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Association of anthropometric measures and dental caries among a group of adolescent cadets of Udupi district, South India.

Introduction

Obesity and overweight are defined as being an excess of body fat related to lean mass, with multi-factorial conditions involving psychological, biochemical, metabolic, anatomic and social alterations [Taubes, 1998]. Obesity has reached epidemic proportions globally, with more than one billion adults overweight--at least 300 million of them clinically obese--and is a major contributor to the global burden of chronic disease and disability. Often coexisting in developing countries with under-nutrition, obesity is a complex condition, with serious social and psychological dimensions, affecting virtually all ages and socio-economic groups [Puska et al., 2003]. Studies from developing countries such as India report a high prevalence of obesity and overweight among school children [Kapil et al., 2002; Ramachandran et al., 2002; Chhatwal et al., 2004; Khadilkar and Khadilkar, 2004; Marwaha et al., 2006]. Economic growth, urbanisation and globalisation of food markets are some of the forces that can possibly influence this epidemic [Puska et al., 2003].

An increased caries experience is biologically plausible in obese/overweight children. Childhood obesity may also lead to serious diseases including decrease in life expectancy, greater risk for type 2 diabetes, cardiovascular disease, asthma, arthritis and poor general health [Sinha et al., 2002]. Obese adolescents are more likely to become obese adults, posing an increased risk of morbidity and early mortality in adulthood [Freedman et al., 2001].

Previous studies have shown inconsistent association between dental caries and body adiposity [Kantovitz et al., 2006; Gerdin et al., 2008]. Dental caries correlated positively with body mass index (BMI) [Larsson et al.,1995: Alm et al., 2008; Honne et al., 2011] while a systematic review of studies published from 1984 to 2004 showed an inconclusive relationship between obesity and dental caries [Kantovitz et al., 2006].

Various parameters such as weight, height for age, weight/ height and body mass indices were used previously in establishing relationships between obesity/overweight and dental caries. Hence the relationship of these various anthropometric measures and dental caries remains questionable. Also, when the prevalence of obesity and overweight or dental caries is low, the relationship cannot be established.

The voluntary civil defence units are an important part of any nation's security apparatus and are of help in times of war, natural disasters and other such national crises. Schools are a fertile area for enrolment into these organisations. The children are taught to become self-dependent, socially responsible adults who can be called upon to serve the nation at times of crisis. The National Cadet Corps (NCC) is one such organisation which is operated by the armed forces in India. The NCC, the reserve defence forces of India, recruit and train cadets enrolled through voluntary participation of adolescents from schools throughout the country. Training involves routine participation in drills, exercises, sports, and other recreational activities like mountaineering and trekking. Since the enrolment process is voluntary, it is not surprising to find adolescents with a more boisterous, aggressive nature with a greater interest in finding their career in armed forces which demand good oral and general health. The association of body adiposity status and dental caries in this physically active group remains ambiguous.

Therefore, we conducted a study to evaluate the relationship between the various anthropometric measures and dental caries among a group of adolescent cadets of Udupi district, India.

Materials and methods:

This study was carried out among a group of National Cadets Corps participating in the annual training camp held in August 2011. These cadets were students from various government and private schools within the field practice area of Manipal University in Udupi District, India. Written informed consent forms were distributed one week before the survey. All the children were asked to get these forms duly signed by either of the parents to express their willingness for participation in the study. Before conducting the survey, a brief description of the study objective and methods was given to all the cadets to encourage their participation. A verbal consent was obtained from the children at the time of participation. The study was also approved by the Institutional Ethics Committee, Manipal University, India. All cadets who were present on the day of the survey (n = 220) and who gave consent for the study were included constituting a total sample of 211. Children with systemic diseases, prolonged illness and those who had undergone orthodontic treatment (n = 6) were excluded from the study. Calibration and training exercises for measurement of clinical indices were conducted in the Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal University.

Demographic measures such as age, sex and parental education were recorded for each cadet before examination. Anthropometric measures recorded were weight, height, mid-upper arm circumference (MUAC), hip circumference (HC) and waist circumference (WC). Measures of weight (kilograms) and height (meters) were assessed using a standard physician's scale and a stadiometer respectively. WC was measured at the minimum circumference between the iliac crest and the rib cage. MUAC measurements were taken in centimetres with non-elastic tape to the nearest 0.1 mm on the upper left arm (halfway between the acromion process and the olecranon process). Hip circumference was recorded as the greatest measurement around the buttocks and below the iliac crest. BMI was calculated by the formula weight/[height.sup.2]. Anthropometric recordings were performed by two trained and calibrated examiners in a closed enclosure with sufficient lighting conditions.

Clinical examination: Caries in the permanent dentition was assessed according to the guidelines given by WHO (1997) using plain mouth mirrors and CPI probes under natural daylight. Decayed, missing and filled teeth (DMFT) due to caries were recorded for each individual and summarised as DMFT index by a calibrated investigator who was not aware of the BMI (PKC). Only teeth missing due to caries were considered as missing. The intra-examiner reliability for caries diagnosis was assessed by re-examining 10% of the sample, one week after the first examination. Cohen's Kappa coefficient for assessment of dental caries was 0.97, indicating good intra-examiner agreement. Cadets were categorised as caries-free (DMFT = 0) and caries experienced (DMFT [greater than or equal to] 1).

Statistical analysis: Chi-square test was performed for assessing differences between socio-demographic factors and caries experience. Poisson regression was used to evaluate the association of various anthropometric measures. A stratified analysis was performed to evaluate independent association of anthropometric measures with dental caries. All statistical analyses were performed using SPSS software (17.0, SPSS Inc., Chicago Ill, USA). A p value of < 0.05 was considered statistically significant.

Results

A total of 211 cadets with age range of 12-19 years constituted the final sample. Males were the major component of the sample (93.8%)., a majority of the parents had primary level education (42.7%). Caries status was significantly different with respect to age and gender (p=0.049 and 0.05 respectively) (Table 1).

Multi-variate analysis was performed using Poisson regression with DMFT as dependent variable and anthropometric measures as predictor variables. To assess the independent association of these predictors, a stratified analysis was performed based on the significant demographic variables.

Height, weight, BMI and WC showed significant association with dental caries status. Cadets who were taller, heavier, obese/overweight, and those had a higher waist circumference were more likely to have more caries scores (OR = 10.61, 1.03, 1.09 and 1.02 respectively) (Table 2).

Stratified analysis was conducted twice using age group and gender (Table 3). Only predictors which had significant association with dental caries in the Poisson regression were used for this analysis. Among 12-14 years only male cadets were present. No association was seen with anthropometric measures (height, weight, BMI and WC) and dental caries in this group. Among 15-19 years age group, both males and females had significant association between anthropometric measures (height, weight and BMI) and dental caries.

Discussion

The study of dental caries remains a daunting task to the oral health professional due to its multi-factorial nature. Due to recent increase in global prevalence of obesity, a plausible biological gradient between obesity and dental caries was proposed in the literature using diet as a common risk factor. A systematic review on this relationship reported inconclusive results [Kantovitz et al., 2006].

The present study showed that weight, height, BMI and WC had significant association with dental caries. Similarly caries experience was significantly different in age groups and gender. Hence we performed a stratified analysis using age and gender to evaluate the specific association if any. This study reported a significant association of dental caries with height, weight and BMI in both males and females of 15-19 year age group only. This was in accordance with previous studies where elevated BMI was found to be associated with increased dental caries [Larsson et al., 1995; Willershausen et al., 2004; Hilgers et al., 2006; Honne et al., 2011].

Exploration of the link between weight and oral health in children has been controversial. A recent study in school children found a positive correlation between weight and caries experience in primary and mixed dentitions. [Willershausen et al., 2007] Other studies, however, have not found any association. [Macek and Mitola, 2006; Moreira et al., 2006; Tambelini et al., 2010] The lack of association between weight and dental caries in 12-14 year children was in accordance with studies conducted by Chen and co-workers [Chen et al., 1998] in 3 year old children and by Moreira and co-workers [Moreira et al., 2006] in 12-15 year olds. This might be due to the fact that many teeth could have recently erupted and for caries to progress, a considerable period of time is needed. When prevalence of caries is low, such a relationship could not be established.

The association between height and dental caries has not explored in the literature. Many studies have considered height as a parameter for calculating the BMI, but have not related it to dental caries. Our study reported a significant association between dental caries and height only in 15-19 year olds. The association of BMI with dental caries is dependent on both height and weight. Hence it is important to evaluate the association of height and dental caries to have an insight into the association of dental caries with obesity.

Waist circumference showed a significant association when the overall sample was considered but failed to show a significant association in stratified analysis. This could be due to the gender variations in wc in the overall sample. The fact that females tend to have higher wc than males could possibly influence such association to be significant. The effect might have been nullified when the stratification was performed as per gender and age groups. The WHO expert consultation committee [2004] recommended that in populations with a predisposition to central obesity, wc should also be used to refine action levels on the basis of BMI. Hence it is recommended that wc be used to evaluate any relation with dental caries in further studies.

Chen and co-workers [Chen et al., 1998] discussed a triangular relationship between dental caries, obesity and frequency of sugar ingestion. Time or duration in years should be taken into consideration to evaluate such relationships. If substantial numbers of teeth are newly erupted, then even in the obese children an association of caries and obesity will not be demonstrated. This could be one of the reasons why many studies including our study in 12-14 years reported a lack of association. During this period, not all the teeth have been in the mouth for long enough to develop clinical dental caries even with significant risk. WHO also recommends in its surveys to evaluate 15 year olds to get the representative view of dental caries in the permanent dentition of adolescents. The caries index which was used in our study did not take into consideration the actual number of teeth at risk. Since it is the most widely accepted index in the dental fraternity and recommended by WHO for oral health surveys, we had considered the same index to ensure comparability with other studies.

A small sample size with respect to the 15-19 year age group was one of the major limitations in the present study as the reported association could not be generalised. Studies conducted previously among NCC adolescents in this area have also reported a low enrolment of females (Singh, 2009; Kalyana et al., 2012). In India, it is not common among females to choose such a boisterous and aggressive career. Others limitations of our study include its cross-sectional nature and lack of any information on dietary habits. Caries prevalence [Acharya et al., 2011] and obesity/overweight [Ramachandran et al., 2002; Marwaha et al., 2006] in India, like in western countries have shown a strong association with socio-economic circumstances as reported by various investigators. In our study, we evaluated only parental education as a proxy measure of socio-economic status which showed no significant difference in caries prevalence. A study conducted in this region showed significant association of dental caries with type of school and socio-economic status. The present study might not represent a true sample of the community although it provides an insight about the association of dental caries and anthropometric measures in different age groups. Caries was diagnosed as per WHO recommendation under natural day light using a mouth mirror and CPI probe [1997]. This method is widely followed in oral health surveys and acceptable for countries like India where resources are scarce.

Conclusion

There was a significant association between anthropometric measures and caries status in the 15-19 years age group while no association was seen in the 12-14 years age group. Obesity and dental caries have common risk determinants and require a comprehensive multi-disciplinary approach by both general health and oral care professionals.

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P.K. Chakravathy *, D. Chenna **, V. Chenna **

* Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal University, Manipal, India.

*** Department of Medicine, ** Rangaraya Medical College, Kakinada, Andhra Pradesh, India.

Postal address: P.K. Chakravarthy, Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal-576104, Manipal University, Karnataka, India.

Email: drkalyan81@gmail.com
Table 1. Comparison of demographic characteristics and caries
status

Parameter                         Caries-free       Caries
                                     N (%)         experienced
                                                      N (%)

Age (years)        12-14          102 (59.6)        69 (40.4)
                   15-19           17 (42.5)        23 (57.5)
sex                Male           115 (58.1)        83 (41.9)
                   Female          4 (30.8)          9 (69.2)
Parent education   Illiterate      13 (59.1)         9 (40.9)
                   Primary         53 (58.9)        37 (41.1)
                   Secondary       45 (59.2)        31 (40.8)
                   Intermediate    4 (30.8)          9 (69.2)
                   Graduate         4 (40)            6 (60)

Parameter                           Total      p-value
                                    N (%)

Age (years)        12-14           171 (81)     0.049
                   15-19           40 (19)
sex                Male           198 (93.8)    0.05
                   Female          13 (6.2)
Parent education   Illiterate     22 (10.4)     0.277
                   Primary        90 (42.7)
                   Secondary       76 (36)
                   Intermediate    13 (6.2)
                   Graduate        10 (4.7)

Distribution significantly different, p < 0.05, Chi-square test

Table 2. Poisson regression analysis with DMFT as
variable and anthropometric measures as independent
variable.

Parameter   p-value    OR        95% CI

                              Lower   upper

Height      < 0.001   10.61   2.81    40.07
Weight      < 0.001   1.03    1.02    1.04
BMI         < 0.001   1.09    1.04    1.14
MUAC         0.559    1.01     .99    1.03
WC           0.040    1.02    1.00    1.03
HC           0.400    1.00    1.00    1.01

BMI = body mass index, MUAC = mid-upper arm
circumference, WC = waist circumference, HC = hip
circumference

Table 3. Stratified analysis for evaluating independent association
of anthropometric measures with dental caries using Poisson regression

Parameter   Age group    sex     p-value    OR       95% CI
             (Years)
                                                  Lower   upper

Height        12-14      Male     0.997     1      .98    1.02
              15-19      Male     0.016    1.03   1.01    1.06
                        Female   < 0.001   1.15   1.07    1.23
Weight        12-14      Male     0.220    0.99   0.97    1.01
              15-19      Male     0.010    1.03   1.01    1.06
                        Female    0.001    1.05   1.02    1.08
BMI           12-14      Male     0.063    0.93   0.85    1.00
              15-19      Male     0.032    1.17   1.01    1.35
                        Female    0.036    1.10   1.01     1.2
WC            12-14      Male     0.980    .98    0.98    1.019
              15-19      Male     0.169    1.04   0.98    1.09
                        Female    0.974    1.00   0.96    1.05
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Author:Chakravathy, P.K.; Chenna, D.; Chenna, V.
Publication:European Archives of Paediatric Dentistry
Article Type:Report
Geographic Code:9INDI
Date:Oct 1, 2012
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