HARM/ETIOLOGY

ARTICLE ANALYSIS & EVALUATION

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION
Obesity and periodontitis in 60-70year-old men Linden G, Patterson C, Evans A, Kee F. J Clin Periodontol 2007;34(6):461-6

Obesity may be Associated with Periodontitis in Elderly Men

SUMMARY Subjects
A total of 1362 men with 6 or more teeth who were enrolled in a cohort study of cardiovascular disease in Northern Ireland were examined between 2001 and 2003.

LEVEL OF EVIDENCE
2

Exposure
Body mass index (BMI) of greater than 30 kg/m2 at examination day, the BMI at 21 years of age, and weight gain of more than 30% since 21 years of age.

PURPOSE/QUESTION
Is obesity associated with periodontitis in 60-70-year-old Western European men?

Main Outcome Measure

Low-threshold periodontitis is at least 2 teeth with 6 mm or more loss of attachment and at least 1 site with a pocket of 5 mm or more; and highthreshold periodontitis as 15% or more sites with 6 mm or more loss of attachment and at least 1 site with a pocket of 6 mm or more.

SOURCE OF FUNDING
Information not available

TYPE OF STUDY/DESIGN
Retrospective Cohort Study

Main Results
BMI greater than 30 kg/m2 was signicantly associated with low-threshold periodontitis (reference, BMI of <25 kg/m2; odds ratio, 1.77; condence interval, 1.20-2.63; P = .004) adjusted for age, smoking, diabetes, years of education, socioeconomic status, dental attendance, and toothbrushing frequency. The BMI at 21 years of age did not predict periodontitis. Weight gain of more than 30% since 21 years of age showed an increased risk of low- and high-threshold periodontitis; however, this was attenuated and not signicant after multivariate adjustment.

Conclusions
Obesity was associated with low-threshold periodontitis in 60- to 70-year-old Western European men. A weaker association was evident between obesity and severe periodontitis. High BMI levels in early life did not predict periodontitis in later life in men studied, but those who had a large (>30%) increase in weight during adult life had poorer periodontal status.

COMMENTARY AND ANALYSIS

An association between obesity and periodontitis was identied in Japanese subjects in 1998 for the rst time1 and a follow-up study indicated that increased abdominal adiposity was a key factor.2 Further studies from Japan3 and Brazil4 also found that obesity was associated with an increased risk of periodontitis. Studies in a US population using a large NHANES III dataset also supported this association,5,6 and especially in young adults this association was clearer, but not signicant in elderly subjects.5 Moreover, 2 studies indicated an association in women.4,7 The present study is the rst report on European subjects and it is interesting that the subjects under investigation here were elderly men. Since a degree of ill effects of obesity on systemic health, such as type 2 diabetes mellitus and cardiovascular disease,

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are different between sexes8 and age groups,9 the association of obesity and periodontitis might also be different between sexes and age groups. Additionally, the effect of obesity on the risk of type 2 diabetes is different between Japanese and Caucasian individuals, which was presumed to be derived from a difference in the amount of insulin secretion. Therefore, the association between obesity and periodontitis might be different between races. Since almost all previous studies indicating an association between obesity and periodontitis were crosssectional, a causal relationship between obesity and periodontitis is not clear at present. Although it is difcult to obtain the periodontal condition of the elderly subjects was examined in early life at 21 years of age in this study, the prevalence of periodontitis in 21-year-olds is considered to be very low and most people remember their approximate weight in early life. Considering this, the present study shows us new retrospective methods to investigate the association between obesity and periodontitis, although it could not indicate a signicant relationship. As a result, the highest tertile of BMI at 21 years of age did not predict periodontitis at 60 to 70 years of age. However, as the authors mentioned, only 17 men were obese at 21 years old, therefore tertile of BMI was used for the analysis. Although the highest cut-off point of BMI tertile was not indicated, it is estimated as about 23.4 from standard normal distribution, since mean value and standard deviation of BMI at 21 years old in Table 1 were indicated as 22.4 and 2.4, respectively. Since the BMI of 23.4 is in the normal range and a healthy value, this analysis might not be appropriate to clarify an association between obesity in early life and periodontitis in later life. On the other hand, those who had a large (>30%) increase in weight during adult life had poorer periodontal status, although it did not reach statistical signicance after multivariate adjustment. It is interesting that, but worse oral health behavior may be correlated with dietary habits leading to obesity. Hujoel et al10 reported the lack of daily ossing was correlated with obesity. Thus, oral and general lifestyle characteristics are considered to be associated with each other and it may be difcult to adjust for these confounders completely. On the other recent study by Amar et al11 indicated that diet-induced obesity in mice causes changes in immune responses and bone loss manifested by Porphyromonas gingivalis. Cani et al12 reported that metabolic endotoxemia induced by chronic lipopolysaccharide stimulation causes lipid accumulation in the liver and the weight of the liver and whole body increased in

mice. More studies are needed to clarify a causal relationship between obesity and periodontitis. Obesity denitely has ill effects on the general health condition, leading to lifestyle-related diseases such as type 2 diabetes, hypertension, and cardiovascular disease. Although a causal association between obesity and periodontitis is not claried at present, this association is useful to raise the motivation of people also in various elds of oral health.

REFERENCES
1. Saito T, Shimazaki Y, Sakamoto M. Obesity and periodontitis. N Engl J Med 1998;339(7):482-3. 2. Saito T, Shimazaki Y, Koga T, Tsuzuki M, Ohshima A. Relationship between upper body obesity and periodontitis. J Dent Res 2001;80(7):1631-6. 3. Nishida N, Tanaka M, Hayashi N, et al. Determination of smoking and obesity as periodontitis risks using the classication and regression tree method. J Periodontol 2005;76(6):923-8. 4. Dalla Vecchia CF, Susin C, Rosing CK, Oppermann RV, Albandar JM. Overweight and obesity as risk indicators for periodontitis in adults. J Periodontol 2005;76(10):1721-8. 5. Al-Zahrani MS, Bissada NF, Borawskit EA. Obesity and periodontal disease in young, middle-aged, and older adults. J Periodontol 2003;74(5):610-5. 6. Wood N, Johnson RB, Streckfus CF. Comparison of body composition and periodontal disease using nutritional assessment techniques: Third National Health and Nutrition Examination Survey (NHANES III). J Clin Periodontol 2003;30(4):321-7. 7. Saito T, Shimazaki Y, Kiyohara Y, et al. Relationship between obesity, glucose tolerance, and periodontal disease in Japanese women: the Hisayama study. J Periodontal Res 2005;40(4):346-53. 8. Kopelman PG. Obesity as a medical problem. Nature 2000;404(6778):63543. 9. Stevens J, Cai J, Pamuk ER, Williamson DF, Thun MJ, Wood JL. The effect of age on the association between body-mass index and mortality. N Engl J Med 1998;338(1):1-7. 10. Hujoel PP, Cunha-Cruz J, Kressin NR. Spurious associations in oral epidemiological research: the case of dental ossing and obesity. J Clin Periodontol 2006;33(8):520-3. 11. Amar S, Zhou Q, Shaik-Dasthagirisaheb Y, Leeman S. Diet-induced obesity in mice causes changes in immune responses and bone loss manifested by bacterial challenge. Proc Natl Acad Sci U S A 2007;104(51):20466-71. 12. Cani PD, Amar J, Iglesias MA, et al. Metabolic endotoxemia initiates obesity and insulin resistance. Diabetes 2007;56(7):1761-72.

REVIEWER
Toshiyuki Saito, DDS, PhD Department of Oral Health, Unit of Social Medicine Nagasaki University Graduate School of Biomedical Sciences Nagasaki, Japan syto@nagasaki-u.ac.jp

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June 2008