Skip to main content
Download PDF

Association between toothbrushing and cardiovascular risk factors: a cross-sectional study using Korean National Health and Nutrition Examination Survey 2015–2017

BMC Oral Health volume 24, Article number: 4 (2024) Cite this article

Abstract

Background

Previous studies have suggested that frequent toothbrushing is associated with a lower risk of future cardiovascular events. We sought to investigate further the relationship between toothbrushing, cardiovascular risk factors, and lifestyle behaviours.

Methods

We analysed a cross-sectional survey including 13,761 adults aged 30 years or older without a history of cardiovascular diseases from the Korean National Health and Nutritional Examination Survey. Conventional cardiovascular risk factors (blood pressure, lipid profiles, and fasting glucose), and inflammatory markers (high-sensitivity C-reactive protein [hsCRP], and white blood cell counts [WBC]) were investigated in relation to the frequency of toothbrushing.

Results

The estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk, calculated using the pooled cohort equations was 13.7%, 9.1%, and 7.3% for participants who reported toothbrushing 0–1, 2, and ≥ 3 times a day, respectively. Both conventional risk factors and inflammatory markers were significantly associated with frequent toothbrushing. However, after adjusting potential confounding factors such as age, sex, comorbidities, and lifestyle behaviours, only inflammatory markers were remained as significant factors.

Conclusions

Oral hygiene behaviours are closely linked to cardiovascular risk factors. This study suggests that reduced systemic inflammatory burden may explain the benefit of improved oral hygiene in terms of cardiovascular risk.

Peer Review reports

Introduction

Oral health and its potential link to cardiovascular disease have been investigated in recent years. [1] Cardiovascular diseases, significant global health burdens, contributes to many morbidity and mortality worldwide. [2] While traditional risk factors like high blood pressure, high cholesterol, smoking, and lack of physical activity are well-established in cardiovascular studies, the potential role of oral health in cardiovascular disease has also been supported by recent emerging evidence. [3, 4].

Several studies have suggested a positive relationship between poor oral health status and atherosclerotic cardiovascular disease [5,6,7]. Poor oral hygiene means a lot of deposits of dental plaques composed of oral microbiome and food debris in the oral cavity. The accumulation of dental plaques causes mild inflammation around teeth, leading to periodontal disease (gum disease) and tooth loss. When the episode of local inflammatory response is repeated, systemic inflammatory response is also triggered, contributing to the development of atherosclerosis, a key underlying process in cardiovascular diseases. [8]

However, it’s essential to note that the relationship between oral health and cardiovascular diseases is complex and multifaceted. The existing body of research in this area has yielded various findings, some supporting this association while others suggesting a more nuanced and intricate relationship. [9,10,11] These controversies could be explained by the fact that oral and cardiovascular diseases share common risk factors, such as advanced age, diabetes, and cigarette smoking. Additionally, the evidence suggesting that periodontal treatment induces a substantial change in cardiovascular risk or outcomes is limited. [12, 13] As a result, this topic remains a subject of ongoing investigation and debate.

Recently, observational studies have proposed that improved oral hygiene care may reduce the risk of future cardiovascular events [14, 15]. Frequent toothbrushing and regular professional cleaning were shown to be related to a reduced cardiovascular risk. However, the association is also subject to the criticism that potential confounding factors might not have been fully assessed or controlled. Individuals with better oral care habits may also have better cardiovascular behaviours. They have a higher socioeconomic status, tend to be non-smokers and physically active, and have a lower prevalence of comorbidities such as hypertension, diabetes, and obesity [15,16,17].

In this study, we aimed at exploring the association between cardiovascular risk and frequency of toothbrushing in the context of traditional risk factors and inflammatory markers, using a nationally representative cross-sectional cohort of the Korean population. We sought to identify potential confounders between toothbrushing and cardiovascular risk, and to estimate the impact of toothbrushing independent of the confounding factors.

Methods

Study design, population and cohort

This was a cross-sectional study using data from the Korean National Health and Nutritional Examination Survey (KNHANES), a nationwide survey, conducted from 2015 to 2017. Of the 23,657 participants, individuals less than 30 years, pregnant women, those who had a history of coronary heart disease or stroke, and those with missing data were excluded (Fig. 1). Thus, data of a total of 13,761 participants were analyzed in the study. Information on the participants’ demographic characteristics, socioeconomic status, health-related behaviours, healthcare utilization, biochemical and clinical profiles for non-communicable diseases, and dietary intakes are included in the KNHANES [18]. This study conformed to the principles outlined in the Declaration of Helsinki and guidelines of Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). This study was approved by the Institutional Review Board (IRB) of Seoul National University Bundang Hospital (X-1910-572-902), and the requirement for informed consent was waived because of the retrospective nature of the study and minimal expected risk to the participants.

Fig. 1
figure 1

Description of the study population

Full size image

Definition and measurements in KNHANES data

Participants were asked to report on their subjective health behaviours using self-report questionnaires (11). The frequency of toothbrushing in a day was considered the primary independent variable. The survey participants were divided into three groups: ≥3 times/day, 2 times/day, and 0−1 times/day. Data on health-related lifestyle behaviours such as smoking status, the consumption of alcohol, and regular leisure-time physical activity were also collected.

Blood pressure (BP) was measured by trained nurses using mercury sphygmomanometers. BP was measured three times on the participants’ right arms after resting in a seated position for at least 5 min. Anthropometric measurements included body weight, height, and waist circumference. Laboratory tests included total cholesterol (mg/dL), low density lipoprotein (LDL)-cholesterol (mg/dL), high density lipoprotein (HDL)-cholesterol (mg/dL), triglyceride (mg/dL), fasting plasma glucose (mg/dL), high-sensitivity C-reactive protein (hsCRP, mg/L), and white blood cell (WBC, 10³/µL) counts.

Comorbidities such as hypertension, dyslipidaemia, and diabetes, as well as their management status were assessed. Hypertension was defined either as systolic BP ≥ 140 mmHg, diastolic BP ≥ 90 mmHg, or the use of an antihypertensive medication [19]. Awareness of hypertension was defined as having had a medical diagnosis of hypertension by medical personnel. Treatment was defined as taking antihypertensive medications for more than 20 days per month. Adequate hypertension control was defined as having systolic and diastolic BP of < 140/90 mmHg. Dyslipidaemia was defined either as total cholesterol ≥ 240 mg/dL, triglyceride ≥ 200 mg/dL, or the use of lipid-lowering therapy. Diabetes was defined as fasting plasma glucose ≥ 126 mg/dL, or treatment with oral hypoglycaemic agents or insulin.

Dependent variables: cardiovascular risk factors

Dependent study variables included conventional cardiovascular risk factors, the estimated 10-year risk for a first atherosclerotic cardiovascular disease (ASCVD) event, and inflammatory markers. Conventional risk factors were systolic and diastolic BP, total cholesterol, HDL-cholesterol, non-HDL-cholesterol, triglycerides, LDL-cholesterol, and fasting plasma glucose. The estimated 10-year ASCVD risk was calculated using the pooled cohort equations including variables such as age, sex, race, total cholesterol, HDL-cholesterol, systolic BP, hypertension treatment status, diabetes, and smoking status [20]. Estimates for White races were used in this study because Asian-specific values were not available for the equations. Inflammatory markers included hsCRP, and WBC levels.

Statistical analysis

Since the KNHANES used a complex survey design, statistical analyses were performed considering the weight of each sample. The weights were derived for sample participants to represent the Korean population by accounting for the survey design, survey non-response, and post-stratification. Baseline characteristics were reported as means ± standard errors for continuous variables and as percentages (standard error) for dichotomous variables. Generalized linear models were used to evaluate the relationships between the independent and dependent variables. Multivariable-adjustment models were developed as follows: model one was unadjusted; model two was adjusted for age and sex; model three was adjusted for age, sex, and lifestyle behaviours such as obesity, current smoking, heavy alcohol drinking, and physical activity; model four was adjusted for the variables listed above as well as hypertension, diabetes, and dyslipidaemia. Since the 10-year ASCVD risk was not normally distributed, it was log-transformed in the statistical model. Statistical analyses were conducted using R programming version 3.3.0 (http://www.R-project.org; The R Foundation for Statistical Computing, Vienna, Austria). P-values less than 0.05 were considered statistically significant.

Results

Among the total study population, 10.4%, 37.2%, and 52.4% brushed their teeth 0−1, 2, and ≥ 3 times a day, respectively. Participants who brushed their teeth more frequently were younger and predominantly female (Table 1). They had a lower prevalence of comorbidities such as hypertension, diabetes, and dyslipidaemia. Improved oral hygiene was also linked to better cardiovascular lifestyle behaviours such as lower frequencies of cigarette smoking and alcohol drinking, higher amount of physical activity, lower body mass indexes and waist circumferences, and higher potassium intake. The total caloric intake was similar across the groups, whilst sodium intake increased with improved health behaviours. The management status of hypertension had an inverse relationship with toothbrushing frequency. Those with frequent toothbrushing showed significantly lower rates of awareness, treatment, and control of hypertension. Treatment of diabetes and dyslipidaemia were not significantly associated with toothbrushing frequency.

Table 1 Baseline characteristics according to toothbrushing behaviours
Full size table

When assessing the relationship between dental hygiene habits and oral health status, frequent toothbrushing was associated with a lower prevalence of discomfort during chewing (Table 2). Those who frequently brushed their teeth made frequent dental visits and had favourable oral hygiene behaviours such as floss and interdental brush use. Study participants with better oral hygiene behaviours had favourable cardiovascular risk profiles. Those who reported more frequent toothbrushing had lower systolic BP and lower non-HDL cholesterol, triglyceride, and fasting plasma glucose levels. Additionally, they had higher HDL cholesterol levels. LDL cholesterol levels did not differ significantly. The estimated 10-year ASCVD risk was 13.7%, 9.1%, and 7.3% for those who brushed their teeth 0–1, 2, and ≥ 3 times a day, respectively.

Table 2 Oral health status and cardiovascular risk factors according to toothbrushing behaviours
Full size table

The differences in traditional cardiovascular risk factors were mitigated after adjusting for potential confounders (Table 3). For example, the differences in the estimated 10-year ASCVD risk based on toothbrushing behaviours were largely attributable to age and sex (≥ 3 vs. 0−1 times/day: unadjusted P < 0.001, age-sex adjusted P < 0.001; 2 vs. 0−1 times/day: unadjusted P < 0.001, age-sex adjusted P = 0.517). The association further lost statistical significance after adding lifestyle behaviours such as obesity, current smoking, heavy alcohol drinking, and physical activity into the model. (≥ 3 vs. 0−1 times/day: lifestyle adjusted P = 0.755; 2 vs. 0−1 times/day: lifestyle adjusted P = 0.068) The estimate became neutral after including comorbidities such as hypertension, diabetes, and dyslipidaemia into the model (≥ 3 vs. 0−1 times/day: multivariable adjusted P = 0.301; 2 vs. 0−1 times/day: lifestyle adjusted P = 0.066). Other conventional risk factors such as systolic BP, non-HDL-cholesterol, HDL-cholesterol, triglyceride, and fasting glucose showed similar patterns. (Fig. 2)

Table 3 Multivariable adjustment for the relationship between tooth brushing and cardiovascular risk factors
Full size table
Fig. 2
figure 2

Unadjusted cardiovascular risk profiles according to toothbrushing frequency. (A) Estimated 10-year atherosclerotic cardiovascular risk calculated using pooled cohort equations, (B) high-sensitivity C-reactive protein (hsCRP), and (C) white blood cell (WBC) counts. Multivariable adjustment for the association between toothbrushing frequency and cardiovascular risk profiles (D). The estimated 10-year ASCVD risk was log-transformed. The red box and line indicate a comparison of toothbrushing ≥ 3 vs. 0−1 times/day; blue indicates that of 2 vs. 0−1 times/day. *Adjusted for age, sex, obesity, current smoking, heavy alcohol drinking, and physical activity; **Adjusted for age, sex, obesity, current smoking, heavy alcohol drinking, physical activity, hypertension, diabetes, and dyslipidaemia. Abbreviations: hsCRP, high-sensitivity C-reactive protein; WBC, white blood cell

Full size image

Notably, hsCRP and WBC levels consistently showed significant associations with toothbrushing frequency even after adjusting for the confounding factors. Participants who reported brushing their teeth ≥ 3 times/day had 0.48 mg/L and 0.32 mg/L lower levels of hsCRP than those who brushed their teeth 2 times/day and 0−1 time/day, respectively (unadjusted P-values < 0.001 for both). Although being partially attenuated, the relationship remained statistically significant after adjusting for all the variables mentioned above between participants brushing their teeth ≥ 3 vs. 0−1 times/day. (≥ 3 vs. 0−1 times/day: -0.22 mg/L, P = 0.022; 2 vs. 0−1 times/day: -0.18 mg/L, P = 0.075). The WBC levels similarly showed significant differences according to toothbrushing behaviours after multivariable adjustment. (-0.20 × 10³/µL, P = 0.013; and − 0.18 × 10³/µL, P = 0.021, respectively).

Discussion

In the current study participants who brushed their teeth more frequently had lower cardiovascular risk including lower systolic BP, higher HDL-cholesterol, and lower 10-year ASCVD risk calculated using the pooled cohort equations. They also had lower systemic inflammation as assessed by serum hsCRP and WBC levels. This study also confirmed that the differences in cardiovascular risk based on toothbrushing habits were heavily confounded by age, sex, comorbidities, and lifestyle factors. However, the association between inflammatory marker and toothbrushing behaviour were independent of common confounding factors.

The association between periodontal and cardiovascular diseases has long been debated [3, 4, 21]. A number of studies have demonstrated a close link between the two diseases [5,6,7, 22]; however, a causal relationship has yet to be established [3]. The two diseases share common risk factors such as smoking, diabetes, and advanced age [15, 23]. The associations between the two diseases disappear or are largely attenuated after controlling for confounding factors. There is also limited evidence supporting the benefit of periodontal treatment in reducing cardiovascular risk. Indeed, recent evidence from randomized controlled trials demonstrated that periodontal treatment reduces systemic levels of interleukin (IL)-6, C-reactive protein, BP, total cholesterol, and E-selectin [12, 24], improves endothelial function [12], and improve metabolic helps glycaemic control and kidney function in patients with type 2 diabetes [25].

Recent observational studies have suggested that improved oral hygiene care may lead to better cardiovascular outcomes. De Oliveira and co-workers analysed 11,869 adults with an average of 8.1 years of follow-up from the Scottish Health Survey showing that participants with poor oral hygiene (never/rarely brushed their teeth) had a 70% increased risk of a cardiovascular event [14]. A study by Park and co-workers, including 247,696 Korean adults who were followed for a mean of 9.5 years, found that performing one more toothbrushing a day and regular dental visits for professional cleaning were associated with a 9% and 14% lower risk of cardiovascular events, respectively [15].

The observations that improving oral health reduces cardiovascular risk add to the causal relationship between oral health and cardiovascular diseases. However, the relationship is also not free from confounding effects. As shown in this study, participants who brush their teeth frequently have favourable cardiovascular lifestyle behaviours such as no cigarette smoking, high physical activity, and a healthy diet [26]. We confirmed that the associations of toothbrushing frequency with conventional cardiovascular risk factors such as systolic BP, total cholesterol, HDL-cholesterol, and fasting glucose were largely attributable to the confounding effects.

The association of oral hygiene with systemic inflammation persisted after controlling for potential confounding factors. hsCRP is one of the most extensively studied biomarkers in predicting cardiovascular risk estimation [4]. While conventional cardiovascular risk factors such as age, sex, BP, blood cholesterol, and cigarettes smoking account for 70−80% of the future risk of cardiovascular events, there is still a remaining uncertainty of 20−30% [27, 28]. Robust evidence indicate that inflammation plays an additional and critical role in atherothrombosis [29, 30]. hsCRP, a downstream biomarker for inflammation, was shown to be associated with an increased risk of cardiovascular events [31, 32]. Diseases characterized by a chronic inflammatory exposure such as rheumatoid arthritis have been associated with increased risk of cardiovascular events [33].

Oral hygiene care is directly linked to the quantity of the dental biofilm and quality of oral microbiome. Daily toothbrushing, with or without adjunctive use of flossing and interdental brush reduces oral microbial burden, which prevents oral diseases such as dental caries and periodontal diseases [34]. Periodontitis is a chronic inflammatory disease resulting from a dysbiotic dental biofilm harbouring pathogenic gram-negative bacteria such as Porphyromonas gingivalis. The presence of a key pathogen such as P. gingivalis determine deregulated immune and inflammatory reaction to protect the host from bacterial invasion [35]. However, as pathogenic bacteria grow, activation of inflammatory responses may become chronic and have the potential to induce a host response. There is a wealth of evidence confirming that patients with periodontitis exhibit higher levels of systemic inflammation compared to controls and that periodontal treatment normalize/reduce the inflammatory burden [36]. As inflammation is thought to be one of the contributors to the pathogenesis of vascular diseases [37], the link between periodontitis and vascular health could be driven by an altered body response to the dental biofilm. P. gingivalis is able to activate endothelial cells to express IL-6, IL-8, and vascular cell adhesion molecule 1, which ultimately could lead to systemic inflammation [38, 39]. Experimental animal studies have shown induction of atherosclerosis by P. gingivalis [40].

The greatest limitation of the present study is its observational and cross-sectional nature. Findings of this study should be considered hypothesis-generating. The benefit of oral hygiene care can only be confirmed by prospective randomized controlled trials. Secondly, data on oral hygiene behaviours were collected using self-report questionnaire, which may be prone to recall bias. Thirdly, although we extracted various potential confounders, we cannot rule out the presence of unmeasured confounding factors. Lastly, the pooled cohort equations used in estimated 10-year ASCVD risk have been developed for White and African American races and not been fully validated in East Asian ethnicities [41].

Conclusions

This cross-sectional study confirmed that individuals with better oral hygiene care had favourable cardiovascular risk profiles. They also had favourable demographics characteristics and cardiovascular lifestyle behaviours. The associations between conventional risk factors and toothbrushing were mostly accounted for by confounding factors. Nevertheless, the associations with inflammatory markers including hsCRP and WBC levels were found to be independent of the confounding effects. Our findings suggest that decreased systemic inflammation might be the key mechanism of lower cardiovascular risk associated with frequent toothbrushing.

Data availability

KNHANES data can be accessed and downloaded from the KNHANES homepage (URL: https://knhanes.cdc.go.kr/knhanes/eng/index.do).

Abbreviations

ASCVD:

Atherosclerotic cardiovascular disease

BP:

Blood pressure

HDL:

high density lipoprotein

hsCRP:

high-sensitivity C-reactive protein

KNHANES:

Korea National Health and Nutrition Examination Survey

LDL:

low density lipoprotein

WBC:

white blood cell counts

References

  1. Dietrich T, Webb I, Stenhouse L, Pattni A, Ready D, Wanyonyi KL, White S, Gallagher JE. Evidence summary: the relationship between oral and Cardiovascular Disease. Br Dent J. 2017;222(5):381–5.

    Article  PubMed  Google Scholar 

  2. Vaduganathan M, Mensah GA, Turco JV, Fuster V, Roth GA. The global burden of cardiovascular diseases and risk: a compass for future health. In., vol. 80: American College of Cardiology Foundation Washington DC; 2022: 2361–2371.

  3. Lockhart PB, Bolger AF, Papapanou PN, Osinbowale O, Trevisan M, Levison ME, Taubert KA, Newburger JW, Gornik HL, Gewitz MH, et al. Periodontal Disease and atherosclerotic vascular Disease: does the evidence support an Independent association? A scientific statement from the American Heart Association. Circulation. 2012;125(20):2520–44.

    Article  PubMed  Google Scholar 

  4. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corra U, Cosyns B, Deaton C, et al. 2016 European guidelines on Cardiovascular Disease prevention in clinical practice: the Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37(29):2315–81.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Joshipura KJ, Pitiphat W, Hung HC, Willett WC, Colditz GA, Douglass CW. Pulpal inflammation and incidence of coronary Heart Disease. J Endod. 2006;32(2):99–103.

    Article  PubMed  Google Scholar 

  6. Howell TH, Ridker PM, Ajani UA, Hennekens CH, Christen WG. Periodontal Disease and risk of subsequent Cardiovascular Disease in U.S. male physicians. J Am Coll Cardiol. 2001;37(2):445–50.

    Article  PubMed  Google Scholar 

  7. Caplan DJ, Chasen JB, Krall EA, Cai J, Kang S, Garcia RI, Offenbacher S, Beck JD. Lesions of endodontic origin and risk of coronary Heart Disease. J Dent Res. 2006;85(11):996–1000.

    Article  PubMed  Google Scholar 

  8. Beck JD, Pankow J, Tyroler H, Offenbacher S. Dental Infections and Atherosclerosis. Am Heart J. 1999;138(5):528–S533.

    Article  Google Scholar 

  9. Joshy G, Arora M, Korda RJ, Chalmers J, Banks E. Is poor oral health a risk marker for incident Cardiovascular Disease hospitalisation and all-cause mortality? Findings from 172 630 participants from the prospective 45 and up study. BMJ open. 2016;6(8):e012386.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Sanz M, D’Aiuto F, Deanfield J, Fernandez-Avilés F. European workshop in periodontal health and Cardiovascular Disease—scientific evidence on the association between periodontal and Cardiovascular Diseases: a review of the literature. Eur Heart J Supplements. 2010;12(supplB):B3–B12.

    Article  Google Scholar 

  11. Hujoel PP, Drangsholt M, Spiekerman C, DeRouen TA. Periodontal Disease and coronary Heart Disease risk. JAMA. 2000;284(11):1406–10.

    Article  PubMed  Google Scholar 

  12. Tonetti MS, D’Aiuto F, Nibali L, Donald A, Storry C, Parkar M, Suvan J, Hingorani AD, Vallance P, Deanfield J. Treatment of periodontitis and endothelial function. N Engl J Med. 2007;356(9):911–20.

    Article  PubMed  Google Scholar 

  13. Offenbacher S, Beck JD, Moss K, Mendoza L, Paquette DW, Barrow DA, Couper DJ, Stewart DD, Falkner KL, Graham SP, et al. Results from the Periodontitis and vascular events (PAVE) study: a pilot multicentered, randomized, controlled trial to study effects of periodontal therapy in a secondary prevention model of Cardiovascular Disease. J Periodontol. 2009;80(2):190–201.

    Article  PubMed  PubMed Central  Google Scholar 

  14. de Oliveira C, Watt R, Hamer M. Toothbrushing, inflammation, and risk of Cardiovascular Disease: results from Scottish Health Survey. BMJ. 2010;340:c2451.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Park SY, Kim SH, Kang SH, Yoon CH, Lee HJ, Yun PY, Youn TJ, Chae IH. Improved oral hygiene care attenuates the cardiovascular risk of oral health Disease: a population-based study from Korea. Eur Heart J. 2019;40(14):1138–45.

    Article  PubMed  Google Scholar 

  16. Park JB, Nam GE, Han K, Ko Y, Park YG. Obesity in relation to oral health behaviors: an analysis of the Korea National Health and Nutrition Examination Survey 2008–2010. Exp Ther Med. 2016;12(5):3093–100.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Park JB, Han K, Park YG, Ko Y. Association between socioeconomic status and oral health behaviors: the 2008–2010 Korea national health and nutrition examination survey. Exp Ther Med. 2016;12(4):2657–64.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Kweon S, Kim Y, Jang MJ, Kim Y, Kim K, Choi S, Chun C, Khang YH, Oh K. Data resource profile: the Korea National Health and Nutrition Examination Survey (KNHANES). Int J Epidemiol. 2014;43(1):69–77.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Kang SH, Kim SH, Cho JH, Yoon CH, Hwang SS, Lee HY, Youn TJ, Chae IH, Kim CH. Prevalence, awareness, treatment, and Control of Hypertension in Korea. Sci Rep. 2019;9(1):10970.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Goff DC Jr., Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB, Sr., Gibbons R, Greenland P, Lackland DT, Levy D, O’Donnell CJ, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice guidelines. J Am Coll Cardiol. 2014;63(25 Pt B):2935–59.

    Article  PubMed  Google Scholar 

  21. Tonetti MS. Periodontitis and risk for Atherosclerosis: an update on intervention trials. 2009, 36(s10):15–9.

  22. D’Aiuto F, Parkar M, Nibali L, Suvan J, Lessem J, Tonetti MS. Periodontal Infections cause changes in traditional and novel cardiovascular risk factors: results from a randomized controlled clinical trial. Am Heart J. 2006;151(5):977–84.

    Article  PubMed  Google Scholar 

  23. Persson GR, Persson RE. Cardiovascular Disease and periodontitis: an update on the associations and risk. 2008, 35(s8):362–79.

  24. D’Aiuto F, Nibali L, Parkar M, Suvan J, Tonetti MS. Short-term effects of intensive periodontal therapy on serum inflammatory markers and cholesterol. J Dent Res. 2005;84(3):269–73.

    Article  PubMed  Google Scholar 

  25. D’Aiuto F, Gkranias N, Bhowruth D, Khan T, Orlandi M, Suvan J, Masi S, Tsakos G, Hurel S, Hingorani AD, et al. Systemic effects of periodontitis treatment in patients with type 2 Diabetes: a 12 month, single-centre, investigator-masked, randomised trial. Lancet Diabetes Endocrinol. 2018;6(12):954–65.

    Article  PubMed  Google Scholar 

  26. Jeong S-W, Kim S-H, Kang S-H, Kim H-J, Yoon C-H, Youn T-J, Chae I-H. Mortality reduction with physical activity in patients with and without Cardiovascular Disease. Eur Heart J 2019.

  27. Mortensen MB, Nordestgaard BG, Afzal S, Falk E. ACC/AHA guidelines superior to ESC/EAS guidelines for primary prevention with statins in non-diabetic europeans: the Copenhagen General Population Study. Eur Heart J. 2017;38(8):586–94.

    PubMed  Google Scholar 

  28. Muntner P, Colantonio LD, Cushman M, Goff DC Jr., Howard G, Howard VJ, Kissela B, Levitan EB, Lloyd-Jones DM, Safford MM. Validation of the atherosclerotic Cardiovascular Disease pooled cohort risk equations. JAMA. 2014;311(14):1406–15.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Penson PE, Long DL, Howard G, Toth PP, Muntner P, Howard VJ, Safford MM, Jones SR, Martin SS, Mazidi M, et al. Associations between very low concentrations of low density lipoprotein cholesterol, high sensitivity C-reactive protein, and health outcomes in the reasons for geographical and racial differences in Stroke (REGARDS) study. Eur Heart J. 2018;39(40):3641–53.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Libby P, Loscalzo J, Ridker PM, Farkouh ME, Hsue PY, Fuster V, Hasan AA, Amar S. Inflammation, immunity, and Infection in Atherothrombosis: JACC Review topic of the Week. J Am Coll Cardiol. 2018;72(17):2071–81.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Ridker PM, Hennekens CH, Buring JE, Rifai N. C-reactive protein and other markers of inflammation in the prediction of Cardiovascular Disease in women. N Engl J Med. 2000;342(12):836–43.

    Article  PubMed  Google Scholar 

  32. Ridker PM, Cushman M, Stampfer MJ, Tracy RP, Hennekens CH. Inflammation, aspirin, and the risk of Cardiovascular Disease in apparently healthy men. N Engl J Med. 1997;336(14):973–9.

    Article  PubMed  Google Scholar 

  33. Agca R, Heslinga SC, Rollefstad S, Heslinga M, McInnes IB, Peters MJ, Kvien TK, Dougados M, Radner H, Atzeni F, et al. EULAR recommendations for Cardiovascular Disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Ann Rheum Dis. 2017;76(1):17–28.

    Article  PubMed  Google Scholar 

  34. White paper on prevention and management of periodontal diseases for oral health and general health. Geneva, Switzerland: FDI World Dental Federation 2018. [https://www.fdiworlddental.org/sites/default/files/media/resources/gphp-2018-white_paper-en.pdf ].

  35. Hasturk H, Kantarci A. Activation and resolution of periodontal inflammation and its systemic impact. Periodontol 2000. 2015;69(1):255–73.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Kinane DF, Stathopoulou PG, Papapanou PN. Periodontal Diseases. Nat Rev Dis Primers. 2017;3:17038.

    Article  PubMed  Google Scholar 

  37. Libby P, Hansson GK. Inflammation and immunity in Diseases of the arterial tree: players and layers. Circ Res. 2015;116(2):307–11.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Yumoto H, Chou HH, Takahashi Y, Davey M, Gibson FC 3rd, Genco CA. Sensitization of human aortic endothelial cells to lipopolysaccharide via regulation of toll-like receptor 4 by bacterial fimbria-dependent invasion. Infect Immun. 2005;73(12):8050–9.

  39. Rodrigues PH, Reyes L, Chadda AS, Belanger M, Wallet SM, Akin D, Dunn W Jr., Progulske-Fox A. Porphyromonas gingivalis strain specific interactions with human coronary artery endothelial cells: a comparative study. PLoS ONE. 2012;7(12):e52606.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Li L, Messas E, Batista EL Jr., Levine RA, Amar S. Porphyromonas gingivalis Infection accelerates the progression of Atherosclerosis in a heterozygous apolipoprotein E-deficient murine model. Circulation. 2002;105(7):861–7.

    Article  PubMed  Google Scholar 

  41. Jung KJ, Jang Y, Oh DJ, Oh BH, Lee SH, Park SW, Seung KB, Kim HK, Yun YD, Choi SH, et al. The ACC/AHA 2013 pooled cohort equations compared to a Korean risk prediction model for atherosclerotic Cardiovascular Disease. Atherosclerosis. 2015;242(1):367–75.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We would like to thank Ms Moon Ju Kim for conducting the data collection and statistical analyses.

Funding

This work was supported by the Basic Science Research Program through the National Research Foundation of Korea [grant number 2019R1C1C1006611, grant number NRF-2022R1A2C1012354]. Contribution of this work was undertaken at UCLH/UCL who received a proportion of funding from the Department of Health’s NIHR Biomedical Research Centre funding scheme. Dr. Leira holds a Senior Clinical Research Fellowship supported by the UCL Biomedical Research Centre who receives funding from the NIHR.

Author information

Author notes

  1. Mi-Gil Moon and Si-Hyuck Kang equally contributed to the work.

Authors and Affiliations

  1. Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Korea

    Mi-Gil Moon, Si-Hyuck Kang, Sun-Hwa Kim, Chang-Hwan Yoon, Tae-Jin Youn & In-Ho Chae

  2. Department of Internal Medicine, Seoul National University, Seoul, Korea

    Mi-Gil Moon, Si-Hyuck Kang, Chang-Hwan Yoon, Tae-Jin Youn & In-Ho Chae

  3. Program of Clinical Dental Education and Dental Research Institute, School of Dentistry, Seoul National University, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea

    Shin-Young Park

  4. Pre-doctoral treatment center, Seoul National University Dental Hospital, Seoul, Korea

    Shin-Young Park

  5. Department of Periodontology and Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Korea

    Yang-Jo Seol

  6. Department of Periodontology, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam-si, Korea

    Hyo-Jung Lee

  7. UCL Eastman Dental Institute, Periodontology Unit, University College London, London, UK

    Yago Leira, Eva Munoz-Aguilera & Francesco D’Aiuto

Authors
  1. Mi-Gil Moon
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Si-Hyuck Kang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sun-Hwa Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Shin-Young Park
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yang-Jo Seol
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Chang-Hwan Yoon
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Hyo-Jung Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Tae-Jin Youn
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. In-Ho Chae
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Yago Leira
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Eva Munoz-Aguilera
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Francesco D’Aiuto
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

M-G Moon, S-H Kang and S-Y Park conceived the study, interpretated the data and drafted the manuscript; S-H Kim analyzed the data; All authors wrote and revised the manuscript. Finally, all authors read and approved the final manuscript.

Corresponding author

Correspondence to Shin-Young Park.

Ethics declarations

Ethics approval and consent to participate

This study conformed to the principles outlined in the Declaration of Helsinki and guidelines of Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). This study was approved by the Institutional Review Board (IRB) of Seoul National University Bundang Hospital (X-1910-572-902), and the requirement for informed consent was waived because of the retrospective nature of the study and minimal expected risk to the participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Moon, MG., Kang, SH., Kim, SH. et al. Association between toothbrushing and cardiovascular risk factors: a cross-sectional study using Korean National Health and Nutrition Examination Survey 2015–2017. BMC Oral Health 24, 4 (2024). https://doi.org/10.1186/s12903-023-03775-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12903-023-03775-5

Keywords

BMC Oral Health

ISSN: 1472-6831

Contact us