Education as a predictor of chronic periodontitis: a systematic review with meta-analysis population-based studies

Abstract

Background: The impact of socioeconomic inequalities on health is well-documented. Despite the links of periodontal disease with cardiovascular diseases, adverse pregnancy outcomes and diabetes, no meta-analysis of socioeconomic variations in periodontal disease exists. This meta-analytic review was conducted to determine the extent to which education attainment influences risk of periodontitis in adults aged 35+ years in the general population.

Methods: The authors searched studies published until November 2010 using EMBASE and MEDLINE databases. References listed were then scrutinised, our own files were checked, and, finally, we contacted experts in the field. The authors included only general population-based studies conducted in adults aged 35 years and more. All articles were blind reviewed by two investigators. In the case of disagreement, a third investigator arbitrated. Using PRISMA statement, two reviewers independently extracted papers of interest.

Results: Relative to the higher education group, people with low education attainment experience a greater risk of periodontitis (OR: 1.86 [1.66-2.10]; p<0.00001). The association was partially attenuated after adjustment for covariates (OR: 1.55 [1.30-1.86]; p<0.00001). Sensitivity analyses showed that methods used to assess periodontitis, definition of cases, study country and categorization of education are largely responsible for the heterogeneity between studies. No significant bias of publication was shown using both the Egger (p = 0.16) and rank correlation tests (p = 0.35).

Conclusions: In the studies reviewed, low educational attainment was associated with an increased risk of periodontitis. Although this evidence should be cautiously interpreted due to methodological problems in selected studies, efforts to eliminate educational inequalities in periodontitis should focus on early life interventions.

Figure 1. Flow chart for identifying eligible studies.

Figure 2. Results of primary meta-analysis: crude risk of periodontitis for individuals with lower education.

Legend: Higher level of education as reference. Weights for individual studies calculated with random effects models and inverse variance method. The centre of each black square is placed at the point estimate, the area of the square is proportional to the sample size, and each horizontal line shows the 95% confidence interval for the estimate for each study. Pooled OR (95% CI): 1.86 (1.66–2.10). p<0.00001.

Figure 3. Results of primary meta-analysis: adjusted risk of periodontal diseases for individuals with low education.

Legend: Higher level of education as reference. Weights for individual studies calculated with random effects models and inverse variance method. The centre of each black square is placed at the point estimate, the area of the square is proportional to the sample size, and each horizontal line shows the 95% confidence interval for the estimate for each study. Pooled OR (95% CI): 1.55 (1.30–1.86). p<0.00001.