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Perio-Systemic Obesity and the Risk of Periodontitis Link

Obesity is a recognized health problem that is increasing worldwide at an alarming rate. As described herein, the detrimental impact of obesity on general health is well established, demonstrating an increased risk of several chronic diseases (ie, type II diabetes, hypertension, cardiovascular disease).1

Obesity was long suspected as a possible risk factor for periodontitis. In an animal study, Perlstein and Bissada reported increased alveolar bone resorption in obese rats as compared to nonobese rats.2 This report gained notice when a number of investigators reported an association between obesity and periodontitis in humans. Saito et al reported an association between body mass index (BMI) and periodontitis among 241 healthy Japanese adults.3 Prevalence of periodontitis was 3.4% among individuals with BMI of 25 kg/m2 to 29.9 kg/m2 and 8.6% among obese individuals (BMI >30 kg/m2). In a subsequent study of 643 healthy Japanese adults, Saito et al reported higher periodontitis prevalence among those with abdominal adiposity as compared to those without this condition.4 These reports were followed by three studies in the US population5-7; of these, Al-Zahrani et al analyzed data from the third National Health and Nutrition Examination survey on 13,665 individuals and reported an association between overall and abdominal obesity, especially among subjects aged 18 to 34 years of age.5 Recently, the results of a study of 706 Brazilian individuals revealed an association between BMI and periodontitis among women, but not among men.8

Obesity generally develops as a result of imbalance between energy intake and expenditure, a result of too much food and too little physical activity.9 Additionally, physical activity was shown to have a protective relationship with periodontitis.10,11 Furthermore, individuals who maintain normal weight, engage in the recommended level of exercise, and eat a healthy diet were found to be 40% less likely to have periodontitis as compared to those not practicing these healthy behaviors.12

The biological mechanism by which obesity may increase susceptibility to periodontitis is not totally understood. A possible mechanism is through increasing secretion of certain proinflammatory cytokines that are known to be associated  with periodontal tissue destruction, such as interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-a).11 Several proinflammatory cytokines, including TNF-α and IL-6, have been shown to be synthesized and secreted by adipose tissue.13,14 These cytokines may interfere with intracellular insulin signaling and subsequently may lead to insulin resistance.13,14 Recently, Genco et al reported that the association between obesity and periodontitis is modulated by insulin resistance.15



Although several epidemiological studies have reported an association between obesity and periodontitis, they are insufficient for making causal inferences. The above published studies on this issue are cross-sectional; thus, it is not possible to determine whether obesity preceded development of periodontitis or vice versa. Longitudinal and intervention studies are needed in order to elucidate and understand the true nature of the obesity-periodontitis relationship. 


*Head, Division of Periodontics, King Abdulaziz University, Jeddah, Saudi Arabia

†Professor and Chairman, Department of Periodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio



  1. US Department of Health and Human Services.  The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity.  Rockville, MD:  US Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2001.
  2. Perlstein MI, Bissada NF.  Influence of obesity and hypertension on the severity of periodontitis in rats. Oral Surg Oral Med Oral Pathol 1977;43(5):707-719.
  3. Saito T, Shimazaki Y, Sakamoto M.  Obesity and periodontitis.  N Engl J Med 1998;339(7):482-483.
  4. Saito T, Shimazaki Y, Koga T, et al.  Relationship between upper body obesity and periodontitis.  J Dent Res 2001;80(7):1631-1636.
  5. Al-Zahrani MS, Bissada NF, Borawski EA.  Obesity and periodontal disease in young, middle-aged, and older adults.  J Periodontol 2003;74(5):610-615. 
  6. Wood N, Johnson RB, Streckfus CF.  Comparison of body composition and periodontal disease using nutritional assessment techniques.  Third National Health and Nutrition Examination Survey (NHANES III).  J Clin Periodontol 2003;30(4):321-327.
  7. Alabdulkarim M, Bissada N, Al-Zahrani M, et al.  Alveolar bone loss in obese subjects.  J Int Acad Periodontol 2005;7(2):34-38.
  8. Dalla Vecchia CF, Susin C, Rsing CK, et al.  Overweight and obesity as risk indicators for periodontitis in adults.  J Periodontol 2005;76(10):1721-1728.
  9. Taubes G.  As obesity rates rise, experts struggle to explain why.  Science 1998;280(5368):1367-1368.
  10. Al-Zahrani MS, Borawski EA, Bissada NF.  Increased physical activity reduces prevalence of periodontitis.  J Dent 2005;33(9):703-710.
  11. Merchant AT, Pitiphat W, Rimm EB, Joshipura K.  Increased physical activity decreases periodontitis risk in men.  Eur J Epidemiol 2003;18(9):891-898.
  12. Al-Zahrani MS, Borawski EA, Bissada NF.  Periodontitis and three health-enhancing behaviors:  Maintaining normal weight, engaging in recommended level of exercise, and consuming a high-quality diet.  J Periodontol 2005;76(8):1362-1366.
  13. Hotamisligil GS, Shargill NS, Spiegelman BM.  Adipose expression of tumor necrosis factor-alpha’s direct role in obesity-linked insulin resistance.  Science 1993;259(5091):87-91.
  14. Hotamisligil GS.  The role of TNF-alpha and TNF receptors in obesity and insulin resistance. J Intern Med 1999;245(6):621-625.
  15. Genco RJ, Grossi SG, Ho A, et al.  A proposed model linking inflammation to obesity, diabetes, and periodontal infections.  J Periodontol 2005;76(11 Suppl):2075-2084.
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