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Dent. Med. Probl. 2015, 52, 2, 131136 Copyright by Wroclaw Medical University
ISSN 1644-387X and Polish Dental Society

Katarzyna Olszewska1, AF, Maria Wana-Olszewska2, AF,

Izabella Dunin-Wilczyska1, A, C, EF

Obesity in Children and Adolescents

aNew Challenge in Orthodontic Practice
Otyo udzieci imodziey nowe wyzwanie wpraktyce ortodontycznej
Chair and Department of Jaw Orthopaedics, Medical University in Lublin, Lublin, Poland

Department of Pediatrics, Specialistic Hospital in Lublin, Lublin, Poland


Aresearch concept and design; Bcollection and/or assembly of data; Cdata analysis and interpretation;
Dwriting the article; Ecritical revision of the article; Ffinal approval of article

Obesity is one of the most common chronic disorders affecting the health and well-being of children and adoles-
cents and its prevalence is increasing steadily and dramatically all over the world. Because of the growing num-
ber of overweight or obese children and adolescents in orthodontic practice, the aim of the study was to discuss
avariety of medical and psychosocial issues associated with childhood obesity which may have an impact on orth-
odontic therapy. Overweight and obesity are usually associated with the early onset of puberty and earlier pubertal
growth spurt. Obesity has been hypothesized to impact craniofacial growth and lead to more precocious skeletal
maturation of the maxilla and the mandible, which has afundamental significance in dentofacial orthopaedics. An
acceleration of dental development in obese children may alter the diagnosis and timing of orthodontic treatment.
In fact, when incorporating orthodontic therapies such as growth modification or serial extractions, the timing of
intervention may require recalculation to consider also the weight status of the patient. Based on available litera-
ture, obesity seems to impact bone metabolism through several mechanisms, which may considerably affect the
orthodontic tooth movement. Obesity in childhood and adolescence is associated with significant psychosocial
problems, which are probably more common than medical consequences. Most typical complications are related
to psychosocial dysfunction and social isolation. Obesity in childhood and adolescence should be considered as
achronic medical condition associated with amultitude of medical and psychosocial consequences, which may
influence orthodontic therapy (Dent. Med. Probl. 2015, 52, 2, 131136).
Key words: obesity, children, overweight, orthodontic treatment, adolescents.
Sowa kluczowe: dzieci, modzie, otyo, nadwaga, leczenie ortodontyczne.

Obesity is one of the most common chron- der the age of 5were reported to be overweight or
ic disorders affecting the health and well-being obese in 2013 [1]. 23.8% of boys and 22.6% of girls
of children and adolescents and its prevalence is from developed countries were diagnosed as over-
increasing steadily and dramatically all over the weight or obese in 2013 [2]. In Europe the highest
world. Due to its serious health consequences, rates of obesity are registered in southern and east-
obesity is commonly considered one of the most ern European countries [2]. In Malta and southern
serious health challenges of the early 21st centu- Italy overweight or obesity were observed in 35%
ry. According to the World Health Organization, of children, whereas the same conditions were reg-
globally 170 million children (aged < 18 years) are istered in 15% of children in Scandinavia and in
estimated to be overweight and in some countries 12% of children in the Netherlands [35]. In Po-
the number of overweight children has trebled land, between 19712000, the prevalence of over-
since 1980 [1]. More than 42 million children un- weight and obesity in children from Cracow dou-
132 K. Olszewska, M. Wana-Olszewska, I. Dunin-Wilczyska

bled from 7.5% to 15.2% in boys and from 6.5% to tion. The idea that weight can affect the timing
11.8% in girls. The data obtained in 2009 pointed of puberty was initially introduced by Frisch and
to the further increase in the percentage of over- Revelle[15] in 1970 as the critical mass theory. In
weight and obese children reaching 35% in boys accordance with this, it was thought that the criti-
and almost 20% in girls [6, 7]. According to WHO, cal weight of 22% body fat had to be reached to let
the definition of overweight and obesity is an ab- puberty progress. Although there was some con-
normal and excessive fat accumulation which has troversy about that hypothesis, the previously pre-
a negative effect on our health. Body mass index sented evidence lends some credibility to the criti-
(BMI) is an index of weight-for-height that is rou- cal mass theory. Leptin was discovered in 1994 by
tinely used to define overweight and obesity in Zhang et al.[16] and is acandidate for ahormone
adults. It accounts for a persons weight in kilo- that may have a regulatory function for body fat
grams divided by the square of his height in me- levels. Leptin is secreted by adipocytes and regu-
ters (kg/m2). ABMI greater or equal to 25 points lates appetite and metabolism through hypotha-
to overweight and aBMI greater and equal than 30 lamic mediators. Research in rodents led to the
points to obesity [1]. BMI values assessed in chil- theory that leptin might be involved in the timing
dren vary depending on sex and age of the exam- of puberty, thus providing the missing link in the
ined individuals but the correlation is not the same critical mass theory. Leptin was reported to slowly
as in adults. Thus it is recommended to use Inter- rise before puberty and may play apermissive role
national Obesity Task Force cut-off points applied for the onset of puberty[17]. In addition to leptin,
for children and adolescents that correspond with it has become increasingly evident that adipose
their age and sex. In accordance with them, obe- tissue is asource of avariety of other secreted sig-
sity is defined as greater than or equal to the 95th nals, such as adiponectin, resistin and several adi-
percentile of body mass index (BMI) and over- pocytokines and is an active site for the conversion
weight is considered greater than the 85th percen- of cortisone to the more active cortisol and of an-
tile of BMI [810]. drogens to estrogen, which contribute to the ear-
As the prevalence and severity of childhood lier activation of the hypothalamic-pituitary-go-
obesity increase, concern about adverse health nadal axis and thereby to the earlier onset of pu-
outcomes in childhood and adolescence is rising. berty in the obese[11].
Obese children are likely to develop awide range
of health problems as adults, like cardiovascular
disease, insulin resistance, musculoskeletal disor- Skeletal Growth
ders (especially osteoarthritis), some cancers (en-
dometrial, breast, colon). Childhood obesity is The relationship between obesity and preco-
strongly related to ahigher risk of obesity, prema- cious skeletal maturation is acontroversial subject
ture death and disability in adulthood. But apart in the literature. It has been suggested that leptin
from increased future risks, obese children expe- produced by the adipose tissue can stimulate skel-
rience breathing difficulties, higher risk of frac- etal growth by the activation of different media-
tures, hypertension, early markers of cardiovas- tors, such as insulin-like growth factor 1and sex
cular disease, insulin resistance and psychological hormones. Alternatively, leptin might show a di-
effects [1, 3, 8]. rect action on the skeletal growth centers. Leptin
Because of the growing number of overweight receptors have been found in the cartilaginous
or obese children and adolescents in orthodontic growth centers that are involved in skeletal mat-
practice, the aim of the study was to discuss ava- uration. Therefore, an obese subject probably has
riety of medical and psychosocial issues associated amechanism of central resistance to leptin and an
with childhood obesity which may have an impact increased sensitivity to leptin at aperipheral level,
on orthodontic therapy. leading to increased differentiation and prolifera-
tion of chondrocytes and resulting in precocious
skeletal maturation [11, 1214, 17].
Timing of Puberty In addition, it has been reported that early on-
set obesity can cause increases in vertebral bone
Nutrition is an important regulator of the tem- density and bone size and an acceleration of skele-
po of human growth. Overweight and obesity are tal growth. In particular, obesity has been hypoth-
usually associated with the early onset of puberty esized to impact craniofacial growth and leads to
and earlier pubertal growth spurt[1114]. Never- more precocious skeletal maturation of the maxil-
theless, there still remain many unanswered ques- la and the mandible, which has afundamental sig-
tions concerning the relationship between child- nificance in dentofacial orthopaedics [18].
hood obesity and childhood growth and matura- There is an evidence suggesting that obesity
Obesity in Children and Orthodontic Practice 133

may influence the timing of puberty and growth for overweight and obese subjects was 1.31 1.22
patterns. Higher BMI in childhood may result in years and 1.53 1.28 years, respectively. Those
an earlier pubertal growth spurt and subsequent findings were in agreement with Eid et al. [25],
earlier cessation of growth. Obese girls and boys who also found a significant correlation between
present an earlier onset of puberty and comple- dental maturity and BMI (0.68 years for males and
tion of puberty with ashorter duration of puber- 0.62 for females).
ty compared to the normal-weight peers. They Mack et al. [26] found that for every 1percen-
tend to be taller during pre-puberty but lose this tile of increase in BMI percentile for age, there was
growth advantage during puberty and have asim- a0.005-year increase in dental age. The study con-
ilar adult height compared to the normal-weight ducted by Mack et al. [26] revealed asignificant re-
children [19]. lationship between weight status defined by BMI
In the study of Giuca et al. [20] obese indi- percentile and dental age and cervical vertebral
viduals presented agreater mean discrepancy be- maturation stage. An increase in BMI percentile
tween skeletal age and chronologic age according was thought to be associated with an increase in
to the carpal analysis and showed a significantly both dental and skeletal maturation [26].
higher mean cervical vertebrae maturation score An acceleration of dental development in
in comparison with the normal weight individu- obese children may alter the diagnosis and orth-
als. Therefore, in the obese individuals with skel- odontic treatment timing. In fact, when incorpo-
etal discrepancies, it may be necessary to perform rating orthodontic therapies like serial extractions
an examination and dentofacial treatment earlier or growth modification, the timing of interven-
than in the normal-weight patients [20]. tion may require recalculation to consider not on-
It is obvious that growth and development can ly sex or race, but also the weight status of the pa-
be influenced by an obese body mass, but to what tient.
level this occurs is currently unknown. The bones
and soft tissues seem to grow differently in obese
patients, and the differences between obese and Craniofacial Morphology
normal-weight subjects have just begun to be ex-
amined. In growing patients, dental development Craniofacial growth is highly dependent on
and skeletal maturation are widely used to deter- interactions between genes, hormones, nutrients
mine the timing of orthodontic treatment and the and epigenetic factors. Disturbances of any of
selection of treatment modalities [2123]. Growth those mechanisms may lead to an aberrant growth
and development issues should be examined care- pattern resulting in a deviant craniofacial mor-
fully in obese and overweight patients. Obese pa- phology.
tients tend to go through puberty earlier than In the study of hrn et al. [27] a majority of
non-obese individuals. Treatment planning for angular and linear measurements were increased
obese patients should assume that they have less in obese adolescents in comparison to the healthy
time until their pubertal growth spurt than nor- controls and the differences between obese and
mal weight subjects, but not to such asignificant non-obese individuals were more significant in
level that craniofacial growth modification should females than males. The most significant dif-
not be attempted [18]. ference was found in the length of the mandible
(Cd-Pgn), which was 6 mm and 8.7 mm great-
er in obese females and males respectively com-
Dentition Development pared to the non-obese individuals. The obese ad-
olescents showed increased maxillary and man-
Orthodontists rely on dental age rather than dibular prognathism, as well as anterior cranial
on chronologic age as an indicator of when to ini- base length. The findings of the study suggest that
tiate the treatment. Accelerated dentition devel- obese adolescents show more intense craniofacial
opment may affect orthodontic treatment timing growth activity than normal weight individuals.
and the selection of treatment options [21, 22]. Sadeghianrizi et al. [28] studied the develop-
Few authors studied the dentition develop- ment of craniofacial complex in obese adolescents
ment in overweight or obese children and adoles- and found that obesity was related to bimaxillary
cents. Hilgers et al. [24] conducted astudy to de- prognathism and relatively greater craniofacial di-
termine if increased body mass index (BMI) is as- mensions such as maxillary length (Pm-A), man-
sociated with accelerated dental development in dibular length (Cd-Pgn), posterior facial height
children. The study revealed that dental devel- (S-Go) and lower anterior facial height (ANS-Gn)
opment was significantly accelerated with an in- despite decreased level of growth hormone. The
creased BMI. The mean dental age acceleration general impression of the study was that obese ad-
134 K. Olszewska, M. Wana-Olszewska, I. Dunin-Wilczyska

olescents presented amore advanced craniofacial on bone metabolism. Adiponectin is another cy-
development in comparison to the normal weight tokine secreted by adipocytes and shows anti-in-
individuals of acorresponding age. Although the flammatory effect. In animal model, adiponectin
craniofacial dimensions were greater in the obese has been showed to inhibit osteoclastogenesis, de-
subjects, their facial proportions did not present crease bone resorption and increase bone mass.
any significant deviation from the norm. Obese individuals present low serum adiponec-
Cephalometric and facial analyses should be tin concentration in comparison with the normal-
altered in the examination of obese or overweight weight subjects.
patients. Normal values for this group should be Finally, ahigh-fat diet that leads to obesity has
viewed with the knowledge that they were orig- been reported to impair intestinal calcium absorp-
inally established on normal weight individuals tion. Free fatty acids are able to form unabsorbable
and therefore might not be appropriate for obese insoluble calcium soaps resulting in decreased cal-
and overweight subjects. Increased tissue thick- cium absorption [3033].
ness can actually allow for greater leeway when
correcting dental and skeletal discrepancies. An
area for future research should aim to examine the Psychosocial Problems
soft-tissue changes observed in obese patients dur-
ing orthodontic therapy. Although clinical chang- Obesity in childhood and adolescence is as-
es are expected in the soft-tissue profile as aresult sociated with significant psychosocial problems,
of bone and tooth movements, it seems reasonable which are probably more common than medical
to assume that the same movements in obese pa- consequences. Most typical complications are re-
tients will result in less dramatic changes in the lated to psychosocial dysfunction and social isola-
profile because of the increased thickness of the tion. Childhood obesity has a significant impact
soft-tissues [29]. on the emotional development of achild or adoles-
cent, who suffers discrimination and stigmatiza-
tion. Individuals who were obese in childhood are
Bone Metabolism more likely to have poor body image and low self-
esteem and confidence. Overweight children and
In accordance with available literature, obesity adolescents commonly report lower health-related
seems to impact bone metabolism through sever- quality of life in physical, emotional and social as-
al mechanisms, which may considerably affect the pects. Adolescent girls have atendency to experi-
orthodontic tooth movement. Obesity is thought ence body dissatisfaction, adrive for thinness, and
to decrease bone formation when increasing ad- atendency to succumb to eating disorders. There
ipogenesis, as adipocytes and osteoblasts derive is evidence that obese children and adolescents de-
from a common multi-potential mesenchymal velop lower self-esteem than their nonobese peers.
stem cell. For instance, mechanical loading pro- Importantly, girls are at a greater risk of self-es-
motes osteoblast differentiation and inhibits ad- teem problems and can develop lower self-esteem
ipogenesis by down-regulating peroxisome pro- during puberty. Adolescents and children might
liferator-activated receptor gamma (PPARg) or discount their condition as acoping mechanism.
through stimulation of adurable beta-catemin sig- They may consider their appearance as unim-
nal. Activation of PPARg decreases differentiation portant, which can be problematic in orthodontic
of osteoblasts, bone mineral density and trabecu- treatment. They could also use distortion as ade-
lar bone mass simultanously with the increase of fense mechanism and underestimate the severi-
differentiation of adipocytes and bone marrow ad- ty of their body image or weight. Depression and
ipose tissue volume. anxiety are more common in obese patients.
Obesity may also stimulate bone resorption An overweight patient might be unwilling
through upregulating proinflammatory cytokines or unable to regard the orthodontic problem as
such as IL-6 and TNF-a. These proinflammato- important, because of the defense mechanisms
ry cytokines are able to enhance osteoclast activ- and disregard for body appearance. The attitude
ity through the regulation of the RANKL/RANK/ could also swing into hyperrealization of appear-
OPG pathway. ance with the patient developing unrealistic ex-
Obesity is considered to influence bone me- pectations. An orthodontist should have a high
tabolism directly or indirectly through adipo- index of suspicion for psychosocial problems as-
cyte-derived cytokines such as leptin and adipo- sociated with childhood obesity to recognize
nectin. Obesity results in asignificant increase in them and deal with them at the right time be-
serum leptin and decrease in adiponectin. Over- fore they become problematic for the orthodon-
production of leptin may have a negative impact tic therapy [3437].
Obesity in Children and Orthodontic Practice 135

Conclusions creasing number of overweight or obese children

and adolescents in orthodontic practice, ortho-
Obesity in childhood and adolescence should dontists should be aware of potential health issues
be considered as achronic medical condition asso- associated with childhood obesity and as health
ciated with amultitude of medical and psychoso- care providers should promote health and actively
cial consequences, which may also have asignifi- refer or counsel overweight patients.
cant impact on orthodontic therapy. Due to the in-

[1] World Health Organization: Prioritizing areas for action in the field of population-based prevention of childhood
obesity. WHO, Geneva 2012.
[2] Ng M., Fleming T., Robinson M.: Global, regional and national prevalence of overweight and obesity in children
and adults during 19802013: asystematic analysis for the Global Burden of Disease Study 2013. Lancet 2014, 384,
9945, 766781.
[3] Aypak C., Tredi ., Yce A.: The association of vitamin Dstatus with cardiometabolic risk factors, obesity and
puberty in children. Eur. J. Pediatr. 2014, 173, 367373.
[4] Garcia E.G., Lopez M.A.V., Martinez R.G.: Prevalence of overweight and obesity in children and adolescents
aged 216 years. Endocrinol. Nutr. 2013, 60, 121126.
[5] Livingstone B.: Epidemiology of childhood obesity in Europe. Eur. J. Pediatr. 2000, 159 (Suppl 1), 1434.
[6] Bac A., Woniacka R., Matusik S., Golec J., Golec E.: Prevalence of overweight and obesity in children aged
613 years alarming increase in obesity in Cracow, Poland. Eur. J. Pediatr. 2012, 171, 245251.
[7] Oblaciska A., Jodkowska M.: Obesity among Polish adolescents: epidemiology, eating behaviours, dieting,
physical activity and well-being among overweight and obese adolescents. Instytut Matki i Dziecka, Warszawa
2007 [in Polish].
[8] Lo J.C., Chandra M., Sinaiko A., Daniels S.R., Prineas R.J., Maring B., Parker E.D., Sherwood N.E., Daley M.F.,
Kharbanda E.O., Adams K.F., Magid D.J., OConnor P.J., Greenspan L.C.: Severe obesity in children: preva-
lence, persistence and relation to hypertension. Int. J. Pediatr. Endocrinol. 2014, 62, 311.
[9] Cole T.J., Bellizzi M.C., Flegal K.M., Dietz W.H.: Establishing astandard definition for child overweight and
obesity worldwide: International survey. BMJ 2000, 320, 12401243.
[10] Palczewska I., Szilagyi-Pgowska I.: Assessment of the somatic development in children and adolescents.
Med. Prakt. Ped. 2002, 3, 17[in Polish].
[11] Sandhu J., Ben-Shlomo Y., Cole T.J., Holly J., Smith G.D.: The impact of childhood body mass index on
timing of puberty, adult stature and obesity: afollow-up study based on adolescent anthropometry recorded at
ChristsHospital. Int. J. Obesity 2006, 30, 1422.
[12] Ahmed M.L., Ong K.K., Dunger D.B.: Childhood obesity and the timing of puberty. Trends Endocrinol. Met.
2009, 20, 237242.
[13] Dunger D.B., Ahmed M.L., Ong K.K.: Effects of obesity on growth and puberty. Best Pract. Res. Clin. Endocrinol.
Metab. 2005, 19, 375390.
[14] Bradner Jasik C., Lustig L.H.: Adolescent obesity and puberty: the perfect storm. Ann. NY Acad. Sci. 2008, 1135,
[15] Frisch R.E., Revelle R.: Height and weight at menarche and ahypothesis of critical body weights and adolescent
events. Sci. 1970, 169, 397399.
[16] Zhang Y., Proenca R., Maffei M.: Positional cloning of the mouse obese gene and its human homologue. Nature
1994, 372, 425432.
[17] Ahmed M.L., Ong K.K., Morrell D.J.: Longitudinal study of leptin concentrations during puberty: sex differen-
ces and relationships to changes in body composition. J. Clin. Endocrinol. Metab. 1999, 84, 899905.
[18] Neeley W.W., Gonzales D.A.: Obesity in adolescence: Implications in orthodontic treatment. Am. J. Orthod.
Dentofacial. Orthop. 2007, 131, 581588.
[19] De Leonibus C., Marcovecchio M.L., Chiavaroli V., de Giorgis T., Chiarelli F.: Timing of puberty and
physical growth in obese children: alongitudinal study in boys and girls. Pediatr. Obes. 2013, 9, 292299.
[20] Giuca M.R., Pasini M., Tecco S., Marchetti E., Giannotti E., Marzo G.: Skeletal maturation in obese patients.
Am. J. Orthod. Dentofacial. Orthop. 2012, 142, 774779.
[21] Ryo-Kalinowska I., Kolasa-Rczka A., Kalinowski P.: Relationship between dental age according to
Demirjian and cervical vertebrae maturity in Polish children. Eur. J. Orthod. 2011, 33, 7583.
[22] Demirjian A., Goldstein H., Tanner J.M.: Anew system of dental age assessment. Hum. Biol. 1973, 45, 211227.
[23] Baccetti T., Franchi L., McNamara J.: An improved version of the cervical vertebral maturation (CVM)
method for the assessment of mandibular growth. Angle Orthod. 2002, 72, 316323.
[24] Hilgers K.K., Akridge M., Scheetz J.P., Kinane D.F.: Childhood obesity and dental development. Pediatr. Dent.
2006, 28, 1822.
[25] Eid R.M., Simi R., Friggi M.N., Fisberg M.: Assessment of dental maturity of Brazilian children aged 6to 14 years
using Demirjiansmethod. Int. J. Paediatr. Dent. 2002, 12, 423428.
[26] Mack K., Philips C., Jain N., Koroluk L.D.: Relationship between body mass index percentile and skeletal
maturation and dental development in orthodontic patients. Am. J. Orthod. Dentofac. Orthop. 2013, 143, 228234.
136 K. Olszewska, M. Wana-Olszewska, I. Dunin-Wilczyska

[27] hrn K., Al-Kahlili B., Huggare J., Forsberg C.M., Marcus C.: Craniofacial morphology in obese adole-
scents. Acta Odontol. Scand. 2002, 60, 193197.
[28] Sadeghianrizi A., Forsberg C.M., Marcus C., Dahllf G.: Craniofacial development in obese adolescents.
Eur. J. Orthod. 2005, 27, 550555.
[29] Ferrario V., Dellavia C., Tartaglia G., Turci M., Sforza C.: Soft tissue facial morphology in obese adole-
scents: athree dimensional non-invasive assessment. Angle Orthod. 2004, 74, 3742.
[30] Holecki M., Wiecek A.: Relationship between body fat mass and bone metabolism. Pol. Arch. Med. Wewn. 2010,
120, 361367 [in Polish].
[31] Cao J.J.: Effects of obesity on bone metabolism. J. Orthop. Surg. Res. 2011, 6, 3037.
[32] Misra M., Klibanski A.: Anorexia nervosa, obesity and bone metabolism. Pediatr. Endocrinol. Rev. 2013, 11, 2123.
[33] Shapses S.A., Sukumar D.: Bone metabolism in obesity and weight loss. Ann. Rev. Nutr. 2012, 21, 287309.
[34] French S., Story M., Perry C.: Self-esteem and obesity in children and adolescents: aliterature review. Obes.
Res. 1995, 3, 479490.
[35] Strauss R.: Childhood obesity and self-esteem. Pediatrics, 2000, 105, e15e20.
[36] Israel A., Ivanova M.: Global and dimensional self-esteem in pre-adolescent and early adolescent children who
are overweight: age and gender differences. Int. J. Eat. Disord. 2002, 31, 424429.
[37] Renman C., Engstrom I., Silfverdal S., Aman J.: Mental health and psychosocial characteristics in adolescent
obesity: apopulation based case-control study. Acta Pediatr. 1999, 88, 9981003.

Address for correspondence:

Katarzyna Olszewska
Uanw 21/28
20-554 Lublin

Conflict of interest: None declared

Received: 11.11.2014
Revised: 16.12.2014
Accepted: 11.01.2015