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Table of Contents   
ORIGINAL RESEARCH  
Year : 2019  |  Volume : 30  |  Issue : 1  |  Page : 4-9
Reconnoitering the association between body mass index and oral health among elementary school children in Hyderabad, Telangana, India


1 Department of Public Health Dentistry, Government Dental College and Hospital, Hyderabad, Telangana, India
2 Department of Public Health Dentistry, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, JSS Medical Institutions Campus, Mysuru, Karnataka, India
3 Department of Orthodontics, Government Dental College and Hospital, Hyderabad, Telangana, India
4 Masters in Biomedical Sciences, Rutgers University, New Brunswick, NJ, USA
5 Food and Nutrition, Nagarjuna University, Vijayawada, Andhra Pradesh, India

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Date of Web Publication20-Mar-2019
 

   Abstract 

Objective: To evaluate the association between body mass index (BMI) and oral health status among elementary school children in Hyderabad, Telangana, India. Materials and Methods: This cross-sectional study was conducted among elementary school children selected from government, private-aided and private-unaided schools in Hyderabad. A stratified cluster random sampling technique was used to select study participants. All parents were requested to be personally present on the day of examination. All eligible children were assembled in a hall and their height in inches and weight in kilograms were recorded by two calibrated investigators. The oral health status of children was assessed using a predesigned oral health assessment proforma. Plaque status was assessed using Sillness and Loe plaque Index and caries using decayed and filled teeth (dft) by a trained and calibrated investigator. Results: One hundred and seventy-one children (89 males and 82 females) were included in the present study. Mean plaque score was 1.4 ± 0.6 with no significant difference in the mean plaque score between children in three different categories of nutritional status (P = 0.07). Mean dft among primary teeth was 1.1 ± 1.1 with a significantly higher score among children who were malnourished (2.4 ± 0.9) compared to children who were overweight (0.9 ± 0.9) and normal (0.4 ± 0.6) (P < 0.001). Conclusion: BMI was negatively associated with caries experience in primary dentition with no association with plaque scores. Overweight children with malnutrition had significantly higher caries experience compared to children with normal BMI.

Keywords: Body mass index, dental caries, dental plaque, malnutrition, overweight

How to cite this article:
Sukhabogi JR, Chandra Shekar B R, Ramana I V, Kumar G S, Harita N, Annapoorna G. Reconnoitering the association between body mass index and oral health among elementary school children in Hyderabad, Telangana, India. Indian J Dent Res 2019;30:4-9

How to cite this URL:
Sukhabogi JR, Chandra Shekar B R, Ramana I V, Kumar G S, Harita N, Annapoorna G. Reconnoitering the association between body mass index and oral health among elementary school children in Hyderabad, Telangana, India. Indian J Dent Res [serial online] 2019 [cited 2019 Jun 16];30:4-9. Available from: http://www.ijdr.in/text.asp?2019/30/1/4/254527

   Introduction Top


Nutrition plays a vital role in physical, mental and emotional development of children.[1] Providing a balanced diet that meets the daily requirements of macro and micronutrients to growing children is very essential to prevent malnutrition and at times, even over nutrition, leading to obesity.[2] Malnutrition continues to be a major public health problem in most developing countries.[3] It is considered an important risk factor for a large proportion of illness and death among preschool children.[4] Evidence suggests prevalence of under-nutrition among under-five year old children to be high and varied widely (under-weight: 39–75%, stunting: 15.4–74%, wasting: 10.6–42.3%), depending on the method used for assessment.[2] Malnutrition refers to under nutrition and over nutrition, ranging from severe nutrient deficiencies to extreme obesity.[5] Eighty percent of the world's malnourished children live in developing countries, with India housing nearly 60 million children who are malnourished.[6] 48% children who are less than five years in India at present are chronically malnourished with 43% being underweight. 54% of all deaths prior to age five in India could be attributed to malnutrition.[6],[7] Malnutrition during early stages in life can lead to vitamin D deficiency, which, in turn, leads to hypo calcification of teeth.[8],[9] Hypo calcified teeth are at a higher risk for development of caries compared to teeth that are normally calcified.[10],[11]

On the other side of this nutritional imbalance, childhood obesity is currently one of the most common health problems in numerous countries, attributed to eating habits and sedentary lifestyles, which can lead to a high prevalence of non-communicable diseases such as diabetes, hypertension, and cardiovascular diseases.[12] Evidence suggests that dental caries have a positive association with obesity.[13] Literature also suggests preschool children with a low body mass index to be at significantly higher risk for dental caries[14] while some studies found no association between childhood obesity and dental caries.[15] Oral hygiene status, which is one of the predisposing factors for dental caries, was found to be poor among government school children compared to private school children in a study conducted in Andhra Pradesh. Prevalence of dental caries was also high among government school children who had poor nutritional status compared to private school children in this study.[16]

Preceding discussion on the relationship between nutritional status and dental caries suggest that malnutrition which could manifest as either malnourishment or obesity on either extremes of nutritional status can both lead to increased risk of dental caries.[8],[9],[10],[11],[12],[13],[14] However, literature is divided on this relationship with a few studies finding no such relationship.[15] Moreover, literature evaluating the association between body mass index and oral health parameters among Indian pre-school children is scanty. Hence, the present study was undertaken to assess the association between nutritional status and oral health among elementary school children in Hyderabad, Telangana, India.


   Materials and Methods Top


This cross-sectional study was conducted among elementary schoolchildren selected from three different schools in Hyderabad, over a period of six months from November 2015 to April 2016 at Osmania Dental College and Hospital, Hyderabad. Ethical clearance was obtained from Institutional Ethics Committee, Osmania Dental College and Hospital, Hyderabad vide reference number GDC and H/PHD/0018/2015. Permission to conduct the study was obtained from the concerned school authorities after explaining the research protocol. Informed consent was obtained from parents of selected school children through an information sheet communicated to parents through the school system.

A stratified cluster random sampling technique was used to select study participants. A list of all elementary schools in Hyderabad was obtained from the district education department. Schools were further stratified into government, private-aided and private-unaided schools. One school each category was selected using lottery method. All elementary school children aged 3–6 years who fulfilled eligibility criteria were considered for the study.

Inclusion criteria

  1. Children with informed consent signed by their parents
  2. Children whose parents were available to provide details on oral hygiene habits on the scheduled day of clinical assessment
  3. Children cooperating for clinical oral examination.


Exclusion criteria

  1. Children with physical and mental disabilities
  2. Children absent on the scheduled day of visit.


Dates of visit to each school were scheduled after coordinating with school authorities. The class teachers were requested to communicate to the parents with regard to obtaining signed informed consent before the scheduled visit. All parents were requested to be personally present on the day of examination. All eligible children were assembled in a hall and their height in inches and weight in kilograms were recorded by two calibrated investigators. Then, oral health status of the children was assessed using a predesigned oral health assessment proforma. It had three sections. The first section contained basic demographic details, the second section contained information on oral hygiene aids used and oral hygiene practices which were filled after discussing with parents by two trained investigators and the third section contained information on plaque and dental caries status. Plaque status was assessed using Sillness and Loe plaque Index.[17] Simplified version with six index teeth in primary dentition was considered in view of children being very young and anticipating some degree of non-cooperation for prolonged clinical examination. The index teeth were 55 (primary maxillary right second molar), 52 (primary maxillary right lateral incisor), 64 (primary maxillary left first molar), 75 (primary mandibular left second molar), 72 (primary mandibular left lateral incisor), and 84 (primary mandibular right first molar). Dental caries was assessed using dft index (decayed and filled primary teeth, Grubbel 1944).[18] Caries was diagnosed to be present if there was visible loss of tooth substance without the characteristics of a developmental defect and in pits and fissures when the point of the probe 'caught' upon gentle pressure. The assessment for plaque and dental caries was done by a trained and calibrated public health dentist using mouth mirror and explorer on a chair under adequate natural day light. Type 3 examination was used for assessing dental caries and plaque status. Mouth mirror, explorer and a torch were used for illumination of the area when the oral examination was carried out. Teeth were dried using a chip blower before examination was done for dental caries. The calibration of investigator for assessment of plaque and dft score was carried out on a group of 10 students in the department. All ten students were initially assessed for plaque and caries status by the investigator and data was recorded on the data sheet. Then, repeat examination of these children was done two hours after their baseline examination in the same visit. Participants in second examination were distributed in a different order. Cronbach's alpha for intra examiner reliability was found to be 0.87 and 0.98 for plaque and dft respectively.

The body mass index of each subject was calculated and compared with age and gender using Center for Disease Control and Prevention (CDC) pediatric growth charts. Based on these growth charts, the sample population was distributed into three groups: Group I: Normal weight (5th–85th percentiles), Group II: Risk of overweight/obese (>85th percentile), and Group III: Underweight (<5th percentile).[19]

Data was analyzed using SPSS version 22 (IBM, Chicago). Quantitative data was presented as mean and standard deviation while qualitative data was expressed in frequencies and percentages. Plaque and caries status between the three categories was compared using one-way ANOVA and Tukey's post hoc test. Pearson's correlation coefficient and simple linear regression were used to identify the association between age, gender, type of school, oral hygiene methods, the body mass index with plaque and caries status. Statistical significance was fixed at 0.05.


   Results Top


A total of 171 children (89 males and 82 females) were included in the present study. Among them, 52 children were from government school, 59 were from private aided and 60 were from private unaided school. There was no significant difference in the age and gender distribution of school children in different schools [P = 0.36, [Table 1]. A significantly higher proportion of males in the present study were either malnourished (23.6%) or overweight (58.4) compared to females [P = 0.02, [Table 2].
Table 1: Distribution of children in relation to age, gender and type of school

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Table 2: Association between gender, type of school with nutritional status

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Mean plaque score among school children in the present study was 1.4 ± 0.6. We found no significant difference in the mean plaque score between children in three different categories of nutritional status (P = 0.07). However, mean plaque score was significantly higher among children considered to be normal (1.4 ± 0.4) compared to those who were either malnourished (1.1 ± 0.7) or overweight (0.9 ± 0.4) when a separate analysis was carried out among children from private aided schools (P < 0.001). Mean decayed primary teeth among children was 0.8 ± 0.9. Mean decayed component was significantly higher among malnourished children (1.8 ± 0.9), followed by overweight (0.7 ± 0.8) and normal children (0.7 ± 0.8) (P = 0.001). Mean number of primary filled teeth in the study population was 0.3 ± 0.5. Mean filled component was significantly higher in malnourished children (0.5 ± 0.5) compared to children who were either normal (0.1 ± 0.3) or overweight (0.3 ± 0.6) (P = 0.001). Mean dft among primary teeth was 1.1 ± 1.1 with a significantly higher score among children who were malnourished (2.4 ± 0.9) compared to children who were overweight (0.9 ± 0.9) and normal (0.4 ± 0.6) [P < 0.001, [Table 3].
Table 3: Association of nutritional status with plaque and decayed and filled teeth scores

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Prevalence of dental caries among children in the present study was 62%. Prevalence of dental caries was significantly higher among malnourished children (100%) compared to children considered to be normal (37%) and overweight, (60.4%) [P < 0.001, [Table 4]].
Table 4: Caries prevalence in relation to nutritional status among study participants

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Among age, gender, type of school, father's occupation, mother's occupation, oral hygiene habits and nutritional status. Only age was significant predictor of plaque core (P = 0.05). 9% of variance in plaque score was explained by these factors [Table 5]. Among age, gender, type of school, father's occupation, mother's occupation, oral hygiene habits and nutritional status. Only nutritional status was a significant predictor of dft core (P < 0.001). 19% of variance in dft score was explained by these factors [Table 6].
Table 5: Summary of correlation and regression analysis on the association of demographic factors, oral hygiene practices, nutritional status with plaque status among children

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Table 6: Summary of correlation and regression analysis on the association of demographic factors, oral hygiene practices, nutritional status with caries experience (decayed and filled teeth) among children

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   Discussion Top


Malnutrition is multifactorial, having an early onset. It may occur during the intrauterine life or childhood, or at a later stage due to poor nutrition.[20] Malnutrition is reported to exert multiple effects on oral tissues and onset of oral diseases. It affects development progression of oral diseases through an altered tissue homeostasis, a reduced resistance to the microbial biofilms and a reduced tissue repair capacity.[21] Deficiencies of vitamin A and D and protein energy malnutrition (PEM) have been proposed to induce enamel hypoplasia. Development of caries requires sugars, bacteria, tooth susceptibility, bacterial profile, quantity and quality of saliva, and duration for which fermentable carbohydrates are available to bacteria.[22]

This study assessed the association between body mass index as indicator of nutritional status with plaque and caries status among elementary school children in Telangana. Study found no significant difference in mean plaque score among participants classified into malnourished, normal and overweight highlighting the fact that plaque score depends more on oral hygiene than nutritional status. However, mean dft was significantly higher among participants who were malnourished compared to those who were overweight. Children with normal body mass index had the least caries experience. This clearly demonstrates that both malnourished and overweight children are at higher risk for dental caries. High caries experience among malnourished children could be hypoplastic teeth in them. Infante et al.[23] found a positive association between linear enamel hypoplasia and caries experience in primary dentition among undernourished Guatemalan children. Another study among Indian children found moderate to severe PEM to be associated with reduced salivary flow, reduced buffering capacity, lower calcium levels, lower protein in stimulated saliva, and reduced agglutinating defense factors in unstimulated saliva.[24] These salivary factors also could have contributed to high caries experience among malnourished children similar to the results of many other studies.[3],[25] Moreover, socioeconomic status is an important parameter that can be linked to both dental caries and nutritional status. Studies have shown dental caries to be significantly higher in low socio-economic status groups who also tend to have poor nutritional status and poor awareness towards oral health.[26],[27] A study by Shailee S et al. (2013) found a higher caries experience among children attending government schools.[16],[28] High caries experience among lower socioeconomic groups could be attributed to lack of awareness, affordability, or underutilization of dental care facilities.

Consumption of junk food, mainly refined carbohydrates at frequent intervals, could have contributed to high caries risk among children who were overweight. Our results were in agreement with a study by Alswat et al.[29] who found significant positive association between the body mass index and DMFT after controlling for potential confounders such as smoking and brushing habits. However, a systematic review by Silva AE[30] did not find sufficient evidence on the association between obesity and dental caries. They concluded that the evidence did not clarify the possible role of diet and other possible effect modifiers on this association.

Strengths and limitations

This study assessed the relationship between body mass index and caries among elementary school children from three different school types which represent three different socio-economic strata. Simple regression analysis found the body mass index to be a significant predictor of caries.

The study was conducted among children from three elementary schools. The sample size was too small to make all subgroup analysis meaningful. Moreover, frequency of sweet intake was not assessed in the present study along with fluoride exposure which can act as confounders.


   Conclusion Top


The study found the body mass index to be negatively associated with caries experience in primary dentition with no association with plaque scores. Overweight children with malnutrition had significantly higher caries experience compared to children with normal body mass index. This highlights the importance of maintaining proper nutritional status with appropriate dietary habits. Diet counseling aimed at motivating adoption of healthy food habits can become effective if adverse consequences of junk foods on nutritional imbalance are highlighted which could severely affect health and dental health adversely.

Acknowledgements

We sincerely thank all the study participants and school authorities for their kind cooperation and at different stages of this project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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[PUBMED]  [Full text]  
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Correspondence Address:
Dr. Jagadeeswara Rao Sukhabogi
Department of Public Health Dentistry, Government Dental College and Hospital, Afzalgunj, Hyderabad - 500 012, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_714_17

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