|Year : 2013 | Volume
| Issue : 2 | Page : 71-75
Association between obesity and periodontal disease: A cross-sectional study
Amandeep Chopra, Manav Lakhanpal, Nidhi Gupta, NC Rao, Shelja Vashisth
Department of Public Health Dentistry, Swami Devi Dyal Hospital and Dental College, Golpura, Barwala, Distt. Panchkula, Haryana, India
|Date of Web Publication||12-Mar-2014|
Department of Public Health Dentistry, Swami Devi Dyal Hospital and Dental College, Golpura, Barwala, Distt. Panchkula, Haryana
Source of Support: None, Conflict of Interest: None
Aim: To study the effect of obesity on periodontal health among patients visiting Outpatient Department of Public Health Dentistry. Materials and Methods: A total of 600 subjects aged 20 years and above who visited Outpatient Department of Public Heath Dentistry, Swami Devi Dyal Hospital and Dental College, Panchkula, were included. Periodontal status of the subjects was recorded. Body mass index was used as measure to assess obesity. Variables like age, gender, smoking and frequency of cleaning, which could act as covariants for the periodontal disease were recorded. Statistical Analysis: Frequency distribution for the determination of prevalence of a number of variables, cross tabulations and Chi square tests were used to find out the significance of differences. Further, multivariate logistic regression analysis was carried out. Results: The periodontal disease shows significant association with age, gender, OHIS, smoking and obesity (P < 0.05). Multivariate regression after adjusting for age, gender, OHIS and smoking showed that obese individuals were at 1.26 times (95% confidence interval 1.02-2.78) at risk for developing periodontal diseases when compared to non-obese individuals. Conclusion: The findings of present study showed significant association between obesity and periodontal disease.
Keywords: Obesity, periodontal disease, risk factors
|How to cite this article:|
Chopra A, Lakhanpal M, Gupta N, Rao N C, Vashisth S. Association between obesity and periodontal disease: A cross-sectional study. Saudi J Obesity 2013;1:71-5
|How to cite this URL:|
Chopra A, Lakhanpal M, Gupta N, Rao N C, Vashisth S. Association between obesity and periodontal disease: A cross-sectional study. Saudi J Obesity [serial online] 2013 [cited 2019 May 27];1:71-5. Available from: http://www.saudijobesity.com/text.asp?2013/1/2/71/128634
| Introduction|| |
Obesity is a major public health problem of new millennium given its potential impact on morbidity, mortality and the cost of health care.  The global epidemic of obesity results from combination of genetic susceptibility, increased availability of high energy food and decreased physical activity in modern society. 
Obesity is multisystem condition and significant risk factors for various adult diseases such as type II diabetes, hyperlipidemia, cholelithiasis, arteriosclerosis, cardio-vascular and cerebro-vascular diseases, certain type of cancer and osteoarthritis. ,,
Besides these risk factors, obesity has also been suggested to be a risk factor for periodontitis, which is a disease of the supporting structures of the teeth resulting from the interaction between pathogenic bacteria and the host immune response. The biological plausibility of the association between obesity and periodontal diseases is based on the effect elevated serum levels of C-reactive protein, IL-6, TNF-α and leptin, suggesting that similar mechanisms are involved in obesity and periodontitis pathophysiologies, and that the secretions of these substances could induce a inflammatory response on periodontal disease. 
Apart from this a myriad of host-related factors including genetic constitution, presence of systemic condition, environmental factors, behavioral and psychosomatic factors play a role in etiopathogenesis of periodontal disease. ,
Although observed associations suggested a causal role for periodontitis in obese people, a consensus opinion demands further evidence. In the light of the above facts, this investigation was designed to study the effect of obesity on periodontal health among patients visiting Outpatient Department of Public Health Dentistry Swami Devi Dyal Hospital and Dental College, Panchkula, Haryana, India.
| Materials and Methods|| |
The study population consisted of convenience and judgment sample of 600 subjects visiting the Outpatient Department of Public Health Dentistry, Swami Devi Dyal Hospital and Dental College, Panchkula, Haryana, India in the period between April and October 2013.
- Dentate persons aged 20 years and above.
- Children were not included, as pediatric manifestations of periodontal disease or diabetes were not within the scope of this research
- Subjects who were on medication, any underlying systemic disease/conditions which can influence the periodontal health were excluded from the study
- Patients who had received periodontal treatment or antibiotics for at least 3 months prior to study
- Physically and mentally challenged patients
- Completely edentulous [toothless], as periodontal disease is not present in conjunction with full edentulism
- Pregnant women and lactating mothers
- Patients who don't give the written consent to participate in the study.
Variables like age, gender, smoking and frequency of cleaning, which could act as covariants for the periodontal disease were recorded.
The patients were stratified according to age to three different age group: 
- Younger age (20-34 years)
- Middle age (35-59 years)
- Older adults (60 years and above).
A complete intraoral examination was done and the oral hygiene was assessed and recorded using Oral Hygiene Index Simplified (OHIS).  The six surfaces examined for the OHI-S are selected from four posterior and two anterior teeth. In the posterior portion of the dentition, the first fully erupted tooth distal to the second bicuspid (15), usually the first molar (16) but sometimes the second (17) or third molar (18), is examined. The buccal surfaces of the selected upper molars and the lingual surfaces of the selected lower molars are inspected. In the anterior portion of the mouth, the labial surfaces of the upper right (11) and the lower left central incisors (31) are scored. In the absence of either of this anterior tooth, the central incisor (21 or 41, respectively) on the opposite side of the midline is substituted.
Criteria for classifying debris
0. No debris or stain present
1. Soft debris covering not more than one-third of the tooth surface, or presence of extrinsic stains without other debris regardless of surface area covered.
2. Soft debris covering more than one-third, but not more than two-thirds, of the exposed tooth surface.
3. Soft debris covering more than two-thirds of the exposed tooth surface.
Criteria for classifying calculus
0. No calculus present
1. Supragingival calculus covering not more than one-third of the exposed tooth surface.
2. Supragingival calculus covering more than one-third but not more than two-thirds of the exposed tooth surface or the presence of individual flecks of subgingival calculus around the cervical portion of the tooth or both.
3. Supragingival calculus covering more than two-third of the exposed tooth surface or a continuous heavy band of subgingival calculus around the cervical portion of the tooth or both.
After the scores for debris and calculus are recorded, the Index values are calculated. For each individual, the debris scores are totaled and divided by the number of surfaces scored. At least two of the six possible surfaces must have been examined for an individual score to be calculated. After score for a group of individual is obtained by computing the average of the individual scores. The average individual or group score is known as the Simplified Debris Index (DI-S).
The same methods are used to obtain the calculus scores or the Simplified Calculus Index (CI-S).
The average individual or group debris and calculus scores are combined to obtain the Simplified Oral Hygiene Index.
The CI-S and DI-S values may range from 0 to 3; the OHI-S values from 0 to 6.
Data regarding periodontal status and loss of attachment were collected using modified W.H.O (1997) format.  Dentition was divided into six sextants, and the highest values found on referent teeth (17 or 16, 11, 26 or 27, 37 or 36, 31, 46 or 47) were recorded. The criteria of CPI: (0) healthy, (1) bleeding on probing, (2) calculus, (3) shallow pocket 3-5 mm, (4) deep pocket 6 mm, (X) excluded sextants without at least two teeth present. The criteria of Loss of attachment (LA): (0) 0-3 mm, (1) 4-5 mm, (2) 6-8 mm, (3) 9-11 mm, (4) 12 mm, (X) excluded sextants.
Body Mass Index (BMI) - The weight of the subjects in kilograms was recorded using standard physician's scale. The height of the subjects in meters was recorded using Stadiometer. Calculation of Body Mass Index (BMI) (kg/m 2 ) was recorded using WHO classification system for BMI.  Body mass index (BMI) was calculated and patients were classified as obese (BMI>=30) or non-obese (BMI < 30).
Data was analyzed using SPSS version 20. Standard descriptive statistics were generated. Frequency distribution for the determination of prevalence of a number of variables, cross tabulations and Chi square tests were used to find out the significance of differences.
Logistic regression analysis was carried out. Outcome variables were transformed into binary variables [presence (1) or absence (0) of periodontal pockets and loss of attachment] for logistic regression analysis. The level of statistical significance was fixed at 0.05.
| Results|| |
The present study was conducted to assess the association between periodontal disease and obesity among 600 subjects (42.8% males; 57.2% females) visiting Outpatient Department of Public Health Dentistry. The mean age of the subjects was 42.70 ± 5.2 years.
[Table 1] shows the cross tabulation of periodontal disease with age, gender, OHIS frequency of brushing, tobacco usage and obesity. The participants with periodontal disease showed significant association with age, gender, OHIS, smoking and obesity (P < 0.05). As the age increases prevalence of periodontal disease also increases. Prevalence of periodontal disease was higher among males. The association between oral hygiene status and periodontal disease is statistically significant and according to oral hygiene status the prevalence of periodontal disease was significantly higher in poor oral hygiene group as compared to good oral hygiene. Prevalence of periodontal disease was significantly more in obese than in non-obese individuals. Stepwise logistic regression analysis showed that obese individuals were at 1.4 times at risk for developing periodontal diseases when compared to non-obese individuals.
[Table 2] shows the cross tabulation of loss of attachment with age, gender, frequency of brushing, tobacco usage and obesity. The participant with loss of attachment shows significant association with age, gender and obesity (P < 0.05).
The multivariate logistic regression model for the occurrence of periodontitis is presented in [Table 3]. It was observed that obesity was significantly associated with periodontitis, presenting respectively OR 1.46 (1.02-3.89). In addition, age, gender, OHIS and smoking remained significantly associated with periodontitis [Table 3].
Final multivariate logistic regression analysis after adjusting for age, gender, OHIS and smoking showed that obese individuals were at 1.26 times (95% confidence interval 1.02-2.78) at risk for developing periodontal diseases when compared to non-obese individuals.
| Discussion|| |
The findings of our study showed significant association between obesity and periodontal disease which is in accordance with many previous studies ,,, and it is comparable in relation to age, sex, obesity and prevalence of periodontal disease.
Obesity was significantly associated with the prevalence of periodontal disease in all the three age groups (young, middle-age and old). This finding is in agreement with Mathur et al.  but not in agreement with the study conducted by AI-Zaharni et al.,  who found a significant association between measures of body fat and periodontal disease among younger adults, but not in middle age and older adults.
The prevalence of periodontal disease was significantly higher in poor oral hygiene group compared to good oral hygiene group. This finding is consistent with previously reported differences with oral hygiene by Al-Zahrani et al.  and Mathur et al. 
Among 109 obese individuals, males were 45 (17.5%) and females were 64 (18.7%). No significant difference was observed in the prevalence of obesity among males and females which was in contrast with the previous study where it was found that overweight/obesity was higher among females (42.1%) than in males (20.9%). 
Presence of periodontal disease was found to be more among individuals who were brushing once daily 520 (61.7%) as compared with those who were brushing more than once. It is in agreement with the previous study. 
Statistically significant difference was seen between sex and periodontal disease. Periodontal disease was found to be less among females as compared with males which is in conformity with study done by NIDCR (1999-2004) (Males 10.65%, Females 6.40%), Ragghianti MS et al. (2004) (higher clinical attachment loss) and El-Angbawi MF et al. (1982) (Males had significantly higher debris, calculus deposits and intense gingivitis counts than females). ,,
Smoking was significantly associated with periodontal disease (P = 0.002). This is in agreement with the previous studies. ,
However few studies , found no statistical significant difference in probing depth and loss of attachment among young smokers and non-smokers but still they concluded that calculus and plaque scores were high among smokers.
For this study, smoking, age, gender and OHIS were controlled and the parameters again analyzed using multiple regression analysis. Results again showed a statistically significant relationship between the studied parameters. Some variables were self-reported which may introduce an inherent bias in the study and similarly confounding variables make analysis difficult to interpret
There are some limitations inherent in this study. One of the most important limitations of this study is its cross-sectional design, which makes it difficult to determine the direction of the causal relationship between obesity and periodontal disease. Some variables that were self-reported may introduce an inherent bias in the study. Finally, the problem of imperfect measurement of confounders can exist. Due to the variability and complexity of the associated parameters, further investigation is necessary to elicit and clarify whether such association exists beyond reasonable doubt.
Obesity is independently associated with periodontal disease, which needs to be verified with analytical study designs.
| Conclusion|| |
The findings of present study showed significant association between obesity and periodontal disease.
Further prospective studies are needed to address the question of causality and to determine if obesity is a true risk factor for periodontal disease, especially among the younger population. Dentist should counsel obese persons regarding the possible oral complications of obesity, to diminish morbidity for these individuals. It is suggested that weight screening should be an integral part of periodontal risk assessment on regular basis.
| References|| |
|1.||World Health Organization. Obesity: Preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 2000;894:1-253. |
|2.||Dahiya P, Kamal R, Gupta R. Obesity, periodontal and general health: Relationship and management. Indian J Endocrinol Metab 2012;16:88-93. |
|3.||World Health Organization. Diet, nutrition and the prevention of chronic diseases. World Health Organ Tech Rep Ser 2003;916:1-149. |
|4.||Pischon N, Heng N, Bernimoulin JP, Kleber BM, Willich SN, Pischon T. Obesity, inflammation and periodontal disease. J Dent Res 2007;86:400-9. |
|5.||Saito T, Shimazaki Y. Metabolic disorder related to obesity and periodontal disease. Periodontol 2000 2007;43:254-66. |
|6.||Ylostalo P, Suominen-Taipale L, Reunanen A, Knuuttila M. Association between body weight and periodontal infection. J Clin Periodontol 2008;35:297-304. |
|7.||Nunn ME. Understanding the etiology of periodontitis: An overview of periodontal risk factors. Periodontology 2000;32:11-23. |
|8.||Genco RJ, Borgnakke WS. Risk factors for Periodontal disease. Periodontol 2000 2013;62:59-94. |
|9.||Al-zaharani MS, Bissada NF, Borawskit EA. Obesity and periodontal disease in young, middle aged and older adults. J Periodontol 2003;74;610-5. |
|10.||Greene JC, Vermillion JR. The Simplified Oral Hygiene Index. J Am Dent Assoc 1964;68:7-13. |
|11.||World Health Organization. Oral health surveys- Basic methods. 4 th ed. Geneva: WHO; 1997. |
|12.||World Health Organization. Global Database on Body Mass Index. Available from: http://apps.who.int/bmi/index.jsp. [Last accessed on 2013 Aug 15]. |
|13.||Elter JR, Williams RC, Champagne CM, Offenbacher S, Beck JD. Association of obesity and periodontitis. J Dent Res 2000;79:625. |
|14.||Wood N, Johnson RB, Streckfus CF. Comparison of body composition and periodontal disease using nutritional assessment techniques: Third National Health and Nutrition Examination Survey (NHANES III). J Clin Periodontol 2003;30:321-7. |
|15.||Nishida N, Tanaka M, Hayashi N, Nagata H, Takeshita T, Nakayama K, et al. Determination of smoking and obesity as periodontitis risks using the classification and regression tree method. J Periodontol 2000 2005;76:923-8. |
|16.||Chaffee BW, Weston SJ. Association Between Chronic Periodontal Disease and Obesity: A Systematic Review and Meta-Analysis. J Periodontol 2010;81:1708-24. |
|17.||Mathur LK, Manohar B, Shankarapillai R, Pandya D. Obesity and periodontitis: A clinical study. J Indian Soc Periodontol 2011;15:240-4. |
|18.||Swami HM, Bhatia V, Gupta AK, Bhatia SPS. An epidemiological study of obesity among elderly in Chandigarh. Indian J Community Med 2005;30:11-3. |
|19.||Löe H. Oral hygiene in the prevention of caries and periodontal disease. Int Dent J 2000;50:129-39. |
|20.||National institute of Dental and Craniofacial Research (NIDCR). Periodontal disease in adults age 20 -64.United States, National Health and Nutrition Examination Survey, 1999-2004. Available from: http://www.nidcr.nih.gov/datastatistics/finddatabytopic/gumdisease/periodontaldiseaseadults20to64.htm. [Last assessed on 2013 Aug 15]. |
|21.||Ragghianti MS, Greghi SL, Lauris JR, Sant′ana AC, Passanezi E. Influence of age, sex, plaque and smoking on periodontal conditions in a population from Bauru, Brazil. J Appl Oral Sci 2004;12:273-9. |
|22.||El-Angbawi MF, Younes SA. Periodontal disease prevalence and dental needs among schoolchildren in Saudi Arabia. Community Dent Oral Epidemiol 1982;10:98-9. |
|23.||Romao C, Wennstrom JL. Periodontal conditions in a Swedish city population of adolescents: A comparison between smokers and nonsmokers. Oral Health Prev Dent 2007;5:105-12. |
|24.||Taani DS. Association between cigarette smoking and periodontal health. Quintessence Int 1997;28:535-9. |
[Table 1], [Table 2], [Table 3]