Braz J Oral Sci. October-December 2007 - Vol.

6 - Number 23

Obesity and periodontal disease:

why suggest such relationship? An
overview
Beatriz de Brito Bezerra1
Enilson Antnio Sallum2
Antnio Wilson Sallum2
1

PhD Student;
Professor
Department of Prosthodontics and
Periodontics, Periodontics Division, Piracicaba
Dental School, State University of Campinas
2

Received for publication: September 19, 2007

Accepted: November 27, 2007

Abstract
Obesity is a chronic condition that has social and economic implications
for public health. It can be associated with periodontal disease since
the metabolic alterations observed in that condition could have some
influence in immunity. The elevated levels of lipid and glucose can be
associated with periodontal disease, contributing to an exacerbated
host inflammatory response, alterations in neutrophil function, and
with the inhibition of macrophage growth factors, reducing tissuehealing capacity. In this way, obese individuals could have higher
chances of undergoing tissue destruction in the presence of periodontal
infection. On the other hand, periodontitis may be involved in
alterations of lipid metabolism, since gram-negative bacteria could
promote a rise in cholesterol and triglyceride levels due to chronic
exposure to low levels of LPS in circulating blood, leading to the
production of cytokines, which could initiate the production of
lipoproteins by the liver. The objective was to review the literature
about obesity and periodontal disease and provide a better
understanding of their relationship.
Key words:
obesity, periodontitis, insulin resistance, hyperlipidemia

Correspondence to:
Beatriz Bezerra
Departamento de Prtese e Periodontia
rea de Periodontia
Av:Limeira, 901
Piracicaba/SP Brazil
CEP: 13.414-903
Phone/fax: +55 19 2106-5301
e-mail: biabezerra@fop.unicamp.br

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Introduction
Obesity is a chronic condition, which can be associated with
periodontal disease, since metabolic alterations that are
present in this condition could have some influence on the
host immunity. Elevations in the levels of lipids and glucose
can be associated with periodontal disease and may
contribute to an exacerbated inflammatory host response,
alterations on the neutrophil functions, and the inhibition of
growth factors by macrophages, reducing the healing
capacity of the tissues. On the other hand, chronic exposure
to bacteria LPS promotes the production of cytokines, which
contribute to the alteration of the lipid metabolism.
Literature Review
Obesity
Obesity is a chronic metabolic condition that has public
health implications because it is a risk factor for many
diseases, such as diabetes, hyperlipidemia, hypertension,
atherosclerosis, cardiovascular disease, among others1-2.
Three metabolic alterations are responsible for the obesity
characteristics:
(1) Hiperinsulinemia: there is increased production of insulin
by beta cells to compensate the resistance in the tissues,
especially the adipose, muscular and hepatic ones.
(2) Hyperglycemia: since there is a resistance to insulin,
the circulating glucose is not taken by the cells and there is
an increase of the blood glucose levels.
(3) Hyperlipidemia: there is an elevation of the seric levels
of cholesterol and triglyceride due to the lipid metabolism
alteration there is an increase in the liver lipogenesis and
lipolysis in the adipocytes.
These alterations seen in obesity are also found in localized
chronic or generalized acute infections. Cytokines, especially
TNF-a, produced by the adipose tissue, are the ones
responsible for those alterations. It is known that the adipose
tissue stores energy as triglycerides and has a secretory
function 3, constitutively producing cytokines. Obesity is
then characterized as a chronic inflammatory state that can
be confirmed by the high levels of C-reactive protein1,4.
Insulin Resistance
Insulin resistance is found in obesity and in infections, as
the result of an increased secretion of cytokines by the
adipose tissue and the macrophages, which are hyperactive
because of the hyperlipidemia in obesity5,6.
TNF-a interferes in insulin signaling and blocks the
translocation of the glucose transporter (GLUT-4) to the cell
membrane, as well the assimilation of the circulating glucose
by the cell7; as a result, a state of hyperglycemia can rise.
Insulin resistance also interferes with lipid metabolism
because the adipocytes resistant to insulin cannot assimilate
the circulating fatty acids. Reaching the liver, these fatty
acids will be broken down in triglycerides and cholesterol8,

Obesity and periodontal disease: why suggest such relationship? An overview

which will worsen the insulin resistance state.

Insulin resistance can be the link between periodontal
disease, obesity and diabetes because in these three
situations there is the production of chronic regulated
cytokines. This chronic regulation contributes to the insulin
resistance state, leading to metabolic alterations9.
Relationship between hyperlipidemia and periodontal disease
The relationship between periodontal disease and
hyperlipidemia has already been studied by other authors5,6,1012
, who verified that patients with periodontal disease could
present elevated levels of triglycerides and cholesterol. This
is because the systemic involvement, since the periodontal
infection is a chronic one. Moreover, chronic exposure to
bacteria LPS promotes the recruitment of defense cells,
specifically macrophages that secrete TNF-a e IL-1b,
increasing lipogenesis and lipolysis and leading to a state of
hyperlipidemia5.
The increased lipid levels promote alterations, for example,
phagocytosis and chemotaxis alterations of the defense cells
(polimorphonuclear cells and macrophages). These cells
release a greater amount of growth factors by the
macrophages, which impair tissue healing5.
Why suggest such a relationship?
New evidences 7,9,13,14 have been showing that insulin
resistance is a link between obesity and periodontal disease
due to the TNF-a produced in both conditions. TNF-a
produced by the adipose tissue helps exacerbate the
periodontal disease and the one produced by periodontal
disease helps perpetuate the insulin resistance seen in
obesity.
Periodontal disease may also unbalance lipid metabolism
worsening the hiperlipidemic state in the obese patients5,6,1012
. In a case-control study by Noack et al.15 the patients with
hyperlipidemia had higher periodontal inflammation than the
control patients, with a higher percentage of sites and sextants
with probing depth (PD) 3.5mm.
A positive relationship between the obesity indicators, body
mass index (BMI) and waist-hip ratio (WHR), and periodontal
disease was found in some studies 14,16-18. Furthermore, a
significant correlation between BMI and the plasmatic
concentrations of TNF-a4, which may suggest that obesity
may lead to an exacerbation of the periodontal disease
because of the higher load of circulating cytokines.
Nevertheless, the BMI is not a good obesity indicator
because it is based on the total fat of the patient. Waist-hip
ratio is a more reliable indicator since it measures the waist
circumference, which shows a close correlation with the
amount of visceral adipose tissue19. Visceral adipose tissue
was shown to be metabolically active and to secrete a great
amount of cytokines and hormones, this way being
responsible for some metabolic alterations19, such as insulin

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Braz J Oral Sci. 6(23):1420-1422

resistance and lipid profile alterations. In addition, in the hip

area, there is the greatest amount of muscle in the body, and
its mass and function are closely related to the systemic
sensitivity to insulin20. This way, many studies are using the
WHR as an obesity indicator and have found a stronger
positive relationship with periodontal disease than the
BMI11,14,16-17.
Final considerations
Obesity is characterized by a chronic inflammatory state,
which can worsen the preexisting periodontal disease.
Periodontal disease has shown to induce metabolic
alterations in the lipid metabolism contributing to the
hyperlipidemic state of obesity.
Further studies are necessary to elucidate the real
relationship between obesity and periodontal disease.
Molecular biology studies are necessary to better
understand the mechanism and biological foundation of the
association between obesity, periodontal disease and insulin
resistance. Longitudinal studies are also necessary to show
a causal relationship. However, before any progress in the
understanding of this relationship, periodontists should
counsel obese patients in relation to the possible oral
complications of obesity, to diminish morbidity for these
individuals. This counseling should include the measurement
of BMI and WHR for periodontal risk evaluation on a regular
basis 21.

Obesity and periodontal disease: why suggest such relationship? An overview

9.

10.

11.

12.

13.

14.

15.

16.

17.

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