The Journal of Pediatrics
Volume 152, Issue 4 , Pages 451-452.e1, April 2008

Integrating Oral Health to the Care of Overweight Children: A Model of Care Whose Time Has Come

  • Sara G. Grossi, DDS, MS
    • ,
  • David N. Collier, MD, PhD, FAAP
    • ,
  • Ronald M. Perkin, MD, MA

      Affiliations

    • Corresponding Author InformationReprint requests: Ronald M. Perkin, MD, MA, Brody School of Medicine, East Carolina University, Department of Pediatrics, 600 Moye Blvd, Greenville, NC 27858-4353.

Department of Pediatrics, Brody School of Medicine, East Carolina University, Greenville, NC.

Article Outline

 

In response to the calls for action that dental caries is the most prevalent infectious disease in our nation’s children,1,2 the American Academy of Pediatrics (AAP) in partnership with the Federal Maternal and Child Health Bureau (MCHB), with the endorsement of the American Dental Association, the American Academy of Pediatric Dentistry, and supporting organizations such as Bright Futures, and other children’s health organizations have implemented the AAP Oral Health Initiative.2 The purpose of this program is to engage the pediatric community in addressing the need to increase oral health services to children and reduce oral health disparities. This program promotes improvement in children’s oral health by offering child health care professionals the tools and support they need to provide community-based collaborative care. The AAP policy statement recommends that pediatricians perform the Oral Health Risk Assessment and Establishment of the Dental Home by the age of 12 months. Along with these initiatives, advocacy campaigns supporting oral health in pediatric primary care have been implemented, resulting in increased awareness of the importance of oral health and, more importantly, that the medical community can play a significant role in reducing oral health disparities. This paradigm change in the relationship between medicine and dentistry, although still in its infancy, has swung the pendulum toward pediatricians working much more closely with dental professionals. However, a limitation in this partnership has been that children’s oral health has been regarded by the medical profession mostly as a tooth decay problem. Accordingly much of the participation of pediatricians in screening of oral disease has been limited to early dental caries and preventive measures have been largely limited to the fluoride varnish program. Much work remains to be done if we are to engage the medical community in oral health promotion and prevention of dental diseases in children.

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Obesity and Poor Oral Health 

Obesity and poor oral health are lifestyle-associated conditions, sharing similar health risk behaviors. Overweight children and adolescents may have adverse lifestyle behaviors such as unhealthy diet, rich in sugar and sweet foods and drinks, which promote both overweight and tooth decay. Poor diet with increase in caloric intake but reduced nutritional values are associated with excessive weight gain and poor oral health as well. The risk for periodontal disease is increased significantly with diets deficient in daily calcium3 and vitamin C.4 The increased risk was especially high for individuals younger than 20 years old, suggesting that calcium intake during the so-called calcium-building years is extremely important in growth and maturation not only of skeletal bone, but alveolar bone around teeth as well. Poor lifestyle habits such as lack of physical activity and exercise of overweight children are also comparable to poor habits of proper oral hygiene such as daily brushing and flossing. The depression and low self-esteem often seen in overweight children is another factor promoting and perpetuating negative self-behavior, leading to more unhealthy habits such as overeating and poor diet choices and less attention to basic hygiene and self-promoting habits. In addition, stress has been identified as a risk factor for periodontal disease and also plays a role in early fat deposition, overeating, and higher consumption of fat and a high-caloric diet.

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Obesity and Periodontal Disease 

Periodontal disease (gum disease) includes 2 distinct groups: gingivitis, which is a reversible inflammatory response to bacterial plaque; and periodontitis, which is an irreversible extension of the inflammatory process into the surrounding periodontal tissues. Periodontitis affects 10% of all adults and one-third of adults beyond the fifth decade of life.5 Although periodontitis is less frequent in children than adults, 2% to 5% of children and adolescents suffer from aggressive forms of early-onset periodontitis.6 Puberty gingivitis is the increased inflammatory gingival response to dental plaque mediated by the hormonal changes associated with puberty. Like dental caries, periodontitis is significantly more frequent in low-income and minority populations, who lack access to dental care and have more of the established risk factors such as poor oral hygiene, diet, ethnicity, and diabetes. Similar to type 2 diabetes, periodontitis, a disease of adults, is more commonly diagnosed in overweight children and adolescents than in their lean counterparts.

Obesity has been identified as an independent risk factor for periodontitis in adults from different ethnic origins and geographic distributions. The risk of periodontitis increased proportionally with increase in body mass index (BMI) from 25 to 30 and above compared with those with BMI ≤ 20 after adjustment for age, sex, oral hygiene, and smoking.6 The increased risk for periodontitis was especially significant in individuals with high waist-hip ratios. Multivariate models controlling for confounders of the relationship between periodontal disease and obesity such as age, sex, race and ethnicity, and smoking, indicate that obesity is a significant predictor for periodontal disease independent of the effect of confounders. Obesity-associated insulin resistance appears to mediate this relationship.7 In adolescents, the risk for periodontitis increased 6% with each 1-kg increase in body weight and 5% with each 1-cm increase in waist circumference.8 This suggests, that periodontitis is associated with central obesity in children, as well as adults, and that it may be a comorbidity of obesity originating early on in the cycle of obesity-related diseases.

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Mechanisms of the Relationship Between Obesity and Periodontal Disease 

The positive relationship between obesity and periodontal disease is mediated by a number of common factors, including non-causal mechanisms such as behavioral and adverse lifestyle factors, as well as biologic factors operative in host-parasite interactions and metabolic regulation. Obesity triggers the immune response generating a state of chronic subclinical systemic inflammation. An increased inflammatory state could set the stage for increased inflammatory response to oral pathogens leading to more severe periodontal disease. Periodontal disease has been associated with cardiovascular disease, diabetes, and insulin resistance; conditions that are believed to be exacerbated by high inflammatory tone. Levels of C-reactive protein are elevated in patients with periodontal disease, an indication of increased systemic inflammation, and periodontal treatment reduces these elevated levels.9 Abdominal adipocytes are highly active at secreting proinflammatory cytokines such as tumor necrosis factor (TNF)-α, which contribute to insulin resistance by inhibiting insulin signaling. Chronic subclinical inflammation has been reported as part of the insulin resistance syndrome.10 Chronic up-regulation of TNF-α production in response to lipopolysaccharide from Gram-negative bacteria in dental plaque has also been proposed as a contributing factor aggravating the state of insulin resistance. Chronic inflammation associated with periodontal infection would worsen the degree of insulin resistance in overweight individuals. Hence, the presence of periodontal infection in obese children may significantly increase their inflammatory burden, resulting in greater metabolic abnormalities.

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Integrating Oral Health to the Care of Overweight Children 

Obese and overweight children are at greater risk for dental caries and periodontal disease compared with normal-weight children of comparable age. Dental caries is associated with abnormal function, significant pain, loss of school days, and potentially life-threatening swelling. Periodontal disease in overweight children could increase the inflammatory burden, worsen the state of insulin resistance and metabolic dysregulation associated with obesity, and potentially interfere with the medical interventions applied to control obesity, as well as accelerate the development of type 2 diabetes. Providing screening, prevention, and treatment of oral diseases to overweight and obese children is an absolute necessity if we are to target children at high risk of oral and chronic disease. Even though most departments of pediatrics and childhood obesity centers currently lack the resources and infrastructure to provide the full range of preventive and treatment dental services required to manage this high-risk population, this should not discourage the medical profession from actively engaging in oral health promotion and disease prevention in this high-risk group. A number of simple, time-efficient, and inexpensive measures are available at our fingertips to help achieve these long-term goals. Pediatricians and other health care professionals engaged in treatment of overweight and obese children should develop the knowledge base to perform oral health risk assessments and include such assessments and oral examination for detection of oral diseases as an integral component of the comprehensive evaluation. Oral examination should include detection of early signs of caries and periodontal disease such as presence of white and brown spots on the enamel surface and presence of gingivitis. Asking the simple question “Do your gums bleed?” provides an effective screening for gingivitis. Referral for dental treatment early on will go a long way in reducing the need for more-extensive treatment. Pediatricians and child health care professionals can play an important role in advising obese children about good nutrition and diet habits that could reduce the risk of obesity and oral disease and about proper daily oral hygiene. Patients/parents should be questioned for frequency of dental care and referral, and establishment of a dental home should be insured in these patients. Health care providers engaged in treatment of overweight children should avail themselves of the opportunities for anticipatory guidance, risk reduction, disease suppression, and primary prevention of oral diseases in this high-risk population. Integration of oral health to the care of overweight and obese children, is within our reach. A critical component is the will and commitment of the pediatric profession to recognize the extent of the problem and the health consequences of failure to address it. Oral health in the overweight child is a significant health problem; solutions are within our reach that could translate in gains in overall health.

References available at www.jpeds.com

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References 

  1. US Department of Health and Human Services. Oral health in America: a report of the Surgeon General. Rockville, Md: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000;
  2. American Academy of Pediatrics, Oral Health PedsCare AAP Oral Health Initiative. http://www.aap.org/commpeds/dochs/oralhealth/pedsCare.cfmAccessed November 29, 2007
  3. Nishida M, Grossi SG, Dunford RG, Ho AW, Trevisan M, Genco RJ. Calcium and risk for periodontal disease. J Periodontol. 2000;71:1057–1066
  4. Nishida M, Grossi SG, Dunford RG, Ho AW, Trevisan M, Genco RJ. Dietary vitamin C and risk for periodontal disease. J Periodontol. 2000;71:1215–1223
  5. Jenkins WMM, Papapanou PN. Epidemiology of periodontal disease in children and adolescents. Periodontol. 2001;26:16–32
  6. Saito T, Shimazaki Y, Sakamoto M. Obesity and periodontitis. N Engl J Med. 1998;339:482–483
  7. Genco RJ, Grossi SG, Ho AW, Nishimura F, Murayama Y. A proposed model linking inflammation to obesity, diabetes, and periodontal infections. J Periodontol. 2005;76(Suppl):2075–2084
  8. Reeves AF, Rees JM, Schiff M, Hujoel P. Total body weight and waist circumference associated with chronic periodontitis among adolescents in the United States. Arch Pediatr Adolesc Med. 2006;160:894–899
  9. D’Aiuto F, Parkar M, Andreou G, Suvan J, Brett PM, Ready D, et al. Periodontitis and systemic inflammation: control of the local infection is associated with a reduction in serum inflammatory markers. J Dent Res. 2004;83:156–160
  10. Festa A, D’Agostino R, Howard G, Mykkanen L, Tracy RP, Haffner S. Chronic subclinical inflammation as part of the insulin resistance syndrome: The Insulin Resistance Atherosclerosis Study (IRAS). Circulation. 2000;102:42–47

PII: S0022-3476(07)01175-4

doi:10.1016/j.jpeds.2007.12.024

The Journal of Pediatrics
Volume 152, Issue 4 , Pages 451-452.e1, April 2008

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