EDITORIAL

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
1

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

2

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

Abstract
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-
ic disorders affecting the health and well-being
of children and adolescents and its prevalence is
increasing steadily and dramatically all over the
world. Due to its serious health consequences,
obesity is commonly considered one of the most
serious health challenges of the early 21st centu-
ry. According to the World Health Organization,
globally 170 million children (aged < 18 years) are
estimated to be overweight and in some countries
the number of overweight children has trebled
since 1980 [1]. More than 42 million children un-
der the age of 5were reported to be overweight or
obese in 2013 [1]. 23.8% of boys and 22.6% of girls
from developed countries were diagnosed as over-
weight or obese in 2013 [2]. In Europe the highest
rates of obesity are registered in southern and east-
ern European countries [2]. In Malta and southern
Italy overweight or obesity were observed in 35%
of children, whereas the same conditions were reg-
istered in 15% of children in Scandinavia and in
12% of children in the Netherlands [35]. In Po-
land, between 19712000, the prevalence of over-
weight and obesity in children from Cracow dou-
132
bled from 7.5% to 15.2% in boys and from 6.5% to
11.8% in girls. The data obtained in 2009 pointed
to the further increase in the percentage of over-
weight and obese children reaching 35% in boys
and almost 20% in girls [6, 7]. According to WHO,
the definition of overweight and obesity is an ab-
normal and excessive fat accumulation which has
a negative effect on our health. Body mass index
(BMI) is an index of weight-for-height that is rou-
tinely used to define overweight and obesity in
adults. It accounts for a persons weight in kilo-
grams divided by the square of his height in me-
ters (kg/m2). ABMI greater or equal to 25 points
to overweight and aBMI greater and equal than 30
points to obesity [1]. BMI values assessed in chil-
dren vary depending on sex and age of the exam-
ined individuals but the correlation is not the same
as in adults. Thus it is recommended to use Inter-
national Obesity Task Force cut-off points applied
for children and adolescents that correspond with
their age and sex. In accordance with them, obe-
sity is defined as greater than or equal to the 95th
percentile of body mass index (BMI) and over-
weight is considered greater than the 85th percen-
tile of BMI [810].
As the prevalence and severity of childhood
obesity increase, concern about adverse health
outcomes in childhood and adolescence is rising.
Obese children are likely to develop awide range
of health problems as adults, like cardiovascular
disease, insulin resistance, musculoskeletal disor-
ders (especially osteoarthritis), some cancers (en-
dometrial, breast, colon). Childhood obesity is
strongly related to ahigher risk of obesity, prema-
ture death and disability in adulthood. But apart
from increased future risks, obese children expe-
rience breathing difficulties, higher risk of frac-
tures, hypertension, early markers of cardiovas-
cular disease, insulin resistance and psychological
effects [1, 3, 8].
Because of the growing number of overweight
or obese children and adolescents in orthodontic
practice, the aim of the study was to discuss ava-
riety of medical and psychosocial issues associated
with childhood obesity which may have an impact
on orthodontic therapy.
Timing of Puberty
Nutrition is an important regulator of the tem-
po of human growth. Overweight and obesity are
usually associated with the early onset of puberty
and earlier pubertal growth spurt[1114]. Never-
theless, there still remain many unanswered ques-
tions concerning the relationship between child-
hood obesity and childhood growth and matura-
K. Olszewska, M. Wana-Olszewska, I. Dunin-Wilczyska
tion. The idea that weight can affect the timing
of puberty was initially introduced by Frisch and
Revelle[15] in 1970 as the critical mass theory. In
accordance with this, it was thought that the criti-
cal weight of 22% body fat had to be reached to let
puberty progress. Although there was some con-
troversy about that hypothesis, the previously pre-
sented evidence lends some credibility to the criti-
cal mass theory. Leptin was discovered in 1994 by
Zhang et al.[16] and is acandidate for ahormone
that may have a regulatory function for body fat
levels. Leptin is secreted by adipocytes and regu-
lates appetite and metabolism through hypotha-
lamic mediators. Research in rodents led to the
theory that leptin might be involved in the timing
of puberty, thus providing the missing link in the
critical mass theory. Leptin was reported to slowly
rise before puberty and may play apermissive role
for the onset of puberty[17]. In addition to leptin,
it has become increasingly evident that adipose
tissue is asource of avariety of other secreted sig-
nals, such as adiponectin, resistin and several adi-
pocytokines and is an active site for the conversion
of cortisone to the more active cortisol and of an-
drogens to estrogen, which contribute to the ear-
lier activation of the hypothalamic-pituitary-go-
nadal axis and thereby to the earlier onset of pu-
berty in the obese[11].
Skeletal Growth
The relationship between obesity and preco-
cious skeletal maturation is acontroversial subject
in the literature. It has been suggested that leptin
produced by the adipose tissue can stimulate skel-
etal growth by the activation of different media-
tors, such as insulin-like growth factor 1and sex
hormones. Alternatively, leptin might show a di-
rect action on the skeletal growth centers. Leptin
receptors have been found in the cartilaginous
growth centers that are involved in skeletal mat-
uration. Therefore, an obese subject probably has
amechanism of central resistance to leptin and an
increased sensitivity to leptin at aperipheral level,
leading to increased differentiation and prolifera-
tion of chondrocytes and resulting in precocious
skeletal maturation [11, 1214, 17].
In addition, it has been reported that early on-
set obesity can cause increases in vertebral bone
density and bone size and an acceleration of skele-
tal growth. In particular, obesity has been hypoth-
esized to impact craniofacial growth and leads to
more precocious skeletal maturation of the maxil-
la and the mandible, which has afundamental sig-
nificance in dentofacial orthopaedics [18].
There is an evidence suggesting that obesity
Obesity in Children and Orthodontic Practice
may influence the timing of puberty and growth
patterns. Higher BMI in childhood may result in
an earlier pubertal growth spurt and subsequent
earlier cessation of growth. Obese girls and boys
present an earlier onset of puberty and comple-
tion of puberty with ashorter duration of puber-
ty compared to the normal-weight peers. They
tend to be taller during pre-puberty but lose this
growth advantage during puberty and have asim-
ilar adult height compared to the normal-weight
children [19].
In the study of Giuca et al. [20] obese indi-
viduals presented agreater mean discrepancy be-
tween skeletal age and chronologic age according
to the carpal analysis and showed a significantly
higher mean cervical vertebrae maturation score
in comparison with the normal weight individu-
als. Therefore, in the obese individuals with skel-
etal discrepancies, it may be necessary to perform
an examination and dentofacial treatment earlier
than in the normal-weight patients [20].
It is obvious that growth and development can
be influenced by an obese body mass, but to what
level this occurs is currently unknown. The bones
and soft tissues seem to grow differently in obese
patients, and the differences between obese and
normal-weight subjects have just begun to be ex-
amined. In growing patients, dental development
and skeletal maturation are widely used to deter-
mine the timing of orthodontic treatment and the
selection of treatment modalities [2123]. Growth
and development issues should be examined care-
fully in obese and overweight patients. Obese pa-
tients tend to go through puberty earlier than
non-obese individuals. Treatment planning for
obese patients should assume that they have less
time until their pubertal growth spurt than nor-
mal weight subjects, but not to such asignificant
level that craniofacial growth modification should
not be attempted [18].
Dentition Development
Orthodontists rely on dental age rather than
on chronologic age as an indicator of when to ini-
tiate the treatment. Accelerated dentition devel-
opment may affect orthodontic treatment timing
and the selection of treatment options [21, 22].
Few authors studied the dentition develop-
ment in overweight or obese children and adoles-
cents. Hilgers et al. [24] conducted astudy to de-
termine if increased body mass index (BMI) is as-
sociated with accelerated dental development in
children. The study revealed that dental devel-
opment was significantly accelerated with an in-
creased BMI. The mean dental age acceleration
133
for overweight and obese subjects was 1.31 1.22
years and 1.53 1.28 years, respectively. Those
findings were in agreement with Eid et al. [25],
who also found a significant correlation between
dental maturity and BMI (0.68 years for males and
0.62 for females).
Mack et al. [26] found that for every 1percen-
tile of increase in BMI percentile for age, there was
a0.005-year increase in dental age. The study con-
ducted by Mack et al. [26] revealed asignificant re-
lationship between weight status defined by BMI
percentile and dental age and cervical vertebral
maturation stage. An increase in BMI percentile
was thought to be associated with an increase in
both dental and skeletal maturation [26].
An acceleration of dental development in
obese children may alter the diagnosis and orth-
odontic treatment timing. In fact, when incorpo-
rating orthodontic therapies like serial extractions
or growth modification, the timing of interven-
tion may require recalculation to consider not on-
ly sex or race, but also the weight status of the pa-
tient.
Craniofacial Morphology
Craniofacial growth is highly dependent on
interactions between genes, hormones, nutrients
and epigenetic factors. Disturbances of any of
those mechanisms may lead to an aberrant growth
pattern resulting in a deviant craniofacial mor-
phology.
In the study of hrn et al. [27] a majority of
angular and linear measurements were increased
in obese adolescents in comparison to the healthy
controls and the differences between obese and
non-obese individuals were more significant in
females than males. The most significant dif-
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-
pared to the non-obese individuals. The obese ad-
olescents showed increased maxillary and man-
dibular prognathism, as well as anterior cranial
base length. The findings of the study suggest that
obese adolescents show more intense craniofacial
growth activity than normal weight individuals.
Sadeghianrizi et al. [28] studied the develop-
ment of craniofacial complex in obese adolescents
and found that obesity was related to bimaxillary
prognathism and relatively greater craniofacial di-
mensions such as maxillary length (Pm-A), man-
dibular length (Cd-Pgn), posterior facial height
(S-Go) and lower anterior facial height (ANS-Gn)
despite decreased level of growth hormone. The
general impression of the study was that obese ad-
134
olescents presented amore advanced craniofacial
development in comparison to the normal weight
individuals of acorresponding age. Although the
craniofacial dimensions were greater in the obese
subjects, their facial proportions did not present
any significant deviation from the norm.
Cephalometric and facial analyses should be
altered in the examination of obese or overweight
patients. Normal values for this group should be
viewed with the knowledge that they were orig-
inally established on normal weight individuals
and therefore might not be appropriate for obese
and overweight subjects. Increased tissue thick-
ness can actually allow for greater leeway when
correcting dental and skeletal discrepancies. An
area for future research should aim to examine the
soft-tissue changes observed in obese patients dur-
ing orthodontic therapy. Although clinical chang-
es are expected in the soft-tissue profile as aresult
of bone and tooth movements, it seems reasonable
to assume that the same movements in obese pa-
tients will result in less dramatic changes in the
profile because of the increased thickness of the
soft-tissues [29].
Bone Metabolism
In accordance with available literature, obesity
seems to impact bone metabolism through sever-
al mechanisms, which may considerably affect the
orthodontic tooth movement. Obesity is thought
to decrease bone formation when increasing ad-
ipogenesis, as adipocytes and osteoblasts derive
from a common multi-potential mesenchymal
stem cell. For instance, mechanical loading pro-
motes osteoblast differentiation and inhibits ad-
ipogenesis by down-regulating peroxisome pro-
liferator-activated receptor gamma (PPARg) or
through stimulation of adurable beta-catemin sig-
nal. Activation of PPARg decreases differentiation
of osteoblasts, bone mineral density and trabecu-
lar bone mass simultanously with the increase of
differentiation of adipocytes and bone marrow ad-
ipose tissue volume.
Obesity may also stimulate bone resorption
through upregulating proinflammatory cytokines
such as IL-6 and TNF-a. These proinflammato-
ry cytokines are able to enhance osteoclast activ-
ity through the regulation of the RANKL/RANK/
OPG pathway.
Obesity is considered to influence bone me-
tabolism directly or indirectly through adipo-
cyte-derived cytokines such as leptin and adipo-
nectin. Obesity results in asignificant increase in
serum leptin and decrease in adiponectin. Over-
production of leptin may have a negative impact
K. Olszewska, M. Wana-Olszewska, I. Dunin-Wilczyska
on bone metabolism. Adiponectin is another cy-
tokine secreted by adipocytes and shows anti-in-
flammatory effect. In animal model, adiponectin
has been showed to inhibit osteoclastogenesis, de-
crease bone resorption and increase bone mass.
Obese individuals present low serum adiponec-
tin concentration in comparison with the normal-
weight subjects.
Finally, ahigh-fat diet that leads to obesity has
been reported to impair intestinal calcium absorp-
tion. Free fatty acids are able to form unabsorbable
insoluble calcium soaps resulting in decreased cal-
cium absorption [3033].
Psychosocial Problems
Obesity in childhood and adolescence is as-
sociated with significant psychosocial problems,
which are probably more common than medical
consequences. Most typical complications are re-
lated to psychosocial dysfunction and social isola-
tion. Childhood obesity has a significant impact
on the emotional development of achild or adoles-
cent, who suffers discrimination and stigmatiza-
tion. Individuals who were obese in childhood are
more likely to have poor body image and low self-
esteem and confidence. Overweight children and
adolescents commonly report lower health-related
quality of life in physical, emotional and social as-
pects. Adolescent girls have atendency to experi-
ence body dissatisfaction, adrive for thinness, and
atendency to succumb to eating disorders. There
is evidence that obese children and adolescents de-
velop lower self-esteem than their nonobese peers.
Importantly, girls are at a greater risk of self-es-
teem problems and can develop lower self-esteem
during puberty. Adolescents and children might
discount their condition as acoping mechanism.
They may consider their appearance as unim-
portant, which can be problematic in orthodontic
treatment. They could also use distortion as ade-
fense mechanism and underestimate the severi-
ty of their body image or weight. Depression and
anxiety are more common in obese patients.
An overweight patient might be unwilling
or unable to regard the orthodontic problem as
important, because of the defense mechanisms
and disregard for body appearance. The attitude
could also swing into hyperrealization of appear-
ance with the patient developing unrealistic ex-
pectations. An orthodontist should have a high
index of suspicion for psychosocial problems as-
sociated with childhood obesity to recognize
them and deal with them at the right time be-
fore they become problematic for the orthodon-
tic therapy [3437].
Obesity in Children and Orthodontic Practice 135

Conclusions creasing number of overweight or obese children

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

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Address for correspondence:

Katarzyna Olszewska
Uanw 21/28
20-554 Lublin
E-mail: catieol@interia.pl

Conflict of interest: None declared

Received: 11.11.2014
Revised: 16.12.2014
Accepted: 11.01.2015