International Dental Journal (2010) 60, 370-374

Income inequality and periodontal

diseases in rich countries: an
ecological cross-sectional study
Wael Sabbah1, Aubrey Sheiham1 and Eduardo Bernabé1,2

1
Department of Epidemiology and Public Health, University College London, London,
UK; 2Departamento de Odontología Social, Universidad Peruana Cayetano Heredia,
Lima, Perú

There are adverse effects of income inequality on morbidity and mortality. This relation-
ship has not been adequately examined in relation to oral health. Aims: To examine the
relationship between income inequality and periodontal disease in rich countries. Partici-
pants: Adults aged 35-44 years in 17 rich countries with populations of more than 2 mil-
lion. 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, inde-
pendently 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 self-
rated 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 ex-
tent to which income is unevenly distributed in a given
society2. The adverse relationship between income in-
equality and health reflects the effect of relative income
(individual’s income compared to other members of the
society) rather than absolute income (actual individual’s
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 depriva-
tion 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 determi-
nants are more particular to periodontal disease23,24. Few
studies have examined the relationship of oral health
doi:10.1922/IDJ_2480Sabbah05

with income inequality25-29 and social capital30. We postu-
late 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 independ-
ent 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 compari-
son and experience of relative deprivation which con-
sequently 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 relation-
ship 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 relation-
ship 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,
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
>4 mm (CPI score 3/4)
r p value
Total correlations
GDP 0.25
GNI 0.23
Gini coefficient 0.50
20:20 ratio 0.59
Partial correlations of relative income measures
Gini coefficient adjusted for GDP 0.54
Gini coefficient adjusted for GNI 0.51
20:20 ratio adjusted for GDP 0.59
  20:20 ratio adjusted for GNI 0.58
371
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, cali-
bration 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 meas-
ures and periodontal disease levels. Partial correlation
coefficients were used to estimate the associations
between income inequality and periodontal disease ad-
justing for absolute national income. This method was
used in similar studies25,27,28.
Percentage of adults with periodontal pockets
>6 mm (CPI score 4)
R p value
0.330 0.22 0.388
0.376 0.25 0.329
0.043 0.51 0.035
0.013 0.62 0.008
0.032 0.55 0.028
0.042 0.53 0.033
0.016 0.62 0.011
0.020 0.61 0.013
Sabbah et al.: Income inequality and periodontal diseases
372

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 significantly related to the percentage of adults with

periodontal pockets of >4 mm (correlation coefficient
The mean percentages of 35-44 year-olds with perio-
0.59, p<0.05) and >6 mm (correlation coefficient 0.62,
dontal pockets of >4mm and >6mm in the 17 countries
p<0.01) (Table 1, Figure 1). After adjusting for GNI and
were 40.8 and 8.4 respectively. The mean Gini coef-
GDP consecutively, the Gini coefficient and 20:20 ratio
ficient and 20:20 ratio were 0.34 and 6.07, respectively.
still showed a significant association with the percent-
Higher levels of Gini coefficient were significantly
age of adults with periodontal pockets of >4 mm and
associated with higher percentages of adults aged 35-44
>6 mm (Table 1). Conversely, absolute national income
with periodontal pockets of >4 mm (correlation coef-
at country level, indicated by GDP and GNI, was not
ficient 0.50, p<0.05) and periodontal pockets of >6 mm
significantly associated with levels of periodontal disease
(correlation coefficient 0.51, p<0.05) (Table 1, Figure 1).
(Table 1).
Similarly, income inequality indicated by 20:20 ratio was
International Dental Journal (2010) Vol. 60/No.5

Discussion
This study showed that higher levels of income inequal-
ity 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 be-
tween 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 socioeco-
nomic 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 abso-
lute national income in rich countries. This finding sup-
ports 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 psy-
chosocial 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 limita-
tions 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-
373
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 peri-
odontal 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 multi-
level 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