Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Individual Factors Are More Important than Contextual Factors 2 for Protection from Dental Caries

Submitted to Int. J. Environ. Res. Public Health 2026.

The study aims to was to identify factors associated with protection from dental caries in five-year-old children, using Salutogenic Theory as reference using secondary data were analyzed from the Minas 38 Gerais Oral Health Survey.

Comments to the Author

Reviewer:

The manuscript is clearly written, the methods are well described with interesting findings, important conclusions and recommendations. The reviewer, however, believed that some points need to be addressed before acceptance for publication.

• In general, the findings that consider “not visiting dentist as protective factor”, need to be revised.

Introduction:

- Missing part in the introduction is the impact of protective factors for healthy dietary habits and good oral hygiene behavior were not included in the introduction part as important protective variables impact the presence of carious lesions-activities/experiences.

- In the introduction part, a presentation of oral health Brazilian system for children (0-18 years old) is needed to identify if the system is providing children with routine oral health preventive/curative treatment appointment/visits for the children or if this protective measurement is not available.

Material & Methods:

• Page 3 line 124: Good if the authors included values for inter-intra-examiner calibrations.
• Page 3, line 137: do the authors mean, income (> or ≤ R$1500 [Brazilian currency]), as working status for the parents or it is social support for living. Working status is important for parents as it indicates more exposure and more information resources that improve oral health knowledge as a protecting factor.
• Page 4, line 156: The statement that a response rate of around 50%, rendering the analysis inviable (reason for visit to dentist), I suggest including reasons of dental visits in the analysis, because routine check-up visit to a dentist (protecting factor), is different from visiting dentist seeking for treatment.
• Page 4 line 165: The authors did not include Model 3 (biological factors), variables on presence of plaque or hygiene parameters (frequency of brushing).
• Results
• Page 6, line 192: The result might change if the reason of the visit is included, “those who had not visited a dentist in the previous year were more likely to have an absence of caries activity”? If we are looking for ECC protecting factors, this should not be considered as one of them, dental visits for check-ups or treatment serve as a protective factor, as dentists provide parents with oral health guidance, including dietary and hygiene advice, during their children’s appointments.
• Page 6-7: As well in the regression analysis (Visit to dentist will decrease the odd for absence of ECC activity or ECC experience. This scientific finding has to be taken with precautions, routine visit to dentist for checkup probably will decrease the chance for ECC.
• Discussion
• Page 8, line 264: (Visiting the dentist per se does not reduce the incidence of caries) this statement should be linked to what was published previously. According to a study carried out in Norway it was found that compared with other children, those with a history of broken appointments had more enamel disturbances, higher caries experience and higher caries activity (more new caries at the examination), and more time was needed to complete their dental treatment. N J Wang, G O Aspelund. Children who break dental appointments. Eur Arch Paediatr Dent. 2009 Jan;10(1):11-4.
• Page 7 line 230: The authors have to bring reports that presented different findings. Regarding sociodemographic characteristics, a higher family income, greater number of material goods and less household crowding were predictors of good oral health. A previous report showed that school children with higher socioeconomic status formed the high caries risk group. Nazik Mostafa Nurelhuda, Tordis Agnete Trovik, Raouf Wahab Ali, Mutaz Faisal Ahmed. Oral health status of 12-year-old school children in Khartoum state, the Sudan; a school-based survey. BMC Oral Health. 2009 Jun 15:9:15.
• It could be of relevance to reflect about the dental health care system for children in Brazil.
• Page 3, line 135-136: One of the limitations of this study, that since participants responded to a questionnaire the dietary and hygiene measures could be included as they are important parameters that impact absence of caries.

 

Note:

In the Abbreviations the authors presented (DMFT Decayed-missing-filled teeth), has to be changed with (dmft), as the latter is an index used for deciduous teeth, not DMFT which is an index used for permanent teeth.

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,

Your manuscript diverges from typical medical studies and represents a refresher for the literature as it investigates caries protection factors through a salutogenic approach. I want to commend the use of Antonovsky's theory because most of the papers focus on risk factors.

However, I believe that a few changes are necessary to make the manuscript ready for publication:

Title:

Lines 2-3: “Individual Factors Are More Important than Contextual Factors
for Protection from Dental Caries”

• I think the title is too categorical. Your results show an association between individual and contextual factors, not direct causation. I suggest changing the title to "Association of Individual and Contextual Factors for Protection from Dental Caries..." or something similar.

Introduction:

• Please specify why 5-year-old children were chosen in your study. Does this relate to the transition from primary to permanent dentition?

Materials and methods:

Lines 114, 117, 120: The Minas Gerais Oral Health Survey was conducted in 2012 and included a sample of 1193 five-year-old children, with representativeness on the state level in three different domains: the state capital and two groups of municipalities denominated Interior I and
Interior II [8]. For the capital, the data were extracted from the 2010 National Oral Health Survey conducted two years earlier. For the 60 municipalities from Interior I and II, the representative sample was based on the mean number of decayed, missing and filled primary teeth (dmft) according to data from the 2010 National Oral Health Survey for the 120 southeast region of the country [8].”

• The data were collected in 2010 and 2012. That is a limitation of the study. The discussion should justify the relevance of 14/16-year-old data. Has there been a progress in the Brazilian healthcare system during that period?
• Furthermore, I believe that what is meant by material good should be explained in more detail.

Discussion:

Lines 208-212: “The present results are in agreement with data in the literature demonstrating that context is not as much of a determinant of caries as individual socioeconomic factors.
While some studies have reported the influence of contextual factors on oral health [30–34], these factors seem not to be addressed in such a way as to strengthen possible protective factors against the occurrence of dental caries in children [35,36].”

• In this section it is necessary to add a deeper critical review of the selected variables. Were the wrong contextual variables examined? The dietary habits, the level of fluoride in water and brushing teeth with fluoride toothpaste are not mentioned, and they are the most important to the etiology of caries.

I recommend a major revision.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

This manuscript presents a population-based cross-sectional analysis investigating individual and contextual factors associated with protection against dental caries among five-year-old children in Minas Gerais, Brazil. Using a salutogenic framework, the authors shift the focus from risk factors toward protective determinants, which represents a relevant and innovative conceptual contribution to pediatric oral epidemiology. The topic is highly relevant to public health, particularly in the context of persistent socioeconomic inequalities in early childhood caries (ECC). The manuscript is generally well structured, methodologically sound, and grounded in an appropriate theoretical framework. However, several methodological and interpretative issues require clarification before publication. 

The use of Salutogenic Theory as a conceptual framework represents an important departure from traditional risk-based models in oral epidemiology; the emphasis on protective factors contributes to health promotion literature and aligns with equity-based policy approaches. The study uses data from the Minas Gerais Oral Health Survey (n = 1,193), ensuring: state-level representativeness, standardized WHO diagnostic criteria, adequate statistical power; this enhances both internal and external validity. The use of two complementary outcomes -absence of caries activity (ACA; d = 0), absence of caries experience (ACE; dmft = 0) strengthens interpretative robustness and allows differentiation between current disease activity and cumulative experience. The hierarchical regression approach (Victora et al.) is appropriate and theoretically justified: it reflects causal ordering and minimizes overadjustment. Findings reinforce the central role of socioeconomic equity in oral health promotion. The discussion appropriately links results to broader social determinants of health and policy implications. 

Major limitations: the cross-sectional nature of the study limits causal inference; the association between “not visiting the dentist” and absence of caries is likely affected by reverse causality (healthy children may not seek care). While acknowledged, this issue deserves deeper discussion, particularly regarding implications for preventive policy. The manuscript states that contextual variables were not associated with outcomes and therefore multilevel modeling was not performed. However the null model rationale should be better explained; intraclass correlation coefficient (ICC) values are not reported; the absence of contextual association may reflect insufficient variability or aggregation bias rather than true absence of contextual influence. The association between white skin color and protection from caries is interpreted as socioeconomic rather than biological. While the discussion acknowledges structural inequities, the manuscript should avoid language that could be misinterpreted as biologically deterministic and more explicitly frame race/skin color as a social construct and proxy for structural disadvantage. The conclusion that contextual factors are less important may be overstated. Four oral health service variables were excluded due to low response rates (~50%). This is a significant limitation, as it weakens interpretation regarding service utilization. The manuscript should report whether missingness was random and any sensitivity analysis performed.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors, Thank you for your detailed response. I have reviewed at your revision and I think that the work is now significantly improved. You have accepted my suggestions regarding the title and provided an explanation for material goods and the choice of five-year-old age group. You correctly addressed the age of the research and the lack of variables on oral hygiene as a limitation of the study. Since you made the necessary corrections, I have no further comments. I believe that the paper is now ready for publication.

Best of luck with your future work.