressed. REVIEWER 1. The authors should clarify their definition of the outcome and explicitly state that they are (or appear to be) using the utilization of dental services as a proxy for access. Please note that while access and utilization are closely related, they are not exactly the same. Response from the Authors: The reviewer's comment was taken into account and promptly addressed. REVIEWER 1. Please explain why some factors (e.g., age, region, and marital status) were not included in the multivariable model. Response from the Authors: The exclusion of certain covariates, such as language, from the multivariable model and the discussion was primarily due to collinearity with other variables included in the analysis, such as geographic region and wealth index, which more comprehensively capture structural inequalities related to access to dental services. While language may play an important role in specific local contexts, its effect was not independent of these variables in preliminary analyses. Therefore, a methodological decision was made to prioritize variables that better represent the broader sociodemographic dynamics of the country. Nevertheless, we acknowledge that this decision may have limited the exploration of specific linguistic barriers, and we have highlighted this limitation in the discussion section as an area to be addressed in future research. REVIEWER 1. Replace "multivariate" with "multivariable," as the former refers to models with multiple outcomes, while the latter describes models with multiple covariates. Response from the Authors: The reviewer's comment was taken into account and promptly addressed. REVIEWER 2. The manuscript title needs to be revised to reflect that the study determined the factors associated with the utilization of dental services. Response from the Authors: The reviewer's comment was taken into account and promptly addressed. REVIEWER 2. The definition of dental service utilization (last dental visit <2 years or ≥2 years) requires an explanation and justification. Why was the 2-year threshold chosen? Is visiting the dentist at least once every 2 years the recommended frequency in Peru? It is unlikely that this threshold is comparable to research conducted in many other countries where the recommended frequency is higher, such as at least once or even twice per year. Response from the Authors:The reviewer's comment was taken into account and promptly addressed. Given the large sample size, it seems feasible to consider more than two categories for dental service utilization, such as within the last year, 1–2 years, and more than 2 years. At the very least, more descriptive summaries of dental service utilization could be provided. However, was dental service utilization perhaps only asked as a dichotomous response (<2 years and ≥2 years)? In any case, it is not evident that the authors have given much thought to the definition of the outcome variable. Response from the Authors: We acknowledge that the large sample size could have allowed for a more detailed categorization of dental service utilization, such as visits within the last year, between 1 and 2 years, and more than 2 years. However, the ENDES survey collected this information through a structured question with a dichotomous response (<2 years or ≥2 years), limiting the possibility of a more specific classification. Additionally, this definition was chosen due to the lack of clear national recommendations regarding the ideal frequency of dental visits, aiming to strike a balance between capturing recent access and ensuring consistency with previous local studies. Nevertheless, we recognize that this choice may simplify some of the complex dynamics of access, and we have included this limitation in the discussion, emphasizing the need for future studies to use more detailed data collection tools for a more precise characterization of dental service utilization. REVIEWER 2. The selection of potential factors associated with dental service utilization requires justification. Were these the only characteristics collected in the survey? Were measures regarding the need for dental care or the reasons for the last dental visit not included? Response from the Authors: Dear Reviewer, We appreciate your thoughtful comments and take this opportunity to provide further clarification: The variables selected for this study, including sex, age, educational level, type of residence, health insurance affiliation, wealth index, self-perceived ethnicity, and physical limitations, are relevant as they represent well-documented sociodemographic and economic determinants of access to healthcare. These variables help identify structural and contextual inequities that directly influence dental service utilization among older adults in Peru. For instance, educational level and wealth index are often associated with the ability to prioritize and afford dental care, while type of residence and geographic region reflect physical and logistical barriers, particularly in rural and remote areas. However, other potentially relevant variables could not be included due to limitations in the data available from ENDES. These include information on the perceived need for dental care, specific reasons for not utilizing dental services, detailed cultural or linguistic barriers, and the quality or type of services received. The absence of such data restricts the ability to capture more complex and detailed dynamics of access to dental services. This limitation underscores the importance of future studies incorporating broader and more specific data collection tools to address these additional dimensions and enhance understanding of the barriers and facilitators to accessing oral healthcare. REVIEWER 2. The description of the regression method is somewhat vague: "a robust variance estimate was used to account for potential distortions in the data." I would recommend describing the method as "crude and adjusted prevalence ratios were calculated using a modified Poisson regression with robust standard error estimates to account for overdispersion." Response from the Authors: The reviewer’s comment was taken into account, and the description was revised as follows: Crude and adjusted prevalence ratios were calculated using a modified Poisson regression with robust standard error estimates to account for overdispersion in the data. REVIEWER 2. In the title of Table 2, clearly indicate that it reports on factors associated with the lack of access to dental services. Additionally, Table 2 should include the overall statistical significance of each variable, as is done in Table 1. Response from the Authors: The reviewer's comment was taken into account and promptly addressed. REVIEWER 2. It is somewhat disconcerting that the authors do not comment on the difference between the crude prevalence rate and the adjusted prevalence rate by type of residence (a prevalence 255% higher for lack of access to dental care versus a prevalence only 5% higher for lack of access to dental care). Should the reader assume that the apparent lack of access to dental care in rural areas compared to urban areas is due to other factors, such as education and wealth? That is, is dental care access similar in rural and urban areas, but rural residents cannot afford dental care or do not consider it important? A more likely explanation is that there are strong correlations between factors beyond just the region of residence, which the authors should consider. Response from the Authors: The reviewer's comment was taken into account and promptly addressed. REVIEWER 2. What about the interactions between factors? It is not mentioned whether the authors accounted for interactions between variables. Once again, the analysis appears to be underdeveloped. Response from the Authors: The reviewer's comment was taken into account and promptly addressed. Attachments Attachment Submitted filename: Response to the Reviewers.doc https://doi.org/10.1371/journal.pone.0316651.r002
11 Dec 2024 Decision Letter - Boyen Huang, Editor PONE-D-24-33797R1Factors associated with the use of dental services in older adults in PeruPLOS ONE Dear Dr. Cossio-Alva, 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 Jan 25 2025 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. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Boyen Huang, DDS, MHA, PhD Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments: According the Authors' response to Reviewers: REVIEWER 2. What about the interactions between factors? It is not mentioned whether the authors accounted for interactions between variables. Once again, the analysis appears to be underdeveloped. Response from the Authors: The reviewer's comment was taken into account and promptly addressed. However, the Editor and Reviewer 2 do not see the authors address the interactions between variables in their recent revision. If the authors believe that the reviewer's comment was taken into account and promptly addressed, please list the page number and line number of the updated content for the Editor's consideration. The Editor would suggest the authors add a paragraph in the Discussion Section to discuss the influecnce from the interactions between variables as shown in Table 2. For example, why was the aPR of the ethnoracial, education, residence type, and wealthy index variables become less significant after the adjustment with other variables? This likely resulted from the interactions among variables. Additionaly, why was the region variable not included in the multivariave model as shown in Table 2? In Lines 180-183 you specified that Adjustment covariates included... Geographical region... Please explain and/or discuss these. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. 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 #1: All comments have been addressed Reviewer #2: 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 #1: Yes Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: (No Response) Reviewer #2: 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 #1: (No Response) Reviewer #2: 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 #1: (No Response) Reviewer #2: 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 #1: (No Response) Reviewer #2: The authors have addressed most of my concerns. But they didn't describe if they assessed for interactions between the predictor variables, and didn't include the p-values for composite tests for categorical predictors with >2 categories. The latter is a common shortcoming of many research articles, which present numerous p-values for subgroup comparisons but omit the overall test for significance. It's sloppy science, which occurs too frequently, but I won't hold it agains the authors, given many journals appear to be okay with promoting with this sloppiness. ****** 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 #1: No Reviewer #2: 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.0316651.r003
Revision 2
12 Dec 2024 Author Response We sincerely appreciate the comments provided, as we did not fully understand the request during the initial review. These comments have been instrumental in enhancing the clarity and depth of the manuscript. In response, we have added a paragraph in the Discussion section that examines how the interaction and overlap of determining factors explain the reduced significance of certain variables after adjustment. Additionally, we have clarified that the exclusion of the geographic region variable from the multivariable model was justified due to collinearity issues, as other included variables more accurately capture the structural inequalities affecting access to dental services. These revisions aim to provide a more thorough and rigorous analysis of the results. The modification can be viewed on page 19, lines 388–402. Attachments Attachment Submitted filename: ACT-Response to the Reviewers.doc https://doi.org/10.1371/journal.pone.0316651.r004
15 Dec 2024 Decision Letter - Boyen Huang, Editor Factors associated with the use of dental services in older adults in Peru PONE-D-24-33797R2 Dear Dr. Cossio-Alva, 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. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. 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. Kind regards, Boyen Huang, DDS, MHA, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): All comments have been addressed. Reviewers' comments: https://doi.org/10.1371/journal.pone.0316651.r005
Formally Accepted
31 Jan 2025 Acceptance Letter - Boyen Huang, Editor PONE-D-24-33797R2 PLOS ONE Dear Dr. Cossio-Alva, 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 Boyen Huang Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0316651.r006

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