F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.150837.3 Research Article Articles The Relationship Between Mental Health and Periodontal Disease: Insights from NHANES Data

[version 3; peer review: 3 approved]

 AlJoghaiman Eman Conceptualization Data Curation Formal Analysis Methodology Resources Software Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-9504-0931 a 1 Department of Preventive Dental Science, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, 12372, Saudi Arabia Ealjoghaiman@iau.edu.sa

No competing interests were disclosed.

 31 10 2025 2024 13 709 29 10 2025 Copyright: © 2025 AlJoghaiman E 2025 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction and aim

Periodontal disease, initiated by dental biofilm and influenced by various local and systemic factors, includes stress as a potential contributor to its progression. Despite associations with severe forms like acute necrotizing ulcerative gingivitis, a comprehensive large-sample study linking stress to periodontal disease is lacking. This study aims to investigate the relationship between mental health and periodontal disease.

 Materials and Methods

Leveraging data (secondary dataset) from the National Health and Nutrition Examination Survey (NHANES) from 2011–2012 and NHANES 2013–2014 cycles, relevant information was extracted. Mental health was the exposure variable, and periodontal disease, assessed through indices following Eke et al.’s definition, served as the outcome. Covariates (demographical characteristics) impacting periodontal disease were considered, and disease status analyses employed the Rao-Scott chi-squared test. A logistic regression model assessed mental health’s impact on periodontal disease.

 Results

Among the 2764 Participants, more than a quarter (29.1%) were aged over 60 years, 52% were females. Logistic regression indicated higher odds of periodontal disease among individuals feeling bad about themselves for more than half of the day (OR 1.170, 95% CI 0.533-2.474), though statistical significance was not reached. Periodontitis prevalence significantly varied based on marital status, with 6.6% of married and 10.8% of unmarried Participants affected. Notably, a statistically significant difference in periodontitis prevalence existed between Participants with health insurance (8.3%) and those without (16.5%).

 Conclusion

Our findings suggest trends in periodontal disease prevalence linked to mental health, marital status, and access to health insurance. However, the absence of statistically significant findings calls for caution in interpreting these relationships. We recommend that future studies further investigate these potential associations to provide a clearer understanding.

 Stress; mental health; periodontal disease; NHANES The author(s) declared that no grants were involved in supporting this work. Amendments from Version 2

This version includes minor formatting and editorial refinements, with no changes to the study data or conclusions.

 Introduction

Periodontal disease is a multifaceted condition influenced by various factors. Its distinctive characteristics, site-specific progression involving complex etiological factors, and the impact of risk factors have continually spurred researchers to delve deeper into unraveling the intricacies of the disease process. 1 While the disease typically begins with dental biofilm, transitioning from gingivitis to periodontitis, it’s important to emphasize that not all instances of gingivitis evolve into periodontitis. Furthermore, there’s notable variation in the prevalence of periodontitis within a given population, with some individuals showing no signs, others exhibiting slow progression, and some experiencing a more rapid advancement. 2 Additionally, on an individual level, not every site displays clinical attachment loss and signs of periodontal disease; certain sites may present severe clinical loss of attachment coupled with bone loss. 3

The diverse manifestations of periodontal disease may arise due to the intricate nature of factors influencing its progression. Both local and systemic factors can exert an influence on the development of the disease. 4 Numerous systemic factors that contribute to the progression of the disease have been thoroughly elucidated. These encompass diabetes, hormonal fluctuations during puberty, pregnancy, and menopause, as well as genetic factors and conditions. 5 Stress and psychological factors are also recognized contributors, impacting the overall periodontal health status and influencing disease progression. 6

Psychological stress refers to the emotional and physiological response individuals undergo when confronted with challenging life events. These events may include exams, adapting to new work conditions, marital conflicts, financial instability, or even profound situations like the loss of a loved one. The intensity of these situations surpasses an individual’s ability to cope effectively, triggering emotional and physiological reactions. It is a significant modifiable risk factor impacting both mental and physical well-being. 7 , 8

The term “stress” encompasses any physical or psychological event perceived as capable of causing harm or emotional distress. Stress is a ubiquitous factor in nearly all chronic diseases. Psychosocial stress is subject to modification by individual perceptions and coping strategies, involving the release of specific products through various pathways: the hypothalamic-pituitary-adrenal axis, leading to glucocorticosteroids; the autonomic nervous system, resulting in the release of catecholamines; and the hypothalamic-pituitary-gonadal axis, leading to the release of sex hormones. 9 Exposure to stress during critical periods is known to alter hormonal and immune systems. The emotional or psychological burden may directly influence immune activities through nerve messenger substances or indirectly through hormones. The oral cavity, as the gateway for systemic components, is not immune to the effects of stress. 10

In the pathophysiological models proposed by Genco et al. (1998), the role of stress as a risk factor for periodontal disease is thoroughly explained. Two models are presented, one detailing the direct effects and the other describing the indirect effects. The primary model posits that psychosocial stressors set off a sequence of events involving the release of corticotrophin-releasing hormone through the hypothalamic-pituitary-adrenal axis, the autonomic nervous system, and the central nervous system. These physiological responses negatively impact the immune-inflammatory cells, increasing the susceptibility to infection and, specifically, periodontal disease. The second model outlines the indirect impact of stress on health-risk behaviors such as inadequate oral hygiene, smoking, overeating, and particularly a high-fat diet, which can result in immunosuppression due to heightened cortisol production. Another potential behavioral consequence influenced by stress and inadequate coping is depression. The interplay of all these factors contributes to the progression of periodontal disease. 9 , 11

The connection between stress and periodontal disease has long been established. Stress is linked to acute necrotizing ulcerative gingivitis, with immune-compromised conditions and poor oral hygiene as contributing factors for this acute condition. 12 Stress and depression can compromise periodontal resistance, fostering opportunistic microbial growth, reducing saliva flow, and impairing gingival blood flow. 13 Elevated levels of epinephrine and non-epinephrine induced by stress alter blood flow and oxygen requirements. Changes in the host response, particularly in neutrophil function, create an environment conducive to bacterial growth, including species like Prevotella intermedia and other spirochetes, leading to necrotizing ulcerative gingivitis. 14 This pathogenic process is supported by increased clinical cases observed during stressful periods, such as exams in students and in individuals with demanding occupations. 15 The literature also reflects a similar correlation between stress and severe periodontitis. 16 Furthermore, in individuals experiencing stress, the virus is believed to reside in connective tissue, contributing to periodontal disease progression alongside other microbial complexities. 17

While studies spanning four decades exist, the number of investigations correlating stress and periodontal disease remains limited. The challenge lies in the varied definitions used to measure stress, encompassing different types of stress, psychological disorders, and various subcategories. These complexities make it challenging to clearly understand the link between stress and periodontal disease. Various types of psychological and psychosocial factors, such as high work stress, job dissatisfaction or unemployment, family status, and the impact of major life events, have been studied and found to be related to periodontal disease. 18 – 20 However, none of these studies distinctly define this association.

Self-perception can be viewed as a form of psychological and psychosocial stress that significantly influences overall mental health. Negative self-perception often leads to heightened stress levels, resulting in anxiety and depressive symptoms. 21 Individuals who struggle with low self-esteem frequently find it challenging to cope with life’s difficulties, which can further exacerbate their mental health issues. 22 This psychological distress not only affects their emotional well-being but can also manifest in maladaptive behaviors, further compromising their health.

The relationship between self-perception and periodontal disease is an area of growing concern. Individuals with poor self-image and elevated stress levels may neglect their oral hygiene, increasing their susceptibility to periodontal conditions. 23 Moreover, the stress associated with negative self-perception can lead to inflammatory responses that adversely affect periodontal health. 24 Despite these associations, there is a notable gap in the literature regarding the comprehensive understanding of how psychological factors like self-perception influence periodontal disease. Therefore, our study investigates the association between mental health problems, specifically self-perception, and periodontal disease to address this gap and contribute to the existing body of knowledge.

 Methods Study design and population <sup> <xref ref-type="bibr" rid="ref34">25</xref> </sup>

This cross-sectional analytical study utilized publicly available data from the National Health and Nutrition Examination Survey (NHANES) 2011–2012 and 2013–2014 cycles. NHANES employs a complex, multistage probability sampling strategy to obtain a nationally representative sample of non-institutionalized U.S. adults. Participants complete structured household interviews and undergo standardized clinical examinations in mobile units operated by trained personnel.

 Study population

Adults aged ≥18 years who completed the periodontal examination and mental health questionnaire were eligible. Participants were excluded if they were edentulous, lacked periodontal assessments, or had incomplete data for the primary exposure or outcome variables. NHANES sample weights were applied to account for differential probabilities of selection and to yield nationally representative estimates.

 Variable of interest

Periodontal examination and outcome definition

Periodontal status was assessed using clinical attachment loss (CAL) and probing depth (PD) measurements collected at six sites per tooth. Periodontitis case status was defined using the Centers for Disease Control and Prevention/American Academy of Periodontology (CDC/AAP) case definitions, which classify disease based on specified thresholds of interproximal CAL and PD. 26

Mental health exposure

Psychological distress was the primary exposure variable. Participants were asked how often during the previous two weeks they had been bothered by feeling bad about themselves or feeling like a failure. Responses were recorded on a four-point scale: Not at all, Several days, More than half the days, and Nearly every day. For analysis, this variable was retained in its original ordinal structure to reflect severity gradients of negative self-perception.

Covariate variable

Covariates were selected according to prior literature establishing links with periodontal outcomes. Sociodemographic variables included age (categorized into NHANES adult age groups), sex, education, and socioeconomic status, measured using the income-to-poverty ratio. Health-related variables included body mass index (BMI), categorized as underweight (<18.5 kg/m 2), normal weight (18.5–24.9 kg/m 2), overweight (25.0–29.9 kg/m 2), or obese (≥30.0 kg/m 2), and self-reported physician-diagnosed diabetes. Alcohol consumption was classified as current drinkers versus non-drinkers. Dental care utilization was determined by time since last dental visit (≤ 1 year, 1–2 years, and > 2 years), and dental insurance coverage was categorized as insured versus uninsured. All covariates were obtained from standardized NHANES interview modules.

 Statistical analysis

Analyses accounted for NHANES sampling weights, strata, and primary sampling units to ensure nationally representative variance estimation. Descriptive statistics summarized the distribution of study variables. Bivariate comparisons between psychological distress categories and periodontitis were evaluated using chi-square tests.

Survey-weighted multivariable logistic regression models were constructed to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the association between psychological distress and periodontitis, controlling for covariates. A significance level of α = 0.05 was set for all statistical tests. Data analysis was performed using SAS version 9.4 (SAS Institute Inc., Cary, NC).

 Results Study characteristic

The demographic characteristics of the study Participants are presented in Table 1. Among the 2764 Participants, more than a quarter (29.1%) were aged over 60 years, (52%) were females, (42.1%) identified as non-Hispanic white, (38.7%) reported a high household level, and over half (54.1%) held either an associate or college degree. A majority of Participants had some form of health insurance, and the majority had visited the dentist within the 12 months preceding the survey.

Demographic characteristics of the study Participants (n=2764).
Total (n) Percentage % a
Age
18-30 years 628 22.7
31-40 years 428 15.5
41-50 years 452 16.4
51-60 years 453 16.4
More than 60 years 803 29.1
Gender
Male 1328 48.0
Female 1436 52.0
Race/ethnicity
Mexican American 378 13.7
Other Hispanic 246 8.9
Non-Hispanic White 1165 42.1
Non-Hispanic Black 566 20.5
Other Races Including Multi-Racial 409 14.8
Household income
Below Poverty Line 843 30.5
Near Poverty 112 4.1
Low-Income 419 15.2
Middle-Income 320 11.6
High-Income 1070 38.7
Education level
Less than High School 568 20.5
High School Level 620 22.4
AA or College Degree 1495 54.1
Weight status (Based on BMI)
Underweight 770 27.9
Normal 738 26.7
Overweight 584 21.1
Obese 672 24.3
Alcohol consumption status
Non-drinker 1770 64.0
Drinker 994 36.0
Diabetes
Present 277 10.0
Not present 2487 90.0
Periodontal disease
Severe 3 0.1
Moderate 28 1.0
Mild 241 8.7
Not present 2492 90.2
Time of most recent dental visit
Less than 1 year 1741 63
1-2 years 498 18
More than 2 years 525 19
Insurance coverage
Yes 2255 82
No 509 18
Mental health
Not at all 2316 83.8
Several days 288 10.4
More than half the days 70 2.5
Nearly every day 90 3.3

Weighted row percentage.

 Association of sociodemographic factors on the prevalence of periodontitis

The Participants were categorized based on the severity of periodontitis, as outlined in Tables 2 and 3, distinguishing between no, mild, moderate, and severe cases. Significant differences in the prevalence of periodontitis were observed based on Participants’ education levels. However, no significant differences were noted in the prevalence of periodontitis based on the Participants’ mental health. Notably, the prevalence of periodontitis varied significantly according to Participants’ marital status, with approximately (6.6%) of married Participants and (10.8%) of unmarried Participants experiencing some form of periodontitis. A statistically significant association was found.

Subject demographics and demographic predictors of periodontics in study Participants (n=2764).
Total (n) Severe periodontitis % Moderate periodontitis % Mild periodontitis % No periodontitis % P-value
Age
18-30 628 0.0% 0.5% 7.6% 91.9% 0.353
31-40 428 0.0% 1.4% 8.9% 89.7%
41-50 452 0.0% 0.4% 10.2% 89.4%
51-60 453 0.0% 1.1% 7.7% 91.2%
More than 60 years 803 0.4% 1.5% 9.2% 88.9%
Gender
Male 1328 0.2% 0.7% 9.3% 89.8% 0.269
Female 1436 0.0% 1.3% 8.1% 90.5%
Race/ethnicity
Mexican American 378 0.0% 1.1% 7.7% 91.3% 0.587
Other Hispanic 246 0.0% 0.4% 8.5% 91.1%
Non-Hispanic White 1165 0.2% 1.4% 7.9% 90.6%
Non-Hispanic Black 566 0.2% 0.5% 9.7% 89.6%
Other Races Including Multi-Racial 409 0.0% 1.0% 10.8% 88.3%
Household income
Below Poverty Line 843 0.1% 1.2% 8.8% 89.9% 0.822
Near Poverty 112 0.0% 1.8% 8.0% 90.2%
Low-Income 419 0.0% 1.0% 7.6% 91.4%
Middle-Income 320 0.3% 0.9% 10.0% 88.8%
High-Income 1070 0.1% 0.8% 8.8% 90.3%
Education level
Less than High School 568 0.0% 0.7% 6.5% 92.8% 0.050 *
High School Level 620 0.2% 1.3% 10.0% 88.5%
AA or College Degree 1495 0.1% 1.0% 8.8% 90.0%
Mental health
Not at all 2316 0.1% 0.9% 8.9% 90.1% 0.686
Several days 288 0.0% 2.4% 6.9% 90.6%
More than half the days 70 0.0% 0.0% 11.4% 88.6%
Nearly every day 90 0.0% 0.0% 7.9% 92.1%
Occupation
Working 1470 0.0% 1.4% 8.2% 0.0% 0.343
Not Working 1294 0.2% 0.6% 9.3% 0.2%
Marital status
Married 2157 0.00% 0.00% 6.60% 93.40% 0.001 *
Not Married 607 0.10% 1.30% 9.30% 89.20%
Alcohol consumption status
Non-drinker 1770 0.2% 1.1% 8.3% 90.4% 0.311
Drinker 994 0.0% 0.8% 9.5% 89.7%
Weight status (Based on BMI)
Underweight 0.0% 1.0% 7.7% 91.3% 0.0% 0.524
Normal 0.0% 0.9% 8.7% 90.4% 0.0%
Overweight 0.3% 1.4% 9.2% 89.0% 0.3%
Obese 0.1% 0.7% 9.5% 89.6% 0.1%
Diabetes
Present 277 0.7% 0.7% 8.3% 90.3% 0.529
Not present 2487 0.0% 1.0% 8.8% 90.1%

Weighted row percentage.

Statistically significant at 0.05.

 Distribution of Periodontitis per Dental Visits, Insurance Coverage, Occupation, and, Marital Status Among Study Participants (n=2764).
Total (n) Severe periodontitis % Moderate periodontitis % Mild periodontitis% No periodontitis % P-value
Time of most recent dental visit
Less than 1 year 1754 0.1% 1.2% 8.6% 90.1% 0.998
1-2 years 274 0.4% 0.4% 9.1% 90.1%
More than 2 years 736 0.1% 0.8% 8.8% 90.2%
Health Insurance
Yes 2255 0.1% 0.9% 7.3% 91.7% 0.001 *
No 509 0.0% 1.4% 15.1% 83.5%

Weighted row percentage.

Statistically significant at 0.05.

Unadjusted odds ratios (OR) were computed through logistic regression, controlling for all confounders, and are presented with a 95% confidence interval (CI) in Table 4. The logistic regression analysis indicated that the odds of periodontal disease were higher among those who reported feeling bad about themselves for more than half of the day compared to those who reported not feeling that way at all (OR 1.170, 95% CI 0.533-2.474). However, this association was not statistically significant (p>0.05).

Logistic regression analysis of the effects of mental health on periodontitis.
Variable OR (95% CI)
Mental health
Not at all Ref
Several days 0.938 (0.617-1.426)
More than half the days 1.170 (0.533-2.473)
Nearly every day 0.765 (0.349-1.674)

No Periodontitis=0 vs. Periodontitis (all three)=1.

 Discussion

The primary objective of this study was to examine the relationship between mental health (self-perception) and periodontal disease. The study findings revealed no discernible difference in the prevalence of periodontitis between individuals with mental health issues and those without. However, it is noteworthy that the odds of periodontal disease were somewhat higher among those who reported feeling bad about themselves for more than half of the day, though this difference did not reach statistical significance. Additionally, male participants exhibited a higher likelihood of periodontal disease compared to female participants. Furthermore, lacking insurance coverage was significantly associated with the prevalence of periodontitis.

The study findings presented here cannot be directly compared with other studies to date due to variations in the measures used to assess stress and psychosocial conditions. Nevertheless, common factors across these studies include stress as a factor and the outcome variable, which is periodontal disease.

Monteiro da Silva et al. (1998) found no significant difference between psychosocial stress and periodontal disease. 27 Similarly, Solis et al. (2004) reported no association between depression, hopelessness, psychiatric symptoms, and established or severe periodontitis. 28 Castro et al. (2006) also concluded that there was no significant association between periodontitis and the analyzed psychosocial factors. 29 The present study aligns with the findings of Shende et al. (2016), where the oral hygiene and periodontal status of individuals with mild anxiety and depression were not different from those without anxiety and depression. 30 Thus, this study does not demonstrate stress as a causative factor for periodontal disease, despite observing a difference in the periodontal status of individuals with or without normal mental health, which was not statistically significant.

The current study’s results are consistent with Genco et al.’s (1998) findings, indicating that various measures of stress, including life events and daily strains, were not correlated with periodontal disease. Only financial strain showed a significant association with greater attachment loss and alveolar bone loss after adjusting for variables such as age and smoking. Participants with higher financial strain and those with depression had a significantly higher risk for periodontal disease. 11

One intriguing observation in the present study was the lower prevalence of periodontal disease and related findings in individuals with dental insurance compared to those without insurance. The possession of dental insurance appears to contribute to a sense of mental well-being, potentially reducing financial-related stress and mitigating the negative impact on periodontal disease. This aligns with the findings of Genco et al. (1998), who demonstrated a correlation between financial strain and poor periodontal health. 11 Similarly, a study exploring the relationship between mental health and oral health in older individuals in Australia highlighted that the availability of free treatment or provision of dental insurance offers a sense of comfort in daily life, potentially shielding against mental health issues. 31 Ng and Leung (2006) also support this perspective, suggesting that individuals with higher mean clinical attachment level values tended to have higher scores on job and financial strain scales compared to periodontally healthy individuals. 32

The findings of the present study diverge from those reported by Mahendra et al. (2011), Reshma et al. (2013), Vyas et al. (2018), and various other animal and human studies. 23 , 24 , 33 These studies employed diverse stress measures, including cortisol levels and other stress assessment methods. Discrepancies between the present study’s findings and those of the aforementioned studies could arise from differences in methodology, the type of assessment employed, considered co-variables, and the demographic characteristics of the study participants. Many studies focused on specific groups exposed to stress, such as police personnel or older individuals, whereas our study encompassed a broader sample, considering individuals from various backgrounds in relation to mental health. The diverse nature of the study population may contribute to the variations observed in the results.

The current investigation has notable strengths, including its reliance on data from a large-scale population-based survey with a robust sampling and weighting system. This survey encompassed a diverse range of participants, including both females and males, various age groups, individuals with different socioeconomic statuses, and those with and without insurance. The inclusion of these variables, which are not often considered collectively in previous studies, enhances the reliability of the associations found within this research. However, there are limitations to consider. Firstly, mental health status was assessed based on self-reported answers from the participants, which may introduce subjectivity and potential bias into the study outcomes. The broad and complex nature of assessing mental health on a single-point measure or limited parameters may not fully capture the true mental health status of individuals. Additionally, the cross-sectional design of the study limits the ability to infer causality in the observed associations. The study does not confirm the outcome, and the link between stress-associated odds of periodontal disease and behavioral or pathophysiological changes remains to be determined.

Moreover, the study acknowledges the potential bidirectional relationship between oral health concerns and mental health status. For instance, the appearance of teeth, mouth, or dentures, as well as problems with them, might impact social interaction, potentially contributing to mental health issues such as feelings of hopelessness and depression. Controlling for these variables in a study investigating the relationship between mental health status and periodontal disease becomes challenging, and the true measured outcome may be affected.

To enhance future research, prospective studies with a focus on biochemical and physiological mechanisms by which psychosocial stress contributes to periodontal destruction are needed. These studies could establish the biological rationale for the observed relationship. Furthermore, refining the definition of stress and employing a standardized protocol to assess stress and associated factors would contribute to clearer comparisons of periodontal status among individuals.

 Conclusion

In conclusion, within the constraints of this study, it can be deduced that there is no statistically significant difference in the periodontal status between individuals with compromised mental health and those without such issues. Our findings suggest trends in periodontal disease prevalence linked to mental health, marital status, and access to health insurance. However, the absence of statistically significant findings calls for caution in interpreting these relationships. We recommend that future studies further investigate these potential associations to provide a clearer understanding.

 Ethics and consent

The protocols for collecting oral health data in the NHANES 2011–2012 and NHANES 2013–2014 cycles received approval from the Centers for Disease Control and Prevention National Center for Health Statistics Research Ethics Review Board. All survey participants provided written informed consent before publishing their information. https://www.cdc.gov/nchs/nhanes/irba98.htm

Data availability

Aljoghaiman, Eman (2024). The Relationship Between Mental Health and Periodontal Disease: Insights from NHANES Data. figshare. Dataset. https://doi.org/10.6084/m9.figshare.25662735 34

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0)

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Periodontol. 2013;17(2):214–218. 23869129 10.4103/0972-124X.113076 PMC3713754 Aljoghaiman E : The Relationship Between Mental Health and Periodontal Disease: Insights from NHANES Data. figshare. 2024. 10.6084/m9.figshare.25662735.v1 10.5256/f1000research.190535.r428868 Reviewer response for version 3 Folayan Morenike 1 Referee https://orcid.org/0000-0002-9008-7730 Obafemi Awolowo University, Ife, Osun, Nigeria

Competing interests: No competing interests were disclosed.

 8 11 2025 Copyright: © 2025 Folayan M 2025 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

Approved

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

No

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

No

Reviewer Expertise:

NA

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

 10.5256/f1000research.173275.r346478 Reviewer response for version 2 Ajwa Nancy 1 Referee https://orcid.org/0009-0004-5842-9317 College of Dentistry, Riyadh Elem University, Riyadh, Saudi Arabia

Competing interests: No competing interests were disclosed.

 17 12 2024 Copyright: © 2024 Ajwa N 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

Thank you, authors, for the revised version.

The authors have addressed previous comments very well. The newly modified introduction is in good shape now. In the methodology section, please mention your study period as well. The tables are now well-constructed. The discussion becomes more insightful with the limitations added. The conclusion aligns well with the results and objectives.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Public Health, Dentistry, Education, Biostatistics, Periodontology, Orthodontology,

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

 10.5256/f1000research.173275.r339002 Reviewer response for version 2 Folayan Morenike 1 Referee https://orcid.org/0000-0002-9008-7730 Obafemi Awolowo University, Ife, Osun, Nigeria

Competing interests: No competing interests were disclosed.

 17 12 2024 Copyright: © 2024 Folayan M 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

Please find unaddressed comments

Comment: What demographic variables were included in the analysis. Abstract is 300 words and the authors have less than that. Please include the details.

Comment: How was mental health measured for this study in the methodology -

You wrote in response to my comment - Response: Our findings suggest trends in periodontal disease prevalence linked to mental health, marital status, and access to health insurance. However, the absence of statistically significant findings calls for caution in interpreting these relationships. We recommend that future studies further investigate these potential associations to provide a clearer understanding. PLEASE NOTE, A CROSS SECTIONAL STUCY CANNOT ESTABLISH TRENDS. PLEASE REVISE THE LANGUAGE OF THE CONCLUDING STATEMENTS.

Response: We listed them as covariates…. YET THE AUTHORS IN THIS STATEMENT, SEEM TO SUGGEST THEY ARE CONFOUNDERS - By meticulously examining and accounting for these covariates, our objective is to obtain results that reflect the true relationship between the exposure and outcome, minimizing the confounding effects of other variables.

Comment: What informed the age categorisation? There is no justification for the age categorisation nor is the interpretation and application of the findings meaningful based on this age categorisation. Secondly, since this data is large and likely not be skewed, it is best to treat age as a continuous variable. – PLEASE TREAT AGE AS A CONTINUOUS VARIABLE IN YOUR ANALYSIS

Comment: Please how were these variables measured - education, socioeconomic status, poverty/income ratio, marital status, BMI, HbA1C, dental insurance coverage, dental visit frequency, and mental health assessment – PLEASE INCLUDE THE INFORMATION IN THE METHODS SECTION WITH REFERENCES WHERE APPROPRIATE

Comment: Please how was the data on poverty indices collected before being categorized into low, middle, and high? - PLEASE INCLUDE THE INFORMATION IN THE METHODS SECTION WITH REFERENCES WHERE APPROPRIATE

Comment: Please did the authors check for collinearity between the variables such as education, socioeconomic status, poverty/income ratio? - PLEASE INCLUDE THE INFORMATION IN THE METHODS SECTION ON HOW COLLINEARITY WAS ADDRESSED

Comment: The authors wrote - ‘Additionally, a logistic regression model was utilized to assess the influence of mental health on periodontal disease’. This was a cross-sectional study and so the data cannot give information on influence. All it can suggest are risk indicators based on the results of the associations. – PLEASE CORRECT THE REFERENCE TO INFLUENCE AND TREND THROUGHOUT THE MANUSCRIPT. THE STUDY DESIGN CANNOT GENERATE THIS INFORMATION.

Comment: Please do not round up the figures to report a quarter etc. Please be precise with the results. You can round up in the discussion.

Comment: Table 4 is not clear – what were the confounding variables adjusted for in this table. ONCE AGAIN. I AM BACK ON THE NON-CLARITY ON THE COVARIATES AS CONFOUNDERS. IF YOU TREATED THE COVARIATES AS CONFOUNDERS THEN PLEASE STATE THEM AS CONFOUNDERS AS CONFOUNDERS AND COVARIATES ARE NOT THE SAME. IF THE MODEL WAS ADJUSTED FOR CONFOUNDERS THEN REPORT AOR AND NOT OR.

NEW COMMENTS

Comment: This study aims to investigate the relationship between mental health and periodontal disease – what relationship – association, trend, correlation? Be specific?

TABLE 2: THE variables ARE NOT predictors BUT risk indicators As this was A cross Sectional study. Please correct

Throughout the document, please use small letter ‘P’articipants for participants when used within sentences.

Throughout the document, please ezclude in-references to years like (1998)

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

No

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

No

Reviewer Expertise:

epidemiology and oral health

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

 10.5256/f1000research.173275.r339003 Reviewer response for version 2 Ahmed Junaid 1 Referee https://orcid.org/0000-0001-9419-0754 Department of Oral Medicine & Radiology, Manipal College of Dental Sciences, Mangalore, Karnataka, India

Competing interests: No competing interests were disclosed.

 20 11 2024 Copyright: © 2024 Ahmed J 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

The modifications in the manuscript are according to the suggestions and is satisfactory

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.

Are all the source data underlying the results available to ensure full reproducibility?

Partly

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Forensic Odontology,TMJ disorders,Oral Cancer,3D Radiology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

 10.5256/f1000research.165439.r317918 Reviewer response for version 1 Ahmed Junaid 1 Referee https://orcid.org/0000-0001-9419-0754 Department of Oral Medicine & Radiology, Manipal College of Dental Sciences, Mangalore, Karnataka, India

Competing interests: No competing interests were disclosed.

 16 9 2024 Copyright: © 2024 Ahmed J 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

1.The inclusion & exclusion criteria needs to be listed more elaborately

2.The authors have not mentioned their source of demographic data including the country from where the data is sourced.

3..Was the NHANES data previously published by the government?.The authors need to clarify.

4.Have the authors taken the necessary permission to publish the data from the competent sources?

5.The study setting in which the objectives of the present research is mentioned is not clear in the manuscript.

6.The authors need to mention the sample size of the data and whether any methodology was utilized for sample size estimation.

7.The self reported mental health status is a big limitation in the present study and any direct relationship between mental health & periodontal disease cannot be inferred from the present study.

8.Quality of written english needs to be improved and a few incoherent sentences needs to be rephrased.

9.A few comments have been highlighted in the attached manuscript

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.

Are all the source data underlying the results available to ensure full reproducibility?

Partly

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Forensic Odontology,TMJ disorders,Oral Cancer,3D Radiology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

AlJoghaiman Eman Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, Saudi Arabia

Competing interests: No competing interests were disclosed.

 9 10 2024

Dear Reviewer,

We would like to express our sincere gratitude for your insightful review and valuable suggestions regarding our manuscript. We have carefully revised the manuscript and provided detailed responses to your comments, which are included alongside the revised version.

Thank you very much for your time and consideration.

Dr. Eman

 AlJoghaiman Eman Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, Saudi Arabia

Competing interests: No competing interests were disclosed.

 9 10 2024

Dear Reviewer,

We would like to express our sincere gratitude for your insightful review and valuable suggestions regarding our manuscript. We have carefully revised the manuscript and provided detailed responses below to your comments one by one. Please let us know if you have any further questions.

Thank you for your time.

Reviewer comment 1: The inclusion & exclusion criteria needs to be listed more elaborately

Author response: Added in the attached manuscript. Thank you

Reviewer comment 2: The authors have not mentioned their source of demographic data including the country from where the data is sourced.

Author response: The National Health and Nutrition Examination Survey (NHANES) is a comprehensive cross-sectional survey conducted in the United States, designed to offer a nationally representative overview of non-institutionalized individuals residing in households.

Reviewer comment 3: Was the NHANES data previously published by the government?. The authors need to clarify.

Author response: Yes, it is published and publicly available for other to re-use the data. The source of the data is provided in the method section.  Thank you

Reviewer comment 4: Have the authors taken the necessary permission to publish the data from the competent sources?

Author response: Yes, the data is available freely. Thank you

Reviewer comment 5: The study setting in which the objective of the present research is mentioned is not clear in the manuscript.

Author response: Can you please specify what exactly should be added?

Reviewer comment 6: The authors need to mention the sample size of the data and whether any methodology was utilized for sample size estimation.

Author response: No sample size was calculated because authors utilized whole data available in the website. Thank you

Reviewer comment 7: The self reported mental health status is a big limitation in the present study and any direct relationship between mental health & periodontal disease cannot be inferred from the present study.

Author response: Noted thank you

Reviewer comment 8: Quality of written English needs to be improved and a few incoherent sentences needs to be rephrased.

Author response: Thank you for the comment, we have done English proofread and rephrased the sentences for more readability.

Reviewer comment 9: A few comments have been highlighted in the attached manuscript

Author response:  Thank you for the comments.

 10.5256/f1000research.165439.r306426 Reviewer response for version 1 Folayan Morenike 1 Referee https://orcid.org/0000-0002-9008-7730 Obafemi Awolowo University, Ife, Osun, Nigeria

Competing interests: No competing interests were disclosed.

 13 8 2024 Copyright: © 2024 Folayan M 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation reject

The Relationship Between Mental Health and Periodontal Disease: Insights from NHANES Data

Thanks for this very important study generated from a secondary analysis of a large database. Please find below suggestions to strengthen the manuscript

Abstract

Please include clearly that this was a secondary data analysis of the NHANEs data

Include information on the period the data was collected

Please provide details on the covariate variables extracted

What kind of analysis was conducted with the Rao-Scott chi-squared test. Please avoid making readers assume what was done.

What demographic variables were included in the analysis

What disease status is been referred too?

How was mental health measured for this study?

What is the sample size for this study? This information should be included in the result section

For the report, please report the descriptive variables before the inferential analysis reports.

Authors noted a significant difference in periodontal status by marital status and by health insurance status but there is no report on the CI or the p value of these observations. There is also no clarity about how the results of these tests of associations answer the study objectives as the objective had Mental health as the dependent variable.

Is ‘feeling bad about themselves for more than half of the day’ the measure of mental health for this study?

The conclusion that ‘The findings underscore potential associations between mental health, marital status, and access to health insurance with periodontal disease’ is not valid based on this study results.

 INTRODUCTION

A comprehensive introduction

The introduction is missing on the conceptual framework that suggest that first suggests that self-perception is a mental health issue, and that there are suggestive links between self-perception (about what) and periodontal diseases. Please address this concisely in the introduction.

 METHODs

Please provide explicit details on how mental health was measured.

Please be explicit about the periodontal index used for this study.

I think what is listed as covariates are defined as confounders. These needs to be clarified please.

What informed the age categorisation? There is no justification for the age categorisation nor is the interpretation and application of the findings meaningful based on this age categorisation. Secondly, since this data is large and likely not be skewed, it is best to treat age as a continuous variable.

Please how were these variables measured - education, socioeconomic status, poverty/income ratio, marital status, BMI, HbA1C, dental insurance coverage, dental visit frequency, and mental health assessment

Please how was the data on poverty indices collected before being categorized into low, middle, and high?

Please did the authors check for collinearity between the variables such as education, socioeconomic status, poverty/income ratio?

This statement is not clear: ‘To analyze the demographics and disease status of the study population, the Rao-Scott chi-squared test was employed, taking into consideration the survey design complexities’. The Rao-Scott chi-squared test is a test of association. Not sure how this can be an analytic tool for ‘the demographics and disease status of the study population’

The authors wrote - ‘Additionally, a logistic regression model was utilized to assess the influence of mental health on periodontal disease’. This was a cross sectional study and so the data cannot give information on influence. All it can suggest are risk indicators based on the results of the associations.

 Results

Please for the results, write the figures and the percentage in brackets

Please do not round up the figures to report a quarter etc. Please be precise with the results. You can round up in the discussion.

Please can you report the study participants as participants rather than subjects

The asterisks in the Table 2 suggests that Rao-Scott chi-square test as not applied to all variables

Table 2 also suggests that the variables listed in the methodology were treated as co-variates and not confounders. Please be clear with your methodology and the use of terminologies.

The test of association cannot measure effect. Please the title to the section is misleading

Please in the narrative on tables 2 and 3, please include information on the determinants of the report of significant associations

Please be specific on the percentage and type of periodontal disease referred too. The table did not report on ‘some forms’ of periodontal diseases

Table 4 is not clear – what were the confounding variables adjusted for in this table.

 In view of the non-clarity of the methodology and results, I am unable to review the discussion until this is clarified. The authors are encouraged to use the TROBE guidelines to guide the review and the structuring of the paper.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

No

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

No

Reviewer Expertise:

epidemiology and oral health

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

AlJoghaiman Eman Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, Saudi Arabia

Competing interests: No competing interests were disclosed.

 9 10 2024

Dear Reviewer,

We would like to express our sincere gratitude for your insightful review and valuable suggestions regarding our manuscript. We have carefully revised the manuscript and provided detailed responses below to your comments one by one. Please let us know if you have any further questions.

Thank you for your time.

Reviewer 1:

Thanks for this very important study generated from a secondary analysis of a large database. Please find below suggestions to strengthen the manuscript.

Comment: Abstract: Please include clearly that this was a secondary data analysis of the NHANEs data

- Response: Added

Comment: Include information on the period the data was collected

- Response: Added

Comment: Please provide details on the covariate variables extracted

- Response: Added

Comment: What kind of analysis was conducted with the Rao-Scott chi-squared test. Please avoid making readers assume what was done.

- Response: It is a chi-square test used for association. Thank you

Comment: What demographic variables were included in the analysis

- Response: All demographic variables included are present in the material method section below because listing them here will be difficult because of word limitation for abstract.

Comment: What disease status is been referred too?

- Response: Periodontal disease

Comment: How was mental health measured for this study?

- Response: Added in the material method section

Comment: What is the sample size for this study? This information should be included in the result section

- Response: Added

Comment: For the report, please report the descriptive variables before the inferential analysis reports.

- Response: Corrected

Comment: Authors noted a significant difference in periodontal status by marital status and by health insurance status but there is no report on the CI or the p value of these observations. There is also no clarity about how the results of these tests of associations answer the study objectives as the objective had Mental health as the dependent variable.

- Response: Periodontal status is the dependent variable, and details are added in the result section. Thank you

Is ‘feeling bad about themselves for more than half of the day’ the measure of mental health for this study?

- Response: Yes

Comment: The conclusion that ‘The findings underscore potential associations between mental health, marital status, and access to health insurance with periodontal disease’ is not valid based on this study results.

- Response: Our findings suggest trends in periodontal disease prevalence linked to mental health, marital status, and access to health insurance. However, the absence of statistically significant findings calls for caution in interpreting these relationships. We recommend that future studies further investigate these potential associations to provide a clearer understanding

INTRODUCTION

Comment: A comprehensive introduction

- Response: Modified. Thank you

Comment: The introduction is missing on the conceptual framework that suggest that first suggests that self-perception is a mental health issue, and that there are suggestive links between self-perception (about what) and periodontal diseases. Please address this concisely in the introduction.

- Response: Based on the reviewer’s comment regarding the ⁠The introduction is missing on the conceptual framework authors have revise the introduction. Thank you

METHOD

Comment: Please provide explicit details on how mental health was measured.

- Response: Added

Comment: Please be explicit about the periodontal index used for this study.

- Response: Added

Comment: I think what is listed as covariates are defined as confounders. These needs to be clarified please.

- Response: We listed them as covariates….

Comment: What informed the age categorisation? There is no justification for the age categorisation nor is the interpretation and application of the findings meaningful based on this age categorisation. Secondly, since this data is large and likely not be skewed, it is best to treat age as a continuous variable.

- Response: Age categorization was done to check the variability in the different age groups.

Comment: Please how were these variables measured - education, socioeconomic status, poverty/income ratio, marital status, BMI, HbA1C, dental insurance coverage, dental visit frequency, and mental health assessment

- Response: Thank you for the comment, authors have listed all categories about the measurements in table 1.

Comment: Please how was the data on poverty indices collected before being categorized into low, middle, and high?

- Response: Based on the poverty income ratios, categories were created to represent different socioeconomic status groups. Here's a common approach:

Below Poverty Line: Participants with a poverty income ratio less than 1.0 are considered below the poverty line.

Near Poverty: Participants with a poverty income ratio between 1.0 and 1.25 are often categorized as near-poverty.

Low-Income: Participants with a poverty income ratio between 1.25 and 2.0 are typically categorized as low-income.

Middle-Income: Participants with a poverty income ratio between 2.0 and 3.0 are considered middle-income.

High-Income: Participants with a poverty income ratio greater than 3.0 are categorized as high-income.

Comment: Please did the authors check for collinearity between the variables such as education, socioeconomic status, poverty/income ratio?

- Response: The authors appreciate your feedback and will consider using collinearity diagnostics in future studies to improve the rigor of our findings. Our investigation focused on ensuring that our regression models were robust and reliable. While we did not directly collect collinearity statistics, we were aware of the possibility of multicollinearity when selecting and incorporating variables in our models.

Comment: This statement is not clear: ‘To analyze the demographics and disease status of the study population, the Rao-Scott chi-squared test was employed, taking into consideration the survey design complexities’. The Rao-Scott chi-squared test is a test of association. Not sure how this can be an analytic tool for ‘the demographics and disease status of the study population’

- Response: The lines are Rephrased.

Comment: The authors wrote - ‘Additionally, a logistic regression model was utilized to assess the influence of mental health on periodontal disease’. This was a cross-sectional study and so the data cannot give information on influence. All it can suggest are risk indicators based on the results of the associations.

- Response: Thank you for your suggestion.

Results

Comment: Please for the results, write the figures and the percentage in brackets

- Response: Done

Comment: Please do not round up the figures to report a quarter etc. Please be precise with the results. You can round up in the discussion.

- Response: Thank you

Comment: Please can you report the study participants as participants rather than subjects

- Response: Done, Thank You

Comment: The asterisks in the Table 2 suggests that Rao-Scott chi-square test as not applied to all variables

- Response: Corrected, Thank you

Comment: Table 2 also suggests that the variables listed in the methodology were treated as co-variates and not confounders. Please be clear with your methodology and the use of terminologies.

- Response: Corrected

Comment: The test of association cannot measure effect. Please the title to the section is misleading

- Response: Corrected

Comment: Please in the narrative on tables 2 and 3, please include information on the determinants of the report of significant associations

- Response: Corrected

Comment: Please be specific on the percentage and type of periodontal disease referred too. The table did not report on ‘some forms’ of periodontal diseases

- Response: Corrected

Comment: Table 4 is not clear – what were the confounding variables adjusted for in this table.

- Response: All demographical characteristics.

Comment: In view of the non-clarity of the methodology and results, I am unable to review the discussion until this is clarified. The authors are encouraged to use the TROBE guidelines to guide the review and the structuring of the paper.

- Response: Thank you for your valuable review