Application of Multilevel Models in Dentistry

  • Mohammad Javad Kharazifard PhD Candidate of Epidemiology, Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
  • Kurosh Holakouie-Naieni Professor, Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
  • Mohammad Ali Mansournia Assistant Professor, Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
Multilevel Analysis, Multicenter Study, Clinical Trials, Dentistry


Multilevel analysis which was primarily introduced to deal with hierarchical data was later applied extensively for research in other fields of science and not only for nested data, but also for repeated measurements or clustered trials. This method of statistical analysis was applied in dental studies in the 1991 for the first time but despite its value for data analysis in dental studies, its application for dental studies remains limited until now. This manuscript reviews the applications of this method in dental studies.


- Goldstein H. Multilevel statistical models. 4th ed., London, Wiley, 2011:24-58.

- Aitkin M, Anderson D, Hinde J. Statistical modeling of data on teaching styles. J Royal Statist Assoc. 1981 Jan;144:419-61.

- Hox, JJ. Multilevel analysis: Techniques and applications. 2nd ed., Routledge, New York, 2010:11-36.

- van der Beek MC, Hoeksma JB, Prahl-Andersen B. Vertical facial growth: a longitudinal study from 7 to 14 years of age. Eur J Orthod. 1991 Jun;13(3):202-8.

- Tellez M, Sohn W, Burt BA, Ismail AI. Assessment of the relationship between neighborhood characteristics and dental caries severity among low-income African-Americans: A multilevel approach. J Public Health Dent. 2006 Mar;66(1):30-6.

- Wamala S, Merlo j, Bostrom G. Inequity in access

to dental care services explains current socioeconomic disparities in oral health: The Swedish National Surveys of Public Health 2004–2005. J Epidemiol Community Health 2006 Dec;60(12):1027-33.

- Levin KA, Currie C. Inequalities in toothbrushing among adolescents in Scotland 1998-2006. Health Educ Res. 2009 Feb;24(1):87-97.

- Riberi Jordao LM, Vasconcelos DN, Moreira RS, Matias Freire MC. Individual and contextual determinants of periodontal health in 12-year-old schoolchildren in a Brazilian capital city. Int J Dent. 2012;2012:325475.

- Santiago BM, Valenca AMG, Vettore MV. Social capital and dental pain in Brazilian northeast: a multilevel cross-sectional study. BMC Oral Health. 2013 Jan 4;13:2.

- Peres MA, Peres KG, Frias AC, Antunes JLF. Contextual and individual assessment of dental pain period prevalence in adolescents: a multilevel approach. BMC Oral Health. 2010 Aug;10:20.

- Ferreira EF, Vargas AM, Castilho LS, Velásquez LN, Fantinel LM, Abreu MH. Factors associated to endemic dental fluorosis in Brazilian rural communities. Int J Environ Res Public Health. 2010 Aug;7(8):3115-28.

- Aleksejūnienė J, Holst D, Brukienė V. Dental caries risk studies revisited: Causal approaches needed for future inquiries. Int J Environ Res Public Health. 2009 Nov 30;6(12):2992-3009.

- Braga MM, Martignon S, Ekstrand KR, Ricketts DNJ, Imparato JCP, Mendes FM. Parameters associated with active caries lesions assessed by two different visual scoring systems on occlusal surfaces of primary molars – a multilevel approach. 2010 Dec;38(6):549-58.

- Muller HP. Dealing with hierarchical data in periodontal research. Clin Oral Investig. 2009 Sep;13(3):273-8.

- Gillot L, Noharet R, Buti J, Cannas B. A retrospective cohort study of 105 patients rehabilitated with immediately loaded mandibular cross-arch bridges in combination with immediate implant placement. Eur J Oral Implantol 2011 Sep;4(3): 247–53.

- Axtelius B, Söderfeldt B, Attström R. A

multilevel analysis of factors affecting pocket probing depth in patients responding differently to periodontal treatment. J Clin Periodontol. 1999 Feb;26(2):67-76.

- Angst PD, Piccinin FB, Opperman RV, Marcantonio RA, Gomez SC. Response of molars and non-molars to a strict supragingival control in periodontal patients. Braz Oral Res. 2013 Jan-Feb;27(1):55-60.

- Kim T-S, Schenk A, Lungeanu D, Reitmeir P, Eickholz P. Nonsurgical and surgical periodontal therapy in single-rooted teeth. Clin Oral Investig. 2007 Dec;11(4):391-9.

- Wan CP, Leung WK, Wong MC, Wong RM, Wan P, Lo EC, et al. Effects of smoking on healing response to non-surgical periodontal therapy: a multilevel modelling analysis. J Clin Periodontol. 2009 Mar;36(3):229-39.

- Pini-Parto GP, Cairo F, Nieri M, Franceschi D, Rotondo R, Cortellini P. Coronally advanced flap versus connective tissue graft in the treatment of multiple gingival recessions: a split-mouth study with 5-year follow-up. J Clin Periodontol. 2010 Jul;37(7):644-50.

- Piovesan C, Antunes JL, Mendes FM, Guedes RS, Ardenghi TM. Influence of children's oral health-related quality of life on school performance and school absenteeism. J Public Health Dent. 2012 Spring;72(2):156-63.

- Yekaninejad MS, Eshraghian MR, Nourijelyani K, Mohammad K, Foroushani AR, Zayeri F, et al. Effect of a school-based oral health-education program on Iranian children: results from a group randomized trial. Eur J Oral Sci. 2012 Oct;120(5):429-37.

- Kopperud SE, Tveit AB, Gaarden T, Sandvik L, Espelid I. Longevity of posterior dental restorations and reasons for failure. Eur J Oral Sci. 2012 Dec;120(6):539-48.

- Stephensen J, Chadwick BL, Playle RA, Treasure ET. Modelling childhood caries using parametric competing risks survival analysis methods for clustered data. Caries Res 2010;44:69-80.

- Gilthorpe MS, Mayhew MT, Bulman JS. Multilevel survival analysis of amalgam restorations amongst RAF personnel. Community Dent Health. 2002 Mar;19(1):3-11.

- Van Der Beek MC, Hoeksma JB, Prahl-Andersen B. Vertical facial growth and statural growth in girls: a longitudinal comparison. Eur J Orthod. 1996 Dec;18(6):549-55.

- Buschang PH, Santos-Pinto A, Demirjian A. Incremental growth charts for condylar growth between 6 and 16 years of age. Eur J Orthod. 1999 Apr;21(2):167-73.

- Arboleda C, Buschang PH, Camacho JA, Botero P, Roldan S. A mixed longitudinal anthropometric study of craniofacial growth of Colombian mestizos 6–17 years of age. Eur J Orthod 2011 Nov;33(4):441-9.

- Barrera LM, Buschang PH, Throckmorton GS, Roldán SI. Mixed longitudinal evaluation of masticatory performance in children 6 to 17 years of age. Am J Orthod Dentofacial Orthop. 2011 May;139(5): e427-34.

- Pini Prato G, Rotundo R, Franceschi D, Cairo F, Cortellini P, Nieri M. 14-year outcomes of coronally advanced flap for root coverage: Follow-up from a randomized trial. J Clin Periodontol. 2011 Aug;38(8): 715-20.

- Mdala I, Haffajee AD, Socransky SS, de Blasio BF, Thoresen M, Olsen I, et al. Multilevel analysis of clinical parameters in chronic periodontitis after root planing/scaling, surgery, and systemic and local antibiotics: 2-year results. J Oral Microbiol. 2012 Jan;4(1):17535.

- Gilthorpe MS, Zamzuri AT, Griffiths GS, Maddick IH, Eaton KA, Johnson NW. Unification of the "burst" and "linear" theories of periodontal disease progression: a multilevel manifestation of the same phenomenon. J Dent Res. 2003 Mar;82(3):200-5.

- Liu SS, Kyung HM, Buschang PH. Continuous forces are more effective than intermittent forces in expanding sutures. Eur J Orthod. 2010 Aug;32(4):371-80.

- Barbeau J, Tanguay R, Faucher E, Avezard C, Trudel L, Cote L, et al. Multiparametric analysis of aterline contamination in dental units. Appl Environ Microbiol. 1996 Nov;62(11):3954-9.

- Tang L, Lund JP, Taché R, Clokie CM, Feine JS. A within-subject comparison of mandibular long-bar and hybrid implant-supported prostheses: evaluation of masticatory function. J Dent Res. 1999 Sep;78(9):1544-53.

- Ramirez-Echave JI, Buschang PH, Carrillo R, Rossouw PE, Nagy WW, Opperman LA. Histologic evaluation of root response to intrusion in mandibular teeth in beagle dogs. Am J Orthod Dentofacial Orthop. 2011 Jan;139(1):60-9.

- Gilthorpe MS, Cunningham SJ. The application of multilevel, multivariate modelling to orthodontic research data. Community Dent Health. 2000 Dec;17(4):236-42.

- Pereira VT, Pavan P, Souza RC, Souto R, Vettore MV, Torres SR, et al. The association between detectable plasmatic HIV viral load and different subgingival microorganisms in HIV-infected Brazilian adults: A multilevel analysis. J Periodontol. 2014 May;85(5):697-705.

- Agbaje JO, Mutsvari T, Lesaffre E, Declerck D. Measurement, analysis and interpretation of examiner reliability in caries experience surveys: some methodological thoughts. Clin Oral Investig. 2012 Feb;16(1):117-27.

- Lewsey JD, Gilthorpe MS, Gulabivala K. An introduction to meta-analysis within the framework of multilevel modelling using the probability of success of root canal treatment as an illustration. Community Dent Health. 2001 Sep;18(3):131-7.

- Finnema KJ, Ozcan M, Post WJ, Ren Y, Dijkstra PU. In-vitro orthodontic bond strength testing: a systematic review and meta-analysis. Am J Orthod Dentofacial Orthop. 2010 May;137(5):615-22.

- Mdala I, Haffajee AD, Socransky SS, de Blasio BF, Thoresen M, Olsen I, et al. Multilevel analysis of bacterial counts from chronic periodontitis after root planing/scaling, surgery, and systemic and local antibiotics:2-year results. J Oral Microbiol. 2013 Jul;5.

- Celeste RG, Fritzel J, Nadanovsky P. The relationship between levels of income inequality and dental caries and periodontal diseases. Cad Saude Publica. 2011 Jun;27(6):1111-20.

How to Cite
Kharazifard MJ, Holakouie-Naieni K, Mansournia MA. Application of Multilevel Models in Dentistry. Front Dent. 14(6):352-360.
Review Article