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Table of Contents
Year : 2020  |  Volume : 16  |  Issue : 4  |  Page : 146-151

Review of the correlation between social economic status and oral diseases in India

1 Department of Public Health Dentistry, Amrita School of Dentistry, AIMS, Kochi, Kerala, India
2 Department of Public Health Dentistry, Azeezia College of Dental Science and Research, Kollam, Kerala, India
3 Department of Public Health Dentistry, Sree Mookambika Institute of Dental Sciences, Kanyakumari, Tamil Nadu, India

Date of Submission14-Jul-2020
Date of Decision18-Jul-2020
Date of Acceptance30-Jul-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Dr. Chandrashekar Janakiram
Department of Public Health Dentistry, Amrita School of Dentistry, AIMS, Ponekkara, Kochi - 682 041, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AMJM.AMJM_51_20

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Socioeconomic inequalities in oral health can be defined as the differences in the prevalence or incidence of oral health problems. We assessed the pooled estimate of prevalence of oral diseases among different socioeconomic status (SES) in India by including all articles published up to December 2016 with the prevalence of the oral diseases in SES population using the confined research terms in databases of PubMed and Google Scholar. All articles which had assessed the dental caries, periodontal disease, malocclusion, and oral cancer in different socioeconomic groups were collected. Out of 209 articles retrieved, 19 studies were included. The pooled estimate for mean DMFT for upper, middle, and lower SES status was 3.1 (95% confidence interval [CI] 3–3.1), 2.6 (95% CI 2.6–2.9) and 3.05 (95% CI 3.05–3.04). The prevalence of periodontal disease for (upper SES 12 [95% CI 11–12], middle SES 28 [95% CI 28–29] and lower SES status 60 (95% CI 59–60)] and in (Kuppuswamy scale Upper SES 22 [95% CI 21–22], middle SES 24 (95% CI 23–24] lower SES status 28 [95% CI 27–28]). Our analysis shows that the SES was inversely proportional to the oral diseases. There was a minor variation between DMFT between groups which may be attributed to the lack of large number of studies assessing the SES and dental caries. The pooled estimate of the mean DMFT across the SES status was inconsistent.

Keywords: Dental caries, India, oral diseases, periodontal disease, socioeconomic status

How to cite this article:
Janakiram C, Varghese NJ, Joseph J. Review of the correlation between social economic status and oral diseases in India. Amrita J Med 2020;16:146-51

How to cite this URL:
Janakiram C, Varghese NJ, Joseph J. Review of the correlation between social economic status and oral diseases in India. Amrita J Med [serial online] 2020 [cited 2023 Jun 4];16:146-51. Available from: https://ajmonline.org.in/text.asp?2020/16/4/146/304578

  Introduction Top

The link between general health and socioeconomic status is well-established, and there is link showing that poor oral health is associated with low socioeconomic status. In both high- and low-income countries, low socioeconomic status is mostly associated with increased risk of oral cancer.[1] Inequalities in socioeconomic status (SES) showed many health disparities in the world. The occupational status, income, and education are intrinsically related and associated with health and oral health.

The concept of socioeconomic inequalities in oral health can be defined as the differences in the prevalence or incidence of oral health problems between individual people of higher and lower SES.[2] Studies have shown that the differences in the oral health status between the individuals with a high and low SES had markedly increased. A study of health inequalities has given a new impetus by development and increasing use of measures of SES.

Studies from NCHS (National Centre for Health Statistics, 1996) show that despite progress in reducing dental caries, individuals in families living below the poverty level suffer caries experience. Certain factors such as age and race/ethnicity are also some of the contributing factors. The presence of periodontal disease and loss of attachment varies in racial/ethnic groups and is seen commonly in individuals at older age groups. At every age, a higher proportion of low SES (SES) level has at least one site with attachment loss of 6 mm or more, compared to those at high SES levels.[3] This study also shows that a higher percentage of individuals living below the poverty level are edentulous than are those living above. The occurrence of cancers in specific sites such as the oral cavity and pharynx varies by sex and race/ethnicity.[4]

The burden of oral diseases in India has considerably increased over the years, the prevalence of dental caries and periodontal diseases have been around 50% (all ages). However, point prevalence studies have shown varied estimates or relation between the SES and oral diseases. The affordability and accessibility of dental care are major challenge for low and middle SES people and to address the issue in equity in oral care. We designed this systematic review to assess the pooled estimate of prevalence of oral diseases among the different SES in India.

  Methodology Top

Data source

We included only cross-sectional studies assessing the prevalence oral disease, namely dental caries, periodontal disease, and oral cancer conducted in India. Studies were included irrespective of the year of publication. Studies in the English language were alone included. The participants were adults and children of both genders.

Search strategy

We searched MEDLINE and Google Scholar bibliographic databases for cross-sectional studies up to December 2016. No restrictions were placed on the language or date of publication when searching the electronic databases. The assessment of SES was by B G Prasad and Kuppuswamy scales and studies carried in India. All references cited in the included trials were checked for additional studies. Socioeconomic status, dental caries, periodontal disease, malocclusion, oral cancer, and India were the MeSH terms used [Figure 1].
Figure 1: Flow diagram of study selection

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Study selection

Two authors (NJV and CJ) independently reviewed all the titles and thereafter the abstracts for this review. If the study did not meet the inclusion criteria of this review, it was considered as discarded. There was no disagreement between the authors in the selection of the studies. Review authors were not blinded to author and source institution. Disagreement was resolved by the consensus or third-party adjudication.

Data collection process and data items

Piloting of data extraction was done by one of the authors (NV) on two articles. Both the authors (NV and CJ) agreed on the design of the data extraction form. Each article was hand searched and manually read by principal investigator. The final data extraction protocol included the following information. Variables collected for the study were – time during which the study was performed, investigators and year of publication of study, area of study, age group, prevalence, mean decayed, missing and filled teeth (DMFT)/dmft with standard deviation and SES of dental caries, periodontal disease, malocclusion, and oral cancer. The SES was measured using B G Prasad Classification and Kuppuswamy. SES also includes social stratification such as religious groups, education status, and caste wise.

Summary measures and synthesis of results

Data were entered in Microsoft Excel sheet and reliability check was done. The prevalence and mean of each SES status segregated according to age and gender wise. The pooled prevalence and means using the weighted mean and their corresponding standard deviation were estimated. The standard error was estimated, and confidence intervals of the pooled estimate of the mean and prevalence were calculated. Age- and gender-wise estimate was not estimated due to variation in ages and less number of the studies. The studies data combined according to different scales of the SES.

  Results Top

Study selection and characteristics

Out of total 209 articles appeared, 52 articles were found based on search words such as sociobehavioral factors, SES, dental caries, periodontal disease, malocclusion, oral cancer, and India, and from this 33 articles were retrieved based on search words, i.e., SES, prevalence, dental caries, periodontal disease, malocclusion, oral cancer, and India. Finally, 19 studies were selected.

Out of 19 articles selected, 12 were related to dental caries, 5 for periodontal disease and 1 for malocclusion, and 4 were related to oral cancer. Among the studies for dental caries, 6 studies were assessed SES using B G Prasad scale and other 6 by Kuppuswamy scale. The age group of the dental caries was from 2 to 57 years. The studies of dental caries were from India only. Among studies for periodontal disease, only one study assessed SES using B G Prasad scale and other 4 by Kuppuswamy scale. The age groups of periodontal disease were from 17 to 60 years. In oral cancer, three studies assessed SES using B G Prasad scale and only one study assessed SES using the Kuppuswamy scale. The age groups were from 10 to 80 years [Table 1].
Table 1: Characteristics of included study population

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Variation of the studies

The included studies have used different scales for the measurement of SES and for assessment of the dental caries and periodontal disease and were conducted in different population. The confidence intervals showed consistent in the entire pooled estimate.

Synthesis of results

Dental caries

There was inconsistent in pooled estimate for dental caries for different SES upper, middle, and lower status RR 3.1 (95% confidence interval [CI] 3–3.1), RR 2.6 (95% CI 2.6–2.9) and RR 3.05 (95% CI 3.05–3.04), respectively, for studies assessed by B G Prasad scale. This trend was common with studies assessed by the Kuppuswamy scales. The pooled prevalence shows increased prevalence of dental caries among lower SES compared to higher SES and inversely linked [Table 2].
Table 2: Summary of findings - oral diseases for socioeconomic status population

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Periodontal disease

The prevalence of periodontal disease is inversely linked to SES status which is common trend in the studies assessed by two different scales (B G Prasad scale: upper SES 12 [95% CI 11–12], middle SES status 28 [95% CI 28–29] and lower SES status 60 [95% CI 59–60]) and (Kuppuswamy scale: upper SES 22 [95% CI 21–22], middle SES status 24 [95% CI 23–24] lower SES status 28 [95% CI 27–28]).


The prevalence of malocclusion is inversely linked to SES status which is assessed by B G Prasad scale (upper SES 54 [95% CI 53–54), middle SES status 21 [95% 20–21], and lower SES 51 [95% CI 50–51]).

Oral cancer

The prevalence of oral cancer is inversely linked to SES status which is common trend in the studies assessed by two different scales (B G Prasad scale: upper SES 16 [95% CI 15–16], middle SES 15 [95% CI 14–15], lower SES 28 [95% C1 27–28]) and (Kuppuswamy scale: upper SES 10 [95% CI 7–12]. Middle SES 20 [95% CI 18–20[and lower SES 45 (95% CI 43-47)).

  Discussion Top

Many studies have shown SES as an indicator for oral health. The incidence and prevalence of oral disease have proven to decrease when SES increases. Since poverty is the chief determinant of malnutrition in developing countries, it develops into intergenerational transfer of poor nutritional status and prevents social improvement.[5],[6] The determinants of oral disease are often linked to social and biomedical factors. The individuals from decreased SES experience financial, social and material disadvantage which would compromise the ability of self-care. Thus all these lead to poor health outcome and low SES promotes a vicious cycle leading to poor educational outcomes, health values and lifestyles.

Social position is often inversely linked to the risk of exposure.[7] We have noticed in our study that the mean DMFT is linked to SES. The pooled estimate of mean DMFT is inconsistent across the various levels for the SES that may be attributed to the lack of large number of studies assessing SES and dental caries. Our included studies have used different scales for assessing SES of which B G Prasad classification is the most acceptable compared to Kuppuswamy.[8] The sampling error and methodological variability means different scales of measurement for dental caries etc., may be a factor explaining the inconsistent and imprecision of the estimate.

SES is a widely used concept in medical sociology. It is a measure of the social standing of an individual or a family in a society. The two components social and economic status are clubbed together, as these two entities are linked to each other directly.[8] The advantages of using B G Prasad scale are: It is applicable to both urban and rural areas in India, thereby maintaining uniformity. It utilizes the per capita monthly income and is therefore applicable to individuals. On the other hand, its disadvantage is that it takes into account only the income, and therefore, may miss out the other factors affecting the social status of an individual.[8] Nevertheless, it remains as one of the most widely used scales to determine the SES in health studies due to its ease of application. Kuppuswamy scale is a composite score of education and occupation of the head of the family along with monthly income. Education and occupation of head of family are not changeable with time. Steady inflation, lower interest rates, and country's current account deficits are the main factors contributing to fall in the value of currency.[9]

The inverse trend is also followed when we assessed the combined prevalence across the age groups. Earlier studies have indicated dental caries is a disease of increased SES population due to accessibility to refined carbohydrates and candy culture.[10] Furthermore, the dental caries is considered as the disease of civilization.[11] The worldwide trends have shown caries are more in developing countries than developed countries which is narrowing off late.[12] There is a wide inequity among dental caries prevalence between different social groups within India. This may be due to differential exposure of risk factors between the groups.[7] In a country like India, the health is a commodity rather than a value that can be purchased based on one social and economic situation.[7]

However, the periodontal disease shows a contrasting trend from dental caries. The pooled prevalence shows increased prevalence of periodontal disease among lower SES compared to higher SES. This could be due to differential vulnerability to the risk factors. Due to the lack of resources, poor social groups have no other choices but to live in unsafe and overcrowded houses. The sense of injustice is increased in such cases as complications tend to cluster together and reinforce each other, making some groups more vulnerable.[13],[14],[15] The higher SES class people can afford for the oral hygiene aids and the level of oral health literacy can be attributed to lower prevalence of periodontal disease compared to others.

Oral cancer mostly affects people from the lower socioeconomic strata due to the increased probability of exposure to risk factors. Similar trend have been estimated in combined pool in our study. There is a strong association between SES and exposure to factors like alcohol and tobacco that could lead to the incidence of oral cancers.[7] It has been shown that tobacco consumption was significantly higher among the poor and less educated populations. Individuals with no education are 2.69 times more likely to smoke and chew tobacco than those with other professional group.[16] According to the Central Bureau of Health Intelligence (CBHI), most Indians trust and visit private health-care institutions though costs tend were significantly higher.[17] The private dental care sector is highly fragmented with over 90% of private healthcare serviced by the unorganized sector. The average out-of-pocket expenditure on dental care was 2,135.95 ± 656 for 3 months, which is about 9% of the family income in Delhi.[7] Hence, the consequences of the effort and accessibility of dental care slides the people into a situation where oral diseases are not a felt need.[18]

We have extracted the pooled values for the prevalence of dental caries, periodontal disease, and oral cancer which gives an estimate for further research and planning of services. Studies assessing oral diseases and SES were few, the combined effect has inconsistencies due to different scale measurements of SES and oral disease assessment and different population in India. This may be one of the limitations of the study. A critical review of the problem of inequalities in oral health strategies for disease prevention and oral health promotion shows that it is not merely a result of individual biological, psychological, and behavioral factors. Oral health status is directly related to socioeconomic position across the socioeconomic gradient in almost all populations.

Since oral diseases are prevalent among worldwide certain strategies like strengthening of public health programs through the implementation of effective oral disease prevention measures and health promotion, and common risk factors approaches should be integrated.[7] There are three levels of public health interventions that may be adopted to improve the health of the population such as downstream efforts (such as treatments, rehabilitation, counseling, and patient education), mid-stream prevention efforts to improve an individual's health consists of primary and secondary prevention, and the upstream approach which consists of healthy public policy interventions that include governmental, institutional, and organizational actions. Further oral health promotion approaches are policies that address the risk factors for oral diseases, such as intake of sugars and tobacco use, can be implemented, which will help reduce chronic diseases.

  Conclusion Top

The pooled estimate of the mean DMFT across the SES status was inconsistent; however, pooled prevalence of the dental caries, periodontal disease, and oral cancer showed an inverse link to status of SES. The high variance in the estimated is related differences in age SES assessment and sampling error.


I would like to thank Dr. Bobby Antony for her support and help in this research project.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2]

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