Community Dent Oral Epidemiol 2012; 40: 315322 All rights reserved

2012 John Wiley & Sons A/S

Body mass index (BMI) and dental caries in 5-year-old children from southern Sweden
Norberg C, Hallstro m Stalin U, Matsson L, Thorngren-Jerneck K, Klingberg G. Body mass index (BMI) and dental caries in 5-year-old children from southern Sweden. Community Dent Oral Epidemiol 2012; 40: 315322. 2012 John Wiley & Sons A/S. Abstract Objectives: The aim of the present survey was to study the association between dental caries and body mass index (BMI) in Swedish preschool children (born in 1999). Methods: A population-based and crosssectional study design was used comprising all 920 5-year-old children in a dened area in and around the city of Lund. Anthropometric measures for the calculation of BMI were retrieved for each child from recordings at Child Health Care Centers (CHC). The occurrence of caries and llings in the primary dentition, dened as deft (decayed, extracted, or lled primary teeth) and dt (decayed primary teeth), was collected from the childrens dental records. Results: The mean BMI was 16.1 (no differences between boys and girls). About 19.2% were overweight, of which 5.1% were obese. Overweight or obese children did not have higher deft or dt than others. However, children with low BMI (below 1 SD of national mean values for Swedish 5-year-olds) had statistically signicantly higher deft and dt than children with normal BMI. Conclusions: Children with low BMI may be at risk of caries development. Low BMI may be associated with eating habits endangering dental health.

m Stalin2, Carina Norberg1,2,3, Ulla Hallstro 1 Lars Matsson , Kristina Thorngren-Jerneck4,5 and Gunilla Klingberg1,6,7
1 Department of Paediatric Dentistry, Faculty of Odontology, Malmo University, Malmo , Sweden, 2Pediatric Dentistry Specialist Clinic, Lund, Sweden, 3Pediatric Dentistry Specialist Clinic, Karlskrona, Sweden, 4 Department of Pediatrics, Lund University Hospital, Lund, Sweden, 5Department of Clinical Sciences, Lund University, Lund, Sweden, 6Mun-H-Center, National Orofacial Resource Centre for Rare Disorders, Go teborg, Sweden, 7Department of Pediatric Dentistry, Sahlgrenska Academy at the University of Gothenburg, Go teborg, Sweden

Key words: caries; epidemiology; pediatric dentistry; BMI; preeschool children Gunilla Klingberg, Department of Paediatric Dentistry, Faculty of Odontology, Malmo University, SE 205 06 Malmo , Sweden Tel.: +46 406 658 480 Fax: +46 406 658 584 e-mail: gunilla.klingberg@vgregion.se Submitted 1 June 2011; accepted 12 February 2012

Prevalence of overweight and obesity has increased worldwide in recent decades. WHO estimates that more than 1 billion people are overweight, of whom at least 300 million are obese (1). Approximately 10% of the worlds child population between 5 and 17 years are overweight, and a quarter of these fulll the criteria for obesity (2). Prevalence gures vary among the regions of the world, and in Europe, approximately 20% are overweight and 5% obese (2). Even young children are affected. Reports in Sweden describe 1520% of 4-year-old children as overweight and 35% as obese. Further, more Swedish girls than boys are reported as overweight or obese, and obesity is more common in subpopulations with generally lower socioeconomic levels (3, 4). Because overweight is a result of an imbalance between energy intake and energy used, nutrition and food consumption play important roles. High
doi: 10.1111/j.1600-0528.2012.00686.x

consumption of fast foods, sucrose-rich beverages, rened wheat bread, etc., may increase the risk of overweight. At the same time, many of these products, especially if consumed frequently, likely increase the risk of dental caries (5). Based on this knowledge, it is plausible to hypothesize a positive relationship between overweight/obesity and dental caries. Data on this matter, however, are conicting. While some studies report a relationship between overweight/obesity and dental caries in children (610), others have failed to nd such an association (1113). Few studies have included children with underweight in their analyses. Oliviera et al. (14) reported an increased risk of caries in underweight 1- to-5-year-old Brazilian children, but only 20 of the more than 1000 children were underweight, and the ages of these underweight children were not reported. On the other hand, lower BMI has been reported to be associated with

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lower df-t/DF-T (numbers of decayed or lled primary/permanent teeth) in 6- to-11-year-old children from Germany (6, 7). To better understand the relationship between dental caries and body weight, dental caries should be studied in relation to the whole span of weight or BMI. The aim of the present study was to analyze the relationship between dental caries and BMI in 5-year-old Swedish children.

Materials and methods

The study design was a cross-sectional populationbased survey. The patient material comprised all 5year-old children (born 1999) registered at seven ne county, Child Health Care Centers (CHC) in Ska southern Sweden. The CHCs were situated in and on the outskirts of the city of Lund and served clientele with varying demographic and socioeconomic backgrounds. Ofcial statistics on socioeconomic status such as level of education, family income, marital status, and type of household were used to ensure that the study population mirrored the population of southern Sweden. The Swedish Public Dental Service (PDS) provides regular dental care free of charge to all children and adolescents between ages 3 and 19 years. In the present study area, more than 95% participated in this program. Similarly, more than 90% of all preschool children took part in the health program at the CHCs, provided by the Public Health Service. Information about height and weight was collected from the CHC records, and BMI was calculated for each child (weight/height2). The children were seen in the CHC at the age of 5 years 3 months. This is an age when all Swedish children are scheduled to have health check-ups and vaccination, and by routine a deviation of up to 3 months from the 5th birthday is accepted. Weight and height were measured by qualied nurses according to a standardized protocol. Dental examination and weight and height measurements were carried out during the year the child was 5 (i.e. in 2004). Data on deft (number of decayed, extracted, or lled primary teeth) and dt (number of decayed primary teeth) were extracted from the childrens dental records. The collected caries data had been calculated for each child at the time of the clinical examinations. This is standard procedure in the Swedish PDS where dentists report caries data as

caries indices, such as deft or DMFT to regional and national report systems. Consequently, it can be assumed that the dentists are familiar with the calculation of deft and dt. Only dentine caries is reported. The criteria for clinical caries are: (i) visible loss of tooth substance without the characteristics of a developmental defect and (ii) in pits and ssures when the point of the probe catches upon gentle pressure. National recommendations are that bitewing radiographs be taken only when indicated and are therefore not performed routinely. Dentine (manifest) radiographic caries is dened as a lesion extending beyond the enameldentine junction. No information on the number of radiographs taken was available. Data for the present study were compiled starting in 2008 by retrieving all records from the CHCs and dental clinics. Overweight was dened as an ISO BMI  25 and obesity as an ISO BMI  30 according to Cole et al. (15). To enable the analyses of the whole BMI span, the material was also grouped into ve BMIrelated categories: U (underweight), L (low weight), N (normal weight), H (high weight), and O (obese). Underweight was dened as having a BMI less than 2 SD of the mean BMI in Swedish 5-year-olds, low weight as BMI 2 to 1 SD, and normal weight was dened as BMI from 1 SD of the mean BMI in Swedish 5-year-olds to ISO BMI < 25 (Table 1). This study used the international denition of overweight (ISO BMI  25) to dene the combination of groups H and O, and the international denition of obesity (ISO BMI  30) to dene group O. Group H was dened as ISO BMI  25 and < 30. Thus, the grouping was based both on criteria recommended by the Obesity Task Force for obesity and overweight (15) and on statistical cutoffs for the groups normal weight, low weight, and underweight based on national epidemiological data on BMI in 5-year-olds in Sweden. A total of 1057 children (515 girls and 542 boys) were registered as living in the catchment areas of the 7 CHCs in this study and thus eligible for participation. Data for calculating BMI were available for 1000 children, and deft and dt from dental records for 962 children. Full information BMI, deft, and dt was compiled for 920 children (87%): 454 girls and 466 boys. To ensure that the dropouts did not differ from the children with full information, comparisons were made regarding deft, dt, BMI, and the proportions of patients with ISO BMI  25 and  30, respectively, between children with full information and those for whom information

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BMI and dental caries in Swedish 5-year-old children Table 1. Body mass index (BMI) group classication of 5-year-old children by sex U groupa BMI Girls Boys  13.49  13.89 L groupa BMI 13.5014.49 13.9014.79 N groupa BMI 14.5017.14 14.8017.41 H groupb BMI (ISO BMI  25-29) 17.1519.16 17.4219.29 O groupb BMI (ISO BMI  30)  19.17  19.30

U group, underweight; L group, low weight; N group, normal weight; H group, high weight; O group, obese. a Based on epidemiological data (growth charts) from Swedish child health care centers; underweight = below 2 SD, low weight = 2 to 1 SD, and normal weight = from 1 SD to ISO BMI < 25. b Based on Cole et al. (15).

on BMI or deft/dt was missing. No statistically signicant differences were found.

Statistics
The Statistical Package for the Social Sciences (SPSS, ver. 15.0; SPSS Inc, Chicago, IL, USA) was used for descriptive and analytic statistics. Chisquare test, MannWhitney test, and KruskalWallis analysis of variance were used. P values  0.05 were regarded as nonsignicant.

Ethics
The study and study design were approved by the Regional Ethics Committee at Lund University. As the study was based on registers, that is, data already accessible through medical and dental records, informed consent was not applicable. However, on request from the Ethics Committee, information about the study was published in the local daily newspapers and parents who did not want their children to participate were informed about the possibility of declining participation. No parent responded to this announcement.

Results
Analyses based on the 920 participants revealed a mean BMI of 16.08 (SD: 1.62). There were no differences in mean BMI between girls and boys (mean 16.03; SD: 1.67 for girls versus mean 16.11; SD: 1.56

for boys). Further, 19.2% of the study population was overweight (ISO BMI  25) and 5.1% obese (ISO BMI  30), with no differences between boys and girls. The number of children in different BMI groups is presented in Table 2. According to the present BMI classication, 3.6% of the children were underweight (< 2 SD of mean BMI in reference population). As is shown in Table 3, 20% of the total study population had caries or llings in at least one primary tooth. Mean number of deft was 0.79 (SD: 2.15; range: 018), with no statistically signicant differences between boys and girls (Table 3). There were no statistically signicant differences in deft between obese children (ISO BMI  30) and others or between children with overweight (ISO BMI  25) and others. A KruskalWallis analysis, however, found signicant differences in deft across the BMI groups (v2 = 11.179; d.f. = 4; P = 0.025). MannWhitney tests then revealed that children in groups U and L had higher deft scores than children in group N (P = 0.010 and P = 0.025, respectively; Table 3 and Fig. 1). Numerical but not statistically signicant differences were noted between groups N and H and between N and O. Also, when the individuals were grouped into three deft groups (deft = 0, 13, or  4), a statistically signicant relationship between deft and BMI groups was revealed (chisquare test, v2 = 26.744; d.f. = 8; P = 0.001), with higher frequencies of children with caries and ll-

Table 2. Patient material (number and % of children) in body mass index (BMI) groups by sex BMI group U group N (%) Total Girls Boys 33 (3.6) 14 (3.1) 19 (4.1) L group N (%) 99 (10.8) 53 (11.7) 46 (9.9) N group N (%) 611 (66.4) 292 (64.3) 319 (68.5) H group N (%) 130 (14.1) 70 (15.4) 60 (12.9) O group N (%) 47 (5.1) 25 (5.5) 22 (4.7) Total N (%) 920 (100) 454 (100) 466 (100)

Groups: U, underweight; L, low weight; N, normal weight; H, high weight; O, obese. Groups H plus O equivalent to ISO denition of overweight (ISO BMI  25) and group O to ISO denition of obesity (ISO BMI  30).

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Norberg et al. Table 3. Decayed, extracted, or lled primary teeth (deft) by body mass index (BMI) group and sex. deft presented as numerical values and as distribution (%) in deft groups

b c

ings in the U and L groups. Data on proportion of children in the different deft groups across the BMI groups are shown in Table 3. This picture was further enhanced when groups U and L and groups H and O were combined to form three BMI groups: UL, N, and HO (data not shown). A signicant difference in deft was seen

Fig. 1. Mean number of decayed, extracted, and lled primary teeth (deft) by body mass index (BMI) group. U group, underweight; L group, low weight; N group, normal weight; H group, high weight; O group, obese (MannWhitney tests).

across these groups (KruskalWallis test; v2 = 9.476; d.f. = 2; P = 0.009). MannWhitney tests subsequently revealed a signicant difference in deft between UL and N (P = 0.002) but not between HO and N. A chi-square test also showed a strong relationship between deft group (deft = 0, 13, or  4) and the three BMI groups (v2 = 18.059; d.f. = 4; P = 0.001), with a high proportion of individuals with deft  4 in the UL group. Mean number of dt was 0.51 (SD: 1.66; range: 018) with no differences between boys and girls (Table 4). No signicant difference between obese children (ISO BMI  30) and others or between overweight children (ISO BMI  25) and others was found. Neither did a KruskalWallis test reveal any signicant differences in dt across the ve BMI groups (v2 = 8.795; d.f. = 4; P = 0.066) (data not shown). However, analyses of dt across the three BMI groups (group UL, group N, and group HO) found a signicant difference in dt across the groups (KruskalWallis test; v2 = 6.857; d.f. = 2; P = 0.032). The subsequent MannWhitney tests

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BMI and dental caries in Swedish 5-year-old children Table 4. Decayed primary teeth (dt) by body mass index (BMI) group and sex. dt presented as numerical values and as distribution (%) in deft groups

revealed a signicant difference in dt between UL and N (P = 0.009; Table 4 and Fig. 2). A chi-square test also showed a strong relationship between dt groups (proportions of children with dt = 0, 13, or  4) and the three BMI groups (v2 = 13.009; d. f. = 4; P = 0.011), with a high proportion of individuals with dt  4 in the UL group. Data on the proportion of children in the different dt groups across the three BMI groups are shown in Table 4.

Discussion
Previous surveys have come to contradictory conclusions concerning BMI and dental caries in children (16). Some studies have reported a

Fig. 2. Mean number of decayed primary teeth (dt) by three body mass index (BMI) groups. UL group, underweight and low weight; N group, normal weight; HO group, high weight and obese (MannWhitney tests).

relationship between high BMI and caries (610), but the majority of studies in preschool children have failed to link high BMI to dental caries. Chen et al. (17) surveyed over 5000 3-year-olds in Taiwan and found no relationship between BMI and dental caries; neither did Hong et al. (12) in a study of 1500 2- to-6-year-olds in the United States or Dye et al. (18) in a survey of more than 4000 2- to5-year-olds in the United States. The present study found no statistically signicant differences in caries prevalence between children with high BMI (obese or overweight; ISO BMI  30 or  25, respectively) and others. In contrast, the children with low BMI (underweight and low weight) had statistically signicantly more caries than children with normal weight. Oliveira et al. (14) reported similar ndings in Brazilian children, although the group of underweight children was small. Our results also nd some support in the Sheller et al. study (19), who reported a higher frequency of children with underweight among healthy 2- to-5-year-olds being treated for severe early childhood caries under general anesthesia than in a reference population. In addition, a Scottish study on 3- to-11-year-olds attending a dental hospital for tooth extraction under general anesthesia reported that children with the worst decay were signicantly thinner (20), and a study on 7year-old Thai children concluded that an increase in decayed, missed, and lled primary tooth sur-

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faces (dmfs) increased the odds of being underweight (21). Our nding of no signicant association between high BMI and dental caries experience is in line with previous studies on preschool children (12, 17, 18) but inconsistent with studies on older children and adolescents, where a positive relationship has been reported (69). A recently published study noted a lower, although not statistically signicant, mean number of defs in overweight/obese 3-year-old Swedish children compared with low normal weight children (22). This difference was reversed in 6-year-old children (age span 4.9 6.6 years) who displayed a higher, although not statistically signicant, mean number of defs in the overweight/obese children, a difference which was statistically conrmed in 15-year-olds. The children in that study (22) were born 11 years prior to the children in the present study, so it is possible that the distribution of both weight/BMI and deft/ dt in the two populations differ. Hypothetically, the reasons for developing overweight/obesity differ between preschool age and school age, with the risk factors for overweight/obesity in young children being less cariogenic. It is also interesting to note the nding by Wa rnberg Gerdin et al. (9) that children who were obese at 4 years of age had signicantly more caries at the age of 12 compared with children with normal weight at 4 years of age. Thus, obese preschool children seem to be at risk for later development of dental caries. The present study design does not allow any conclusions on why low and underweight children have more caries. While dental caries is more related to the frequency of consumption (5), obesity, apart from genetic factors, is also related to environmental factors including intake of energyrich food and drink. Thus, it is essential to acknowledge that the etiologies of obesity and caries are not identical. Children who eat small meals, who eat slowly without much interest in food, and who often have strong food preferences have been described as picky eaters (23). Dubois et al. (23) reported that picky eaters were twice as likely to be underweight at age 4.5 years as children who had never been picky eaters, and that overeaters were more likely to be overweight at the same age. Being a picky eater may, especially if the child is underweight, lead to parents pressuring the child to eat, or make the parents more prone to offer other kinds of food. It is also possible that parents offer special treats to ensure that the child eats, or that they serve food or drink more frequently in order

to stimulate the childs appetite. Consequently, there is a risk of establishing eating patterns in picky eaters with low BMI that will endanger their dental health. Interestingly, a Swedish study on the relationship of food frequencies and overweight/ obesity found that frequent intake of candy was negatively associated with overweight/obesity in 5-year-olds (24). Thus, there are indications that the relationship between intake of food and BMI is neither linear nor simple. It is also important to note that the low BMI in some of the children could be caused by problems related to dental decay, that is, caries might have a cause-related effect on BMI. Tooth problems, pain or even toothache, will affect appetite and may, if untreated, lead to weight loss and lower BMI. However, an in-depth perusal of the dental health records in the two groups with lowest BMI values found no indication that these groups included more children with very high deft. In fact, all BMI groups had individuals with a deft exceeding 10 and groups L, N, and O had individuals with a dt exceeding 10. In any case, it remains essential to point out that dental caries in young children should be treated and that dentists should be sensitive to the needs of children with severe dental decay. The present population-based study had a crosssectional design and included all children in welldened catchment areas. The seven CHCs were chosen to ensure a study population that comprised varying socioeconomic standards, that is, the socioeconomic standard in the areas served by the CHCs was evaluated based on statistical data concerning the populations educational level, mean income, type of housing, and so on. The proportion of children with overweight or obesity in the study group was in line with that in other Swedish studies (3, 4), as was the proportion of children with dentine caries (25). The dropout rate was low, and the dropouts did not differ from the children included in the study regarding deft, dt, or BMI. Thus, it seems reasonable to assume that the children in the present study are representative of children in southern Sweden and possibly also of children in Sweden as a whole. Still the results should be interpreted with care because dietary habits in children differ between different populations and countries, which are probably also true of the etiology of obesity and underweight. Further, because no data were available on variables such as diet or family situation, the statistical tests were restricted to bivariate analyses using informa-

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tion on BMI and caries. Future studies should explore possible cause-related relationships. Child Health Care Centers were used as units for inclusion because more than 99% of the child population in Sweden is registered at a CHC. Enrolled children are called regularly to the CHCs, and attendance is very high during the rst year of life. Between age 2 and 6 years, approximately 90% of the children are seen regularly. At special scheduled health evaluations such as before starting school and for vaccinations, attendance exceeds 90%. Information on BMI was available for 95% of the original sample, which is a high gure. Despite the lack of BMI information for the remaining 5%, dropout analyses revealed no differences in deft between dropouts and participants. It is, thus, plausible that the dropout group includes children with severe medical conditions or complicated disabilities who see pediatricians at hospitals or outpatient clinics instead. Data on dental caries experience (deft/dt) were available for 91% of the child population. No information was available on how often radiographs were taken to diagnose dental caries, but it is likely that the vast majority of examinations were carried out using dental mirror and explorer only, which should be taken into account when analyzing the data. Little is known concerning childrens eating habits, composition of meals, and so on in relation to BMI and growth development. This is especially true for children with low weight or underweight. Thus, there is an urgent need for more research in this area, including oral health aspects. Poor eating habits may lead to low weight or underweight, and from the present nding of a correlation between low BMI and dental caries, it is feasible to hypothesize that children with adverse eating patterns, for example, picky eating (23), may be at risk of caries development. But to verify this hypothesis, more research is required, preferably longitudinal studies comprising large and well-dened populations where BMI, dental health, dietary habits, and socioeconomic factors are followed from preschool years into adolescence. In conclusion, the present study did not reveal any signicant differences in dental caries between children with high BMI (obese and overweight) and children with normal BMI, but a signicant relationship between low BMI and dental caries in preschool children was found. Low BMI may be associated with eating habits that have a negative impact on dental health; however, this needs further investigation.

Acknowledgements
This study was supported by the grants from the Public ne and The Swedish Institute Dental Service Region Ska rdalinstitutet). We thank Per-Erik for Health Sciences (Va Isberg, Department of Statistics, Lund University, for statistical assistance.

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