|Year : 2014 | Volume
| Issue : 3 | Page : 197-201
Reconnoitring the association of nutritional status with oral health in elementary school-going children of Ghaziabad City, North India
Shveta Sood, Vipin Ahuja, Swati Chowdhry
Department of Pedodontics and Preventive Dentistry, Manav Rachna Dental College, Faridabad, Haryana, India
|Date of Web Publication||2-Jul-2014|
Department of Pedodontics and Preventive Dentistry, Manav Rachna Dental College, Faridabad, Haryana - 121 001
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Purpose: The purpose of this study was to evaluate the association between anthropometric measurements and oral health status in the primary dentition of school-going children. Materials and Methods: In this study, 280 elementary school children (116 girls and 164 boys, age: 3-6 years) were examined. Body mass index (BMI) of each subject was calculated and compared with age and gender using Centers 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 (5 th -85 th percentiles), Group II: Risk of overweight/obese (>85 th percentile), and Group III: Underweight (<5 th percentile). Each subject was examined for caries frequency (decayed and filled primary teeth (dft) values) and plaque status (plaque index (PI)) and these values were compared with their BMI figures. Results: Among the study group, 58.3% of children were suffering from malnutrition. Out of the total population, 33.9% had caries affecting their primary dentition. The largest section (39.5%) of caries affected children was underweight. The mean number of dft in Group II was highest at 1.47 ± 2.77 followed by Groups I and III, respectively. The mean value of PI in Group III was highest at 0.33 ± 0.53 followed by Groups II and I. Conclusions: A definite correlation was observed between the oral health status and BMI of elementary school-going children.
Keywords: Body mass index, dft index, malnutrition, oral health, primary dentition, plaque index
|How to cite this article:|
Sood S, Ahuja V, Chowdhry S. Reconnoitring the association of nutritional status with oral health in elementary school-going children of Ghaziabad City, North India. J Indian Soc Pedod Prev Dent 2014;32:197-201
|How to cite this URL:|
Sood S, Ahuja V, Chowdhry S. Reconnoitring the association of nutritional status with oral health in elementary school-going children of Ghaziabad City, North India. J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2020 Aug 14];32:197-201. Available from: http://www.jisppd.com/text.asp?2014/32/3/197/135824
| Introduction|| |
Nutrition has an unimaginable impact on our overall health including oral health. Nutritious diet is of paramount importance especially during the initial years of growth and development. An assessment of nutritional status using anthropometric measurements provides information on the growth and body composition. Obtaining and analyzing this data gives us valuable information for categorizing children as underweight, normal, and overweight/obese. Childhood nutrition is an extremely significant social issue and requires a comprehensive, integrated management.
Oral health and nutrition share an interdependent relationship. Malnutrition may affect tooth development, tooth eruption time, and it may exacerbate periodontal and oral infectious diseases. However, the most significant effect of nutrition on teeth is the local action of diet in the mouth and development of oral biofilm and dental caries. 
Over the last 40 years, the primary focus of oral healthcare has been the prevention of dental caries in children with an emphasis on dietary influences on plaque formation. The oral cavity contains the only known anatomical aspect of the human body that does not have a regulated system of shedding surfaces: The teeth. So, constant accumulation of oral microbial flora on these non-shedding hard tissues leads to the formation of dental plaque.  Bacteria in the plaque use carbohydrates to produce acid which causes demineralization leading to dental caries. This action depends upon the sustainability and adherence of plaque on the hard tissues of the oral cavity. 
Despite improved trends in levels of dental caries in developed countries, there is a high prevalence rate of dental caries in some developing countries.  Dental caries have a considerable impact on self-esteem and quality of life and is a costly burden. In animals, it is well-documented that early malnutrition affects tooth development and eruption and later results in increased incidence of biofilm deposits and dental decay. 
Many studies have been conducted to compare either BMI with dental caries or with oral hygiene status in children. But till date, no study has compared both these parameters together with BMI in primary dentition age group using Centers for Disease Control and Prevention (CDC) growth charts. Therefore, our study is an attempt to understand the association between nutritional status and oral health in primary dentition.
| Materials and Methods|| |
In this study, 280 elementary school children (116 girls and 164 boys, age: 3-6 years) were examined. Two independent examiners from the Department of Pedodontics and Preventive Dentistry, Krishna Dental College, Ghaziabad recorded the height and weight of each subject individually and the mean value of both was calculated. Height was measured using a stadiometer by having the subject standing erect without shoes. The weight was measured with a portable digital scale, and the weight was always rounded off to the nearest 100-g value. Body mass index (BMI) was calculated using the following formula: Weight in kg/(height in meters) square (kg/m 2 ). The BMI, an anthropometric index of weight and height was then compared with gender and age ranked percentages using the CDC pediatric growth charts [Figure 1] and [Figure 2]. According to the recommendations by the WHO Expert Committee on Physical Status, cutoffs of BMI-for-age values are as follows: BMI-for-age at or above 95 percentile were considered overweight, BMI-for-age between 85 th and 95 th percentiles were considered risk of overweight, BMI-for-age less than 5 th percentile were considered underweight, and BMI-for-age between 5 th and 85 th percentiles were considered under normal weight category.  The BMI-for-age was plotted for each and every subject on the growth charts as standardized by CDC and a database was created.  Based on these growth charts, the sample population was distributed into three groups:
|Table 1: Descriptive statistics showing gender variation among the three groups|
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Group I: Normal weight (5 th -85 th percentiles)
Group II: Risk of overweight/obese (>85 th percentile)
Group III: Underweight (<5 th percentile)
The dental examination included the determination of plaque status (plaque index (PI)) and caries experience (decayed and filled primary teeth (dft) values). Examination of the subjects only took place with the written consent of the parents and/or guardian. The dental examination was Type 3,  that is, non-invasive (mirror, probe, and cotton roll), and included optimal illumination of the oral cavity. After establishing a dry field with cotton balls and wads, the condition of the teeth was examined and recorded. PI given by Sillness and Loe in 1964  was recorded for every subject. Index teeth selected were 55, 52, 64, 75, 72, and 84. If the index tooth was absent, then the tooth distal to it was considered or only five teeth were considered. Each index tooth was divided into four surfaces, mesiofacial, facial, distofacial, and palatal/lingual for scoring. The plaque score for each tooth was calculated by adding the plaque scores of the four surfaces and dividing it by four. The PI for each subject was calculated by adding the individual scores of all the index teeth and dividing by the total number of index teeth examined.
The 'dft' index was given by Grubbel in 1944.  Decayed deciduous teeth that were in need of treatment, were marked as cavities. These carious teeth as well as restored teeth with secondary caries or caries on another surface were marked as 'd'. Teeth with restorations without any recurrent decay were marked as 'f'. Missing teeth were not marked correspondingly, since no definite statement could be made without a proper anamnesis whether the tooth really existed, or if an early extraction had taken place. Due to missing indication criteria, no X-rays were taken. To detect the caries frequency the dft value was used, since it gives a good insight into the state of decay in the patient. The findings always referred to the respective tooth (dft value), not to the tooth surface (dfs value).
Results were expressed as mean ± standard deviation, range, and percentages. Categorical data was analyzed via the chi-square and Fisher's exact tests. For all tests, a P-value of 0.05 or less was considered statistically significant.
| Results|| |
Two hundred and eighty elementary school-going children participated in our study, out of which 164 were boys and 116 were girls. In Group II (obese group), 74.7% were boys and 25.3% were girls. In Group III (underweight group), 44.2% were boys and 55.8% were girls. The differences between the gender values among the three groups were significant (chi-square value = 15.71, P = 0.00, S) [Table 1].
A large proportion of the study population suffered from abnormal nutritional status, accounting for 58.3% of total subjects; 28.21% were overweight and obese, 30.7% underweight, and 41.7% had normal nutritional status. Of the total subjects, 66.1% were free from caries, while 33.9% of them suffered from caries in the primary dentition. There was a significant negative correlation between nutritional status and total number of subjects suffering from caries. Out of the total population suffering from caries, 39.5% fell under Group III (underweight) followed by Group II (obese) and Group I (normal). However, the values are not statistically significant (chi-square value = 2.19, P = 0.34) [Table 2].
|Table 2: Descriptive statistics showing mean and standard deviation for the comparison of dental caries experience (dft index) among the various groups|
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The mean number of dft in primary dentition in the total study is 1.45 ± 2.96 per person. The mean number of dft in Group I (normal group) was 1.45 ± 3.28. The mean number of dft in Group II (obese group) was 1.47 ± 2.77. The mean number of dft in Group III (underweight group) was 1.42 ± 2.68.
The differences between the mean dft values among the three groups were not significant (P = 0.99, NS) [Table 3].
|Table 3: Descriptive statistics showing mean and standard deviation for the comparison of mean dft values (df index) and mean plaque scores (PI index) among the various groups|
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The mean number of plaque score (PI) in primary dentition in the total study is 0.30 ± 0.53 per person. The mean number of PI in Group I (normal group) was 0.29 ± 0.53. The mean number of PI in Group II (obese group) was 0.29 ± 0.53. The mean number of PI in Group III (underweight group) was 0.33 ± 0.53. The differences between the PI values among the three groups were not significant (P = 0.86, NS) [Table 3].
| Discussion|| |
Current research projects worldwide aim to explore and understand the controversial association between general and oral health. Our study is a step further in this endeavor. Malnutrition both in the form of underweight and obesity is a haunting health problem affecting an increasing statistics of children worldwide. The World Bank estimates that India is ranked second in the world for the number of children suffering from malnutrition after Bangladesh. The prevalence of underweight children in India is among the highest in the world, and is nearly double that of sub-Saharan Africa.  In our study, 58.92% of the subjects suffered from malnutrition, 28.21% were obese, and 30.71% were underweight. We found that obesity was affecting boys more when compared to girls and these findings were found similar to a study done by Serdula et al.  More girls were found to fall under the underweight category when compared to boys and these findings coincide with statistics appraisal given by Government of India in 2012. 
Dental caries is the most widespread multifactorial infectious disease affecting the oral cavity. In our study, 33.9% of subjects suffered caries and 66.1% were caries-free. This cross-sectional study demonstrated nonsignificant relationships between nutritional status and oral health among the study subjects. Similar observations were found in studies, where it has been reported that children with low BMI may be at risk of caries development. A systematic review by Hooley et al., throws a light on the fact that 48% of studies found no association between dental caries and BMI. However, the maximum numbers of children suffering from dental caries were found in the underweight category. Similar observations were found in studies, where it has been reported that children with low BMI may be at risk of caries development.  Hooley et al., highlighted that there is an inverse relationship between dental caries and BMI from studies done in developing countries.  Animal studies have shown that early malnutrition affects tooth structure, delays tooth eruption, and results in increased dental caries.  It has been suggested that early malnutrition may produce defects in teeth during the period of development so that they are more susceptible to subsequent dental caries after eruption. ,,,
However, the mean number of dft in the obese group was highest at 1.47 ± 2.77 when compared to the mean number of dft in the underweight group, which was 1.42 ± 2.68. Given the causative relation between refined carbohydrates and dental caries, it is appropriate to hypothesize that overweight might also be a marker for dental caries in children of developing age group. Negative changes in eating and activity patterns, increased frequency of snacking, and increased consumption of fermentable carbohydrates are common in both obesity and caries in children. 
The mean number of plaque score (PI) in primary dentition in our study is 0.30 ± 0.53 per person. The differences between the PI values among the three groups were not significant, which proves that nutrition has a nonsignificant effect on plaque formation. In our study, the mean PI falls into the category of fair to good score, which may not only be a reflection of the socioeconomic background, where parents/guardians are able to buy toothbrushes and toothpastes, but also the education of parents which includes dental awareness regarding regular brushing of teeth at least once a day.
There is evidence that oral health is associated with BMI, although the precise nature of these associations remains unclear. It has been supported by previous studies that multifarious factors like socioeconomic status, parental education level, ethnicity, access to services and support, and exposure to fermentable carbohydrates are involved in the development of plaque and caries. , We recommend future research and a comprehensive, multidisciplinary approach to explore various factors that mediate the association between BMI and dental caries.
| Conclusion|| |
The findings of this study indicate an association between BMI and dental caries and plaque aggregation supporting the fact that malnourished individuals are at risk of developing more plaque and caries. This emphasizes the fact that dentists have the opportunity to be among the first ones to interconnect and create awareness regarding nutritional imbalance and oral health. Dental professionals, especially pediatric dentists, should therefore thoroughly evaluate the relationship between body composition and oral health, in order to provide the best service for pediatric patients, and should also counsel caretakers on nutrition and diet.
| References|| |
|1.||Psotera WJ, Reid BC, Katz RV. Malnutrition and dental caries: A review of the literature. Caries Res 2005;39:441-7. |
|2.||The "bad guys" of dental bacteria - all oral bacteria are not equal. [Internet]. Available from: http://www.mainlinedental.com/blog/all-bacteria-are-not-equal/ [Last cited on 2013 Dec 25]. |
|3.||Sadeghi M, Alizadeh F. Association between dental caries and body mass index-for-age among 6-11-year-old children in Isfahan in 2007. J Dent Res Dent Clin Dent Prospects 2007;1:119-24. |
|4.||Moynihan P, Petersen PE. Diet, nutrition and the prevention of dental diseases. Public Health Nutr 2004;7:201-26. |
|5.||Alvarez JO. Nutrition, tooth development, and dental caries. Am J Clin Nutr 1995;61:410-6S. |
|6.||Using the BMI-for-age growth charts - centers for disease control and prevention. Internet. Available from: http: //www.cdc.gov/nccdphp/dnpa/growthcharts/training/modules/module1/text/module1print.pdf [Last cited on 2009 Aug 4]. |
|7.||Peter S. Survey procedures. In: Essentials of Preventive and Community Dentistry. 3 rd ed. New Delhi 110002 (India). Arya (Medi) Publishing House Pvt Ltd; 2006. p. 594. |
|8.||Tandon S. Case history, diagnosis and treatment plan. In: Textbook of Pedodontics. 2 nd ed. Hyderabad 500095 (India). Paras Medical Publishers; 2009. p. 14. |
|9.||Peter S. Indices in dental epidemiology. In: Preventive and Community Dentistry. 4 th ed. New Delhi 110002 (India). Arya (Medi) Publishing House Pvt Ltd.; 2009. p. 346-7. |
|10.||Children in India 2012 - A statistical appraisal. Ministry of statistics and Programme Implementation, Government of India Internet. Available from: http: //www.mospi.nic.in/mospi_news/children_in_ India_2012.pdf [Last cited on 2012 Oct 9]. |
|11.||Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Prev Med 1993;22:167-77. |
|12.||Norberg C, Hallström Stalin U, Matsson L, Thorngren-Jarneck K, Klingberg G. Body mass index (BMI) and dental caries in 5-year-old children from southern Sweden. Comm Dent Oral Epidemiol 2012;40:315-22. |
|13.||Hooley M, Skouteris H, Boganin C, Saturj J, Kilpatrick N. Body mass index and dental caries in children and adolescents: A systematic review of literature published 2004-2011. Syst Rev 2012;1:57. |
|14.||Abolfotouh MA, Hassan KH, Khattab MS, Youssef RM, Sadek A, El-Sebaiei M. Dental caries: Experience in relation to wasting and stunted growth among schoolboys in Abha, Saudi Arabia. Ann Saudi Med 2000;20:360-3. |
|15.||Cantekin K, Gurbuz T, Demirbuga S, Demirci T, Duruk G. Dental caries and body mass index in a sample of 12-year-old eastern Turkish children. J Dent Sci 2012;7:77-80. |
|16.||Mirmiran P, Mirbolooki M, Azizi F. Familial clustering obesity and the role of nutrition: Tehran lipid and glucose study. Int J Obes Relat Metab Disord 2002;26:1617-22. |
|17.||Prashanth ST, Babu V, Kumar VD, Amitha HA. Comparison of association of dental caries in relation with body mass index (BMI) in government and private school children. J Dent Sci Res 2011;2:1-5. |
|18.||Gerdin EW, Angbratt M, Aronsson K, Eriksson E, Johansson I. Dental caries and body mass index by socio-economic status in Swedish children. Community Dent Oral Epidemiol 2008;36:459-65. |
|19.||Marshall TA, Eichenberger-Gilmore JM, Broffitt BA, Warren JJ, Levy SM. Dental caries and childhood obesity: Roles of diet and socioeconomic status. Community Dent Oral Epidemiol 2007;35:449-58. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]