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The Association Between Periodontal Disease and Overweight and Obesity: A

Systematic Review

Article  in  Journal of Periodontology · February 2015

DOI: 10.1902/jop.2015.140589 · Source: PubMed

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 The association between periodontal disease and overweight and

obesity: a systematic review

Amélie Keller (AK) MPH*, Jeanett F Rohde (JFR) MSc*† , Kyle Raymond (KR) PhD*, Berit

L Heitmann (BLH) DDS, PhD*†‡

“NOTE: this is the author’s version of a work that was accepted for publication in the Journal of

Periodontology. Changes resulting from the publishing process, such as peer review, editing,

corrections, structural formatting, and other quality control mechanisms may not be reflected in this

document. Minor changes may have been made to this manuscript since it was accepted for

publication. A definitive version is published in the Journal of Periodontology, 2015 Jun;86(6):766-

76. doi: 10.1902/jop.2015.140589.”

*
Institute of Preventive Medicine, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
†
Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
‡
The Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders, The University of Sydney, Australia

1
Abstract

Introduction: Periodontitis and obesity are among the most common chronic disorders

affecting the world’s populations, and recent reviews suggest a potential link between

overweight/obesity and periodontitis. However, due to the scarcity of prospective evidence,

previous reviews were primarily based on cross-sectional studies, with only few

longitudinal or intervention studies included.

The objective was to examine the time-dependent association between obesity and

periodontitis and how weight-changes may affect the development of periodontitis in the

general population. Therefore, longitudinal and experimental studies that assessed the

association between overweight, obesity, weight gain, waist circumference and

periodontitis were reviewed

Method: Intervention and longitudinal studies with overweight or obesity as their exposure

and periodontitis as their outcome were searched through the platforms Pubmed/Medline

and Web of Knowledge.

Results: Eight longitudinal and five intervention studies were included. Two of the

longitudinal studies found a direct association between degree of overweight at baseline

and subsequent risk of developing periodontitis, and further three studies found a direct

association between obesity and development of periodontitis among adults. Two

intervention studies on the influence of obesity on periodontal treatment effects found that

the response to non-surgical periodontal treatment was better among lean than obese

patients, the remaining three studies did not report treatment differences between obese

and lean. Among the eight longitudinal studies, one study adjusted for CRP and biological

markers of inflammation such as CRP, IL-6 and TNFα and inflammation markers were

analyzed separately in three of the five intervention studies.

2
Conclusion: This systematic review suggests that overweight, obesity, weight gain and

increased waist circumference may be risk factors for development or worsening with

regard to periodontal measures.

3
Introduction

Overweight and obesity are defined as excessive accumulation of fat that may impair

health. An adult is considered overweight if its body mass index (BMI= weight kg/height2m),

is ≥ 25 and obese if its BMI is ≥30 Kg/m2.1 The prevalence of overweight and obesity has

increased worldwide during the last decades, raising concern due to its health and

socioeconomic impacts.2 Obesity is accompanied by a state of low-grade inflammation

and has been found to predispose to major chronic diseases such as cardiovascular

diseases and diabetes, and potentially also periodontitis. 2, 3

Periodontitis is a chronic inflammatory disease affecting the supporting structures of the

teeth resulting from the interaction between pathogenic bacteria and the host’s immune

response 4, 5 that may results in partial or complete loss of teeth.6 With a prevalence of

47.2% in the general ≥30 years-old US population in 2009, 7 periodontitis, like obesity, is

one of the most common chronic disorders in the world. 8-10 The exact mechanism

underlying the development of periodontitis has not yet been established and different

factors, such as augmented secretion of pro-inflammatory cytokines have been

hypothesized to contribute. 11 An association between obesity and periodontitis was first

reported in 197712, when changes in the periodontium of obese rats was found.12 In

humans, cross-sectional studies suggest that obesity may be directly associated with

periodontitis. 13-17,18-25 However, temporal relationship between obesity and periodontitis

cannot be determined in cross-sectional studies, and the risk of reverse causation is high.
26

During the past years, two systematic reviews 3, 27 and other non-systematic reviews 6, 11,
28-36
summarizing the results from studies of association between overweight/obesity and

periodontitis have been published. However, due to scarcity of prospective evidence at

4
time of previous reviews, mainly cross-sectional studies were included. 3,27 Reviews based

on cross-sectional studies are useful to summarize current findings. However, the level of

the evidence cannot be assessed due to the low hierarchy of evidence from this study

design.

Therefore, to examine the time-dependent association between obesity and periodontitis

and how weight-changes may affect the development of periodontitis in the general

population, longitudinal and experimental studies that assessed the association between

overweight, obesity, weight gain, waist circumference and periodontitis were reviewed.

Methods

Included studies had overweight or obesity as exposure and periodontitis as outcome.

Only cohort studies and intervention studies among children, adolescents and adults

published in English were included.

The literature search was performed during December 2013 and June 2014 through the

platforms Pubmed/Medline and Web of Knowledge. The following key terms were used:

Body Weight Changes OR Body Weight OR Weight Gain OR Adiposity OR Body

Composition OR Waist Circumference OR Waist-Hip Ratio OR Body Mass Index OR

Overnutrition OR Overweight OR Obesity OR Metabolic Syndrome

AND

Periodontal Diseases OR Periodontitis OR Alveolar Bone Loss OR Tooth Loss OR Dental

Plaque OR Gingivitis OR Tooth Injuries OR Oral health

Another search combined the abovementioned key words with AND Inflammation OR

Inflammation Mediator

Filters: Humans

5
The selection of articles was performed by two researchers (AK, JFR). First, relevant titles

in the databases were selected. Second and third, all abstracts and full texts were

screened. When uncertainty occurred regarding the inclusion of an article, a third

researcher (BLH) was involved. Reference lists of the included articles and other reviews

were cross-checked to include eventual non-identified studies.

Data on overweight; obesity; waist circumference (WC); weight gain; periodontitis status,

measures and treatment were extracted. Furthermore, data on inflammatory markers, age,

socioeconomic status (SES), smoking, gender, oral hygiene and diabetes were sought.

Study quality and grading of the strength of the evidence (grade I (good/strong) to V (not

assignable)) was assessed by two researchers (AK, JFR) using the “Quality Criteria

Checklist: Primary Research and Primary Research – Non human Subjects” of the

Academy of Nutrition and Dietetics 37. (More information in Supplement: Method and

Supplement: Table 2)

Results

After full texts selection, thirteen papers, eight prospective cohort studies (referred to as

longitudinal studies)38-45 and five clinical trials (referred to as intervention studies)46-50 were

included (Supplement: Figure 1).The eight38-45 longitudinal studies examined association

between overweight/obesity and development of periodontitis. Four clinical trials46, 47, 49, 50

examined the outcome of non-invasive periodontal treatment (NIPT) between obese and

non-obese patients. The fifth study48 investigated NIPT outcome between bariatric surgery

patients and controls. Four longitudinal studies38-41 included men only; the remaining

included both gender.42-45 Four46, 48-50 intervention studies included both gender; one47

included women, only. Two studies were from the same authors group (Gorman et al.).38,

6
39
The list of excluded articles is given in Supplement: Table 1. Characteristics of included

studies are presented in Tables 1-2.

Three longitudinal studies38, 40, 42 found a direct association between obesity at baseline

and subsequent periodontitis development 38, 40, 42, and two studies40, 42 found a direct

association between overweight and periodontitis development. (Table 3-4)

In one study38, 27-year progression in clinical attachment loss (AL) (adjusted-HR=1.52

95%CI 1.05-2.21), alveolar bone loss (ABL) (adjusted-HR=1.60 95%CI 1.07-2.38) and

probing pocket depth (PD) (adjusted-HR=1.40 95%CI 1.02-1.91) was worse for obese

compared to normal-weight men. Another study40 found a 30% increased risk of

developing periodontitis over 20 years among obese men. A 5-year study of Japanese

workers 42 found a three-fold risk of periodontitis development related to obesity among

women HR=3.24; (95%CI 1.32-7.94), but not men (HR=1.44; (95%CI 0.97-2.14)).

Similarly, increased risk of developing periodontal disease was observed for overweight

men in one study40 and for overweight men and women in another.48 No associations were

seen in the study by Saxlin et al.43 (Tables 3-4)

Three studies38, 39, 45 found that weight-gain was directly associated with development of

periodontitis, and men with moderate to large weight-gains, developed more PD or ABL

events than low weight-gainers. 38, 39, 45 A fourth41 study did not find an association

between weight gain from age 21 to 60-70 years and thresholds of periodontitis in adjusted

models.41 (Table 5)

7
Regarding WC, one study38 found that a 1% increment in baseline waist-height-ratio was

associated with 3% increase in the hazard of experiencing AL, ABL or PD progression

over 27 years, and an augmentation of 1cm in WC was associated with a 1-2% increase in

the hazard of AL and PD.38 Another study among overweight men found39 that increased

WC was associated with simultaneously developing incident PD events (p<0.01) over 30

years. Similarly, a third study40 found that, men in the extreme quintile of change in WC

and waist-to-hip-ratio had a 27% and 34% increased risk of developing periodontitis,

respectively, over 20 years.40 (Table 6)

Two cohort studies44, 45 focusing on youth, were identified. 44, 45 In one study, no

association between overweight and obesity and the odds of developing gingivitis, calculus

or PD were found in the adjusted model at eight years.44. However, there was an

association between the number of episodes of obesity, which was calculated by counting

the number of times each participant was considered obese during follow-up, between age

15-24 years, and the simultaneous risk of presenting dental calculus at age 2444. WC was

also directly associated with the odds of developing gingivitis (OR 2.03 (1.20-3.45)) and

calculus (PR 1.08 (1.01-1.15)) at eight year. 44 Mixed results were found in the other study
45
with an increase in BMI over 3 years being directly associated with simultaneous

development of periodontitis when assessed using the Community Periodontal Index score

(p<0.05). No associations were found when using bleeding on probing or PD (p>0.05).45

Among intervention studies46-50, two 48, 50 found that the response to NIPT was better

among lean than obese, whereas three other studies did not find significant differences. 46,
47, 49
(Table 2) One study 50 showed less improvement in clinical parameters following

8
NIPT among obese than among overweight patients, and obese had on average 3.2%

more sites with PD >4mm than normal-weight patients following treatment. Furthermore,

for every BMI difference of 10 kg/m2, the mean percentage of sites with PD >4mm two

months following treatment increased by 2.5%. 50 Another study found response to NIPT in

bariatric patients compared to controls with greater improvement in mean gingival index,

PD, AL and bleeding on probing. 48 Two studies46,49, did not show differences in

periodontal healing between obese and non-obese patients undergoing NIPT (p>0.05). At

baseline, plasma levels of the inflammation markers TNFα and leptin were significantly

higher in the obese (p<0.05; p<0.01) 46, whereas IL-6 and CRP levels were identical. 46 At

follow-up, only IL-6 was significantly lower in the non-obese compared to the obese.46 In

the fifth study 47, there was a trend towards better systemic response to treatment among

normal-weight women compared to obese women, however the difference was not

significant. CRP levels were significantly higher among obese women at baseline,

however no differences were seen after treatment. 47

One longitudinal study44 adjusted for C-reactive protein (CRP), the other studies38-43, 45

only mentioned inflammation in their discussion. Biological markers of inflammation such

as CRP, IL-6 and TNFα were analyzed separately in three46, 47, 49 of the intervention

studies.

Other risk factors than inflammation cited were age, smoking, SES, oral hygiene and

diabetes. All but one 44 longitudinal studies adjusted for age. Six38-42, 44 adjusted for

cigarette smoking and two43, 45 others included only non-smokers. Five studies adjusted for

SES. 38, 39, 41, 43, 44 Oral hygiene was adjusted for in four studies. 38, 41, 43, 45 Four studies38,
40-42
adjusted for diabetes and three38, 43, 45 studies included non-diabetic participants only.

9
The quality score was positive for nine38-41, 43, 44, 46, 47, 49 studies and neutral for four42, 45, 48,
50
(Supplement: table 2). Studies with neutral quality scores presented either undetailed

description of participants, 42, 45 or undetailed descriptions of exposure and outcome. 3, 42,

45, 48, 50
Two studies presented some ambiguities regarding handling of withdrawals.42, 48

The strength of the evidence between development of periodontitis and overweight/obesity

was graded limited to fair, fair for weight gain and good for WC. Regarding periodontal

treatment among overweight/obese patients, the strength of the evidence was graded

limited to fair. (Supplement: table 3-4)

Funding and conflict of interest

All studies but one had a statement regarding conflict of interest. All studies were publicly

funded and one study further reported partial private funding. 50 (Supplement: table 5)

Discussion

The results of the present review suggest that overweight, obesity, weight gain and

increased WC may be risk factors for development or worsening of periodontal measures

such as PB, ABL, AL or plaque index. Evidence from longitudinal studies, with a follow-up

≥ 20 years38-40 was clearer than evidence from studies with shorter follow-ups or from

intervention studies. 41-45 Long-term follow-up minimizes the risk of reverse causation or

confounding from chronic disease at baseline. Short-term longitudinal studies might not

allow for an appropriate temporal sequence of overweight/obesity before periodontitis.

The occurrence of periodontitis seems to be affected by age. Prevalence and severity of

periodontitis increases with age, probably due to longer exposure-time of the periodontal

10
tissue to bacterial plaque.28 Furthermore, as fat increases and lean mass decreases with

age, even minor weight-gains might involve important adverse changes in body

composition that may influence periodontal health.51 Therefore, studies with a longer

follow-up time, and among older participants, might be more likely to show a direct

association. However, as most included studies38-43, 45 adjusted for age, there seems to be

an age-independent association between overweight/obesity and periodontitis. 28, 52

Associations were more consistent for visceral than general adiposity suggesting that

measurement of accumulation of visceral fat may be more strongly associated with

periodontitis incidence than BMI. This is in line with the fact that pro-inflammatory

adipocytokines such as TNF-α and IL-6 are primarily produced by the abdominal adipose

tissue. Several mechanisms are linked to increased levels of TNF-α that may contribute to

the onset of periodontitis. The stimulation of osteoclasts formation and effect on host

response to periodontal bacterial pathogens of TNF-α induce the destruction of alveolar

bones and participate in connective tissues degradation. Regarding IL-6, its association

with periodontitis onsets remains unclear due to its dual pro and anti-inflammatory effect.
29
Seemingly, the role of other cytokines on the pathway between overweight/obesity and

periodontitis has not yet been clarified. 4, 31 The mechanism of how obesity affects the

periodontium is still poorly understood, and this association may be bidirectional. 29, 31,53

Obesity related inflammation may promote periodontitis by secretion of inflammatory

markers by the adipose tissue that may increase gingival inflammation and promote

bacterial proliferation on the tooth root surface. But, periodontitis also induces the

production of pro-inflammatory cytokines that might prompt obesity and other chronic

metabolic diseases. 30, 31

11
Low SES may both influence the propensity to obesity and risk of developing periodontitis.

A recent review 28 concluded that there was a clear association between low SES and

gingivitis but the association was less direct for periodontitis. 28 In the present review,

five38, 39, 41, 43, 44 longitudinal studies controlled for SES in their analyses, showing

discrepant effects.

Among the eight longitudinal studies38-45, four were on men only38-41, and the remaining

included men and women.42-45 Among the latter, one study42 analyzed men and women

separately whereas the other three43-45 did not. In this study, Saxlin et al. (2010) 43 tested

for modification by gender but found no significant interaction, suggesting that gender did

not seem to influence the association between obesity and periodontitis. In a recent study
54
, overweight, obesity and waist-to-hip ratio were associated with increased risk of tooth

loss among men and women. However, the results suggested that markers of

inflammation such as CRP and IL-6 may be mediators of the association between obesity

and tooth loss in men, only. 54

Some studies indicate 28, 55 that men are more at risk for developing periodontitis than

women; whereas others28,56 suggest that women might, during certain periods, be more

vulnerable to development of periodontitis, because of hormone fluctuations that increase

gingival inflammation. From the results of this review, it is not possible to make a clear

conclusion regarding the influence of gender on the association between

overweight/obesity and development of periodontitis, and further studies are needed.

Smoking has been found to contribute to the destruction of the periodontal tissue which

increases periodontitis progression. 28 Studies also show that smokers have a higher

prevalence of periodontitis, deeper periodontal pockets, greater attachment loss and

furcation defects than non-smokers. 57, 58 However, smokers tend to weigh less and gain

12
less weight, limiting the possibility that the association between obesity and risk of

periodontitis is related to smoking. 59 Studies either had excluded smokers, or adjusted for

smoking, which limits the confounding effect of smoking.

The strength of our review lies in its systematic approach and the inclusion of longitudinal

and intervention studies only, limiting the risk of reverse causation. However, among

longitudinal studies, two38, 45 reported results from simultaneous changes in exposure and

outcome, therefore being more prone to reverse causation due to their design resembling

a cross-sectional one. 60

To strengthen the quality of this systematic review, the article search was performed

independently by two researchers (AK, JFR) and a validated quality assessment tool was

used. A limitation of our study is the inclusion of only published studies and restriction to

English language. Publication bias cannot be excluded, as studies with positive results

tend to be more easily published.61

At first, performing a meta-analysis was considered, however, the included longitudinal

studies used different measures and cut-offs to define periodontitis, making a meta-

analysis difficult. Generally PD was the most common measure with seven studies using it.

However, among these studies, the cut-offs used for PD varied from ≥3mm to≥5mm.

(Supplement: table 6) Furthermore, variations regarding the sites and numbers of teeth

examined were present. Such differences in definition and cut-offs might influence study

results, and no clear pattern could be established. Different measures of associations were

also used that were difficult to combine in a meta-analysis and some of the statistical

analyses performed could have introduced bias. In one study38, the time to periodontal

progression was defined as the number of years from the baseline exam to the first exam

where periodontal progression was noted. Therefore, the time to periodontal progression

13
was interval censored, i.e. it occurred sometime between examinations. It is difficult to

assess the nature, direction and size of such bias that arises from the imputation, but

potentially it led to attenuation rather than inflation of the association, giving credit to the

observed direct associations in that study. Furthermore, the anthropometric measures

used in the model associated with the event were treated as time-dependent covariates.

However, the values of the covariates were only obtained at each examination. This

implies that the authors use the last observation carried forward. Again, the magnitude of

the bias associated with such an imputation is difficult to assess. In another study42, the

authors used Cox regression to assess the 5-year incidence of periodontal disease.

However, the data collected is an example of current status data, 62 a special case of

interval censoring where individual's status is observed at one time point . The only

information pertaining to the event of interest corresponds to whether it has occurred in the

5-year period between the baseline and follow-up exam. The choice of model does not

account for the characteristics of the data collected. The subsequent bias arising from both

analyses is, therefore difficult to assess.

Conclusion

Evidence from longitudinal studies, particularly those with a follow-up ≥ twenty years,

suggest that overweight, obesity, weight gain and increased waist circumference, may be

risk factors for developing periodontitis or worsening with regard to periodontal measures.

Results from intervention studies on periodontal clinical response between obese and

normal weight patients undergoing non-surgical periodontal treatment are few and the

evidence for an effect limited. Inflammation, gender and socioeconomic status are likely to

14
play a role in the pathogenesis of obesity and periodontitis. Therefore, more studies

focusing on the influence of these factors are required.

Conflict of interest

This review was supported by Tryg foundation, Virum, Denmark. The authors declare not

having any conflict of interest.

15
 Table 1: included studies with weight (overweight/obesity/weight gain) as the main exposure and periodontitis as the outcome

Reference Study Dataset Population Follow-up Outcome RR/HR/OR/PR /β Exposure Results¥ Inflammation Confounders Q
(author design used and characteristics (+) direct association
and date) country (no anaylized, (NS) no association
gender, age) (-) inverse association

Gorman et Cohort VA Dental 1038 27 years Periodontitis HR Overweight NS - Age A

al. 2012 38 Longitudinal Adults (1969-1996) (ABL, PD, Obesity +* Smoking
Study, USA M AL) WC + Education
21-84 y.o Ttt
N decayed
Prophylaxis
Diabetes

Gorman et Cohort VA Dental 893 30 years Periodontitis Mean±SD Weight gain +** - Age A
al. 2012 39 Longitudinal Adults (1968-1998) (PD) β-coefficient WC +** Smoking
Study, USA M Education
21-84 y.o Oral hygiene

Jimenez et Cohort Health 36910 20years Periodontitis HR Overweight +* - Age A

al. 2012 40 Professional Adults (1986-2006) (self- Obesity +** Smoking
s Follow-up M reported) WC +** Race
Study, USA 40-75 y.o PA
F+V
OH
Dental profession
Diabetes
N teeth

Linden et Cohort Prospective 1362 12 years Periodontits OR Weight change from NS - Age A
al. 2007 41 Epidemiologi Adults (1991-2003) (lth‡/hth#) age 21 to 60-70 y.o Smoking
cal Study of M Education
Myocardial 50-60 y.o SES
Infarction Oral hygiene
(PRIME), Diabetes
Northern
Ireland
Morita et Cohort Nagoya, 2787 5 years Periodontitis HR Overweight + ♂ ** - Age B
al. 2011 42 Japan Adults (2001/2002- (PD) + ♀** Smoking
M+F 2006/2007 Obesity NS ♂ Diabetes
21-69 y.o +♀*
Saxlin et Cohort Health 2000 396 4 years Periodontitis IRR Overweight NS - Age A
al. 2010 43 Survey, Adults (2000-2004) (PD) Obesity NS Gender
Finland M+F Education
30-59 y.o Dental plaque
Oral hygiene
Ttt
N teeth

16
de Cohort Oral health 720 8 years Periodontitis PR Overweight NS CRP Smoking A
Castilhos Study Adolescents/ (GI, calculus, Obesity NS Gender
et al. 2012 (OHS), young adults PD) WC + GI only Education
44
Brazil M+F SES
15-23 y.o Race
Diet

Ekuni et al. Cohort Japan 224 3 years Periodontitis OR BMI increase + CPI* - Age B
2014 45 Adolescents/ (CPI;%BOP, NS;%BOP, PD Gender
young adults PD) Oral hygiene
M+F
17-19 years

World Health Organization (2000) classification: normal weight equated to BMI ≥18.5<25 kg/m2, overweight ≥25 to ≤30 kg/m2 and obese >30 kg/m2. WC normal (men < 94 cm, women < 80 cm), level 1 (men 94 and <102
cm, women 80 and <88 cm) and level 2 (men 102 cm; women 88 cm). Lean et al. 1995
¥ adjusted models
(+) direct association; (NS) no association; * P<.05; **P<.01
Q=Quality: A: Positive – low bias level; B: Neutral – intermediate bias level; C: Negative – high bias level
‡
Lth=Low-threshold: at least two teeth with non-contiguous inter-proximal sites with ≥6mm loss of attachment and with at least one pocket of ≥5 mm
#
Hth: High-threshold: ≥15% of all sites measured had loss of attachment ≥6mm and there was at least one site with deep pocketing (≥6 mm)
M=male; F=female; RR=risk/rate ratio; HR=hazard ratio; OR=odds ratio; PR prevalence ratio; IRR=incidence risk ratio
TTT= treatment; WHtS=waist-height ratio; WHR=waist-hip ratio; CP= chronic periodontitis; TL= tooth loss; PI=plaque index; GI=gingivitis/gingival regression; tertile 2= moderate weight gain; tertile 3=large weight gain;
CPI=Community Periodontal Index; BOP=bleeding on probing

17
 Table 2: included studies on periodontal treatment outcomes among participants with different weight status (overweight/obesity/weight gain)

Reference Study Dataset Population Follow- Outcome Periodo RR/ Intervention/ Exposure Results¥ Inflammation Quality
(author design used and characteristi up ntal TTT HR/OR/
and date) country cs PR
(no Β
anaylized,
gender, age)
Altay, Clinical trial Turkey 46 3 Periodontitis non- Median value Test : Obese + CP Control : Non NS CRP, IL-6, TNF- A
Gürgan Adults months (AL, PD, PI, invasive Mean±SD obese + CP α, leptin
and M+F GI, BOP)
Agbaht >25 y.o
2013 46
Al-Zahrani Clinical trial Saudi 40 2 Periodontitis non- Mean±SD Test : Obese + CP Control : Non NS CRP A
& Arabia Adults months (AL, PD, PI, invasive obese + CP
AlGhamdi F BOP)
2012 47 >35 y.o
Lakkis et Clinical trial US 30 6 weeks Periodontitis non- Mean±SD Test : ¶Obese+ CP Control : Obese + +** - B
al. 2012 48 Adults (PD, AL, GI, invasive + BS CP
M+F PI, BOP)
35-59 y.o

Zuza et al. Clinical trial Brazil 52 3 Periodontitis non- Mean±SD Test : Obese + CP Control : Non NS Il-1β, IL-6, A
2011 49 Adults months (PD, AL, GI, invasive obese + CP TNFα, IFNγ
M+F PI, BOP)
35-55 y.o

Suvan et Secondary UK, Italy 260 2 Periodontitis non- coefficient (95% CI) Test : Control : Normal - B
al. 2014 50 analysis Adults months (PD, invasive Overweight + weight
(pooled M+F %PD>4mm obese
data of 5 27-77 y.o AL, FMBS)
clinical
trials)
World Health Organization (2000) classification1: normal weight equated to BMI <25 kg/m2, overweight ≥25 to ≤30 kg/m2 and obese >30 kg/m2
¥ adjusted model
(+) direct association; (NS) no association; * P<.05; **P<.01
Quality: A: Positive – low bias level; B: Neutral – intermediate bias level; C: Negative – high bias level
‡
Lth=Low-threshold: at least two teeth with non-contiguous inter-proximal sites with ≥6mm loss of attachment and with at least one pocket of ≥5 mm
#
Hth: High-threshold: ≥15% of all sites measured had loss of attachment ≥6mm and there was at least one site with deep pocketing (≥6 mm)
¶
The intervention group are obese people with a loss of 40% excess weight after BS; The control group are obese people without BS nor weight loss
M=male; F=female; RR=risk/rate ratio; HR=hazard ratio; OR=odds ratio; PR prevalence ratio; IRR=incidence risk ratio; SD=standard deviation; SE=standard error
WhtS=waist-height ratio; WHC=waist-hip ratio; CP= chronic periodontitis; TL= tooth loss; PI=plaque index; GI=gingivitis/gingival regression; BOP=bleeding on probing; BS=bariatric surgery; FMBS=full-mouth gingival
bleeding scores

18
 Table 3: Association between obesity and periodontitis by gender

Reference Years of Age Exposure Outcome Association HR (95%CI) IRR (95%CI) PR

(author and date) follow-up (year)

F M
Gorman et al 27 21-84 Obesity Periodontitis (PD) + 1.40 (1.02-1.91)
201238
Jimenez et al 20 40-75 Obesity Periodontitis + 1.30 (1.17-1.45)
201240
Morita et al 5 21-69 Obesity Periodontitis + NS 3.24 (1.32-7.94)
201142 1.44 (0.97-2.14)
Saxlin et al 4 30-59 Obesity Periodontitis NS NS 1.3 (0.7-2.1)
201043
Castilhos et al 8 15-23 Obesity Periodontitis NS NS 1.01 (0.25-4.0)
201244
F: female; M: male

Table 4: Association between overweight and periodontitis by gender

Reference Years of Age Exposure Outcome Association HR (95%CI) IRR (95%CI) PR

(author and date) follow-up (year)

F M

Jimenez et al 20 40-75 Overweight Periodontitis + 1.09 (1.02-1.18)

201240
Morita et al 5 37.3 Overweight Periodontitis + + 1.70(1.15-2.55); 1.30
201142 (1.11-1.53)
Saxlin et al 4 30-59 Overweight Periodontitis NS NS 1.2 (0.7-1.8)
201043
Castilhos et al 8 15-23 Overweight Periodontitis NS NS 0.99 (0.25-4.00)
201244
F: female; M: male

19
 Table 5: Association between weight gain and periodontitis by gender

Reference Years of Age Exposure Outcome Association HR (95%CI) OR (95%CI) P-value

(author and follow-up (year)
date)

F M
Gorman et al 27 21-84 Weight gain Periodontitis + 1.05 (1.01-1.09)
201238
Gorman et al 30 21-84 Weight gain Periodontitis + P<.01
201239
Linden et al 12 50-60 Weight gain Periodontitis NS 1.33 (0.95-1.86)
200741
Ekuni et al 3 17-19 Weight gain Periodontitis + + 1.95 (1.05-3.57)
201445 (BMI)
F:female; M: male

Table 6: Association between waist circumference and periodontitis by gender

Reference Years of Age Exposure Outcome Association HR (95%CI) OR (95%CI) P-value

(author and follow-up (year)
date)

F M
Gorman et al 30 21-84 Waist circumference Periodontitis + P<.05
201239
Gorman et al 27 21-84 Waist circumference Periodontitis + 1.03 (1.01-1.05)
201238
Jimenez et al 20 40-75 Waist circumference Periodontitis + 1.27 (1.11-1.46)
201240
Castilhos et al 8 15-23 Waist circumference Periodontitis + + 2.03 (1.20-3.45)
201244
F:female; M: male

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