- Email: [email protected]
Body mass characterization of dental diseases – A quantitative prospective study
Indian Journal of Dentistry 2012 AprileJune Volume 3, Number 2; pp. 68e71
Original Article
Body mass characterization of dental diseases e A quantitative prospective study Jaspal Singha,*, Anshu Sharmab, Nishita Gargc, Pathivada Lumbinic
ABSTRACT Dental caries is the result of confluence of 4 major factors host, agent, environment and time. Diet is one such factor which is common to this cascade, diet contributes not only to obesity but it affects periodontal status as well. Overweight and obesity, especially in children, are increasing public health problems worldwide. Obesity can be very well calculated by Body mass index (BMI). The body mass index (BMI), or Quetelet index, is a heuristic proxy for human body fat based on an individual’s weight and height.1) BMI was found to have a negative correlation with DMFT (r ¼ 0.011) which was statistically non-significant. BMI was found to have a negative correlation with periodontal Index (r ¼ 0.062) which was statistically non-significant. The mean values for BMI, DMFT and PI scores were 19.74, 1.29 and 0.24, respectively. The distribution of BMI for levels 1, 2, 3 and 4 was 43.5, 44.8, 8.3 and 3.5%, respectively. The caries prevalence for the whole sample was 36.8%, and it ranged from 28.6% (BMI-4) to 42.4% (BMI-3). © 2012 Indian Journal of Dentistry. All rights reserved. Keywords: Dental caries, Quetelet index, DMFT, BMI, Obesity
INTRODUCTION Dental caries is defined as an infectious disease of microbial origin which is related to every specialty of dentistry in one or the other way.1 Dental caries is the result of confluence of 4 major factors host, agent, environment and time. Diet is one such factor which is common to this cascade, diet contributes not only to obesity but it affects periodontal status as well. Overweight and obesity, especially in children, are increasing public health problems worldwide. Obesity can be very well calculated by Body mass index (BMI). The body mass index (BMI), or Quetelet index, is a heuristic proxy for human body fat based on an individual’s weight and height. It was invented between 1830 and 1850 by the Belgian polymath Adolphe Quetelet during the course of developing “social physics”. Body mass index is defined as the individual’s body weight divided by the square of his or her height. Significantly, obesity is
increasing rapidly in developing countries undergoing rapid nutrition and lifestyle transition, and it often coexists with under-nutrition. Recent trends in Indian population indicate a rise in obesity in children. Recent data shows that the prevalence of obesity among adolescent children (14e17 y) was 29% in private schools and 11.3% in government funded schools in 2006e2007.2 Overweight and obese children are at increased risk for developing psychosocial and medical problems compared with individuals with normal weight.3,4 A diet of high sugar intake, including snacks and soft drinks, is more common among overweight and obese children/adolescents than those with normal weight.5 Frequent sugar intake is also a recognized risk factor for dental caries. Thus, the diet pattern may be a common risk factor for overweight and caries. Periodontal status of an individual may be also affected according to the nature of diet. Periodontal disease is a serious and prevalent condition, affecting roughly 80 percent of adults.
a Associate Professor, b Senior Lecturer, c Junior Resident, Department of Pedodontics, Teerthankar Mahaveer Dental College & Research center, Moradabad, Uttar Pradesh, India. * Corresponding author. Tel.: þ91 9872763751, email: [email protected] or [email protected] Received: 25.10.2011; Accepted: 15.3.2012 Ó 2012 Indian Journal of Dentistry. All rights reserved.
doi: 10.1016/j.ijd.2012.03.005
Body mass characterization of dental diseases
Left untreated, early stages of the disease e characterized by gum inflammation and oral bleeding e can advance to more chronic levels, resulting in bone decay, loss of connective tissue and even the removal of teeth. Though periodontal disease results from a number of lifestyle and genetic factors, diet plays an important role in its progression and prevention. Hence the present study was under taken to determine dental caries status of an individual and its correlation with BMI and periodontal status of an individual.
MATERIALS AND METHODS Sample collection A cross-sectional survey was conducted among 400 individuals between 18 and 22 years of age were randomly selected from schools in the city of Moradabad. Only the children whose parents had signed an informed consent form were included. Authorizations were obtained from the ethics committee who officially informed the heads of the schools about the procedure. Inclusion criteria 1) All children selected were of the same religion, and same ethnic origin
Original Article
69
(no.17), shepherd probe (no. 23), and odontoscope (mouth mirror) under natural diffused light source. Sterile cotton was used during the procedure so as to clean the tooth during examination procedure.
BMI CALCULATION Height and weight were measured of the selected children by using a standard physician scale and a weighing scale, respectively. In each child height was measured to the nearest full centimeter and body weight was measured to the nearest 0.1 kg. Measurements were made with the children wearing light clothing and without footwear. BMI was calculated by using the following formula BMI ¼
massðkgÞ ðheightðmÞÞ2
BMI was categorized into four groups as follows: BMI-1 ¼ Insufficient (underweight), under 18.5 kg/m2; BMI-2 ¼ normal weight, between 18.5 and 25 kg/m2; BMI-3 ¼ overweight, between 25 and 30 kg/m2; BMI-4 ¼ obesity, over 30 kg/m2. Other potential explanatory variables with regard to caries experience were included in the analysis: gender, type of school (public or private), sugar consumption (less than 3 times a day/3e5 times a day/6 times a day or more) and soft drink consumption (less than once a day/once a day or more).
2) Children selected were free from any systemic disease 3) Children selected were following same dietary pattern and belong to same geographic area. 4) Fluoride content in the water of the residing area was determined previously.
Periodontal examination The condition of the periodontium was estimated by using the Periodontal Index developed by Russell.8 The Periodontal Index (PI) has a possible range of scores from zero to eight-the poorer the condition of the periodontal tissues, the larger the assigned score.
Exclusion criteria 1) children suffering from any disease or systemic illness were excluded from the study. 2) children who had history of antibiotic consumption in the recent past were excluded from the study. 3) those having mixed diet were excluded from the study.
Dental caries examination Relevant case history was obtained from the study cohort and dental caries was recorded using ‘DMFT’ index for permanent teeth, with the help of a right angle probe
Statistical methods Descriptive statistics were firstly performed to compute means and standard deviations of age, height, weight, Table 1 Descriptive statistics. Parameter
Number
Mean
Std. Deviation
Age Weight Height BMI DMFT PI index
400 400 400 400 400 400
13.66 49.28 1.58 19.74 1.29 0.24
0.94 11.55 0.08 3.94 2.46 0.612
70
Indian Journal of Dentistry 2012 AprileJune; Vol. 3, No. 2
DMFT and PI scores and BMI (Table 1). KruskaleWallis test was used for comparison between groups. Pearson Correlation test was used to determine associations between DMFT, PI scores and BMI.
Singh et al.
Table 3 Correlations. BMI PI index
Mean
Std. Deviation
19.74 0.24
3.94 0.612 PI index
RESULTS
BMI
Following results were drawn from the study 1) BMI was found to have a negative correlation with DMFT (r ¼ 0.011) which was statistically non-significant (Table 2)
Mean
Std. Deviation 3.95 2.46
Table 4 BMI groups.
DISCUSSION BMI is a sensitive measure of the obesity level as well as the risk for dental caries may be also correlated from it since diet is common to both the parameters. Though there is a controversy on the subject, since previous studies have shown mixed results. Positive results i.e. High caries experience and higher BMI have been shown by Reifsnider, 2004,6 Willershausen, 2006, Draper 2006. Negative association i.e. high caries experience and low bmi (Ayhan 1996,7 Table 2 Correlations.
Pearson correlation Sig. (2-tailed) N
BMI was found to have a negative correlation with Plaque Index (r ¼ 0.062) which was statistically non-significant.
19.74 1.29
4) The caries prevalence for the whole sample was 36.8%, and it ranged from 28.6% (BMI-4) to 42.4% (BMI-3) (Table 5) Pearson correlation models showed a negative correlation between DMFT and BMI (0.011), which was not statistically significant. A negative correlation was also found between PI and BMI (0.062) which was again not statistically significant.
BMI
0.062 0.218 400
Aces, 1999. No association has been shown by Tuomi 1989, Chen 1995, Whelton 2004, Kim 2006, Mcdougal 2006, Hayes 2006. In our study, the results appear to show an association between BMI and the presence of dental caries and oral hygiene in the dentition in a group of Indian school children. The data showed that school children who were having higher BMI scores were at greater risk for developing dental caries and having poorer oral hygiene as compared to lower BMI groups. Interestingly, in this study, the small number of children in group BMI-4 showed an inverse relation of BMI with that of DMFT and PI scores. The results are similar to a study done in Mexican preschool children, in which there was a significant association between at-risk overweight and overweight children and caries in the primary dentition.3 Another study in Swedish children found that BMI had an independent, though weak, effect on caries variation.5 Isabelle et al observed that obese children had a high level of caries experience as compared to non-obese group.2 However, several studies have shown no relation between BMI and caries occurrence.3,4,5 The exact mechanism for the association of body weight and dental caries is not yet known. It has been proposed that consumption of refined carbohydrates might serve as a link between obesity and the onset of dental caries. Marshall et al 4 found that children <5 years of age with dental caries had a higher soft drink intake than children without caries. However, they could not establish a relation between soft drink consumption and BMI levels. On the other hand, a study by Ochoa et al found that children who consume
2) BMI was found to have a negative correlation with periodontal Index (r ¼ 0.062) which was statistically nonsignificant (Table 3) 3)The mean values for BMI, DMFT and PI scores were 19.74, 1.29 and 0.24, respectively. The distribution of BMI for levels 1, 2, 3 and 4 was 43.5, 44.8, 8.3 and 3.5%, respectively (Tables 3 and 4)
BMI DMFT
Pearson correlation Sig. (2-tailed) N
DMFT 0.011 0.823 400
BMI was found to have a negative correlation with DMFT (r ¼ 0.011) which was statistically non-significant.
Less than 18.5 18.5e25.0 25.1e30.0 More than 30 Total
Frequency
Percent
174 179 33 14 400
43.5 44.8 8.3 3.5 100.0
Body mass characterization of dental diseases
Original Article
Table 5 BMI Groups* caries Cross tabulation. BMI groups
Less than 18.5 18.5e25.0 25.1e30.0 More than 30 Total
Dental caries Caries free
Caries present
112 64.4% 112 62.6% 19 57.6% 10 71.4% 253 63.3%
62 35.6% 67 37.4% 14 42.4% 4 28.6% 147 36.8%
SOURCE OF FUNDING Total
None. 174 100.0% 179 100.0% 33 100.0% 14 100.0% 400 100.0%
sugar-sweetened beverages have a 1.74 times greater risk of being obese as compared with children who do not consume this type of beverage. Anita Alm et al8 showed that overweight and obese adolescents had more approximal caries than normal weight individuals and the frequent consumption of snacking products during early childhood was a risk indicator for caries at 15 years. Both dental caries and obesity are multifactorial diseases related to dietary habits. Health professionals should work in a multidisciplinary manner with these patients with the aim of establishing good dietary habits. Mary Tavares and Virginia Chomitz suggested a “Healthy Weight Intervention” (HWI) protocol for promoting awareness of child obesity risk in the dental setting and providing necessary recommendations, goal-setting, and referrals. Future preventive programmes should therefore include, on a multidisciplinary level, strategies to prevent and reduce both obesity and dental caries at an early age.
CONFLICT OF INTEREST None.
71
ACKNOWLEDGMENTS None.
REFERENCES 1. Sharma A, Somani R. Dermatoglyphic characterization of dental caries and its correlation with salivary ph e an in vivo study. J Ind Soc Pedo Prev Dent. vol. 27(1):17e21. 2. Bhardwaj S, Misra A. Childhood obesity in Asian Indians: a burgeoning cause of insulin resistance, diabetes and sub-clinical inflammation. Asia Pac J Clin Nutr. 2008;17(S1): 172e175. 3. Mossberg HO. 40-year follow-up of overweight children. Lancet. 1989;26:491e493. 4. Burniat W. Child and adolescent obesity: causes and consequences, prevention and management. Cambridge: Cambridge University Press; 2002. pp. 145e146. 5. WHO. Diet, nutrition and the prevention of chronic diseases. Geneva: World Health Organization; 2003. Technical Report Series 916. 6. Reifsnider, Elizabeth. Journal of Multicultural Nursing & Health/Summer 2004 Childhood Obesity and Early Childhood Caries in a WIC Population. 7. Update on the 1987 Task Force Report on High Blood Pressure in Children and Adolescents: a working group report from the National High Blood Pressure Education Program. National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents. Pediatrics. 1996 Oct; 98(4 Pt 1): 649e658. 8. Alm A, Isaksson H, Fåhraeus C, et al. BMI status in Swedish children and young adults in relation to caries prevalence. Swed Dent J. 2011;35(1):1e8.
Original Article
Body mass characterization of dental diseases e A quantitative prospective study Jaspal Singha,*, Anshu Sharmab, Nishita Gargc, Pathivada Lumbinic
ABSTRACT Dental caries is the result of confluence of 4 major factors host, agent, environment and time. Diet is one such factor which is common to this cascade, diet contributes not only to obesity but it affects periodontal status as well. Overweight and obesity, especially in children, are increasing public health problems worldwide. Obesity can be very well calculated by Body mass index (BMI). The body mass index (BMI), or Quetelet index, is a heuristic proxy for human body fat based on an individual’s weight and height.1) BMI was found to have a negative correlation with DMFT (r ¼ 0.011) which was statistically non-significant. BMI was found to have a negative correlation with periodontal Index (r ¼ 0.062) which was statistically non-significant. The mean values for BMI, DMFT and PI scores were 19.74, 1.29 and 0.24, respectively. The distribution of BMI for levels 1, 2, 3 and 4 was 43.5, 44.8, 8.3 and 3.5%, respectively. The caries prevalence for the whole sample was 36.8%, and it ranged from 28.6% (BMI-4) to 42.4% (BMI-3). © 2012 Indian Journal of Dentistry. All rights reserved. Keywords: Dental caries, Quetelet index, DMFT, BMI, Obesity
INTRODUCTION Dental caries is defined as an infectious disease of microbial origin which is related to every specialty of dentistry in one or the other way.1 Dental caries is the result of confluence of 4 major factors host, agent, environment and time. Diet is one such factor which is common to this cascade, diet contributes not only to obesity but it affects periodontal status as well. Overweight and obesity, especially in children, are increasing public health problems worldwide. Obesity can be very well calculated by Body mass index (BMI). The body mass index (BMI), or Quetelet index, is a heuristic proxy for human body fat based on an individual’s weight and height. It was invented between 1830 and 1850 by the Belgian polymath Adolphe Quetelet during the course of developing “social physics”. Body mass index is defined as the individual’s body weight divided by the square of his or her height. Significantly, obesity is
increasing rapidly in developing countries undergoing rapid nutrition and lifestyle transition, and it often coexists with under-nutrition. Recent trends in Indian population indicate a rise in obesity in children. Recent data shows that the prevalence of obesity among adolescent children (14e17 y) was 29% in private schools and 11.3% in government funded schools in 2006e2007.2 Overweight and obese children are at increased risk for developing psychosocial and medical problems compared with individuals with normal weight.3,4 A diet of high sugar intake, including snacks and soft drinks, is more common among overweight and obese children/adolescents than those with normal weight.5 Frequent sugar intake is also a recognized risk factor for dental caries. Thus, the diet pattern may be a common risk factor for overweight and caries. Periodontal status of an individual may be also affected according to the nature of diet. Periodontal disease is a serious and prevalent condition, affecting roughly 80 percent of adults.
a Associate Professor, b Senior Lecturer, c Junior Resident, Department of Pedodontics, Teerthankar Mahaveer Dental College & Research center, Moradabad, Uttar Pradesh, India. * Corresponding author. Tel.: þ91 9872763751, email: [email protected] or [email protected] Received: 25.10.2011; Accepted: 15.3.2012 Ó 2012 Indian Journal of Dentistry. All rights reserved.
doi: 10.1016/j.ijd.2012.03.005
Body mass characterization of dental diseases
Left untreated, early stages of the disease e characterized by gum inflammation and oral bleeding e can advance to more chronic levels, resulting in bone decay, loss of connective tissue and even the removal of teeth. Though periodontal disease results from a number of lifestyle and genetic factors, diet plays an important role in its progression and prevention. Hence the present study was under taken to determine dental caries status of an individual and its correlation with BMI and periodontal status of an individual.
MATERIALS AND METHODS Sample collection A cross-sectional survey was conducted among 400 individuals between 18 and 22 years of age were randomly selected from schools in the city of Moradabad. Only the children whose parents had signed an informed consent form were included. Authorizations were obtained from the ethics committee who officially informed the heads of the schools about the procedure. Inclusion criteria 1) All children selected were of the same religion, and same ethnic origin
Original Article
69
(no.17), shepherd probe (no. 23), and odontoscope (mouth mirror) under natural diffused light source. Sterile cotton was used during the procedure so as to clean the tooth during examination procedure.
BMI CALCULATION Height and weight were measured of the selected children by using a standard physician scale and a weighing scale, respectively. In each child height was measured to the nearest full centimeter and body weight was measured to the nearest 0.1 kg. Measurements were made with the children wearing light clothing and without footwear. BMI was calculated by using the following formula BMI ¼
massðkgÞ ðheightðmÞÞ2
BMI was categorized into four groups as follows: BMI-1 ¼ Insufficient (underweight), under 18.5 kg/m2; BMI-2 ¼ normal weight, between 18.5 and 25 kg/m2; BMI-3 ¼ overweight, between 25 and 30 kg/m2; BMI-4 ¼ obesity, over 30 kg/m2. Other potential explanatory variables with regard to caries experience were included in the analysis: gender, type of school (public or private), sugar consumption (less than 3 times a day/3e5 times a day/6 times a day or more) and soft drink consumption (less than once a day/once a day or more).
2) Children selected were free from any systemic disease 3) Children selected were following same dietary pattern and belong to same geographic area. 4) Fluoride content in the water of the residing area was determined previously.
Periodontal examination The condition of the periodontium was estimated by using the Periodontal Index developed by Russell.8 The Periodontal Index (PI) has a possible range of scores from zero to eight-the poorer the condition of the periodontal tissues, the larger the assigned score.
Exclusion criteria 1) children suffering from any disease or systemic illness were excluded from the study. 2) children who had history of antibiotic consumption in the recent past were excluded from the study. 3) those having mixed diet were excluded from the study.
Dental caries examination Relevant case history was obtained from the study cohort and dental caries was recorded using ‘DMFT’ index for permanent teeth, with the help of a right angle probe
Statistical methods Descriptive statistics were firstly performed to compute means and standard deviations of age, height, weight, Table 1 Descriptive statistics. Parameter
Number
Mean
Std. Deviation
Age Weight Height BMI DMFT PI index
400 400 400 400 400 400
13.66 49.28 1.58 19.74 1.29 0.24
0.94 11.55 0.08 3.94 2.46 0.612
70
Indian Journal of Dentistry 2012 AprileJune; Vol. 3, No. 2
DMFT and PI scores and BMI (Table 1). KruskaleWallis test was used for comparison between groups. Pearson Correlation test was used to determine associations between DMFT, PI scores and BMI.
Singh et al.
Table 3 Correlations. BMI PI index
Mean
Std. Deviation
19.74 0.24
3.94 0.612 PI index
RESULTS
BMI
Following results were drawn from the study 1) BMI was found to have a negative correlation with DMFT (r ¼ 0.011) which was statistically non-significant (Table 2)
Mean
Std. Deviation 3.95 2.46
Table 4 BMI groups.
DISCUSSION BMI is a sensitive measure of the obesity level as well as the risk for dental caries may be also correlated from it since diet is common to both the parameters. Though there is a controversy on the subject, since previous studies have shown mixed results. Positive results i.e. High caries experience and higher BMI have been shown by Reifsnider, 2004,6 Willershausen, 2006, Draper 2006. Negative association i.e. high caries experience and low bmi (Ayhan 1996,7 Table 2 Correlations.
Pearson correlation Sig. (2-tailed) N
BMI was found to have a negative correlation with Plaque Index (r ¼ 0.062) which was statistically non-significant.
19.74 1.29
4) The caries prevalence for the whole sample was 36.8%, and it ranged from 28.6% (BMI-4) to 42.4% (BMI-3) (Table 5) Pearson correlation models showed a negative correlation between DMFT and BMI (0.011), which was not statistically significant. A negative correlation was also found between PI and BMI (0.062) which was again not statistically significant.
BMI
0.062 0.218 400
Aces, 1999. No association has been shown by Tuomi 1989, Chen 1995, Whelton 2004, Kim 2006, Mcdougal 2006, Hayes 2006. In our study, the results appear to show an association between BMI and the presence of dental caries and oral hygiene in the dentition in a group of Indian school children. The data showed that school children who were having higher BMI scores were at greater risk for developing dental caries and having poorer oral hygiene as compared to lower BMI groups. Interestingly, in this study, the small number of children in group BMI-4 showed an inverse relation of BMI with that of DMFT and PI scores. The results are similar to a study done in Mexican preschool children, in which there was a significant association between at-risk overweight and overweight children and caries in the primary dentition.3 Another study in Swedish children found that BMI had an independent, though weak, effect on caries variation.5 Isabelle et al observed that obese children had a high level of caries experience as compared to non-obese group.2 However, several studies have shown no relation between BMI and caries occurrence.3,4,5 The exact mechanism for the association of body weight and dental caries is not yet known. It has been proposed that consumption of refined carbohydrates might serve as a link between obesity and the onset of dental caries. Marshall et al 4 found that children <5 years of age with dental caries had a higher soft drink intake than children without caries. However, they could not establish a relation between soft drink consumption and BMI levels. On the other hand, a study by Ochoa et al found that children who consume
2) BMI was found to have a negative correlation with periodontal Index (r ¼ 0.062) which was statistically nonsignificant (Table 3) 3)The mean values for BMI, DMFT and PI scores were 19.74, 1.29 and 0.24, respectively. The distribution of BMI for levels 1, 2, 3 and 4 was 43.5, 44.8, 8.3 and 3.5%, respectively (Tables 3 and 4)
BMI DMFT
Pearson correlation Sig. (2-tailed) N
DMFT 0.011 0.823 400
BMI was found to have a negative correlation with DMFT (r ¼ 0.011) which was statistically non-significant.
Less than 18.5 18.5e25.0 25.1e30.0 More than 30 Total
Frequency
Percent
174 179 33 14 400
43.5 44.8 8.3 3.5 100.0
Body mass characterization of dental diseases
Original Article
Table 5 BMI Groups* caries Cross tabulation. BMI groups
Less than 18.5 18.5e25.0 25.1e30.0 More than 30 Total
Dental caries Caries free
Caries present
112 64.4% 112 62.6% 19 57.6% 10 71.4% 253 63.3%
62 35.6% 67 37.4% 14 42.4% 4 28.6% 147 36.8%
SOURCE OF FUNDING Total
None. 174 100.0% 179 100.0% 33 100.0% 14 100.0% 400 100.0%
sugar-sweetened beverages have a 1.74 times greater risk of being obese as compared with children who do not consume this type of beverage. Anita Alm et al8 showed that overweight and obese adolescents had more approximal caries than normal weight individuals and the frequent consumption of snacking products during early childhood was a risk indicator for caries at 15 years. Both dental caries and obesity are multifactorial diseases related to dietary habits. Health professionals should work in a multidisciplinary manner with these patients with the aim of establishing good dietary habits. Mary Tavares and Virginia Chomitz suggested a “Healthy Weight Intervention” (HWI) protocol for promoting awareness of child obesity risk in the dental setting and providing necessary recommendations, goal-setting, and referrals. Future preventive programmes should therefore include, on a multidisciplinary level, strategies to prevent and reduce both obesity and dental caries at an early age.
CONFLICT OF INTEREST None.
71
ACKNOWLEDGMENTS None.
REFERENCES 1. Sharma A, Somani R. Dermatoglyphic characterization of dental caries and its correlation with salivary ph e an in vivo study. J Ind Soc Pedo Prev Dent. vol. 27(1):17e21. 2. Bhardwaj S, Misra A. Childhood obesity in Asian Indians: a burgeoning cause of insulin resistance, diabetes and sub-clinical inflammation. Asia Pac J Clin Nutr. 2008;17(S1): 172e175. 3. Mossberg HO. 40-year follow-up of overweight children. Lancet. 1989;26:491e493. 4. Burniat W. Child and adolescent obesity: causes and consequences, prevention and management. Cambridge: Cambridge University Press; 2002. pp. 145e146. 5. WHO. Diet, nutrition and the prevention of chronic diseases. Geneva: World Health Organization; 2003. Technical Report Series 916. 6. Reifsnider, Elizabeth. Journal of Multicultural Nursing & Health/Summer 2004 Childhood Obesity and Early Childhood Caries in a WIC Population. 7. Update on the 1987 Task Force Report on High Blood Pressure in Children and Adolescents: a working group report from the National High Blood Pressure Education Program. National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents. Pediatrics. 1996 Oct; 98(4 Pt 1): 649e658. 8. Alm A, Isaksson H, Fåhraeus C, et al. BMI status in Swedish children and young adults in relation to caries prevalence. Swed Dent J. 2011;35(1):1e8.