*Katarzyna Deszczyńska1, Paweł Piątkiewicz1, Renata Górska2
The effects of overweight and obesity on oral health status in children and adolescents
Wpływ nadwagi i otyłości na stan zdrowia jamy ustnej dzieci i młodzieży
1Department of Clinical Anatomy, Center of Biostructure, Medical University of Warsaw, Poland
Head of Department: Professor Bogdan Ciszek, MD, PhD
2Department of Periodontal and Oral Mucosa Diseases, Medical University of Warsaw, Poland
Head of Department: Professor Renata Górska, MD, PhD
Streszczenie
Wstęp. Nieprawidłowe nawyki żywieniowe wśród dzieci i młodzieży często prowadzą do nadwagi i otyłości. Badania wskazują, że są to czynniki ryzyka wielu chorób, w tym chorób występujących w jamie ustnej.
Cel pracy. Analiza korelacji wybranych parametrów stanu uzębienia, tkanek przyzębia i higieny jamy ustnej u dzieci i młodzieży z nadwagą i otyłością oraz w grupie kontrolnej.
Materiał i metody. Badaniem objęto 120 pacjentów w wieku 11-18 lat, których podzielono na grupę badaną 60 osób z nadwaga? i otyłos?cia? oraz grupę kontrolną 60 osób z prawidłową masą ciała stwierdzoną na podstawie wskaźnika BMI (ang. body mass index).
U każdego pacjenta dokonano pomiarów antropometrycznych, takich jak wzrost (cm) i masa ciała (kg), na ich podstawie wyliczano wskaźnik BMI. Mierzono obwód talii (WC) oraz obwód bioder (HC) celem wyliczenia wskaźnika talia-biodro (WHR). Badanie kliniczne jamy ustnej obejmowało ocenę stanu uzębienia (liczba PUW ? Próchnica Ubytek Wypełnienie), higieny jamy ustnej (wskaźnik API ? Approximal Plaque Index) i tkanek przyze?bia (PD ? Pocket Depth, CAL ? Clinical Attachment Level, %BOP ? Bleeding On Probing) oraz wskaźnik CPITN (The Community Periodontal Index for Treatment Needs).
Wyniki. W grupie pacjentów z BMI ≥ 25 i BMI < 25 stwierdzono róz?nice? istotna? statystycznie w wartościach wskaz?ników: liczby PUW p = 0,005, API p < 0,001, %BOP p < 0,001, PD p < 0,001, CPI p < 0,001.
Wnioski. U dzieci z nadwagą i otyłością stwierdzono gorsze parametry stanu uzębienia, tkanek przyzębia i higieny jamy ustnej w porównaniu z grupą kontrolną. Obserwacje własne wskazują, że nadwaga oraz otyłość mogą być czynnikami ryzyka rozwoju chorób przyzębia w badanej grupie.
Summary
Introduction. Improper eating habits among children and adolescents often lead to overweight and obesity. Research indicates that these are risk factors for many diseases, including diseases in the oral cavity.
Aim. To analyse the correlations of selected parameters of dental and periodontal health as well as oral hygiene status in overweight and obese children and adolescents versus control group.
Material and methods. The study included 120 patients aged 11-18 years, who were classified into a study group with 60 overweight/obese individuals and a control group of 60 individuals with normal body weight based on BMI (Body Mass Index).
Each patient underwent anthropometric measurements, such as height (cm), body weight (kg), which were used to calculate BMI. Additional measurements were taken of waist circumference (WC) and hip circumference (HC), to obtain the waist-hip ratio (WHR). Clinical examination of the oral cavity included an assessment of dentition (DMF), oral hygiene API (Approximal Plaque Index) and periodontal tissue (PD ? Pocket Depth, CAL ? Clinical Attachment Level, %BOP ? % Bleeding On Probing) and CPITN (The Community Periodontal Index for Treatment Needs).
Results. Statistically significant differences were found between patient groups with BMI ≥ 25 and BMI < 25 in the values of the following parameters: DMF p = 0.005, API p < 0.001, %BOP p < 0.001, PD p < 0.001, CPI p < 0.001.
Conclusions. Overweight and obese children were found to have worse parameters of dental and periodontal health as well as oral hygiene status compared to the group with normal weight. Our observations indicate that overweight and obesity may be potential risk factors for periodontal diseases in the study group.
Introduction
Obesity, long regarded as a by-product of life in affluent industrial societies, has also become a threat for the inhabitants of developing countries. Nutrition specialists are warning against a global epidemic of obesity-related diseases, such as type 2 diabetes, hypertension, cancer or cardiovascular diseases. One of the most recent studies led by the WHO and Imperial College London published data on the prevalence of obesity and overweight among children and adolescents (aged between 5 and 19 years). Looking at changes, including those in BMI, which took place between 1975 and 2016, the study revealed that the number of obese people between 5 and 19 years of age has risen tenfold over the past four decades. In 1975, the obesity rate among children and adolescents was under 1% (11 million), whereas in 2016 it had risen up to 6 and 8% (124 million) among girls and boys, respectively (1).
Like obesity, periodontal disease affects an increasing percentage of the human population. Epidemiological studies have shown that more than 2/3 of the global population suffer from periodontal diseases. Albandar et al. found in their study assessing the prevalence of early-onset periodontitis in a group of young people from the USA, that 0.6% of 13-15 year olds, and 2.75% of 16-17 year olds were affected by chronic periodontitis (2).
Lately, there has also been a growing number of scientific reports linking obesity with periodontal disease (3). Up until recently, the adipose tissue was perceived merely as the body’s energy storage. Today, it is known to be metabolically active, secreting numerous pro-inflammatory hormones and cytokines (adipocytokines), including TNF-alpha (tumour necrosis factor alpha) and IL-6 (interleukin 6) (4). The majority of cytokines produced by the adipose tissue are also involved in the development of periodontal disease, suggesting that similar mechanisms are at play in the pathophysiology of periodontitis and obesity. These observations suggest that both these conditions share a similar pathogenesis and remain closely linked to each other (5). Even though obesity and oral health are some of the most important health challenges in children and adolescents worldwide, there is very little research into the associations between obesity and periodontal status or the prevalence of dental caries in children. Therefore, it seems relevant to try and explore the relationship between the anthropometric factors of overweight and obesity and the factors of oral health, notably dental caries and periodontal disease. If demonstrated, such a relationship may have significant implications for our current views on public health.
Aim
The aim of this paper was to analyse the correlations of selected parameters of dental and periodontal health as well as oral hygiene status with anthropometric measures in overweight/obese children and adolescents and in the control group.
Material and methods
The study included 120 patients (boys and girls) at developmental age between 11 and 18 years, participating in holiday fitness and weight loss camps for children, as well as patients treated at a private dental practice in Warsaw between June 2013 and May 2015.
Overweight or obesity, confirmed by BMI score ≥ 25 kg/m2, was the inclusion criterion. The patients were classified into 2 groups. Group I (study group) included 60 overweight and obese patients aged between 11 and 18 years, with mean age of 14 years, including 37 girls and 23 boys with BMI ≥ 25 kg/m2. Group II (control group) included 60 children, including 38 girls and 22 boys aged between 11 and 18 years, with mean age of 15 years, with BMI scores in the range of 18-24.9 kg/m2.
All patients from groups I and II underwent a clinical assessment of dentition, oral hygiene status and periodontal tissue. Dental health was assessed using DMF oral hygiene status was evaluated using the Approximal Plaque Index (API) according to Lange et al.; the clinical condition of gums and periodontium was assessed based on the Offenbacher scale, with reference to the measurements of pocket depth PD (PD) and bleeding on probing %BOP; periodontal probing was also employed to measure pocket depth PD and clinical attachment level CAL in the evaluation of periodontal status. The Community Periodontal Index for Treatment Needs (CPITN) procedure according to Ainamo was applied to assess prevention and treatment needs of the participants.
Each patient underwent selected anthropometric measurements, such as height (cm), body weight (kg), which were then used to calculate the BMI (Body Mass Index) score.
Additional anthropometric measures of overweight and obesity included waist circumference WC and hip circumference HC, which were then used to calculate the waist-hip ratio (WHR).
The relationships between the individual parameters describing periodontal and oral hygiene status and anthropometric measurements were presented using Spearman’s rank correlation coefficient (or Spearman’s rho) in tables and graphically. Multiple regression analysis was also used to calculate partial correlations, which consider the influence of age and sex simultaneously. A level of statistical significance was assumed at p < 0.05 for all tests. Calculations were performed using the STATISTICA 12.0 PL package (StatSoft, Inc. 2015, Tulsa, USA). Supporting calculations, tables and charts were made in the form of MS Excel spreadsheet (Microsoft Corporation 2010, Redmond, USA).
Moreover, additional dichotomisation was employed in statistical analysis, based on the median value of selected parameters describing periodontal and oral hygiene status (median-split). The adopted watershed in the children’s group was (i) the median value of BOP and (ii) the median value of API (the CAL values in children ≤ 2 mm did not demonstrate sufficient differentiation to allow for reliable dichotomisation).
Results
Statistically significant p values were marked dark grey in tables, whereas values approaching statistical significance (the so-called tendencies) were signed as moderate (<0,5).
Comparative analysis of correlations between anthropometric measures of overweight and obesity and oral hygiene and periodontal health parameters in the study group vs. control group in the population of children and adolescents
Among children with BM I ≥ 25, the correlation analysis revealed a strong correlation between DMF and body weight (rho 0.56), a moderate correlation with age (rho 0.41), height (rho 0.44), WC (rho 0.37), HC (rho 0.38), and a positive correlation with BMI (rho 0.28).
In the analysis of subsequent parameters, a strong correlation was found between API and BMI (rho 0.52), and a moderately strong one with body weight (rho 0.43), waist circumference WC (rho 0.38) and hip circumference HC (rho 0.37).
The variable %BOP was moderately correlated with body weight (rho 0.41), BMI (rho 0.40), WC (rho 0.49), and HC (rho 0.30).
In turn, pocket depth PD showed a moderate correlation with WHR (rho 0.33) and a positive correlation with WC (rho 0.28).
For CAL, a strong correlation was observed with age (rho 0.53) and a weak one with hip circumference HC (rho 0.27) (tab. 1, 2).
Tab. 1. Spearman’s rank correlation analysis of relationships between age, weight, height, BMI, WC, HC, WHR vs. DMF, API, %BOP, PD, CAL in the population of children and adolescents with BMI ≥ 25
| Children with BMI ≥ 25, Spearman’s correlation | DMF | API | %BOP | PD | CAL |
| | rho | P | rho | P | rho | P | rho | P | rho | P |
| Age | 0.41* | 0.001** | 0.06 | 0.653 | 0.23 | 0.082 | 0.01 | 0.928 | 0.53* | < 0.001** |
| Weight | 0.56* | < 0.001** | 0.43* | 0.001** | 0.41* | 0.001** | 0.11 | 0.394 | 0.17 | 0.187 |
| Hight | 0.44* | < 0.001** | 0.14 | 0.277 | 0.18 | 0.165 | 0.08 | 0.550 | 0.23 | 0.078 |
| BMI | 0.28* | 0.030** | 0.52* | < 0.001** | 0.40* | 0.002** | 0.12 | 0.372 | -0.04 | 0.757 |
| WC | 0.37* | 0.004** | 0.38* | 0.003** | 0.49* | 0.000** | 0.28* | 0.031** | 0.14 | 0.281 |
| HC | 0.38* | 0.002** | 0.37* | 0.004** | 0.30* | 0.021** | -0.06 | 0.626 | 0.27* | 0.035** |
| WHR | -0.02 | 0.874 | 0.06 | 0.654 | 0.20 | 0.128 | 0.33* | 0.010** | -0.11 | 0.405 |
BMI ? Body Mass Index; WC ? Waist Circumference; HC ? Hip Circumference; API ? Approximal Plaque Index; %BOP ? Bleeding On Probing; PD ? Pocket Depth; CAL ? Clinical Attachment Level; WHR ? Waist-Hip Ratio; DMF ? Determination of Caries Intensity Index; p** ? statistically significant, rho* ? significant strenght of correlation, rho ? not significant
Tab. 2. A graphic representation of Spearman’s rank correlation for the study group and the control group in the population of children and adolescents
| | | API | %BOP | PD | CAL |
| | BMI | BMI | BMI | BMI | BMI |
| | < 25 | ≥ 25 | < 25 | ≥ 25 | < 25 | ≥ 25 | < 25 | ≥ 25 | < 25 | ≥ 25 |
| Age | | | | | | | | | | |
| Weight | | | | | | | | | | |
| Hight | | | | | | | | | | |
| BMI | | | | | | | | | | |
| WC | | | | | | | | | | |
| HC | | | | | | | | | | |
| WHR | | | | | | | | | | |
Corelation
Non relevant Weak (< 0.3) Moderate (< 0.5) Significant (< 0.7) Very significant (0.7+)
In the group of children with BMI < 25, Spearman’s rank correlation analysis did not reveal statistically significant dependencies between anthropometric factors of overweight and obesity and oral hygiene and periodontal health parameters (tab. 2, 3).
Tab. 3. Spearman’s rank correlation analysis of relationships between age, weight, height, BMI, WC, HC, WHR vs. DMF, API, %BOP, PD, CAL in the population of children and adolescents with BMI < 25
| Children with BMI < 25, Spearman’s correlation | DMF | API | %BOP | PD | CAL |
| | rho | P | rho | P | rho | P | rho | P | rho | P |
| Age | 0.11 | 0.416 | 0.21 | 0.109 | 0.13 | 0.309 | 0.15 | 0.249 | -0.04 | 0.751 |
| Weight | 0.01 | 0.961 | 0.14 | 0.292 | 0.04 | 0.733 | 0.09 | 0.472 | -0.14 | 0.276 |
| Hight | -0.01 | 0.951 | 0.04 | 0.759 | 0.06 | 0.646 | 0.01 | 0.931 | -0.03 | 0.819 |
| BMI | -0.04 | 0.739 | 0.14 | 0.280 | 0.03 | 0.834 | 0.12 | 0.350 | -0.19 | 0.142 |
| WC | 0.11 | 0.388 | 0.01 | 0.951 | 0.14 | 0.295 | 0.04 | 0.774 | -0.21 | 0.100 |
| HC | -0.09 | 0.485 | -0.07 | 0.606 | -0.13 | 0.330 | -0.10 | 0.454 | -0.05 | 0.732 |
| WHR | 0.14 | 0.292 | 0.06 | 0.654 | 0.16 | 0.216 | 0.10 | 0.470 | -0.20 | 0.119 |
BMI ? Body Mass Index; WC ? Waist Circumference; HC ? Hip Circumference; API ? Approximal Plaque Index; %BOP ? Bleeding On Probing; PD ? Pocket Depth; CAL ? Clinical Attachment Level; WHR ? Waist-Hip Ratio; DMF ? Determination of Caries Intensity Index; rho ? not significant strength correlation, p ? statistically not significant
Comparative multiple regression analysis of correlations between anthropometric measures of overweight and obesity and oral hygiene and periodontal health parameters in the population of children and adolescents including sex and age
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