original article

Influence of body mass index on severity of

dental caries: cross-sectional study in healthy
adults
Majdy Idrees,a Mohammad Hammad,b Asmaa Faden,c Omar Kujand
From aPrivate dental practice, Manama, Bahrain; bSchool of Dentistry, Taibah University, Madinah, Saudi Arabia; cSchool of Dentistry, King
Saud University, Riyadh, Saudi Arabia; dUWA Dental School, University of Western Australia, Australia

Correspondence: Dr. Omar Kujan · UWA Dental School, University of Western Australia, 17 Monash Avenue, Nedlands, Western Australia,
6009, Australia · T: +61 8 6457 7649 · [email protected] · ORCID: http://orcid.org/0000-0002-5951-8280

Ann Saudi Med 2017; 37(6): 444-448

DOI: 10.5144/0256-4947.2017.444

BACKGROUND: The relationship between body mass index (BMI) and dental caries is still undetermined.
OBJECTIVE: This study aimed to assess the relationship between the dental status by decayed, missed,
filled teeth index (DMFT), and BMI by age and gender among healthy adults.
DESIGN: Analytical, cross-sectional study.
SETTINGS: University dental hospital in Riyadh.
SUBJECTS AND METHODS: Healthy adults aged between 18 and 35 years were recruited during the
10-month period from March 2015 to December 2015. Dental caries severity was estimated using the DMFT
index.
MAIN OUTCOME MEASURE: The prevalence of overweight/obesity and the association of BMI category
with the DMFT index.
RESULTS: The mean age of 502 subjects was 24.3 (4.9) years. The caries severity of the study population
was considered moderate according to the WHO caries severity scale (mean [standard deviation] DMFT
13.3 [3.8]). The mean (SD) DMFT of male and female subjects was 13.1 (4.0) and 13.36 (3.7), respectively.
No significant association was seen between dental caries and BMI. Logistic regression analysis showed that
males had two times more risk of developing dental caries compared to females. In addition, the risk of car-
ies development was increased by about 5 times for every year of age.
CONCLUSION: Dental caries was not associated with BMI but age significantly influenced the DMFT index
and gender was associated with more missing teeth. Further longitudinal studies with larger cohorts from
several geographic regions are warranted.
LIMITATION: Convenience sampling and recruitment from a single dental center may have some impact on
the generalization of data.

O
besity and overweight according to the World leading cause of mortality worldwide and has been
Health Organization (WHO) are characterized identified as a major risk factor for several non-commu-
by an abnormal and excessive accumulation nicable diseases such as cardiovascular diseases, mus-
of fat that may impair health.1 The primary cause of this culoskeletal diseases and certain types of cancer like
condition is an imbalance between calorie intake and breast, prostate, liver, and colon cancer.2
calorie consumption. A recent report demonstrated Dental caries is the most prevalent disease globally,3
that the global prevalence of obesity and overweight and has been considered historically the most impor-
doubled between 1980 and 2014.1 Interestingly, the tant global oral health burdens, affecting about 60% to
WHO stated in 2014, that nearly 2.5 billion adults aged 90% of schoolchildren, and about 100% of the adult
≥18 years suffer from obesity and overweight.1 This population.4 Dental caries has a complicated etiology
equals approximately one-third of the world’s popula- and pathobiology; however, the role of nourishment, in
tion. Furthermore, overweight is considered the fifth addition to oral hygiene, nutrients, saliva, and oral flora,

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BMI AND DENTAL CARIES original article
play a significant role in caries initiation and progres- condition that might adversely affect either oral and/or
sion.5 The association between oral health status and systemic health status (e.g. diabetes), had undergone
weight of patients is a subject of controversy.6 This de- orthodontic treatment, were female patients who were
bate is partially attributed to the nature of the published pregnant or taking an oral contraceptive. A detailed
studies as population sampling has focused on school- medical and drug history was taken.
children.6 Interestingly, Thippeswamy et al7 reported a Subjects meeting the inclusion criteria were subject
significant association between overweight/obesity and to a standard dental inspection that was performed by
caries rates among school children; the obese children a calibrated and experienced dental specialist using
had more caries than both the overweight and normal sterile dental examination instruments on a dental unit
weight children. Likewise, Modéer et al8 revealed that with the standard white headlight. Two bilateral bite-
obese subjects exhibited a higher number of decayed wing radiographs were taken for each participant to
surfaces compared to non-obese subjects. Additionally, diagnose the presence of hidden proximal caries in the
Willershausen et al9 examined 2071 primary school posterior teeth.
pupils aged 6 to 10 years, and reported a significant Dental caries severity was diagnosed and recorded
correlation between body mass index (BMI) and caries according to the WHO criteria, the DMFT.16 The index
frequency; a low BMI showed a correlation with the ab- indicates the number of decayed (D), missed (M) and
sence of carious lesions, and a high BMI was linked to filled (F) teeth in each patient. Any tooth with caries or
a high number of caries lesions. Most recently, a sig- tooth with a filling and recurrent caries is considered a
nificant association between dental caries and BMI in decayed tooth (D). The number of teeth with restorative
young adult subjects was reported.10 In contrast, in a fillings is referred to as filled teeth (F). The number of
recent study that examined adult subjects, BMI was not teeth removed due to dental caries is considered miss-
associated with dental caries, but had a significant as- ing teeth (M).16 Any tooth that was extracted as a result
sociation with periodontitis.11 On the other hand, the of trauma or hereditary malformation was not counted
findings of a study by Sede et al12 revealed that BMI as missing teeth.16
related to neither dental caries, nor periodontitis; how- BMI was measured to classify the obesity and over-
ever, the study supported a strong link between the weight of study subjects.1 The weight and height of
gingival bleeding index and BMI. In addition, several subjects were quantified by a calibrated digital scale
studies failed to demonstrate a significant relationship (Beurer, Germany). Participants were divided into
between childhood obesity and dental caries.13-15 Given groups depending on their BMI according to WHO cri-
the current debate, this study, therefore, aimed to as- teria into four groups: 1 obese (BMI >30 kg/m2), over-
sess the relationship between teeth status represented weight (BMI 25-30 kg/m2), normal weight (BMI 18.5-25
by decayed, missed, filled teeth index (DMFT), and BMI kg/m2, or underweight (BMI <18.5 kg/m2).
among healthy adults. Data was analyzed using IBM SPSS version 22.0,
Armonk, NY: IBM Corp. A P value of <.05 was con-
SUBJECTS AND METHODS sidered statistically significant. Tests of normality were
In this cross-sectional study conducted at the dental done to check the distribution of dental variables
hospital of Al-Farabi Colleges in Riyadh, Saudi Arabia, (DMFT, DT, MT and FT) by the Kolmogorov test.
patients who visited the dental clinics during the period Quantitative variables were presented as means and
from March 2015 to December 2015 were eligible to standard deviations, whereas qualitative variables were
participate. Subjects were selected based on conve- presented as frequencies and percentages. The Mann-
nience and the criteria of being healthy (without sys- Whitney test and Kruskal-Wallis test were used for the
temic disease, even if controlled) and being an adult non-parametric quantitative variables. The chi-square
≥18 years and ≤35 years of age. This study was pre- test was used for dichotomous variables. A multinomial
pared in accordance with the STROBE statement (www. logistic regression model was performed to detect sig-
strobe-statement.org). The study was ethically ap- nificant predictors of DMFT score.
proved by the Institutional Review Board of Al-Farabi
College for Dentistry and Nursing. All subjects were RESULTS
asked to sign a consent form, and all procedures were Of 578 patients that initially examined for study enroll-
undertaken in accordance with the principles of the ment, 502 subjects met the inclusion criteria and were
Helsinki Declaration. Subjects were excluded if they subject to full examination and subsequent analysis.
had genetic or acquired teeth anomalies such as fluo- The 502 subjects included 192 males (38.2%) and 310
rosis or amelogenesis imperfecta, any chronic medical females (61.8%) with a mean ages of 26.5 (4.8) and 22.8

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 original article BMI AND DENTAL CARIES

(4.5), respectively (Table 1). The mean DMFT of the had slightly more decayed teeth (Table 2).
study subjects was 13.28 (3.8) and the mean DMFT of There was no statistically significant relation be-
male and female subjects was 13.1 (4.0) and 13.4 (3.7), tween BMI categories and either gender or age of
respectively. No significant relationship was found be- subjects (Table 3) (Chi-square test, P=.23) and no sta-
tween the DMFT, DT, and FT and subjects’ gender, ex- tistically significant correlation between BMI categories
cept for MT (Table 2). Furthermore, older age subjects and dental caries severity (Table 4). However, after tak-
had significantly more missing and filled teeth com- ing the age and gender into consideration, the relation-
pared with younger subjects, while the younger group ship between the dental variables and body mass index
categories showed that the mean value of DMFT was
significantly greater among underweight older males
Table 1. Distribution of study subjects by gender and age.
compared with other age groups (P<.001) (Table 5). A
Gender multiple regression model found that gender and age
Age range Total
Male N (%) Female N (%) were significant in relationship to DMFT (odds ratio 2.3,
confidence interval=0.13 , 1.56, P=.021), and (odds
18–24 years 82 (26.2) 231 (73.8) 313
ratio 4.94, 95% confidence interval (CI)=0.11, 0.26,
25–35 years 110 (58.2) 79 (41.8) 189 P<.001) with an adjusted R-square of 0.042, respec-
Total 192 (38.2%) 310 (61.8%) 502 tively. A multiple regression model found that gender
and age were significant in relationship to DMFT, male
subjects had more than 2 times risk for caries devel-
Table 2. The relationship between dental and demographic variables. opment compared to females, while the risk of caries
Variable DMFT DT MT FT development was increased by about 5 times for each
year of age (odds ratio 2.3, confidence interval=0.13,
Gender
1.56, P=.021), and (odds ratio 4.94, 95% confidence
Male 13.2 (3.9) 8.9 (4.1) 0.8 (]1.3) 3.4 (3.9) interval (CI)=0.11, 0.26, P<.001), respectively, with an
Female 13.4 (3.7) 8.3 (4.0) 1.2 (1.7) 3.9 (3.8) adjusted R-square of 0.042.

P value 0.597 0.116 0.029 0.088

DISCUSSION
Age Caries severity and prevalence are significantly affected
categories by several factors including age, educational back-
18–24 years 12.9 (3.8) 8.8 (4.1) 0.8 (1.5) 3.3 (3.6) grounds, socioeconomic status, genetic susceptibility,
fluoride percentage in drinking water, and level of den-
25–35 years 13.9 (3.6) 8.1 (4.0) 1.3 (1.7) 4.6 (4.1)
tal awareness.5 Consequently, study of caries-related
P value .006 .046 <.001 <.001 factors is complex. These variables explain the inequal-
Data are mean (standard deviation). DMFT: decayed, missed, filled teeth index; DT: decayed teeth; MT: ity in the dental caries scale among various studies.
missing teeth; FT: filled teeth. Statistical analysis by Mann-Whitney test The severity of dental caries worldwide ranges greatly,
from less than 5 to more than 20 (DMFT index).17,18 The
Table 3. Distribution of gender and age by category of body mass index. mean of DMFT in this study was 13.3, which is con-
sidered moderate according to the WHO caries sever-
Males by age group Female by age group Total
n (%) ity scale.17 Our findings were similar to those reported
BMI
(number in other countries, such as United States, Russia, and
category 18-24 25-35 18-24 25-35 male, Australia.17
female)
The objective of this study was to determine the
34 (6.8) association between BMI category and dental caries
Underweight 7 (63.6) 4 (36.4) 20 (87) 3 (13)
(11, 23)
among adults, but it is well known that being older
230 (45.8) than 35 years is considered a risk factor for tooth loss
Normal 36 (46.2) 42 (53.8) 124 (81.6) 28 (18.4)
(78, 152)
as a result of periodontal diseases.19 Therefore, to ex-
137 (27.3) clude any external age-related factors that might influ-
Overweight 19 (33.3) 38 (66.7) 56 (70) 24 (30)
(57, 80) ence the oral health status negatively of study subjects,
101 (20.1) our study subjects were limited to adults aged 35 years
Obese 20 (43.5) 26 (56.5) 31 (56.4) 24 (43.6)
(46, 55) and younger.10
Data are number (percentage). Age groups in years. Underweight <18.5 kg/m2, normal 18.5-25 kg/m2, The relationship between BMI and dental caries
overweight 25-30 kg/m2, obese >30 kg/m2 is indecisive. A 2012 systematic review that included

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BMI AND DENTAL CARIES original article
48 papers that assessed the potential relationship Table 4. Statistical comparison of dental variables by body mass index.
between BMI and dental caries in children and ado-
DMFT DT MT FT
lescents, found no association in 23 studies, while the
remaining 25 studies found the opposite, making a de- BMI category
cisive conclusion impossible.20 However, it is important Underweight 14.0 (3.8) 8.2 (4.6) 0.8 (1.5) 4.9 (4.6)
to note that most of the previous studies that found
Normal 13.0 (3.9) 8.4 (4.1) 1.0 (1.5) 3.6 (3.9)
a relationship between dental caries and BMI, either
positive or negative, were conducted on children or Overweight 13.8 (3.1) 9.0 (4.1) 1.0 (1.4) 3.8 (3.5)
adolescents aged less than 18 years.20-22 On the other Obese 12.9 (4.4) 8.4 (3.9) 1.0 (1.8) 3.5 (3.9)
hand, few studies were conducted to test this relation-
P value .150 .369 .953 .205
ship among adult subjects. Moreover, a systematic re-
Data are mean (standard deviation). DMFT: decayed, missed, filled teeth index; DT: decayed teeth; MT:
view conducted in 2006 demonstrated that only one
missing teeth; FT: filled teeth. BMI: body mass index. Statistical analysis by Kruskal-Wallis test.
study with a high level of evidence showed a direct
and significant association between dental caries and
Table 5. Statistical comparison of dental variables and category of body mass
obesity.21 index by age and gender.
A study in 2016 on adults aged between 18 to 35
DMFT DMFT DMFT DMFT
years revealed a strong association between high BMI
and DMFT, but the number of study subjects in that Female Female Male Male
study was limited to 200; in addition, no logistic re- 18-24 y 25-35 y 18-24 y 25-35 y
(n=231) (n=79) (n=82) (n=110)
gression model was performed to test the effect of
confounders.10 On the other hand, the present study BMI category
found a statistically significant relationship between
dental caries and males who were underweight and Underweight 13.3 (3.0) 12.7 (3.5) 13.0 (3.7) 20.5 (1.7)
older. The same results were found in a previous study 11.9 (4.3)
Normal 13.1 (3.8) 13.4 (3.8) 13.4 (3.6)
and were attributed to the negative impact of caries le-
sions in childhood development.22 Nevertheless, these Overweight 13.0 (3.2) 14.6 (2.3) 14.4 (3.5) 14.3 (2.9)
results could not be applied to our study for many rea-
Obese 12.7 (4.7) 15.2 (4.0) 11.4 (4.2) 12.1 (3.8)
sons. First, the study was conducted in children aged
8 years, not on adults. In addition, a logistic regression P value .966 .181 .110 <.001
model of our data showed that age and gender played Data are mean (standard deviation). DMFT: decayed, missed, filled teeth index; DT: decayed teeth; MT:
a significant role in this relationship, not BMI. missing teeth; FT: filled teeth. BMI: body mass index. Statistical analysis by Kruskal-Wallis test.

In our opinion, the diversity and contradiction of

results among the studies could be attributed to varia- horts.24,25 Specifically, our study found that the obesity
tions in genetic susceptibility to caries and obesity, rate in males and females was 23.9% and 17.8%, re-
lifestyle, and dietary habits, which are unique for each spectively, which is similar to that reported in Al-Hazzaa
community and population. However, all of these vari- et al study in the Riyadh region. They reported an obe-
ables must be included in the future in a longitudinal sity rate of 22.7% and 13.8% in males and females,
study with larger cohorts from several geographic re- respectively.24 The lack of detailed information on the
gions to get a more precise estimation of the relation- socioeconomic status of participants could be con-
ship between BMI and dental caries. sidered an additional limitation to the present study,
Like other published studies, the present paper though 95% of the participants labeled themselves as
has some limitations. The cross-sectional nature pre- middle class.
vented the discovery of any cause and effect relation- Finally, according to our results, being male means
ship between the variables. Another limitation was lack that the risk of caries development is increased by
of information on the nutritional behavior of subjects. more than two times compared to females, and this
Yet another limitation was the single center design. could be attributed to a poor attitude towards oral
However, the age and gender of our participants was health, dietary habits, and potentially genetic varia-
close to that published by the Saudi National Office tions. In addition, our previous study examined the gin-
of Statistics;23 thus, our study probably represents the gival and plaque indices (GI and PI) in adults,26 where
healthy Saudi adult population. Furthermore, the re- males were shown to have significantly higher indices
ported obesity rate in our study was similar to that pre- than females, and therefore, were more susceptible to
viously reported in published studies from Saudi co- dental caries than females. Similarly, the risk of caries

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 original article BMI AND DENTAL CARIES

development is related significantly to age. For every However, further longitudinal studies with larger co-
one year increase in age, the risk of caries develop- horts from several geographic regions are required to
ment is increased by about five times, which is consis- validate the exact relationship between BMI and dental
tent with many previous studies that considered age as caries among adults.
a risk factor for caries development.27
In conclusion, our study showed that dental car- Conflict of interest
ies was not related to BMI whereas age significantly The authors declare that they have no conflict of inter-
influenced the development of dental caries, and fe- ests, and the work was not supported or funded by any
male gender was associated with more missing teeth. drug company.

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