How Dentists Should Consider Obesity in Patients
Obesity is a chronic disease associated with increased fatty deposition that leads to metabolic, biomechanical and psychosocial consequences and can be associated with frequent relapses. It is a serious condition that continues to be on the rise in the United States. Approximately 42% of Americans are diagnosed with obesity, which is a chronic condition that is associated with multiple comorbidities and is costly to the healthcare system to treat.1 Racial and ethnic disparities associated with obesity exist in the United States — increased prevalence is seen in Black and Hispanic populations.2 The worldwide prevalence of obesity has tripled since 1975.3 Over 650 million adults globally were obese in 2016, and the global consequences of reduced quality of life, loss of productivity and increased healthcare costs remain staggering.3
Childhood obesity also continues to rise, more than tripling in the United States since the 1970s.4 If obesity is not adequately treated in childhood, patients will continue to be obese as adults and are at increased risk of being affected by comorbidities to a higher degree than patients who were initially diagnosed with obesity as adults.
Dentistry and Obesity
Obese individuals are at higher risk of developing heart disease, type 2 diabetes and many other health conditions that lead to poor health outcomes and potentially death. So, where do dentists fit in to help treat these patients? Patients are often more likely to see their general dentist than their physician,5 and dental appointments can be opportunities to improve overall patient health. However, potential comorbidities associated with obesity might alter a dentist’s overall treatment plan. Obese patients are more likely to have type 2 diabetes, and, if so, they will have more difficulty with metabolic control.6 Diabetes, particularly when uncontrolled, is associated with worse outcomes after dental surgery, poor control of periodontal disease, and lesser ability to control fungal or bacterial infections.7-9 While this might not always change a treatment plan, it might cause a dentist to be more cautious.
In addition, obesity impacts dental treatment through increased risk of adverse outcomes during sedation.10 Increased fatty deposition can constrict the upper airway, leading to a higher potential for collapsibility and reduced central lung volume. Fatty tissue can also obscure normal anatomical landmarks and potentially make rescue procedures more difficult.
There are a wide range of treatments for obesity, such as bariatric surgery. However, the surgery can have detrimental effects on the mouth. After weight loss surgery, patients are more likely to develop caries, periodontal disease and tooth wear.11 Some types of weight loss surgery will increase the likelihood of gastric reflux, resulting in a more acidic oral environment. This acidic environment favors the development of caries and more rapid wear of tooth structures during grinding or clenching.
After weight loss surgery, absorption of the gastrointestinal system can change, resulting in malabsorption of minerals and vitamins. It is possible that vitamin D deficiency contributes to worsening periodontal status after weight loss surgery; however, the full mechanism is not yet known or understood. Changes in periodontal status can be seen within six months after weight loss surgery.12 If a patient undergoes weight loss surgery, he or she should schedule a dental appointment within six months after surgery to ensure optimal oral health. As dental providers, we must be aware of these consequences and serve as advocates for obesity management before surgical intervention is required.
Medical Perspectives on Obesity
Physicians assess obesity traditionally by using a body mass index (BMI) which is calculated using weight and height. Adult classifications of BMI are normal (18.5–24.9), overweight (25.0–29.9), Class I obesity (30.0–34.9) and Class II obesity (35.0 – 39.9). Childhood obesity is classified as BMI greater than or equal to the 95th percentile.1 While measurements of weight and height are easily obtained, BMI does not account for sarcopenia or changes in muscle mass. Other methods, like waist circumference, can be more predictive of health outcomes such as cardiovascular disease, hypertension and type 2 diabetes that result from excess body weight. In men, waist circumference of greater than or equal to 40 inches is considered obese, and a waist circumference of greater than or equal to 35 inches in women is considered obese.13
Since obesity is a complex disease, it is important to fully understand the patient’s health history, comorbidities, medications that contribute to weight gain, past experiences with weight loss treatment and their understanding of the disease. Behavioral change is required to maintain weight loss benefits. Providers can employ motivational interviewing techniques to more effectively understand why the patient would like to lose weight and then address any roadblocks that could prevent successful treatment. Motivational interviewing is a nonjudgmental and empathetic method that uses reflective listening and positive affirmations and works particularly well for those who may be resistant to change. Providers motivate their patients by understanding their perceived risks and then use these perceived risks to motivate behavior change. The goal is to help the patient decrease the discrepancy between their current behavior and their life values or goals.14
Overall, obesity treatment requires an individualized multifaceted approach. No specific diet is guaranteed to work for all patients. Generally, a low-fat and/or low-carbohydrate diet is encouraged in addition to using a meal or calorie tracker. A minimum of 150–200 minutes of moderate-intensity exercise weekly is recommended — an increase in exercise is associated with better weight control. Medications can be used for short-term treatment concurrently with diet and behavioral modifications. Commonly used medications include phentermine, liraglutide, phentermine/topiramate extended release, naltrexone/bupropion and orlistat. Bariatric surgery is indicated for patients with a BMI greater than or equal to 40 or patients with a BMI greater than or equal to 35 who have comorbidities. Some types of weight loss surgeries include gastric bypass surgery, laparoscopic adjustable gastric banding, sleeve gastrectomy, single anastomosis duodenal switch and biliopancreatic diversion with duodenal switch. Obesity management is a long-term process, and patients who receive surgical treatment may require returning to pharmacologic or other treatments to achieve long-term success.
Talking to Your Patients
Are you interested in being a part of your patients’ weight loss teams and an advocate for your patients’ health in your dental office? The topic of obesity can be difficult to address for anyone; however, initial steps can be as simple as adding height and weight to new patient forms or asking for permission to start the conversation. Interactions about weight should be nonjudgmental and respectful in a culturally sensitive manner. As providers, we should understand that underlying causes for obesity may exist, and patients might be trying to control their weight without achieving benefits.15 Motivational interviewing is a good technique to incorporate in the dental office because it can be used for any behavioral modification. As dental providers, we have the opportunity to collaborate with other healthcare professionals and refer patients for further evaluation and treatment if they are interested in starting or continuing their weight loss journeys.
Aaron Glick, DDS, is a clinical assistant professor, and C.D. Johnson, DDS, and Ben Warner, DDS, MD, are professors in the Department of General Practice & Dental Public Health, School of Dentistry, University of Texas Health Science Center at Houston. Jessica Glick, DO, is in private practice at Magnolia Family Medicine in The Woodlands, Texas.
References
1. Hales, C.M., et al. “Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018.” National Center for Health Statistics, NCHS Data Brief, no. 360, cdc.gov/nchs/products/databriefs/db360.htm. Accessed 25 May 2021.
2. Fryar, Cheryl D., et al. “Prevalence of Overweight, Obesity, and Severe Obesity Among Adults Aged 20 and Over: United States, 1960–1962 Through 2017–2018.” National Center for Health Statistics, cdc.gov/nchs/data/hestat/obesity-adult-17-18/obesity-adult.htm. Accessed 25 May 2021.
3. Chooi, Yu Chung, et al. “The Epidemiology of Obesity.” Metabolism, vol. 92, 2019, pp. 6-10.
4. Fryar, Cheryl D., et al. “Prevalence of Overweight, Obesity, and Severe Obesity Among Children and Adolescents Aged 2–19 Years: United States, 1963–1965 Through 2017– 2018.” National Center for Health Statistics, cdc.gov/nchs/data/hestat/obesity-child-17-18/obesity-child.htm. Accessed 25 May 2021.
5. Wood, Nelson, et al. “Comparison of Body Composition and Periodontal Disease Using Nutritional Assessment Techniques: Third National Health and Nutrition Examination Survey (NHANES III).” Journal of Clinical Periodontology, vol. 30, no. 4, 2003, pp. 321-327.
6. Sonmez, Alper, et al. “Impact of Obesity on the Metabolic Control of Type 2 Diabetes: Results of the Turkish Nationwide Survey of Glycemic and Other Metabolic Parameters of Patients With Diabetes Mellitus (TEMD obesity study).” Obesity Facts, vol. 12, no. 2, 2019, pp. 167-178.
7. Schimmel, Martin, et al. “Effect of Advanced Age and/or Systemic Medical Conditions on Dental Implant Survival: A Systematic Review and Meta-Analysis.” Clinical Oral Implants Research, vol. 29, 2018, pp. 311-330.
8. Genco, Robert J., and Wenche S. Borgnakke. “Diabetes as a Potential Risk for Periodontitis: Association Studies.” Periodontology 2000, vol. 83, no. 1, 2020, pp. 40-45.
9. Vernillo, Anthony T. “Dental Considerations for the Treatment of Patients With Diabetes Mellitus.” The Journal of the American Dental Association, vol. 134, 2003, pp. 24S-33S.
10. Saiso, Krittika, et al. “Complications Associated With Intravenous Midazolam and Fentanyl Sedation in Patients Undergoing Minor Oral Surgery.” Journal of Dental Anesthesia and Pain Medicine, vol. 17, no. 3, 2017, p. 199.
11. Cummings, Sue, and Janey Pratt. “Metabolic and Bariatric Surgery: Nutrition and Dental Considerations.” The Journal of the American Dental Association, vol. 146, no. 10, 2015, pp. 767-772.
12. Fontanille, Isabelle, et al. “Bariatric Surgery and Periodontal Status: A Systematic Review With Meta-Analysis.” Surgery for Obesity and Related Diseases, vol. 14, no. 10, 2018, pp. 1618-1631.
13. Han, Thang S., and Mike EJ Lean. “A Clinical Perspective of Obesity, Metabolic Syndrome and Cardiovascular Disease.” JRSM Cardiovascular Disease, vol. 5, 2016, pp. 1-13.
14. Kushner, Robert F., and Daniel H. Bessesen, eds. Treatment of the Obese Patient. New York: Humana Press, 2007.
15. Setchell, Jenny, et al. “Physical Therapists’ Ways of Talking About Overweight and Obesity: Clinical Implications.” Physical Therapy, vol. 96, no. 6, 2016, pp. 865-875
Childhood obesity also continues to rise, more than tripling in the United States since the 1970s.4 If obesity is not adequately treated in childhood, patients will continue to be obese as adults and are at increased risk of being affected by comorbidities to a higher degree than patients who were initially diagnosed with obesity as adults.
Dentistry and Obesity
Obese individuals are at higher risk of developing heart disease, type 2 diabetes and many other health conditions that lead to poor health outcomes and potentially death. So, where do dentists fit in to help treat these patients? Patients are often more likely to see their general dentist than their physician,5 and dental appointments can be opportunities to improve overall patient health. However, potential comorbidities associated with obesity might alter a dentist’s overall treatment plan. Obese patients are more likely to have type 2 diabetes, and, if so, they will have more difficulty with metabolic control.6 Diabetes, particularly when uncontrolled, is associated with worse outcomes after dental surgery, poor control of periodontal disease, and lesser ability to control fungal or bacterial infections.7-9 While this might not always change a treatment plan, it might cause a dentist to be more cautious.
In addition, obesity impacts dental treatment through increased risk of adverse outcomes during sedation.10 Increased fatty deposition can constrict the upper airway, leading to a higher potential for collapsibility and reduced central lung volume. Fatty tissue can also obscure normal anatomical landmarks and potentially make rescue procedures more difficult.
There are a wide range of treatments for obesity, such as bariatric surgery. However, the surgery can have detrimental effects on the mouth. After weight loss surgery, patients are more likely to develop caries, periodontal disease and tooth wear.11 Some types of weight loss surgery will increase the likelihood of gastric reflux, resulting in a more acidic oral environment. This acidic environment favors the development of caries and more rapid wear of tooth structures during grinding or clenching.
After weight loss surgery, absorption of the gastrointestinal system can change, resulting in malabsorption of minerals and vitamins. It is possible that vitamin D deficiency contributes to worsening periodontal status after weight loss surgery; however, the full mechanism is not yet known or understood. Changes in periodontal status can be seen within six months after weight loss surgery.12 If a patient undergoes weight loss surgery, he or she should schedule a dental appointment within six months after surgery to ensure optimal oral health. As dental providers, we must be aware of these consequences and serve as advocates for obesity management before surgical intervention is required.
Medical Perspectives on Obesity
Physicians assess obesity traditionally by using a body mass index (BMI) which is calculated using weight and height. Adult classifications of BMI are normal (18.5–24.9), overweight (25.0–29.9), Class I obesity (30.0–34.9) and Class II obesity (35.0 – 39.9). Childhood obesity is classified as BMI greater than or equal to the 95th percentile.1 While measurements of weight and height are easily obtained, BMI does not account for sarcopenia or changes in muscle mass. Other methods, like waist circumference, can be more predictive of health outcomes such as cardiovascular disease, hypertension and type 2 diabetes that result from excess body weight. In men, waist circumference of greater than or equal to 40 inches is considered obese, and a waist circumference of greater than or equal to 35 inches in women is considered obese.13
Since obesity is a complex disease, it is important to fully understand the patient’s health history, comorbidities, medications that contribute to weight gain, past experiences with weight loss treatment and their understanding of the disease. Behavioral change is required to maintain weight loss benefits. Providers can employ motivational interviewing techniques to more effectively understand why the patient would like to lose weight and then address any roadblocks that could prevent successful treatment. Motivational interviewing is a nonjudgmental and empathetic method that uses reflective listening and positive affirmations and works particularly well for those who may be resistant to change. Providers motivate their patients by understanding their perceived risks and then use these perceived risks to motivate behavior change. The goal is to help the patient decrease the discrepancy between their current behavior and their life values or goals.14
Overall, obesity treatment requires an individualized multifaceted approach. No specific diet is guaranteed to work for all patients. Generally, a low-fat and/or low-carbohydrate diet is encouraged in addition to using a meal or calorie tracker. A minimum of 150–200 minutes of moderate-intensity exercise weekly is recommended — an increase in exercise is associated with better weight control. Medications can be used for short-term treatment concurrently with diet and behavioral modifications. Commonly used medications include phentermine, liraglutide, phentermine/topiramate extended release, naltrexone/bupropion and orlistat. Bariatric surgery is indicated for patients with a BMI greater than or equal to 40 or patients with a BMI greater than or equal to 35 who have comorbidities. Some types of weight loss surgeries include gastric bypass surgery, laparoscopic adjustable gastric banding, sleeve gastrectomy, single anastomosis duodenal switch and biliopancreatic diversion with duodenal switch. Obesity management is a long-term process, and patients who receive surgical treatment may require returning to pharmacologic or other treatments to achieve long-term success.
Talking to Your Patients
Are you interested in being a part of your patients’ weight loss teams and an advocate for your patients’ health in your dental office? The topic of obesity can be difficult to address for anyone; however, initial steps can be as simple as adding height and weight to new patient forms or asking for permission to start the conversation. Interactions about weight should be nonjudgmental and respectful in a culturally sensitive manner. As providers, we should understand that underlying causes for obesity may exist, and patients might be trying to control their weight without achieving benefits.15 Motivational interviewing is a good technique to incorporate in the dental office because it can be used for any behavioral modification. As dental providers, we have the opportunity to collaborate with other healthcare professionals and refer patients for further evaluation and treatment if they are interested in starting or continuing their weight loss journeys.
Aaron Glick, DDS, is a clinical assistant professor, and C.D. Johnson, DDS, and Ben Warner, DDS, MD, are professors in the Department of General Practice & Dental Public Health, School of Dentistry, University of Texas Health Science Center at Houston. Jessica Glick, DO, is in private practice at Magnolia Family Medicine in The Woodlands, Texas.
References
1. Hales, C.M., et al. “Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018.” National Center for Health Statistics, NCHS Data Brief, no. 360, cdc.gov/nchs/products/databriefs/db360.htm. Accessed 25 May 2021.
2. Fryar, Cheryl D., et al. “Prevalence of Overweight, Obesity, and Severe Obesity Among Adults Aged 20 and Over: United States, 1960–1962 Through 2017–2018.” National Center for Health Statistics, cdc.gov/nchs/data/hestat/obesity-adult-17-18/obesity-adult.htm. Accessed 25 May 2021.
3. Chooi, Yu Chung, et al. “The Epidemiology of Obesity.” Metabolism, vol. 92, 2019, pp. 6-10.
4. Fryar, Cheryl D., et al. “Prevalence of Overweight, Obesity, and Severe Obesity Among Children and Adolescents Aged 2–19 Years: United States, 1963–1965 Through 2017– 2018.” National Center for Health Statistics, cdc.gov/nchs/data/hestat/obesity-child-17-18/obesity-child.htm. Accessed 25 May 2021.
5. Wood, Nelson, et al. “Comparison of Body Composition and Periodontal Disease Using Nutritional Assessment Techniques: Third National Health and Nutrition Examination Survey (NHANES III).” Journal of Clinical Periodontology, vol. 30, no. 4, 2003, pp. 321-327.
6. Sonmez, Alper, et al. “Impact of Obesity on the Metabolic Control of Type 2 Diabetes: Results of the Turkish Nationwide Survey of Glycemic and Other Metabolic Parameters of Patients With Diabetes Mellitus (TEMD obesity study).” Obesity Facts, vol. 12, no. 2, 2019, pp. 167-178.
7. Schimmel, Martin, et al. “Effect of Advanced Age and/or Systemic Medical Conditions on Dental Implant Survival: A Systematic Review and Meta-Analysis.” Clinical Oral Implants Research, vol. 29, 2018, pp. 311-330.
8. Genco, Robert J., and Wenche S. Borgnakke. “Diabetes as a Potential Risk for Periodontitis: Association Studies.” Periodontology 2000, vol. 83, no. 1, 2020, pp. 40-45.
9. Vernillo, Anthony T. “Dental Considerations for the Treatment of Patients With Diabetes Mellitus.” The Journal of the American Dental Association, vol. 134, 2003, pp. 24S-33S.
10. Saiso, Krittika, et al. “Complications Associated With Intravenous Midazolam and Fentanyl Sedation in Patients Undergoing Minor Oral Surgery.” Journal of Dental Anesthesia and Pain Medicine, vol. 17, no. 3, 2017, p. 199.
11. Cummings, Sue, and Janey Pratt. “Metabolic and Bariatric Surgery: Nutrition and Dental Considerations.” The Journal of the American Dental Association, vol. 146, no. 10, 2015, pp. 767-772.
12. Fontanille, Isabelle, et al. “Bariatric Surgery and Periodontal Status: A Systematic Review With Meta-Analysis.” Surgery for Obesity and Related Diseases, vol. 14, no. 10, 2018, pp. 1618-1631.
13. Han, Thang S., and Mike EJ Lean. “A Clinical Perspective of Obesity, Metabolic Syndrome and Cardiovascular Disease.” JRSM Cardiovascular Disease, vol. 5, 2016, pp. 1-13.
14. Kushner, Robert F., and Daniel H. Bessesen, eds. Treatment of the Obese Patient. New York: Humana Press, 2007.
15. Setchell, Jenny, et al. “Physical Therapists’ Ways of Talking About Overweight and Obesity: Clinical Implications.” Physical Therapy, vol. 96, no. 6, 2016, pp. 865-875