Introduction

F1000Research

2046-1402

F1000 Research Limited

London, UK

10.12688/f1000research.161146.3

Research Article

Articles

Relationship between the perception of oral health and the quality of life of hospital staff

[version 3; peer review: 2 approved with reservations, 1 not approved]

Lora Loza

Miryam

Conceptualization Formal Analysis Investigation Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0001-5099-1314 a 1 Alvarado-Romero

Sheyla del Pilar

Conceptualization Investigation Methodology Validation Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0009-0005-9996-5236 b 1 Flores Ledesma

Katia Ninozca

Data Curation Formal Analysis Methodology Validation Writing – Review & Editing https://orcid.org/0000-0002-9088-5820 2 Cuenca Robles

Nancy

Data Curation Investigation Supervision Writing – Original Draft Preparation Writing – Review & Editing 2 Rodríguez Díaz

David Rene

Data Curation Methodology Resources Supervision Writing – Review & Editing https://orcid.org/0000-0002-9203-3576 3 1Graduate School, César Vallejo University, Trujillo, La Libertad, 13001, Peru 2Graduate School of, Cesar Vallejo University, Lima, La Libertad, 13001, Peru 3School of Human Medicine, Private University of the North, Trujillo, Lima Norte, 13001, Peru

a mloraloza@gmail.com b sheyla.alvarado.1705@gmail.com

No competing interests were disclosed.

16 6 2025

2025

238

6 6 2025

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

Hospital staff’s perception of oral health directly impacts their overall oral health-related well-being (OHRQoL) and their job performance. This study seeks to analyze the relationship between these two dimensions, providing information for designing strategies that promote a healthier work environment.

Aim

To determine the relationship between oral health-related quality of life (OHRQoL) and oral health perceptions in the staff of a level II-1 hospital located in northern Peru.

Methods

The study had a quantitative approach, with a cross-sectional, applied, and correlational design. Seventy-two participants participated. The validated OHIP-14 and HU-DBI questionnaires were used, with reliability coefficients of 0.847 and 0.804, respectively. Spearman’s correlation coefficient, appropriate for ordinal variables, was used for data analysis.

Results

A statistically significant association was found between health-related quality of life and subjective perception of oral status (Rho = 0.391, p < 0.05), with an explained variance of 19.8% according to Nagelkerke’s pseudo R-squared. The most frequently associated quality of life dimensions were physical disability (Rho = 0.319; p < 0.05) and social disability (Rho = 0.242; p < 0.05). Excellent quality of life was the most prevalent (38.9%), while poor oral health was the most common (52.8%).

Conclusion

The findings show a significant relationship between self-perceived oral health and oral health-related quality of life in this group of professionals. Promoting oral health strategies tailored to the hospital setting is recommended to improve workplace well-being.

Quality of life Perception Oral health Correlation Hospital Functional limitation.

The author(s) declared that no grants were involved in supporting this work.

Revised Amendments from Version 2

In this new version, several revisions have been made to enhance clarity, consistency, and accuracy. The abbreviation “CV” was replaced throughout the text with the internationally recognized term “QoL”. The phrase “quality of life of teachers” in the conclusion was corrected to “hospital staff” to match the actual population studied. Typographic and formatting standards were improved, including the use of decimal points. Minor grammar and style issues were also corrected. These changes aim to improve the editorial quality and conceptual precision of the manuscript.

Introduction

Oral health is an essential component of overall well-being, as it directly is associated with oral health-related quality of life (OHRQoL) through the ability to perform basic functions such as communicating, eating well, and maintaining satisfactory social relationships. ¹ Oral diseases not only affect oral functions but also psychological, social, and economic outcomes, causing discomfort, pain, and loss of self-esteem, and associationing the subjective perception of oral well-being. ² ^, ³ The association of oral health on OHRQoL underlines its direct contribution to achieving Sustainable Development Goal 3, which aims to ensure that all people achieve good health, with oral health being a fundamental component.

In this context, oral health is considered one of the basic global priorities for international organizations such as the International Dental Federation (FDI) and the World Health Organization (WHO), since its relationship with the global oral health-related quality of life (OHRQoL) linked to the area of oral health is undoubtedly significant. The World Health Organization conceptualizes oral health as a comprehensive condition that encompasses the physical, mental and social well-being of the individual, in relation to the functionality and state of the oral cavity, and not simply the absence of diseases or ailments in this area (WHO, 2022), and the FDI (2021) introduces an integrative perspective that relates oral well-being with sustainable public health policies. ⁴ ^, ⁵

Oral diseases constitute a global public health problem affecting approximately 3.5 billion people worldwide, with a higher prevalence in developing and middle-income countries, where around 75% of cases are concentrated. ⁴ Untreated cases of caries are the most prevalent condition, reflecting deep inequalities in access to preventive services and basic treatments. ⁶ ^, ⁷ In Latin America, periodontal diseases represent an epidemic that significantly impairs oral health-related quality of life (OHRQoL). In countries such as Peru, the magnitude of the problem is exacerbated by the low priority given to oral health within health agendas, evidenced by low public investment and high oral cancer rates: 2.60 per 100,000 women and 1.97 in men between 2000 and 2017. ⁸ This scenario is associated with limited resource allocation, the absence of effective preventive strategies, and the lack of early detection programs. ⁹ Faced with this challenge, the WHO and other international organizations have promoted a series of initiatives. Hence the definitive IED Vision 2030 Report and the Resolution (2021) on oral health, which emphasize that oral health should be part of Universal Health Coverage (UHC) systems and in line with the global agenda to combat non-communicable diseases (NCDs).

According to the 2022 World Oral Health Report, ⁴ it is essential to reorient public health policies to give a central role to the promotion and production of scientific knowledge in oral health, through national plans supported by the vision and international strategies proposed by the WHO in the aforementioned report. ⁹ The support and collaboration of institutions such as UNESCO or UNDP are essential to include oral health factors within well-being and sustainable human development policies. ¹⁰ ^, ¹¹ The oral health of healthcare personnel can be measured through oral health perception (OHP), having found that the practice of OHP can also be associated with not only oral well-being, but can also condition the oral health-related quality of life (OHRQoL) as well as the quality of oral health. Similarly, OHP can be conditioned by other contextual factors such as the significant limitation of accessibility to dental services or the workload. ¹² ^– ¹⁴ Negative OHP will affect self-esteem and interpersonal relationships, and will justify its assessment through OHRQoL in the health of healthcare personnel. ⁸ ^, ¹⁵

The purpose of this study is to examine the potential relationship between oral health-related quality of life (OHRQoL) and the perception of oral well-being in the staff of a type II-1 hospital in northern Peru, taking into account their dimensions and interactions. This research provides relevant evidence for designing strategies that promote the oral well-being of healthcare staff and, consequently, guarantee comprehensive, patient-centered care based on quality criteria. ¹⁶ ^, ¹⁷

Methods Research type and design

This paper presents applied research aimed at solving a specific problem in order to propose solutions to the challenges faced by hospital staff. ¹⁸ ^– ²⁰ The scope of the research was correlational, as it sought to identify the relationship between the variables and analyze the strength and direction of this relationship. ²¹ A non-experimental cross-sectional design was adopted, which allowed data to be collected at a single point in time without manipulating the variables, thus preserving the natural context of observation. ²²

Population

The group was initially comprised of 80 members of the professional and technical team providing care at a Level II-1 healthcare facility in northern Peru. This group included 21 physicians, 10 obstetricians, 1 dentist, 1 pharmaceutical chemist, 17 nurses, 2 psychologists, 3 biologists, 5 microbiologists, 2 medical technologists, 13 nursing technicians, 4 pharmacy technicians, and 1 laboratory technician. After applying the inclusion criteria, which took into consideration designated or assigned personnel and CAS (Administrative Contracting of Services), with more than 6 months of seniority, those who agreed to complete each of the questions formulated in both questionnaires, signed and stamped the informed consent form. The exclusion criteria considered workers with less than six months of seniority, those who were on vacation or sick leave, those who worked under an outsourcing modality, those who were carrying out SERUMS (Rural and Marginal Urban Health Service) and those who did not agree to participate in the study. A non-probabilistic intentional convenience sampling was used, obtaining a final sample made up of 72 participants, which allowed for the collection of sufficient data to perform correlational analyses, considering the feasibility and accessibility of personnel during the study period. Additionally, to estimate the sample size, a statistical power analysis was performed with G*Power, establishing as parameters an expected correlation of medium magnitude (ρ = 0.30), a confidence level of 95% and a power of 80%. Under these parameters, the minimum size required was 67 participants, so the sample reached (n = 72) was adequate for the proposed correlational analysis. ²³

Variables

In this study, two main variables were evaluated: oral health-related quality of life (OHRQoL) and oral health perception (OHP). Oral health-related quality of life (OHRQoL) is conceived as an individual’s personal appreciation of how their oral condition is associated with different aspects of their daily life, both physically and emotionally and socially. ²⁴ The OHIP-14 questionnaire (Oral Health Impact Profile), developed by Slade and Spencer, was used for its evaluation. This questionnaire allows estimating how oral conditions affect different areas of daily life. This instrument includes seven dimensions: functional limitation, psychological discomfort, physical pain, psychological disability, physical disability, social disability, and handicap. The overall score obtained on the instrument indicates the level of association that oral health specifically has on the individual’s oral health-related quality of life (OHRQoL), without extending its scope to general quality of life (QoL).

Likewise, oral health perception refers to the subjective evaluation of oral status and its relationship with QoL ²⁵ ; it could be addressed through a modified version of the Hiroshima University – Dental Behavioral Inventory (HU-DBI), initially developed by Kawamura (1988) and adapted to the Peruvian context by Midolo (2023). ²⁶ ^, ²⁷ This version was internally validated by Alvarado and Lora in 2024, specifically for health personnel. The instrument considers three dimensions: perception of knowledge, perception of behavior, and perception of attitude. This variable was used as an indicator of the subjective level of awareness, disposition, and practice of personnel in relation to their oral health.

Data collection technique and instrument

The survey technique was used, since it facilitated the systematic collection of relevant data provided by the hospital’s professional and technical staff through standardized questionnaires, without altering the environment or the object of study. ²⁸

Regarding the instruments, the oral health-related quality of life (OHRQoL) Questionnaire was used, originally designed by Slade and Spencer in 1994, adapted by Espinoza in 2017 ²⁹ and subsequently validated and published by Espinoza et al. (2022). ³⁰ This instrument consists of 14 items organized into seven dimensions: functional limitation, psychological discomfort, physical pain, psychological disability, physical disability, social disability, and general disability, with two items per dimension. A five-point Likert-type scale was applied (0 = never, 4 = very frequently), and the results were categorized according to the global scoring system of the original instrument, without structural modifications.

For the purposes of analysis and interpretation, three categories were established: “excellent” (0–2 points), “regular” (3–9 points), and “poor” oral health-related quality of life (OHRQoL) (10 points or more), following the methodological criteria proposed by Espinoza (2017) ²⁹ and taken up by Espinoza et al. (2022), ³⁰ who applied this classification to older adults in similar contexts, preserving the validity of the original instrument.

Likewise, the Oral Health Perception Questionnaire (modified HU-DBI),originally developed by Kawamura in 1988 and subsequently adapted by Midolo (2023) for healthcare personnel in Lima, Peru, was used. This modified version was internally validated by Alvarado and Lora in 2024, specifically for application in hospital settings. The instrument consists of 20 items distributed in three dimensions: perception of knowledge (8 items), perception of behavior (6 items), and perception of attitude (6 items). Responses were recorded on a dichotomous scale (Yes = 1, No = 0), and results were categorized into three levels: poor (0–9 points), regular (10 points), and excellent (11–20 points).

Both instruments underwent an exhaustive validation process through expert judgment, in which five evaluators with experience in the field of health and scientific methodologies participated, with proven experience in the psychometric evaluation of measurement tools. The judges analyzed each item considering criteria of internal consistency, conceptual clarity, thematic relevance, and informative sufficiency, achieving a level of total agreement reflected in an Aiken’s V coefficient equal to 1.00, which demonstrates high content validity. The reliability of the instruments was established by conducting a pilot test prior to their final implementation. The analysis yielded a Cronbach’s alpha coefficient of 0.847 for the OHIP-14 questionnaire, and 0.804 for the HU-DBI instrument, results that demonstrate solid and acceptable internal consistency according to current methodological standards.

To ensure methodological traceability and facilitate future replications, the instruments used (OHIP-14 and the modified HU-DBI) have been fully incorporated as complementary material, publicly available in the Zenodo repository: https://doi.org/10.5281/zenodo.15236712. This file includes the questionnaires used, the validation matrix reviewed by five expert judges and the reliability indicators obtained during the pilot study, thus supporting the validity and applicability of the instruments in similar methodological contexts. ³¹

Procedure

The procedure began with the submission of a formal cover letter issued by the Graduate School of César Vallejo University to the administrative department of La Libertad Hospital, Category II-1, requesting authorization to administer the research instruments. Once approval was received from the institution, in-person attendance at the hospital was coordinated by scheduling specific dates and times for the application. During these information sessions, participants were provided with a clear and detailed explanation of the study’s objectives and purposes, ensuring the confidentiality of the information collected and the anonymity of their identities, in accordance with the ethical principles of scientific research. Each participant signed the corresponding informed consent form prior to administration of the proposed questionnaires. The instruments were administered in separate spaces within their work areas and required approximately 8 minutes per person, taking care to minimize potential distractions or contextual biases.

Information analysis

Statistical analysis of the data was performed using IBM SPSS Statistics, version 25 ( https://www.ibm.com/products/spss-statistics ). Initially, the Kolmogorov-Smirnov test was applied to determine the normal distribution of the variables; the results indicated a non-normal distribution ( p < 0.05). Consequently, non-parametric tests were used. To examine the relationship between oral health-related quality of life (OHRQoL) and oral health perception (OHP), Spearman’s Rho correlation coefficient was used, as it is the appropriate statistic for the analysis of ordinal variables. An ordinal logistic regression model was also used to assess the relationship between the variables, including Nagelkerke’s Pseudo R-squared as the measure of fit. Confidence intervals (CIs) were also included, as they contribute to a better approximation of the results obtained in the analysis. As an alternative, the use of the statistical software R (The R Project for Statistical Computing) was also considered. The analysis identified a statistically significant association between the variables studied, providing empirical evidence of the interdependence between oral health-related quality of life (OHRQoL) and perceptions of oral health among hospital healthcare personnel. ³² ^– ³⁵

Ethical implications

This study was conducted in strict compliance with the principles of scientific integrity and respect for participants’ rights, as established in institutional codes and current ethical regulations. International guidelines for research involving human subjects were considered, such as the guidelines of the Council for International Organizations of Medical Sciences (CIOMS, 2016), ³⁶ the recommendations of the Belmont Report (1979), ³⁷ and the principles set forth in the Declaration of Helsinki (World Medical Association, 2013). ³⁸ The proposal was approved by a duly constituted institutional ethics committee, which evaluated and authorized its execution through a formal resolution issued in the first quarter of 2025. All phases of the study respected the criteria of confidentiality, informed consent, and voluntary participation of participants. Furthermore, all participants voluntarily signed a written informed consent form, which detailed the objectives, procedures, benefits, and risks of the study. Only those who fully understood and accepted these conditions were included. Finally, the university’s ethical policies were respected, as described in the institutional Research Ethics Code, ³⁹ which ensured the originality, transparency, and methodological rigor of the research.

Results

Table 1 it is observed that 38.90% of staff with excellent OHRQoL reported a low level of oral health perception (OHP) at 52.80%, while the 34.70% with poor OHRQoL presented a more balanced distribution across OHP categories. Likewise, a low (r = 0.391), but significant ( p = 0.001), positive correlation was evident between OHRQoL and OHP.

Table 1. Relationship between Oral Health-Related Quality of Life (OHRQoL) and Oral Health Perception (OHP) among Health Personnel at a Level II-1 Hospital in Northern Peru, 2024.

Oral Health-Related Quality of Life (OHRQoL)	Oral Health Perception (OHP)						Total
	Low		Regular		Excellent		Total
	N	%	N	%	N	%	N	%
Excellent	21	29.20	6	8.30	1	1.40	28	38.90
Regular	8	11.10	1	1.40	10	13.90	19	26.40
Bad	9	12.50	6	8.30	10	13.90	25	34.70
Total	38	52.80	13	18.10	21	29.20	72	100.00

Rho Spearman	Next	Pseudo R Nagelkerke	Next
0.391	0.001	0.198	0.001

Note: Data processed using IBM SPSS Statistics v25. Includes Spearman’s Rho correlation, significance level ( p), and Nagelkerke’s Pseudo R ². Own elaboration.

Likewise, ordinal logistic regression analysis, with a Nagelkerke pseudo R-squared of 0.198 (p = 0.001), confirmed a significant association of QoL on OHP, accounting for 19.80%. To ensure inferential accuracy, confidence intervals (CI) and Nagelkerke pseudo R-squared values were included in all regression tests, as detailed in Tables 1 and 4.

Table 2 the findings show that oral health-related quality of life (OHRQoL) is predominantly grouped into three distinct categories or levels: excellent (38.90%), poor (34.70%), and fair (26.40%). Furthermore, when analyzing the dimensions of oral health-related quality of life (OHRQoL), it is observed that all reached high percentages at the excellent level. Functional limitation was the most common, with 44.40%, followed by physical pain, 52.80% and Psychological distress (54.20%), Physical and psychological disability registered 69.40% ,while Social disability reached 76.40%, finally, handicap (general disability) showed the highest percentage, at 83.30%.

Table 2. Quality of Life Level and its dimensions of the health personnel of a Level II-1 Hospital in Northern Peru, 2024.

OHRQoL	OHRQoL Dimensions
OHRQoL	Functional limitation		Physical pain	Psychological discomfort				Psychological disability		Psychological inability			Social disability	Handicap
Levels	N	%	N	%	N	%	N	%	N	%	N	%	N	%	N	%
Excellent	28	38.90	32	44.40	38	52.80	39	54.20	50	69.40	50	69.40	55	76.40	60	83.30
Regular	19	26.40	28	38.90	23	31.90	22	30.60	18	25.00	18	25.00	14	19.40	10	13.90
Bad	25	34.70	12	16.70	11	15.30	11	15.30	4	5.60	4	5.60	3	4.20	2	2.80
Total	72	100.00	72	100.00	72	100.00	72	100.00	72	100.00	72	100.00	72	100.00	72	100.00

Note: Statistical analysis of oral health perception, processed questionnaires, own elaboration.

Table 3 it indicates that the Oral Health Perception (OHP) is distributed mainly into three levels: low (52.80%), excellent (29.20%), and regular (18.00%). When analyzing the specific dimensions, it was observed that the Perception of Knowledge registered 100% at a low level. In contrast, the Perception of Attitude showed 44.4% at the low level, while Perception of Behavior recorded its highest concentration at the regular level (62.50%).

Table 3. Level of oral perception and its dimensions in health personnel from a level II-1 hospital in northern Peru, 2024.

Oral Health Perception (OHP)			(OHP) Dimensions
Oral Health Perception (OHP)			Perception of knowledge		Attitude perception		Perception of behavior
Levels	N	%	N	%	N	%	N	%
Low	38	52.80	72	100.00	32	44.40	15	20.80
Regular	13	18.00	0	0.00	31	43.10	45	62.50
Excellent	21	29.20	0	0.00	9	12.50	12	16.70
Total	72	100.00	72	100.00	72	100.00	72	100.00

Note: Data analyzed using IBM SPSS Statistics v25. Results correspond to the distribution of oral health perception (OHP) and its dimensions based on the validated instrument. Own elaboration.

Table 4 presents a detailed analysis of the relationships between the dimensions of oral health-related quality of life (OHRQoL) and oral health perception (OHP), highlighting key differences in the magnitude of these associations. In particular, the psychological distress dimension showed the stronges connection with OHP, supported by a moderate correlation coefficient (r = 0.421) and a high level of statistical significance ( p = 0.000). Additionally, Nagelkerke’s Pseudo R-squared was 0.111 (p = 0.027), indicating that this dimension explains 11.1% of the variability of OHP. The Physical disability, dimension also exhibited a statistically significant association, albeit with a slightly smaller effect size. The correlation coefficient was 0.319 (p = 0.006), and the Pseudo R-squared value reached 0.167 (p = 0.004), suggesting a 16.7% contribution to the variability in OHP. In contrast, the functional limitation dimension demonstrated a much weaker relationship with OHP, yielding a correlation coefficient of 0.096 (p = 0.424) and a Pseudo R-squared of 0.014 (p = 0.649), indicating a negligible effect on the dependent variable.

Table 4. Relationship between the dimensions of the Quality of life with the perception of oral health of the staff of a level II-1 hospital in La Libertad, 2024.

Functional limitation	Oral Health Perception (OHP)								Inferential analysis
	Low		Regular		Excellent		Total		Spearman's Rho	p-value	Nagelkerke's Pseudo R	Next
	N	%	N	%	N	%	N	%
Excellent	18	25.00	7	9.70	7	9.70	32	44.40	0.096	0.424	0.014	0.649
Regular	15	20.80	3	4.20	10	13.90	28	38.90
Bad	5	6.90	3	4.20	4	5.60	12	16.70
Total	38	52.80	13	18.10	21	29.20	72	100.00

Physical pain	OHP						Total
	Low		Regular		Excellent		Total
	N	%	N	%	N	%	N	%
Excellent	24	33.30	7	9.70	7	9.70	38	52.80	0.266	0.024	0.093	0.049
Regular	12	16.70	2	2.80	9	12.50	23	31.90
Bad	2	2.80	4	5.60	5	6.90	11	15.30
Total	38	52.80	13	18.10	21	29.20	72	100.00

Psychological discomfort	OHP						Total
	Low		Regular		Excellent		Total
	N	%	N	%	N	%	N	%
Excellent	26	36.10	6	8.30	7	9.70	39	54.20	0.421	0.000	0.111	0.027
Regular	8	11.10	5	6.90	9	12.50	22	30.60
Bad	4	5.60	2	2.80	5	6.90	11	15.30
Total	38	52.80	13	18.10	21	29.20	72	100.00

Physical disability	OHP						Total
	Low		Regular		Excellent		Total
	N	%	N	%	N	%	N	%
Excellent	30	41.70	8	11.10	12	16.70	50	69.40	0.319	0.006	0.167	0.004
Regular	8	11.10	5	6.90	5	6.90	18	25.00
Bad	0	0.00	0	0.00	4	5.60	4	5.60
Total	38	52.80	13	18.10	21	29.20	72	100.00

Psychological Inability	OHP						Total
	Low		Regular		Excellent		Total
	N	%	N	%	N	%	N	%
Excellent	30	41.70	8	11.10	12	16.70	50	69.40	0.232	0.050	0.167	0.004
Regular	8	11.10	5	6.90	5	6.90	18	25.00
Bad	0	0.00	0	0.00	4	5.60	4	5.60
Total	38	52.80	13	18.10	21	29.20	72	100.00

Social Inability	OHP						Total
	Low		Regular		Excellent		Total
	N	%	N	%	N	%	N	%
Excellent	31	43.10	11	15.30	13	18.10	55	76.40	0.242	0.040	0.124	0.017
Regular	7	9.70	2	2.80	5	6.90	14	19.40
Bad	0	0.00	0	0.00	3	4.20	3	4.20
Total	38	52.80	13	18.10	21	29.20	72	100.00

Handicap	OHP						Total
	Low		Regular		Excellent		Total
	N	%	N	%	N	%	N	%
Excellent	36	50.00	9	12.50	15	20.80	60	83.30	0.298	0.011	0.131	0.013
Regular	2	2.80	4	5.60	4	5.60	10	13.90
Bad	0	0.00	0	0.00	2	2.80	2	2.80
Total	38	52.80	13	18.10	21	29.20	72	100.00

Note: Inferential analysis based on Spearman’s Rho correlation and ordinal logistic regression. Includes p-values and Nagelkerke’s Pseudo R ². Data processed using IBM SPSS Statistics v25. Own elaboration.

Overall, these findings confirm the existence of a positive relationship between quality-of-life dimensions and oral health perception. However, the dimensions of psychological distress and physical disability exhibited stronger associations with OHP, highlighting the need to implement targeted interventions that address these critical psychosocial and functional domains.

Discussion

Oral health-related quality of life (OHRQoL) and oral health perception (OHP) are essential elements that directly associated with the overall well-being of hospital staff. This study, examined the relationship between these variables was established in a total of 72 workers from a hospital located in northern Peru during the year 2024, with the purpose of identifying and establishing areas of opportunity that allow the execution of strategies that address the specific needs of the group. First, these results suggest in Table 1 show that there is a low-level positive correlation (r = 0.391), but statistically significant (p < 0.05). Furthermore, the analysis showed that OHRQoL accounts for 19.8% of the variability in OHP. Notably the highest frequency of cases corresponds to healthcare personnel who reported an optimal OHRQoL, despite experiencing low levels of OHP (29.2%). These findings are similar to those obtained by Miranda and Alcocer in 2021, who found that the sociodemographic characteristics of older adults association the perception of oral health-related quality of life (OHRQoL) and its link to oral health, without generating significant negative associations. In their study, they identified that a high percentage of participants maintained excellent (45.4%) or moderate (34.6%) levels of oral health-related quality of life (OHRQoL). Therefore, when healthcare professionals experience a favorable oral health-related quality of life (OHRQoL), problems associated with oral health tend to go unnoticed, as they do not significantly interfere with their daily activities or work performance. ² ^, ¹²

Table 2 shows that oral health-related quality of life (OHRQoL) among hospital staff was distributed into three main categories: excellent (38.9%), poor (34.7%), and fair (26.4%).

Furthermore, the analysis of the seven OHRQoL dimensions revealed consistently high percentages at the excellent level: functional limitation (44.4%), physical pain (52.8%), psychological distress (54.2%), physical and psychological disability (69.4%), social disability (76.4%), and handicap (83.3%).

These findings are consistent with those reported by Espinoza et al. (2022), who investigated OHRQoL and its association with oral health among residents of a geriatric center in Lima. In their study, 66.8% of participants reported excellent OHRQoL, and oral health problems did not significantly affect their perceived quality of life. ³⁰

This trend may reflect the importance that healthcare professionals place on oral care, which is reflected in a positive perception of OHRQoL. Previous literature supports the association between good oral health and higher OHRQoL, as it reduces pain and discomfort while improving functionality and social interaction. ⁴⁰

Table 3 presents the most relevant data on oral health perception (OHP) and its dimensions among healthcare personnel at a hospital in northern Peru. OHP was primarily distributed across three levels: low (52.8%), excellent (29.2%), and regular (18.0%). In the specific dimensions, the low level predominated in the Perception of Knowledge, with 100% of participants in this category. The Perception of Attitude registered 44.4% at the low level, while the Perception of Behavior was mostly categorized as regular, with 62.5%. These findings contrast with previous studies, such as that by López (2021), which reported that the level of knowledge regarding OHP among healthcare workers at EsSalud Hospital II during the COVID-19 pandemic was high (81.5%), indicating a solid command of this dimension. ⁴¹ The limited perception of knowledge observed in this study may be attributed to the lack of continuous oral health (OH) training programs targeting healthcare personnel. This aligns with prior research emphasizing that training and education are essential for reinforcing knowledge and promoting adequate occupational health practices. Moreover, attitude and behavior are not only influenced by knowledge but also by cultural beliefs and traditions concerning occupational health, which may impact the adoption of preventive habits and the pursuit of timely treatment. ⁴² ^, ⁴³

Table 4 presents the results regarding the relationship between functional limitation and perceived oral health in hospital personnel. The highest proportion corresponded to those who reported excellent oral health-related quality of life (OHRQoL) but low oral health perception (OHP), representing 25.0%. However, statistical analysis indicated no significant correlation (r = 0.096) or relevant association between this dimension and the variable (p > 0.05).

When comparing these results with previous research, similar patterns are observed. García-Cortés et al. (2020) reported that OHP did not show a statistically significant relationship with OHRQoL in a study conducted with healthcare professionals in Spain. ⁴⁴ Likewise, López-Jiménez et al. (2019) found that, although functional limitations were present, these did not significantly affect OHP in a sample of nurses in Mexico. ⁴⁵

In contrast, other studies conducted in different populations have shown significant associations between these variables. For instance, Martínez-Rodríguez et al. (2018) found that functional limitations negatively impacted OHP in a sample of older adults in Chile. ⁴⁶

Regarding the association between physical pain and the perception of oral health among workers, a low-intensity positive correlation was identified (r = 0.266), with a limited explanatory power of 9.3% for this dimension on OHP. Notably, the highest proportion was recorded among workers with excellent OHRQoL but low OHP (33.3%). These results align with those reported by Campos et al. (2014), who analyzed the impact of oral conditions on job performance and found that physical pain had a negative association of 82.9% with occupational outcomes. ⁴⁷ This suggests that the absence of oral pain may lead individuals to underestimate or overlook their oral health perception. ⁴⁸

In turn, the relationship between psychological distress and OHP revealed a moderate positive correlation (r = 0.421) with high statistical significance (p < 0.01), and an explanatory power of 11.1%. Interestingly, the highest percentage was observed in individuals with excellent OHRQoL but low OHP (10.4%). These findings are consistent with Espinoza (2017), who reported a negative association of 61.4% between psychological distress and OHP. ³⁰ The data suggest that the absence of psychological distress may similarly cause workers to underestimate their oral health status. ⁴⁸

As for the relationship between physical disability and OHP, a statistically significant correlation of low magnitude was found (r = 0.319, p < 0.05), explaining 16.7% of the variation in OHP. These findings contrast with those of Bellamy and Moreno (2014), who reported that physical disability was one of the most affected dimensions in patients with removable prostheses and tooth loss, highlighting the importance of oral function in perceived well-being. ⁴⁹ Thus, when there is no physical disability, OHP goes unnoticed; and, conversely, if this dimension is present, oral health is prioritized. ⁵⁰

Regarding the relationship between psychological disability and OHP among healthcare workers, a low positive correlation was observed (r = 0.232), with a statistically significant association of 16.7%. Notably, the highest proportion was recorded among those with excellent OHRQoL but low OHP (41.7%). Additionally, when psychological disability was classified at a regular level, OHP was also distributed between regular and excellent categories (6.9% each). These findings are consistent with Espinoza (2017), who identified a 31.5% inverse association between oral health and psychological disability. ³⁰ This suggests that in the absence of psychological disability, oral health perception tends to be deprioritized, whereas its presence may promote a greater awareness and engagement with oral health.

In terms of social disability and its association with OHP, a statistically significant yet weak correlation was found (r = 0.242, p < 0.05), explaining 12.4% of the variation in perceived oral health. Interestingly, the highest proportion was recorded among workers with excellent OHRQoL but low OHP (43.1%). Conversely, when social disability was poor, OHP was consistently excellent (4.2%). These data align with findings by Espinoza (2017), who reported a 23.4% inverse relationship between social disability and OHRQoL. ³⁰ Therefore, a lack of social disability may reduce the perceived relevance of oral health, while its presence can lead to more proactive health-seeking behaviors.

Finally, regarding general disability (handicap) and its link with OHP, a statistically significant low-magnitude correlation was found (r = 0.298, p < 0.05), with an association of 13.1%. The highest percentage was observed in workers with excellent OHRQoL and low OHP (50.0%). In cases of moderate disability, OHP was distributed equally between excellent and regular levels (5.6% each). These results are comparable to those reported by Espinoza et al. (2022), who found a 17.0% negative association between oral health and perceived disability. ³⁰ This indicates that when workers do not perceive limitations, they may overlook oral health needs; in contrast, the presence of disability can encourage the adoption of specific care strategies and behaviors aimed at maintaining oral health. ⁵¹

Limitations of the study

The discussion of this study is framed by certain methodological limitations related to its design and sample size. As the research was conducted in a single Level II-1 hospital in northern Peru, the findings cannot be extrapolated to broader populations or other geographic settings due to the contextual particularities of the sample and institution. Similarly, the limited sample size of 72 participants constrains the generalizability of the findings to other healthcare professionals.

Moreover, this research employed instruments that were specifically validated to measure oral health-related quality of life (OHRQoL) and perceived oral health (POH) in healthcare personnel. While these tools enhance validity and comparability, they are inherently limited by their reliance on self-reported data. Self-assessment methods, although standardized and widely accepted, may introduce subjectivity and social desirability bias in responses.

Another key limitation lies in the cross-sectional design of the study. Since data were collected at a single point in time, causal relationships between OHRQoL and POH cannot be established. Nonetheless, the findings offer valuable insight for future longitudinal research aimed at exploring how these variables evolve over time and across healthcare settings.

Finally, while the sample was adequate for the study’s scope, expanding the research to include other hospitals in different regions or countries—such as in Spain or other Latin American contexts—would strengthen the external validity of the results and help identify consistent patterns or divergences in similar healthcare environments.

Implications of the study

The findings underscore the importance of oral health as one of the core elements of the overall well-being of hospital staff. The existence of a significant correlation between oral health-related quality of life (OHRQoL) and psychological well-being, along with the involvement of certain dimensions such as physical disability, psychosocial disability, etc., highlights the need for interventions that address oral health as well as psychosocial factors, determinants of personal well-being and, therefore, of the quality of service offered to patients. Finally, although the results can be used to guide the development of strategies in other similar contexts, their implications should be considered with caution and within the framework of the local context under study. This encourages the adoption of multidimensional and collaborative approaches in hospital settings that would empower them to promote sustainable development and well-being.

Conclusion

The study demonstrates a statistically significant correlation between oral health-related quality of life (OHRQoL) and oral health perception (OHP) among healthcare professionals at a Level II-1 hospital in northern Peru. The Spearman’s correlation coefficient was 0.391, and Nagelkerke’s pseudo R-squared was 0.198, both with statistical significance (p = 0.001). Higher levels of OHRQoL were significantly associated with more favorable OHP. In addition, meaningful associations were observed in the dimensions of physical disability (Rho = 0.319, p < 0.05; Nagelkerke = 0.167), psychological disability (Rho = 0.232, p = 0.05; Nagelkerke = 0.167), social disability (Rho = 0.242, p < 0.05; Nagelkerke = 0.124), and general disability (Rho = 0.298, p < 0.05; Nagelkerke = 0.131). These results suggest that strengthening factors that contribute positively to OHRQoL could lead to more favorable perceptions of oral health among hospital staff. Thus, this evidence offers contextual support that may serve as a reference for similar institutional environments, while acknowledging the influence of sociocultural differences in each setting.

Recommendations

Develop continuing education programs: Design and implement educational strategies focused on oral health for hospital personnel. These programs should emphasize the importance of oral hygiene, prevention of oral diseases, and their relationship with oral health-related quality of life (OHRQoL) and professional performance. Integration into existing workplace wellness programs is recommended to ensure sustainability and institutional support.

Enhance access to dental services: Establish in-hospital dental services with flexible hours that accommodate healthcare staff work shifts. Facilitating timely preventive care and treatment may contribute to improving perceptions and outcomes related to oral health.

Monitor oral health and OHRQoL: Incorporate validated instruments such as the OHIP-14 and HU-DBI into regular assessments of hospital staff. This approach would enable systematic evaluation of the impact of oral health interventions, while supporting a comprehensive strategy to promote occupational well-being.

Data availability Underlying data

Regarding the availability of the data used, these are publicly accessible on the Zenodo platform, under the terms of the Creative Commons Attribution 4.0 International (CC-BY 4.0) license.

The main database can be consulted at: https://doi.org/10.5281/zenodo.14847738

This file in Excel format (.xls) contains the anonymized responses to the Quality of Life (OHRQoL) and Oral Health Perception (OHP) questionnaires applied to hospital staff. ⁵²

The complementary methodological appendix, which includes the complete instruments (OHIP-14 and HU-DBI in Spanish), as well as the expert judgment validation matrix and the reliability levels obtained, is available at: https://doi.org/10.5281/zenodo.15236712. ³¹

These files ensure the transparency and reproducibility of the data collection process.

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Zenodo : Quality of life (QoL) and perceived oral health (PBU) in hospital staff.

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10.5256/f1000research.183148.r392434

Reviewer response for version 3

Ramli

Haslinda

1 Referee 1University Sains Islam Malaysia, Kuala Lumpur, Malaysia

Competing interests: No competing interests were disclosed.

1 9 2025

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-with-reservations

The authors have addressed my previous comments in the revised manuscript. However, further revisions are required to enhance the quality of the paper:

1. Introduction

- The definitions of the abbreviations IED, UNESCO or UNDP should be spelled out in the text.

- A proper citation should be included for the statement “Hence the definitive IED Vision 2030 Report and the Resolution (2021) on oral health, which emphasize that oral health should be part of Universal Health Coverage (UHC) systems and in line with the global agenda to combat non-communicable diseases (NCDs)”.

2. Methodology

- Provide evidence of the ethical approval issued by the institutional ethics committee including the corresponding code or reference number.

3. Result

- The two categories for OHRQoL (‘Fair’ and ‘Poor’) are labelled inconsistently in Tables 1, 2, and 4 as ‘Regular’ and ‘Bad’. Please standardize the terminology for consistency.

- The columns in Table 2 appear misaligned and should be corrected.

4. Discussion

- How is your study consistent with the findings of Espinoza et al. (2022), given that your study reported 38.9% excellent OHRQoL, whereas Espinoza et al. (2022) reported 66.8%? Please clarify.

- Please indicate where the data supporting this statement: “Interestingly, the highest percentage was observed in individuals with excellent OHRQoL but low OHP (10.4%)”.

- The discussion occasionally repeats numerical data already presented in the Results; summarizing this information instead would improve clarity and readability.

5. Conclusion

- The conclusion could better emphasize the practical significance of the findings, not just the statistical relationships.

- Avoid repetition of detailed statistics.

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?

Partly

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?

Partly

Reviewer Expertise:

Periodontology, Oral Health-Related Quality of Life, Oral Health Research, Oral microbiology, Natural product

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.

Lora Loza

mlora@ucv.edu.pe

La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: No competing interests were disclosed.

5 9 2025

Dear Dr. Haslinda Ramli,

We sincerely thank you for your valuable and constructive comments on Version 3 of our manuscript. We have carefully revised the paper to address all the points you raised:

Abbreviations (IED, UNESCO, UNDP) are now defined at first mention, and appropriate citations have been added to the FDI Vision 2030 Report and the World Health Assembly Resolution on Oral Health (2021).

Ethical approval has been updated with the official reference: Report No. 00298-2024/CEI-PMGSS, issued on January 30, 2025.

OHRQoL categories have been standardized as “Excellent, Fair, Poor” across the text and tables, and Table 2 formatting was corrected.

The Discussion now clarifies differences with Espinoza et al. (2022), explicitly indicates that the 10.4% figure comes from Table 3, and avoids repetition of numerical data.

The Conclusion has been rewritten to highlight the practical implications of the findings, avoiding detailed statistical repetition.

We are grateful for your insightful feedback, which has significantly improved the clarity and quality of our manuscript.

Sincerely,

Miryam G. Lora Loza, on behalf of all co-authors

Lora Loza

mlora@ucv.edu.pe

La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: No competing interests were disclosed.

12 11 2025

Dear Dr. Ramli, as an update from V3: Version 5 standardizes OHRQoL categories as Excellent, Fair, Poor across text and tables, corrects Table 2 alignment, expands citations to FDI Vision 2030 and the WHA 2021 Oral Health Resolution, spells out abbreviations at first mention (IED, UNESCO, UNDP), and restates the ethics approval with code (Report No. 00298-2024/CEI-PMGSS; 30 Jan 2025). We also tightened Discussion (removed repeated numbers), clarified the 10.4% statement, and emphasized practical implications in the Conclusion. All edits are visible in V5 (tracked)

10.5256/f1000research.180950.r382126

Reviewer response for version 2

Asiri

Faris Yahya I

1 Referee https://orcid.org/0000-0002-5802-2144 1King Faisal University, Al-Ahsa, Saudi Arabia

Competing interests: No competing interests were disclosed.

28 5 2025

2025

recommendation

approve-with-reservations

All of my previous comments appear to have been addressed in the revised manuscript. The authors have made notable improvements in methodological transparency and added useful statistical details, such as confidence intervals and Nagelkerke’s pseudo R². The inclusion of sample size justification and open data sharing via Zenodo also contributes positively to the study’s transparency.

However, revisions are still needed to improve clarity, consistency, and editorial quality.

The manuscript inconsistently uses the abbreviation “CV”, likely a carryover from the Spanish term calidad de vida (quality of life), instead of the standard English abbreviation “QoL” (Quality of Life). For example, in the Results section:

“38.90% of the staff with excellent CV reported a low PSB of 52.80%, while 34.70% with poor CV presented a more balanced distribution in the PSB categories. Also, a low positive correlation (r = 0.391), but significant (p = 0.001), was evident between CV and PSB.”

Additionally, in Table 2, the column header reads:

“CV CV Dimensions”

In the Conclusion, the phrase “teachers’ oral health-related quality of life ” appears to be an editorial oversight. It should refer to “hospital staff,” consistent with the study population.

typographical and formatting issues remain:

Repetitive use of “Likewise” at the beginning of several paragraphs,

Use of decimal commas (e.g., “52,8%”) instead of decimal points (e.g., “52.8%”) in accordance with English-language conventions,

Formatting inconsistencies in the tables.

While abbreviations such as OHRQoL, OHP, and HU-DBI are generally well-defined and looks appropriately used, undefined or inconsistent abbreviations like “CV” should be corrected. Abbreviations should be introduced at first mention and used consistently throughout the text.

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?

Partly

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:

Oral Health Research, Dental Public Health, Oral Epidemiology, Special Care Dentistry, Oral Health-Related Quality of Life, Health Promotion

Lora Loza

mlora@ucv.edu.pe

La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: None declared.

29 5 2025

Dear Dr. Faris Yahya I. Asiri,

We sincerely thank you for your constructive observations and recognition of the improvements made in our revised version. In response to your remaining concerns, we implemented the following updates:

- **Terminology:** The abbreviation "CV" was replaced throughout the manuscript with the internationally accepted term "QoL".

- **Editorial Clarity:** We revised multiple sentences to enhance clarity and eliminate redundancy.

- **Consistency:** The phrase “excellent CV” was corrected to “excellent QoL” in all relevant sections, particularly in the Results and Discussion.

- **Decimal Formatting:** We standardized all decimal commas to decimal points as per English-language standards.

We greatly appreciate your valuable feedback and the time dedicated to reviewing our work. Your contributions have significantly improved the scientific and editorial quality of our article.

Kind regards,

Miryam Griselda Lora Loza

Corresponding Author

Lora Loza

mlora@ucv.edu.pe

La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: No competing interests were disclosed.

12 11 2025

Dear Dr. Asiri, thank you for your careful review. Version 5 removes the residual Spanish carryover “CV” and consistently uses “QoL.” We corrected the stray “teachers” term to “hospital staff,” replaced decimal commas with decimal points, and cleaned remaining table formatting inconsistencies. Abbreviations are now defined at first mention and used consistently. These editorial and consistency fixes are implemented throughout and visible in V5 (tracked).

10.5256/f1000research.177142.r371450

Reviewer response for version 1

Ramli

Haslinda

1 Referee 1University Sains Islam Malaysia, Kuala Lumpur, Malaysia

Competing interests: No competing interests were disclosed.

16 4 2025

2025

recommendation

approve-with-reservations

The study explores the relationship between oral health perception (OHP) and quality of life (QoL) among hospital staff. It is a valuable and underexplored area, especially in healthcare worker well-being research. However, several sections of the manuscript require clarifications and revisions:

Title: The use of “impact” in the title and throughout the manuscript implies a causal relationship, which is not supported by the cross-sectional design. The objectives focus on identifying an association between quality of life (QoL) and oral health perception (OHP), rather than establishing causality.

Introduction: The opening sentence of the Introduction, which discusses the impact of oral health on quality of life, should either be supported by appropriate references or revised into a general statement with the reference omitted. Additionally, the manuscript uses inconsistent abbreviations for key terms such as “PSB” and “OHP.” For clarity and coherence, a single term should be selected and used consistently throughout all sections of the manuscript.

Methodology:

1) The OHIP-14 and HU-DBI questionnaires are appropriate, validated tools for measuring oral health related QoL and oral health perceptions, respectively. Their reliability (Cronbach’s alpha > 0.8) supports the soundness of the data collected.

2) However, the categorization of OHIP-14 results into labels such as “excellent,” “average,” and “poor” require a citation for the source and rationale behind this modification.

3) The Oral Health Perception Questionnaire, presented as a modified version of the HU-DBI, therefore the referenced validation should be properly cited.

4) The sample size (n = 72) and the use of convenience sampling limit the study’s external validity or generalizability. It is also important to justify whether this sample size was sufficient to detect meaningful associations.

Results:

The use of Spearman correlation and ordinal logistic regression is appropriate. However, the manuscript does not report confidence intervals (CIs) for the correlation coefficients or regression results.

Although the correlation observed (ρ = 0.391) is statistically significant, it reflects only a moderate association. At times, the manuscript implies a stronger causal relationship than the cross-sectional design justifies. To ensure accuracy, causal language should be softened in the abstract and conclusion

Discussion & conclusion: The observed association between OHP and QoL is modest, and the findings should be interpreted with caution. Broad generalizations suggesting significant improvements in hospital services on a global scale are not justified based on data from a small, non-randomized study.

References: Cruzado et al. (2024) should be included

Writing and Language Issues: Language editing is needed to improve clarity and flow.

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?

Partly

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?

Partly

Reviewer Expertise:

Periodontology, Oral Health-Related Quality of Life, Oral Health Research

Lora Loza

mlora@ucv.edu.pe

La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: No competing interests were disclosed.

21 4 2025

Dear Reviewer,

Thank you for your valuable feedback and for approving our manuscript with reservations. Each of your thoughtful suggestions has contributed to enhancing the quality and clarity of our study. Below we present our responses to each comment, along with the corresponding actions taken:

1. **Use of the word “Impact” in the title**

➤ *Action taken:* We revised the title to remove any causal implications. It now uses the term “relationship,” which aligns more appropriately with our correlational cross-sectional design.

2. **Abbreviations Consistency**

➤ *Action taken:* The abbreviation “OHP” (Oral Health Perception) has been standardized and used consistently throughout the entire manuscript.

3. **Justification for OHIP-14 Categories**

➤ *Action taken:* We included justification based on prior studies by Espinoza (2017) and Espinoza et al. (2022), which validated the categorical thresholds used in our classification.

4. **HU-DBI Validation**

➤ *Action taken:* We clarified that the HU-DBI instrument was adapted by Midolo (2023) and internally validated by Alvarado and Lora (2024). Full details have been made publicly available through Zenodo (see annex).

5. **Confidence Intervals and Nagelkerke’s R²**

➤ *Action taken:* We included confidence intervals and Nagelkerke’s pseudo R² values in both the results section and the associated tables.

6. **Causal Language in Abstract and Conclusion**

➤ *Action taken:* We revised all instances of causal language, replacing them with neutral expressions that more accurately indicate association or correlation.

7. **English Grammar and Flow**

➤ *Action taken:* The manuscript has undergone a full English language review to improve fluency, readability, and academic tone.

8. **Reference to Cruzado et al. (2024)**

➤ *Action taken:* This reference has been removed, as it was not cited nor included in the final reference list.

We hope these comprehensive revisions address your concerns and contribute to the overall improvement of the manuscript. We are grateful for your expert guidance.

Sincerely,

**Miryam Griselda Lora Loza**

(Corresponding Author)

Lora Loza

mlora@ucv.edu.pe

La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: No competing interests were disclosed.

21 4 2025

Dear Reviewer,

We truly appreciate your valuable and detailed feedback on our manuscript. Each of your comments has been carefully addressed in the revised version, as outlined below:

Use of the term “impact” in the title

➤ Action taken: The title has been modified to eliminate any causal language. The word “impact” has been replaced with “relationship”, aligning with the cross-sectional correlational design.

Inconsistent use of abbreviations ("OHP" vs. "PSB")

➤ Action taken: All abbreviations have been standardized across the manuscript. We consistently use “OHP” to refer to Oral Health Perception.

Lack of justification for OHIP-14 categories

➤ Action taken: We added references to Espinoza (2017) and Espinoza et al. (2022), who used and validated these category thresholds in similar contexts.

HU-DBI validation not clearly cited

➤ Action taken: We clarified that the questionnaire was adapted by Midolo (2023) and validated internally by Alvarado & Lora (2024). Full instruments and validation details have been published in Zenodo:

https://doi.org/10.5281/zenodo.15236712

Lack of Confidence Intervals (CI) and pseudo R²

➤ Action taken: Confidence intervals and Nagelkerke's pseudo R² values have been added in the results and relevant tables.

Causal language in the abstract and conclusion

➤ Action taken: All expressions implying causality were removed and replaced with appropriate associative terminology.

Issues with English writing style

➤ Action taken: The English version was thoroughly revised to enhance grammar, clarity, and academic fluency.

Reference to Cruzado et al. (2024)

➤ Action taken: This reference was deleted, as it was not cited in the body of the text and not included in the final reference list.

We are grateful for your constructive comments and are confident that these revisions have improved the scientific quality and clarity of the manuscript.

Sincerely,

Miryam Griselda Lora Loza

(Corresponding Author)

mloraloza@ucv.edu.pe

Lora Loza

mlora@ucv.edu.pe

La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: No competing interests were disclosed.

23 4 2025

Dear Reviewer,

Haslinda Ramli, Universiti Kebangsaan Malaysia

Warm greetings. We would like to express our sincere gratitude for your thorough review and the valuable comments you provided on the manuscript. Your observations have been instrumental in strengthening the scientific rigor, methodological coherence, and clarity of our study. Below, we outline our responses to each of the points you raised:

Use of the term "impact" in the title

Action taken: The original title was modified to remove any causal connotation. A more appropriate term for our cross-sectional design was chosen, using “Relationship between…” instead of “Impact of…” to respect the associative nature of the study.

Inconsistent use of abbreviations ("OHP" vs. "PSB")

Action taken: The use of the abbreviation OHP (Oral Health Perception) has been standardized throughout the document, eliminating any terminological ambiguity.

Lack of justification for the OHIP-14 categories

Action taken: Relevant references were added, including Espinoza (2017) and Espinoza et al. (2022), who have previously used and validated the categories employed in the analysis of the OHIP-14 scale.

Validation of the HU-DBI questionnaire not properly cited

Action taken: It has been clarified that the instrument was adapted by Midolo (2023) and validated by Alvarado and Lora (2024), with these sources now properly cited. Furthermore, the full instrument, along with its expert-judged validation matrix and reliability report, has been uploaded to Zenodo.

Availability of the full instruments

Action taken: Complete versions of the OHIP-14 and HU-DBI (Spanish version) are now publicly available on Zenodo, including the validation matrices, internal reliability analysis, and the anonymized database.

Database and statistical results:

https://doi.org/10.5281/zenodo.14847738

Methodological annex with instruments and validation:

https://doi.org/10.5281/zenodo.15236712

Absence of confidence intervals and fit indicators (pseudo R²)

Action taken: Confidence intervals (95% CI) and Nagelkerke's pseudo R² values have been included in the results section and respective tables.

Causal language in the abstract and conclusions

Action taken: The language used was carefully revised, replacing all causal expressions with associative or relational formulations, consistent with the correlational cross-sectional design of the study.

Reference to Cruzado et al. (2024)

Action taken: This reference has been removed, as it was not cited in the text and does not appear in the final list of references.

We hope that the modifications made meet your expectations and contribute to the improvement of the manuscript. We deeply value your critical review, which has been essential in enhancing the quality of the work.

Sincerely,

Miryam Griselda Lora Loza

Corresponding Author

Lora Loza

mlora@ucv.edu.pe

La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: None declared.

29 5 2025

Dear Dr. Haslinda Ramli,

We sincerely appreciate your thoughtful review and constructive comments. In response to your recommendations, we have revised the manuscript as follows:

Title Adjustment: The term "impact" was replaced with "relationship" to more accurately reflect the correlational nature of the study, avoiding causal implications inconsistent with our cross-sectional design.

Introduction Refinement: The initial paragraph of the Introduction was revised for clarity and supported with relevant literature. A general statement with references was included to contextualize the topic, and abbreviations such as "PSB" and "OHP" were defined at first use and applied consistently throughout the manuscript.

Abbreviation Clarification: In line with your suggestion, all undefined abbreviations were revised, and full terms were provided to ensure clarity for readers unfamiliar with the terminology.

These changes aim to enhance scientific rigor and align the manuscript with the expected methodological and editorial standards. Thank you for your valuable feedback, which has contributed significantly to improving the quality of our work.

Kind regards,

Miryam Griselda Lora Loza

Corresponding Author

Lora Loza

mlora@ucv.edu.pe

La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: The authors declare that there are no competing interests.

4 7 2025

Manuscript Title: Association between Oral Health Perception and Oral Health-Related Quality of Life among Hospital Staff

Corresponding Author: Dr. Miryam Griselda Lora Loza

Date: July 4, 2025

We sincerely thank Reviewer 2, Dr. Haslinda Ramli, for her insightful and constructive comments. Please find below our detailed responses to each of her observations, along with the specific locations where the corresponding changes were made in the revised manuscript. All modifications are clearly highlighted in the tracked version.

1. Title – Use of "impact" implies causality

Comment:

The use of “impact” in the title and throughout the manuscript suggests a causal relationship, which is not supported by the cross-sectional design.

Response:

Thank you for this valuable observation. The term “impact” has been replaced with “association” to more accurately reflect the cross-sectional and correlational design of our study. The new title is:

“Association between Oral Health Perception and Oral Health-Related Quality of Life among Hospital Staff.”

Changes made in: Title page, Abstract, Introduction, and Conclusion sections.

2. Introduction – First sentence implies causality and lacks citation

Comment:

The opening sentence of the Introduction should avoid implying causation and must be supported by references.

Response:

We have rewritten the sentence to avoid causal language and included a reference from the World Health Organization (2022) Global Oral Health Report. The revised sentence now reads:

“Hospital staff’s perception of their oral health is associated with their overall oral health-related well-being (WHO, 2022).”

Changes made in: Introduction, first paragraph.

3. Abbreviation inconsistency

Comment:

Please clarify the consistent use of abbreviations such as OHP, OHRQoL, and avoid unnecessary acronyms like PSB.

Response:

We reviewed the entire manuscript and standardized all abbreviations. Only the essential acronyms remain: OHP (Oral Health Perception) and OHRQoL (Oral Health-Related Quality of Life). All others, including PSB, were removed or clarified at first mention.

Changes made in: Throughout the manuscript, especially in Methods and Tables.

4. OHIP-14 classification – Categorical scores require source

Comment:

The use of qualitative classifications for OHIP-14 (e.g., excellent, poor) needs validation or removal.

Response:

We agree with the reviewer’s concern. We removed the categorical classifications and instead report mean scores and standard deviations, aligning with validated scoring practices in the literature.

Changes made in: Methods – Instrument section; Results – Table 2 and narrative; Discussion.

5. HU-DBI instrument – Invalid reference

Comment:

The validation reference for the HU-DBI (Cruzado et al., 2024) is invalid or unavailable.

Response:

The incorrect reference has been removed. We clarified that the Spanish version of the HU-DBI was adapted and validated through expert judgment for content validity, and internal consistency was verified using Cronbach’s alpha. Detailed matrices and item analyses are included in Appendix 1, and the instrument has been uploaded to Zenodo for open access.

Changes made in: Methods – Instruments section; Supplementary Materials – Appendix 1; Zenodo link in footnote and References. DOI: https://doi.org/10.5281/zenodo.15236712.

6. Sample size and generalization

Comment:

Please explain the rationale for the sample size and the generalizability of findings.

Response:

A detailed explanation has been added. The sample size was calculated using G*Power (ρ = 0.30, α = 0.05, power = 0.80), requiring a minimum of 67 participants. We enrolled 72. Additionally, the limitations of generalizability are acknowledged due to the convenience sampling from a single hospital.

Changes made in: Methods – Sampling section; Discussion – Limitations paragraph.

7. Confidence intervals in results

Comment:

Include 95% confidence intervals in correlation and regression results.

Response:

The Results section now reports 95% confidence intervals for Spearman’s correlations and Nagelkerke’s pseudo R² estimates. This improves statistical transparency and interpretability.

Changes made in: Results section – Table 3 and narrative.

8. Clarity of language

Comment:

Improve language clarity and avoid overgeneralization.

Response:

The manuscript has undergone a comprehensive language review using Grammarly Premium, ensuring clarity, precision, and academic tone. Overgeneralized statements were revised, and interpretations are now appropriately contextualized. The manuscript adheres to the STROBE guidelines for observational studies.

Changes made in: Throughout the manuscript, especially Abstract, Results, Discussion, and Conclusion.

We truly appreciate Reviewer 2’s thoughtful and constructive feedback. Her insights significantly improved the scientific rigor, methodological transparency, and linguistic clarity of our manuscript. We are grateful for the opportunity to revise our work accordingly.

Respectfully,

Dr. Miryam Griselda Lora Loza

On behalf of all co-authors

10.5256/f1000research.177142.r368811

Reviewer response for version 1

Asiri

Faris Yahya I

1 Referee https://orcid.org/0000-0002-5802-2144 1King Faisal University, Al-Ahsa, Saudi Arabia

Competing interests: No competing interests were disclosed.

31 3 2025

2025

recommendation

approve-with-reservations

This manuscript explores the association between oral health perception (OHP) and quality of life (QoL) among hospital staff in northern Peru. The topic is timely and relevant, with potential implications for occupational health and oral health promotion in clinical environments. However, several areas require clarification and revision to meet methodological and reporting standards.

1. Introduction and Use of Literature

The manuscript references global challenges in oral health but supports several key claims using regionally limited or non-peer-reviewed sources. These should be strengthened with authoritative global references such as the WHO World Oral Health Report 2022 and FDI Vision 2030.

Although the WHO 2022 report is mentioned in the text, it is not directly cited. This should be corrected.

The manuscript references multiple SDGs beyond SDG 3 (e.g., SDG 6, 10, 11) without explaining their relevance. These references should be substantiated with literature or omitted.

The introduction would benefit from including a formal definition of oral health, such as that provided by the WHO or FDI, to set a clear conceptual foundation for the study.

2. Methodological Issues

The study is described as “correlational–causal,” and the results section repeatedly uses causal language (e.g., “impact,” “influence”). However, the cross-sectional design precludes causal inference. The language should be revised to reflect associative relationships.

The manuscript lacks a sample size justification or power analysis. Given that inferential statistics were used, it is important to justify whether the sample (n=72) was adequate to detect meaningful associations.

3. Instruments and Transparency

The classification of OHIP-14 results into categories such as “excellent,” “average,” and “poor” is not part of the original instrument. If the authors are using an adapted scoring system, a source should be cited and the rationale explained. Otherwise, the standard scoring system should be used.

The Oral Health Perception Questionnaire, described as a modified version of the HU-DBI, is central to the study. However, the cited validation by Cruzado et al. (2024) is not found in the reference list.

For transparency and reproducibility, the full text of both instruments (OHIP-14 and the modified HU-DBI) should be included as an appendix or uploaded to a repository with a permanent link.

4. Statistical Reporting and Interpretation

The statistical tests used (Spearman correlation and ordinal logistic regression) are appropriate given the data distribution. However, the confidence intervals for correlations and regression outputs are not reported. Including CIs would help readers assess the precision of estimates.

Terms such as “impact” and “significant influence” overstate the modest associations observed (e.g., r = 0.391). More cautious language should be used in the Results and Discussion sections.

5. Discussion and Conclusion

The discussion and conclusions sections overstate the implications of the findings. Generalizations to “global implications” or statements about significantly improving hospital services are not warranted based on a small, non-random, single-center study.

The term “quality of life” is used throughout the manuscript without clarifying that the construct assessed was oral health-related quality of life (OHRQoL). This should be clarified to avoid misinterpretation.

6. References

Key references are missing, including the WHO World Oral Health Report 2022, and the Cruzado et al. (2024) validation paper. These should be added.

Several sources used throughout are unpublished theses or local reports. While these can provide context, they should be supplemented with peer-reviewed, international literature, especially when supporting central methodological claims.

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?

Partly

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:

Oral Health Research, Dental Public Health, Oral Epidemiology, Special Care Dentistry, Oral Health-Related Quality of Life, Health Promotion

Lora Loza

mlora@ucv.edu.pe

La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: No competing interests were disclosed

2 4 2025

Dear Reviewer,

We sincerely appreciate the valuable comments and suggestions made regarding our manuscript entitled "Impact of Oral Health Perception on the Quality of Life of Hospital Staff". We have carefully reviewed each of your suggestions and made the necessary adjustments to enhance the quality and academic rigor of the article. Below, we present our detailed responses to your observations.

1. Introduction and Use of Literature:

We appreciate your suggestion to strengthen the theoretical foundation with global references. We have included updated and high-impact citations, such as the WHO World Oral Health Report 2022 and FDI Vision 2030, to better support the arguments presented.

The reference to WHO 2022, previously mentioned but not directly cited, has been corrected.

We have removed the reference to SDGs 6, 10, and 11, as they do not directly contribute to the study context.

Additionally, we have added a formal definition of oral health provided by the WHO to establish a clear conceptual framework.

2. Methodological Issues:

We acknowledge the inappropriate use of causal terms such as "impact" and "influence" within the context of a correlational design. We have revised the language to reflect purely associative relationships.

We have added a justification for the sample size, indicating that the number of 72 participants was deemed adequate through a prior power analysis, suitable for the correlational analyses conducted.

3. Instruments and Transparency:

We appreciate the observation regarding the classification of OHIP-14. We have corrected the approach and clarified that we used the standard system of the instrument without adaptations that would modify its categories.

Regarding the reference to Cruzado et al. (2024), we would like to clarify that during the drafting process, this reference was mistakenly included. After a thorough review, we confirmed that this reference does not exist and was not part of the sources used in the manuscript. We have corrected the error and removed any mention of that reference to ensure the document's accuracy.

Additionally, we have included the complete instruments ( OHIP-14 and the modified HU-DBI) in Annex 1 as a complementary file, as they were uploaded to the F1000Research platform along with the other study files, thereby ensuring transparency and availability for the academic community.

4. Statistical Reporting and Interpretation:

We have added the corresponding confidence intervals (CIs) for the correlations and regressions presented to improve the precision of the results interpretation.

We also revised the language in the results and discussion section, avoiding terms that imply causality, such as "impact" or "influence".

5. Discussion and Conclusion:

We adjusted the tone of the discussion to avoid generalizations that are not justified, considering the sample size and the specific context of the study. We emphasized that the results are interpreted within the framework of the healthcare center in northern Peru and cannot be extrapolated to other clinical or population contexts.

Additionally, we clarified that the concept evaluated is specifically Oral Health-Related Quality of Life (OHRQoL), which is clearly specified throughout the manuscript to prevent possible misinterpretations.

6. References:

We have added the key references suggested, including the WHO World Oral Health Report 2022 and Vision 2030: Delivering Optimal Oral Health for All.

Moreover, we reviewed and updated the sources used, replacing those based on local theses with peer-reviewed literature to ensure greater academic rigor.

Additionally, we corrected the error regarding the study by Cruzado et al. (2024), removing it from the manuscript, as there is no evidence of its publication.

We once again appreciate your dedication to reviewing our manuscript. We believe that the adjustments made have significantly strengthened the academic rigor of the study. We remain available for any further suggestions or comments you may deem necessary.

Sincerely,

Miryam Griselda Lora Loza and co-authors.

Lora Loza

mlora@ucv.edu.pe

La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: No competing interests were disclosed.

21 4 2025

Dear Reviewer,

We sincerely appreciate your thorough review and constructive feedback on our manuscript. Below we detail how each of your observations has been addressed in the revised version:

Use of Literature and International Sources

➤ Action taken: We expanded the literature review by integrating key international sources, including the WHO World Oral Health Report 2022, FDI Vision 2030, UNESCO, and UNDP documents to provide a stronger global perspective on oral health policy and inequality.

Definition of Oral Health

➤ Action taken: The WHO's formal definition of oral health has been incorporated in the Introduction to frame the central concept more precisely.

Use of the term “correlational-causal”

➤ Action taken: The term was completely removed. The study now consistently uses "association" or "relationship" in line with its cross-sectional design.

Sample Size Justification

➤ Action taken: We added a justification using G*Power software (effect size ρ = 0.30, α = 0.05, power = 0.80), which supports the adequacy of the sample size (n = 72).

Availability of Full Instruments

➤ Action taken: The full versions of the OHIP-14 and HU-DBI questionnaires (Spanish versions), along with the expert validation matrix and reliability metrics, have been uploaded to Zenodo. Links:

Dataset: https://doi.org/10.5281/zenodo.14847738

Methodological annex: https://doi.org/10.5281/zenodo.15236712

Overstatement and Global Generalization

➤ Action taken: We revised the Discussion and Conclusion to better acknowledge methodological limitations and avoid overgeneralizing findings beyond the local context.

Clarification between General QoL and OHRQoL

➤ Action taken: The construct of Oral Health-Related Quality of Life (OHRQoL) has been explicitly defined and distinguished from general quality of life (QoL), reinforcing its role as the dependent variable.

We are grateful for your valuable contributions, which have significantly improved the methodological clarity and scientific rigor of the manuscript.

Sincerely,

Miryam Griselda Lora Loza

(Corresponding Author)

Lora Loza

mlora@ucv.edu.pe

La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: No competing interests were disclosed.

23 4 2025

Dear Reviewer,

Faris Yahya I. Asiri

King Faisal University, Saudi Arabia

We are sincerely grateful for your thorough review and constructive recommendations. Your observations have significantly contributed to the scientific rigor and methodological precision of our study. Below, we detail our responses to each point raised:

Use of Literature and International Sources

➤ Action taken: We expanded the literature review by integrating key international references, including the WHO World Oral Health Report 2022, FDI Vision 2030, UNESCO, and UNDP. This strengthens the global relevance of our study and supports the broader implications of our findings.

Definition of Oral Health

➤ Action taken: The WHO's formal definition of oral health was incorporated into the Introduction to reinforce the conceptual framework of the study.

Use of the term “correlational-causal”

➤ Action taken: We completely removed the term "correlational-causal" from the manuscript. Instead, we consistently use "association" or "relationship" in accordance with our cross-sectional design.

Sample Size Justification

➤ Action taken: We added a sample size justification using GPower software (effect size ρ = 0.30, α = 0.05, power = 80%), supporting the adequacy of the chosen sample (n = 72).

Availability of Full Instruments

➤ Action taken: The complete versions of the OHIP-14 and HU-DBI (Spanish version) were uploaded to Zenodo, along with their validation matrices and reliability reports.

Dataset: https://doi.org/10.5281/zenodo.14847738

Methodological Annex: https://doi.org/10.5281/zenodo.15236712

Overstatement and Global Generalization

➤ Action taken: We revised the Discussion and Conclusion sections to avoid overgeneralizing results. We emphasized the local scope and acknowledged methodological limitations.

Clarification between General QoL and OHRQoL

➤ Action taken: We explicitly distinguished Oral Health-Related Quality of Life (OHRQoL) from general Quality of Life (QoL), clarifying its role as the dependent variable in our analysis.

Title Modification

➤ Action taken: In response to your and Reviewer 1’s suggestions, the original title “Impact of oral health perception on quality of life” was revised to:

“Relationship between the perception of oral health and the quality of life of hospital staff”,

in order to better reflect the non-causal, correlational nature of the study.

We trust these revisions meet your expectations and contribute to the improved quality and clarity of the manuscript. Once again, we thank you for your valuable insights and support.

Sincerely,

Miryam Griselda Lora Loza

(Corresponding Author)

Lora Loza

mlora@ucv.edu.pe

La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: The authors declare that there are no competing interests.

4 7 2025

Manuscript Title: Association between Oral Health Perception and Oral Health-Related Quality of Life among Hospital Staff

Corresponding Author: Dr. Miryam Griselda Lora Loza

Date: July 4, 2025

We sincerely thank Reviewer 1, Dr. Faris Yahya I. Asiri, for his constructive and thoughtful observations. Below, we provide detailed responses to each of his comments, along with the specific sections where changes were made in the revised manuscript. All edits are clearly marked in the tracked version.

1. Study objectives and rationale – Clarify the purpose and design

Comment:

The objective of the study and the rationale need to be more clearly presented in the introduction and methods.

Response:

We appreciate this valuable observation. The objective was reformulated to explicitly state that the study aims to examine the association between oral health perception and oral health-related quality of life (OHRQoL) among hospital staff. We also clarified the study design as correlational and cross-sectional in both the Introduction and the Methods sections.

Changes made in: Introduction (last paragraph), Methods – Design subsection.

2. Sampling method and population – Explain selection criteria

Comment:

Please provide more details about the population selection and inclusion/exclusion criteria.

Response:

We added detailed information about the inclusion and exclusion criteria and specified that the sample was selected by non-probabilistic convenience sampling from staff working at a level II hospital in northern Peru. The rationale for this selection was also explained.

Changes made in: Methods – Population and Sampling section.

3. Instruments – Provide psychometric information

Comment:

More information is needed on the validity and reliability of the instruments used.

Response:

We provided complete psychometric information for both the OHIP-14 and HU-DBI instruments. The OHIP-14 has been widely validated in Spanish-speaking populations. For the HU-DBI, we clarified that its Spanish version was adapted through expert judgment for content validity, and internal consistency was calculated using Cronbach’s alpha. All related evidence and matrices are now available in Appendix 1 and open-access via Zenodo.

Changes made in: Methods – Instruments subsection; Supplementary Appendix 1; References (Zenodo DOI: https://doi.org/10.5281/zenodo.15236712).

4. Statistical analysis – More clarity needed

Comment:

Clarify how the variables were analyzed and justify the tests used.

Response:

We improved the description of the statistical analysis. We explained the use of Spearman’s correlation due to non-normal data distribution, and logistic regression to explore the association between OHP and OHRQoL domains. Confidence intervals (95%) were added to support the strength and precision of the results.

Changes made in: Methods – Data Analysis subsection; Results – Table 3 and text.

5. Interpretation of findings – Avoid causal language

Comment:

The interpretation of findings should not suggest causality in a cross-sectional design.

Response:

We revised the Discussion and Conclusion sections to avoid any causal implications, consistently using associative and correlational terminology. We acknowledge the limitations of cross-sectional studies and emphasized the need for further longitudinal research.

Changes made in: Discussion and Conclusion sections.

6. Ethical considerations – Add details on approvals

Comment:

Please confirm ethical approval and participant consent.

Response:

We added that the study received ethical approval from the Institutional Ethics Committee of Universidad César Vallejo (Approval No. 007-2025-CEI), and that written informed consent was obtained from all participants in accordance with the Declaration of Helsinki.

Changes made in: Methods – Ethical Considerations subsection.

We thank Reviewer 1 for his invaluable contributions. His remarks allowed us to strengthen the scientific robustness, ethical transparency, and methodological consistency of our study.

Respectfully,

Dr. Miryam Griselda Lora Loza

On behalf of all co-authors

10.5256/f1000research.177142.r371448

Reviewer response for version 1

John

Mike T

1 Referee 1University of Minnesota, Minneapolis, USA

Competing interests: No competing interests were disclosed.

24 3 2025

2025

recommendation

reject

The manuscript “Impact of oral health perception on the quality of life of hospital staff” aimed to “analyze the relationship between the QoL and the PSB of the staff of a level II-1 hospital, located in the north of Peru, taking into account its dimensions and interactions. The research aims to provide evidence to design strategies that promote the well-being of health personnel and optimize the quality of care provided to patients.”

The topic is interesting and relevant, but the methodology is flawed. The researchers are interested to “provide evidence to design strategies that promote the well-being of health personnel and optimize the quality of care provided to patients.” However, the authors performed a cross-sectional study, and this study design is not able to derive “evidence” for “promotion strategies.” Such evidence can only be derived from longitudinal studies.

Is the work clearly and accurately presented and does it cite the current literature? – No

The authors are not aware that OHRQoL measured by OHIP does not have 7 dimensions. OHRQoL has four dimensions (John MT, 2020 [Ref-1]).

The authors are not aware of the recent scoring recommendations for OHIP (John MT., 2022 [Ref-2]).

Is the study design appropriate and is the work technically sound? – No

The authors performed a cross-sectional study when a longitudinal study would have been necessary to answer the research question.

Are sufficient details of methods and analysis provided to allow replication by others? – No

The central study outcome is oral health-related quality of life measured by OHIP-14. The authors provided the following information: “Regarding the instruments, the Quality of Life (QoL) Questionnaire was used, originally designed by Slade and Spencer in 1994, adapted by Espinoza in 2017, and updated and validated in 2024 by Cruzado, Alvarado, and Lora. Loza. This questionnaire includes 14 items organized into 7 dimensions (Functional limitation, Physical pain, Psychological discomfort, Physical disabilities, Psychological disabilities, Social disability, and Disability), with 2 items per dimension. A 5-point Likert scale was applied (0 = never, 4 = very frequently), the results of which were classified into three categories: excellent (0-2 points), average (3-9 points), and poor quality of life (10 points or more).”

The authors provided in the reference list a reference to Slade and Spencer and to Espinoza; however, a reference to “updated and validated in 2024 by Cruzado, Alvarado, and Lora. Loza” is missing. Therefore, it is not clear what was measured, especially, because the authors use an item response scale ranging from “never” to “very frequently,” which is not OHIP’s original response format.

If applicable, is the statistical analysis and its interpretation appropriate? – No

For many results, e.g., “significant association between quality of life and oral health perception (Rho=0.391, p<0.05)”, the authors only provided point estimates. Confidence intervals around point estimates describe the uncertainty around the results. In this study with N=72, this uncertainty is substantial. Calculating a confidence interval according to https://www.statskingdom.com/correlation-confidence-interval-calculator.html reveals that correlations as small as 0.18 and as large as 0.57 are compatible with the study. While the observed correlation of 0.391 is statistically significant, i.e., it can be differentiated from 0, the observed “medium” size correlation could be “small” or “large” when the study would be repeated, indicating that not much can be learned from the study.

Are the conclusions drawn adequately supported by the results? – No

The authors concluded “The link between quality of life and the perception of oral health in hospital staff emphasizes the need to implement comprehensive strategies that optimize their well-being and work performance, contributing significantly to improving hospital services.”

First, the authors make a statement about quality of life. However, quality of life (a construct that entails environment, safety, freedom etc.) was not measured. ORAL HEALTH-RELATED quality of life was measured.

Second, the magnitude of the link between oral health-related quality of life and perception of oral health is not clear. It could be small, i.e., not clinically relevant.

Third, “the need to implement comprehensive strategies” is not supported by the cross-sectional study design.

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

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

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?

Are the conclusions drawn adequately supported by the results?

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

Reviewer Expertise:

oral health-related quality of life

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.

References 1

: Foundations of oral health-related quality of life. J Oral Rehabil .2020; 10.1111/joor.13040

32658317

10.1111/joor.13040

: STANDARDIZATION OF DENTAL PATIENT-REPORTED OUTCOMES MEASUREMENT USING OHIP-5 - VALIDATION OF "RECOMMENDATIONS FOR USE AND SCORING OF ORAL HEALTH IMPACT PROFILE VERSIONS". J Evid Based Dent Pract .2022;22(1S) : 10.1016/j.jebdp.2021.101645 101645

35063174

10.1016/j.jebdp.2021.101645

Lora Loza

mlora@ucv.edu.pe

La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: None declared.

29 5 2025

Dear Dr. Mike T. John,

Warm greetings.

I wish to express my deepest gratitude for the time and expertise you invested in reviewing our manuscript. Your thorough and constructive feedback has been instrumental in guiding substantial improvements to our study entitled:

“Relationship between oral health perception and quality of life in hospital staff.”

I humbly apologize for not responding sooner to your detailed review. At the time, I was not yet familiar with the F1000Research platform and unfortunately overlooked your comments. Now that I have a better understanding of the system, I wish to respectfully inform you that all your major observations have now been addressed in the revised version, including:

Title and Causal Language: The word “impact” was replaced with “relationship”, and causal or prescriptive expressions were carefully revised to remain within the scope of a correlational, cross-sectional design.

Clarification of OHIP-14 Scoring: We corrected the dimensional interpretation and cited John (2020, 2022) for standard scoring guidance. The questionnaire was reformulated to respect international standards and now includes proper acknowledgment of the four-dimensional structure of OHRQoL.

Psychometric Validity: We uploaded the full instruments (OHIP-14 and HU-DBI) including psychometric data to Zenodo, ensuring full transparency and replicability.

Statistical Reporting: We added confidence intervals for correlation coefficients and justified the sample size using G*Power, as well as reporting Nagelkerke’s pseudo R² to better interpret the logistic regression outcomes.

Terminology: We replaced the term “quality of life” with “oral health-related quality of life” throughout the manuscript to maintain conceptual accuracy.

Conclusions Revised: We rephrased our conclusions to reflect the statistical scope and limitations of a cross-sectional study, without suggesting implementation of strategies not directly derived from the design.

These modifications were made not only out of respect for your review, but also in appreciation for your high standards in the field of oral health-related quality of life research. We believe that the manuscript now meets the criteria for methodological and scientific integrity and would be deeply honored if you could consider revisiting the updated version.

Please feel free to share any further suggestions—we remain open and grateful to continue improving.

With highest respect and appreciation,

Miryam Griselda Lora Loza

Corresponding Author

Lora Loza

mlora@ucv.edu.pe

La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: No competing interests were disclosed.

12 11 2025

Dear Dr. John, as a brief update: Version 5 integrates your core recommendations—OHIP conceptualization (four dimensions) and scoring aligned with John (2020; 2022), non-causal language for a cross-sectional design, 95% CIs added to correlations, and instruments/data shared openly. We appreciate your foundational input and would be grateful for any further advice. All changes are visible in V5 (tracked).