PlaqueIndex,OralHygieneHabits,andDepressive...

Research ArticlePlaque Index Oral Hygiene Habits and DepressiveSymptomatology as Predictors of Clinical Attachment Loss APilot Study

Norma Idalia Rodrıguez Franco1 and Jose Moral de la Rubia 2

1Universidad Autonoma de Nuevo Leon Facultad de Odontologıa Monterrey NL ZIP 64460 Mexico2Universidad Autonoma de Nuevo Leon Facultad de Psicologıa Monterrey NL ZIP 64460 Mexico

Correspondence should be addressed to Jose Moral de la Rubia jose_moralhotmailcom

Received 29 February 2020 Revised 13 June 2020 Accepted 24 June 2020 Published 14 July 2020

Academic Editor Li Wu Zheng

Copyright copy 2020 Norma Idalia Rodrıguez Franco and Jose Moral de la Rubia0is is an open access article distributed under theCreative CommonsAttribution License which permits unrestricted use distribution and reproduction in anymedium providedthe original work is properly cited

Background0e effect of depressive symptomatology on periodontitis is not clear in its path of actionObjective To test amodel topredict clinical attachment loss by direct effect of the dental plaque accumulation which is a direct effect of worse oral hygienehabits and an indirect effect of greater depressive symptomatology Methods 0ree incidental samples were collected 35 dentalpatients with periodontitis 26 mental health patients with depressive symptomatology and 29 people from the general pop-ulation 0e Beck Depression Inventory-II and the Oral Hygiene Habits Scale were applied Plaque index and clinical attachmentloss were assessed Path analysis was used to test the model 0e parameters were estimated by the maximum-likelihood methodResults Depressive symptomatology had no direct effect on oral hygiene habits nor an indirect effect (mediated by oral hygienehabits) on the plaque index in any of the 3 samples Oral hygiene habits had a large-size direct effect on plaque index and amedium-size indirect effect on clinical attachment loss in the general population sample 0e plaque index had a direct effect onclinical attachment loss with a large effect size in general population sample and with a medium effect size in dental patients anddepressive symptomatology patients Conclusion 0e model shows that dental plaque accumulation has a direct effect on clinicalattachment loss in the 3 samples and oral hygiene habits have an indirect effect on attachment loss mediated by dental plaqueaccumulation only in the general population sample However depressive symptomatology is not a relevant variable

1 Introduction

Periodontitis is an infectious disease that results in in-flammation of the supporting tissues of the teeth clinicalattachment loss (CAL) and bone loss It is associated withthe presence of dental plaque and calculus [1] 0e clinicalcharacteristics that identify periodontitis are as followsinterproximal CAL ge2 or 3mm interdental CAL detectableat 2 or more nonadjacent teeth and presence of inter-proximal tissue loss confirmed through radiographic as-sessments [2] as well as bleeding at probing periodontalpockets ge4 to 6mm and CAL ge3 to 5mm [3]

0e severity of periodontitis is classified according toCAL and three stages are defined stage I with a CAL from 1to 2mm stage II with a CAL from 3 to 4mm and stage III

with a CAL ge5mm0e extent of periodontal disease can beconsidered localized if less than 30 of the sites are affectedand generalized if more than 30 of the sites are involved[4]

0e periodontitis has multiple determinants Systemicdiseases and conditions that affect periodontal supportingtissues such as diabetes mellitus nicotine dependence orarthritis can worsen periodontal deterioration [5] On theother hand poor oral hygiene generates accumulation ofdental plaque which first leads to gingivitis Subsequentlythe chronification of gingivitis causes a destruction of thetissues that support the teeth and finally periodontitis ap-pears [6] Hence oral hygiene instructions for self-care areimportant to preserve periodontal health as well as me-chanical or chemotherapeutic removal of dental plaque to

HindawiInternational Journal of DentistryVolume 2020 Article ID 3257937 13 pageshttpsdoiorg10115520203257937

minimize disease activity It has been pointed out that thedifficulty in modifying oral hygiene habits may be due to lackof motivation or problems with the implementation ofprescribed oral hygiene procedures [7]

Depressive disorders are related to a decrease in oralhealthcare consultations as well as an increased risk ofperiodontal disease and tooth loss 0e findings have strongimplications throughout life since early-onset mental dis-orders increase their potential to negatively impact oralhealth over time [8] In addition negligence in oral hygieneduring periods of depression is associated with the loss ofconnective tissue attachment and tooth [9] However sci-entific evidence for this effect of depression on periodontitisis weak [5] It is worth mentioning that in a systematicreview of the literature and meta-analysis on the associationbetween depression and periodontitis Araujo et al [10]found a great heterogeneity in reported effect sizes and couldnot conclude that there was a significant association betweendepression and periodontitis

As the effect and mechanism of action of depression onperiodontitis are not clear the objective of this study is totest a predictive model for CAL including depressivesymptomatology oral hygiene habits and dental plaqueaccumulation0is hypothetical model proposes that CAL isa direct effect of a greater dental plaque accumulation and anindirect effect of greater depressive symptomatology andworse oral hygiene habits 0e first hypothesis to specify themodel is that depressive symptomatology has a direct effecton oral hygiene habits [8] as well as an indirect effect ondental plaque (mediated by oral hygiene habits) and on CAL(mediated by the 2 previous variables that is oral hygieneand dental plaque) [7 11] In other words greater levels ofdepressive symptoms determine worse oral hygiene habitsdue to depressive apathy and neglect in personal careLikewise greater depressive symptoms have an indirecteffect on the increased accumulation of bacterial plaque dueto these poor oral hygiene habits As a final consequence thisincreased accumulation of bacterial plaque results in CALtherefore greater depressive symptoms also have an indirecteffect on CAL 0e second hypothesis is that oral hygienehabits have a direct effect on dental plaque and an indirecteffect on CAL (mediated by the dental plaque accumulation)[6] 0at is to say worse oral hygiene habits determinegreater bacterial plaque accumulation and this consequentaccumulation produces CAL hence worse oral hygienehabits have an indirect effect on CAL Finally it was statedthat the dental plaque accumulation has a direct effect onCAL [12] that is greater bacterial plaque accumulationresults directly in greater CAL (Figure 1)

To enhance the attributable effects in this nonexperi-mental study the hypothetical model is tested on 3 samplesdrawn from 3 different populations and on the sample thatresulted from joining them A population is defined by CALor disease under study (dental patients with periodontitis)Another population is defined by depressive symptomswhich is one of the two risk factors considered (mentalhealth patients with depression) In the third populationCAL and depressive symptoms have a natural prevalenceand are not defining features (general population) 0is

choice of population is made to enhance the effects at-tributable to depressive symptoms in a cross-sectional de-sign (data collected at a single time point)0e intention is tohave a pooled sample in which people defined by clinicaldepression CAL and neither of these two clinical criteriacan be distinguished in such a way that the behavior of theparameters can be observed in each individual sample andwhen joining the three samples

In relation to this design the 3 samples collected areexpected to differ significantly in the variables that definethem (CAL and depressive symptoms) including in oralhygiene habits 0e expectations are that the CAL will begreater in dental patients than in the other two pop-ulations with the greatest difference between dental pa-tients and general population people [13] depressivesymptoms are more frequent in mental health patientsthan in the other two populations with the greatest dif-ference between depressive patients and general pop-ulation people [14 15] and oral hygiene habits are worsein both types of patients than in the general population[16] Besides it is intended that the 3 samples be asequivalent as possible in sociodemographic variables tocontrol effects attributable to sociodemographic biases Itis expected that the specified direct and indirect effects aresignificant and the hypothetical model shows a good fit tothe data in the 3 samples and pooled sample

2 Materials and Methods

21 Design and Participants 0is empirical research withbase on its objectives was descriptive and correlationalpredictive and has a cross-sectional nonexperimental design[17] Nonprobabilistic sampling was used Conveniencesamples from 3 populations were taken 0e common in-clusion criteria for the 3 samples were as follows residing inMonterrey or its metropolitan area (Nuevo Leon Mexico)being an age between 35 and 65 years and not receivingdental treatment or taking antibiotics or analgesics at the

Oralhygienehabits

Depressivesymptomatology

Dentalplaque

accumulation

Clinicalattachment

loss

+

e2e1

e3

ndash

ndash

Figure 1 Hypothetical model

2 International Journal of Dentistry

time of sampling For the sample of dental patients it wasadded to have received a diagnosis of periodontitis and notto have initiated periodontal treatment For the sample ofmental health patients it was added to have received aformal diagnosis of depressive disorder to have a total scorein the Beck Depression Inventory-II ge14 [14 18] and not tobe taking antidepressant medication or having less than 2weeks of starting it 0e exclusion criteria were as followsbeing a pregnant woman suffering from diabetes or someother systemic disease using orthodontic appliances andbeing a smoker 0e purpose of these criteria was to selectthe ages with the highest prevalence of periodontitis [19 20]excluding the subgroup of adults aged over 65 years due toits more specific health characteristics [21] On the otherhand specific causes of risk for periodontal deterioration(systemic diseases pregnancy orthodontic appliances andsmoking) were eliminated [5] In addition it was intendedthat the periodontal treatment did not alter the naturalevolution of the periodontitis in dental patients

22Procedures 0e sample of dental patients was composedof 35 people who consulted at the Department of Peri-odontics of the Faculty of Dentistry of the UniversidadAutonoma de Nuevo Leon (UANL) Once the patients werediagnosed with periodontitis and after checking the inclu-sion and exclusion criteria they were invited to participatein the study If the patient wanted to participate he signedthe informed consent form and answered the self-reportquestionnaire in an empty room

0e mental health sample was made up of 26 patientswith depressive disorder 16 (615) from the PsychologicalServices Unit of the UANL Faculty of Psychology 6 (231)from the Department of Psychiatry at the University Hos-pital of UANL and 4 (154) from the Psychiatric Reha-bilitation Unit of the Secretary of Health of the State ofNuevo Leon 0e department heads were contacted Oncepermission was granted the medical record base wasreviewed When a case was detected the psychiatrist orpsychologist informed the patient about the study Afterleaving the consultation if the patient wanted to participateheshe signed the informed consent form answered thequestionnaire and finally underwent periodontalevaluation

0e 29 participants in the general population samplewere contacted 23 (793) in workplaces and 6 (207) infamily homes After being informed about the study theywere asked to attend the Periodontics Clinic of the UANLFaculty of Dentistry to sign the informed consent answerthe questionnaire and be submitted to periodontalevaluation

First the sample of dental patients was collected betweenFebruary 2016 and May 2017 0en the sample of mentalhealth patients was completed between August 2016 andNovember 2017 Finally the general population sample wasrecruited between July and September 2018 and an attemptwas made to match the previous two in demographiccharacteristics 0is was done to minimize effects attribut-able to sociodemographic biases

Unstimulated whole saliva samples were collected fromthe 2 samples of patients (dental and mental health patients)to determine the concentration of 3 biomarkers of proin-flammatory activity using enzyme-linked immunosorbentassay (ELISA) matrix metalloproteinase-8 (MMP-8) in-terleukin-1β (IL-1β) and interleukin-6 (IL-6) 0ese datawere used in another study [22]

23 Instruments of Assessment Two periodontal parameterswere assessed CAL and plaque index In addition theparticipants answered a self-report questionnaire consistingof questions about sociodemographic information (sex ageschooling subjective socioeconomic status civil status andoccupation) and 2 self-report scales 0e scales were thefollowing Beck Depression Inventory-II (BDI-II)[14 15 18] and Oral Hygiene Habits Scale (OHHS) [23]

0e translation of BDI-II from English into Spanish bySanz and Vazquez [15] was used 0e BDI-II consists of 21items that are answered by choosing 4 response options thatare scored from 0 to 3 Four levels of depression are dis-tinguished based on the BDI-II total score between 0 and 13minimum between 14 and 19 mild between 20 and 28moderate and between 29 and 63 severe [14]0e BDI-II hasbeen validated in Mexico It has shown excellent internalconsistency reliability in a sample of 420 medical students(α 092) and good in a community sample of 220 adultsfrom Mexico City (α 087) a 3-factor structure (negativeattitude performance difficulties and somatic elements)showed the best fit to the data [18]

OHHS was developed in Mexico It consists of 8 directitems with 5 response options that are scored from 0 to 4 Byadding the scores obtained in the items and dividing by 8the OHHS total score is obtained in a continuum from 0 to 4Higher score reflects better oral hygiene habits 0ere are 3levels of oral hygiene habits based on the OHHS total scorebetween 0 and 099 bad between 1 and 2124 regular andbetween 2125 and 4 good In Mexico its internal consis-tency reliability was good (ordinal α 083 among 256 adultsin the general population and 087 among 240 dental pa-tients) and it had 2-factor structure dental brushing andflossing [23]

For the periodontal evaluation the 15mm North Car-olina periodontal probe was used 0e evaluation wasperformed by a single examiner It was a full mouth ex-amination CAL wasmeasured by the distance in millimetersbetween the cementoenamel line and the bottom of theperiodontal pocket In each dental piece 6 sites wereevaluated (3 vestibular and 3 palatine or lingual) 0e valuereported per participant corresponds to the average of siteswith CAL (ge1mm) CAL was classified into 4 orderedcategories without CAL 0mm stage I between 1 and2mm stage II between 3 and 4mm and stage III ge5mm[4]

0e plaque index assesses the amount of dental plaquevisible on the vestibular and lingual surfaces of all teethexcept the third molars 0e bacterial plaque developersolution was used to define cumulative amounts of plaquewith criteria from 0 to 5 [24] Once the values of the

International Journal of Dentistry 3

individual teeth are recorded they are added and divided bythe number of teeth examined to obtain the plaque index ofeach patient

24 Statistical Analysis Data analysis was performed withthe SPSS version 24 AMOS version 16 and Microsoft Excel2013 0e 2-tailed tests with a significance level of 005 werecomputed Due to the incidental nature of the samples therandomness of the data sequence (in its order of samplecollection) was tested through theWaldndashWolfowitz runs testfor randomness this was done to justify the use of inferentialstatistics

In the sample description the differences among themeans in the numerical variables of the 3 samples weretested using analysis of variance (ANOVA) 0e assumptionof normal distribution in each sample was tested through theShapirondashWilk test and the assumption of the equality ofvariances through Levenersquos test When equality of variancescould not be assumed Welchrsquos correction was used 0edifferences among the medians in the ordinal variables of 3samples were tested using the KruskalndashWallis test 0ehomogeneity among 3 samples regarding their distributionof frequencies in each categorical variable was tested usingPearsonrsquos chi-square test

0e internal consistency reliability among items com-posing each psychometric scales (BDI-II and OHHS) wasverified in 3 samples using the ordinal omega coefficient(ordinal ω) 0is coefficient does not require compliancewith the assumption of tau-equivalent items (equivalentmeasurement weights between the items) Moreover itscalculation is based on measurement weights computedfrom the polychoric correlation matrix [25] Precisely thistype of correlation is considered more suitable for ordinalvariables such as Likert-type items than Pearsonrsquos product-moment correlation [26] 0e measurement weights wereestimated by the weighted least squares method which isalso considered more suitable for these types of variables[27] and polychoric correlations by the 2-step maximum-likelihoodmethod It was interpreted that values of ordinalωbetween 070 and 079 reflect an acceptable level of reli-ability between 080 and 089 good and ge090 excellent [28]

0e hypothetical model was tested using path analysis0is technique was chosen instead of modeling structuralequations to not include the measurement models of eachvariable due to the sample size limitation [29] However thereliability of the measurement models (items composing ofeach scale) of depressive symptomatology and oral hygienehabits was checked by the ordinal omega coefficient [28]0e assumption of multivariate normality of the 4 variablesincluded in the model was verified by Mardiarsquos asymmetryand kurtosis tests 0e punctual estimation of parameterswas performed through maximum-likelihood method Dueto the limited sample size the standard error and 95confidence interval for each parameter were calculated byparametric bootstrapping (Monte Carlo method) with thesimulation of 10000 samples since data showed a goodapproximation to multivariate normality [30 31] 0egoodness of fit was assessed using 5 indices likelihood ratio

chi-square test (χ2) BollenndashStinersquos bootstrap probabilityvalue with the simulation of 2000 random samples (BSbootstrap p) relative or normed chi-square (χ2df) good-ness-of-fit index (GFI) and root mean square of error ofapproximation (RMSEA) P(χ2gt 1minusαχ2df ) and BS bootstrap p

values gt 010 χ2dfle 2 GFIge 095 and p value gt010 for H0RMSEAle 005 shows a good fit On the other handp(χ2gt 1minusαχ2df ) and BS p values gt005 χ2dfle 3 GFIge 090and p value gt005 for H0 RMSEAle 005 reflects an ac-ceptable fit [29]

3 Results

31 TestingRandomness 0e null hypothesis of randomnesswas supported for the sequence of data (in its order ofsample collection) by the runs test with a significance level of005 for all variables in the 3 samples except for item 9 onsuicidal ideation in the general population sample because itwas a constant (0 ldquoneverrdquo) (Table 1)

32 Internal Consistency Reliability of Psychosocial VariablesTable 2 shows the levels of internal consistency reliability forthe 8 items composing of the OHHS and the 21 itemscomposing of the BDI-II which varied from good (ordinalωge 080) to excellent (ordinal ωge 090)

33 Description of the Sociodemographic and ClinicalVariables 0e frequency of participants was statisticallyequivalent among the 3 samples (one-sample chi-square testχ2 [2] 140 asymptotic p value 0497) Table 3 shows thefrequency distributions of the sociodemographic variables(sex age schooling subjective socioeconomic status civilstatus and occupation) oral clinical variables (classificationsof CAL and plaque index) and psychosocial variables (levelsof depressive symptomatology and oral hygiene habits) inthe 3 samples as well as the statistical comparison of eachvariable among the 3 samples

According to the claim of equivalence in sociodemo-graphic variables to avoid biases attributable to these vari-ables the frequencies of both sexes were statisticallyequivalent among the 3 samples (one-sample chi-square testχ2 [2] 086 asymptotic p value 0650) Consequently thesex ratio in the pooled sample (binomial test for null hy-pothesis π 05 two-tailed p value 0916) showed thatthere were half men and half women in each sample Alsothe frequencies of the 5 categories of civil status were sta-tistically equivalent among the 3 samples (chi-square test forhomogeneity χ2 [8] 1129 exact two-tailed p val-ue 0180) as well as the levels of schooling and SSES(KruskalndashWallis test H[2] 272 p value 0257 and H[2] 4 p value 0136 respectively) and the mean age (one-way between-group ANOVA F[2 86] 172 p val-ue 0186) 0e civil status mode corresponded to thecategory of ldquomarriedrdquo marital status with two-thirds of thesample 0e median schooling corresponded to ldquohighschoolrdquo level and SSES to ldquomiddle-middlerdquo social stratus0eaverage age was 47 years (Table 3)


However there were differences in occupation (chi-square test for homogeneity χ2 [4] 1164 exact two-tailedp value 0019) 0ere were more homemakers in thesample of mental health patients compared to that of thegeneral population in turn there were more unskilledmanual workers and low-skilled technicians in the dentalpatient sample compared to the mental health patient

sample (Table 3)0e strength of the association between thetype of sample and occupation was small (CramerrsquosV 027)

0ere was heterogeneity of variances in CAL and plaqueindex among the 3 samples by Levenersquos test and thusWelchrsquos ANOVA was used 0is omnibus test rejected thenull hypothesis that means were equal among the 3 samples0e effect of sample type on the oral health variable was largethrough omega squared (ω2gt 014) 0e GamesndashHowell testfor multiple pairwise comparisons showed that mean ofdental patients was higher than means of mental healthpatients and general population persons in both variables(Table 4)

0e means in OHHS total score (oral hygiene habits)were equivalent among the 3 groups with a level of sig-nificance set at 005 but their difference would be significantif the level of significance is set at 001 (F[2 87] 290 p

value 0060) 0e effect of the group type on oral hygienehabits was small (006gtω2gt 001) When performingmultiple pairwise comparisons through Tukeyrsquos test therewas no significant difference in a 2-tailed test with a level ofsignificance set at 005 but there was a significant differenceusing Fisherrsquos least significant difference (LSD) test 0emean of the dental patients was higher than the mean of thegeneral population persons (Fisherrsquos LSD t[87] 229 p

value 0025) 0e comparison of means in the total BDI-IIscore was carried out through Welchrsquos ANOVA due to theunfulfillment of the variance homogeneity assumption 0edifference was significant and the effect size was very large(ω2gt 050) 0e mean in depressive symptomatology ofmental health patients was higher than the means of theother 2 groups between which the mean difference was notsignificant (Table 4)

34 Testing Model Table 5 shows the descriptive statisticsand normality test in the sample of 35 dental patients 0eassumption of multivariate normality was fulfilled (Mardiarsquosmultivariate skewness 442 Z 2581 and p value 0172Mardiarsquos multivariate kurtosis 2183 χ2[20 N 35] minus

093 and p value 0355)Figure 2 shows the model estimated in the sample of

dental patients Only the direct effect of the plaque index onCAL was significant (Table 6) Its size was medium 0egoodness of fit of the model was good based on 4 indices (χ2[3 N 35] 413 p value 0241 BS bootstrap p

value 0253 χ2df 1377 and RMSEA 0110 90 CI (00325) p value 0283 under null hypothesis H0

Table 2 Internal consistency reliability through coefficient ordinalomega

Scale DPS (n 35) MHS (n 26) GPS (n 29)BDI-II 0800 0881 0909lowastOHHS 0851 0932 0901Note Samples DPS sample of dental patients with periodontitisMHS sample of mental health patients with depressive symptomatologyand GPS general population sample Variables BDI-IIBeck DepressionInventory-II and OHHSOral Hygiene Habits Scale lowastWithout item 9(thoughts or wishes of suicide) because it was a constant (0 ldquoneverrdquo)

Table 1 Runs test for the randomness of the data sequence

VariableDPS (n 35) MHS (n 26) GPS (n 29)

n0 n1 R p

value n0 n1 R p

value n0 n1 R p

valueBDI-1 31 4 9 0845 16 10 15 0533 26 3 7 0836BDI-2 28 7 12 1 13 13 14 1 26 3 7 0836BDI-3 32 3 7 0858 17 9 13 1 28 1 3 1BDI-4 29 6 12 0559 17 9 11 0517 27 2 3 0071BDI-5 27 8 12 0638 18 8 14 0469 23 6 7 0050BDI-6 33 2 5 1 18 8 11 0640 28 1 3 1BDI-7 28 7 11 0580 19 7 11 1 26 3 7 0836BDI-8 23 12 17 1 15 11 15 0684 22 7 8 0055BDI-9 34 1 3 1 15 11 15 0684 0 29 1 -BDI-10 30 5 9 0854 10 16 15 0533 26 3 7 0836BDI-11 30 5 11 0550 18 8 13 0834 26 3 7 0836BDI-12 30 5 9 0854 13 13 14 1 27 2 5 1BDI-13 32 3 7 0858 16 10 14 0834 28 1 3 1BDI-14 32 3 4 0024 16 10 16 0294 27 2 5 1BDI-15 18 17 20 0615 17 9 14 0661 13 16 16 0854BDI-16 19 16 19 0861 11 15 14 1 16 13 13 0445BDI-17 26 9 12 0378 18 8 10 0358 27 2 5 1BDI-18 28 7 13 0856 15 11 12 0544 24 5 9 1BDI-19 26 9 13 0649 12 14 12 0551 23 6 13 0272BDI-20 13 22 18 0852 14 12 16 0428 18 11 14 0839BDI-21 31 4 9 0845 16 10 15 0533 26 3 7 0836BDI-22 28 7 12 1 13 13 14 1 26 3 7 0836BDI-II 15 20 14 0164 14 12 16 0428 18 11 12 0317OHHS-1 14 21 20 0477 11 15 16 0414 11 18 14 0839

OHHS-2 22 13 17 1 15 11 15 0684 14 15 15 1

OHHS-3 15 20 14 0164 12 14 17 0233 19 10 16 0525

OHHS-4 20 15 23 0114 11 15 16 0414 11 18 14 0839

OHHS-5 29 6 9 0437 16 10 14 0834 20 9 12 0664

OHHS-6 22 13 19 0591 15 11 16 0414 20 9 12 0664

OHHS-7 33 2 3 0059 25 1 3 1 22 7 8 0055

OHHS-8 32 3 7 0858 18 8 12 1 14 15 10 0056

OHHS 16 19 15 0300 14 12 18 0065 19 10 10 0097CAL 19 16 14 0166 12 14 12 0551 9 20 10 0188PI 17 18 17 0732 16 10 16 0294 14 15 14 0706Note Samples DPS sample of dental patients with periodontitisMHS sample of mental health patients with depressive symptomatology andGPS general population sample Statistics n0number of caseslt arithmeticmean n1number of casesge arithmetic mean Rnumber of runs and p

value two-tailed exact probability value Variables BDI-i item i (1 to 21) ofthe Beck Depression Inventory-II BDI-IIBDI-II total score OHHS-i item i(1 to 8) of the Oral Hygiene Habits Scale OHHSOHHS total scoreCAL clinical attachment loss and PI plaque index


RMSEAle 005) and acceptable based on one (GFI 0946)When reviewing modification indices for the fit improve-ment there was no suggestion

Table 5 shows the descriptive statistics and normality testin the sample of 26 mental health patients with depressivesymptomatology 0e assumption of multivariate normality

was fulfilled (Mardiarsquos multivariate skewness 433Z 1875 p value 0538 Mardiarsquos multivariatekurtosis 2263 χ2[20 N 35] minus050 p value 0614)Figure 3 shows the model estimated in this sample As in theprevious model only the effect of plaque index on the CALwas significant (Table 6) Its size was medium 0e 5

Table 3 Sociodemographic and clinical variables and statistical comparison among the 3 samples

Variable DPS MHS GPS Total p valuen () n () n ()

Sample 35 (389) 26 (289) 29 (322) 90 (100) 0497χ2 test

Sex Women 16 (457) 15 (577) 15 (517) 46 (511) 0650χ2 testMen 19 (543) 11 (423) 14 (483) 44 (489)

Age

35ndash39 6 (171) 8 (308) 5 (172) 19 (211)0186

ANOVA40ndash49 14 (40) 12 (462) 11 (379) 37 (411)50ndash59 12 (343) 5 (192) 12 (414) 29 (322)60ndash65 3 (86) 1 (38) 1 (34) 5 (56)

Schooling

Primary 5 (143) 3 (115) 2 (69) 10 (111)

0257KruskalndashWallis test

Secondary 9 (257) 10 (385) 4 (138) 23 (256)High school 6 (171) 1 (38) 7 (241) 14 (156)Vocational 7 (20) 5 (192) 5 (172) 17 (189)Bachelor 7 (20) 5 (192) 10 (345) 22 (244)

Postgraduate 1 (29) 2 (77) 1 (34) 4 (44)

SSESLow 2 (57) 2 (77) 1 (34) 5 (56) 0136

Kruskal-Wallis testMiddle-low 12 (343) 13 (50) 8 (276) 33 (367)Middle-middle 21 (60) 11 (423) 20 (69) 52 (578)

Civil status

Married 25 (714) 13 (50) 23 (793) 61 (678)

0180χ2 test

Single 2 (57) 6 (231) 4 (138) 12 (133)Divorced or separated 3 (86) 5 (192) 1 (34) 9 (10)

Cohabitating 3 (86) 1 (38) 1 (34) 5 (56)Widow 2 (57) 1 (38) 0 (0) 3 (33)

Occupation

White-collar worker 15a (429) 13a (50) 17a (586) 45 (50)0015χ2 test

Homemaker 11ab (314) 12b (462) 3a (103) 26 (289)Blue-collar worker 8a (229) 0b (0) 4ab (138) 12 (133)

Others 2a (57) 1a (38) 5a (172) 8 (89)

Classification of CAL

Without CAL 0 (0) 0 (00) 6 (207) 6 (67)0001

KruskalndashWallis testStage I 0 (0) 0 (0) 1 (34) 1 (11)Stage II 17 (486) 24 (923) 15 (517) 56 (622)Stage III 18 (514) 2 (77) 7 (241) 27 (30)

Classification of plaque index Low 0a (0) 0a (0) 10b (345) 10 (111) lt0001χ2 testHigh 35a (100) 26a (100) 19b (655) 80 (889)

Level of depressive symptomatology

Minimal 35 (100) 0 (0) 29 (100) 64 (711)lt0001

KruskalndashWallis testMild 0 (0) 8 (308) 0 (0) 8 (89)

Moderate 0 (0) 7 (269) 0 (0) 7 (78)Severe 0 (0) 11 (423) 0 (0) 11 (122)

Classification of oral hygiene habitsBad 13 (371) 10 (385) 7 (241) 30 333 0107

KruskalndashWallis testRegular 20 (571) 15 (577) 16 (552) 51 (567)Good 2 (57) 1 (38) 6 (207) 9 (10)

Note Samples DPS sample of dental patients with periodontitis MHS sample of mental health patients with depressive symptomatology andGPS general population sample Variables age the 4 age ranges shown in the table are used for descriptive purposes since the mean comparisons are madewith the quantitative variable ldquoyears of agerdquo using the one-way between-group analysis of variance (ANOVA) SSES subjective socioeconomic statusoccupationwhite-collar worker (clerk receptionist telephone operator salesperson and supervisor) homemaker (housewife and househusband) andblue-collar worker including both unskilled manual worker (cleaning worker waiter stevedore assembly line worker keeper and security guard) and low-skilled technician (mason painter plumber electrician carpenter glazier hauler heavy equipment operator and clinical assistant) and others (self-employed worker unemployed and retired) classification of CAL classification of clinical attachment loss (without CAL 0mm stage I 1 to 2mm stageII 3 to 4mm and stage III 5mm or more) classification of plaque index classification of the TureskyndashGilmorendashGlickman plaque index (low 0 to 1 andhigh 2 to 5) level of depressive symptomatology (minimalBDI-II total score from 0 to 13 mild 14 to 19 moderate from 20 to 28 and severe from 29 to 63)and classification of oral hygiene habits (badOHHS total score from 0 to 0999 regular from 1 to 2124 and good from 2125 to 4) Statistics n absolutefrequency p value probability value for a 2-tailed test and a b each subscript letter denotes a subset of categories whose column proportions do not differsignificantly from each other at the 005 level applying Bonferronirsquos correction


goodness-of-fit indices evidenced a close fit to the data χ2[3N 26] 186 p value 0601 BS bootstrap p value 0547χ2df 0621 GFI 0965 and RMSEA 0 90 CI (00281) p value 0625 under null hypothesis H0RMSEAle 005

Table 5 shows the descriptive statistics and normality testin the sample of 29 participants from the general populationA mathematical transformation was applied to CAL raisingthe squared scores to correct the negative skewness andachieve a normal distribution 0e assumption of multi-variate normality was fulfilled (Mardiarsquos multivariateskewness 485 Z 2342 p value 0269 Mardiarsquos multi-variate kurtosis 2264 χ2[20 N 35] -053 p val-ue 0598) Figure 4 shows the model estimated in thissample Depressive symptomatology had no direct effect on

oral hygiene habits nor indirect effect (mediated by oralhygiene habits) on the dental plaque accumulation as in theprevious 2 samples Oral hygiene habits had a direct neg-ative and large-size effect on the dental plaque accumulationand an indirect negative andmedium-size effect on CAL Inaddition the dental plaque accumulation had a directpositive and large-size effect on CAL (squared scores)(Table 6) 0e model explained 29 of the variance of theplaque index and 41 of the variance of the CAL 0egoodness of fit of this model was good based on 3 indices (χ2[3 N 29] 615 p value 0105 BS bootstrap p val-ue 0151 and RMSEA 0193 90 CI (0 0414) p val-ue 0125) and acceptable based on 2 indices (χ2df 2048and GFI 0908) When reviewing modification indices forthe fit improvement there was no suggestion

Table 4 One-way analysis of variance for independent groups and multiple pairwise comparisons of means

Variable Sample M (95 CI) LeveneANOVA

ω2 Multiple comparisonsF p

CALDPS 456 (445 468)

3176lowastlowastlowast Welch 1950 lt0001 0185GamesndashHowell

MHS 405 (390 421) DPSgtGPS 327 (256 397) MHSGPS

Plaque indexDPS 284 (268 3)



OHHS total scoreDPS 112 (094 130)

127ns 290 0060 0041Fisher DPSgtGPS

MHS 118 (088 148) DPSMHSGPS 150 (122 178) MHSGPS

BDI-II total scoreDPS 586 (441 730)


MHS 2581 (22 2961) MHSgtGPS 369 (236 502) DPSGPS

Note Samples DPS sample of dental patients with periodontitis MHS sample of mental health patients with depressive symptomatology andGPS general population sample Levene testing statistic of Levenersquos test for equality of variance nsnonsignificant p value gt0050 and lowastlowastlowastp value le0001 or probability value under null hypothesis of equality of variances ANOVA F testing statistic for Fisherrsquos one-way analysis of variance for in-dependent groups Welch testing statistic of Welchrsquos test for equality of means and p value probability value under null hypothesis of equality of meansω2 omega-squared or effect size estimator Multiple comparisons groups whose means were statistically different by the GamesndashHowell test for multiplepairwise comparisons or Fisherrsquos least significant difference test

Table 5 Descriptive statistics and normality test in the sample of 35 dental patients

Sample VariableDescriptive statistics ShapirondashWilkrsquos test

Min Max Sk ZSk K3 ZK3 W df p

Dental patient sample

BDIminusII 0 13 0162 0391 minus1228 minus1483 0922 35 0016OHHS 025 250 0275 0663 minus0077 minus0093 0959 35 0215CAL 380 542 0515 1243 0965 1165 0957 35 0192PI 2 372 0181 0436 minus0947 minus1144 0971 35 0463

Mental health patient sample

BDIminusII 14 50 0699 1456 minus0059 minus0062 0932 26 0086OHHS 025 350 1045 2176 1676 1744 0905 26 0020CAL 321 478 minus0536 minus1116 minus0044 minus0046 0958 26 0353PI 213 363 0366 0762 minus0699 minus0728 0955 26 0301

General population sample

BDIminusII 0 11 0902 1983 minus0251 minus0276 868 29 0002OHHS 050 337 0847 1861 0127 0139 928 29 0050CAL 0 6 minus0882 minus1940 minus0547 minus0601 828 29 lt0001CAL2 0 36 0003 0006 minus0578 minus0636 939 29 0095PI 083 356 minus0244 minus0537 minus1014 minus1114 954 29 0235

Note Variables BDI-II total score in Beck Depression Inventory-II OHHS total score in Hygiene Habits Scale CAL clinical attachment lossCAL2 clinical attachment loss values squared to correct negative skewness and PI plaque index Statistics Minminimum MaxmaximumSk coefficient of skewness based on central moments ZSk standardized value of the coefficient of skewness K3 excess kurtosis ZK3 standardized valueof excess kurtosis W ShapirondashWilkrsquos testing statistic df degree of freedom and p value probability value under null hypothesis that empirical dis-tribution follows a normal distribution


It should be noted that when the 3 samples were pooledthe direct effect of oral hygiene habits on dental plaqueaccumulation (1113954β minus043 95 CI (minus060 minus027) Z minus505 pvalue lt0001) and its indirect effect on CAL (β minus027 95CI (minus040 minus014 Z minus406 p value lt0001) as well as thedirect effect of dental plaque accumulation on CAL (1113954β 06395 CI (050 075) Z 963 p value lt0001) were signifi-cant As in previous models depressive symptoms had nodirect effect on oral hygiene habits (1113954β minus010 95 CI (minus031010) Z minus099 p value 0322) nor indirect effects ondental plaque accumulation or CAL Goodness-of-fit indicesvaried from acceptable (χ2[3 N 90] 737 p value 0052BollenndashStine bootstrap p value 0060 χ2df 2579 andRMSEA 0133 90 CI (0 0253) p value 0095) to good(GFI 0959)

4 Discussion

0e purpose of this research was to analyze the relationshipbetween 4 variables 2 psychosocial (depressive symptom-atology and oral hygiene habits) and 2 oral health variables(plaque accumulation and CAL) in 3 different populationsOn the one hand the samples were extracted from 2 clinicalpopulations one defined by CAL (dental patients withchronic periodontitis) and another defined by depressivesymptomatology (mental health patients) On the otherhand it was considered a population in which periodontaland depressive pathology were not distinctive features(general population) Before using inferential statistics toanalyze the data it was necessary to verify its randomnesssince the sample data were collected through a

3

Oralhygienehabits


6

Dentalplaque

accumulation

11

Clinicalattachment

loss

e2e1

e3

ndash024ns

(ndash056 008)

017ns

(ndash016 050)

034lowast

(004 064)

Figure 2 Maximum-likelihood parameter point estimates and 95 Monte Carlo confidence intervals (with 10000 bootstrap samples) inthe sample of 35 dental patients

Table 6 Standardized direct and indirect effects

SampleDirect effect Indirect effect

PR PD95 CI

PD95 CI

PD95 CI

PE LL UL PE LL UL PE LL UL

DPSDS OHH 017 (minus016 050) DPA minus004 (minus015 007) CAL minus001 (minus006 003)

OHH DPA minus024 (minus056 007) CAL minus008 (minus022 006)DPA CAL 034lowast (004 064)

MHSDS OHH minus009 (minus049 030) DPA 002 (minus010 014) CAL 001 (minus006 007)

OHH DPA minus021 (minus058 017) CAL minus010 (minus031 010)DPA CAL 048lowastlowast (017 079)

GPS

DS OHH minus013 (minus050 024) DPA 007 (minus015 029) CAL 004 (minus010 019)

OHH DPA minus054lowastlowastlowast (minus081minus027) CAL minus035lowastlowast (minus058

minus011)DPA CAL 064lowastlowastlowast (041 087)

Note Samples DPS sample of dental patients with periodontitis MHS sample of mental health patients with depressive symptomatology andGPS general population sample Variables PR predictor PD predicted variable DS depressive symptomatology (BDI-II total score) OHH oralhygiene habits (OHHS total score) DPA dental plaque accumulation (plaque index) and CAL clinical attachment loss Statistics PE point estimationthrough the maximum-likelihood method and 2-tailed probability value using Z-test lowastp value le 005 lowastlowastp value le 001 lowastlowastlowastp value le 0001 95 CI intervalestimation with a confidence level of 95 through parametric (Monte Carlo) bootstrap method LL lower limit and UL upper limit


nonprobabilistic incidental sampling [32] 0e null hy-pothesis of randomness was maintained in the variablesincluding in the model as well as in the items composing 2psychometric scales 0erefore the data sequences of the 3samples can be considered random

In the design of this cross-sectional study we tried toachieve an equivalence in sociodemographic characteristicsbetween the 3 samples so that there were no biases due to

different sociodemographic composition and were morecomparable First the 2 clinical samples were collected andthen the general population sample with which we tried toachieve this equivalence Statistical analysis shows that thisobjective was met 0e 3 samples are equivalent in size andsociodemographic characteristics

0e only difference was in the occupation variable Officeemployees dominated and its proportion was statisticallyequivalent between the 3 samples However the sample ofdental patients had the highest proportion of blue-collarworkers (unskilled manual workers and low-skilled tech-nicians) and the sample of mental health patients had thehighest proportion of housewives What caused the differ-ence in these occupational categories On the one handhousewives dominate among middle-aged women who at-tend depression treatments which is attributed precisely totheir occupational role [33] On the other hand the inter-section of sex (man) and occupation (blue-collar worker) is arisk factor for periodontitis with a large effect size [34]Consequently these differences are determined by thecharacteristics of each population

0e 3 samples were balanced in terms of sex which is arepresentative feature of the general population [35] andpatients with periodontitis [19] although the sex ratioamong depressive patients is approximately 2 women per 1man [33] 0e 3 samples were also balanced in terms of age0e age range was limited based on the prevalence ofperiodontitis [19 20] 0e minimum age was 35 years andthe maximum age was 65 Adults over 65 years of age werenot included since it constituted a subpopulation with re-spect to periodontal pathology [21] 0e average age wasequivalent among the 3 groups dominating middle-agedadults (between 40 and 59 years old) 0e distribution of the5 qualitative categories of civil status among the 3 sampleswas also equivalent Two-thirds of the participants weremarried followed by a tenth of separated or divorcedpersons which is representative of the civil status of middle-aged adults in Mexico [35] 0e median schooling corre-sponded to high school and the median of the subjectivesocioeconomic status (SSES) to middle-middle Both me-dians were equivalent among the 3 samples and correspondto those of the urban population of Monterrey for schoolingand objective socioeconomic status [36] However theupper-middle and high SSES were not represented 0is wasdue to the fact that patient samples were collected in clinicsbelonging to a public university [37] It should be noted thatobjective and subjectivemeasurements of the socioeconomicstatus have high correlations [38] Since it is easier to de-termine the SSES especially given the sensitivity of pro-viding the information necessary to estimate the objectivesocioeconomic status and being a better predictor of healthoutcomes [39] it was decided to measure SSES

In the study design an equivalence in sociodemographicvariables was intended to avoid biases and reinforce theeffects attributable to the variables included in the modelHowever it was an expected difference among the samplesin the variables including in the model According to theexpectative for the design [13] the CAL and plaque indexmeans in dental patients were significantly higher than the

1

Oralhygienehabits


4

Dentalplaque

accumulation

23

Clinicalattachment

loss

e2e1

e3

ndash021ns

(ndash058 017)

ndash009ns

(ndash049 030)

048lowastlowast

(017 079)

Figure 3 Maximum-likelihood parameter point estimates and95 Monte Carlo confidence intervals (with 10000 bootstrapsamples) in the mental health sample of 26 patients with depressivesymptomatology

3

Oralhygienehabits


29

Dentalplaque

accumulation

41

Clinicalattachment

losslowast

e2e1

e3

064lowastlowastlowast

(041 087)

ndash054lowastlowastlowast

(ndash081 ndash027)

ndash013ns

(ndash050 024)

Figure 4 Maximum-likelihood parameter point estimates and95 Monte Carlo confidence intervals (with 10000 bootstrapsamples) in the general population sample of 29 participants lowast0esquared clinical attachment loss scores were used since thismathematical transformation improved their fit to normaldistribution


corresponding means in general population and mentalhealth patients and there were no mean differences betweenthe latter 2 groups It should be noted that there were onlycases without CAL in the general population approximatelya fifth 0e periodontal health was rather bad in the 3samples from the indicator of the CAL 0is result contrastswith the lower prevalence of periodontitis reported by theHealth Secretary in the general population [19] but it doescoincide with other research studies on CAL carried out inthe general population from Latin American countries suchas Chile Colombia and Guatemala [40] and Mexico [41]

Regarding psychosocial variables the mean of depressivesymptomatology in the mental health patient sample wasgreater than the means in the dental patient and generalpopulation samples between which there was no differenceIn the samples of the general population and dental patientsthere were no cases of depression when the mean of de-pressive sintomatology in the mental health patient samplecorresponded to a moderate level [14 15 18] 0ese data fitthe expected difference [14 15] On the other hand using anomnibus test (Fisherrsquos ANOVA) with a significance level setat 001 there was a significant difference in means of oralhygiene habits among the 3 samples and using Fisherrsquos leastsignificant difference test there was a significant differencebetween the means of dental patient and general populationsamples in a 2-tailed test with a significance level set at 0050ese data also fit the expected difference Clearly regularoral hygiene habits prevail Good oral hygiene habits wereonly found in approximately a fifth of the general populationsample and a twentieth of the 2 samples of patients 0is lowproportion of good habits is also observed in other studies[40 41]

0e objective enunciated for this study was to test amodel to predict the CAL by direct effect of the dental plaqueaccumulation and indirect effect of poor oral hygiene habits(mediated by dental plaque accumulation) and depressivesymptomatology (mediated by oral hygiene habits anddental plaque accumulation) [42] To this end path analysiswas used since this technique does not require a largesample [29] Despite the limited sample size there wereapproximately 5 participants per parameter to estimatewhich is usually considered an adequate minimum [43]Since no measurement models were included the internalconsistency reliability of each scale was checked and reli-ability levels varied from good (in dental patients) to ex-cellent (in general population) In addition the ordinalomega coefficient was used to estimate the reliability insteadof the Cronbach alpha coefficient since it is the most suitablefor ordinal variables such as Likert-type items and does notrequire equivalence of variances and covariances betweenthe items [25] 0e assumption of normality was also testedData showed a good approximation to multivariate nor-mality and this opened up the possibility of an analysisstrategy to compensate for the limited sample size such asthe use of parametric bootstrap [30] 0e standard error ofeach parameter was estimated by this method and thisbootstrap error was used to test the significance of theparameter To this end a very large number of randomsamples namely 10000 bootstrap samples were generated

Precisely this procedure is considered one of the mostappropriate practices for data analysis but it is usually ig-nored [31] 0e implementation of these procedures thepositive results of reliability and the fulfillment of as-sumptions made it possible to adapt the data analysis to theresearch objective

0ree hypotheses were formulated to specify the pre-dictive model 0e first hypothesis about the direct effect ofdepressive symptomatology on oral hygiene habits and itsindirect effect on dental plaque mediated by oral hygienehabits was not confirmed 0e structural weights were notsignificant in any of the 3 samples even if the 3 samples arepooled 0ese results contrast with the study conducted inItaly by Luca Luca Vittorio Grasso and Calandra [11]where the researchers state that the severity of depressionresults in worse periodontal health greater dental plaqueaccumulation and poorer oral hygiene habits Other studieshave also found that depression increases the risk of peri-odontal disease [6 7] and negligence in oral hygiene [9]However the strength of association is small and the presentdata coincide with studies in which the association ofperiodontitis and depression has not been significant[44 45] including a meta-analysis [10]

0e second hypothesis to specify the model stated thatoral hygiene habits have a direct effect on dental plaque andan indirect effect on CAL mediated by dental plaque 0eevidence in favor of this hypothesis was provided by thegeneral population sample and pooled sample In the 2samples of patients the weights were not significant buttheir signs corresponded to the hypotheses 0erefore thepresent results support the assertion that oral hygiene in-structions are important to preserve periodontal health andminimize disease activity in the general population [7 46] Itshould be noted that smoking [47] diabetes [48] pregnancy[49] and wearing orthodontic appliances [50] are factorsthat increase the risk of periodontitis but in the presentstudy they were controlled through elimination that is therewere no cases in the samples 0erefore poor oral hygiene isdirectly attributable to deficient brushing technique and notusing or misusing dental floss without any interaction of anyof these 4 factors

Finally the third hypothesis to specify the model statedthat the dental plaque accumulation has a direct effect onCAL 0is hypothesis was confirmed in all samples 0e sizeof the effect of dental plaque on CAL was large in the generalpopulation sample and pooled sample and was medium inthe 2 patient samples Dental plaque is the primary etio-logical factor of periodontal disease in patients with de-pression [51] and in patients without depression [52] Itsaccumulation causes inflammation and CAL [6 12 42]0erefore these data are consistent with the positioning ofthe American Academy of Periodontics which states thatperiodontitis is associated with the presence of dental pla-que CAL and bone loss [2]

A first limitation of the study is the use of non-probabilistic sampling and thus inferences should be takenwith due caution in dental patients with periodontitismental health patients with depressive symptoms andgeneral population persons resident in Monterrey and its


metropolitan area all of them were middle-aged adultscorresponding to a SSES varying from low tomiddle-middleAll the patients were attended in public or university clinics(focused on low-income people) so people of medium-highor high ESES and professionals were absent in the 3 samplesA second limitation is the reduced sample size 0is impliesthat weak or trivial associations at the population level maybe nonsignificant in the sample Despite the efforts made inthe data analysis to overcome the limitations (verification ofassumptions of randomness and multivariate normality andthe use of repetitive sampling procedures with a highnumber of bootstrap samples to generate errors in the es-timates) this research should be considered as a pilot studyas a result of a second limitation A third limitation is thenonexperimental cross-sectional design therefore no causalinferences can be made and only predictive relationships arediscussed

5 Conclusion

0e hypothetical predictive model is partially validated 0edirect effect of the dental plaque index on CAL is confirmed inthe 3 samples with a medium effect size in dental patients withperiodontitis and mental health patients with depressivesymptomatology and large effect size in general populationBoth the direct effect of oral hygiene habits on the dental plaqueaccumulation and its indirect on the CAL mediated by dentalplaque accumulation are confirmed although only in thesample of general population Nevertheless depressivesymptomatology is an irrelevant variable since its direct effecton oral hygiene habits and indirect effect on dental plaque orCAL were not significant in any sample moreover themodification indexes for the fit improvement did not suggestany additional path for this variable

It is suggested to focus on public health interventions onoral hygiene habits to reduce dental plaque and preventperiodontitis especially in general population It is invited topromote dental consultation assistance in symptomaticpatients to achieve better oral health It seems that the studyof the effect of oral hygiene habits on periodontitis is morefruitful in the general population than in very specificclinical populations 0is article joins the set of studies thatconclude that depressive symptoms do not have a relevantrole in the etiology of periodontitis [10] Although it could beconsidered as a pilot study because its sample size waslimited (approximately 30 cases per sample and 90 in thepooled sample) and it has a cross-sectional design trivial orvery small effect sizes of depression on oral hygiene habitsdental plaque accumulation and CAL are replicable resultswith a larger sample size (ge200 per sample and 600 in thepooled sample) due to the analysis methodology used (pathanalysis estimation in each sample and in the pooledsample and bootstrapping) Consequently the variabledepression is not important for preventive purposes Itsrelevance for treatment requires specific longitudinal data inthis regard (pain sensitivity poor treatment adherenceenhanced side effects and decreased immune competence)[53] 0ese effects have been little studied in dental patientstreated for periodontitis and thus we suggest their study

Data Availability

0e data files are available upon request from the corre-sponding author

Ethical Approval

0e research was approved by the Research Ethics Com-mittee of the Psychiatric Rehabilitation Unit (registrationkey CONBIOETICA 19CEI01720130828) 0e research wasregistered in the Department of Education Health Researchand Quality of the Health Services of Nuevo Leon withregistration number DEISC-19-01-16-16 People who weredetected periodontitis were offered treatment in the Peri-odontics Clinic of the UANL Faculty of Dentistry

Consent

Informed written consent was requested and the informa-tion was kept strictly confidential in accordance with theRegulations of the General Health Law on Research Subjectfor Health [54] and 1964 Helsinki Declaration and its lateramendments [55]

Conflicts of Interest

0e authors declare that they have no conflicts of interest

Acknowledgments

0e authors express their acknowledgements for the supportreceived to collect the sample of mental health patients to DrSeveriano Lozano Gonzalez Director of the PsychiatricRehabilitation Unit and Dr Perla Elizabeth OrozcoGonzalez Research Coordinator Department of TeachingTraining and Research Secretary of Health of the State ofNuevo Leon to Dr Stefan Mauricio Fernandez ZambranoHead of the Department of Psychiatry UANL UniversityHospital and to Dr Guillermo Vanegas Arrambide DeputyDirector of Educational and Assistance Projects and MScMiguel Villegas Lozano Coordinator of the Department ofEquity and Gender Psychological Services Unit UANLFaculty of Psychology 0e research was funded by ConsejoNacional de Ciencia y Tecnologıa (CONACyT) grantnumber scholarship (335643)

References

[1] American Academy of Periodontology Glossary of PeriodontalTerms American Academy of Periodontology Chicago ILUSA 2019 httpsmembersperioorglibrariesglossary_ga=222057244320480296691566420619-19227607491510809338ampssopc=1

[2] P N Papapanou M Sanz N Buduneli et al ldquoPeriodontitisconsensus report of workgroup 2 of the 2017 world workshopon the classification of periodontal and peri-implant diseasesand conditionsrdquo Journal of Periodontology vol 45 no 20pp 162ndash170 2018

[3] B Holtfreter J M Albandar T Dietrich et al ldquoStandards forreporting chronic periodontitis prevalence and severity in


epidemiologic studiesrdquo Journal of Clinical Periodontologyvol 42 no 5 pp 407ndash412 2015

[4] J Caton G Armitage T Berglundh et al ldquoA new classifi-cation scheme for periodontal and periimplant diseases andconditions Introduction and key changes from the 1999classificationrdquo Journal of Clinical Periodontology vol 45no 20 pp 1ndash8 2018

[5] J M Albandar C Susin and F J Hughes ldquoManifestations ofsystemic diseases and conditions that affect the periodontalattachment apparatus case definitions and diagnostic con-siderationsrdquo Journal of Periodontology vol 45 no 20pp 171ndash189 2018

[6] A Lertpimonchai S Rattanasiri S Arj-Ong VallibhakaraJ Attia and A 0akkinstian ldquo0e association between oralhygiene and periodontitis a systematic review and meta-analysisrdquo International Dental Journal vol 67 no 6pp 332ndash343 2017

[7] D Slot L Wiggelinkhuizen N Rosema andG Van der Weijden ldquo0e efficacy of manual toothbrushesfollowing a brushing exercise a systematic reviewrdquo Inter-national Journal of Dental Hygiene vol 10 no 3 pp 187ndash1972012

[8] C A Okoro T W Strine P I Eke S S Dhingra andL S Balluz ldquo0e association between depression and anxietyand use of oral health services and tooth lossrdquo CommunityDentistry and Oral Epidemiology vol 40 no 2 pp 134ndash1442012

[9] A E Rosania K G Low C M McCormick andD A Rosania ldquoStress depression cortisol and periodontaldiseaserdquo Journal of Periodontology vol 80 no 2 pp 260ndash2662009

[10] M M Araujo C C Martins L C M Costa et al ldquoAsso-ciation between depression and periodontitis a systematicreview and meta-analysisrdquo Journal of Clinical Periodontologyvol 43 no 3 pp 216ndash228 2016

[11] M Luca A Luca C M A Vittorio Grasso and C CalandraldquoNothing to smile aboutrdquo Neuropsychiatric Disease andTreatment vol 10 no 275 pp 1999ndash2008 2014

[12] J Slots ldquoPeriodontitis facts fallacies and the futurerdquo Peri-odontology 2000 vol 75 no 1 pp 7ndash23 2017

[13] P N Papapanou and C Susin ldquoPeriodontitis epidemiology isperiodontitis under-recognized over-diagnosed or bothrdquoPeriodontology 2000 vol 75 no 1 pp 45ndash51 2017

[14] A T Beck R A Steer and G K BrownManual for the BeckDepression Inventory-II Psychological Corporation SanAntonio USA 1996

[15] A T Beck R A Steer and G K Brown BDI-II Inventario deDepresion de Beck-II (Spanish adaptation by Jesus Sanz andCarmelo Vazquez) Pearson Educacion Madrid Spain 2011

[16] P Melo S Marques and O M Silva ldquoPortuguese self-re-ported oral-hygiene habits and oral statusrdquo InternationalDental Journal vol 67 no 3 pp 139ndash147 2017

[17] R Hernandez-Sampieri C Fernandez-Collado andP Baptista-Lucio Metodologıa de la Investigacion McGraw-Hill Ciudad de Mexico Mexico City Mexico 6th edition2014

[18] D A Gonzalez A Resendiz-Rodrıguez A Resendiz andI Reyes ldquoAdaptation of the BDI-II in Mexicordquo Salud Mentalvol 38 no 4 pp 237ndash244 2015

[19] Secretarıa de Salud Resultados del Sistema de Vigilancia Epi-demiologica de Patologıas Bucales SIVEPAB 2017 Secretarıa deSalud Ciudad de Mexico Mexico City Mexico 2017 httpswwwgobmxsaludacciones-y-programassivepab-sistema-de-vigilancia-epidemiologica-de-patologias-bucales

[20] J E Frencken P Sharma L Stenhouse D Green D Lavertyand T Dietrich ldquoGlobal epidemiology of dental caries andsevere periodontitis ndash a comprehensive reviewrdquo Journal ofClinical Periodontology vol 44 no 18 pp 94ndash105 2017

[21] E M Chavez L MWong P Subar and D A Young ldquoWongdental care for geriatric and special needs populationsrdquoDental Clinics of North America vol 62 no 2 pp 245ndash2672018

[22] N I Rodrıguez Franco J Moral de la Rubia and A G AlcazarPizantildea ldquoPredictive model of clinical attachment loss and oralhealth-related quality of life through depressive symptom-atology oral hygiene habits and proinflammatory bio-markers a pilot studyrdquo Dentistry Journal vol 8 no 2pp 1ndash21 2018

[23] J Moral and N I Rodrıguez ldquoEstructura factorial y con-sistencia interna de la Escala de Habitos de Higiene Bucal enmuestras de poblacion general y clınica odontologicardquoCiencia UAT vol 12 no 1 pp 36ndash51 2017

[24] S Turesky N D Gilmore and I Glickman ldquoReduced plaqueformation by the chloromethyl analogue of victamine CrdquoJournal of Periodontology vol 41 no 1 pp 41ndash43 1970

[25] C Viladrich A Angulo-Brunet and E Doval ldquoUn viajealrededor de alfa y omega para estimar la fiabilidad deconsistencia internardquo Anales de Psicologıa vol 33 no 3pp 755ndash782 2017

[26] H F Ozdemir Ccedil Toraman and O Kutlu ldquo0e use of pol-ychoric and Pearson correlation matrices in the determina-tion of construct validity of Likert type scalesrdquo Turkish Journalof Education vol 8 no 3 pp 180ndash195 2019

[27] M T Barendse F J Oort and M E Timmerman ldquoUsingexploratory factor analysis to determine the dimensionality ofdiscrete responsesrdquo Structural Equation Modeling A Multi-disciplinary Journal vol 22 no 1 pp 87ndash101 2015

[28] F Timmerman Scale Development Eeory and ApplicationsSAGE Publications Los Angeles CA USA 4th edition 2016

[29] B Byrne Structural Equation Modelling with AMOS BasicConcepts Applications and Programming Routledge NewYork NY USA 3rd edition 2016

[30] K J Preacher and J P Selig ldquoAdvantages of Monte Carloconfidence intervals for indirect effectsrdquo CommunicationMethods and Measures vol 6 no 2 pp 77ndash98 2012

[31] A M Schoemann A J Boulton and S D Short ldquoDeter-mining power and sample size for simple and complex me-diation modelsrdquo Social Psychological and Personality Sciencevol 8 no 4 pp 379ndash386 2017

[32] M A Bujang F E Sapri and F E Sapri ldquoAn Applicationof the runs test to test for randomness of observationsobtained from a clinical survey in an ordered populationrdquoMalaysian Journal of Medical Sciences vol 25 no 4pp 146ndash151 2018

[33] C Kuehner ldquoWhy is depression more common amongwomen than amongmenrdquoEe Lancet Psychiatry vol 4 no 2pp 146ndash158 2017

[34] M Carasol J C Llodra A Fernandez-Meseguer et al ldquoPeri-odontal conditions among employed adults in Spainrdquo Journal ofClinical Periodontology vol 43 no 7 pp 548ndash556 2016

[35] Consejo Nacional de Poblacion La situacion demografica deMexico 2018 Secretarıa de Gobernacion y CONAPO Ciudadde Mexico Consejo Nacional de Poblacion Mexico CityMexico 2019 httpswwwgobmxconapodocumentosla-situacion-demografica-de-mexico-2018

[36] V M Maldonado and G Alarcon ldquoCambio demografico enNuevo Leon Realidad datos y espaciordquo Revista Internacionalde Estadıstica y Geografıa vol 7 no 3 pp 4ndash23 2016


[37] J C Maya N Sanchez A Posada A A Agudelo andJ E Botero ldquoCondicion periodontal y su relacion con vari-ables sociodemograficas y clınicas en pacientes adultos de unainstitucion docencia-serviciordquo Revista Odontologica Mex-icana vol 21 no 3 pp 165ndash172 2017

[38] T Doshi B L Smalls J S Williams T E Wolfman andL E Egede ldquoSocioeconomic status and cardiovascular riskcontrol in adults with diabetesrdquo Ee American Journal of theMedical Sciences vol 352 no 1 pp 36ndash44 2016

[39] E Zang and A R Bardo ldquoObjective and subjective socio-economic status their discrepancy and health evidence fromEast Asiardquo Social Indicators Research vol 143 no 3pp 765ndash794 2019

[40] A Duque ldquoPrevalencia de periodontitis cronica en Iber-oamericardquo Revista Clınica de Periodoncia Implantologıa yRehabilitacion Oral vol 9 no 2 pp 208ndash215 2016

[41] A Zeron ldquoEditorialrdquo Revista de la Asociacion Dental Mex-icana vol 74 no 2 p 62 2017

[42] P Bouchard M C Carra A Boillot F Mora and H RangeldquoRisk factors in periodontology a conceptual frameworkrdquoJournal of Clinical Periodontology vol 44 no 1 pp 125ndash1312017

[43] D L Jackson ldquoSample size and number of parameter esti-mates in maximum likelihood confirmatory factor Analysis aMonte Carlo investigationrdquo Structural Equation Modeling AMultidisciplinary Journal vol 8 no 2 pp 205ndash223 2001

[44] G R Persson R E Persson C I MacEntee C C I I WyattL G Hollender andH A Kiyak ldquoPeriodontitis and perceivedrisk for periodontitis in elders with evidence of depressionrdquoJournal of Clinical Periodontology vol 30 no 8 pp 691ndash6962003

[45] A C O Solis A H Marques C M Pannuti R F M Lotufoand F Lotufo-Neto ldquoEvaluation of periodontitis in hospitaloutpatients with major depressive disorderrdquo Journal ofPeriodontal Research vol 49 no 1 pp 77ndash84 2014

[46] A Wolff and H Staehle ldquoImproving the mechanical prop-erties of multiuse dental floss holdersrdquo International Journalof Dental Hygiene vol 12 no 4 pp 245ndash250 2014

[47] F R M Leite G G Nascimento F Scheutz and R LopezldquoEffect of smoking on periodontitis a systematic review andmeta-regressionrdquo American Journal of Preventive Medicinevol 54 no 6 pp 831ndash841 2018

[48] Y S Khader A S Dauod S S El-Qaderi A Alkafajei andW Q Batayha ldquoPeriodontal status of diabetics compared withnondiabetics a meta-analysisrdquo Journal of Diabetes and ItsComplications vol 20 no 1 pp 59ndash68 2006

[49] R P Esteves Lima R M Cyrino B de Carvalho Dutra et alldquoAssociation between periodontitis and gestational diabetesmellitus systematic review and meta-analysisrdquo Journal ofPeriodontology vol 87 no 1 pp 48ndash57 2016

[50] S N Papageorgiou A A Papadelli and T Eliades ldquoEffect oforthodontic treatment on periodontal clinical attachment asystematic review and meta-analysisrdquo European Journal ofOrthodontics vol 40 no 2 pp 176ndash194 2018

[51] S Shrestha S Sharma N Sapkota D K Giri and D BaralldquoAssociation between anxiety and depression with chronicperiodontitisrdquo Journal of College of Medical Sciences-Nepalvol 13 no 2 pp 268ndash274 2017

[52] D Kinane P G Stathopoulou and P N PapapanouldquoPeriodontal diseasesrdquo Nature Reviews Disease Primersvol 22 no 3 Article ID 17038 2017

[53] B Laurence and D Woods ldquoDepression and dental out-comesrdquo British Dent Journal vol 221 no 3 p 101 2016

[54] Secretarıa de SaludDecreto por el que se reforman adicionan yderogan diversas disposiciones del Reglamento de la LeyGeneral de Salud en Materia de Investigacion para la SaludDiario Oficial de la Federacion vol 1ndash6 Secretarıa de SaludMexico City Mexico 2014httpwwwdofgobmxnota_detallephpcodigo=5339162ampfecha=02042014

[55] General Assembly of the World Medical Association ldquoWorldMedical Association Declaration of Helsinki ethical princi-ples for medical research involving human subjectsrdquo Journalof the American College of Dentists vol 81 no 3 pp 14ndash182014


minimize disease activity It has been pointed out that thedifficulty in modifying oral hygiene habits may be due to lackof motivation or problems with the implementation ofprescribed oral hygiene procedures [7]

Depressive disorders are related to a decrease in oralhealthcare consultations as well as an increased risk ofperiodontal disease and tooth loss 0e findings have strongimplications throughout life since early-onset mental dis-orders increase their potential to negatively impact oralhealth over time [8] In addition negligence in oral hygieneduring periods of depression is associated with the loss ofconnective tissue attachment and tooth [9] However sci-entific evidence for this effect of depression on periodontitisis weak [5] It is worth mentioning that in a systematicreview of the literature and meta-analysis on the associationbetween depression and periodontitis Araujo et al [10]found a great heterogeneity in reported effect sizes and couldnot conclude that there was a significant association betweendepression and periodontitis

As the effect and mechanism of action of depression onperiodontitis are not clear the objective of this study is totest a predictive model for CAL including depressivesymptomatology oral hygiene habits and dental plaqueaccumulation0is hypothetical model proposes that CAL isa direct effect of a greater dental plaque accumulation and anindirect effect of greater depressive symptomatology andworse oral hygiene habits 0e first hypothesis to specify themodel is that depressive symptomatology has a direct effecton oral hygiene habits [8] as well as an indirect effect ondental plaque (mediated by oral hygiene habits) and on CAL(mediated by the 2 previous variables that is oral hygieneand dental plaque) [7 11] In other words greater levels ofdepressive symptoms determine worse oral hygiene habitsdue to depressive apathy and neglect in personal careLikewise greater depressive symptoms have an indirecteffect on the increased accumulation of bacterial plaque dueto these poor oral hygiene habits As a final consequence thisincreased accumulation of bacterial plaque results in CALtherefore greater depressive symptoms also have an indirecteffect on CAL 0e second hypothesis is that oral hygienehabits have a direct effect on dental plaque and an indirecteffect on CAL (mediated by the dental plaque accumulation)[6] 0at is to say worse oral hygiene habits determinegreater bacterial plaque accumulation and this consequentaccumulation produces CAL hence worse oral hygienehabits have an indirect effect on CAL Finally it was statedthat the dental plaque accumulation has a direct effect onCAL [12] that is greater bacterial plaque accumulationresults directly in greater CAL (Figure 1)

To enhance the attributable effects in this nonexperi-mental study the hypothetical model is tested on 3 samplesdrawn from 3 different populations and on the sample thatresulted from joining them A population is defined by CALor disease under study (dental patients with periodontitis)Another population is defined by depressive symptomswhich is one of the two risk factors considered (mentalhealth patients with depression) In the third populationCAL and depressive symptoms have a natural prevalenceand are not defining features (general population) 0is

choice of population is made to enhance the effects at-tributable to depressive symptoms in a cross-sectional de-sign (data collected at a single time point)0e intention is tohave a pooled sample in which people defined by clinicaldepression CAL and neither of these two clinical criteriacan be distinguished in such a way that the behavior of theparameters can be observed in each individual sample andwhen joining the three samples

In relation to this design the 3 samples collected areexpected to differ significantly in the variables that definethem (CAL and depressive symptoms) including in oralhygiene habits 0e expectations are that the CAL will begreater in dental patients than in the other two pop-ulations with the greatest difference between dental pa-tients and general population people [13] depressivesymptoms are more frequent in mental health patientsthan in the other two populations with the greatest dif-ference between depressive patients and general pop-ulation people [14 15] and oral hygiene habits are worsein both types of patients than in the general population[16] Besides it is intended that the 3 samples be asequivalent as possible in sociodemographic variables tocontrol effects attributable to sociodemographic biases Itis expected that the specified direct and indirect effects aresignificant and the hypothetical model shows a good fit tothe data in the 3 samples and pooled sample

2 Materials and Methods

21 Design and Participants 0is empirical research withbase on its objectives was descriptive and correlationalpredictive and has a cross-sectional nonexperimental design[17] Nonprobabilistic sampling was used Conveniencesamples from 3 populations were taken 0e common in-clusion criteria for the 3 samples were as follows residing inMonterrey or its metropolitan area (Nuevo Leon Mexico)being an age between 35 and 65 years and not receivingdental treatment or taking antibiotics or analgesics at the

Oralhygienehabits


Dentalplaque

accumulation

Clinicalattachment

loss

+

e2e1

e3

ndash

ndash

Figure 1 Hypothetical model





















3 Results




















n0 n1 R p

value n0 n1 R p

value n0 n1 R p


OHHS-2 22 13 17 1 15 11 15 0684 14 15 15 1

OHHS-3 15 20 14 0164 12 14 17 0233 19 10 16 0525

OHHS-4 20 15 23 0114 11 15 16 0414 11 18 14 0839

OHHS-5 29 6 9 0437 16 10 14 0834 20 9 12 0664

OHHS-6 22 13 19 0591 15 11 16 0414 20 9 12 0664

OHHS-7 33 2 3 0059 25 1 3 1 22 7 8 0055

OHHS-8 32 3 7 0858 18 8 12 1 14 15 10 0056









Sample 35 (389) 26 (289) 29 (322) 90 (100) 0497χ2 test


Age

35ndash39 6 (171) 8 (308) 5 (172) 19 (211)0186


Schooling

Primary 5 (143) 3 (115) 2 (69) 10 (111)



Postgraduate 1 (29) 2 (77) 1 (34) 4 (44)

SSESLow 2 (57) 2 (77) 1 (34) 5 (56) 0136


Civil status

Married 25 (714) 13 (50) 23 (793) 61 (678)

0180χ2 test



Occupation



Others 2a (57) 1a (38) 5a (172) 8 (89)


Without CAL 0 (0) 0 (00) 6 (207) 6 (67)0001




Minimal 35 (100) 0 (0) 29 (100) 64 (711)lt0001


Moderate 0 (0) 7 (269) 0 (0) 7 (78)Severe 0 (0) 11 (423) 0 (0) 11 (122)











CALDPS 456 (445 468)

























4 Discussion


3

Oralhygienehabits


6

Dentalplaque

accumulation

11

Clinicalattachment

loss

e2e1

e3

ndash024ns

(ndash056 008)

017ns

(ndash016 050)

034lowast

(004 064)




PR PD95 CI

PD95 CI

PD95 CI






GPS












1

Oralhygienehabits


4

Dentalplaque

accumulation

23

Clinicalattachment

loss

e2e1

e3

ndash021ns

(ndash058 017)

ndash009ns

(ndash049 030)

048lowastlowast

(017 079)


3

Oralhygienehabits


29

Dentalplaque

accumulation

41

Clinicalattachment

losslowast

e2e1

e3


(041 087)


(ndash081 ndash027)

ndash013ns

(ndash050 024)













5 Conclusion



Data Availability


Ethical Approval


Consent




Acknowledgments


References















































































3 Results




















n0 n1 R p

value n0 n1 R p

value n0 n1 R p


OHHS-2 22 13 17 1 15 11 15 0684 14 15 15 1

OHHS-3 15 20 14 0164 12 14 17 0233 19 10 16 0525

OHHS-4 20 15 23 0114 11 15 16 0414 11 18 14 0839

OHHS-5 29 6 9 0437 16 10 14 0834 20 9 12 0664

OHHS-6 22 13 19 0591 15 11 16 0414 20 9 12 0664

OHHS-7 33 2 3 0059 25 1 3 1 22 7 8 0055

OHHS-8 32 3 7 0858 18 8 12 1 14 15 10 0056









Sample 35 (389) 26 (289) 29 (322) 90 (100) 0497χ2 test


Age

35ndash39 6 (171) 8 (308) 5 (172) 19 (211)0186


Schooling

Primary 5 (143) 3 (115) 2 (69) 10 (111)



Postgraduate 1 (29) 2 (77) 1 (34) 4 (44)

SSESLow 2 (57) 2 (77) 1 (34) 5 (56) 0136


Civil status

Married 25 (714) 13 (50) 23 (793) 61 (678)

0180χ2 test



Occupation



Others 2a (57) 1a (38) 5a (172) 8 (89)


Without CAL 0 (0) 0 (00) 6 (207) 6 (67)0001




Minimal 35 (100) 0 (0) 29 (100) 64 (711)lt0001


Moderate 0 (0) 7 (269) 0 (0) 7 (78)Severe 0 (0) 11 (423) 0 (0) 11 (122)











CALDPS 456 (445 468)

























4 Discussion


3

Oralhygienehabits


6

Dentalplaque

accumulation

11

Clinicalattachment

loss

e2e1

e3

ndash024ns

(ndash056 008)

017ns

(ndash016 050)

034lowast

(004 064)




PR PD95 CI

PD95 CI

PD95 CI






GPS












1

Oralhygienehabits


4

Dentalplaque

accumulation

23

Clinicalattachment

loss

e2e1

e3

ndash021ns

(ndash058 017)

ndash009ns

(ndash049 030)

048lowastlowast

(017 079)


3

Oralhygienehabits


29

Dentalplaque

accumulation

41

Clinicalattachment

losslowast

e2e1

e3


(041 087)


(ndash081 ndash027)

ndash013ns

(ndash050 024)













5 Conclusion



Data Availability


Ethical Approval


Consent




Acknowledgments


References










































































n0 n1 R p

value n0 n1 R p

value n0 n1 R p


OHHS-2 22 13 17 1 15 11 15 0684 14 15 15 1

OHHS-3 15 20 14 0164 12 14 17 0233 19 10 16 0525

OHHS-4 20 15 23 0114 11 15 16 0414 11 18 14 0839

OHHS-5 29 6 9 0437 16 10 14 0834 20 9 12 0664

OHHS-6 22 13 19 0591 15 11 16 0414 20 9 12 0664

OHHS-7 33 2 3 0059 25 1 3 1 22 7 8 0055

OHHS-8 32 3 7 0858 18 8 12 1 14 15 10 0056









Sample 35 (389) 26 (289) 29 (322) 90 (100) 0497χ2 test


Age

35ndash39 6 (171) 8 (308) 5 (172) 19 (211)0186


Schooling

Primary 5 (143) 3 (115) 2 (69) 10 (111)



Postgraduate 1 (29) 2 (77) 1 (34) 4 (44)

SSESLow 2 (57) 2 (77) 1 (34) 5 (56) 0136


Civil status

Married 25 (714) 13 (50) 23 (793) 61 (678)

0180χ2 test



Occupation



Others 2a (57) 1a (38) 5a (172) 8 (89)


Without CAL 0 (0) 0 (00) 6 (207) 6 (67)0001




Minimal 35 (100) 0 (0) 29 (100) 64 (711)lt0001


Moderate 0 (0) 7 (269) 0 (0) 7 (78)Severe 0 (0) 11 (423) 0 (0) 11 (122)











CALDPS 456 (445 468)

























4 Discussion


3

Oralhygienehabits


6

Dentalplaque

accumulation

11

Clinicalattachment

loss

e2e1

e3

ndash024ns

(ndash056 008)

017ns

(ndash016 050)

034lowast

(004 064)




PR PD95 CI

PD95 CI

PD95 CI






GPS












1

Oralhygienehabits


4

Dentalplaque

accumulation

23

Clinicalattachment

loss

e2e1

e3

ndash021ns

(ndash058 017)

ndash009ns

(ndash049 030)

048lowastlowast

(017 079)


3

Oralhygienehabits


29

Dentalplaque

accumulation

41

Clinicalattachment

losslowast

e2e1

e3


(041 087)


(ndash081 ndash027)

ndash013ns

(ndash050 024)













5 Conclusion



Data Availability


Ethical Approval


Consent




Acknowledgments


References

































































Sample 35 (389) 26 (289) 29 (322) 90 (100) 0497χ2 test


Age

35ndash39 6 (171) 8 (308) 5 (172) 19 (211)0186


Schooling

Primary 5 (143) 3 (115) 2 (69) 10 (111)



Postgraduate 1 (29) 2 (77) 1 (34) 4 (44)

SSESLow 2 (57) 2 (77) 1 (34) 5 (56) 0136


Civil status

Married 25 (714) 13 (50) 23 (793) 61 (678)

0180χ2 test



Occupation



Others 2a (57) 1a (38) 5a (172) 8 (89)


Without CAL 0 (0) 0 (00) 6 (207) 6 (67)0001




Minimal 35 (100) 0 (0) 29 (100) 64 (711)lt0001


Moderate 0 (0) 7 (269) 0 (0) 7 (78)Severe 0 (0) 11 (423) 0 (0) 11 (122)











CALDPS 456 (445 468)

























4 Discussion


3

Oralhygienehabits


6

Dentalplaque

accumulation

11

Clinicalattachment

loss

e2e1

e3

ndash024ns

(ndash056 008)

017ns

(ndash016 050)

034lowast

(004 064)




PR PD95 CI

PD95 CI

PD95 CI






GPS












1

Oralhygienehabits


4

Dentalplaque

accumulation

23

Clinicalattachment

loss

e2e1

e3

ndash021ns

(ndash058 017)

ndash009ns

(ndash049 030)

048lowastlowast

(017 079)


3

Oralhygienehabits


29

Dentalplaque

accumulation

41

Clinicalattachment

losslowast

e2e1

e3


(041 087)


(ndash081 ndash027)

ndash013ns

(ndash050 024)













5 Conclusion



Data Availability


Ethical Approval


Consent




Acknowledgments


References


































































CALDPS 456 (445 468)

























4 Discussion


3

Oralhygienehabits


6

Dentalplaque

accumulation

11

Clinicalattachment

loss

e2e1

e3

ndash024ns

(ndash056 008)

017ns

(ndash016 050)

034lowast

(004 064)




PR PD95 CI

PD95 CI

PD95 CI






GPS












1

Oralhygienehabits


4

Dentalplaque

accumulation

23

Clinicalattachment

loss

e2e1

e3

ndash021ns

(ndash058 017)

ndash009ns

(ndash049 030)

048lowastlowast

(017 079)


3

Oralhygienehabits


29

Dentalplaque

accumulation

41

Clinicalattachment

losslowast

e2e1

e3


(041 087)


(ndash081 ndash027)

ndash013ns

(ndash050 024)













5 Conclusion



Data Availability


Ethical Approval


Consent




Acknowledgments


References





























































4 Discussion


3

Oralhygienehabits


6

Dentalplaque

accumulation

11

Clinicalattachment

loss

e2e1

e3

ndash024ns

(ndash056 008)

017ns

(ndash016 050)

034lowast

(004 064)




PR PD95 CI

PD95 CI

PD95 CI






GPS












1

Oralhygienehabits


4

Dentalplaque

accumulation

23

Clinicalattachment

loss

e2e1

e3

ndash021ns

(ndash058 017)

ndash009ns

(ndash049 030)

048lowastlowast

(017 079)


3

Oralhygienehabits


29

Dentalplaque

accumulation

41

Clinicalattachment

losslowast

e2e1

e3


(041 087)


(ndash081 ndash027)

ndash013ns

(ndash050 024)













5 Conclusion



Data Availability


Ethical Approval


Consent




Acknowledgments


References


































































1

Oralhygienehabits


4

Dentalplaque

accumulation

23

Clinicalattachment

loss

e2e1

e3

ndash021ns

(ndash058 017)

ndash009ns

(ndash049 030)

048lowastlowast

(017 079)


3

Oralhygienehabits


29

Dentalplaque

accumulation

41

Clinicalattachment

losslowast

e2e1

e3


(041 087)


(ndash081 ndash027)

ndash013ns

(ndash050 024)













5 Conclusion



Data Availability


Ethical Approval


Consent




Acknowledgments


References






































































5 Conclusion



Data Availability


Ethical Approval


Consent




Acknowledgments


References




























































PlaqueIndex,OralHygieneHabits,andDepressive...

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