DR LI-SHENG CHEN (Orcid ID : 0000-0001-9750-3015)

Accepted Article
Article type : Original Manuscript

Effects of Risk Factors on Periodontal Disease Defined by Calibrated

Community Periodontal Index and Loss of Attachment Scores

Chiu-Wen Su1, Amy Ming-Fang Yen2,3, Hongmin Lai4,5 ,Yungling Lee6, Hsiu-Hsi Chen6 ,

Sam Li-Sheng Chen2,3

1. Big Data Research Center, Changhua Christian Hospital

2. School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei,

Taiwan

3. Oral Health Care Research Center, College of Oral Medicine, Taipei Medical University,

Taipei, Taiwan

4. Department of Dentistry, Shuang-Ho Hospital, Taipei Medical University, New Taipei

City

5. Taiwan Dental Health Care Organization, Taiwan

6. Institute of Epidemiology and Prevention Medicine, College of Public Health, National

Taiwan University, Taipei, Taiwan

This article has been accepted for publication and undergone full peer review but has not

been through the copyediting, typesetting, pagination and proofreading process, which may

lead to differences between this version and the Version of Record. Please cite this article as

doi: 10.1111/odi.12678

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 Running title: Measurement errors in effect size of PD
Accepted Article
Keywords: Community Periodontal Index; Loss Attachment; Sensitivity and Specificity;

Outcome Measurement Error; Risk Factor; Validation Study

Correspondence and reprint request to: Dr. Sam Li-Sheng Chen

School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, No.250,

Wuxing St., Taipei 11031, Taiwan. Tel: 02-27361661 ext 5211, Fax: 02-27362295, E-mail:

samchen@tmu.edu.tw/Professor Hsiu-Hsi Chen

Graduate Institute of Epidemiology and Prevention Medicine, College of Public Health,

National Taiwan University, Room 533, No. 17, Hsuchow Road, Taipei, 100, Taiwan., Tel:

+886-2-33668033, Fax: +886-2-23587707, E-mail:chenlin@ntu.edu.tw

Abstract

Objectives: We evaluated whether and how the effects of risk factors on periodontal disease

(PD) were modified by measurement errors using community periodontal index (CPI) and

loss attachment (LA) in the community-based survey.

Methods: A pilot validation study was performed to estimate the rates of false negative and

false positive for both CPI and LA in 31 subjects from different regions using measurements

from 12 well-trained dentists and a senior periodontist as a gold standard. Afterward, a

Taiwanese nationwide survey was conducted by enrolling 3860 participants to estimate the

effect of each risk factor on PD calibrated with both sensitivity and specificity of two indices.

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 Results: The values obtained for the sensitivity to false positive ratio for CPI ranged widely
Accepted Article
from 1.12 to 7.71, indicating regional variation in both errors. The calibrated adjusted odds

ratio for smoking versus non-smoking was higher than the uncalibrated odds ratio for PD

defined by CPI (2.75(2.01, 3.77) versus 2.02(1.63, 2.52)) and LA (3.85(2.44, 6.13) versus

1.93(1.47, 2.54)) scores. Similar underestimation was noted for other risk factors.

Conclusion: The effects of risk factors on PD measured using CPI and LA in a large

population-based survey were underestimated without correcting for measurement errors.

Introduction

Periodontal disease (PD) is an insidious and progressive ailment with clinical

presentations varying from mild symptoms and signs (such as gingival bleeding and calculus),

to various degrees of mobility, and finally loss of tooth. To detect PD earlier, the community

periodontal index (CPI) and loss of attachment (LA) are often used to measure dental pocket

depth and destruction of supporting tissue of the teeth and reflect disease severity. More

importantly, CPI is recommended by the WHO to use as an indicator of early PD for

individuals 35 years and older as a part of large community-based screening programmes.

In addition to its multistage and progressive properties, PD is characterized as a

multifactorial chronic disease. Elucidating risk factors responsible for PD is therefore

important for strengthening primary prevention of PD (Petersen et al, 2005). Numerous

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 previous studies have identified a constellation of causative risk factors, including male
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gender, old age, smoking, education, and comorbidities such as type 2 diabetes and obesity

(Haber et al, 1993; Jan Bergström and Preber, 1994; Kinane and Chestnutt, 2000; Lai et al,

2007; Wang et al, 2009; Lai et al, 2015).

While these epidemiological studies have reported the effect sizes (often reported by

odds ratio or relative risk) of risk factors associated with PD, it is argued that measurement

errors (false negative and false positive) in CPI or LA may affect these estimations. The effect

of measurement errors on the evaluation of risk factors for PD measured by CPI or LA may

not be a serious problem in clinical studies because if PD is severe, its diagnosis is unlikely to

be affected by measurement errors. However, the misclassification of PD, particularly when

examined by even well-trained general dentists, may result in either an underestimation or

overestimation of the effect sizes for the risk factors of interest in the setting of a community

survey in which many of the participants may be pre-symptomatic PD cases.

At this time, few studies have been conducted to address this issue. A previous

Taiwanese study of a large-scale community-based survey, targeted to residents aged 18 years

and older, used CPI and LA, as measured by a group of trained general dentists, to assess the

prevalence of PD and a collection of conventional risk factors. These study characteristics

render it a candidate study for assessing the impact of measurement errors on effect size. The

aim of this study was to apply a two-stage design: the first stage included a pilot validation

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 study conducted to estimate the rates of false negative and false positive results for the CPI
Accepted Article
and LA measured by the examiners, and the second stage used these estimations of

measurement errors to correct the effect sizes of the risk factors associated with PD based on

the calibrated CPI and LA measured by the same examiners in a large-scale community-based

survey to assess whether measurement errors underestimated or overestimated the effect sizes

of each risk factor.

Materials and Methods

Study design

In the current study, we used a two-stage study design to estimate sensitivity and

specificity. In the first stage, we conducted a validation study to calibrate the discrepancy in

CPI and LA measurement between the gold standard (a senior periodontist, Lai H) and

dentists after professional training in PD. The estimated sensitivity and specificity from this

pilot study were used to calibrate the association between risk factors and PD obtained from

the main study, a nationwide survey. The periodontal examination was measured by CPI

(WHO, 1997). The examination consisted of CPI scores in the following five categories:

healthy, gingival bleeding, calculus, shallow pockets of 4-5 mm and deep pockets of 6 mm or

deeper (Ainamo et al, 1982). All participants provided informed consent after receiving

sufficient information. This study was approved by the Joint Institutional Review Board of

Taipei Medical University (TMUJIRB No.201207011).

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 Validation study
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General dentists who participated in a nationwide survey of periodontal disease were

invited to participate in a validation study comparing their measurements of CPI and LA with

those taken by a senior dentist specializing in periodontology (gold standard). Two trained

dentists selected from each area to participate in the nationwide survey (6 areas: two northern,

one central, two southern, and one eastern area of Taiwan), and one gold standard dentist

examined a total of 31 subjects; these data were included in the analysis of the intra- and

inter-rater reliability of the CPI and LA measurements. We excluded subjects that had

undergone scaling or treatment for periodontitis in two months before calibration. Each

subject was examined by both the trained general and gold standard dentists. All the teeth of

each subject were examined by the different raters at six conventional sites: mesiobuccal,

mid-buccal, disto-buccal, mesiolingual, mid-lingual, and disto-lingual. At each site, CPI and

LA score was measured and recorded. The highest score of all the sites in each sextant was

treated as the representative of that sextant.

Nationwide survey with calibration

The main objective of the nationwide survey, commissioned by the Health Promotion

Administration, Ministry of Health and Welfare, Taiwan in 2008, was to explore the

prevalence and severity of periodontal disease and its association with oral hygiene, lifestyle,

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 and other risk factors in adults aged 18 years and older. The details of this study have been
Accepted Article
described in full elsewhere (Lai et al, 2015). The nationwide survey invited 13 dentists and

one gold standard dentist to measure the sextant-level CPI and LA for 4601 subjects from

different regions. As one dentist did not complete the calibration stage, we excluded data

related to that dentist, leaving twelve dentists and one gold standard dentist and their

measurements on 3860 subjects (17,244 sextants) for inclusion in the current study. These

data were used to calculate the uncalibrated and calibrated ORs for the association between

the risk factors and PD with simultaneous consideration of the correlated properties of

sextant-level data from the same subject or the same region using the following Bayesian

hierarchical random-effect model.

Risk Factors

For periodontal participants in the main survey, we designed a structured questionnaire

to collect information on a constellation of variables, including demographic variables;

anthropometric measurements, such as height and weight; lifestyle factors, including cigarette

smoking, alcohol consumption, and betel-quid chewing; and personal diseases, such as type 2

diabetes mellitus. The questionnaire was administered by public health nurses between 2007

and 2008 in the CIS programme.

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 Definition of underestimation and overestimation
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In epidemiological studies, biases due to these measurement errors are classified into

differential and non-differential. If the effect size is away from the null hypothesis (no

association expressed by OR=1), it is a differential misclassification and often results in

overestimation of effect size if uncorrected. On the other hand, if the effect size is towards the

null hypothesis, it is called non-differential misclassification and often results in

underestimation if uncorrected.

We conducted a validation study to assess the possibility of measurement errors. The

Supplementary provides an example demonstrating how the effect size of smoking on the

odds of PD measured by CPI was substantially changed after correcting for the measurement

errors; these results were classified as non-differential misclassification due to the

underestimation of the effect size of smoking, which inflated from 2 to 4.43 for the

uncalibrated and calibrated odds ratios, respectively. This Bayesian hierarchical model may

be further applied to large-scale epidemiological surveys to calibrate the odds ratios of other

risk factors.

Statistical analyses

In order to measure the impact of the risk factors on PD, the attributable proportion

(AR) and population attributable proportion (PAR) were used in the analysis. AR was defined

as the proportion of disease in the exposed group that could be attributed by a given risk

factor. The AR was formally written as

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Attributable proportion=

Accepted Article
PAR is the proportional reduction in population disease that would occur if exposure to

a risk factor were reduced to an alternative exposure scenario. The formula was written as

( %)×( )
Population attributable proportion=( ( %)×( ))

In the calibration study, the estimates of sensitivity and specificity comparing PD status

measured as by participating trained dentists and PD status measured by the gold standard

dentist and their confidence intervals following binomial distribution were reported. For the

nationwide survey, we first reported the distribution of sextant-level PD measured by the

participating trained dentists by personal characteristics, including gender, age, education

level, body mass index (BMI), type 2 diabetes mellitus (DM), and lifestyle factors such as

cigarette smoking and alcohol consumption. To take into account the correlated property of

sextant-level data from the same subject or the same dentist, we applied a Bayesian

hierarchical model with the incorporation of correlated properties (Yen, 2006) and

measurement errors to estimate the calibrated odds ratio between risk factors and PD; we

applied this hierarchical univariate logistic regression model with a random intercept,

accounting for different baselines in the same cluster, to estimate the crude odds ratio (cOR)

for the effect of each risk factor on PD. The random intercept term was assumed to follow a

normal distribution centred at zero with a standard deviation, denoted by σ, which was used

to test whether the random effect is statistically significant. Finally, the hierarchical

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 multivariable logistic regression models with and without calibration were further applied to
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calculate the calibrated odds ratio (OR) adjusting for confounding factors with each other. We

also calculated attributable proportion (AR) and population attributable proportion (PAR) for

each risk factor given the estimated adjusted odds ratios before and after calibration. The

estimation of the hierarchical models was accomplished using the Markov chain Monte Carlo

simulation underpinning the developed Bayesian directed acyclic graphic model and

Windows-based Bayesian Inference Using Gibbs Sampling (WinBugs) software

(Spiegelhalter et al, 2004). The 95% confidence interval was extracted from the posterior

distribution of each parameter and reported for the assessment of statistical significance.

Results

The overall sensitivity and specificity of CPI measurement at the sextant level were

0.73 and 0.82. The corresponding figures were 0.67 and 0.73 for LA measurement and 0.78

and 0.69 for CPI and LA. The number of sextants by status of PD with CPI and LA defined

by the gold standard and by participating trained dentists who were involved in the

nationwide survey, and the corresponding estimates of sensitivity and specificity are shown in

Supplementary sTable 1. The results show that measurement errors varied by regions and had

a wide range of positive likelihood ratios (sensitivity/false positive) from 1.12 to 7.71 for CPI

and from 0.92 to 5.71 for LA.

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 Table 1 shows the descriptive data for the nationwide survey on periodontal disease at
Accepted Article
the sextant-level with CPI and LA scores. Table 2 shows the comparisons of crude and

adjusted odds ratios (ORs) with PD defined by CPI ≥3 or LA≥1 as the outcome between the

uncalibrated and the calibrated models. The effect sizes for calibrated cORs for each variable

in the univariate analysis were more considerably further away from the null (cOR=1),

displaying so-called non-differential misclassification, in the calibrated model in comparison

with the corresponding uncalibrated model, suggesting an underestimation of the influence of

each variable on PD in the absence of calibration. Taking smoking as an example, the cOR

for the odds of PD for smokers vs. non-smokers was two times greater with calibration than

without calibration and increased from 3.42 (2.81, 4.17) to 6.50 (4.65, 9.39). Similar

underestimations of cORs were also noted for other variables with various extents of

non-differential misclassification.

Table 2 also shows that the influence of such non-differential misclassification on the

underestimation of effect sizes was attenuated by adjustment, but the tendency towards

non-differential misclassification still remained in the multivariate analysis with adjustment

for variables with (multivariate model 2) and without (multivariate model 1) incorporation of

alcohol drinking.

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 The underestimation of effect sizes with PD defined by CPI ≥3 alone is listed in Table
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3. Elevated effect sizes for calibrated and uncalibrated ORs and 95% confidence intervals

were noted for the association between smoking and PD in the univariate analysis (2.62 (2.19,

3.18) to 4.29 (3.22, 5.84)) and in multivariate analysis 2.02 (1.63, 2.52) to 2.75 (2.01, 3.77).

The calibrated OR was still consistently higher than the uncalibrated OR using different

cut-offs of CPI score (Supplementary sTable 2). These findings suggest such a

non-differential misclassification is unlikely to be modified by different definitions of PD.

Table 4 shows the corresponding results using a LA score ≥1 alone. It is interesting to

note that the alteration of effect size was greater than that observed using CPI alone. However,

such a change was ameliorated when all the variables were considered in the multivariate

analysis.

Table 5 shows the comparison of the proportion of risk for PD attributed to each selected

variable at individual level (AR) and population level (PAR) between the uncalibrated and the

calibrated estimates. For smoking, for example, the estimated AR and PARs increased after

calibration by 14% and 10% for CPI and by 26% and 21% for LA, respectively. The

corresponding figures for other variables were increased by 0~10% of PAR for CPI and by

9~21% of PAR for LA.

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 Discussion
Accepted Article
Because periodontal probing measurements depend on a hand-held probe, the outcome

measurements are subject to a dentist’s subjective judgement and periodontal expertise (such

as probing force and position). Therefore, the potential probability of measurement error for

PD is greater than for other diseases when community-based screening for early detection of

PD is conducted. This may explain why prevalence of PD varied from study to study.

As expected, the periodontal measurement errors in our validation study varied with

region. There were higher sensitivities in the northern and eastern area but more false

negative cases in the central area and two southern areas. For periodontal disease prevalence

surveys, the measurement errors exist across dentists. Therefore, before a nationwide survey,

we had conducted a validation study to assess the measurement errors in the measures for PD

and use them for calibration to improve the accuracy of PD prevalence estimation. Moreover,

the magnitude of the effects of the risk factors on periodontal disease was also affected.

The results of the effect of the calibration of the estimation of effect size for each risk

factor associated with the risk for PD was consistently demonstrated as non-differential

misclassification using either CPI or loss of attachment (LA) score. Specifically, the

calibrated OR was generally higher than the uncalibrated OR, although the underlying effect

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 sizes in terms of OR varied with different cut-offs for CPI score. These findings suggest that
Accepted Article
non-differential misclassification is unlikely to be modified due to using different outcomes

to define PD.

The implications of our findings are two-fold for prevention and treatment of PD. First,

if the effect of a risk factor, for example smoking, on PD is underestimated without

calibration, the contribution of this risk factor may be neglected and primary prevention of

PD may not target these risk factors. This can be easily observed from our AR and PAR

results. Second, the biased estimated odds ratio may also affect the risk stratification of PD in

the underlying population and, in turn, may lead to inaccurate individual risk prediction for

PD.

One might be interested to know whether the measurement errors are different by

different sites. Suppose senior periodontist are less likely to include such kind of gingival

recession as the outcome of CPI, the sensitivity of mid-buccal sites is supposed to be lower

than that of other sites in addition to the quality of professional training in the skills of CPI

and LA. It is interesting to assess the impact of measurement errors attributed to this drive

resulting from brushing. Unfortunately, we did not collect data at site-level and only at

sextant level in the main study and we could not re-analyse the data by sensitivity analysis

with and without excluding mid-buccal. However, we can check the influence of this concern

on measurement errors by examining sensitivity and specificity by different sites using data

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 from the first stage of validation study that were collected on the basis of site level. Based on
Accepted Article
the validation data on 31 participants, the sensitivity of mid-buccal site (36%) was lower than

other sites (47%) for the CPI measurements. The sensitivity of mid-buccal site (56%) was

lower than other sites (67%) for the LA measurements. The impact of lower sensitivity might

underestimate the effect size of the risk factors. However, the analysis of data on the main

study can be only limited to sextant-level due to unavailable information on site level. This is

one of our study limitations. Another limitation is that our periodontal measurements were

recorded at the sextant-level in a large-scale epidemiological study, and the measurement at

sextant-level was determined by index teeth. The highest score of all sites in each sextant was

selected as the representative of that sextant in our calibration. However, whether

measurement error at the sextant-level in the validation study can represent measurement

error in a large epidemiological study should be confirmed in future studies.

In conclusion, our study shows that the effect of measurement error on PD varied with

dentists and regions. The results of our validation study provide the basis for correcting the

effect size regarding the association between relevant correlates and PD. The estimated odds

ratio for certain risk factor (such as smoking) in association with PD was substantially

underestimated without calibration, which may also undervalue the ability of risk factor

intervention through health education to impact PD at the population level.

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 Acknowledgements
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The study was supported by the Department of Health, Taiwan (DOH97-HP-1304), National

Science Council (NSC 101-2314-B-038-032-MY2), and Ministry of Science and Technology,

Taiwan (MOST 104-2118-M-038-002, and MOST 105-2118-M-038-001).We gratefully

acknowledged the support and participation of the staff of the Keelung, Taipei, Changhua,

Tainan, Taitung and Matsu Health Bureau.

Conflict of Interest

The authors declare no conflicts of interest.

Author Contributions

CWS, HHC and SLC conceived the study concept and design. AMY and HL were

responsible for data analysis. AMY, HL, and YLL contributed on interpretation of the results.

CWS wrote the first draft. CWS and AMY contributed on concepts for analysis. HHC and

SLC revised the manuscript. All authors approved the MS before submission.

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 References
Accepted Article
Ainamo J, Barmes D, Beagrie G, Cutress T, Martin J, Sardo-Infirri J (1982). Development of

the World Health Organization (WHO) community periodontal index of treatment needs

(CPITN). Int Dent J 32: 281-291.

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Haber J, Wattles J, Crowley M, Mandell R, Joshipura K, Kent RL (1993). Evidence for

cigarette smoking as a major risk factor for periodontitis. J Periodontol 64:16-23.

Kinane DF, Chestnutt, IG (2000). Smoking and Periodontal Disease. Critical Reviews in Oral

Biology & Medicine 11: 356-365.

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epidemiological study of periodontal disease in Keelung, Taiwan: a model from Keelung

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851-859.

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Cambridge, UK: MRC Biostatistics Unit.

Petersen PE, Ogawa H (2005). Strengthening the prevention of periodontal disease: theWHO

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 approach. J Periodontol 76:2187-2193.
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Wang TT, Chen TH, Wang PE, Lai H, Lo MT, Chen PY, Chiu SY (2009). A

population-based study on the association between type 2 diabetes and periodontal disease

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 Table 1 Descriptive data on nationwide survey of periodontal disease at sextant-level with
CPI score and LA score
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CPI ≥3 or LA≥1 CPI ≥3 LA≥1
Variable
Non-PD PD Non-PD PD Non-PD PD
Gender Female 9,237 4,251 10,684 2,804 10,899 2,589
Male 5,381 4,213 6,924 2,670 6,453 3,141

Age 18-49 9,001 3,629 10,200 2,430 10,316 2,314

Over 50 4,031 3,775 5,334 2,472 5,172 2,634

Education >9 years 8,501 3,667 9,745 2,423 9744 2,424

<=9 years 4,531 3,737 5,789 2,479 5744 2,524

BMI <25 kg/m2 9,029 4,519 10,620 2,928 10,494 3,054

2
>=25 kg/m 4,354 3,008 5,397 1,965 5,316 2,046

DM Normal 11,214 5,640 13,153 3,701 13,118 3,736

pre-DM 1,982 1,444 2,501 925 2,455 971
DM 616 656 829 443 808 464

Smoking No 11,037 5,295 12,927 3,405 12,868 3,464

Yes 2,393 2,227 3,126 1,494 2,994 1,626

Alcohol No 7,933 4,541 9,612 2,862 9,363 3,111

Drinking Yes 3,914 2,008 4,630 1,292 4,482 1,440

CPI: Community Periodontal Index

LA: Loss of Attachment
PD: Periodontal Disease

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 Table 2 Estimated adjusted odds ratio of risk factors for periodontal disease with CPI and LA
(CPI ≥3 or LA≥1) at sextant-level for univariate logistic regression model before and after
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calibrating measurement errors using Bayesian hierarchical model

Univariate Multivariate – Model 1 Multivariate – Model 2

Variable Uncalibrated cOR Calibrated cOR Uncalibrated aOR Calibrated aOR Uncalibrated aOR Calibrated aOR
(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI)
Gender
Male/ Female 2.64 4.37 1.76 2.05 1.83 2.21
(2.24, 3.12) (3.33, 5.89) (1.45, 2.13) (1.56, 2.70) (1.47, 2.27) (1.60, 3.09)
Age
per year 1.08 1.13 1.07 1.11 1.07 1.12
(1.07, 1.09) (1.12, 1.15) (1.06, 1.08) (1.10, 1.12) (1.06, 1.08) (1.11, 1.14)
Education
≤9/ >9 years 3.65 9.56 1.37 1.76 1.44 1.97
(3.07, 4.33) (7.03, 13.60) (1.13, 1.67) (1.32, 2.32) (1.15, 1.80) (1.43, 2.75)
BMI
≥25/<25 kg/m2 1.81 2.78 1.02 1.05 1.01 1.06
(1.53, 2.15) (2.08, 3.76) (0.86, 1.20) (0.82, 1.36) (0.83, 1.23) (0.80, 1.42)
DM
pre-DM/ Normal 1.18 1.16 1.03 1.33 0.98 1.36
(0.90, 1.57) (0.65, 2.11) (0.83, 1.29) (0.95, 1.85) (0.76, 1.27) (0.92, 2.04)
DM/ Normal 1.39 2.09 1.62 2.90 1.53 2.48
(0.89, 2.17) (0.83, 5.53) (1.15, 2.29) (1.68, 5.06) (1.05, 2.27) (1.34, 4.72)
Smoking
Yes/ No 3.42 6.50 2.00 2.76 2.00 2.81
(2.81, 4.17) (4.65, 9.39) (1.61, 2.49) (2.00, 3.84) (1.55, 2.58) (1.93, 4.10)
Alcohol Drinking
Yes/ No 0.76 0.56 1.14 1.18
-- --
(0.62, 0.93) (0.40, 0.78) (0.93, 1.40) (0.86, 1.61)
DIC -- -- 17921.9 18103.6 15268.8 15438.4
aOR: Adjusted Odds Ratio
cOR: Crude Odds Ratio
CPI: Community Periodontal Index
DIC: Deviance Information Criterion
LA: Loss of Attachment

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 Table 3 Estimated adjusted odds ratio of risk factors for periodontal disease with CPI (CPI ≥3)
at sextant-level for univariate and multivariate logistic regression model before and after
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calibrating measurement errors using Bayesian hierarchical model

Univariate Multivariate
Variable Uncalibrated cOR Calibrated cOR Uncalibrated aOR Calibrated aOR
(95% CI) (95% CI) (95% CI) (95% CI)
Gender
1.87 2.64 1.30 1.47
Male/ Female
(1.61, 2.19) (2.08, 3.39) (1.07, 1.57) (1.12, 1.94)
Age
1.06 1.08 1.05 1.07
per year
(1.05, 1.06) (1.07, 1.09) (1.05, 1.06) (1.06, 1.09)
Education
2.75 4.26 1.27 1.44
≤9/ >9 years
(2.33, 3.23) (3.29, 5.65) (1.04, 1.56) (1.10, 1.89)
BMI
1.56 1.99 1.10 1.15
≥25/ <25 kg/m2
(1.32, 1.86) (1.55, 2.58) (0.93, 1.32) (0.90, 1.47)
DM
1.65 2.22 0.99 1.13
pre-DM/ Normal
(1.33, 2.06) (1.62, 3.09) (0.79, 1.25) (0.82, 1.56)
3.28 6.75 1.50 2.26
DM/ Normal
(2.38, 4.56) (4.08, 11.38) (1.07, 2.10) (1.39, 3.71)
Smoking
2.62 4.29 2.02 2.75
Yes/ No
(2.19, 3.18) (3.22, 5.84) (1.63, 2.52) (2.01, 3.77)
Alcohol Drinking
0.85 0.79
Yes/ No -- --
(0.70, 1.03) (0.59, 1.08)
DIC -- -- 15917 16106.8
aOR: Adjusted Odds Ratio
cOR: Crude Odds Ratio
CPI: Community Periodontal Index
DIC: Deviance Information Criterion

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 Table 4 Estimated adjusted odds ratio of risk factors for periodontal disease with LA (LA ≥1)
at sextant-level for univariate and multivariate logistic regression model before and after
Accepted Article
calibrating measurement errors using Bayesian hierarchical model

Univariate Multivariate
Variable Uncalibrated cOR Calibrated cOR Uncalibrated aOR Calibrated aOR
(95% CI) (95% CI) (95% CI) (95% CI)
Gender
4.01 12.72 2.65 3.88
Male/ Female
(3.30, 4.91) (8.10, 21.50) (2.08, 3.38) (2.58, 6.06)
Age
1.09 1.19 1.07 1.15
per year
(1.08, 1.10) (1.17, 1.22) (1.06, 1.08) (1.13, 1.18)
Education
3.47 22.24 1.29 2.14
≤9/ >9 years
(2.81, 4.28) (13.08, 38.74) (1.00, 1.63) (1.44, 3.21)
BMI
1.82 3.03 0.91 0.86
≥25/ <25 kg/m2
(1.46, 2.28) (1.94, 4.79) (0.72, 1.14) (0.59, 1.23)
DM
2.07 8.35 0.96 1.51
pre-DM/ Normal
(1.56, 2.73) (4.42, 16.73) (0.72, 1.27) (0.93, 2.44)
5.13 48.86 1.49 3.24
DM/ Normal
(3.28, 8.06) (18.77, 148.86) (0.98, 2.25) (1.58, 6.84)
Smoking
4.22 16.28 1.93 3.85
Yes/ No
(3.26, 5.42) (9.23, 30.94) (1.47, 2.54) (2.44, 6.13)
Alcohol Drinking
0.84 0.52
Yes/ No -- --
(0.65, 1.09) (0.26, 0.99)
DIC -- -- 13968.3 14059.6
aOR: Adjusted Odds Ratio
cOR: Crude Odds Ratio
DIC: Deviance Information Criterion
LA: Loss of Attachment

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 Table 5 AR and PAR by status of PD with CPI and LA at sextant level
Accepted Article
% Uncalibrated Calibrated
Variable
Exposure aOR AR PAR aOR AR PAR

CPI ≥3 or LA ≥1

Education 0.4 1.37 27% 13% 1.75 43% 23%

BMI 0.35 1.02 2% 1% 1.05 5% 2%

pre-DM 0.16 1.03 3% 0% 1.31 24% 5%

DM 0.06 1.62 38% 4% 2.96 66% 11%

Smoking 0.22 2 50% 18% 2.86 65% 29%

CPI ≥3

Education 0.4 1.27 21% 10% 1.44 31% 15%

BMI 0.35 1.1 9% 3% 1.15 13% 5%

pre-DM 0.16 0.99 -1% 0% 1.13 12% 2%

DM 0.06 1.5 33% 3% 2.26 56% 7%

Smoking 0.22 2.02 50% 18% 2.75 64% 28%

LA ≥1
Education 0.4 1.29 22% 10% 2.14 53% 31%

BMI 0.35 0.91 -10% -3% 0.86 -16% -5%

pre-DM 0.16 0.96 -4% -1% 1.51 34% 8%

DM 0.06 1.49 33% 3% 3.24 69% 12%

Smoking 0.22 1.93 48% 17% 3.85 74% 39%
aOR: Adjusted Odds Ratio
BMI: Body Mass Index
DM: Diabetes Mellitus
CPI: Community Periodontal Index
LA: Loss of Attachment
AR (Attributable Proportion)= (Odds Ratio-1)/(Odds Ratio)
PAR(Population Attributable Proportion)= ((Exposure %)×(Odds Ratio-1))/(1+(Exposure
%)×(Odds Ratio-1))

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