10.59987/ads/2016.3.65-72
Objective. The association between obesity and periodontitis has been extensively investigated in adults but not in young people. The aim of this study was to examine the association between overweight-obesity and periodontal disease in pediatric subjects.
Methods. Controlled cross-sectional study involving 100 school children of both gender (50 M and 50 F) between 7 and 12 years of age (mean age 9,19±1,57). Two groups were formed based on Body Mass Index value: test group with BMI ≥ 25 Kg/m2 and control group with BMI ≤ 24 Kg/m2. Diet intake and oral hygiene habits were recorded by a specific questionnaire and the periodontal clinical parameters were evaluated.
Results. The periodontal examination in the control group revealed a full-mouth plaque score (FMPS) value equal to 21.86% against 50.08% in the group of patients overweight/obese; the fullmouth bleeding score (FMBS) in the control group amounted to 12.7% against 26.24% of test group. No patient in either group included in the study presented a probing pocket depth (PPD) ≥3, so a significant difference regarding this value was not found. Regarding the frequency and quantity of food consumption, the number of obese patients who did not follow a balanced diet largely exceeded the number of normal-weight patients (70 versus 20%).
Conclusions. These results focus the attention on the negative impact of obesity on gingival health in young subjects, probably due to a combination of metabolic and inflammatory profiles and the result of a careless attitude towards prevention diseases of the oral cavity.
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Annali di stomatologia
food habits
Childhood overweight-obesity and periodontal diseases: is there a real correlation?
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Case Report
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2016
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Childhood overweight-obesity and periodontal diseases: is there a real correlation?
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                                                                                                  Case report



    Childhood overweight-obesity and periodontal
    diseases: is there a real correlation?




                                                                                                         i
                                                                                                       al
    Gian Luca Sfasciotti                                  Conclusions. These results focus the attention on
    Roberta Marini                                        the negative impact of obesity on gingival health




                                                                                            n
    Andrea Pacifici                                       in young subjects, probably due to a combination
    Gaetano Ierardo                                       of metabolic and inflammatory profiles and the re-




                                                                                         io
    Luciano Pacifici                                      sult of a careless attitude towards prevention dis-
    Antonella Polimeni                                    eases of the oral cavity.




                                                              az
                                                          Key words: periodontal diseases, gingival dis-
    Department of Oral and Maxillofacial Sciences,        eases, pediatric obesity, child nutrition disorders,
    “Sapienza” University of Rome, Italy                  food habits.




                                                            rn
    Corresponding author:                                 Introduction
    Roberta Marini
    Department of Oral and Maxillofacial Sciences,        Obesity is defined as an excess of body fat that caus-




                                                          te
    “Sapienza” University of Rome                         es an alteration in the balance of the physical person
    Via Caserta 6                                         who is affected. The Body Mass Index (BMI) is the
    00168 Rome, Italy                                     most scientifically accurate system to determine the
    E-mail: r.marini@uniroma1.it
                                                     In   amount of fat mass in a subject: it is measured divid-
                                                          ing the weight of the subject in kilograms and the
                                                          square of his height in meters (Kg/m 2). The World
    Summary                                               Health Organization (WHO) and the National Heart,
                                                          Lung and Blood Institute (NHLBI) define overweight
                                                ni

    Objective. The association between obesity and        people with a BMI between 25 and 29.9 and obese
    periodontitis has been extensively investigated in    with BMI>30 (1, 2).
    adults but not in young people. The aim of this       The prevalence of obesity has increased dramatically
                                       io


    study was to examine the association between          in a rather short period of time, doubling for adults
    overweight-obesity and periodontal disease in pe-     and tripling in children and adolescents (3-8). Around
    diatric subjects.                                     31% (about 59 million) of American adults is obese
                              iz



    Methods. Controlled cross-sectional study involv-     and more than 65% reported a BMI>25. In addition,
    ing 100 school children of both gender (50 M and      15.8% of children (6-11 years) and 16.1% of adoles-
    50 F) between 7 and 12 years of age (mean age         cents (12-19 years) are suffering from obesity (1-3).
               Ed




    9,19±1,57). Two groups were formed based on           The United States of America reflect the prevalence
    Body Mass Index value: test group with BMI ≥ 25       internationally regarding obesity, except for the
    Kg/m2 and control group with BMI ≤ 24 Kg/m2. Di-      African continent (3).
    et intake and oral hygiene habits were recorded       Obesity is not only an aesthetic problem but is con-
    by a specific questionnaire and the periodontal       sidered a chronic disease caused by multifactorial eti-
    clinical parameters were evaluated.                   ology represented by genetic, environmental, socio-
 IC




    Results. The periodontal examination in the con-      economic and behavioral components (9-13).
    trol group revealed a full-mouth plaque score         The association between obesity and inflammatory
    (FMPS) value equal to 21.86% against 50.08% in        process has long been known. Adipose tissue is in
    the group of patients overweight/obese; the full-     fact an endocrine organ, metabolically active, produc-
C




    mouth bleeding score (FMBS) in the control group      ing immuno-regulatory factors involved in the regula-
    amounted to 12.7% against 26.24% of test group.       tion of vascular and metabolic processes associated
    No patient in either group included in the study      with alterations like high blood pressure, osteoarthri-
    presented a probing pocket depth (PPD) ≥3, so a       tis, other respiratory disorders, diseases of the gall-
@




    significant difference regarding this value was not   bladder, the hyperlipidemia, atherosclerosis, pancre-
    found. Regarding the frequency and quantity of        atitis, hepatitis and diabetes mellitus (3, 14).
    food consumption, the number of obese patients        Regarding the association between obesity and peri-
    who did not follow a balanced diet largely exceed-    odontal disease, several hypotheses have been for-
    ed the number of normal-weight patients (70 ver-      mulated with the aim to explain the biological interac-
    sus 20%).                                             tions including impaired glucose tolerance, abnormal



    Annali di Stomatologia 2016;VII (3):65-72                                                                 65
    G. L. Sfasciotti et al.


    lipid profile, deficiency of the immune system, an in-       Inclusion criteria:
    creased activation of macrophages, alterations of the        • Children aged between 7-12 years (males and fe-
    microcirculation and secretion of pro-inflammatory                males);
    substances by the adipose tissue such as TNF-a, IL-          • Absence of systemic diseases;
    6 and C-reactive protein (15-19).                            • No drugs intake within 7 days before the visit.
    Although the topic has been treated and investigated         Exclusion criteria:
    in the literature, few appear to be the studies con-         • Girls had menarche.




                                                                                                                     i
    ducted on groups of patients with a specific age             To avoid bias related to teeth eruption states, the




                                                                                                                   al
    range and still today lack the scientific explanations       measures were made only on the first permanent mo-
    that may justify the higher incidence of periodontal         lars and the upper and lower central and lateral in-
    disease in overweight/obese children.                        cisors. The deciduous teeth were not included in the




                                                                                                     n
    The purpose of this study was firstly to assess the          periodontal evaluation.
    state of periodontal health in a group of obese and          For each patient an anamnestic folder containing in-




                                                                                                  io
    normal children between 7 and 12 years in order to           formation about the personal data and medical histo-
    determine if there was a real correlation between pe-        ry was compiled: in addition children were asked to
    riodontal diseases and obesity and, secondly, to find        fill out a questionnaire regarding their oral hygiene




                                                                     az
    a possible cause of this relationship.                       habits – i.e. how many times the child brushes his
                                                                 teeth, the presence of pain and/or bleeding during the
                                                                 tooth brushing etc., and their lifestyle – i.e. their food
    Material and methods                                         habits, possible food intolerances, but also the time




                                                                   rn
                                                                 spent watching TV and/or playing sports, etc. More-
    One hundred patients (50 males; 50 females) aged 7-          over, the Authors investigated about the possible
    12 years (mean age 9.19±1.57), referred at Depart-           presence of sleep disorders (such as noisy breathing,
    ment of Oral and Maxillo-Facial Sciences - “Sapien-          apnea, para-functions, etc.).




                                                                 te
    za” University of Rome, Division of Pediatric Den-           The following data were collected for every patient:
    tistry, between September 2013 and September                 • Age
    2014, were included in the study. The selected pa-           • Weight (Kg)
    tients were divided into 2 groups based on Body
                                                          In     • Height (cm)
    Mass Index (BMI): the test group included 50 patients        • BMI (Body Mass Index) value, according to the
    overweight/obese with BMI ≥ 25 kg/m²; the control            program of the ‘US Department of Health & Human
    group was represented by 50 children of normal               Services’.
    weight with BMI ranging between 18.5-24.9 kg/m².             For each patient both a photographic examination,
                                             ni

    The ethical committee of “Sapienza” University of            comprising 5 photos (Fig. 1), and an evaluation of the
    Rome approved the study protocol (CE 3732 –                  periodontal health, using mirror and periodontal probe
    26/10/2015), and for each patient the relative in-           UNC 15 (Fig. 2), were performed by a single operator
                                    io


    formed consent form was obtained.                            to evaluate the following clinical parameters:
    The study was designed as an observational case-con-         • full mouth plaque score (FMPS): the full-mouth
    trol to assess the state of periodontal health in children        plaque score is defined as the percentage of sites
                              iz



    obese/overweight versus normal weight children.                   where plaque is present divided by the number of
    The statistical analysis of data was performed by mean            sites examined;
    ± standard deviation of each measured parameter.             • full-mouth bleeding score (FMBS): the full-mouth
               Ed




                                                                                    Figure 1. Photographic examination.
 IC
C
@




    66                                                                               Annali di Stomatologia 2016;VII (3):65-72
    Childhood overweight-obesity and periodontal diseases: is there a real correlation?


                                                                            Figure 2. Periodontal evaluation.




                                                                                                                     i
                                                                                                       n           al
                                                                                                    io
                                                                       az
        bleeding score is defined as the percentage of sites       ≥ 25 and a control group consisting of 50 children of




                                                                     rn
        bleeding with respect to the number of sites examined;     normal weight (25 M and 25 F) of the same age.
    •   probing pocket depth (PPD): is the distance from           The group of overweight/obese had a weight average
        the gingival margin to the bottom of the gingival          of 50.76±9.24 kg (mean value ± SD) and an height




                                                                   te
        sulcus/pocket. It is measured by means of a grad-          measured in centimeters of 142.38±10.64. From
        uated periodontal probe with a standardised tip            these data was obtained the mean value of BMI =
        diameter of 0.5 mm. Measurement is taken for               26.38±1.42 kg/m², ranging from 25 (36% of the sam-
        each tooth at the mesio-buccal line angle, the             ple) to a maximum value of 30 (only 1 patient, 2% of
                                                          In
        mid-buccal, the distobuccal line angle, the dis-           the test group). The children in test group had a
        tolingual line angle, the mid-lingual and the              mean age of 9.26±1.62 years old.
        mesio-lingual line (six sites for each tooth). The         The control group included children defined as nor-
        physiological value of PPD is considered to be ≤ 3         mal weight based on the classification of the World
                                                ni

        mm. PPD allows an immediate evaluation of dis-             Health Organization (WHO) with an average weight
        eased sites.                                               of 35.12±4.97 kg and a height of 134.7±8.53 cm: the
                                                                   mean value of BMI was 18.79±2.52kg/m². The aver-
                                       io


                                                                   age age in this group was 9.36±1.78 years old. The
    Results                                                        characteristics of two groups are summarized in Fig-
                                                                   ures 3, 4.
                              iz



    A total of 100 patients (50 males and 50 females), di-         The difference in weight between the two groups is
    vided into two groups in accordance with the classifi-         statistically significant, with a value of 15,64 kg. Re-
    cation of BMI (Body Mass Index), were included in              garding the height of the children, the test group
               Ed




    the study: a test group consisting of 50 children (25 M        showed to be 7,68 cm higher compared to the control
    and 25 F) aged between 7 and 12 years with a BMI               group, but this difference is less significant.
 IC




                                                                                      Figure 3. Characteristics of the control
                                                                                      group.
C
@




    Annali di Stomatologia 2016;VII (3):65-72                                                                              67
    G. L. Sfasciotti et al.


                                                                                   Figure 4. Characteristics of the test
                                                                                   group.




                                                                                                                       i
                                                                                                         n           al
                                                                                                      io
                                                                      az
    Questionnaire:                                                when compared with those of normal weight, evi-




                                                                    rn
    Although the questionnaire had been specially de-             dence that helps explain the apparent gingival inflam-
    signed to be well understood by children, all ques-           mation of patients overweight/obese.
    tions were posed to the parents too in order to avoid         The percentages of the answers regarding the oral
    possible bias in the compilation and understanding of         hygiene habits of the two groups are summarized in




                                                                  te
    the same.                                                     Tables 1, 2.
    As regards to the oral hygiene, the majority of sub-          The food habits and lifestyle questionnaires revealed
    jects in both groups reported brushing their teeth at         that the majority of patients in both groups (respec-
    least twice a day (75 and 81%, respectively for the
                                                         In       tively 90% of obese/overweight children and 85% of
    overweight/obese and normal group) with oscillators           normal weight patients) did not have food intoler-
    and rotators movements, especially using the manual           ances. Consumption of fruits and vegetables was
    toothbrush.                                                   high both in the test and in the control groups (re-
    The majority of subjects in both groups reported to           spectively 85 and 90%). Regarding the frequency and
                                              ni

    have recently gone to the dentist for a check-up visit        quantity of food consumption, the number of obese
    (51 and 70%, respectively, for test and control               patients who did not follow a balanced diet largely ex-
    group). Despite these results, in both groups were            ceeded the number of normal-weight patients (70 ver-
                                    io


    found incorrect procedures in oral hygiene. In fact,          sus 20%). In both groups, the majority of patients
    the 85% of test group’s patients reported to brush            practiced sports. The study finally reported sleep
    their teeth with less than 2 minutes and 75% to               anomalies in patients overweight/obese: 80% of
                              iz



    change the brush only when it broke.                          these children, in fact, were affected by sleep disor-
    The overweight/obese children have also shown a               ders such as noisy breathing, apnea and/or parafunc-
    worse predisposition in oral hygiene procedures               tional habits of the stomatognathic system (clenching,
               Ed




    Table 1. Percentages of the answers regarding the oral hygiene habits of the control group.

                                                     CONTROL GROUP
 IC




    How many times brushing teeth         1                          2                            3
                                          4%                         81%                          15%
    Time spend to brushing                1 min                      < 2 min                      >2min
                                          4%                         85%                          11%
C




    Toothbrush chancing                   Every month                Every 2 months               When it broken
                                          25%                        70%                          15%
@




    Gingival pain                         Yes                                     No
                                          15%                                     85%
    Gingival bleeding                     Yes                                     No
                                          15%                                     85%
    Topical fluoride use                  Yes                                     No
                                          60%                                     40%


    68                                                                                 Annali di Stomatologia 2016;VII (3):65-72
    Childhood overweight-obesity and periodontal diseases: is there a real correlation?


    Table 2. Percentages of the answers regarding the oral hygiene habits of the test group.

                                                               TEST GROUP
    How many times brushing teeth               1                        2                        3
                                                15%                      75%                      10%
    Time spend to brushing                      1 min                    < 2 min                  >2min




                                                                                                                     i
                                                                                                                   al
                                                10%                      85%                      5%
    Toothbrush chancing                         Every month              Every 2 months           When it broken
                                                5%                       20%                      75%




                                                                                                         n
    Gingival pain                               Yes                                  No
                                                80%                                  20%




                                                                                                      io
    Gingival bleeding                           Yes                                  No
                                                80%                                  20%




                                                                          az
    Topical fluoride use                        Yes                                  No
                                                80%                                  20%




                                                                        rn
    teeth grinding), compared to 20% of the subjects en-              and obesity has been extensively studied in adults,
    rolled in the control group.                                      this correlation was not as investigated in children
    The specific percentages for each answer regarding                population. In this study, the Authors examined 100




                                                                      te
    these topics are summarized in Tables 3, 4.                       children referred at the Unit of Pediatric Dentistry,
                                                                      Department of Oral and Maxillo-Facial Sciences,
    Clinical evaluation:                                              “Sapienza” University of Rome, with aiming to test
    The clinical examination of periodontal health in the
                                                                In    the association between obesity and periodontal dis-
    control group revealed a FMPS value equal to                      ease in children between 7 and 12 years, assessing
    21.86% against 50.08% in the group of patients over-              the FMPS, FMBS and PPD. The choice of this range
    weight/obese; the FMBS in the control group amount-               age was dictated by the need to have subjects that
    ed to 12.7% against 26.24% of test group. No patient              presented the central and lateral permanent in-
                                                    ni

    in either group included in the study presented a                 cisors, upper and lower, and the first permanent mo-
    PPD≥3, so a significant difference regarding this val-            lars. The decision to not evaluate subjects with
    ue was not found.                                                 more than 12 years old has been established to pre-
                                       io


    The periodontal measures of both groups are sum-                  vent potential bias related to hormonal disorders of
    marized in Table 5.                                               menarche.
                                                                      The results showed that the presence of plaque is the
                              iz



                                                                      most significant early sign of gingival inflammation.
    Discussion                                                        An high value of FMPS (%) is in fact recorded in all
                                                                      studied subjects: our results showed that an increase
               Ed




    While the relationship between periodontal disease                in fat mass corresponds to an increase of the plaque

    Table 3. Percentages for each answer regarding food and life habits of the control group.

                                                              CONTROL GROUP
 IC




    Food intolerances                                   Yes                                No
                                                        15%                                85%
    Consumption of fruits and vegetables                Yes                                No
C




                                                        90%                                10%
    Balanced diet                                       Yes                                No
                                                        80%                                20%
    Sport                                               Yes                                No
@




                                                        95%                                5%
    Watch tv more than 1 hour/day                       Yes                                No
                                                        100%                               0%
    Sleep disorders                                     Yes                                No
                                                        15%                                85%


    Annali di Stomatologia 2016;VII (3):65-72                                                                           69
    G. L. Sfasciotti et al.


    Table 4. Percentages for each answer regarding food and life habits of the test group.

                                                          TEST GROUP
    Food intolerances                              Yes                                  No
                                                   10%                                  90%
    Consumption of fruits and vegetables           Yes                                  No




                                                                                                                       i
                                                                                                                     al
                                                   85%                                  15%
    Balanced diet                                  Yes                                  No
                                                   30%                                  70%




                                                                                                       n
    Sport                                          Yes                                  No
                                                   95%                                  5%




                                                                                                    io
    Watch tv more than 1 hour/day                  Yes                                  No
                                                   100%                                 0%




                                                                       az
    Sleep disorders                                Yes                                  No
                                                   80%                                  20%




                                                                     rn
    Table 5. Periodontal results of both groups.

                 TEST GROUP                                               CONTROL GROUP




                                                                   te
    FMPS%                          FMBS%                         FMPS%                           FMBS%

    50.08%                         26.24%                        21.86%                          12.7%
                                                          In
    FMPS= Full mouth plaque score; FMBS= Full-mouth bleeding score.



    index and gingivitis, as well as demonstrated in other        creasing weight and waist circumference. In particu-
                                             ni
    studies (15, 16, 20). Resulting clear the mechanism           lar, it was found that in subjects between 17 and 21
    by which adipose tissue secretes cytokines and acti-          years, each increase of 1 kg was associated with a
    vates molecules involved in inflammation, still the sci-      6% increase in the risk of periodontal disease; simi-
                                    io


    entific opinion is confused and contradictory regard-         larly, every increase of 1 inch of waist circumference
    ing the relationship between obesity and periodontal          was related to a 5% increase in the risk of periodonti-
    disease. Saxlin et al. (21) have shown in a long-term         tis. In contrast, there was no relationship between
                              iz



    study, which involved 396 obese subjects with a               these parameters in younger children aged between
    mean follow-up of 4 years, as obesity is associated           13 to 16 years.
    with periodontal disease but does not constitute a risk       Modéer et al. (28) have recently investigated pedi-
               Ed




    factor. In contrast, in another longitudinal study of         atric obesity as an indicator risk for periodontal dis-
    3,590 Japanese adults, a dose-dependent correlation           ease comparing a group of 52 obese children and
    between BMI and the development of periodontitis              adolescents between 11 and 17.9 years and a group
    was demonstrated (22). Another study carried out on           of 52 subjects of the same age of normal weight. The
    4,246 adults of Korean nationality revealed that sub-         study reported a worse oral hygiene, an higher inci-
    jects with a BMI>25 had a minimal risk compared to            dence of bleeding on probing (BOP%) and the pres-
 IC




    individuals of normal weight to develop periodontitis,        ence of pathological periodontal pockets (>4 mm) in
    while subjects with abdominal fat were significantly          obese subjects compared to the control group.
    exposed to the gingival disease (23): this result is to       Our results do not resolve the dilemma on the causes
    suggest that the metabolic syndrome plays a role in           of the correlation between periodontal diseases and
C




    inflammation of the periodontium, like suggested in           excess body fat: what is evident though is that the ac-
    other studies (24-26).                                        cumulation of plaque and the consequent gingival in-
    On the other hand, some Authors have pointed out              flammation is much more common in children with
    that the scientific evidence supporting the presence          BMI>25. Obese children show, in addition, a lifestyle
@




    of a biological mechanism underlying the association          less correct than normal-weight peers. While for
    between obesity and periodontal infection is not fully        adults the correlation between unhealthy lifestyles
    convincing, assuming a bias related to poor oral              (smoking, high-calorie diet, physical activity) and on-
    health of obese individuals. Reeves et al. (27) ana-          set of periodontitis is well-known, the same cannot be
    lyzed this possible correlation in a group of American        said for children because all the patients declared to
    teenagers between 13 and 21 years concluding that             devote insufficient time to brushing teeth and to con-
    the onset of periodontitis may be associated with in-         sume high amounts of cariogenic foods.

    70                                                                                 Annali di Stomatologia 2016;VII (3):65-72
    Childhood overweight-obesity and periodontal diseases: is there a real correlation?


    Conclusions                                                                  Jan;107(1):81-91.
                                                                             12. Cinar AB, Murtooma H. Interrelation between obesity, oral
                                                                                 health and life-style factors among Turkish school children.
    In conclusion, the results want to focus the attention
                                                                                 Clinical oral invest. 2011 Apr;15(2):177-184.
    on the negative impact of obesity on gingival health
                                                                             13. Wardle J, Carnell S, Haworth CM, Plomin R. Evidence for
    in young subjects, probably due to a combination of                          a strong genetic influence on childhood adiposity despite the
    factors, like metabolic and inflammatory profiles and                        force of the obesogenic environment. Am J Clin Nutr. 2008
    the result of a careless attitude towards prevention




                                                                                                                                        i
                                                                                 Feb;87(2):398-404.




                                                                                                                                      al
    diseases of the oral cavity, including hygiene proce-                    14. Mohamed-Ali V, Pinkey JH, Copack, SW. Adipose tissue as
    dures at home, knowledge of a balance diet and re-                           an endocrine and paracrine organ. Int J Obes Relat Metab
    spect for periodic check-up to the dentist (29, 30). In                      Disord. 1998 Dec;22(12):1145-58.
    the literature is described the possibility of using                     15. Scorzetti L, Marcattili D, Pasini M, Mattei A, Marchetti E, Mar-




                                                                                                                      n
    protective microorganisms present in dental plaque                           zo G. Association between obesity and periodontal disease
    as Lactobacillus brevis to suppress the growth of                            in children. Eur J Paediatr Dent. 2013 Sep;14(3):181-4.




                                                                                                                   io
                                                                             16. Dalla Vecchia CF, Susin C, Rösing CK, Oppermann RV, Al-
    pathogenic bacteria. Lactobacillus brevis has anti-
                                                                                 bandar JM. Overweight and obesity as risk indicators for pe-
    inflammatory activity due to its ability to inhibit, in                      riodontitis in adults. J Periodontol. 2005 Oct;76(10):1721-8.
    particular macrophages, the nitrogen oxide synthase




                                                                                 az
                                                                             17. D’Aiuto F, Sabbah W, Netuveli G, Donos N, Hingorani AD,
    activity, indirectly causing a reduction in the levels                       Deanfield J, Tsakos G. Association of the metabolic syndrome
    of inflammatory cytokines (31). These considera-                             with severe periodontitis in a large U.S. population-based sur-
    tions suggest the need to investigate more deeply                            vey. J Clin Endocrinol Metab. 2008 Oct;93(10):3989-94.
    the relationship between severe obesity and peri-                        18. Chaffee BW, Weston SJ. The association between chron-




                                                                               rn
    odontal health, evaluating the possible presence of                          ic periodontal disease and obesity: a systematic review with
    microbiological alterations at the level of saliva                           meta-analysis. J Periodontol. 2010 Dec;81(12):1708-24.
    and/or the crevicular fluid in the test group respect                    19. Ylöstalo P, Suominen-Taipale L, Reunanen A, Knuuttila M.
                                                                                 Association between body weight and periodontal infection.
    the control sample (32, 33).




                                                                             te
                                                                                 J Clin Periodontol. 2008 Apr;35(4):297-304.
                                                                             20. Franchini R, Petri A, Migliario M, Rimondini L. Poor oral hy-
    Conflict of interest                                                         giene and gingivitis are associated with obesity and over-
    The Authors disclosure that they have not been any                           weight status in paediatric subjects. J Clin Periodontol. 2011
    conflict of interest for the study.
                                                                     In          Nov;38(11):1021-8.
                                                                             21. Saxlin T, Ylo¨stalo P, Suominen-Taipale L, Mannisto S, Knu-
                                                                                 uttila M. Association between periodontal infection and obe-
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        Pischon T. Obesity, inflammation, and periodontal dis-                   90(2):199-202.
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        Loyola-Rodríguez JP. Relationship between overweight-obe-                nation Survey. J Periodontol. 2010 Apr; 82(4):533-42.
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