Obesity and Periodontal Health: What’s the link? Should I be concerned?

by Wendy E. Ward1, B. Arts & Sci. (Hons), MSc, PhD & Peter C. Fritz1-3, BSc, DDS, FRCD(C), PhD (Perio),

Are the waistlines of your patients changing? Are your patients heavier than they were 10 years ago? Canadian statistics suggest that the answer is a resounding “yes”. Over the past 20 years, the percent of men and women who are obese has increased by 8-10%. The latest estimate is that almost 25% of all Canadians, both men and women, are obese. These data were determined from reported findings from the Canadian Health Measures Survey.1 This survey is designed such that all Canadians–whether healthy or not–are represented and thus findings from this survey closely resemble the “actual” health of Canadians. The overall aim of the survey is to determine relationships between disease risk factors and health status, providing health researchers with valuable information to understand and develop strategies to counter the health issues facing Canadians. While obesity is well established to be a risk factor for development of chronic diseases such as cardiovascular disease and type II diabetes, other researchers have specifically investigated the relationship between obesity and periodontal health. Many studies are showing that obesity is associated with greater risk of developing periodontal disease.2-7 Before reviewing these findings, let us first review how obesity is determined.

How Is Obesity Determined?
Obesity can be determined by calculating the Body Mass Index (BMI) of an individual. BMI is a measure of body fat, based on the body weight and height of an adult man or woman. To calculate BMI, you need to know body weight (in kilograms) and height (in meters). BMI is then calculated using the following equation:

BMI = Body Weight (kg)/Height (m2)

As shown in Table 1, BMI is categorized as obese, overweight, normal weight and underweight. Within the obese category, there are three classifications of obesity. Being obese and having other risk factors that may be associated with heavier body weight, puts an individual at risk of many chronic diseases, particularly heart disease. These other risk factors may include hypertension; high or uncontrolled blood glucose and an unhealthy blood lipid profile (high LDL cholesterol, low HDL cholesterol and/or high triglycerides). BMI classifications are not ideal for everyone but continues to be used to guide health recommendations. Other measures of obesity (or adiposity) include waist circumference (WC) or waist-to-hip ratio (WHR). Both measure abdominal fat and are good predictors of an individual’s risk for heart disease, stroke, high blood pressure, high blood cholesterol and Type 2 diabetes. Differences in body fat distribution among individuals are sometimes described as “apple-shaped” to identify an individual with greater abdominal obesity as opposed to a “pear-shaped” individual who carries more fat in their hips. “Apple-shaped” is associated with greater health risks. In men and women, WC less than 102cm (or 40 inches) or 88cm (or 35 inches), respectively, is recommended. Lower cut-offs are recommended for some ethnic groups. With respect to WHR, men and women should have a WHR less than 0.9 or 0.85, respectively, to reduce risk of developing a chronic disease. Studies investigating links between obesity and periodontal disease have used one or more of these measures to define obesity.

Obesity Is A Risk Factor For Periodontal Disease
Findings from prospective studies have provided some of the strongest evidence linking obesity and periodontal disease. In these studies, subjects did not have periodontal disease at time of enrollment in the study. A 5-year prospective study demonstrated that both men and women with a BMI over 30, regardless of smoking status or diabetes, had a greater risk of developing periodontal disease than individuals with healthy body weight.2 Moreover, even overweight women (BMI = 25-29.9, Table 1) had a greater risk of developing periodontal disease than healthy weight women,2 identifying that even a higher BMI that is not classified as “obese” also raises the risk of periodontal disease. The Health Professional Follow-Up Study, also a prospective study but included only men, showed that males classified as “obese” by BMI, WC or WHR were at greater risk of developing periodontal disease over the follow-up period than males with healthy BMI, WC or WHR.3 Moreover, this study showed significant trends for greater occurrences of periodontal disease with increasing BMI, WC and WHR.3 That these relationships persisted in subjects without diabetes and non-smokers strongly supports the role of obesity in periodontal disease development.

Data from cross-sectional studies support the findings from prospective studies.4–7 Data from the National Health and Nutrition Examination Survey (NHANES) in the U.S., showed that greater BMI and WHR was associated with periodontitis, by measuring periodontal attachment loss, pocket depth, gingival bleeding and calculus index.4 Findings from the Health 2000 Health Examination Survey in Finland showed that obese BMI was associated with greater periodontal infection, measured by number of teeth with deepened periodontal pockets (4mm or deeper), in non-smokers.5 Similar findings were shown in this same population when smokers were included in the overall analysis.6 A study in women demonstrated that being obese or overweight was associated with poorer periodontal health: more bleeding on probing, greater probing depth, and greater clinical attachment loss.7 It is known that obese individuals may also have other risk factors for periodontal disease such as smoking and/or Type 2 diabetes, and interestingly, the studies discussed have accounted for these factors in the statistical analyses and in many studies, the relationship between obesity and periodontal disease remains.

How Does Obesity Contribute To Periodontal Disease?
The exact mechanism by which obesity contributes to periodontal disease is unknown. It is generally believed that fat (adipose) tissue promotes a more proinflammatory state, and that when fat cells (adipocytes) increase in size, recruitment of macrophages occurs and stimulates the production of soluble proinflammatory mediators (interleukin-6, tumor necrosis factor-alpha) and adipokines (leptin, adiponectin, plasminogen activator inhibitor-1) that may contribute to periodontal disease. With greater amounts of adipose tissue, production of such mediators may be higher. Indeed, individuals with higher BMI and WHR can have elevated levels of proinflammatory markers including C-reactive protein, fibrinogen and leukocytes.8,9 Release of proinflammatory mediators by adipose tissue may signal release of acute phase proteins from the liver such as C-reactive protein, a marker of whole body inflammation.

Yes, Dentists Should Be Concerned Aabout Obesity In A Patient
Just as smoking and uncontrolled blood glucose are significant risk factors for developing periodontal disease, there are a substantial number of studies that identify obesity, or “overweight BMI” as a risk factor for periodontal disease. Further studies are needed to clearly identify how gender or age may modify this relationship. Regardless, based on current evidence, being cognizant that obesity may predispose your patient to periodontal disease is prudent. Communicating to patients that a healthy body weight, in addition to reducing risks of chronic diseases such as heart disease and associated risk factors (high blood pressure, high LDL and/or triglycerides, low HDL, smoking, physical inactivity), is also linked to better oral health is an important step in guiding patients to a healthier lifestyle. BMI, WC and/or WHR can be easily measured at a patient visit. Practical guidance and online links to useful resources to help patients achieve healthier body weights is provided in the next section.10–14

Take Home Points and Reso
urces for Your Patients

• Attaining and maintaining a healthy body weight (or BMI, WC or WHR) is critical for overall health and this includes oral health, particularly periodontal health.

• Poor oral health and/or missing teeth, is associated with lower nutritional status and heavier body weight.

• Achieve a healthy or healthier BMI, WC and WHR through diet modification and incorporating appropriate physical activity.

• Be sure to have realistic goals and expectations of yourself!

• Remember that even small changes in body weight–5 to 10% of current weight–can be beneficial to your health and lower the risk of chronic diseases.

• The Heart and Stroke Foundation has developed useful resources to achieve a healthy weight through diet and physical activity.10

* Diet modification:

• Consult the guidance provided through Health Canada’s “Eating Well with Canada’s Food Guide” that can be customized by age and gender.11

• Be mindful of serving size.12

• Keep a food diary so you can track your food choices and quantities

• Plan your meals and coordinate grocery purchases

• Join a weight loss program after consulting with a health professional. Hire a dietitian to set meal plans and goals.13

• Avoid fad diets (remember the adage “if it is too good to be true, it probably is”)

* Incorporate regular physical activity:14

• The Canadian Physical Activity Guidelines provide evidence-based guidelines for health promotion and chronic disease prevention with age appropriate levels of physical activity. These guidelines are specific for 5 different life stages: adults age 18-64 years and over age 64 years as well as younger ages (0-4 years, 5-11 years and 12-17 years of age).

• Multiple types of exercise–strength training, weight-bearing aerobic, flexibility, and stability/balance exercises–are important for healthy living and chronic disease prevention. Adults age 18 years and older should:

– accumulate 150 minutes of moderate-to-vigorous-intensity aerobic physical activity per week, in bouts of 10 minutes or more (a few examples: brisk walking, bike riding, jogging, swimming, cross-country skiing)

– perform muscle and bone strengthening activities using major muscle groups at least 2 times per week.

• Figure out what works with your lifestyle and stage of life. i.e. gym/club membership, setting up a home-gym, outdoor activities. Consider hiring a personal trainer, finding a workout partner or group, activities to do with the family.

• Find a program of activities that you will like, it will make it easier to keep with the program over the long-term.OH

1Center for Bone and Muscle Health, Faculty of Applied Health Sciences, Brock University, 500 Glenridge Avenue, WC262, St. Catharines, Ontario, Canada, L2S 3A1. Phone: 905 688 5550 X3024, Fax: 905 688 8364 wward@brocku.ca

2Reconstructive Periodontics and Implant Surgery, 165 Highway 20 West, Suite One, Fonthill, Ontario, Canada L0S 1E5.

3Staff Periodontist, Niagara Health System Phone: 905 892 0800, Fax: 905 892 0005 peter.fritz@utoronto.ca

Oral Health welcomes this original article.


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10. Your Health, Your Weight: simple steps to making healthy choices. Heart and Stroke Foundation of Canada. (accessed August 27, 2012). http://www.heartandstroke.com/atf/cf/{99452D8B-E7F1-4BD6-A57D-B136CE6C95BF}/Your-health-your-weight-en.pdf

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12. Aim for a Healthy Weight: Keep an eye on portion size. U.S. Department of Human Health and Services, National Institutes of Health. (accessed August 27, 2012) http://www.nhlbi.nih.gov/health/public/heart/obesity/PortionSize_ZCard_taggd.pdf

13. Dietitians of Canada (accessed August 27, 2012) http://www.dietitians.ca

14. Canadian Physical Activity Guidelines, Canadian Society for Exercise Physiology. (accessed August 27, 2012) http://www.csep.ca/english/view.asp?x=804