Association between obesity and periodontal disease among 35 – 44 years old patients visiting Teerthanker Mahaveer Dental College and Research Centre, Moradabad: A cross sectional study

ABSTRACT

Introduction:

Obesity had been the most neglected public health problem increasing at an alarming rate affecting both the developed and developing countries. Periodontitis is a chronic inflammatory disease which is highly prevalent worldwide affecting 20–50% of the global population. Thus, a research was conducted to evaluate the relationship between obesity and periodontal disease among 35–44-year-old patients who were visiting the Oral Medicine and Radiology Department (OMDR) in TMDCRC, Moradabad.

Objective:

To know the prevalence of obesity and periodontal health. To record the body mass index (BMI) and to co-relate with periodontal disease. To recommend preventive measures for periodontitis and the obese population.

Materials and Method:

A cross-sectional study was conducted in the Department of OMDR, TMDCRC, Moradabad. A total of 566 subjects were examined aged 35–44 years visiting the out patient department (OPD) of the OMDR Department. Informed consent was obtained from the participants. Questionnaire-based proforma was used comprising information regarding oral hygiene practices, frequency of toothbrushing, and method of brushing. A World Health Organization (WHO)-modified 2013 assessment form was used to record the periodontal status of the participants.

Results:

The examination of 550 subjects was done. It was found that there is a significant association of periodontal disease in factors like BMI, age, gender, smoking status, and loss of attachment (LOA) is found in BMI, gender, smoking status, and smoking frequency. It was also found that there is a significant association of the community periodontal index (CPI) scores in obese individuals.

Conclusion:

The main aim is to find and control the risk factor and eliminate it. Our study confirms that obesity is one of the risk indicators of periodontitis. With the scope and limitations of the study, it has been concluded that obesity and periodontitis have a significant relationship with each other. This study states the importance of good oral hygiene maintenance in obese and normal patients.

Introduction

Obesity has been the most neglected public health problem by primary care providers.[1] It has a potential impact on various comorbidities, mortality, and the cost of health care.[2] According to the World Health Organization (WHO), obesity has been defined as a multifactorial disease in which there is an excessive accumulation of fat in the body as a result of the interaction of environmental and genetic factors.[3]

Obesity is a multisystem condition which predisposes to many life-threatening medical conditions including arterial hypertension, various cardiovascular diseases, diabetes mellitus, various cancers, like cancer of the esophagus, thyroid, kidney, uterus, colon, and osteoarthritis.[4]

According to the global health survey of the WHO, obesity or overweight is the leading cause of death each year worldwide for at least 2.8 million people.[5] It is a systemic condition which contributes to an increase in the overall inflammatory condition through its various parameters increasing its susceptibility to periodontal disease.[6,7] Besides other risk factors, periodontitis is responsible for the destruction of the peri-tooth components that support the tooth.[8,9]

Periodontitis is a chronic inflammatory disease which is highly prevalent worldwide affecting 20–50% of the global population.[10] It can result in a clinical attachment loss which progressively can lead to the loosening of teeth or eventually the loss of teeth.[11]

Despite tremendous efforts by primary care physicians to reduce obesity and their link with oral hygiene among the masses, the gap between them remains the same. Thus, the exact link between obesity and periodontitis is yet to be found.[12,13]

Many studies have reported that adverse effects of obesity are mediated through increase in the production of pro-inflammatory cytokines such as interleukin, Tumor necrosis factor (TNF-α), interleukin-1 and interleukin-6, and various bioactive substances like bioactive reactive species which may affect the periodontal tissues directly.[14] Perlstein et al.,[15] in 1977, first reported that there is a relation between obese people and periodontitis. They suggested that more bone loss is present in obese rats in comparison with normal ones.

In the Indian context, the sociodemographic characteristics, lifestyle factors, poor maintenance of oral hygiene along with an increase in the cariogenic diet affect the periodontal tissues. Thorough knowledge of oral health and hygiene practices should be acquired by every individual for better upliftment of his/her oral and general health.[16] Weight loss can reduce the risk factors for various chronic diseases, therefore, health care professionals need to discuss weight-loss strategies, healthy lifestyles, physical activities, and proper utilization of oral health services.[17]

Therefore, to know if an individual is called an obese person, his or her body mass index (BMI) is more than or equal to 30. The Quetelet’s Index is known as the BMI, the most common tool to calculate obesity. The calculation of BMI is done by dividing a person’s body weight (kg) by squaring the height in meters (m²).[18] There is no documentation about the relationship between obesity and periodontal disease in the population of Moradabad. By keeping the above facts in mind, research was conducted to evaluate the relationship between obesity and periodontal disease among 35–44-year-old patients to know its impact on oral as well as general health.

Materials and Methods

A cross-sectional study was conducted to know the association of obesity and periodontal disease among 35–44-year-old patients visiting the Teerthanker Mahaveer Dental College and Research Center, Moradabad, Uttar Pradesh. The present study was conducted among the study subjects in the Outpatient Department (OPD) of the Moradabad Dental College. A total sample of 566 patients aged between 35 and 44 years was selected in OPD from the Teerthanker Mahaveer Dental College and Research Center. The sample size for the present study was calculated based on the data obtained from the pilot study. The sample size was determined at a confidence interval of 95%. The prevalence of periodontal disease was 38%.

Inclusion criteria

All the patients who were attending the OPD of Oral Medicine and Radiology aged 35–44 years. The patients who were ready to sign the consent form were included in the study.

Exclusion criteria

• The subjects who were on antibiotics or who had received periodontal management for at least 3 months before.

• Physically handicapped and mentally disturbed subjects.

• Pregnant women and lactating mothers.

• The patients who did not provide written permission to contribute in the study.

• The patients having underlying systemic conditions which could disturb the periodontal health.

Data were collected through a survey which included clinical examination and a structured questionnaire. Ethical clearance for the study was obtained by the ethical committee of the TMDCRC committee with reference number TMDCRC/IEC/18-19/PHD3. Written informed consent was taken from each participant.

Data collection for the study was done for about 3 months from November 2020 to January 2021.

Demographic details of the patients were recorded using a pre-structured questionnaire consisting of questions related to name, age, oral hygiene practices, toothbrushing techniques, frequency of changing the toothbrush, and weight and height of the patients.

Clinical examination

A Type III examination was followed using a mouth mirror, CPI probe, and natural light. The oral health status was assessed using the World Health Organization Oral Health Assessment Form (2013).[19] The periodontal index was assessed by the Community Periodontal Index and loss of attachment (LOA).

Training and calibration

A 2-day training session for the standardization and calibration of the data collection methods was organized in the Department of Oral Medicine and Radiology. The instruments were sterilized using an autoclave before going for the survey. The investigator used disposable mouth masks and gloves during the examination.

Statistical Analysis

Data were analyzed using the SPSS 21.0 version software package. The descriptive data were included along with the mean and standard deviation.[20] The intergroup comparison was done using the Chi-square test and one-way analysis of variance (ANOVA) to find out the differences between the individual groups. The level of significance for the present study was fixed at 5%.

Results

Demographic details

In the study population of 550 subjects, 289 (52.5%) subjects were males in the age group of 35–44 years and 261 (47.5%) subjects were females in the same age group, respectively.

Among the participants, the distribution of the responses on the use of other oral hygiene aids reported that many participants 257 (46.7%) used mouth rinse as an oral hygiene measure while 243 (44.2%) used a toothpick as aid. Only 50 (9.1%) participants used a tongue cleaner as a preventive measure.

Out of the 550 subjects, 320 (58.2%) participants preferred to use a toothbrush for oral hygiene, however, 167 (30.4%) subjects used a finger for their oral hygiene. Only 63 (11.5%) subjects were using a toothpowder.

In the study population, 489 (88.9%) participants brushed once a day whereas 66 (11.1%) brushed twice a day.

Among the study subjects, a majority of the participants (276, 50.2%) preferred to use the horizontal method of toothbrushing, although 256 (46.5%) used the circular method of cleaning. Only 18 (3.3%) used a vertical method of toothbrushing, respectively [Table 1].

Table 1.

Demographic details of the participants

Demographic details	Frequency	Percentage
Sex
Males	289	52.5
Females	261	47.5
Oral hygiene practice
Mouth rinse	257	46.7
Toothpick	243	44.2
Tongue cleaner	50	9.1
Cleaning type
Finger		30.4
Toothbrush	320	58.2
Toothpowder	63	11.5
Brushing frequency
Once	489	88.9
Twice	61	11.1
Cleaning method
Horizontal	276	50.2
Vertical	256	46.5
Circular	18	3.3

Association between periodontal disease and other factors

Out of the 550 study subjects, the BMI of the normal individuals with periodontal disease and without periodontal disease was 159 (69.7%) and 69 (30.3%), respectively. A majority of the participants, 215 (77.6%) overweight were having periodontal disease while 62 (22.4%) subjects were not having periodontal disease. Almost every participant in the obese category was having periodontal disease. There was a statistically significant difference (P- value = 0.001) noted in the study population according to the BMI in relation to the periodontal disease. Among the 550 study subjects, 131 (54.8%) participants were without the periodontal disease, 108 (45.2%) participants were present with the periodontal disease belonging to the 35–39-year age group. While in the age group of 40–44 years, 188 (60.5%) were present with the periodontal disease and 123 (39.5%) subjects were without the periodontal disease. A P value of <_ 0.05 (P = 0.001) was observed to be statistically significant in the periodontal disease in relation to age [Table 2].

Table 2.

Association between periodontal disease and body mass index

Parameters	Periodontal disease absent	Periodontal disease present	Chi-square value	P
BMI
Normal	159	69	149.59	0.01 (Sig)**
	69.7%	30.3%
Overweight	62	215
	22.4%	77.6%
Obese	0	45
	0.0%	100.0%
Age
35-39 years	131	108	12.663	0.001 (Sig)**
	54.8%	45.2%
40-44 years	123	188
	39.5%	60.5%

**Highly Significant P<0.01. BMI: Body mass index

Association between LOA and other factors

Out of the 550 study subjects, 142 (59.4%) participants were in the age group of 35–39 years and were present with LOA in their teeth whereas 97 (40.6%) subjects in the same age group were not having any attachment loss. Most of the 124 (39.9%) participants were from the 40–44-year age group with the absence of LOA, whereas 187 (60.1%) subjects were present with LOA in their teeth. There was no statistically significant relation found in relation to age with LOA.

Among the study population of 550; 159 (69.7%) participants were in the normal category with LOA absent in their teeth whereas 69 (30.3%) subjects were present with an attachment loss in the same category. Most of the study population (215, 77.6%) was present with an attachment loss in the overweight category whereas only 62 (22.4%) were not having an attachment loss in the same category. Only 45 (100%) were in the obese category with LOA. It was reported that a statistically significant difference was there in relation to the BMI with the attachment loss [Table 3].

Table 3.

Association between loss of attachment and various factors

Parameters	Loss of attachment absent	Loss of attachment present	P
BMI
Normal	159	69	0.001 (Sig)**
	69.7%	30.3%
Overweight	62	215
	22.4%	77.6%
Obese	0	45
	0.0%	100.0%
Age
35-39 years	97	142	0.885 (NS)*
	40.6%	59.4%
40-44 years	124	187
	39.9%	60.1%

*Significant P<0.05, **Highly significant P<0.001. BMI: Body mass index

Distribution Of Study Population Based On Cpi Scores

Among the study population of 550, the distribution of responses based upon CPI scores were found to be statistically significant [Table 4].

Table 4.

CPI score among the study subjects based on the BMI index

	Healthy	Bleeding	Calculus	Pocket	P
Normal	36	60	52	80	0.001
	15.8%	26.3%	22.8%	35.1%	(Sig)**
Overweight	25	36	36	180
	9.0%	13.0%	13.0%	65.0%
Obese	0	0	9	36
	0.0%	0.0%	20.0%	80.0%

**Highly significant. P<0.001. Chi-square test

Discussion

Obesity has become a major public health problem. It has become a fast-growing disease worldwide including developing countries like India. Some of the health professionals have suggested that obesity and periodontitis is associated with each other affecting the systemic health of the individual.[21] Due to a change in the nutritional pattern and unhealthy lifestyles, it is necessary to know the relation between the two factors. Smoking cigarette is a risk indicator for periodontitis.[22]

The WHO had also recognized that BMI is the most important tool to measure the overweight and obese population for all age groups. Hence, the BMI was used to measure obesity in this study. The WHO index age group of 35–44 years was selected because several studies had reported an association in this age group.[14] In daily life, changes in dietary patterns and eating habits could lead to a strong relationship between obesity and periodontitis.[23]

In our study, 289 (52.5%) subjects were males and 261 (47.5%) subjects were females, which was similar to a study conducted by Amandeep Chopra et al.,[14] where females had fewer chances of getting periodontitis as compared to males. In the present study, it was found that the prevalence of periodontitis was more in overweight individuals as compared to normal people. It was also noticed that almost every obese person tends to have periodontitis. In agreement to a study done by Sarthak Bhola et al.[22], obese people tend to have periodontitis compared to normal ones. This might be because obese people have an unhealthier pattern of diet.[23] They have more sugar consumption, unhealthy habits of eating, and less content of essential micronutrients. Hence, these unhealthy dietary patterns destroy the periodontal ligament.[24]

Although no evidence has been reported for the exact mechanism of obesity and periodontitis, it has been found that high levels of cytokines and hormones known as adipokines play a major role in the process of inflammation.[25] This finding was not in agreement with a study conducted by V-hema which does not show any association between obese people and periodontitis.[16]

In the present study, the prevalence of periodontitis (PD) is noted more in people aged 40–44 (60.5%) years followed by those of 35–39 years (45.2%). The results found were also statistically significant and suggested periodontitis with advancing age. Similar findings were noted in a study done by Nguyen et al.,[16] who found that the subjects aged over 35 years were prone to periodontitis.[16] This was in concordance with a study done by Fatemah Sarlati et al.,[17] who found the prevalence of PD in young adults but not in middle-aged and older people.

Obesity constitutes to be a major public health problem affecting not only general health but also systemic effects leading to major problems. Unfortunately, the public is unaware of the risk and does not have enough awareness to avoid the practices affecting the oral quality of life.[26] On the contrary, health care professionals, including dentists, do not focus on the prevention of periodontal diseases but give importance to the treatment of diseases.[27] The preventive campaigns should highlight the prevention of obesity because prevention is the key to better oral hygiene and general health. This study is cross-sectional in design, so it does not investigate the effect and cause relation.[28] The results of this study cannot be generalized for the general population because of the age group (35–44 years).

Therefore, prevention of periodontitis is the most enviable action. It ought to be the responsibility of every oral health care provider to screen, recognize the patients with obesity, and counsel the obese people regarding the complications of oral health.[29] Screening of weight should be done regularly to reduce the risk of developing periodontitis.

Conclusion

Obesity is a multifactorial and complex disease. It is a public health concern in both developed and developing countries. It has been implicated as the highest risk factor for other systemic diseases like cardiovascular diseases, diabetes, strokes, and hypertension. The main aim is to find and control the risk factors and eliminate them. Our study confirms that obesity is one of the risk indicators of periodontitis. With the scope and limitations of the study, it has been concluded that obesity and periodontitis have a significant relationship with each other. This study gives the importance of good oral hygiene maintenance in obese and normal patients. It was also noticed that the participants who were having poor oral health status and insufficient knowledge about oral health were prone to oral diseases.

As primary care physicians, it ought to be our primary responsibility to reduce the burden of diseases by health education, adopting healthy practices, and modifying diet to lead a happy and productive life. An effort should be taken to ensure the causative factor, monitoring, and preventive role in the obese people and to make them aware of the risk of neglecting the treatment and its possible consequences on the oral as well as general health. Educational programs should be necessary to improve public health importance regarding the causes, prevention, and consequences on systemic health.

Recommendations

Obesity is one of the most neglected problems affecting society all over the world. It also has an impact on systemic health affecting the quality of life. It also has an impact on the oral health status of the population leading to periodontal structures of the teeth. The following recommendations are given:

1. Health awareness programs with strictly controlled actions of periodontitis and obesity should be conducted.

2. Encouragement to the patients should be provided by general practitioners, including dentists, to improve oral health, improve the quality of life, and reduce the risk of periodontitis.

3. Promotion of healthy lifestyles and physical activity to reduce the burden of the disease.

4. Public health dentists play an important role in preventing both the disease on an individual as well as community basis.

5. Further studies are recommended with a large sample size covering wider areas.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.