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Turk J Med Sci
2012; 42 (6): 970-976
© TÜBİTAK
E-mail: medsci@tubitak.gov.tr
doi:10.3906/sag-1202-82
e oral health status of healthy and obese children in a Turkish
population: a cross-sectional study
Günseli GÜVEN POLAT1, Sevi Burçak ÇEHRELİ2, Mehmet Emre TAŞÇILAR3,
Özlem Martı AKGÜN1, Ceyhan ALTUN4, İlker Tolga ÖZGEN4
Aim: To compare the oral health status of a group of obese and healthy Turkish children.
Materials and methods: e study involved 43 healthy (19 boys and 24 girls, mean age: 9.88) and 53 obese (18 boys and
35 girls, mean age: 10.4) children who were admitted to a pediatric dentistry clinic in 2008 and 2009. e parents were
asked to complete a questionnaire concerning medical history and dietary/oral hygiene habits. e number of decayed,
missing, and lled permanent teeth (DMFT); number of decayed, missing, and lled primary teeth (dm ); and gingival
bleeding index (GBI) scores of patients were recorded. Statistical di erences were evaluated using Student’s t-test and
the Mann-Whitney U test and the nominal variables were tested with Pearson’s chi-square test and Fisher’s exact test
(P ≤ 0.05).
Results: e educational status of parents did not di er signi cantly between obese and healthy children (P = 0.064).
On a daily basis, obese children consumed signi cantly more snacks (P = 0.003). e carbohydrate intake of healthy
children was restricted to mealtimes (P < 0.001) while obese children consumed signi cantly more carbohydrates as
snacks (P < 0.001). In both groups, the participants displayed similar oral hygiene habits and DMFT and dm scores
although GBI scores were signi cantly higher in obese children.
Conclusion: No relationship was found between obesity and the oral health status of the child population evaluated.
Similar oral hygiene habits and socioeconomic status might have contributed to this result.
Key words: Childhood obesity, dental caries, gingival health
Original Article
Received: 22.02.2012 – Accepted: 02.03.2012
1 Department of Pediatric Dentistry, Gülhane Military Medical Academy, Ankara - TURKEY
2 Department of Pediatric Dentistry, Faculty of Dentistry, Başkent University, Ankara - TURKEY
3 Department of Pediatrics, Gülhane Military Medical Academy, Ankara - TURKEY
4 Department of Pediatrics, Faculty of Medicine, Bezmialem University, İstanbul - TURKEY
Correspondence: Özlem Martı AKGÜN, Department of Pediatric Dentistry, Gülhane Military Medical Academy, Ankara - TURKEY
E-mail: ozlemmartiakgun@gmail.com
Introduction
e increasing prevalence of childhood obesity has
become a serious health problem worldwide (1,2).
Obesity is a risk factor for several diseases such as
heart disease, hyperinsulinemia, hypertension, early
atherosclerosis, and obstructive sleep apnea, as well
as for the early onset of puberty in women (3,4).
Environmental and genetic factors, the consumption
of energy-dense and highly re ned foods, dietary
habits, and food insecurity have been identi ed as
potential contributors to obesity (5,6). Although
the contribution of genetic factors to obesity is not
yet fully understood, a possible cause appears to be
the variability in genes coding for hormones and
neurotransmitters such as growth hormone, leptin,
ghrelin, neuropeptide Y, and melanocortin (7).
Dental caries, the most prevalent chronic disease
of childhood, is a signi cant public health problem
known to a ect 58.6% of children aged 5-12 years
in the United States (8). In the search for possible
associations between childhood obesity and dental
caries, it has been demonstrated that childhood
G. GÜVEN POLAT, S. B. ÇEHRELİ, M. E. TAŞÇILAR, Ö. M. AKGÜN, C. ALTUN, İ. T. ÖZGEN
971
obesity is responsible for an increase in dental caries
and alterations in dental development (9,10). Alm
et al. (11) investigated the prevalence of approximal
caries in the posterior teeth of 15 year olds and
demonstrated that overweight or obese adolescents
had a signi cantly higher prevalence of approximal
caries than did normal weight individuals. However,
a study by Chen et al. (12) failed to demonstrate
any signi cant di erence in the total decayed or
lled primary tooth (d ) scores of child groups
with di er ent body mass indexes (BMIs). Similarly,
no signi cant associations were found between
childhood obesity and caries in the United States
National Health and Nutrition Examination Survey
carried out from 1999 to 2002 (13).
Because of con icting results published thus far,
Hilgers et al. (9) suggested that there is a need for
future studies in order to assess the e ect of obesity
on caries, taking into account patient demographics
and behavioral patterns. erefore, the present cross-
sectional study aimed to compare the dietary habits,
oral hygiene, and dental caries rates of obese and
healthy Turkish children. e study tested the null
hypothesis that childhood obesity is not associated
with a higher incidence of dental caries.
Materials and methods
Patient selection
is was a cross-sectional study conducted at a
university pediatric dentistry clinic a er approval
was received from the institutional review board and
informed consent from the participants’ parents.
Inclusion criteria stipulated that the children were
living in an area without uoridated drinking water
and had not previously bene ted from any form of
systemic or professionally applied uoride.
A questionnaire that assessed dietary habits,
oral hygiene habits, familial health history, and
socioeconomic status was implemented. Among
patients who were admitted for regular check-ups
between November 2008 and February 2009, 43
healthy (19 boys and 24 girls, mean age: 9.88) and
53 obese children (18 boys and 35 girls, mean age:
10.4) who met the inclusion criteria and whose
parents agreed to their participation were included
in the study. Children in the obese group had been
previously diagnosed by the department of pediatric
endocrinology at the same institution. Participants’
BMI was calculated as weight (in kg) divided by
height (in m2). Participants with a BMI above the
95th percentile for their age and sex were classi ed as
obese. Children in the control group were randomly
chosen from among otherwise healthy patients
admitted to the same pediatric dentistry clinic for
regular dental visits in the absence of any dental
complaint.
e questionnaire assessed the following criteria:
A. History: Medical history and family history of
obesity
B. Parental educational status
C. Monthly income
D. Dietary habits: Snack eating (snack eating at
school, snack eating before going to bed, and snack
eating at any time during the day); breakfast eating
status; chewing rapidly or slowly; large or small bite
sizes; and intake of carbohydrates.
E. Oral hygiene habits: Tooth brushing at bedtime;
tooth brushing in the morning; brushing with
uoridated toothpaste; using ultrasonic toothbrush;
and using dental oss.
Clinical examination
e dental health status of patients was examined
using number of decayed, missing, and lled
permanent teeth (DMFT) and number of decayed,
missing, and lled primary teeth (dm ) scores.
e periodontal status was recorded in accordance
with the gingival bleeding index (GBI), based on
WHO criteria (14). An experienced pediatric dentist
performed all intraoral examinations. During the
visual examination, a dental explorer was used to
con rm questionable caries ndings (15). Dental
caries, missing teeth, and restored teeth (DMFT,
dm ) were diagnosed and recorded.
e GBI was evaluated by the same operator. In
brief, a standard periodontal probe was used to measure
the extent of gingival bleeding and periodontal
destruction at the buccal and mesiobuccal sites.
A er gentle probing, the ndings were categorized as
bleeding or no bleeding. Additionally, parents were
asked about the frequency of spontaneous bleeding
and answers were categorized as “yes,” “no,” or
“rarely.”
e oral health status of healthy and obese children
972
Statistical analyses
All data were analyzed using SPSS (Version 11.5,
SPSS Inc., Illinois, USA). Descriptive statistics
included continuous data, shown as mean ± standard
deviation, and categorical data, shown as frequency
and contingency tables. Statistical di erences
between groups were evaluated using Student’s t-test
and the Mann-Whitney U test for continuous data,
and the nominal variables were tested with Pearson’s
chi-square test and Fisher’s exact test. For all analyses,
a P-value of ≤0.05 was considered statistically
signi cant.
Results
e systemic and oral hygiene status of obese
and healthy children and their cariogenic food
consumption and eating habits are presented in Tables
1-4. e mean ages of obese and healthy children were
10.4 and 9.88 years, respectively. Both sex and age
showed homogeneity among the groups (P = 0.306
and P = 0.393, respectively). e socioeconomic
statuses of families were similar for obese and healthy
children (P > 0.05). e educational statuses of the
mothers and fathers were also similar (P = 0.064),
revealing that the majority of mothers had graduated
from high school while the majority of fathers were
college or university graduates. Obese children had
signi cantly more systemic disease (P = 0.002) and
obese relatives in their families (P < 0.001) than
did healthy children, with the majority of reported
systemic diseases being metabolic syndromes other
than diabetes.
e evaluation of dietary habits showed that the
majority of obese (86%) and healthy (99%) children
had breakfast before starting the day. Obese children
consumed signi cantly more snacks during the
daytime and chewed signi cantly larger pieces of
food while eating (P < 0.05 for both). Chewing time
did not signi cantly di er among obese and healthy
children (P = 0.960). Obese children consumed more
carbohydrates as snacks while the carbohydrate
intake of healthy children was restricted to mealtimes
only (P < 0.001 for both; Table 4).
Signi cantly more healthy children than obese
children brushed their teeth at night (P = 0.011)
while tooth brushing in the morning did not di er
among the obese and healthy groups. Other than
tooth brushing at night, both obese and healthy
children had similar oral hygiene habits. e majority
of participants (75% of obese and 81.4% of healthy
children) brushed their teeth with uoridated
toothpaste and a manual toothbrush. Only a few
obese (9.4%) and healthy (11.6%) children reported
the use of ultrasonic toothbrushes. e majority of
the obese (51%) and a large proportion of healthy
(41%) children did not use dental oss.
DMFT and dm scores were similar between
groups. However, GBI was signi cantly higher among
obese children (P < 0.001) than among healthy
children. In contrast, the frequency of spontaneous
bleeding did not di er among obese and healthy
children (P = 0.151) (Table 5).
Discussion
It is widely accepted that a BMI between the 85th
and 95th percentiles is de ned as overweight and a
BMI greater than the 95th percentile de nes obesity
(16). However, cross-national di erences may a ect
BMI values (17,18). For example, the 85th percentile
of children of the United States, which brings the
percentage of obesity to about 12.5%, ts into the
95th percentile of Brazilian children and the 90th
percentile of British children (18). A recent study
con rmed that data and curves of BMI values in
Table 1. Systemic statuses of obese and healthy children. Values are presented in percent (%).
Obese children Healthy children
Obesity in relatives 54.7* 4.7
Present systemic diseases 24.5** 0
* P = 0.002, ** P = 0.000
G. GÜVEN POLAT, S. B. ÇEHRELİ, M. E. TAŞÇILAR, Ö. M. AKGÜN, C. ALTUN, İ. T. ÖZGEN
973
healthy Turkish children are compliant with those of
Western countries (19). us, in the present study,
the widely accepted cut-o values, in which a BMI
between the 85th and 95th percentile indicates
being overweight and a BMI greater than the 95th
percentile equates to being obese, were used for the
diagnosis of obesity.
Since the 2 prevalent diseases in this study,
dental caries and obesity, are clearly related to the
consumption of fermentable carbohydrates, it would
be reasonable to assume that they would correlate well.
However, most authors have failed to report a positive
association between dental caries and obesity. Studies
conducted within and outside the United States
have reported con icting results (9,12,13,20,21).
In addition, obvious ethnic and cultural di erences
between countries may limit the applicability of the
results of those studies to other nations. Obesity
alone was found to be a poor predictor of dental
caries in Finnish children aged between 7 and 16
years (20). However, the accuracy of predicting
risk of dental caries increased a er controlling for
a history of dental caries and obesity (20). Larsson
et al. (21) evaluated the relationship between dental
caries and risk factors for atherosclerosis in Swedish
adolescents. ey compared DFS scores with obesity
in 15-year-old children and found a signi cant
positive correlation between DFS scores and BMI.
e results of a recent study conducted in a Mexican
population showed that children with a high BMI had
Table 2. Oral health statuses and oral hygiene habits of obese and healthy children. Values are presented in percent (%).
Criteria Obese children Healthy children
DMFT 0.43 1
dm 1.64 2
Gingival bleeding (+) 84.8* 39.5
Tooth ossing 3.8 4.7
To ot h br u s hi n g a t ni g h t 4 1. 5 * * 6 7. 4
Tooth brushing in the morning 34.0 44.2
Using an ultrasonic toothbrush 9.4 11.6
Using uoridated toothpaste 75.5 81.4
* P < 0.001, ** P = 0.011
Table 3. Frequencies of carbonated beverage and carbohydrate consumption in obese and healthy children. Values are presented in
percent (%).
Carbonated beverages Carbohydrates
Frequency Obese children Healthy children Obese children Healthy children
1/day 11.3 7.0 11.3 7.0
2/day 1.9 7.0 1.9 7.0
4/day 1.9 0 1.9 0
1/week 34.0 30.2 34.0 30.2
2/week 11.3 14.0 11.3 14.0
3/week 1.9 2.3 1.9 2.3
4/week 1.9 2.3 1.9 2.3
None 35.8 37.2 35.8 37.2
e oral health status of healthy and obese children
974
lower levels of dental caries in their primary teeth,
whereas no association was detected between BMI
and DMFS scores (22). Regarding these con icting
results, the authors stated that both dental caries and
obesity are multifactorial diseases in which social
and behavioral aspects play important roles. us,
the di erent trends observed with respect to the
association between obesity and dental caries re ect
the complex etiology of both conditions.
e authors do not think that the systemic disease
of obese children would a ect the results. Although
some diseases, such as Type 1 diabetes mellitus
(T1DB), have been reported to be related with
dental caries, a recent study failed to demonstrate
the correlation (23). None of the children had T1DB
in the present study. Obese children had other
metabolic syndromes weakly related with dental
caries or periodontal disease (24).
In the present study, both DMFT and dm of
obese and healthy children were similar, resulting
in an acceptance of the null hypothesis. is might
be due to 2 factors: First, the majority of participants
brushed their teeth with uoridated dentifrice at least
once a day (in the morning). Second, and perhaps
more importantly, the socioeconomic statuses of the
parents in both groups were found to be similar. It has
been previously documented that a high prevalence
of caries is associated with low socioeconomic status
(25); therefore, the similarity in DMFT and dm
among healthy and obese children in the present
study could be attributed to the similarity of the
socioeconomic status of the parents.
Compared with the relationship between obesity
and dental caries, the association between periodontal
disease and obesity is subtle, but has been widely
acknowledged (26,27). Although the association is
still under careful evaluation, possible mechanisms
have been reported, including the interaction
between salivary ora and gut ora. Obesity resulting
from infection is known as “infectobesity” (28).
It is estimated that approximately 1 g of bacteria
(1011) is swallowed with 500-1500 mL of saliva
that is produced daily (29). It is therefore plausible
that salivary micro ora a ect gastrointestinal
micro ora. A recent study demonstrated that 98.4%
of overweight individuals were correctly identi ed by
the presence of the bacterium Selenomonas noxia at
a concentration greater than 1.05% of the total gut
ora (28).
Table 4. Eating habits of children. Values are presented in percent (%).
Criteria Obese children Healthy children
Carbohydrate intake between meals 73.6* 23.3
Carbohydrate intake during meals 24.5** 74.4
Eating fast 67.9 67.4
Chewing large pieces 60.4*** 20.9
Number of snacks 2.38 (mean)**** 1.44 (mean)
Having breakfast 86.8 97.7
* P < 0.001, ** P < 0.001, *** P < 0.001, **** P = 0.003
Table 5. Occurrence of spontaneous bleeding.
Occurrence of gingival bleeding Obese children Healthy children
Yes 10% 10%
No 30% 29%
Sometimes 13% 4%
G. GÜVEN POLAT, S. B. ÇEHRELİ, M. E. TAŞÇILAR, Ö. M. AKGÜN, C. ALTUN, İ. T. ÖZGEN
975
Another mechanism underlying the link between
periodontal disease and obesity may be related
to in ammatory mediators, as it is well known
that both conditions produce increased levels of
in ammatory mediators (27,30). Since adipose tissue
has been recognized as a reservoir for in ammatory
cytokines, it has been suggested that obesity can a ect
periodontal disease (30). Although the present study
did not directly aim to test the salivary microbiota
or in ammatory mediators, GBI, which was
assessed in this study, is the rst and most common
tool in the clinician’s arsenal to assess periodontal
health. Further research is required to con rm the
association between obesity and gingival disease, as
well as the mechanism underlying this correlation.
Along with the strict inclusion criteria regarding
exposure to uorides, the cross-sectional design of
this study, which is inevitably limited by the sample
size, can be regarded as a technical shortcoming that
merits further improvement.
Conclusion
Although the frequency of spontaneous bleeding
did not di er signi cantly between healthy and
obese children, GBI was signi cantly higher in obese
children. us, obesity should be recognized as a
predisposing risk factor for gingival disease. is
interpretation is noteworthy for both the pediatrician
and the dentist who provide obese patients with
counseling regarding healthy diets in childhood and
adolescence.
Acknowledgments
e authors would like to thank the anonymous
reviewers for their valuable comments and
suggestions in improving the quality of the paper.
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