INTRODUCTION:

Paediatric obesity is a major global concern. It was estimated that up to 124 million children and adolescents had obesity (adult equivalent body mass index [BMI], 30 kg/m²) in 2016, more than an eightfold increase in age-standardized prevalence from estimated figures from 1975.¹ Although the prevalence of obesity has plateaued in many high-income countries, there is emerging evidence that the severity of obesity may be increasing.² Obesity in childhood and adolescence is associated with both physiological and psychological comorbidities, which have been well described, and severe obesity (adult equivalent BMI, 35 kg/m²) is associated with a higher degree of risk.^3-7 Being above a healthy weight in childhood or adolescence is associated with a higher likelihood of obesity persisting in adulthood, with up to 90% of adolescents with obesity becoming adults with obesity.⁸This is due to a number of factors including a global shift in diet and a trend towards decreased physical activity due to the sedentary nature of modern work and transportation and increasing urbanisation. The disturbing sequelae of this increased trajectory of overweight populations are the parallel increases in chronic diseases that are co-morbidities of obesity.

According to the WHO, obesity can be defined as an abnormal or, excessive level of fat accumulation that may impair health.⁹ Like many chronic diseases, obesity has significant associated morbidity, mortality and economic impact and is largely preventable. Primary health care providers, including dental professionals, are well-positioned to address this public health problem at the patient level. It is increasingly evident that the dental profession is a stakeholder in the weight status of its patients and can be part of a coordinated effort to prevent and intervene in obesity problem. In 2010, WHO reported that approximately 43 million children younger than 5 years were overweight and that the distribution was no longer heavily skewed towards high income countries. Nearly 35 million overweight children are part of the developing world and 8 million are in developed nations.¹⁰ The same report states that 65% of the world’s population lives in countries where overweight and obesity kill more people than underweight conditions. The onset of Type 2 diabetes (DM) in young children aged 6 to 11 with Type 2 diabetes (DM) had doubled in past 20 years.¹¹ Internationally, it was estimated in 2008 that 1.5 billion adults, 20 and older, were overweight. Of these, over 200 million men and nearly 300 million women were obese. It was concluded that more than 1 in 10 of the global adult population is considered obese, a trend that has developed in the past decade.¹²

Demographically, 13.9% of people meet the adult classification of obesity with a body mass index (BMI) of 30 or, greater. Furthermore, a study by Ritchie and colleagues found that a child who was overweight at any one point during the elementary school years was 25 times more likely to be overweight at age 12 than a child who was never previously overweight.¹³ It is predicted that 70% of overweight children become obese adults with all the chronic disease implications attached which underscores the importance of early intervention efforts. National Health and Nutrition Examination Survey (NHANES) results from 2009 to 2010 found that more than one-third of adults were obese and there were no significant differences found between genders.¹⁴

Body Mass Index (BMI) and BMI Percentile: Body mass index is defined as an individual's body mass divided by the square of his or, her height. The formulae universally used in medicine produce a unit of measure of kg/m².

BMI= mass (kg)/ (height (m))²

WHO regards a BMI of less than 18.5 as underweight and may indicate malnutrition, an eating disorder, or, some other health problems, while a BMI greater than 25 is considered overweight and above 30 is considered obese.¹⁵ These ranges of BMI values are valid only as statistical categories.

BMI for children: Overweight and obesity are defined differently for children and teens than for adults. Children are still growing and boys and girls mature at different rates. BMIs for children and teens compared their heights and weights against growth charts that take age and sex into account recognized as BMI-for-age percentile. A child or, teen's BMI-for-age percentile shows how his or, her BMI compare with other boys and girls of the same age.¹⁶Instead of set thresholds for underweight and overweight, the BMI percentile allows comparison with children of the same sex and age.¹⁷ A BMI that is less than the 5th percentile is considered underweight and above the 95th percentile is considered obese for people 20 and under. People under 20 with a BMI between the 85th and 95th percentile are considered to be overweight.

Health consequences of obesity on general health: Overweight individuals are at increased risk for many diseases and health conditions including hypertension, dyslipidemia (for example, high LDL cholesterol, low HDL cholesterol, or, high levels of triglycerides), Type 2 diabetes mellitus (DM), coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems and some cancers (especially, endometrial, breast and colon).¹⁸ Moreover, obesity, also, has psychological, social and economical as well as oral health consequences. The only positive effect of obesity is a reduced risk of developing pre-menopausal breast cancer and osteoporosis in females.¹⁹ Obesity is a systemic disease that predisposes to a variety of co-morbidities and complications that not only affect the overall health but, also, influence oral health.

Obesity and Orthodontic treatment: The first study aiming at establishing a connection between obesity and the rate of induced orthodontic tooth movement was conducted by Saloom et al (2017)²⁰; however, it could not effectively nor significantly reveal any direct influence or effect. Despite being identified during the first week, differences could not be explained and treatment time remained unchanged. In spite of lack of studies in the literature on the connection between obesity and the rate of induced tooth movement, in clinical practice, courses or specialized training, we should not have protocols changed nor adopt any measures or expect significant differences between normal-weight and obese individuals. It should be emphasized that unsuccessful cases or cases of root resorption associated with treatment should not be assigned to obesity, since scientific data is insufficient to do so.

According to Alberto Consolaro (2017)²¹, there is no direct connection between obesity and orthodontic treatment. Extrapolating findings on the influence of obesity to periodontal and bone tissues during orthodontic movement requires some degree of caution. Variables regarding obesity itself and patients’ overall health, in addition to variables regarding tooth movement, are plenty. Whenever great variability is involved, studies on a high number of people to be observed throughout time, usually for many years, are required. In spite of lack of studies in the literature on the connection between obesity and the rate of induced tooth movement, in clinical practice, courses or specialized training, we should not have protocols changed nor adopt any measures or expect significant differences between normal-weight and obese individuals. It should be emphasized that unsuccessful cases or cases of root resorption associated with treatment should not be assigned to obesity, since scientific data is insufficient to do so.

BMI and dental caries: From the findings of Moles, D. R., and P. Ashley (2009), like obesity, dental caries has a high impact on individuals and health services, for example the majority of admissions to hospital for children in England in the period 1997–2006 were primarily due to dental caries.²² To add further to it, a study conducted in England revealed, both obesity and dental caries share a pro-poor association with social deprivation, with children from more deprived backgrounds being at greater risk.²³ Dietary intake is a risk factor for both dental caries and obesity; as a result, it is believed that modifying dietary practices may be an effective intervention to reduce both dental caries and obesity. This approach has been one of the pillars of dental health policy and assumes that dental caries and obesity in children are associated and share common risk factors²⁴. While some systematic reviews found no association, two systematic reviews found some evidence in favour of an association under specific conditions^25,26.

There found a linear association between obesity and dental caries in bivariate analyses; however, this association disappeared after accounting for the effect of deprivation. Furthermore, researchers showed that the association between obesity and dental caries was not uniform; rather, the strength and direction of this association varies by modifying characteristics such as deprivation, ethnicity and lone parenthood. These findings are relevant to oral health policies aiming to reduce dental caries and obesity through the common risk factor approach. The relationship between childhood obesity and dental caries is complex and moderated by socio-demographic factors. Health policies aiming to reduce obesity and dental caries through the common risk factor approach need to account for the complexity of this relationship and the effect of socio-demographic modifiers^27,28.

BMI and tooth brushing: The association between toothbrushing habits and obesity was found, even though periodontal condition and several lifestyle factors were adjusted for in multivariate models, suggesting that this association is explained by other related factors. It was found that a low frequency of toothbrushing was associated with the development of obesity after adjusting for covariates and, furthermore, that not brushing teeth at night in participants with toothbrushing frequency of 1 time a day was associated with hyperglycemia. This longitudinal study reinforced the results of a previous cross-sectional study, which showed the association between a low frequency of toothbrushing and obesity. The effect of brushing teeth at night on hyperglycemia was observed in participants with toothbrushing frequency of 1 time a day. Not brushing teeth at night in individuals with low frequency of toothbrushing can easily cause poor oral hygiene status, because saliva flow is low while sleeping, and bacterial clearance is reduced, resulting in greater bacterial colonization of oral tissues.²⁹

Health consequences of obesity on oral health: The most common health consequences of obesity on oral health include obesity which is related to several aspects of oral health, such as caries, periodontitis and xerostomia. In addition, obesity may have implications for the dental treatment plan. Several recent studies suggest that periodontitis occurs more frequently in obese individuals than in subjects with a normal body weight. The obese individuals exhibited significantly greater mean pocket depth and a higher percentage of sites exhibiting visible plaque. Obesity has emerged as a risk indicator of periodontal disease and studies have reported that individuals with periodontitis had higher blood pressure than individuals without periodontitis. Furthermore, Iacopino, Anthony M. (2001) reported that periodontitis is more prevalent in persons with diabetes and that individuals with periodontitis have abnormal lipid metabolism.³⁰

Recently, obesity has emerged as one of the major risk indicators of periodontal disease and conversely, the remote effects of periodontal disease on various systemic diseases have been proposed. Amongst the systemic health disorders, Type 2 diabetes (DM) and CVD are established obesity-related diseases. If obesity is a true risk factor for periodontal disease, the association amongst periodontal disease, obesity, and Type 2 diabetes (DM) or, CVD must be very complex because each is a confounding factor for the other. In addition, several studies have suggested that periodontal disease affects both glucose and lipid metabolism which are themselves very important factors in the development of both Type 2 diabetes (DM) and CVD.Children who are obese and overweight prefer sweet and fatty foods more frequently compared to children with normal weight. Hence, there is higher prevalence of dental caries in overweight and obese children in both the primary and permanent teeth. Elevated BMI is associated with an increased incidence of permanent molar interproximal caries.³¹Hormonal changes in the obese patients may affect mineral metabolism. The metabolic changes caused by obesity that have an impact on bone growth, also, affect tooth eruption. Children with a high BMI had higher eruption rates.

There is a well-described connection between periodontal disease and diabetes with implications that the relationship may be bidirectional. Clearly, these associations should be the reasons for the dental profession to intervene in the rise of obesity. Insufficient sleep is another factor in obesity problem and screening for sleep habits could be part of a comprehensive dental assessment along with height, weight and blood pressure. The dental profession is in a unique position to identify and aid in the treatment of obstructive sleep apnea (OSA), a condition associated with obesity and diabetes³².

The rise of obesity and Type 2 diabetes in children is of great concern and the dental profession can play a role in raising awareness of overweight status as well as obesity risk behaviours. Obtaining BMI and BMI percentile measurements can be a feasible addition to the dental protocol as it is non-invasive and requires a small time commitment and minimal cost.³³Accepting the premise that weight status is associated with oral health, weight screening, obesity prevention and intervention in dental offices can be advocated as part of the comprehensive dental assessment and treatment.

Given the tremendous increase in the prevalence of obesity, dental professionals should promote a healthy diet not only to prevent dental decay but, also, to reduce the risk of obesity. In future preventive programmes, the importance of nutrition should not only be emphasized with respect to general diseases but, also, with regard to carious lesions, periodontal diseases, oral cancers and various other oral diseases. Dental professionals should participate in multidisciplinary medical teams managing obese individuals. Obesity is a complex disease and its relationship to oral health has been realized in recent years and therefore, the purpose of the study was to undertake a systematic review of the relationship between BMI and oral health.

BMI and Dental considerations:Dental professionals may be confronted with several aspects of obesity. In the first place, the obese patient may be too big for the dental chair. A body weight in excess of 140 kg may exceed the weight limitation for motorized chair function. The obese patient may be unable to extend the neck fully limiting optimal patient positioning. Sometimes the patient has to be treated in a semi-upright position to prevent respiratory problems. A decreased oral opening and an excess tongue volume hinder with visualization and makes it difficult to locate landmarks for instilling local anesthesia. To prevent post operative airway problems, unilateral treatment is recommended. The obese patients frequently have hypertension and diabetes. Children bodies react differently to medications with drug dosing being an important issue in obese children.³⁴

BMI and Xerostomia:The pharmacological treatment of obesity may have oral side effects. The obsolete appetite-suppressive drugs fenfluramine and dexfenfluramine inhibited salivary flow leading to xerostomia. Xerostomia affects speech and leads to rampant caries. The obese patients frequently have hypertension and diabetes. Also, anti-hypertensive drugs lead to oral side effects such as xerostomia, and lichenoid reactions etc. to add a few. Diabetic patients show poor wound healing, parotitis, xerostomia, increased sugar level in gingival crevicular fluid (GCF) which leads to periodontitis and loss of alveolar bone.³⁵

BMI and Dental traumatic injuries and Tooth fracture: Obese children have only enamel and enamel dentine fractures due to more indoor play. The main reported trauma caused by obese children was indoor play (38.7%) while the most frequently reported cause for non-obese children was outdoor play.³⁶ Although the Brazilian study amongst 116, 12 years old children failed to find a statistically significant relation between obesity and dental trauma.³⁷Another study from the same country reported those children with the BMI greater than 23 kg/m², 1.93 times more likely to have traumatic dental injuries than non-obese children.³⁸ A Finnish survey at the age of 31 years, also, found that obesity was associated with a high prevalence of dental displacements and avulsions.³⁹

A Role for the Dental Professionals: It has been demonstrated that specific repeated messages from multiple resources are more likely to promote behavioural change than single source message. Primary care physicians and pediatricians are well-equipped to address the obesity issue. The American Academy of Pediatrics recommends that the health care providers should encourage healthy eating patterns and routine physical activity and discourage TV and video time by providing families with education and anticipatory guidance.⁴⁰ However, evidence suggests that busy providers do not adequately follow these recommendations. Several studies have found that the detection of obesity during routine medical appointments is low and time constraints limit how much a clinician is willing or, able to discuss with patients.Tools targeting specific behaviours may be helpful. Dental professionals are in a good position to be able to supplement and reinforce the information received in the medical setting as well as to initiate the conversation. Travares and Chomitz (2009), also, developed and tested the feasibility of a dental-office based tool for children targeting obesity risk behaviors.⁴¹ The Healthy Weight Intervention based on the concepts of Motivational Interviewing was designed for children of all weights and requires approximately 10 minutes during the routine hygiene visit.⁴² Using standard, evidence-based recommendations for improving obesity risks, this preventive intervention does not require specialized training.

The dental team is in a unique and favourable position to offer healthy weight intervention and obesity prevention. Most healthy patients visit dental professionals more frequently than a physician on an annual basis. Children and adolescents, in particular, follow the paradigm or, annual medical and semi-annual dental visits potentially allowing for twice the annual frequency of any intervention. Additionally, it is already a standard practice for the dental professionals to promote dietary habits that avoid calorie and sugar-dense foods and beverages for caries prevention. They can easily expand their counselling to emphasize the implications of these dietary practices, in addition, to the positive effects of physical activity and other lifestyle changes on both oral and systemic health⁴².

For patients with suspected weight issues, the dentist can work alongside paediatricians, family physicians and dieticians by providing referrals.⁴³Some dental settings, particularly, paediatric dental practices, already measure weight and height for other purposes particularly for calculating dosages for local and general anesthesia.⁴⁴ Obtaining BMI and BMI percentile measurements can be a feasible addition to the dental protocol as it is non-invasive and requires a small time commitment and minimal cost.^45-47 Accepting the premise that weight status is associated with oral health, weight screening, obesity prevention and intervention in dental offices can be advocated as part of the comprehensive dental assessment and treatment.^48-50 There are strong links between obesity and oral health, particularly, with respect to diabetes and periodontal disease. Decreasing obesity risks through diet and lifestyle changes can have a positive impact on oral as well as systemic health. It is important for the dental team to consider all the key domains of obesity risk behaviours such as physical activity, screen time, and meal patterns, not only the diet.^51,52

CONCLUSION:

Dental professionals must be aware of the increasing numbers of the obese patients and of the significance of obesity as a multiple risk factor syndrome for oral and overall health. Dental professionals have a crucial role in the prevention and detection of many oral and systemic diseases because of their diagnostic and screening abilities as well as the frequency of patient visits. There is a well-described connection between periodontal disease and diabetes with implications that the relationship may be bi-directional. Insufficient sleep is another factor in the obesity problem and screening for sleep habits could be part of a comprehensive dental assessment along with height, weight and blood pressure. Ultimately, a health condition as prevalent and serious as obesity must be approached by a concerted and collaborative effort of many disciplines and organizations. The dental profession should include itself in this collaboration using the tools and education opportunities available. Although the connection between oral health and obesity is critical to understand, it should not be the sole motivating factor for taking action. It was found a linear association between obesity and dental caries in bivariate analyses. The association between tooth brushing habits and obesity was found, even though periodontal condition and several lifestyle factors were adjusted for in multivariate models, suggesting that this association is explained by other related factors.

RECOMMENDATIONS:

· BMI calculation should be included in the standard dental evaluation of any paediatric patient, as it can provide a screen for potential health complications of the growing child.

· Informing and educating the health care providers about the importance of healthful eating and physical activity.

· Encouraging partnership between health care providers, schools, faith based groups and other community organization might, also, be useful in prevention of obesity.

· Weight screening should be an integral part of periodontal risk assessment on a regular basis as it will reduce the patient’s risk of developing chronic diseases including periodontitis.

· The dietary intervention to induce weight loss has often, also, positive impact has on the level of periodontitis and caries. Therefore, dieticians and dental professionals should collaborate in the treatment of obese individuals.

· Future studies should address which factors specific to overweight in children might be protective against oral health conditions.

· Given the importance of overweight as a public health concern, however, clinicians are encouraged to continue providing health education and dietary counselling to their overweight child patients.

· Introducing systemic health screenings and prevention and intervention protocols in dental health education is a key element in widespread implementation. Finding methods to work within the constraints of the current practice modalities is important for feasibility.

CONFLICT OF INTEREST:

There is no conflict of interest between authors.

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Received on 15.12.2021 Modified on 29.01.2022

Research J. Pharm.and Tech 2022; 15(2):896-902.

DOI: 10.52711/0974-360X.2022.00150