J.

Adv Oral Research ORIGINAL RESEARCH

All Rights Res

Association between Dental caries and

body mass index among 12 and 15 years
school children in Shimla, Himachal
Pradesh
Fotedar Shailee* Sogi GM Sharma KR

*MDS, Lecturer, Department of Public Health Dentistry, H.P Government Dental

College, Shimla, Himachal Pradesh- India,MDS, Professor, Department of Public Health
Dentistry, KLE VK Institute of Dental Sciences, Belgaum, Karnatka, MDS, Professor
and Head, Department of Public Health Dentistry, HP Government Dental College,
Shimla, Himachal Pradesh, India. Email:drfotedar@rediffmail.com

Abstract:
Objective: The aim of our study was to evaluate
the association between weight and dental caries
among 12 and 15 years school children in Shimla
city, Himachal Pradesh, India.
Method: A sample of 1011 school children was
selected by a two stage cluster sampling method.
Clinical recording of dental caries, was done
according to WHO diagnostic criteria 1997 and
BMI percentile was calculated based on age and
gender-adjusted published scales. The data was
analyzed by Statistical Package for Social Sciences
(SPSS) version 13. The statistical tests used were
t-test, ANOVA, chi-square test and correlation
analysis. A p value < 0.05 was considered
statistically significant.
Results: The lower percentage of children
belonged to normal range of Body Mass Index in
Government schools as compared to private
schools and the difference was statistically
significant (P < 0.001). Correlation analysis
showed BMI had a negative correlation with
DMFT (r = 0.312, p < 0.011).
Conclusion: This study showed higher percentage
of children was in the underweight category of
BMI and the mean DMFT was higher in
underweight as compared to overweight. These
children would have acute or
Serial Listing: Print-ISSN (2320-2068)
Online-ISSN (2320-2076)
Formerly Known as Journal of Advanced Dental
Research
Bibliographic Listing: Indian National Medical
Library, Index Copernicus, EBSCO Publishing
Database, Proquest, Open J-Gate.
Journal of Advanced Oral Research, Vol 4; Issue 1: Jan - Apr 2013
chronic nutritional stress due to poor
socioeconomic status and lack of knowledge about
general and oral health. Continous education and
motivation of parents and children can help to
some extent to improve their health status.
Keywords: Dental caries, body mass index, school
children.
Introduction:
Obesity and overweight are defined as
having an excess of body fat related to lean mass,
with multifactorial conditions involving
psychological, biochemical, metabolic, anatomic
and social alterations.[1] At present obesity among
children is a problem in both developed and less
developed countries around the world.
Furthermore, children who are at risk for being
overweight during preschool years carry a greater
probability of being overweight by age twelve.[2]
Weight status in children is measured by
assessment of body mass index (BMI)
corresponding to gender and age-ranked
percentages. Children are considered to be
overweight if they are between the 85th and 95th
percentile of age and gender related BMI and are
considered to be obese if they are at or beyond the
95th percentile of age and gender related BMI
according to Center for Disease Control and
Prevention (CDC) guidelines.[3]
Childhood obesity may lead to serious
disease, a decrease in life expectancy and
numerous other problems. A higher body weight is
associated with a greater risk for type 2 diabetes
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and might be at risk factor for cardiovascular
disease, asthma, arthritis, and general poor
health.[4,5] Obesity in children may also result in
emotional unhealthiness.[6]
Increase of obesity worldwide is due to
using non-alcoholic beverages, fast food and a
decrease in exercise.[7] Diet plays an important role
in the obesity epidemic, as dietary habits in
children have suffered major changes in the last
thirty years.[8] Consumption of soft drinks is
associated with reduced vitamin and mineral
intake and an excess of dietary carbohydrates. The
oral health implications of nutritional practices
were demonstrated by a review of childrens eating
habits in the United States between 1988 and
1994.[9] The authors of that study found an
association between poor dietary practices (meal
fragmentation, missed breakfast, low fruit, and
higher carbohydrate intake) and caries.
Due to the strong evidence, supporting the
association of dental caries with irregular dietary
patterns & quality and also the fact that the
abnormal dietary intake has been linked to the
development of obesity at a young age[10], a link
between dental caries and weight is biologically
plausible. So, the present study was conducted to
evaluate the relationship between BMI and dental
caries among 12 and 15-year old school children in
Shimla city, Himachal Pradesh, India.
Materials and Method:
A cross sectional epidemiological study
was conducted among the school going children
aged 12 and 15 years in Shimla city. Ethical
approval to conduct the study was obtained from
the Institutional Review Board of H.P.
Government Dental College and Hospital, Shimla.
Written consent for the participation of the
children in the study was obtained from the
Principals of the concerned schools.
A pilot study was conducted by randomly
selecting one government and one private school
from the available list of schools obtained from the
Directorate of Education H.P. Results from this
pilot study showed the prevalence of dental caries
was 23.4%. The sample size was calculated by
taking this prevalence rate and computed using the
Epi Infoversion 6 statistical package at 95%
confidence interval which came out to be 985.
The sample frame consisted of middle and
high schools (public and private) in Shimla city,
obtained from the Directorate of Education H.P.
The study sample was recruited by a two-stage
cluster sampling technique. For the purpose of the
study, Shimla city was arbitrarily divided into 4
Journal of Advanced Oral Research, Vol 4; Issue 1: Jan - Apr 2013
8
geographical regions, which correspond to the four
varying demographic areas of the city: Shimla
municipal and 3 Shimla Planning Areas (Dhalli,
Tutu and New Shimla). Schools from each region
were randomly selected to obtain the desired
sample size, such that there was an equal
representation from each of the four zones. Out of
the total number (43) of government (26) and
private schools (17), 7 public and 5 private schools
were randomly selected. In the second stage,
eligible school children were stratified according
to age and gender, and randomly selected in
proportion to the total number of 12 and 15 years
old students enrolled in each school to reach the
sample of about 1011 subjects over a period of
three months April- June 2009. The fluoride levels
in water in Shimla city is less than 1.5.[11]
All the children were clinically examined
for dental caries by one of the authors (SF) trained
for clinical examination during several educational
and clinical sessions in the department of Public
Health Dentistry, Government Dental College,
Shimla. The procedure, diagnostic criteria were
those recommended by the World Health
Organization (1997)[12] for assessment of dental
caries. Data regarding general information, was
obtained through interview and recorded on a
modified WHO proforma. The subjects were
examined by Dunning type III[13] clinical
examination in their respective schools on a
comfortable chair.
Body weight was recorded to the nearest 100-gram
using a standard beam balance scale with the
subject barefoot and wearing light dresses. The
balance was calibrated at the beginning of each
working day and at frequent intervals throughout
the day. Body height was recorded to the nearest
0.5 cm according to the following protocol: no
shoes, heels together and head touching the ruler
with line of sight aligned horizontally. To avoid
subjective errors, all the measurements were done
by the same person and by one recording assistant.
Body Mass Index (BMI) was calculated using the
standard formula Mass (Kg)/height (m). BMI
percentile was calculated by Center for Disease
Control (CDC) BMI- for age growth chart. Using
age and gender specific criteria, subjects were
categorized as underweight (<5%), normal (<5%
to <85%), overweight (85 to <95 %), and obese
(95 %).[3]
Intra-examiner reproducibility as
determined using Kappa statistic was 0.85. Five
students were randomly selected by asking the
teacher to send any five of the students examined
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 9

the previous day and re-examined the next day to determine intra-examiner reproducibility.
Table 1. Distribution of subjects according to gender and schools

Age Schools Male n % Female n % Total n %

229 (46.1%)
Govt. 156 48.4% 73 41.7%
268 (53.9%)
Private 166 51.6% 102 58.3%
12 years
322
Total 100.0% 175 100.0% 497 (100.0%)
250 (48.6%)
Govt. 148 48.7% 102 48.6%
264 (51.4%)
Private 156 51.3% 108 51.4%
15 years
514 (100.0%)
Total 304 100.0% 210 100.0%

Table 2. Distribution of subjects according to Body Mass Index and School Category

Age Body Mass Index Govt. N % Private N % Total N %

<18.5 207 51.8% 192 48.2% 399 (80.3%)

18.5-24.99 19 20.8% 72 79.1% 91 (18.3%)

125-29.99 3 42.8% 4 57.2% 7 (1.4%)

12
years >= 30 0 0% 0 0% 0 (0%)

Total 229 44.1% 268 55.9% 497 (100.0%)

<18.5 199 58.1% 144 41.9% 343 (66.7%)

18.5-24.99 46 30.8% 103 69.1% 149 (28.9%)

1
15 25-29.99 4 26.6% 11 73.4% 15 (2.9%)
years
>= 30 1 14.3% 6 85.7% 7(1.36%)

Total 250 48.6% 264 51.4 % 514 (100.0%)

P<0.000

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Table 3. Mean DMFT according to Gender

Age Sex Mean DMFT S. D P value

12 years Male 0.537 0.940 0.007*

Female 0.794 1.125

Total 0.62 1.016

15 years Male 0.996 1.343 0.232

Female 1.152 1.594

Total 1.060 1.451

S.D Standard deviation * Statistically significant

Table 4: BMI and Dental Caries

Age BMI Mean DMFT S.D P value

12 yrs Under weight 0.7143 1.003 0.092

Normal weight 0.7033 1.090
Over weight 0.6070 0.755
Obese 0 0
Total 0.6278 1.016
15 yrs Under weight 1.1370 1.504 0.012
Normal weight 0.9866 1.380
Over weight 0.7143 .560
Obese 0.7112 .519
Total 1.060 1.451

Table 5: Correlation analysis between strata of BMI and DT, MT, FT and DMFT

BMI Pearsons Corelation DT MT FT DMFT

coefficient
R -0.312* 0.011 0.023 -0.201*

p value <0.001 0.423 0.613 <0.001

*Statistically significant

DT: Decayed teeth; MT: Missing teeth; FT:Filled teeth; DMFT: Decayed Missing Filled Teeth; BMI:
Body Mass Index.

Journal of Advanced Oral Research, Vol 4; Issue 1: Jan - Apr 2013 www.joaor.org

Instruments were sterilized by autoclaving at the
end of the days clinical examination. At the site,
chemical sterilization was followed.
Inclusion criteria:
School children (Male and Female) who have
completed their twelve and fifteen years of age.
Children present on the day of examination.
Exclusion Criteria:
Those children who refused to participate were
excluded.
Medically compromised children
Statistical Analysis:
The data collected was analyzed by
Statistical Package for Social Sciences (SPSS)
package 13. The statistical tests used were t- test
and ANOVA for continuous variables and chi-
square tests for categorical data. Correlation
analysis was done to check the association
between BMI and DT, MT, FT and DMFT.A level
of P < 0.05 was considered statistically significant
and P < 0.001 was taken as highly statistically
significant.
Results:
Out of the total population, we had 49.1%
of children at 12 years and 50.9% of children at 15
years. There were 64.8% of males and 35.2% of
females at 12years while as 59.1% of males and
40.9% of females at 15 years. At the age of 12
years we had 46.1% in government schools and
53.9% in private schools whereas at the age of 15
years we had 48.6% in Government schools and
51.4% in private schools. (Table 1)
Table 2 shows there were 18.3% of students in the
normal range of BMI at the age of 12 years and
28.9% at the age of 15 years. On comparison of
BMI between Government and Private schools it
was found that lower percentage of children
belonged to normal range of Body Mass Index in
Government schools as compared to private
schools and the difference was statistically
significant, P< 0.001
At the age of 12 years, the mean DMFT
was 0.62 +1.42 and it was 1.06 + 2.93 at the age of
15 years. At both the age groups, females showed
higher mean DMFT as compared to the males and
difference was statistically significant at 12 yrs.
The highest mean DMFT (0.714+ 1.003)
was seen in underweight category and the lowest
mean DMFT was reported in over weight category
(0.607+ 0.755) of BMI at the age of 12 years but
the difference was not statistically significant. At
the age of 15 yrs also underweight category had
highest mean DMFT as compared to other
categories and the difference was statistically
Journal of Advanced Oral Research, Vol 4; Issue 1: Jan - Apr 2013
11
significant. Correlation analysis showed BMI had
a negative correlation with DMFT and DT(r =
0.312, p< 0.011).
Discussion:
In the present study, most of the children
in both the age groups were in the underweight
category which may be attributed to the
topography of the state, i,e being hilly children
have to walk up and down the hills to reach their
schools or from one place to another. Further
higher percentage of overweight children was
found in private schools in both the age groups
which was also reported by Swati Tripathi[14],
Prashant ST[15], Ana F Granvile-Garcia et al,[16] and
Partrica vasconcelos leitao moreira.[17] This may be
explained by low-intensity physical activities
together with consuming high-energy value food
among the higher socio economic levels (private
schools) as compared to lower socioecomic levels
(Govt. schools).[18,19]
In the present study, the mean DMFT at 12 years
and at 15 years was 0.62 and 1.06 respectively
which was also reported by Naidu R[20] and
Peterson PE[21] but is less than 2.4 as reported by
National Oral Health Survey in H.P.[11] Females
had a significantly higher mean DMFT value than
males. This is in line with the findings of Al
Shammery et al,[22] Salapatal et al,[23] Dummer.[24]
This may be due to the fact that teeth erupt earlier
in females than males which leads to prolonged
exposure of the teeth to the oral environment in
females.
This study describes an inverse
relationship between dental caries and weight
which was also reported by Prashant S[15],
Mojard[25], Sheiham A[26], Kantovitz KR[27] and
Macek and Mitola.[28] This may be because the
underweight children would have acute or chronic
nutritional stress due to poor socioeconomic status
and lack of knowledge about general and oral
health.
On the contrary, Kenan Cantekin[29] on a
sample of 12 yrs in Turkey reported a positive
relationship between BMI and mean DMFT.
Another Swedish study of 15-year-old children
revealed a significant positive correlation between
DMFS indices and relative BMIs in the obese
group[30] High caries experience and higher BMI
have also been shown by Hilgers et al[31]
Willershausen.[32]
The exact mechanism for the association
of body weight and dental caries is not yet known.
It has been proposed that consumption of refined
carbohydrates might serve as a link between
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obesity and the onset of dental caries. Marshall et
al[33] found that children <5 years of age with
dental caries had a higher soft drink intake than
children without caries. However, they could not
establish a relation between soft drink
consumption and BMI levels. On the other hand, a
study by Ochoa et al[34] found that children who
consume sugar-sweetened beverages have a 1.74
times greater risk of being obese as compared with
children who do not consume this type of
beverage. Anita Alm et al[35] showed that
overweight and obese adolescents had more
proximal caries than normal weight individuals
and the frequent consumption of snacking products
during early childhood was a risk indicator for
caries at 15 years.
The dentists should be in the forefront in
promoting good nutrition for general health and
oral health by informing caregivers and parents
about the importance of integrating healthful snack
and meal patterns into their oral hygiene practices.
Conclusion:
This study showed higher percentage of
children was in the underweight category of BMI.
Further, higher percentage of underweight children
was in government schools as compared to private
schools. Mean DMFT was higher in underweight
children as compared to other strata of BMI.
Correlation analysis showed BMI had a negative
correlation with DMFT. These children would
have acute or chronic nutritional stress due to poor
socioeconomic status and lack of knowledge about
general and oral health. Continuous education and
motivation of parents and children can help to
some extent to improve their health status.
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