Abstract
Studies/trials assessing status and progression of periodontal disease (PD) usually focus on quantifying the relationship between the clustered (tooth within subjects) bivariate endpoints, such as probed pocket depth (PPD), and clinical attachment level (CAL) with the covariates. Although assumptions of multivariate normality can be invoked for the random terms (random effects and errors) under a linear mixed model (LMM) framework, violations of those assumptions may lead to imprecise inference. Furthermore, the response-covariate relationship may not be linear, as assumed under a LMM fit, and the regression estimates obtained therein do not provide an overall summary of the risk of PD, as obtained from the covariates. Motivated by a PD study on Gullah-speaking African-American Type-2 diabetics, we cast the asymmetric clustered bivariate (PPD and CAL) responses into a non-linear mixed model framework, where both random terms follow the multivariate asymmetric Laplace distribution (ALD). In order to provide a one-number risk summary, the possible non-linearity in the relationship is modeled via a single-index model, powered by polynomial spline approximations for index functions, and the normal mixture expression for ALD. To proceed with a maximum-likelihood inferential setup, we devise an elegant EM-type algorithm. Moreover, the large sample theoretical properties are established under some mild conditions. Simulation studies using synthetic data generated under a variety of scenarios were used to study the finite-sample properties of our estimators, and demonstrate that our proposed model and estimation algorithm can efficiently handle asymmetric, heavy-tailed data, with outliers. Finally, we illustrate our proposed methodology via application to the motivating PD study.