Possible inverse relationship between level of educational attainment and risk for chronic periodontitis Critical Summary Prepared by: Satheesh Elangovan BDS., ScD., DMSc 


  • Systematic Review Conclusion:

    Evidence suggests that low educational attainment is associated with an increased risk of chronic periodontitis.

  • Critical Summary Assessment:

    This review suggests that when developing public health programs, planners should consider the level of educational attainment in target population.

  • Evidence Quality Rating:


A Critical Summary of:

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

Boillot, A., El Halabi, B., Batty, G. D., Range, H., Czernichow, S., Bouchard, P.. PLoS ONE [Electronic Resource]. 2011;6(7):e21508

  • Clinical Questions:

    In adults aged 35 and older, is there an association between the level of educational attainment and the risk of chronic periodontitis?

  • Review Methods:

    Two independent reviewers searched two electronic databases through November 2010. In addition, the authors manually searched the references listed in the articles of interest, searched their own files and contacted experts in the field. They considered all English language observational studies involving adults aged 35 and older.. They also included studies containing a case definition of periodontitis, a variable describing the level of education and a quantitative assessment of the relationship between the level of education and periodontitis. If consensus was not reached through discussion by the two primary reviewers, they brought in a third reviewer. Two reviewers also conducted data abstraction for meta-analysis independently. The authors used appropriate statistical tests to assess the inter-rater reliability between reviewers, heterogeneity in results (and, if found, the causes for heterogeneity), and the possibility of publication bias.

  • Main Results:

    The search process yielded a total of 18 observational studies conducted in different parts of the world, comprising more than 40,000 subjects. Of the included studies, 16 were cross-sectional and two were longitudinal. The analysis revealed that groups attaining lower levels of education, when compared to groups attaining higher levels of education, experienced a higher risk of periodontitis (OR: 1.86 [1.66-2.10]; p<0.00001). When adjusted for covariates, the association was partially attenuated, but still statistically significant (OR: 1.55 [1.30-1.86]; p<0.00001). Sensitivity analyses showed that the observed heterogeneity was largely attributed to the variations in the methods used to assess periodontitis, definition of cases, study location and categorization of education.

  • Conclusion:

    Although the results suggest that low educational attainment was associated with an increased risk of periodontitis, they should be interpreted with caution due to methodological issues with selected studies, which contributed to heterogeneity. The review underscores the importance of early life interventions and recommends consideration of educational attainment as a factor in planning preventive programs to address periodontal disease.

  • Source of funding:

    Authors report no support or funding for this report.


  • Importance and Context:

    Though the underlying etiology for chronic periodontitis is bacterial plaque with strong influences from systemic factors, poor social circumstances could be a potential risk factor for this common condition. This is the first systematic review to exclusively assess the association of educational attainment level and periodontal disease risk.

  • Strengths and Weaknesses of the Systematic Review:

    The review addressed an important question using an adequate search strategy with some limitations. For example, the authors did not search grey literature or hard-copy journals, and only included studies in English. The authors employed well-defined inclusion and exclusion criteria. More than one reviewer carried out both the article selection and data extraction with good agreement between them. The authors assessed the level of heterogeneity among included articles, used sensitivity analysis to identify the source of heterogeneity, and used a random effects model to account for heterogeneity between studies. Although they adequately addressed publication bias, the authors did not assess the quality or risk of bias of the included articles, which is a significant limitation of the review.

  • Strengths and Weaknesses of the Evidence:

    The review encompassed a large sample size with generally narrow confidence intervals making the results statistically and clinically relevant. All the included studies were observational; therefore, causal inference cannot be made between the selected variables with a significant risk of confounding bias. All of the included studies—except two longitudinal ones—were cross-sectional, providing only limited "snap shot" information. The evidence of an association is limited only to chronic periodontitis and cannot be extrapolated to aggressive periodontitis. Although most of the included studies demonstrated an association between low educational attainment and periodontitis, these findings merit further exploration due to significant heterogeneity in data resulting from differences in the methodology used to assess periodontitis, extent of clinical assessment, definition of cases, geographic location, and categorization of educational levels.

  • Implications for Dental Practice:

    The question that this review addresses has several important clinical and policy implications. This review suggests that when developing public health programs, planners should consider the level of educational attainment in the target population. Due to the intricate connection between socio-economic circumstances, periodontitis and other chronic medical conditions, any interventional strategy intended to address periodontitis that takes educational level into account may affect the overall well-being of the target population. In addition, early educational intervention is key to establishing periodontal health, and oral health providers should begin discussing periodontitis with young children.

  • Critical Summary Publication Date: 10/8/2012

These summaries are not intended to, and do not, express, imply, or summarize standards of care, but rather provide a concise reference for dentists to aid in understanding and applying evidence from the referenced systematic review in making clinically sound decisions as guided by their clinical judgment and by patient needs. American Dental Association ©

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