Review Reports - Prevalence and Socio-Behavioural Determinants of Periodontal Disease Among Adults in the Northern West Bank: A Cross-Sectional Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,
Thank you for the opportunity to review this scientific paper. This study aimed to assess the prevalence of PD among teachers of 9th grade in the northern governorates of the West Ban. The topic is interesting, but there are some important inaccuracies. Please find below my suggestions:

In the background, there is no connection to 9th grade teachers, who represent the target sample of this study. It is important to address this point and explain why only 9th grade teachers were included, rather than all school teachers.
3 lines 115-116 “By targeting these teachers, the research aimed to complement parallel surveys conducted with adolescents, utilising their familiar school environment to investigate intergenerational dynamics in oral health” Please rewrite this sentence or delete it; in its current form it sounds forced and unclear.
Section 2.3. Please specify which tools were used to perform all these measurements. I also suggest including the results of the pilot sample in the supplementary material.
The manuscript uses the CPITN for adults, but the classification reported includes the categories “pocket <3 mm” and “pocket ≥3 mm,” which do not correspond to the standard CPITN codes (0, 1, 2, 3 = 4–5 mm, 4 = ≥6 mm). This must be clarified and corrected throughout the manuscript (text, tables, methods, and results).
It is stated that the OHI-S ranges from 0–3, “focusing on debris and calculus.” In reality, the combined OHI-S index ranges from 0–6 (Debris 0–3 + Calculus 0–3). Please clarify whether you reported the sub-scores or a recoding, and specify how “good/medium/bad” categories were defined.
For CPITN (categorical/ordinal variable), the ICC is not the most appropriate metric; a weighted kappa would be more suitable for ordinal data.
Some sentences confuse gingivitis with the “earliest and most common form of periodontitis.” Gingivitis is not periodontitis. I recommend correcting these statements according to the EFP/AAP classification.
Given the complexity of the questionnaire (47 items; α = 0.967), I suggest providing appendices with the full instrument (EN/AR), the scoring scheme, a codebook of recodings, and a STROBE checklist table.

Author Response

Manuscript title: Prevalence and Socio-Behavioural Determinants of Periodontal Disease Among Adults in the Northern West Bank: A Cross-Sectional Study

We want to express our gratitude to the reviewers for their valuable and insightful feedback. Their comments have contributed to enhancing the scientific rigour and clarity of our manuscript.

Kindly note that all changes made in response to your constructive feedback have been marked clearly in red within the manuscript for easy identification.

Reviewer 1

In the background, there is no connection to 9th-grade teachers, who represent the target sample of this study. It is important to address this point and explain why only 9th-grade teachers were included, rather than all school teachers.

A new paragraph has been added to the background section to explain the rationale for selecting 9th-grade teachers as the study population. The added paragraph establishes the connection between this study and our previous research conducted on 9th-grade students, emphasizing the importance of teachers’ influence on adolescents’ oral health behaviors and ensuring consistency between both study phases.

The following paragraph has been added to the background:

Recognizing the importance of understanding how these behavioral determinants manifest in adults, the present study focused on 9th-grade teachers, a population of particular interest. The selection of this group was purposeful, as their students (15 years of age) were the subjects of a previous school-based survey by the same research team, which revealed a high prevalence of early PD and several unfavourable behaviours related to oral hygiene, diet, and smoking. Investigating the teachers of these students offers an opportunity to examine PD within an adult cohort which are directly connected to adolescents who are already shown to be at risk. In addition, 9th-grade teachers represent a socially influential segment of the community who can model and transmit health-related behaviours to younger generations. Their lifetime experiences with oral hygiene, dietary choices, and smoking, coupled with varying socioeconomic circumstances, make them an informative group for understanding community-level determinants of PD [23]. Furthermore, their occupational setting provides a feasible platform for implementing and evaluating workplace-based oral-health promotion programs [24].

3 lines 115-116 “By targeting these teachers, the research aimed to complement parallel surveys conducted with adolescents, utilising their familiar school environment to investigate intergenerational dynamics in oral health” Please rewrite this sentence or delete it; in its current form it sounds forced and unclear.

The sentence has been revised for clarity (see the paragraph above).

3.Section 2.3. Please specify which tools were used to perform all these measurements. I also suggest including the results of the pilot sample in the supplementary material.

The tools used for the statistical measurements have now been specified in the revised version of the manuscript. The following sentence was added at the end of the Pilot Study section:

All statistical analyses, including the Exploratory Factor Analysis (EFA), the Kaiser–Meyer–Olkin (KMO) Test, and Bartlett’s Test of Sphericity, were conducted using IBM SPSS Statistics version 25.0 (IBM Corp., Armonk, NY, USA).

4.The manuscript uses the CPITN for adults, but the classification reported includes the categories “pocket <3 mm” and “pocket ≥3 mm,” which do not correspond to the standard CPITN codes (0, 1, 2, 3 = 4–5 mm, 4 = ≥6 mm). This must be clarified and corrected throughout the manuscript (text, tables, methods, and results).

The CPITN categories have been corrected and standardized throughout the manuscript (text, methods, tables, and results) according to the WHO classification. The definitions have been clarified to reflect the standard codes: shallow pockets (4–5 mm) and deep pockets (≥6 mm).

5.It is stated that the OHI-S ranges from 0–3, “focusing on debris and calculus.” In reality, the combined OHI-S index ranges from 0–6 (Debris 0–3 + Calculus 0–3). Please clarify whether you reported the sub-scores or a recoding and specify how “good/medium/bad” categories were defined.

The description of the OHI-S has been revised in the Clinical Examination section to reflect the full range (0–6) accurately and the detailed scoring for both the Debris Index–Simplified (DI-S) and Calculus Index–Simplified (CI-S), as shown in the newly added paragraph as follows:

This study utilised the Oral Hygiene Index-Simplified (OHI-S), developed by Greene and Vermillion [36], to determine the oral hygiene status of the subjects. The index comprises two components: the Debris Index–Simplified (DI-S), representing the soft plaque index, and the Calculus Index–Simplified (CI-S), representing the calcified plaque index. Debris Index–Simplified (DI-S)—Soft Plaque: Score 0: No soft debris or extrinsic stain, 1: Soft debris covering not more than one-third of the tooth surface, Score 2: Soft debris covering more than one-third but not more than two-thirds of the tooth surface, Score 3: Soft debris covering more than two-thirds of the tooth surface. While the Calculus Index–Simplified (CI-S)—Calcified Plaque have the following scores: Score 0: No calculus present, Score 1: Supragingival calculus covering not more than one-third of the tooth surface, Score 2: Supragingival calculus covering more than one-third but not more than two-thirds of the tooth surface, or isolated flecks of subgingival calculus around the cervical portion of the tooth, Score 3: Supragingival calculus covering more than two-thirds of the tooth surface, or a continuous heavy band of subgingival calculus around the cervical portion of the tooth. Six index teeth (16, 11, 26, 36, 31, and 46) were examined on specific surfaces (buccal for upper molars and lower incisors, lingual for lower molars, and labial for upper incisors). For each participant, DI-S and CI-S scores were calculated by summing the scores for the examined surfaces and dividing by the number of surfaces examined. The OHI-S score was obtained by adding the DI-S and CI-S scores, yielding a range from 0 to 6, with higher scores indicating poorer oral hygiene.

In addition, a sentence specifying the categorization of oral hygiene status (good = 0.0–1.2, fair = 1.3–3.0, poor = 3.1–6.0) has been included in the Data Management and Analysis section.

6.For CPITN (categorical/ordinal variable), the ICC is not the most appropriate metric; a weighted kappa would be more suitable for ordinal data.

The Intraclass Correlation Coefficient is commonly used in test-retest reliability analyses. Reliability refers to the extent to which measurements can be consistently replicated (Daly & Bourake, 2000; Russell et al., 2012). Although the Community Periodontal Index of Treatment Needs (CPITN) is a hierarchical ordinal index, it is represented by numeric scores. In several periodontal studies, the CPITN has been treated as a numeric variable to evaluate examiners' agreement through the Intraclass Correlation Coefficient (Botelho et al., 2019; Bassani & Silva-Boghossian, 2006). This methodology was employed in the present study, as the ICC provides a dependable measure of consistency between quantitative assessments.

Daly LE, Bourke GJ. Interpretation and use of medical statistics. Oxford: Blackwell Science Ltd; 2000. 2. Portney LG, Watkins MP. Foundations of clinical research: applications to practice. New Jersey: Prentice Hall; 2000. 3. Bruton A, Conway JH, Holgate ST. Reliability: what is it, and how is it measured? Physiotherapy 2000;86:94–9.

Russell BS, Muhlenkamp KA, Hoiriis KT, Desimone CM. Measurement of lumbar lordosis in static standing posture with and without high-heeled shoes. J Chiropr Med 2012;11:145–53.

Botelho, J., Machado, V., Proença, L., Alves, R., Cavacas, M. A., Amaro, L., & Mendes, J. J. (2019). Study of Periodontal Health in Almada-Seixal (SoPHiAS): A cross-sectional study in the Lisbon Metropolitan Area. Scientific Reports, 9(1), 1-10. https://doi.org/10.1038/s41598-019-52116-6

Bassani DG, Silva-Boghossian CM, Oppermann RV. Validity of the Community Periodontal Index of Treatment Needs (CPITN) for population periodontitis screening. Cad Saude Publica. 2006;22(2):277-83. doi:10.1590/S0102-311X2006000200005

7.Some sentences confuse gingivitis with the “earliest and most common form of periodontitis.” Gingivitis is not periodontitis. I recommend correcting these statements according to the EFP/AAP classification.

We have thoroughly reviewed the manuscript and revised all related sentences to clearly differentiate between gingivitis and periodontitis, in line with the 2017 EFP/AAP classification. Gingivitis is now accurately described as a reversible inflammation of the gums, whereas periodontitis is presented as a separate, more advanced condition that involves attachment loss. All pertinent statements have been corrected accordingly throughout the text.

Given the complexity of the questionnaire (47 items; α = 0.967), I suggest providing appendices with the full instrument (EN/AR), the scoring scheme, a codebook of recodings, and a STROBE checklist table.

Most of these files, including the full questionnaire in English versions and the scoring scheme, have already been included in the supplementary material

We hope that the revised manuscript, along with the clarifications provided in this response document, adequately addresses all concerns. We remain open to any further suggestions and sincerely thank the reviewers again for their constructive input.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors The manuscript is well-written, and the research has a reproducible methodology, but some observed correlations need to be reviewed to avoid raising doubts about what was actually observed and associated.
- How was brushing time assessed?
- The relationship between brushing in the morning and disease-free status is not supported by the data obtained or the current literature, but it is still asserted.
- The same applies to the relationship between red meat consumption and disease, and with nut consumption; the data obtained and the literature do not support this relationship.
We need to discuss data that can contribute to the advancement of science, not assumptions. Why wasn't the use of dental floss or interproximal brushes evaluated?
These are important for maintaining gingival health, not meat or nut consumption.
I suggest rewriting the results and the discussion without focusing on the influence of assumptions on periodontal status, but rather on the evidence we have for maintaining periodontal health.

Best regards

Comments on the Quality of English Language some sentences need to be reviewed and rewritten, but without major modifications

Author Response

POINT BY POINT RESPONSE PAPER

Manuscript title: Prevalence and Socio-Behavioural Determinants of Periodontal Disease Among Adults in the Northern West Bank: A Cross-Sectional Study

We want to express our gratitude to the reviewers for their valuable and insightful feedback. Their comments have contributed to enhancing the scientific rigour and clarity of our manuscript.

Kindly note that all changes made in response to your constructive feedback have been marked clearly in red within the manuscript for easy identification.

Reviewer 2

The manuscript is well-written, and the research has a reproducible methodology. However, some observed correlations need to be reviewed to avoid raising doubts about what was actually observed and associated.

How was brushing time assessed?

Brushing time was assessed through an interviewer-administered questionnaire, as enumerated in the methodology (questionnaire section). The data collectors asked each participant to report their usual toothbrushing duration, and the responses were recorded using predefined categories (less than 1 minute, 1–2 minutes, or more than 2 minutes). This method is commonly used in previous epidemiological studies assessing oral hygiene behaviors (e.g., Kebede et al., 2022; Eigbobo & Arigbede, 2020). The complete questionnaire has been provided as a supplementary document for reviewers’ reference.

Kebede, N., Wondiye, H., Melkamu, L., Anagaw, T. F., Assefa, E., Bogale, E. K., Hailu, G., Mohammed, Y., & Adane, B. (2022). Application of the integrated behavioral model to identify the predictors of toothbrushing practices among primary school children at Bahir Dar city, Ethiopia. BMC Oral Health, 22, Article 638. https://doi.org/10.1186/s12903-022-02676-3 bmcoralhealth.biomedcentral.com+1

Eigbobo, J. O., & Arigbede, A. O. (2020). Tooth brushing skills and oral hygiene practices in a selected group of Nigerian children. African Journal of Medicine and Medical Sciences, 49(1), 95–102.

2.The relationship between brushing in the morning and disease-free status is not supported by the data obtained or the current literature, but it is still asserted.

We want to clarify that there is a statistically significant association between morning tooth brushing and periodontal health, as indicated by our multivariate logistic regression model (Adjusted Odds Ratio = 0.015, p = 0.002; 95% Confidence Interval = 0.001–0.206). This suggests that participants who brushed their teeth in the morning were considerably less likely to exhibit signs of periodontal disease.

This finding is supported by existing literature that underscores the notion of preventive benefits of morning brushing. For example, Kaneyasu et al. (2020) found that brushing teeth early in the day effectively removes bacterial accumulation that occurs overnight and reduces gingival inflammation. Likewise, Abdulkareem et al. (2023) described how brushing disrupts the formation of bacterial biofilm, which typically occurs during nighttime when salivary flow is reduced. This disruption helps prevent calculus formation and periodontal inflammation.

Therefore, we assert that the statement in the manuscript is data-driven and aligns with current scientific evidence. To enhance clarity, we have revised the discussion to outline the direction and magnitude of the association clearly and have cited the relevant supporting studies.

3.The same applies to the relationship between red meat consumption and disease, and with nut consumption; the data obtained and the literature do not support this relationship.
We need to discuss data that can contribute to the advancement of science, not assumptions.
We respectfully disagree with this comment. The associations between red meat intake, nut consumption, and periodontal disease were not based on assumptions but on statistically significant findings obtained from the final multivariate logistic regression model. Specifically, higher red meat intake was negatively associated with periodontal health (AOR = 0.032, p = 0.007; 95% CI = 0.003–0.396), whereas frequent nut consumption was protective (AOR = 0.227, p = 0.017; 95% CI = 0.067–0.765).

These relationships are biologically plausible and supported by literature. Diets high in red meat and saturated fats promote systemic inflammation through increased pro-inflammatory cytokines (IL-6, TNF-α, CRP) and oxidative stress, which have been linked to periodontal breakdown (Chapple et al., 2017; Rodan et al., 2023). In contrast, nuts are rich in omega-3 fatty acids, antioxidants, and vitamin E, which reduce oxidative stress and modulate the host immune response, thereby protecting against periodontal inflammation (Nishida et al., 2000; Chapple et al., 2017).

Accordingly, the inclusion of these dietary variables contributes novel, evidence-based insights into the multifactorial nature of periodontal disease within the Palestinian adult population. The discussion has been slightly refined to emphasise the biological mechanisms and to clarify that these findings are statistically significant and grounded in current evidence.

4.Why wasn't the use of dental floss or interproximal brushes evaluated?

The questionnaire included a section (B.8: Oral and Dental Hygiene Habits) that assessed the use of dental floss and interdental brushes. Participants were asked about their usage of various oral hygiene aids, including floss, interdental brushes, and mouthwash. However, the results for these variables were not statistically significant in either the bivariate or multivariate analyses. As a result, they were not included in the final logistic regression model presented in Table 7.

5.Why wasn't the use of dental floss or interproximal brushes evaluated?
These are important for maintaining gingival health, not meat or nut consumption.

Our study was designed to thoroughly examine three key domains related to periodontal health —oral hygiene practices, dietary habits, and smoking —along with socioeconomic factors. Each domain was appropriately emphasized in both the questionnaire and the analysis. By incorporating these diverse domains, we aimed to capture both modifiable and non-modifiable determinants that influence periodontal disease within a single study. This comprehensive approach allows us to identify determinants that can be targeted in prevention and intervention programs, which represents the next phase of our ongoing research.

While we agree that oral hygiene behaviors such as tooth brushing and interdental cleaning are primary and well-established predictors of gingival health, dietary habits remain an essential component of periodontal disease research. Accumulating evidence indicates that diet influences systemic inflammation, immune response, and the oral microbiome, all of which are relevant to periodontal status (Chapple et al., 2017; Najeeb et al., 2016).

Therefore, the inclusion of dietary variables such as red meat and nut consumption was intentional and evidence-based. These factors represent modifiable lifestyle components that may contribute to periodontal inflammation or protection. Their evaluation complements the oral hygiene and smoking variables, providing a more holistic understanding of the determinants of periodontal health. Accordingly, the discussion was retained but refined to highlight the data-driven nature of these associations rather than assumptions.

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

Review for the Manuscript ID: dentistry-3895951 entitled “Prevalence and Socio-Behavioural Determinants of Periodontal Disease Among Adults in the Northern West Bank: A Cross-Sectional Study”

Abstract: periodontal disease, is not condition it is a disease, correct it, define abbreviations when used for the first time,
Introduction: well written, just the last paragraph has to be moved to be before the paragraph “This study aimed……. Teachers?
Methods: line 115 to 121 should be moved to introduction section. Conducting pilot study is a very good point.
Methods: A copy of the questionnaire should be presented as a figure to allow reader replicate it in the future study.
Statistical analysis section very detailed and need to be shortened.
Table 1, better to be presented as Figure.
Why the authors did not use CDC/AAP criteria for periodontal disease definition? This need to be justified in the discussion section.
The reasons for selecting only 9^th grade teacher need to be justified, why not all teachers across all schools not involved?
Discussion well written and detailed.
Conclusion need to be trimmed and only answer the study aim.

BW,

Comments on the Quality of English Language

NIL

Author Response

POINT BY POINT RESPONSE PAPER

Manuscript title: Prevalence and Socio-Behavioural Determinants of Periodontal Disease Among Adults in the Northern West Bank: A Cross-Sectional Study

We want to express our gratitude to the reviewers for their valuable and insightful feedback. Their comments have contributed to enhancing the scientific rigour and clarity of our manuscript.

Kindly note that all changes made in response to your constructive feedback have been marked clearly in red within the manuscript for easy identification.

Reviewer 3

Abstract: periodontal disease is not condition it is a disease, correct it, define abbreviations when used for the first time,

The wording in the Abstract has been corrected — the term “condition” has been replaced with “disease” to describe periodontal disease accurately.

Introduction: well written, just the last paragraph has to be moved to be before the paragraph “This study aimed……. Teachers?

The structure of the Introduction section has been revised accordingly. The last paragraph was moved to appear before the paragraph beginning with “This study aimed…”, as suggested.

2.Methods: line 115 to 121 should be moved to introduction section. Conducting pilot study is a very good point.

We appreciate your suggestion. However, we believe that this part is more appropriate to remain in the Methods section, as it describes specific procedural aspects related to the study design rather than background information.

Methods: A copy of the questionnaire should be presented as a figure to allow reader replicate it in the future study.

The full version of the questionnaire has been made available as a supplementary document.

The statistical analysis section is very detailed and needs to be shortened.

We have summarized the Statistical Analysis section and removed some unnecessary details to make it more concise and focused.P.6

5.Table 1, better to be presented as Figure.

We have converted Table 1 and Table 2 into figures and included them in the supplementary materials. Both figures are also properly referred to in the main text.

Why the authors did not use CDC/AAP criteria for periodontal disease definition? This need to be justified in the discussion section.

The justification for selecting CPITN over BPE is presented in the Discussion section (page 14). Specifically, the following paragraph has been added to clarify the rationale behind choosing this index .

CPITN is a valuable and reliable tool for conducting epidemiological surveys [45]. It offers a more straightforward approach compared to other methods that require detailed measurements of clinical attachment loss, such as the Basic Periodontal Examination (BPE), which is primarily suited for routine clinical screening [62]. In turn, the CDC/AAP case definitions were not applied in this study because they are mainly designed for surveillance and clinical case classification systems used in epidemiological surveillance in the United States [63]. However, the present study focused on community-based assessment using the CPITN, which emphasizes essential indicators such as gingival bleeding, the presence or absence of supra- or subgingival calculus, and periodontal pockets. CPITN aligns well with international standards, and its findings have been included in over 500 publications. Furthermore, in larger studies, the extensive time and resources required for detailed Clinical Attachment Level (CAL) measurements can be quite considerable. Consequently, CPITN is a more cost-effective and practical alternative for periodontal assessments [64].

7.The reasons for selecting only 9^th grade teacher need to be justified, why not all teachers across all schools not involved?

The rationale for including only 9th-grade teachers has now been clarified in the Introduction section. Specifically, only 9th-grade teachers were selected because a parallel study was conducted among their students (9th-grade students) to assess periodontal diseases. Therefore, including their teachers ensured consistency between the teacher and student populations and allowed for meaningful comparison between the two related studies. Furthermore, we would like to note that this study is part of a larger research project. In the next phase, we plan to conduct an educational intervention to assess the effect of interactive education on periodontal disease among both 9th-grade students and their teachers.

8.Discussion well written and detailed.

Conclusion need to be trimmed and only answer the study aim.

The conclusion has been shortened to focus solely on the study aim. Additionally, the recommendations have been moved to a separate section for better clarity and structure as follow:

Conclusion

In this study, which involved 9th-grade teachers from three northern governorates of the West Bank, a significant prevalence of PD was observed. Notably, only about one in nine participants exhibited completely healthy gingival conditions. Overall, the periodontal status of the participants was classified as ranging from the presence of calculus to shallow pocketing. Several determinants were found to be significantly associated with periodontal health in this population. These include geographic variations between the Nablus and Tulkarm governorates, as well as oral hygiene practices such as frequent tooth brushing, brushing in the morning, and regular replacement of toothbrushes. Additionally, cigarette consumption and the intake of red meat and nuts appear to be significant determinants. These findings suggest that both behavioral and lifestyle factors play a substantial role in influencing periodontal health outcomes in this age group.

Recommendations

The findings of this study highlight the necessity for adult-focused preventive programs in schools where teachers act as role models for adolescents. These preventive programs should also promote a morning brushing routine and the importance of brushing twice daily, encourage regular replacement of toothbrushes, integrate tobacco cessation support into staff wellness programs, and provide dietary counseling to reduce red meat consumption while promoting healthier snack options. Additionally, the findings suggest coordinating periodontal screenings and maintenance visits for teachers with the Ministry of Education and conducting studies to assess program effectiveness using clinical measures beyond CPITN.

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript is well-written, but the results found are not supported by the conclusions presented. I believe that interproximal cleaning is essential for maintaining oral health, and this is never addressed in the study. It is necessary to include and discuss these data. It is important to assess diet, but before that, we need to determine whether oral hygiene care is being performed, and interproximal cleaning is not reported on the form, type, or time of day.

It is necessary to evaluate the correlation between brushing, interproximal cleaning, dietary habits, and periodontal status.

Regarding examiner calibration: how was it performed? Which tests were applied, and their results?

I believe that after these adjustments (in methodology, results, and discussion), the conclusions may be different and support the study findings.

Author Response

POINT BY POINT RESPONSE PAPER

Manuscript title: Prevalence and Socio-Behavioural Determinants of Periodontal Disease Among Adults in the Northern West Bank: A Cross-Sectional Study

We want to express our gratitude to the reviewers for their valuable and insightful feedback. Their comments have contributed to enhancing the scientific rigor and clarity of our manuscript.

Kindly note that all changes made in response to your constructive feedback have been marked clearly in red within the manuscript for easy identification.

Reviewer 1

The manuscript is well-written, but the results found are not supported by the conclusions presented.

The conclusion section has been revised to accurately reflect the study's main findings. The updated version now presents a clearer conclusion that aligns with these findings.

I believe that interproximal cleaning is essential for maintaining oral health, and this is never addressed in the study. It is necessary to include and discuss these data. It is important to assess diet, but before that, we need to determine whether oral hygiene care is being performed, and whether interproximal cleaning is not reported on the form, type, or time of day. It is necessary to evaluate the correlation between brushing, interproximal cleaning, dietary habits, and periodontal status.

The questionnaire already included a specific item assessing interproximal cleaning practices (Question B.8), such as the use of dental floss or interdental brushes. However, the proportion of teachers who reported engaging in these practices was very low. Consequently, this variable did not show any statistically significant association with periodontal status in either the bivariate or multivariate analyses. This finding is consistent with previous evidence showing that interproximal cleaning practices are infrequently performed in many populations, particularly in low- and middle-income settings. For instance, a large national study in Iran reported that only 7.6% of adults flossed at least once daily, and only 3.5% practiced both twice-daily toothbrushing and daily flossing (Ghorbani et al., 2020). Similarly, a population-based survey among Korean adults aged 30 years and older found that the use of interdental care products, such as dental floss and interdental brushes, remained below 40% and was strongly associated with socioeconomic status (Kwon et al., 2022).

We appreciate the reviewer’s comment and agree that oral hygiene care is essential in this study. Thus, we comprehensively assessed and analyzed various oral hygiene practices, including brushing frequency (Question B.1 in our study questionnaire), timing (Question B.2), technique (Question B.4), and toothbrush replacement. As reported in both the Results and Discussion sections, brushing frequency and morning brushing were among the strongest predictors of periodontal health. Interproximal cleaning was also included in the questionnaire (Question B.8), but very few participants reported using interdental aids; therefore, this variable did not reach statistical significance and was excluded from the final model.

Regarding examiner calibration: how was it performed? Which tests were applied, and their results?

Examiners' calibration was performed during the pilot phase of the study, as described in Section 2.4 (Clinical Screening). Inter-examiner reliability was assessed using a two-way random-effects model of the Intraclass Correlation Coefficient (ICC), following the recommendations of Koo and Li (2016). Five trained dentists independently examined 20 teachers on five separate occasions. The resulting ICC values were 0.79 for the Community Periodontal Index for Treatment Needs (CPITN) and 0.89 for the Simplified Oral Hygiene Index (S-OHI), both indicating strong inter-examiner reliability. These details were already included in the methodology; however, we have now emphasized them further in the revised manuscript to ensure greater clarity as follows:

During the pilot phase of our study, inter-examiner reliability was evaluated using a two-way random-effects model of the Intraclass Correlation Coefficient (ICC), as described by Koo and Li [41]. A total of five trained data collectors conducted independent assessments of 20 teachers on five separate occasions. The results yielded ICC values of 0.79 for CPITN and 0.89 for S-OHI, both indicating strong inter-examiner reliability. The selection of the ICC model was based on the premise that the raters were randomly selected from a broader population of dentists practising in the West Bank and maintained consistent participation throughout the study, as supported by the works of Portney et al. [42] and Bruton et al. [43].

I believe that after these adjustments (in methodology, results, and discussion), the conclusions may be different and support the study findings.

All the mentioned sections (methodology, results, discussion, and conclusion) have been carefully revised and adjusted accordingly. The updated version ensures better consistency and alignment among all parts of the manuscript.

Author Response File: Author Response.pdf