Association Between Periodontal Health, Body Mass Index, and Vascular

Age: A Cross-Sectional Study

Abstract

Background & Objectives: Periodontitis is a chronic immune-mediated disease linked to

various systemic conditions, particularly cardiovascular disease and obesity. This study aims to
investigate the relationship between body mass index (BMI), periodontitis, and vascular age
while comparing blood parameters to clarify their systemic health implications.

Materials & Methods: A total of 491 participants were evaluated in the study. Participants'
demographics, along with periodontal health measured by the Community Periodontal Index
(CPI), vascular age through the Pulse Wave Velocity technique (PWV), body mass index (BMI),
fasting blood sugar (FBS), and blood lipid profiles (triglycerides [TG], cholesterol [CHOL],
HDL, and LDL levels), were recorded. Statistical analyses included t-tests, Mann-Whitney U,
and chi-square tests.

Results: Participants' ages ranged from 35 to 60 years, with the controls averaging 42.15 ± 6.20
years and the case group averaging 48.51 ± 7.46 years. The periodontitis group exhibited
significantly higher pulse wave velocity, FBS, TG, and CHOL levels, with no significant
differences in BMI and HDL.

Conclusions: The findings indicate that the risk of periodontal disease increases with age. HDL
and BMI were not significantly different between healthy and periodontitis groups. Patients with
periodontitis exhibited higher PWV, CHOL, FBS, and TG, suggesting an elevated risk of
cardiovascular disease. Since many patients may be unaware of their systemic conditions,
dentists can play a crucial role in early diagnosis and alerting patients, thus minimizing disease
complications.

Keywords: BMI, Cardiovascular Disease, Obesity, Oral Health-Related Quality of Life

(OHRQoL), Periodontal Disease, Periodontal Medicine, Periodontitis, Vascular Age
Introduction

Periodontal diseases are pathological processes affecting the periodontium, the tooth-
attachment apparatus. The first and mildest form of periodontal disease is gingivitis,
characterized by inflammation of the gingiva due to the accumulation of dental plaque. If left
untreated, gingivitis can progress into a chronic, destructive, and irreversible inflammatory
disease state (1). Bacteria can infiltrate the epithelial cell barrier and penetrate deeper into the
underlying tissues and surrounding periodontium. Once inside the cells, the bacteria continue to
grow and multiply in an environment devoid of rival microorganisms, causing collagen,
periodontal ligament, and alveolar bone loss, leading to periodontitis (2, 3). As the most
prevalent chronic inflammatory non-communicable disease (NCD) in humans, periodontitis
represents a significant public health challenge (4).
In recent years, evidence has accumulated linking periodontal diseases, such as periodontitis,
with various systemic conditions, a field of study known as periodontal medicine (5). Among
these conditions, the strongest associations, supported by substantial evidence, include
cardiovascular disease and obesity (6, 7).
Cardiovascular disorders are pervasive worldwide and were the leading cause of mortality in
2023, responsible for over 20.5 million deaths per year, primarily in low- and middle-income
countries (8). In Iran, for instance, cardiovascular diseases account for 46% of deaths and 23% of
disease-related disabilities (9). Several clinical and meta-analysis studies have demonstrated an
association between periodontitis and cardiovascular disease (7, 10-12). This connection can be
understood through shared genetic factors (13, 14) and common risk factors such as age,
smoking, diabetes, obesity, alcohol consumption, hypertension, hyperlipidemia, and poor
socioeconomic conditions (15, 16). Additionally, patients with periodontitis frequently
experience episodes of bacteremia, where periodontal bacteria enter the bloodstream, leading to
increased systemic inflammation (15, 17). Evidence also suggests that periodontitis patients
exhibit higher levels of dyslipidemia, including elevated serum total cholesterol (CHOL), low-
density lipoproteins (LDLs), triglycerides (TG), very low-density lipoproteins (VLDL), oxidized
LDL, and phospholipase-A2, along with reduced high-density lipoprotein (HDL) levels (15).
Obesity has also emerged as a severe global issue, independent of a country’s development
status(18). In 2023, over one billion people worldwide were living with obesity, including nearly
880 million adults and 159 million children and adolescents aged 5-19 (19). Obesity is closely
linked to diseases such as hypertension, diabetes, atherosclerosis, and cardiovascular disease, as
well as being a risk factor for periodontal disease(20). Several studies suggest a potential
bidirectional relationship between periodontitis and obesity (21).
Given that many patients are unaware of their systemic diseases, further investigation into the
relationships between obesity, cardiovascular diseases, and periodontitis is warranted. Such
research could lead to better collaboration between general physicians and dentists, ultimately
minimizing disease complications and reducing medical costs(22, 23). This study aims to
investigate the relationship between body mass index (BMI) (as a measurement for obesity),
periodontal indicators, and vascular age (as a marker of cardiovascular health), and to compare
blood factors in patients with periodontitis and healthy individuals.

Methods and Materials

Study Design
This cross-sectional study investigated the Association Between Periodontal Health, BMI,
and Vascular Age. The study population included all patients who met the predetermined
inclusion criteria and were referred to the health monitoring plan at Mashhad University of
Medical Sciences, from September 2020 to September 2021.

Ethical Considerations
The study was approved by the Ethics Committee of Mashhad University of Medical Sciences
(IR.MUMS.DENTISTRY.REC.1399.023). All participants were assured of confidentiality and
provided a confidential code to access their evaluation results.

Participant Selection
A total of 491 subjects aged 35–60 years were evaluated. The subjects were part of the Health
Monitoring Project at Mashhad University of Medical Sciences and had maintained continuous
participation. Exclusion criteria were the presence of orthodontic appliances, pregnancy,
smoking, and the use of drugs affecting lipids, vascular stiffness, anti-inflammatory drugs, and
blood clotting drugs, as well as individuals needing prophylaxis.
Data collection
The Participants’ ages and genders were recorded, along with their fasting blood sugar (FBS),
blood lipid profile (Including TG, CHOL, HDL, and LDL levels), and their Height and weight
for calculating their BMI. Patients were examined for different stages of periodontitis using the
Community Periodontal Index (CPI) method. Vascular age was measured and reported by the
cohort center of Mashhad University of Medical Sciences using the carotid-femoral pulse wave
velocity (cf-PWV) or (PWV) with a bio-impedance device, SphygmoCor® (Atcor Medical,
Australia) applanation tonometer device with the participant in the supine position following
standard procedures.

 Diagnostic criteria of periodontitis:

The CPI method, utilizing a Williams probe, was employed to assess participants. The CPA
scores are listed in Table 1. teeth numbered 3, 8, 14, 19, 24, 30 and 31 were examined.

Individuals were categorized based on their CPI scores, as follows:

Control Group: CPI scores less than 2 in all sextants.

Case Group: CPI score of 2 (Moderate Periodontitis) or 3 and 4 (Severe Periodontitis) in at least
one sextant.

 Calculating BMI:

BMI was calculated by weight(kg) and height squared(m2) ratio. Usually, if the number is
between 25 and 29.9 the person is overweight, while a BMI over 30 indicates obesity.

 Vascular Age Measurement:

Vascular age was calculated using the PWV technique: dividing the path length) distance
traveled by the pulse wave ((m) over the time taken to travel this distance(s).

Data analysis
 Statistical analysis was performed using SPSS version 22 (SPSS Inc., Chicago, IL).
Qualitative variables were presented as percentages, quantitative variables were expressed as
mean ± standard deviation (SD) for normally distributed data, and medians and interquartile
ranges (IQR) for non-normally distributed data. The normality of the data was assessed using the
Shapiro-Wilk or Kolmogorov-Smirnov tests.
Correlation coefficients were calculated to examine the relationships between variables.
Differences in means between the two groups were compared using t-tests for normally
distributed data, and the Mann-Whitney U test for non-normally distributed data. Chi-square
tests were employed to evaluate associations between nominal variables. The influence of
independent variables on the dependent variable was assessed using regression analysis, with a
significance level set at 5%.
Binary multiple logistic regression analysis was conducted to evaluate the relationship between
BMI and periodontal status. The dependent variable for logistic regression analysis was
categorized into the control group (scores 0-1 of the Community Periodontal Index, CPI) and the
periodontitis group (scores 2, 3, and 4 of the CPI).
To determine the predictors of blood vessel metrics, a multiple regression analysis was
conducted with gender, age, HDL, and FBS as independent variables.
Missing data were addressed by excluding incomplete samples from the analysis. Confounding
factors were controlled by multiple logistic regression, with both crude and adjusted odds ratios
calculated to assess the influence of independent variables on periodontal status, with 95%
confidence intervals.

Result

The recordings of 491 participants of the Mashhad University of Medical Sciences cohort
plan, including 274 females (55.8%) and 217 males (44.2%) were reviewed in this study.
Table 2 presents the mean age and gender frequency distribution for the case and control groups,
highlighting the significant differences (p < 0.001 for both). While BMI and HDL levels did not
differ significantly across the groups, the patient group exhibited notably higher PWV, FBS, TG,
CHOL, and LDL values (Table 3).
 Gender, age, HDL, FBS, CHOL, and TG each have a significant impact on predicting BMI.
When all other variables are held constant:
The average BMI for women is 1.15 points higher than that for men. Each additional year of age
is associated with a 9% increase in average BMI. For each unit increase in FBS, the average BMI
increases by 4%. A one-unit rise in TG results in a 0.6% increase in average BMI. Each unit
increase in CHOL is associated with a 1.2% increase in average BMI. Conversely, each unit
increase in HDL corresponds to a 6.7% decrease in average BMI (Table 4).

The variables gender, age, HDL, and FBS are the most influential in predicting blood vessel
metrics. When all other factors are held constant:
On average, women's blood vessel measurements are 87.4% smaller than men's. The average
number of blood vessels increases by 5.1% for each additional year of age. Each unit increase in
FBS is associated with a 1.4% increase in the number of blood vessels. A one-unit rise in HDL
leads to a 1.5% increase in the average number of blood vessels (Table 5).

Discussion
This study investigates the relationship between periodontal health assessed by CPI, obesity
quantified by BMI, and vascular age (as a criterion for cardiovascular health). Our results
indicated that the risk of periodontal disease increases with age and is more common in men than
women.
Previous studies have also identified aging as a significant risk factor for the incidence and
severity of periodontitis(24, 25), while better health practices may contribute to periodontal
disease being generally less common in women(15).

Periodontal disease in relation to Blood Parameters, and Cardiovascular Risk

The patient group exhibited significantly higher mean values for FBS, TG, CHOL, LDL, and
most importantly, a higher PWV compared to the healthy group, indicating a higher risk of
cardiovascular diseases in periodontitis patients. Vascular stiffness is a major and independent
risk factor for cardiovascular disease and is often considered a hallmark of atherosclerosis (30).
The PWV method used in this study is regarded as the gold standard for assessing AS and has
strong epidemiological evidence of its predictive value for CV events(26). Multiple studies have
demonstrated a significant relationship between periodontal disease and PWV, with patients
suffering from chronic periodontitis exhibiting higher vascular stiffness than controls (32-34).
Nicolosi et al. (35) reported increased vascular stiffness in patients with severe periodontitis,
potentially raising cardiovascular disease risk.
Other research has linked periodontitis and other chronic diseases, to endothelial dysfunction
and cardiovascular disease, mediated by chronic infections, immunological responses to bacteria
involved in periodontal infections, and bacterial penetration into the bloodstream affecting
platelets, macrophages, and endothelium (Sanz-Miralles et al. 36) (27-29). Additionally,
numerous common risk factors between periodontal and cardiovascular diseases have been
studied, including socioeconomic conditions, oral health, smoking, and diabetes (45). According
to Jalaluddin, Penumarthy, and Sandi, patients with periodontitis have higher serum LDL, HDL,
TG, CHOL, and glucose levels compared to controls, suggesting that periodontitis may also be a
risk factor for hyperlipidemia (38-40). Periodontal disease can increase systemic exposure to
bacteria, endotoxins, lipopolysaccharides, and other bacterial products, leading to an enzymatic
response (25). The release of TNF-α cytokines, IL-1, and IL-6 can ultimately affect hepatic lipid
metabolism and catabolism. TNF-α and IL-1 both lead to the release of lipoprotein-degrading
enzymes, resulting in increased serum levels of lipids and cholesterol (26).

Periodontal disease in relation to BMI

Our study found no significant differences in BMI and HDL between groups. Obesity may lead
to a more intense inflammatory response by altering T lymphocytes, monocytes, and
macrophages, affecting microbial disease. Increased secretion of cytokines such as IL-1, IL-6,
IL-8, and TNFα can enhance gingival inflammation (42). A study by Khan et al., which reviewed
4170 cases, found no significant association between periodontitis and obesity/overweight (22).
Castilhos' study linked obesity to gingivitis of two teeth but not to periodontal disease (43).
Irigoyen's study, which focused on high school students, found a significant relationship between
obesity and periodontal status, with more calculus observed in obese patients (44). The
differences in findings may be due to variations in the populations studied(our age range was
between 35 and 60) and the methodologies used (The Irigoyen study used BOP and the presence
of calculus, while the present study is based on the CPITN index).
However, recent reviews link obesity to prior dental disease and list it as a risk factor, possibly
explained by BMI while other studies have included waist circumference.

Public Health Implications

Cardiovascular and related diseases have a high global mortality rate, significantly impacting
quality of life (5). Obesity is another critical public health concern, affecting many individuals
and serving as a risk factor for various diseases (16). Given the associations between periodontal
disease, obesity, and cardiovascular health, integrated healthcare approaches involving general
physicians and dentists are needed. Early identification and management of periodontal disease
could reduce the burden of cardiovascular diseases and associated healthcare costs. Proper dental
hygiene, including regular brushing and flossing, can significantly reduce the risk of periodontal
disease and, consequently, cardiovascular disease (43).
Study Limitations
While our study had a sufficient sample size and used the gold-standard PWV method for
measuring vascular stiffness, it had limitations. Evaluating other risk factors and the inability to
examine the possible relationships between different risk factors and cardiovascular and
periodontal diseases were beyond the scope of this study. Future research should replicate this
study on a larger, multicenter scale, incorporating common risk factors such as socioeconomic
status. Large, multicenter studies should validate our findings and investigate additional risk
factors.

Conclusion
This study highlights that the risk of periodontal disease increases with age and is more common
in men than women. There were no significant differences in HDL and BMI between healthy
individuals and those with periodontitis. People with periodontitis had higher levels of PWV,
CHOL, FBS, and TG, indicating a higher risk of cardiovascular disease in these patients.

Ethics Approval and Consent to Participate

All procedures performed in this study involving the human participant were following the
ethical standards of our institutional research committee and with the 1964 Helsinki Declaration.
This study was approved by the Ethics and Research Committee of Mashhad University of
 Medical Sciences (IR.MUMS.DENTISTRY.REC.1399.023). The authors certify that all data
collected during the study are as stated in the manuscript, and no data from the study has been or
will be published separately elsewhere.

Standards of reporting

The STROBE (Strengthening the Reporting of Observational Studies in Epidemiology)

instructions were followed and no intervention was done during this research.

Conflict of interest

None declared.

Fundings

No funding was received to assist with the preparation of this manuscript.

Table 1 The explanation of CPI codes and related descriptions

Code Description
0 No clinical signs of inflammation (bleeding, redness), no calculus, and no overhanging restorations; the
black band of the probe is fully visible.
1 Presence of bleeding or inflammation without calculus or defective restorations; the black band is fully
visible.
2 Presence of supra- or subgingival calculus; the black band is still fully visible.
3 The black band is partially visible.
4 The black band is completely invisible.

Table 2 Comparison of the mean age and Gender frequency distribution in the study groups
Number of Gender
Age (year) Age (year)
Group participants p-value (%) p-value
Mean  SD Min-Max
(%) Male Female
Control 430(87.6) 42.15 6.20 35-60 177(41.2) 253(58.8)
Case 61(12.4) 48.51 7.46 36-60 P<0.001 40(65.6) 21(34.4) P<0.001
Total 491(100) 42.93 6.7 35-60 217(44.2) 274(55.8)
The Mann–Whitney U test (Z=7.06) and chi-square test (X2=12.91) were used in this table.

Table 3 Comparison of the variables’ means between groups

Mann–
Variables Groups Mean  SD Max-Min middle Whitney U
test result
BMI Control 26.34  3.60 41.5 - 16.1 26.10 Z=1.59
 Case 27.14  3.73 40.2 - 18.4 26.50 P=0.112
Pulse Wave Control 6.56  1.44 14.80 - 2.02 6.37 Z=2.18
Velocity
Case 7.01  1.67 12.05 - 2.89 6.85 P=0.029
(PWV)
Control 94.57  11.85 162.0 - 63.0 94.00 Z=4.33
FBS
Case 102.03  13.12 136.0 - 79.0 101.00 P<0.001
Control 116.61  70.82 523.0 - 25.0 98.00 Z=2.14
TG
Case 128.05  61.30 355.0 - 37.0 106.00 P=0.032
Control 176.74  39.90 512.0 - 84.0 173.00 Z=3.12
CHOL
Case 189.82  33.34 272.0 - 111.0 190.00 P=0.002
Control 51.87  11.13 91.0 - 22.0 51.00 Z=0.24
HDL
Case 51.87  11.87 90.0 - 26.0 50.00 P=0.814
Control 100.96  30.24 290.8 - 24.8 98.20 Z=2.75
LDL
Case 111.49  30.63 175.4 - 41.6 110.40 P=0.006

Table 4 Variables affecting BMI using the Backward method in linear regression

Variable The regression SD t-value P-value 95% confidence interval for the
coefficient regression coefficient
Infimum supremum

constant 17.681 1.721 10.272 <0.001 14.299 21.063

gender 1.152 0.343 3.362 0.001 0.479 1.826
age 0.089 0.024 3.694 <0.001 0.042 0.136
FBS 0.041 0.014 2.998 0.003 0.014 0.067
TG 0.006 0.003 2.223 0.027 0.001 0.011
CHOL 0.012 0.005 2.549 0.011 0.003 0.021
HDL -0.068 0.017 -4.132 <0.001 -0.101 -0.036

Table 5 Variables affecting blood vessels using the Backward method in linear regression

Variable The regression SD t-value P-value 95% confidence interval for the
coefficient regression coefficient
Infimum supremum

constant 3.595 0.660 5.446 <0.001 2.298 4.893

gender -0.874 0.133 -6.552 <0.001 -1.136 -0.612
age 0.051 0.009 5.527 <0.001 0.033 0.070
FBS 0.014 0.005 2.738 0.006 0.004 0.025
HDL 0.015 0.006 2.713 0.007 0.004 0.027

References
1. Gasner NS, Schure RS. Periodontal Disease. StatPearls. Treasure Island (FL): StatPearls
Publishing
Copyright © 2024, StatPearls Publishing LLC.; 2024.
2. Harvey JD. Periodontal Microbiology. Dent Clin North Am. 2017;61(2):253-69.
3. Pinto G, Silva MD, Peddey M, Sillankorva S, Azeredo J. The role of bacteriophages in
periodontal health and disease. Future Microbiol. 2016;11:1359-69.
4. Herrera D, Sanz M, Shapira L, Brotons C, Chapple I, Frese T, et al. Periodontal diseases
and cardiovascular diseases, diabetes, and respiratory diseases: Summary of the consensus
report by the European Federation of Periodontology and WONCA Europe. Eur J Gen Pract.
2024;30(1):2320120.
5. Beck JD, Papapanou PN, Philips KH, Offenbacher S. Periodontal Medicine: 100 Years of
Progress. J Dent Res. 2019;98(10):1053-62.
6. Arbildo-Vega HI, Cruzado-Oliva FH, Coronel-Zubiate FT, Aguirre-Ipenza R, Meza-Málaga
JM, Luján-Valencia SA, et al. Association between Periodontal Disease and Obesity: Umbrella
Review. Medicina (Kaunas). 2024;60(4).
7. Lavigne SE, Forrest JL. An umbrella review of systematic reviews of the evidence of a
causal relationship between periodontal disease and cardiovascular diseases: Position paper
from the Canadian Dental Hygienists Association. Can J Dent Hyg. 2020;54(1):32-41.
8. Di Cesare M, Perel P, Taylor S, Kabudula C, Bixby H, Gaziano TA, et al. The Heart of the
World. Glob Heart. 2024;19(1):11.
9. Sarrafzadegan N, Mohammmadifard N. Cardiovascular Disease in Iran in the Last 40
Years: Prevalence, Mortality, Morbidity, Challenges and Strategies for Cardiovascular
Prevention. Arch Iran Med. 2019;22(4):204-10.
10. Belinga LEE, Ngan WB, Lemougoum D, Nlo'o A, Bongue B, Ngono A, et al. Association
between periodontal diseases and cardiovascular diseases in Cameroon. Journal of public
health in Africa. 2018;9(1):761.
11. Gheorghita D, Eördegh G, Nagy F, Antal M. [Periodontal disease, a risk factor for
atherosclerotic cardiovascular disease]. Orvosi hetilap. 2019;160(11):419-25.
12. Liccardo D, Cannavo A, Spagnuolo G, Ferrara N, Cittadini A, Rengo C, et al. Periodontal
Disease: A Risk Factor for Diabetes and Cardiovascular Disease. International journal of
molecular sciences. 2019;20(6).
13. Seitz MW, Listl S, Bartols A, Schubert I, Blaschke K, Haux C, et al. Current Knowledge on
Correlations Between Highly Prevalent Dental Conditions and Chronic Diseases: An Umbrella
Review. Prev Chronic Dis. 2019;16:E132.
14. Loos BG, Van Dyke TE. The role of inflammation and genetics in periodontal disease.
Periodontol 2000. 2020;83(1):26-39.
15. Herrera D, Sanz, M., Shapira, L., Brotons, C., Chapple, I., Frese, T., Graziani, F., Richard
Hobbs, F. D., Huck, O., Hummers, E., Jepsen, S., Kravtchenko, O., Madianos, P., Molina, A.,
Ungan, M., Vilaseca, J., Windak, A., & Vinker, S. Association between periodontal diseases and
cardiovascular diseases, diabetes and respiratory diseases: Consensus report of the Joint
Workshop by the European Federation of Periodontology (EFP) and the European arm of the
World Organization of Family Doctors (WONCA Europe). Journal of Clinical Periodontology.
2023.
16. Zhou M, Dong J, Zha L, Liao Y. Causal Association between Periodontal Diseases and
Cardiovascular Diseases. Genes (Basel). 2021;13(1).
17. Herrera D, Molina A, Buhlin K, Klinge B. Periodontal diseases and association with
atherosclerotic disease. Periodontol 2000. 2020;83(1):66-89.
18. Tengku HT, Peh WY, Shoaib LA, Baharuddin NA, Vaithilingam RD, Saub R. Oral Diseases
and Quality of Life between Obese and Normal Weight Adolescents: A Two-Year Observational
Study. Children (Basel). 2021;8(6).
19. Federation WO. Prevalence of Obesity 2024 [Available from:
https://www.worldobesity.org/about/about-obesity/prevalence-of-obesity.
20. Martinez-Herrera M, Silvestre-Rangil J, Silvestre FJ. Association between obesity and
periodontal disease. A systematic review of epidemiological studies and controlled clinical
trials. Med Oral Patol Oral Cir Bucal. 2017;22(6):e708-e15.
21. review Tbrboapdan. 2023.
22. Moeintaghavi A, Pourjavad M, Dadgar S, Tabbakh NS. Evaluation of the association
between periodontal parameters, osteoporosis and osteopenia in post menopausal women.
Journal of Dentistry (Tehran, Iran). 2013;10(5):443.
23. Moeintaghavi A, Arab HR, Moghaddam MA, Shahmohammadi R, Bardan BY, Soroush Z.
Evaluation of effect of surgical and nonsurgical periodontal therapy on serum C-reactive
protein, triglyceride, cholesterol, serum lipoproteins and fasting blood sugar in patients with
severe chronic periodontitis. The Open Dentistry Journal. 2019;13(1).
24. Huang Q, Dong X. Prevalence of periodontal disease in middle-aged and elderly patients
and its influencing factors. Am J Transl Res. 2022;14(8):5677-84.
25. Gholami M, Asadinejad SM, Kakavand D, Jafari Doudaran P, Fathi AH. Association of
Periodontitis and Aging-Related Diseases: A Review of Mechanistic Studies. Journal of Research
in Dental and Maxillofacial Sciences. 2023;8(1):62-70.
26. González LdM, Romero-Orjuela SP, Rabeya FJ, del Castillo V, Echeverri D. Age and
vascular aging: an unexplored frontier. Frontiers in Cardiovascular Medicine. 2023;10.