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  • Ivan Ivanov 1,*,
  • Anjelika Velkova 2 and
  • Emilia Naseva 3

Reviewer 1: Anonymous Reviewer 2: Anonymous

Round 1

Reviewer 1 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

Dear Colleagues,

Your study "Periodontal Status and Oral Health-Related Quality of Life in Bulgarian Adults: A Cross-Sectional Study" addresses a relevant topic. A significant advantage and element of novelty in the publication is the inclusion of sleep quality as a behavioral determinant in the analytical model. Nevertheless, I have identified a number of significant shortcomings.

  1. First, you characterize the study as "cross-sectional observational" and state that it involves "consecutive adult patients" (line 99). However, in the limitations section (line 361), it is indicated that this is a "convenience sample." This contradiction should be resolved. Furthermore, the indication that patients were recruited from a university clinic significantly limits external validity. The findings are applicable only to the population of patients seeking dental care and cannot be generalized to all Bulgarian adults.

  2. Second, dichotomization by the median is a common but debatable method, leading to loss of information and statistical power (which the authors acknowledge in the limitations). However, in this case, it has created a critical problem with interpretation.

  3. Third, you cite studies (e.g., Bernabé, 2010; Sanders, 2009) that show a positive association between periodontitis and poorer OHRQoL. At the same time, your own result (in its current interpretation) completely contradicts these findings. Your result (OR=0.329) means that patients with periodontitis have THREE TIMES LOWER odds of having impaired OHRQoL. This contradicts not only the literature but also common sense. Such a result is only possible due to an error in coding the dependent variable or the reference category. This is not a "complex non-linear relationship" but a methodological error that must be corrected as a priority. You should reconsider your analysis.

  4. Among minor comments, I would like to draw your attention to the handling of tables. In Table 1, which is presented across different pages (a violation of publication preparation standards), the row "Age, years (median, IQR)" contains shifted data presented in an unreadable format. For greater clarity, vertical data could also be linked to the number of cases, indicating n=... .

Considering all the above, I recommend a major revision of the manuscript.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

The revisions requested in the manuscript have been incorporated.

Tables and figures have been organized, and the research methods and main text, which were previously unclear, have been systematically organized.

This study will attract the interest of relevant readers regarding periodontal status and oral health quality of life.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.


Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Hello, dear colleagues!

The manuscript addresses a relevant topic, but methodological and interpretative shortcomings significantly reduce the validity and clarity of the results. I have several questions regarding the text.

1. A clear hypothesis regarding the expected direction or strength of the relationship between periodontitis and OHRQoL is not formulated, especially given the literature (which typically reports worsening OHRQoL with periodontitis).
2. Sample. Consecutive adult patients from a single dental clinic are a convenience sample, not a population-based one. The authors refer to the "adult population of the Republic of Bulgaria," which is misleading.
This should be stated in the limitations, or the value of such a narrow sample should be further discussed.
3. The distinction between "healthy periodontium" and "periodontitis" is very crude. Stage and severity are missing.
4. Table 1: The distribution of periodontitis by age is expected, but the authors do not comment on possible collinearity between income, education, and place of residence.
5. The discussion implies that poor sleep causes worsening OHRQoL, but the reverse causality (oral pain or discomfort disrupting sleep) is no less plausible and is not considered.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This study identifies the relationship between periodontal disease occurring globally and quality of life. I believe this study will provide broader insights into periodontal disease.

Authors are requested to supplement the manuscript by referring to the following.

  1. What is the basis for categorizing OHIP-14 scores based on the sample median?

 

  1. The classification and definition of periodontal disease are very important in this study. Please describe the ‘2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions’ mentioned in the manuscript.

 

  1. Results Lines 153 : Table 1. Please write the statistical analysis method for the analysis method in the footnote.

 

  1. Lines 162 : OHIP-14 Distribution

I cannot find a table or figure for the relevant data.

Referring to a graph (marked with dots) to check the distribution would likely help the reader understand the situation.

 

  1. Lines 170-188 : 3.3. Multivariable Logistic Regression Analysis

The content of the main text differs from Table 2. Please verify it again and enter the numbers accurately.

Please make Table 2 clearer, Please list the independent and dependent variables in Table 2, and perform statistical analysis by applying a correction model for covariates.

Related details must be written in the footnote.

  1. Lines 189-200 : 3.4. Additional Linear Regression Analysis

The content was not displayed in the table.

Please insert the table.

 

  1. The distribution of the study participants' OHIP-14 scores, sleep quality levels, etc., cannot be found at all in the manuscript.

Table 2 is difficult to understand.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors!

I am satisfied with your responses.

Reviewer 2 Report

Comments and Suggestions for Authors

The authors of this study have revised the text to maintain clarity, visualization, and systematic structure.

I believe this study will be of great interest and helpful to readers interested in periodontal disease and quality of life.