International Dental Journal (2010) 60, 370-374

Wael Sabbah1, Aubrey Sheiham1 and Eduardo Bernab1,2

Income inequality and periodontal diseases in rich countries: an ecological cross-sectional study

Department of Epidemiology and Public Health, University College London, London, UK; 2Departamento de Odontologa Social, Universidad Peruana Cayetano Heredia, Lima, Per

There are adverse effects of income inequality on morbidity and mortality. This relationship has not been adequately examined in relation to oral health. Aims: To examine the relationship between income inequality and periodontal disease in rich countries. Participants: Adults aged 35-44 years in 17 rich countries with populations of more than 2 million. Methods: National level data on periodontal disease, income inequality and absolute national income were collected from 17 rich countries with populations of more than 2m. Pearson and partial correlations were used to examine the relationship between income inequality and percentage of 35-44-year-old adults with periodontal pockets >4mm and >6mm deep, adjusting for absolute national income. Results: Higher levels of income inequality were significantly associated with higher levels of periodontal disease, independently of absolute national income. Absolute income was not associated with levels of periodontal disease in these 17 rich countries. Conclusion: Income inequality appears to be an important contextual determinant of periodontal disease. The results emphasise the importance of relative income rather than absolute income in relation to periodontal disease in rich countries. Key words: Wealth, periodontal disease, older adults

Income inequality has adverse effects on population health1,2 and on mortality rates3. Higher levels of income inequality are linked to higher all-cause mortality risk4, higher prevalence of depressive symptoms5, poorer selfrated health1,6-9 and health-deteriorating behaviours10. The effect of income inequality on health appears to be independent of race, education, income and access to health insurance1,8,11,12. Income inequality is the extent to which income is unevenly distributed in a given society2. The adverse relationship between income inequality and health reflects the effect of relative income (individuals income compared to other members of the society) rather than absolute income (actual individuals income)2. The distribution of income in a given society might affect health via material and behavioural factors, such as diet and smoking13. Some suggest that income inequality
2010 FDI/World Dental Press 0020-6539/10/05370-05

affects health through a process of social comparison, status competition and individuals feelings of relative deprivation2,14. Social comparison and relative deprivation affect health through psycho-neuroendocrine and behavioural pathways15. Income inequality has also been linked to a decline in social capital and trust, behavioural and psychological consequences and disinvestment in public resources such as education and health care, as the interests of the rich diverge from those of the poor16,17. There is a commonality of the social determinants of oral and general health18-20. Studies have also shown the effects of individuals income on oral health through behaviours21,22, and psychosocial pathways23,24. The aforementioned relationships and the common determinants are more particular to periodontal disease23,24. Few studies have examined the relationship of oral health
doi:10.1922/IDJ_2480Sabbah05

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with income inequality25-29 and social capital30. We postulate that income inequality at the country level is related to periodontal health in the same manner it relates to general health2 and that this relationship is independent of national income. The hypothesis of this study is that countries with higher levels of income inequality will also have higher levels of periodontal disease. The relationship between income inequality and periodontal disease operates through the process of social comparison and experience of relative deprivation which consequently affect individuals psychosocial wellbeing2,14, behaviour10 and periodontal status22,23. The relationship between income inequality and periodontal disease could also operate through a decline in social capital and the consequential disinvestment in public services including oral health services16,17. To demonstrate the importance of relative deprivation rather than material deprivation our study was limited to rich countries31,32. The objective of this study is to examine the relationship between income inequality and periodontal disease in rich countries for individuals aged 35-44 years old.
Subjects and methods

We used an ecological study design to test the relationship between income inequality and periodontal disease, adjusting for absolute national income. The richest 50 countries in the world were selected, based on Gross National Income per capita in 199433, corresponding to the midpoint of the time when periodontal data was collected (1984 to 2003). Countries with less than two million inhabitants were excluded to avoid possible tax havens31,32, which reduced the eligible countries to 26. The analysis was conducted for 17 countries (65.4%) that had comparable data on income inequality and periodontal disease, namely Australia, Austria, Denmark,

France, Germany, Greece, Hong-Kong, Ireland, Italy, Japan, Korea, Netherlands, New-Zealand, Portugal, Spain, UK and USA. National statistics on periodontal disease for 35-44 year-old adults were obtained from the WHO Oral Health Country/Area Profile Programme34, expressed as the percentage of adults with periodontal pockets >4 mm Community Periodontal Index (CPI) 3 or 4 and with periodontal pockets >6 mm (CPI 4). Specific details of the clinical data for individual countries are available from the data source34. Data collection, calibration and reliability were conducted according to the WHO criteria35. Periodontal data pertain to national surveys conducted between 1984 and 2003. Data on income inequality were obtained from the United Nations Human Development Indicators for the period 1993-200236. Income inequality was indicated by Gini coefficient and the ratio between annual income of richest and poorest 20% of the population (20:20 ratio). Higher values of Gini coefficient and 20:20 ratio indicate greater inequality37-39. Data on absolute national income were obtained from the World Bank: Gross Domestic Product (GDP) and Gross National Income (GNI) per capita in 199433. While more recent absolute income data is available, we opted to use data from 1994 as they represent a mid-point for the periodontal data used in this analysis.
Data analysis

Pearson correlation coefficients were used to estimate the linear associations between income inequality measures and periodontal disease levels. Partial correlation coefficients were used to estimate the associations between income inequality and periodontal disease adjusting for absolute national income. This method was used in similar studies25,27,28.

Table 1 Total and partial correlation coefficients of income and income inequality measures with periodontal disease levels of 35-44-year-old adults among rich countries Income measures Percentage of adults with periodontal pockets >4 mm (CPI score 3/4) r Total correlations GDP GNI Gini coefficient 20:20 ratio 0.25 0.23 0.50 0.59 0.330 0.376 0.043 0.013 0.22 0.25 0.51 0.62 0.388 0.329 0.035 0.008 p value >6 mm (CPI score 4) R p value

Partial correlations of relative income measures Gini coefficient adjusted for GDP Gini coefficient adjusted for GNI 20:20 ratio adjusted for GDP 20:20 ratio adjusted for GNI 0.54 0.51 0.59 0.58 0.032 0.042 0.016 0.020 0.55 0.53 0.62 0.61 0.028 0.033 0.011 0.013

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Figure 1. Scatter plots for the relationship of income inequality measures (Gini coefficient and 20:20 ratio) with the percentage of 35-44-year-old adults with periodontal pockets >4 and >6 mm in 17 rich countries.

Results

The mean percentages of 35-44 year-olds with periodontal pockets of >4mm and >6mm in the 17 countries were 40.8 and 8.4 respectively. The mean Gini coefficient and 20:20 ratio were 0.34 and 6.07, respectively. Higher levels of Gini coefficient were significantly associated with higher percentages of adults aged 35-44 with periodontal pockets of >4 mm (correlation coefficient 0.50, p<0.05) and periodontal pockets of >6 mm (correlation coefficient 0.51, p<0.05) (Table 1, Figure 1). Similarly, income inequality indicated by 20:20 ratio was
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significantly related to the percentage of adults with periodontal pockets of >4 mm (correlation coefficient 0.59, p<0.05) and >6 mm (correlation coefficient 0.62, p<0.01) (Table 1, Figure 1). After adjusting for GNI and GDP consecutively, the Gini coefficient and 20:20 ratio still showed a significant association with the percentage of adults with periodontal pockets of >4 mm and >6 mm (Table 1). Conversely, absolute national income at country level, indicated by GDP and GNI, was not significantly associated with levels of periodontal disease (Table 1).

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Discussion

This study showed that higher levels of income inequality in rich countries were associated with higher levels of periodontal disease in adults, even after adjusting for measures of absolute national income. These findings are consistent with previous studies on the relationship between income inequality and oral health25-29. However, this study is unique in examining the relationship between income inequality and periodontal disease in rich countries, hence demonstrating that this relationship is independent of absolute poverty and national income. Furthermore, this study showed that income inequality has a relationship with periodontal disease similar to that between income inequality and mortality rates3,4, general health1,2,6-9, and health-deteriorating behaviours10. There is a relationship between periodontal diseases on the one hand and individuals income and socioeconomic position20,23, and national absolute income25 on the other hand. Psychosocial, stress, and behavioural pathways have been depicted as possible explanations for the aforementioned relationships22-24. This study expands our knowledge of the social determinants of periodontal disease as it demonstrates the presence of a relationship between periodontal diseases and income inequality indicated by two markers (Gini coefficient and 20:20 ratio). It is reasonable to assume that the same pathways that link individuals and absolute national income to periodontal disease play the same role in the relationship between income inequality and periodontal disease. While level of periodontal diseases was associated with income inequality, it was not associated with absolute national income in rich countries. This finding supports the theory that in rich countries income inequality is a more important determinant of health than absolute income2. The theories on the relationship between income inequality and social comparison and relative deprivation14, social capital16,17, and the theories on psychosocial pathways to inequality in oral health23,24,29 are possible explanations for our findings. Ecological studies are useful for the formulation of hypothesis but they cannot test them40. This ecological study design at the country level has been extensively used in medical and dental literatures3,25,28,32,41. However, the findings of the current study should be interpreted with caution considering the limitations of country-level ecological and cross-sectional studies, and the limitations of the aggregated datasets. Due to the nature of the study we could not adjust for other determinants of periodontal disease, such as age, ethnicity, smoking and oral hygiene, at the individual level23 or draw conclusion on differences in periodontal disease between individu-

als. However, other studies on the effects of income inequality on general health have shown that this effect was independent of individual risk factors1,8,11,12. This is the first study examining the relationship between two measures of income inequality and periodontal disease among 35-44-year-old individuals in rich countries. The results support, to some extent, theories on the effects of relative deprivation and social comparison on health, through psychosocial pathways. There is a need for research in this area, using multilevel analysis to adjust for individual risk factors and socio-demographic characteristics and to examine the pathways for the relationship between income inequality and periodontal disease.

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Correspondence to: Wael Sabbah, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK. Email: w.sabbah@ucl.ac.uk

International Dental Journal (2010) Vol. 60/No.5