|Year : 2016 | Volume
| Issue : 1 | Page : 23-26
Association between Smoking, Body Mass Index, and Periodontal Disease: A Case-Control Study
Shelly Arora, Srinivas Sulugodu Ramachandra, Kalyan C Gundavarapu
Faculty of Dentistry, SEGi University, Petaling Jaya, Malaysia
|Date of Web Publication||27-Jun-2016|
Faculty of Dentistry, SEGi University, No. 9, Jalan Teknologi, Taman Sains, Kota Damansara, Petaling Jaya, Selangor
Source of Support: None, Conflict of Interest: None
Introduction: Smoking and obesity are associated with chronic periodontal disease. Chronic periodontal disease has been suggested to be an associated risk factor for obesity. The aim of this study was to evaluate the effect of smoking on body mass index (BMI) and periodontal status of patients. Materials and Methods: A total of 134 subjects (67 smokers and 67 nonsmokers) aged between 24 and 45 years were included in the study. Periodontal status was categorized into healthy, gingivitis, and periodontitis (mild, moderate, and severe, and into localized and generalized). BMI was calculated using height and weight of the patients. A simple descriptive statistics was obtained by analyzing the collected data using MedCalc 15.4. Results: The results indicated that nonsmokers have higher BMI (mean = 23.4 kg/cm 2 , 95% confidence interval [CI] = 22.7-24) as compared to smokers (mean = 21.1 kg/cm 2 , 95% CI = 20.7-21.6). Among 134 subjects, 49 were suffering from chronic periodontitis. People in the overweight category were 26. Subjects who were both overweight and suffering from chronic periodontitis were only 6% (n = 8). Conclusions: The study found an association between periodontal disease and smoking, but no association between obesity and periodontal disease was noticed. Studies with larger sample size and patients from obesity clinics should be studied.
Keywords: Body mass index, obesity, periodontal status, smoking
|How to cite this article:|
Arora S, Ramachandra SS, Gundavarapu KC. Association between Smoking, Body Mass Index, and Periodontal Disease: A Case-Control Study. Indian J Oral Health Res 2016;2:23-6
|How to cite this URL:|
Arora S, Ramachandra SS, Gundavarapu KC. Association between Smoking, Body Mass Index, and Periodontal Disease: A Case-Control Study. Indian J Oral Health Res [serial online] 2016 [cited 2020 Jul 11];2:23-6. Available from: http://www.ijohr.org/text.asp?2016/2/1/23/184731
| Introduction|| |
Cigarette smoking is considered as a major risk factor for mortality and morbidity around the world.  Smokers in the developing countries comprise 73% of the world's smoking population, and these countries are at increased risk of health, economic, and social impacts of smoking-related diseases.  Smoking-related diseases have been the primary cause of mortality and morbidity for the past three decades in Malaysia.  Cigarette smoking is an established risk factor of oral and periodontal diseases. Scientific literature indicates that smoking and body weight are related.  Body mass index (BMI) and smoking are inversely related, and smoking cessation has been linked to weight gain.  Consumption of energy-dense nutrient-poor foods (sugar-sweetened beverages, chips, and baked foods) has been a traditional risk factor for obesity.  Recent data have shown that obesity or weight gain is also associated with oral diseases, particularly chronic periodontal disease.  Adipose tissue secretes various cytokines and hormones that are involved in the inflammatory cascade, thus indicating that similar pathways are linked in the pathophysiology of obesity and chronic periodontal disease. It has been suggested that obesity is second only to smoking as the strongest risk factor for chronic periodontal tissue destruction. ,
A systematic review concluded a positive association between weight gain and chronic periodontal disease.  The study opined that these results were from limited evidence and suggested the need for more studies. The aim of this study was to evaluate the effect of smoking on BMI and periodontal status. The study also evaluates the correlation between these parameters (BMI, smoking, and periodontal status).
| Materials and methods|| |
A total of 158 patients reporting to Oral Health Center of the University and were approached to participate in the study. Among these patients, 134 subjects volunteered to participate in the study. The study was approved by the Institutional Review Board and Ethics Committee of the university. Informed consent was obtained from the participants. All the participants in the study were age and sex matched. Subjects in the age group of 25-45 years were included in the study. Subjects who were smoking ten or more cigarettes a day for more than a year were considered as smokers. Patients who were suffering from aggressive periodontitis and systemic diseases such as diabetes mellitus, hypertension, asthma, and cardiovascular disease were excluded from the study. The subjects were divided into the two groups: smokers (Group I) and nonsmokers (Group II). The periodontal statuses of all the subjects were examined by two calibrated examiners using a mouth mirror and the University of North Carolina-15 probe. Subjects were categorized into healthy, chronic gingivitis, and chronic periodontitis. Chronic periodontitis was further categorized into localized and generalized based on extent and into mild, moderate, and severe based on severity. Chronic gingivitis and chronic periodontitis were diagnosed based on bleeding on probing and clinical attachment loss (CAL), respectively.  CAL of 1-2 mm, 3-4 mm, and >5 mm was used to categorize mild, moderate, and severe periodontitis. 
BMI was measured using height and weight of the subjects. BMI was calculated using the formula weight/square height.  BMI between 19 and 24, 25-29, and >30 kg/cm 2 was categorized as normal, overweight, and obese, respectively. A simple descriptive statistics was obtained by analyzing the collected data using MedCalc 15.4 (Medcalc software bvba, Belgium).
| Results|| |
Among the 158 patients approached to participate in the study, 134 agreed to be included in the study. Hence, the response rate was 85% which is good. Among 134 subjects, 67 were smokers and 67 nonsmokers, in the age range of 24-45 years. Among the smokers, 45 males and 22 females were present with an average age of 32 years. In the nonsmokers group, 41 were males and 26 were females with an average age of 30 years. An inverse relationship was observed between smoking and BMI. BMI was found to be higher among nonsmokers (mean = 23.4 kg/cm 2 , 95% confidence interval [CI] = 22.7-24) as compared to smokers (mean = 21.1 kg/cm 2 , 95% CI = 20.7-21.6) [Table 1]. Among smokers, 90% of the subjects were in the category of 18.5-24.9 kg/cm 2 (normal). In nonsmokers, 58% were in the category of 18.5-24.9 kg/cm 2 (normal) BMI and 37% were in the category of 25-29.9 kg/cm 2 BMI (overweight).
|Table 1: Age, gender, education, and mean body mass index in smokers and nonsmokers |
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Among the nonsmokers, 72% were diagnosed with chronic gingivitis and 28% were diagnosed with chronic periodontitis. Among the chronic periodontitis group, 8% were suffering from localized periodontitis of mild severity and 3% were having localized periodontitis of moderate severity. Around 5% had generalized periodontitis of mild severity and 6% had generalized periodontitis of moderate severity [Table 2]. Among smokers, 55% cases were diagnosed with chronic gingivitis and 45% were diagnosed with chronic periodontitis. In the localized periodontitis group, 16%, 4%, and 10% were suffering from mild, moderate, and severe variety of periodontitis, respectively. Under generalized periodontitis, 3% were mild and 10% were moderate periodontitis [Table 2].
Among 134 subjects, 26 were in the category of overweight (25.0-29.9 kg/cm 2 BMI). Among these 26, 13.5% (n = 18) were having chronic gingivitis, 2.2% (n = 3) mild localized periodontitis, 0.75% (n = 1) moderate localized periodontitis, 0.75% (n = 1) mild generalized periodontitis, and 2.2% (n = 3) moderate generalized periodontitis. Among 134 subjects, 49 were suffering from chronic periodontitis. People in the overweight category were 26. Subjects who were both overweight and suffering from chronic periodontitis were only 6% (n = 8). There was no association found between BMI and chronic periodontitis.
| Discussion|| |
Current scientific literature suggests obesity is a risk factor for development, progression, and severity for chronic periodontal disease. Quetelet index is used to quantify BMI into normal, overweight, and obese. Cigarette smoking is a modifiable risk factor for periodontal disease. Smoking also leads to decreased BMI and cessation of smoking is associated with weight gain. This study evaluated the association between smoking, obesity, and chronic periodontal disease.
The findings in our study showed a significant association between smoking and BMI. In smokers, the majority of the subjects (90%) had normal BMI, whereas in nonsmokers, 58% were in the normal BMI category, whereas 37% were in the overweight BMI category. Hence, BMI was lower in smokers compared to nonsmokers. The findings of our study are in agreement with literature reported earlier. ,,, This can be explained on the basis that nicotine consumption leads to suppression of appetite, decreased intake of food, and weight loss.  Clinicians who are attempting tobacco cessation on patients should be aware of the possibility of weight gain in these patients.  Clinicians should address this issue as well as in tobacco cessation therapies. 
In this study, 45% of smokers had chronic periodontal disease. Preclinical and clinical data are unanimous in demonstrating that smokers present increased susceptibility, greater severity, and faster progression of periodontal disease compared with nonsmokers. ,, In comprehensive periodontal therapies, identification and adjustment of modifiable risk factors are significant. Studies have shown that patients benefit with improved periodontal health upon enrolling in smoking cessation programs since smoking is a modifiable risk factor. Hence, clinicians should encourage smokers to enroll in cessation strategies. 
Systematic reviews have found that overweight, obesity, weight gain, and increased waist circumference may be risk factors in initiation and development of periodontal disease. , Obesity is hypothesized to involve immune-inflammatory alterations, and the condition has been related to increased susceptibility to periodontitis.  However, in the present study, there was no association observed between obesity and periodontal disease. This is in agreement with studies conducted by Awad et al. and Kongstad et al. Awad et al. concluded that mean age of 24 years was the possible reason for nonassociation between obesity and periodontal disease.  The mean age in the present study was 30 years. This could be the possible reason for nonassociation between obesity and periodontal disease. Awad et al. used pocket depths to diagnose periodontal disease in their subjects, which could result in underestimation of the periodontal disease.  In the present study, CAL was used to diagnose and quantify the severity of periodontal disease. de Castilhos et al. used CAL to measure and quantify periodontal disease in their study on obesity and periodontal disease. The study showed no association between obesity and periodontal disease; however, positive between gingivitis and obesity was observed. 
Limitations of the study
The design of the study was cross-sectional in nature. The mean age of the patients was around 30 years, so application of the results of this study to the general population would not be appropriate. The small sample size is also a limitation of the study.
| Conclusions|| |
The study found an association between BMI and smoking, whereas no association was noticed between BMI and chronic periodontal disease. A significant association was observed between smoking and chronic periodontal disease. Smoking was confirmed as a risk factor for chronic periodontal disease. Longitudinal studies, studies with larger sample size and studies in obesity clinics could be useful in substantiating these findings.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gilmore AB, Fooks G, Drope J, Bialous SA, Jackson RR. Exposing and addressing tobacco industry conduct in low-income and middle-income countries. Lancet 2015;385:1029-43.
Lim HK, Ghazali SM, Kee CC, Lim KK, Chan YY, Teh HC, et al.
Epidemiology of smoking among Malaysian adult males: Prevalence and associated factors. BMC Public Health 2013;13:8.
Tian J, Venn A, Otahal P, Gall S. The association between quitting smoking and weight gain: A systemic review and meta-analysis of prospective cohort studies. Obes Rev 2015;16:883-901.
Drewnowski A. The real contribution of added sugars and fats to obesity. Epidemiol Rev 2007;29:160-71.
Nascimento GG, Leite FR, Do LG, Peres KG, Correa MB, Demarco FF.
Is weight gain associated with the incidence of periodontitis? A systematic review and meta-analysis. J Clin Periodontol 2015;42:495-505.
Keller A, Rohde JF, Raymond K, Heitmann BL.
Association between periodontal disease and overweight and obesity: A systematic review. J Periodontol 2015;86:766-76.
Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4:1-6.
Munafò MR, Tilling K, Ben-Shlomo Y. Smoking status and body mass index: A longitudinal study. Nicotine Tob Res 2009;11:765-71.
Dare S, Mackay DF, Pell JP. Relationship between smoking and obesity: A cross-sectional study of 499,504 middle-aged adults in the UK general population. PLoS One 2015;10:e0123579.
Macera CA, Aralis HJ, Macgregor AJ, Rauh MJ, Han PP, Galarneau MR. Cigarette smoking, body mass index, and physical fitness changes among male navy personnel. Nicotine Tob Res 2011;13:965-71.
Plurphanswat N, Rodu B. The association of smoking and demographic characteristics on body mass index and obesity among adults in the U.S 1999-2012. BMC Obes 2014;1:18.
Jo YH, Talmage DA, Role LW. Nicotinic receptor-mediated effects on appetite and food intake. J Neurobiol 2002;53:618-32.
Nociti FH Jr., Casati MZ, Duarte PM. Current perspective of the impact of smoking on the progression and treatment of periodontitis. Periodontol 2000 2015;67:187-210.
Santos A, Pascual A, Llopis J, Giner L, Kim DM, Levi P Jr., et al.
Self-reported oral hygiene habits in smokers and nonsmokers diagnosed with periodontal disease. Oral Health Prev Dent 2015;13:245-51.
Visvanathan R, Mahendra J, NA, Pandisuba, Chalini. Effect of smoking on periodontal health. J Clin Diagn Res 2014;8:ZC46-9.
Palle AR, Reddy CM, Shankar BS, Gelli V, Sudhakar J, Reddy KK. Association between obesity and chronic periodontitis: A cross-sectional study. J Contemp Dent Pract 2013;14:168-73.
Awad M, Rahman B, Hasan H, Ali H. The relationship between body mass index and periodontitis in Arab patients with type 2 diabetes mellitus. Oman Med J 2015;30:36-41.
Kongstad J, Hvidtfeldt UA, Grønbaek M, Stoltze K, Holmstrup P. The relationship between body mass index and periodontitis in the Copenhagen City Heart Study. J Periodontol 2009;80:1246-53.
de Castilhos ED, Horta BL, Gigante DP, Demarco FF, Peres KG, Peres MA. Association between obesity and periodontal disease in young adults: A population-based birth cohort. J Clin Periodontol 2012;39:717-24.
[Table 1], [Table 2]