PONE-D-24-31397Comparative analysis of oral health behaviour and utilisation of oral health care services in the general population and among patients with non-communicable diseases in Korea: a repeated cross-sectional survey conducted from 2008 to 2022PLOS ONE

Dear Dr. Ock,

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Pracheth Raghuveer, MD, DNB

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PLOS ONE

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This study was supported by a grant from the National R&D Program for Cancer Control, Ministry of Health & Welfare, Republic of Korea (HA21C0107). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Reviewers' comments:

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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: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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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

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Reviewer #2: Yes

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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:  The study provides a crucial and timely examination of oral health behavior and service utilization among patients with non-communicable diseases (NCDs). Given the global rise in NCDs, this research holds significant relevance to both clinical practice and public health, highlighting the disparities in oral health care that may exist for this vulnerable group. The analysis is bolstered by the use of a robust dataset from the Korea Community Health Survey spanning a substantial 14-year period (2008–2022), offering a comprehensive view of trends over time. This extended period enables meaningful insights into how oral health behaviors and utilization of services have evolved, both in the general population and in patients with NCDs.

One of the study's major strengths is its identification of the disparities in oral health behaviors between the general population and those with NCDs. By demonstrating that NCD patients generally exhibit poorer oral health behaviors, the research points to specific areas for intervention, which is essential for developing tailored strategies to improve their oral health outcomes. Furthermore, the study has significant public health implications, as it provides an evidence-based foundation for healthcare policymakers. Identifying gaps in oral health services for NCD patients paves the way for strategies that can enhance preventive care and improve access to services, ultimately leading to better overall health outcomes for these patients.

However, some critical points require further attention to maximize the study's impact:

Lack of Specificity in Patient Subgroups: While the analysis covers 15 different NCDs, the abstract does not clarify whether specific trends or significant differences were observed among the various NCD subgroups. It would strengthen the study to explore whether particular conditions, such as diabetes mellitus or hypertension, have distinct oral health behaviors or service utilization patterns. Additionally, these 15 NCDs could be grouped into major categories (such as metabolic, cardiovascular, and mental health conditions) for more granular analysis. Since oral diseases share common risk factors with several NCDs, a subgroup analysis could reveal important clusters of risk factors and provide insights into how interventions might be more effectively targeted.

Generalized Recommendations: The abstract concludes with a recommendation to implement educational and promotional measures, but these suggestions are somewhat broad. Providing more specific or innovative strategies tailored to the needs of NCD patients could enhance the recommendations' impact. For instance, highlighting which specific oral health behaviors or service utilization gaps—such as annual scaling or regular oral examinations—should be prioritized for intervention would make the recommendations more actionable.

Comparison with General Population: Although the comparison between NCD patients and the general population is briefly mentioned, the abstract does not delve deeply into the implications of these differences. A more thorough discussion of why oral health service utilization rates are lower in NCD patients, whether due to access issues, awareness gaps, or other barriers, could provide valuable insights that inform future public health strategies.

Limited Focus on Policy Implications: While the study emphasizes the need for improved oral health behaviors in NCD patients, it could better emphasize the potential policy changes or adjustments in healthcare systems necessary to address these gaps. Given the increasing global burden of NCDs, incorporating a discussion on the importance of medical-dental integration and coordinated care for patients with NCDs would significantly strengthen the study. Policy suggestions that focus on better integrating dental care within overall NCD management could offer long-term solutions for improving health outcomes in this population.

The following suggestions may further enhance the clarity and impact of the study:

Provide more specificity on differences in oral health behavior and service utilization across distinct NCD subgroups to offer more targeted insights. (to explore whether Major NCDs and other NCDs can be subgroup in the analysis )

Strengthen the policy implications by discussing potential strategies for medical-dental integration and more coordinated care for NCD patients.

Clarify and expand upon the regional variations identified, including potential reasons for these disparities and tailored approaches to address them.

These revisions will further solidify the paper’s contribution to the field and its practical relevance for addressing oral health gaps in NCD care.

Reviewer #2:  1. The authors have used available survey data from community health surveys and tried to capture the trends/changes in oral health behaviour among those with non communicable diseases (NCDs) and among the other general population. A problem with public health surveys as compared to registry-like data is that the sample is bound to change every year, (900 who are sampled per public health center, will change every year!). Within the limits of the available data, the authors have tried to capture the trends using a suitable statistical trend analysis/regression.

2. The main issue in the analysis that I noticed is that the change in oral health behaviours is on the up-trend for all population but, those with NCDs it is still less. In addition to the "self reported" nature and the associated false reporting by people, the other thing is that those with highest risk (among the NCD and non NCD population) may not be captured because they are either not coming into the system or they are lost... Also, this self-reporting will also under-report those who have not yet been identified or diagnosed with NCD, which in high probabiility are people who do not access the health system. These limitations should reflect in the discussion.

3. Some NCDs have a higher morbidity and higher association with poor oral health. In addition, NCDs being a lifestyle related disease, especially hypertension, diabetes (DM); those with common risk factors may also have a poor oral health behaviour and this may reflect on their overall low use of health resources and their consequent poor oral health. The change in behaviour would not happen without targetted interventions. And hence, they will remain low. Some segments of population with mental health challenges, may also resort to poor self-care and ignore their usual care routines, including tooth brushing etc., The authors could explain such associations in the discussion. They have explained the possible causes for poor oral health habits among those with stroke, but different NCDs may affect their ability to maintain or access the system in different ways. For example, arthritis may affect their dexterity to brush well and also their mobility and hence decreased access. Those with another NCDs may have different challenge, and is not discussed even in broad sense. A table to highlight this or a short paragraph on the same will be good, and this should be loco-regionally informed by prior data or known experience of the authors and not just speculation.

4. I feel, the policy level suggestions and system level changes suggested by the authors based on their work appear too generic and not data driven- as per the data presented. Also, with so much missing data in so many years and with information only on 'tooth brushing habits', it is difficult to justify major policy level recommendations. The strongest point is the recommendation that oral health has to be integrated with NCD screening. Majority of individuals in general population and those with NCDs have shown similar habits except some specific conditions such as stroke. The authors have themselves identified potential issues in this group of population. They have found a reverse trend in patients with arthritis & dyspidemia. The potential reason is that arthritis & dyslipidemia have both increased in prevalence since 2008, and a large number of individuals with good oral health habits may also have developed dyslipidemia and are now here, where-in their habits has not changed, just their categorisation. With respect to arthritis, the reason for increased in oral examination in previous years may be due to the pre-joint replacement oral health screening, to remove foci of infections prior to reconstruction/replacement (or possibly some other reasons).

The authors have included 15 NCDs and have tried to explain a lot of changes, but during the discussion and conclusion they resort to generic suggestions than to base it on the data along with known trends in NCDs in their country. A suggestion would be to correlate the oral health behaviours to changing prevalence in NCDs which may reveal whether those with NCDs are actually neglecting their oral health. It is also prudent to highlight those conditions where the impact of poor oral health can be more detrimental. Atopic dermatitis, allergic rhinitis conditions with a poor oral health behaviour is a problem, but not so much as a person with DM or hypertension or stroke, where the risks may be higher.

The overall impact of the paper and the policy level suggestions they can provide can be better improved if the data is interprepted or discussed based on prevalence and change in prevalence of the NCDs themselves especially with respect to those with higher morbidity and stronger established association with poor oral health such as DM.

5. What regional factors/system level factors affect their poor utilisation ? Is there poor access ? Or some other reasons, this is best explained by authors since they know the system better at their country.

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Reviewer #1: No

Reviewer #2: Yes:  Akilesh. R

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PONE-D-24-31397R1Comparative analysis of oral health behaviour and utilisation of oral health care services in the general population and among patients with non-communicable diseases in Korea: a repeated cross-sectional survey conducted from 2008 to 2022PLOS ONE

Dear Dr. Ock,

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 Feb 24 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,

Pracheth Raghuveer, MD, DNB

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.

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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

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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: Yes

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: Yes

Reviewer #2: Yes

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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: Yes

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: the comments to reviewer is satisfactory and the article presents important findings for medical dental integration.

Reviewer #2: The authors have addressed the major concerns adequately. A few additional points for revision are submitted for the consideration of the authors.

1. Abstract - Result section can be improved and may consider the following suggestions.

First part of the result section is on oral health behaviour. So, logically, the second can start with "Regarding Oral health service utilisation..." and follow it up with key results. The third part can be on "inter-regional" variations.

2. Results pg 11 Line 4: From the study design, the total number is NOT 3,428, 968 patients, but datapoints (since around 200,000 per year are surveyed, with substantial overlap every year, which would be difficult to track). Unless, the survey method avoids resampling the same individual. And may consider either rephrasing the line 4 for total number of patients or may remove that from results to avoid confusion. Or may report the number of individuals sampled in the last survey alone. Or can mention, number surveyed in 2008 and the number surveyed in 2022.

Similar issues with the numbers presented for HTN, DM, arthritis etc., I think, the authors can use the LATEST survey result to summarise this data for the Table 1 and for reporting purposes. This gives the current or recent information that may be useful for policy decisions. The number of individuals with specific conditions in 2008 is less relevant compared to the number of people with the condition/disease in 2022. This revision will make the numbers easier to interpret. Table 1 may be updated in similar manner with latest data only, I feel.

4. Oral Health Behavior results: pg 14-15

The trends can be explained as a summary and since figures are self-explanatory, the important data alone may be highlighted and rest mentioned or labeled in figures. The information that is removed during this editing may be added to a supplement file under same headings.

Oral Health service utilisation and Inter-regional indicators may remain with sufficient detail as it is in the main article.

5. Discussion: pg 18 Line 3: Main findings & significance of the study - The heading is redundant.

6. pg 18 Line 4-6: The first sentence of discussion shall be the result and not what the authors did and may be removed or moved to next paragraph. The discussion may begin with line 7 in this page where the authors are summarising the study findings.

7. The limitations section may be brought up before "interpretation and implications" so the reader may understand the limitations before reading the interpretations, and then policy suggestions followed by conclusion. Necessary minor changes may be needed to maintain the logical flow of the article/writing.

8. pg 19-21 Implications This section has repeated much of the "Result section" information including the numbers. This repetition is redundant. This section can remove most of the statistical data, except the ones that are pivotal for further "policy recommendations" or "informing future research". Further sections on implications may also follow similar strategies of summary and implication instead of repeating the data from results section again.

Very important, very large or unexpected results/data may be retained for contextual purposes such as three fold increase or alarming decrease to emphasize or compare some key data. Otherwise, repetition of results data is redundant in discussion. In most paragraphs under "Implications", the second half of each paragraph contains information relevant to discussion section and first half has repetition from Results section. These lines may be removed for brevity and to remove redundancy.

9. Pg 21; lines 6-9, 19,20 May be shifted to policy suggestion section and may add about "improving access".

10. pg 21-23 Policy Suggestions

The policy recommendation section may be shifted to just before conclusion. Vulnerable and marginalized population specific recommendations may mention about improving access and promoting preventive oral care.

11. The third limitation from pg 24 can inform policy recommendation about integrating medical-dental care and about need to include dental/oral health related items in the KCHS surveys. Bridging this data-gap is an important policy recommendation, I feel.

12. pg 25 Lines 1-13 Conclusion: I feel that the oral Health behaviour and utilising oral health services alone are not sufficient to prevent worsening of NCDs and I feel that the data in the study doesn't support the first line of conclusion. The authors may instead add a note on "common risk factors" as a link between oral health and general health. May take this suggestion, if agreeable, since this may appeal to a larger audience and it will be an effective way to push for integration of dental and medical care in the health system. Following this, the authors can also add a note on "integration of medical-dental health" in conclusion. In addition, the repetitive sentences from other sections of discussion may be removed or summarised and rephrased briefly. Lines 8-13 appear good and may be retained.

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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: Yes:  Akilesh R

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[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.

Comparative analysis of oral health behaviour and utilisation of oral health care services in the general population and among patients with non-communicable diseases in Korea: a repeated cross-sectional survey conducted from 2008 to 2022

PONE-D-24-31397R2

Dear Dr. Ock,

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.

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Kind regards,

Pracheth Raghuveer, MD, DNB

Academic Editor

PLOS ONE

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