Open Journal of Stomatology, 2013, 3, 59-64 OJST
http://dx.doi.org/10.4236/ojst.2013.39A009 Published Online December 2013 (http://www.scirp.org/journal/ojst/)
Oral health status and performance of oral functions in
children and adolescents in the treatment for
overweight or obesity
Maria Ívina Gomes Janoca, Manoel de Oliveira Dantas Filho,
Fernando Henrique Pereira de Vasconcelos, Armiliana Soares Nascimento,
Rosa Maria Mariz de Melo Sales Marmhoud Coury, Criseuda Maria Benício Barros,
Silvio Romero do Nascimento, Luciana de Barros Correia Fontes*
Rua Ester Foigel, 110, ap. 1102, Ed. Victor Rodrigues, Iputinga, Recife, Pernambuco, Brasil
Received 25 October 2013; revised 3 December 2013; accepted 21 December 2013
Copyright © 2013 Maria Ívina Gomes Janoca et al. This is an open access article distributed under the Creative Commons Attribu-
tion License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
ABSTRACT
The objective of this study was to evaluate the per-
formance of oral functions and oral conditions in
children and adolescents with overweight or obesity,
investigating possible associations with treatment for
weight reduction. Developing a cross-sectional re-
search and quantitative approach with inductive and
descriptive and critical analysis of data, such as from
a range of 95%, the universe was represented by
children and adolescents who were overweight or ob ese,
in both sexes, treated at reference cente rs f or the treat -
ment of obesity by the National Health System, in
Campina Grande, Paraíba, 2010-2012. As the con-
tro l gr oup considered subjects of the same age, in the
process of screening for attention in the places listed,
but without the condition of overweight or obese, the
research was started after the approval by the Ethics
Resarch Committee of the UEPB under the protocol
number 0513.0.133.000-09. As instruments for data
collection were used in the questionnaire and clinical
examination, of the 70 surveyed, most were female,
ranging in age from 3 to 17 years, overweight, with-
out comorbidities and carriers of deleterious oral
habits; especially the nail biting, significantly associ-
ated with female sex p < 0.05. Consistency was the
preferred food paste and chewing quickly, unilater-
ally, without discomfort or gagging constant. There
was a significant difference between the values of the
DMFT index, the presence of visible biofilm and the
frequency of halitosis, for groups with overweight or
obe sit y, w i t h asso ciation between time of treatment and
medications.
Keywords: Stomatognathic System; Oral Health;
Overweight; Obesity; Comprehensive Health Care of
Children and Adolescents; Pediatric Dentistry
1. INTRODUCTION
Obesity is a serious public health problem worldwide
due to the increase in its incidence and prevalence rates,
the notorious impairment of a population increasingly
young (particularly juvenile) and possible implications
on life quality of affected individuals and their care
needs.
Brazil is passing through the nutritional transition pe-
riod, where malnutrition is giving way to overweight and
obesity as a nutritional disorder is most prevalent in vir-
tually all strata of population; evidencing polarization in
regions with high poverty levels, such as the northeast of
the country [1].
This situation is characterized by abnormal accumula-
tion of body fat compared with body size. Usually, the
Body Mass Index or BMI (kg/m2) is overall used for the
body weight assessment. This should be linked to other
parameters in order to identify the risk conditions to
health, particularly in children and adolescents. The lev-
els related to the problem vary from the overweight or
pre-obesity, with BMI between 25 and 29.9, obesity class
I from 30 to 34.9, obesity class II from 35 to 39.9 and
obesity class III, also called morbid obesity over 40 [2].
The treatment of obesity is difficult due to its multi-
factorial etiology resulting from the complex interaction
of environmental, genetic and psychological factors, as-
suming different clinical situations to individuals in dif-
ferent socioeconomic realities. In th is context, p r even tio n
*Corresponding a uthor.

M. Í. G. Janoca et al. / Open Journal of Stomatology 3 (2013) 59-64 60
and intervention programs need to consid er the co ntro l of
habits and possible behaviors, according to the cultural
characteristics [3,4].
Obesity is a problem acquired throughout life, pro-
grammed in its early stage and fed over time. When in
childhood and adolescence, it represents an important
risk factor for the development of future co-morbidities,
even with the challenge in definin g its role in this causal-
ity. Thus, it becomes necessary to implement measures
to combat this nutrition al disorder in younger indiv iduals
[5].
Among the key policy components of a healthy life in
this age group, the promotion of increased physical ac-
tivity, implementation of programs of physical exercise
and acquisition of healthy eating habits are highlighted
[6]. In this context, the states of Pernambuco and Paraí-
ba appear as references in attempt to control anemia
and overweight/obesity, especially in the frameworks of
metabolic syndrome involving children and adolescents
[7].
It is known that the performance of masticatory func-
tion is directly related to body and oral or buccal vari-
ables, and the masticatory difficult being the most likely
mechanism by which impaired oral health can affect
food intake [8]. Associations were found between oral
health and obesity: a small number of teeth, a great
number of restored teeth, xerostomia, dental visiting
habits and self-perceived oral health in adults [9]. How-
ever, there is little information on the oral conditions of
children and adolescents with overweight or obesity and
their masticatory performance when undergoing treat-
ment for weight control.
Thus, according to what has been previously reported,
this study was developed under the guiding question or
problem: Is there any association between oral conditions
and masticatory performance in children and adolescents
with overweight and obesity before and after treatment
for weight control?
2. METHODOLOGY
The study was cross-sectional and quantitative with in-
ductive approach and descriptive and analytical data
analysis. Its covered area included hospitals for treatment
of obesity and oral health by the Unified Health System
(SUS) located in Campina Grande, Paraíba State.
The universe was represented by children and adoles-
cents overweight or obese, both sexes, attended at the
Center for Endocrinology and Childhood Obesity, Health
Institute Elpidio de Almeida (ISEA), through the project
“Metabolic Study in Children Obese and Overweight”
and the Unit of Endocrinology and Diabetes Severino
Bezerra de Carvalho, University Hospital Alcides Car-
neiro (HUAC). Children and adolescents on the screen-
ing for these services and without diagnosis of over-
weight or obesity were selected as control group.
The sample corresponded to 70 volunteers, aged be-
tween three and eighteen years, who sought care in the
previously reported centers or under treatment, during
2010-2012. Patients with disabilities (mental, hearing,
visual and physical, reporting to the motor impairment),
customers or patients without accurate information on
weight and height, immunocompromised individuals,
and those who do not agreed on participation, even with
the consent of those responsible, were excluded from the
study.
No conflict of interest, the study was approved by the
Research Ethics Committee (REC) of the State Univer-
sity of Paraíba (UEPB) under the protocol number
0513.0.133.000-09 and started after signing the Letter of
Consent by the responsible regarding the investigated
service and signing the informed consent by those re-
sponsible in relation to the study volunteers (in case of
adolescents, also their signature). Below is the flow dia-
gram of this study:
Population
(189)
↓
Sample
(70)
Non obesity
Control groupOverweight Obesity I, II or III
Oral health condition and functional performance
As instruments for data collection were used: face to
face interview with questionnaire, intra-oral and extra-
oral physical examination and application of adapted
masticatory assessment protocol [10]; those conducted in
the Department of Dentistry UEPB, under artificial light,
following the guidelines of the World Health Organiza-
tion for epidemiological surveys on oral health [11] and
with respect to biosafety standards. Information regard-
ing medical history was recorded from the data in re-
cords.
The list of variables analyzed included: sex, national
origin, diagnosis and degree of obesity (weight/height
ratio by Body Mass Index or BMI), treatment time and
modality, use of medications, weight loss, family history
of obesity, presence of comorbidity, presence of delete-
rious oral habits, history of nervous bulimia, food pre-
ferred consistency, performance characteristics of masti-
catory function, pr esence of visible biofilm, spontaneou s
gums bleeding, halitosis, changes in teeth/occlusion or
soft tissues, dmft and mean DMFT.
For statistical analysis were used 95% confidence in-

M. Í. G. Janoca et al. / Open Journal of Stomatology 3 (2013) 59-64 61
terval and tests: ANOVA, chi-square test of association,
F test and Pearson’s correlation, using the statistical
software package SPSS (Statistical Package for the So-
cial Sciences) in its version 15. The descriptive part con-
sidered measures of central tendency and dispersion with
the relative frequencies.
3. RESULTS
The total sample in this study was 70 children and ado-
lescents (37% of universe), distributed as shown in Fig-
ure 1. The volunteers’ mean age was 9.4 years (Standard
Deviation or SD, 2.2 years). Females accounted for
68.6% of the volunteers.
The volunteers’ mean weight was 57.4 Kg (SD 4.2 kg):
the control group with 40.4 Kg (SD 6.1 Kg), overweight
group with 73.5 Kg (SD 5.3 Kg) and obese group with
102.5 (SD 10.1 Kg). The highest percentage of over-
weight or obesity occurred in females (64.5%). However,
male volunteers showed higher degree of obesity (obe-
sity class II). Among the eleven volunteers with such
condition, 63.6% were male.
Of the 70 children and adolescents investigated, 60
were under treatment and 10 in evaluation. For individu-
als who were under treatment, all had the recommenda-
tion of practicing exercise and diet control; the psycho-
logical therapy appearing in 35.7% of cases and the use
of drugs in 21.4%. The programs varied in time over a
period of 1 month to 2 years. The maximum weight re-
duction occurred in 8 kg, but in 35.7% of patients the
opposite occurred with gains of up to 6 Kg for adolescent
with obesity class II.
Figure 2 shows the distribution of 58.6% of volun-
teers investigated who had family history of obesity.
There was significant association between maternal obe-
sity and overweight or obesity status (p < 0.05).
Comorbidities were mentioned for 11.4% of respon-
dents, being high dyslipidemia (75%), hypertension
(62.5%) and triglycerides (62.5%) the most reported fol-
lowed by diabetes (50%).
Figure 1. Graphic showing the distribution of volunteers ac-
cording to diagnosis of obesity. Campina Grande, PB, 2010-
2012.
Regarding the presence of harmful oral habits, this
was confirmed to 67.1% of the sample and is shown in
Figure 3. History of nervous bulimia existed for 4.3% of
children and adolescents.
The Table 1 presents the masticatory pattern of vol-
unteers. For variables analyzed there was no significant
difference between the groups without obesity, over-
weight or obesity (p > 0.05).
Regarding the oral health data, more specifically, the
mean dmft was set at 2.5 and the DMFT at 3.4. For the
DMFT the difference was not significant (p > 0.05) be-
tween the groups of volunteers with or without obesity
(2.7 non-obese, 3.8 overweight, 4.3 obese class I, 4.4
obese class II). Evaluating the components DMFT sepa-
rately, it could not test safely the possible associations
for the first one due to a low frequency value. The com-
ponent D was significantly higher in the overweight or
obese group (p < 0.05), setting a p < 0.01 when com-
pared the non-obese and obese groups.
The presence of visible biofilm and halitosis was also
more significant (p < 0.05) in overweight or obese indi-
viduals compared to those non-obese, with relative fre-
quencies of 14. 3% an d 70%, respecti vel y .
It was found spontaneous gingival bleeding in 24.3%
of the sample. For other changes surveyed occurred the
Figure 2. Graphic showing the distribution of reports of obe-
sity in the family. Campina Grande, PB, 2010-2012.
Figure 3. Graphic showing the distribution of volunteers, ac-
cording to the type of deleterious oral habits presented.
Campina Grande, PB, 2010-2013.

M. Í. G. Janoca et al. / Open Journal of Stomatology 3 (2013) 59-64 62
Table 1. Chewing pattern of the volunteers. Campina Grande,
PB, 2010.
VARIABLES N %
Preferr ed consistency of food
Solid 35.7
Paste 58.6
Liquid 5.7
Side masticatory
Both 45.7
Right 31.4
Left 22.9
Presence of choking
Yes -
No 100
Chewing with mouth open
Yes 4.3
No 95.7
Chewing speed
Slow 31.4
Regular/normal 22.9
Fast 45.7
Pain when chewing
Yes 8.6
No 91.4
Difficult to open or close the mouth
Yes 4.3
No 95.7
percentage distribution following also not proved statis-
tically significant, yielding global values of 22.9% of
patients with open bite or dental crowding (each one),
14.3% with wear on tooth surface or sharp spacing be-
tween teeth, 11.4% with crossbite bite or tooth fracture,
5.7% with sharp anomaly or overbite/deep overbite.
The significant parameters for oral health conditions
and masticatory performance between groups were eva-
luated according to the Table 1. Those obtained from
prior correlation with all variables investigated.
4. DISCUSSION
The higher frequency of females associated with obesity
was also highlighted in the studies of Lima and Sampaio
[12] and Marscicano [13]; those with percentages higher
than 74% and 72%, respectively. A systematic literature
review conducted by Berghofer et al. [14] corroborated
the works consulted when finding higher prevalence of
obesity in women.
Promoting changing conditions to healthy habits for
nutrition and physical exercise among children and ado-
lescents is no simple task. We agree with Vignolo et al.
[15], when they mention the value of a multidisciplinary
team and family participation in programs aimed at
weight loss and gain in life quality. It sho uld seek to un-
derstand the individual and environmental factors that
may be determinant of these changes, which requires
time. To the aforementioned authors, five years of fol-
low-up, in the present study a maximum of two years.
The satisfaction with activities in the program for
weight reduction, where access organization and educa-
tional content are key elements, were not measured.
However, organizational content, according to Kitscha et
al. [16], included the nutritional re-education, physical
activity, necessary interventions (medication and psy-
chotherapy), guidelines for participants and their parents
or guardians (taking into account the family history of
obesity).
From a psychological standpoint, there is a need for
special attention to obese individuals, particularly chil-
dren and adolescents, due to common problems to ac-
ceptance in the school (with bulling cases) or family en-
vironments and self-esteem, with low possibility of de-
veloping leadership attitudes, reduced cycle of friend-
ships and prone to more aggressive behaviors directed at
their self-image or identity [17].
Oliveira et al. [18] demonstrated association between
family history of obesity and a high BMI, especially with
maternal obesity; a fact confirmed in this study (p < 0.05
in both overw eight and obesity).
The associated comorbidities are in agreement with
the study of Franca and Alves [19]. These authors sug-
gested early prevention of obesity and cardiovascular
diseases as a priority in public health programs.
The relationship between changes in nutrition world-
wide with increased overweight and obesity on the oral
health status has been highlighted [20]. However, infor-
mation gaps exist regarding the functional performance
of the stomatognathic system, particularly the orofacial
motricity, making it difficult to compare the data ob-
tained in this study with other studies in the literature.
Regarding the presence of deleterious oral habits, this
was confirmed for 67.1% of the sample being shown in
Figure 3. It is noteworthy that most of the observed hab-
its is directed to the performance of the mastication and
beyond the significant emotional factor, there may be a
compensatory way.
History of nervous bulimia existed for 4.3% of chil-
dren and adolescents. For Peterson et al. [21], this disor-

M. Í. G. Janoca et al. / Open Journal of Stomatology 3 (2013) 59-64 63
der would be directly related to high levels of stress and
depression in patients with eating disorders and would
need to be computed so odd to conduct th e treatment and
control of these individuals when losing weight.
Chewing has implications for activation of histamine
neurons (HA), those responsible for the increased lipoly-
sis in adipose tissues and the feeling of fullness or satiety
[22]. However, little is surveyed on the influence of mas-
tication in the process of weight reduction. Apolinário,
Moraes and Motta [23] in the study involving the masti-
catory evaluation of 30 patients on the diet, reported that
the guidelines on chewing are made in most of guidelines
with emphasis on the speed and number of chewing cy-
cles. They added that there is adaptation of the mastica-
tory process, despite the unilateral mastication having
been much noted. In this study, besides one preferred
side, there was a preferred food consistency and speed
masticatory unfavorable to the process; however, with no
significant differences between overweight/obese group
and that one without this conditio n.
When reporting to oral conditions themselves, Bail-
leul-Forestier et al., [24] identified a higher DMFT in
obese patients (mean 6.9) compared to those non-obese
(4.3); superior results to those found in this study.
The inadequate food habits associated with frequency
of food intake and low self-esteem (which includes care
with personal hygiene) can be considered a risk factor for
periodontal diseases by favoring the formation and calci-
fication of the dent al bi o fi lm.
Genco et al., [25] found significant association be-
tween BMI and periodontal disease in obese individuals.
These authors mentioned insulin resistance as a mediator
of this relationship, without highlighting the occlusal
aspects. The malocclusions observed in this study also
possessed no significant association with BMI of volun-
teers.
The clinical implications of this study point to a
different approach for the planning of Dental Caries Pre-
ventive Programs in children and adolescents obese or
overweight.
A Different Approach for the Planning of Dental Car-
ies Preventive Programs.
5. CONCLUSION
Based on the results, a longer treatment with medication
was directly associated with oral conditions in children
and adolescents overweight or obese, particularly with
the higher DMFT rates, presence of visible biofilm and
higher frequency of halitosis.
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