Volume 86 Number 7

Associations Among Oral Hygiene

Behavior and Hypertension Prevalence
and Control: The 2008 to 2010 Korea
National Health and Nutrition
Examination Survey
Hye Min Choi,* Kyungdo Han, Yong-Gyu Park, and Jun-Beom Park

Background: Recently, a positive association has been reported between hypertension and periodontitis.
The authors hypothesized that oral hygiene promotion activities could have an effect on hypertension prevention or the degree of hypertension control. Therefore, this study examines the relationship between oral
hygiene behaviors and hypertension using data from a nationally representative survey, the Korea National
Health and Nutrition Examination Survey (KNHANES).
Methods: Using data from the KNHANES (2008 to 2010), 19,560 adults with complete data sets were
included. The authors analyzed the relationship of the prevalence and control rate of hypertension and
numerous variables, including oral hygiene behavior.
Results: As the frequency of toothbrushing increased, the prevalence of hypertension decreased in
multivariate analysis after adjusting for various factors, including the presence of periodontitis. In a subgroup analysis, this relationship was also observed in individuals without periodontitis. In particular,
systolic blood pressure levels progressively decreased as the frequency of toothbrushing and the number of secondary oral products used increased. The adjusted odds ratio of hypertension prevalence was
1.195 (95% confidence interval 1.033 to 1.383) for individuals who brushed their teeth hardly ever or
once daily compared with those who brushed after every meal.
Conclusions: Individuals with poor oral hygiene behavior are more likely to have a higher prevalence
of hypertension, even before periodontitis is shown. Oral hygiene behavior may be considered an independent risk indicator for hypertension, and maintaining good oral hygiene may help to prevent and
control hypertension. J Periodontol 2015;86:866-873.
KEY WORDS
Blood pressure; epidemiology; hypertension; oral hygiene; periodontitis; prevalence.
* Department of Internal Medicine, Myongji Hospital, Goyang, Gyeonggi-do, Republic of Korea.
Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
Department of Periodontics, College of Medicine, The Catholic University of Korea.

doi: 10.1902/jop.2015.150025

866

J Periodontol July 2015

ypertension is highly prevalent, affecting 30%

of adults in the United States and 25% in
Korea, and is a major cause of cardiovascular
morbidity and mortality.1,2 Periodontitis is a chronic
inflammatory disease of periodontal tissue, affecting
nearly 50% of the general population.3 During the last
decade, periodontitis has received great attention for
its association with several diseases including diabetes,
metabolic syndrome, and atherosclerotic vascular
complications such as stroke and coronary heart
disease.4-6 The chronic inflammatory processes of
periodontitis are considered to be the basis of the
associations.7 It is known that inflammatory and immunologic reactions following periodontitis induce
the production of pro-inflammatory cytokines and
the breakdown of the epithelium and the connective
tissue.8 Periodontitis may lead to increased systemic
inflammatory mediators and cross-reactive systemic
antibodies, which promote inflammation, atheroma,
and dyslipidemia, resulting in systemic disease such
as atherosclerosis and cardiovascular disease.9
Recently, several studies have shown the involvement
of periodontitis in the initiation and progression of
hypertension.10-13 However, few publications have
evaluated whether oral hygiene promotion activities
could have an effect on hypertension prevention or
the degree of hypertension control.
Therefore, this study assesses the relationship between oral hygiene behaviors and hypertension in
a large probability sample of the Korean population
using data from the Korea National Health and
Nutrition Examination Survey (KNHANES).14

MATERIALS AND METHODS

Overview of the Survey
Data from the KNHANES collected in the years 2008
to 2010 by the Korean Ministry of Health and Welfare
were used for this study. KNHANES is a nationwide
study that used a stratified, multistage probability
sampling design to select a representative sample of
non-institutionalized civilians. Additional details about
the study design and methods are provided elsewhere.14 Only participants with complete data sets
were included, and data from 19,560 individuals (9,801
men [aged 19 to 91 years; mean age: 44.9 0.3 years]
and 9,759 women [aged 19 to 95 years; mean age:
43.1 0.3 years]) were used for this study. The survey
was composed of three parts: a health interview
survey, a health examination survey, and a nutrition
survey. KNHANES was performed according to the
guidelines of the Declaration of Helsinki as revised
in 2000. All of the participants in the survey signed
an informed consent form. The Institutional Review
Board of Seoul St. Marys Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea,
approved the protocol (study no. KC14EISI0336).

Choi, Han, Park, Park

Demographic Variables
All participants were asked about their demographic
characteristics, socioeconomic characteristics, and
medical history. Trained interviewers conducted faceto-face interviews with a structured questionnaire.
Smoking status was categorized into three groups:
1) non-smokers, who had never smoked or had
smoked <100 cigarettes in their lifetime; 2) ex-smokers,
who had smoked in the past and had stopped smoking;
and 3) current smokers, who were smoking currently
and had smoked 100 cigarettes.15,16
The amount of pure alcohol consumed (grams per
day) was calculated, and the participants were divided into three groups depending on the amount of
alcohol consumption per day (non-drinker; light-tomoderate drinker [1 to 30 g/day]; and heavy drinker
[>30 g/day]).17,18
The nutrition surveys included questions about the
participants eating patterns, use of dietary supplements, knowledge of nutrition, and food intake using
the 24-hour recall method. Total energy intake and
percentage of energy from each nutrient (fat, carbohydrate, and protein) were then calculated.
Exercise was defined as strenuous physical activity performed for 20 minutes at a time at least
three times a week. Low income corresponds to the
lowest quartile of household income. Education level
was classified as high if the respondent finished education beyond high school. Data about place of
residence (urban or rural areas), presence of spouse,
and self-reported oral status were also obtained.
Measurements
Physical measurements of the participants were done
by trained staff members in the Division of Chronic
Disease Surveillance under the Korea Centers for
Disease Control and Prevention and the Korean Ministry
of Health and Welfare.
A standard mercury sphygmomanometer was
used for blood pressure (BP) measurement. Systolic
BP (SBP) and diastolic BP (DBP) were measured twice
at 5-minute intervals, and the average values were
used for the analysis. Hypertension was defined as an
average BP 140/90 mmHg or the use of antihypertensive medication.2,19 Hypertension was considered
to be controlled if participants with hypertension had
an average BP <150/90 for individuals aged 60 years
and BP <140/90 for everyone else, according to recently revised Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure recommendations.20
Total body fat was measured using dual-energy x-ray
absorptiometry examinations.i Total body fat percentage was determined as fat mass divided by total mass.
Baumanometer, W.A. Baum, Copiague, NY.
i Discovery-W fan beam densitometer, Hologic, Bedford, MA.

867

Hypertension and Oral Hygiene Behavior

Oral Health Behavior

This study checked both the toothbrushing frequency
per day and the number of secondary oral products
used. Secondary oral products included dental floss,
mouthwash, interdental brush, and electric toothbrush.
Periodontitis
The World Health Organization (WHO) community
periodontal index (CPI) was used to assess periodontitis. When the CPI code is 3, it is defined as
periodontitis.21-23 Code 3 indicates that at least one
site had a >3.5-mm pocket in one of the index teeth,
which are 2, 3, 8, 14, 15, 18, 19, 24, 30, and 31
according to the Universal Numbering System
adopted by the American Dental Association. The
mouth was divided into sextants. A CPI probe with
a 0.5-mm ball tip, which met WHO guidelines, was
used. A sextant was examined only if there were two
or more teeth present. If no index teeth were present
in a sextant qualifying for examination, all remaining
teeth were examined, and the highest score was recorded as the score for that sextant.
Statistical Analyses
All data are presented as mean SE or % (SE). If
necessary, logarithmic transformation was performed
to achieve a normal distribution. Statistical analyses
were performed using the survey procedure of the statistical software package# to account for the complex
sampling design. Comparisons of groups were done by
Student t test, one-way analysis of variance, or x2 test,
as appropriate. Analysis of covariance was used to
compare the distribution of BP levels according to the
toothbrushing frequency or the number of secondary oral products used. Univariate and multivariate
logistic regression analyses were used to assess the
associations between hypertension and oral health
behavior. In multivariate analyses, adjustments were
made for age, sex, total body fat percentage, smoking,
alcohol consumption, exercise, education, income,
energy intake, fat intake, and the presence of periodontitis to identify the relationship between oral
behavior and hypertension.
RESULTS
Participant characteristics are presented in Table 1.
Of the 19,560 participants, 5,921 were diagnosed
with hypertension. Table 1 describes the characteristics of the study population by the presence of
hypertension. A higher percentage of individuals with
hypertension were male, had low income and education level, lived in rural areas, and had spouses
(P <0.05). Moreover, individuals with hypertension
had higher levels of age, obesity (total body fat
percentage, body mass index, and waist circumference), periodontitis and higher number of ex-smokers
(P <0.05). However, individuals with hypertension had
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Volume 86 Number 7

lower levels of calorie and fat intake and a lower number

of current smokers (P <0.05). Overall, toothbrushing
frequency and use of secondary oral products was lower
in participants with hypertension compared with individuals without.
Table 2 compares the prevalence and control of
hypertension according to oral hygiene behaviors.
The prevalence of hypertension progressively decreased with an increase in toothbrushing frequency
(30.6% 1.2%, 27.6% 0.8%, 26.4% 0.8%, and
22.8% 0.7% in adults who brushed hardly ever,
once, twice, and three times a day, respectively) and
more frequent use of secondary oral products (29.0%
0.6%, 20.7% 0.7%, and 18.0% 1.3% in adults
who used none, one, and two or more, respectively).
As expected, periodontitis existed more frequently in
individuals with poor oral hygiene behaviors.
Adjusted odds ratios (ORs) and their 95% confidence
intervals (CIs) of oral hygiene behaviors for hypertension prevalence and control are shown in Table 3. As the
frequency of toothbrushing decreased, the OR for
hypertension increased (P = 0.0217). The adjusted OR
for hypertension was 1.195 (95% CI 1.033 to 1.383)
among participants who brushed their teeth hardly
ever or once daily, compared with those who brushed
after every meal. Moreover, there was a tendency for
individuals who hardly ever brushed their teeth to have
less-controlled hypertension (P = 0.0507). In terms of
secondary oral products, hypertension was controlled
better in participants who used more secondary oral
products (P = 0.0258). There was no significant relationship, however, between the prevalence of hypertension and the use of secondary oral products.
The final P values for all the variables included in
the multivariate analyses are presented as supplementary data (see supplementary Tables 1 and 2 in
online Journal of Periodontology). Moreover, similar
trends were seen in the relations between toothbrushing frequency and the prevalence of hypertension even in populations without periodontitis in
a subgroup analysis (see supplementary Table 3 in
online Journal of Periodontology).
In addition, blood pressure was classified into four
stages, according to severity: Level 1, SBP <130
mmHg and DBP <80 mmHg; Level 2, 130 SBP
< 140 mmHg or 80 DBP < 90 mmHg; Level 3, 140
SBP < 160 mmHg or 90 < DBP < 100 mmHg; and
Level 4, SBP 160 mmHg or DBP 100 mmHg.24 The
distribution of BP levels according to oral hygiene
behaviors is presented in Figure 1. The proportion of
individuals with moderately high BP (Level 3) and
severely high BP (Level 4) decreased with increasing
toothbrushing frequency (Fig. 1A) and increasing
use of secondary oral products (Fig. 1B).
PWHO, Osung MND, Seoul, Korea.
# SAS, v.9.2 for Windows, SAS Institute, Cary, NC.

Choi, Han, Park, Park

J Periodontol July 2015

Table 1.

Characteristics of Study Population (mean 6 SE or % [SE])

Hypertension
No

Yes

13,639

5,921

Age (years)

40.1 0.2

55.1 0.3

<0.0001

Male sex

47.2 (0.4)

56.8 (0.7)

<0.0001

Total body fat (%)

27.1 0.1

28.5 0.2

<0.0001

Body mass index (kg/m2)

23.1 0.0

25.1 0.1

<0.0001

Waist circumference (cm)

79.1 0.1

86.0 0.2

<0.0001

Exercise (yes)

24.7 (0.5)

26.1 (0.8)

0.0727

Higher education

79.1 (0.6)

50.1 (1.1)

<0.0001

Low income

12.4 (0.5)

24.7 (0.9)

<0.0001

Characteristic

Total energy (kcal/d)

2,012.4 12.2

1,967.4 16.9

0.0225

Energy from fat (%)

18.8 0.1

15.9 0.2

<0.0001

Rural residence

17.3 (1.5)

22.3 (1.8)

<0.0001

Spouse (yes)

66.6 (0.7)

74 (0.8)

<0.0001

Periodontitis (yes)

23.9 (0.7)

42.4 (1)

Smoking
Non-smoker
Ex-smoker
Current smoker

57.9 (0.5)
14.4 (0.3)
27.7 (0.5)

50.6 (0.7)
24.2 (0.7)
25.2 (0.7)

Alcohol Consumption
Non-drinker
Light-to-moderate drinker
Heavy drinker

20.4 (0.4)
62.6 (0.5)
17 (0.5)

29.8 (0.7)
45.3 (0.9)
24.9 (0.7)

Toothbrushing frequency (times/day)

3
2
0 or 1

28.3 (0.6)
33.0 (0.6)
38.7 (0.7)

23.3 (0.7)
33.2 (0.9)
43.5 (1.0)

Use of secondary oral products (n)

2
1
0

7.4 (0.3)
25.6 (0.5)
67.0 (0.6)

4.6 (0.3)
18.7 (0.7)
76.7 (0.8)

<0.0001
<0.0001

<0.0001

<0.0001

<0.0001

The distribution of SBP and DBP according to oral

hygiene behaviors is shown in Figure 2. SBP significantly decreased with increasing toothbrushing frequency (P = 0.0243) and increasing use of secondary
oral products (P = 0.0004) after adjustment in a
multivariate analysis.
DISCUSSION
This study assesses the associations among oral
hygiene behaviors and hypertension prevalence and

control in a large probability sample of the Korean

population. In summary, as the frequency of toothbrushing increased, the prevalence of hypertension
decreased in the multivariate analysis after adjusting
for various confounding risk factors for hypertension,
including the presence of periodontitis. Interestingly,
this relationship was also observed even in a population
without periodontitis in the subgroup analysis. In particular, SBP levels progressively decreased as the frequency of toothbrushing and the number of secondary
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Hypertension and Oral Hygiene Behavior

Volume 86 Number 7

Table 2.

Hypertension Prevalence (% [SE]) in a Multivariate Logistic Regression Model for

Toothbrushing Frequency
Variable

Prevalence

Toothbrushing frequency (times/day)

0
1
2
3

30.6
27.6
26.4
22.8

Use of secondary oral products (n)

0
1
2

29.0 (0.6)
20.7 (0.7)
18.0 (1.3)

Control

<0.0001

Periodontitis (yes)

<0.0001

0.0627

(1.2)
(0.8)
(0.8)
(0.7)

26.6
30.4
32.4
30.9

(1.7)
(1.4)
(1.4)
(1.7)

<0.0001

31.5
31.0
28.8
25.2

(1.3)
(0.9)
(0.9)
(0.8)
<0.0001

0.0231
31.4 (1)
26.6 (1.7)
32.7 (3.5)

30.9 (0.8)
24.9 (0.9)
20.3 (1.4)

Table 3.

Hypertension Prevalence (OR [95% CI]) Multivariate Logistic Regression Model for Oral
Hygiene Behaviors
Variable

Prevalence

Toothbrushing frequency (times/day)

3
2
0 or 1

1
1.137 (1.000 to 1.297)
1.195 (1.033 to 1.383)

Use of secondary oral products (n)

2
1
0

1
0.947 (0.753 to 1.191)
1.010 (0.811 to 1.258)

Control

0.0217

P
0.0507

1
1.148 (0.92 to 1.232)
0.863 (0.708 to 1.011)
0.4819

0.0258
1
0.712 (0.469 to 1.081)
0.626 (0.421 to 0.929)

Adjusted for age, sex, total body fat percentage, smoking, drinking, exercise, education, income, total energy intake, fat intake, and periodontitis.

oral products increased. Hypertension was controlled

better in participants who used more secondary oral
products in the multivariate analysis. ORs for hypertension in people who brushed their teeth hardly ever or
once daily was 1.195 (95% CI: 1.033 to 1.383) compared with those who brushed after every meal.
Both dental disease and hypertension are important
health issues. Recently, the potential relationships
between these two conditions, which seem unrelated,
were evaluated. Hypertension is a multifactorial disease, and it has been believed that oxidative stress,
endothelial dysfunction, and inflammation are among
the critical components in the development of hypertension, along with other factors (e.g., smoking).25
Recently, a positive association has been reported
between hypertension and periodontitis, and several
studies showed that periodontitis is related to BP elevation and may contribute to poor control of hypertension.13,26 A possible pathogenic background of
an effect of periodontitis on BP may include the systemic generalization of local oral inflammation, a di870

rect microbial effect on the vascular system, and

alterations in endothelial function, resulting in arterial
stiffening as well as atherosclerosis.27-29
The present authors hypothesized that oral hygiene
promotion activities produce improvements in periodontal health, resulting in preventive effects on hypertension. In this study, a low level of toothbrushing is
independently associated with the prevalence of hypertension after adjusting for potential confounding
factors related to hypertension.
For the prevalence and control of hypertension,
both direct and indirect effects of oral hygiene behavior could be speculated. Oral hygiene behaviors
could reflect general health behaviors, indirectly affecting the prevalence of hypertension. In fact, there
is a previous report showing that toothbrushing frequency was the most predictive indicator of general
health behaviors (smoking, drinking, exercise, eating
breakfast, and having medical checkups).30 However, these authors considered various factors, such
as lifestyles involving smoking, alcohol, exercise,

Choi, Han, Park, Park

J Periodontol July 2015

Figure 1.

A) Distribution of BP levels according to toothbrushing frequency

(P <0.001). B) Distribution of BP levels according to number of secondary
oral products used (P <0.001). Level 1 = SBP <130 mmHg and DBP <80
mmHg; Level 2 = 130 SBP < 140 mmHg or 80 DBP < 90 mmHg;
Level 3 = 140 SBP < 160 mmHg or 90 DBP < 100 mmHg; Level
4 = SBP 160 mmHg or DBP 100 mmHg.

dietary intake, and socioeconomic status, minimizing

the effects of confounding variables. Also, there
could be direct effects of oral hygiene behavior on
hypertension.31,32 Improvements in oral hygiene may
cause a decrease of bacterial load, leading to improvements in periodontal health.9,31
It is also important to note that in this study, oral
behavior is associated with the prevalence of hypertension even in the population without periodontitis.
Periodontitis is defined as a chronic inflammatory
disease of microbial origin, which is characterized by
a progressive loss of alveolar bone around the teeth as
well as pocket formation around the teeth and/or gum
recession.33,34 The present authors believe that although periodontitis is not seen yet, inflammatory and
immune reactions could take place by local bacteria,
host immune response, and reactive oxygen species
produced by locally infiltrating neutrophils. Previously,
it was shown that individuals who cleaned their teeth
at least twice a day had less visible plaque compared

Figure 2.

A) Distribution of SBP and DBP according to toothbrushing frequency

after adjustment for age, sex, total body fat percentage, periodontitis,
smoking, drinking, exercise, education, income, energy intake, fat intake,
and medication (P = 0.0243 and 0.0565 for SBP and DBP, respectively).
B) Distribution of SBP and DBP according to the number of secondary oral
products used after adjustment (P = 0.0004 and 0.8105 for SBP and
DBP, respectively).

with those who cleaned their teeth less than once a day
or never.35 Toothbrushing is an effective healthy behavior that reduces the amount of bacterial plaque and
gingivitis.
The CPI, which was used as an index of periodontitis in the present study, is widely used to
measure the level of periodontal disease and define
periodontitis.21,23 However, there is a limitation because the index does not reflect oral hygiene; therefore, it is suggested that the combined use of an oral
hygiene index and the CPI should be recommended to
assess oral health.36
Currently, many studies recommend lifestyle
modifications such as weight reduction, smoking
cessation, and exercise to decrease the prevalence of
hypertension and improve BP control. If a simple
871

Hypertension and Oral Hygiene Behavior

lifestyle modification such as toothbrushing could

help prevent hypertension, it might be emphasized
for the prevention of hypertension, as well as for the
prevention of inflammatory periodontal disease.
The present study has several important strengths.
First, this study is based on a nationally representative sample of Koreans, providing sufficient power
for the investigation of the relationships and the
availability of various relevant confounding factors.37
Second, although a potential association between
oral health and hypertension has been suggested
before, most previous studies have focused on
periodontitis, which requires periodontal tissue
breakdown by definition. In this study, the authors
confirmed the previous reports regarding the positive
relations between periodontitis and hypertension
prevalence. Further, the present study showed an
independent correlation of oral hygiene behaviors
with hypertension even before periodontitis is shown,
although the CPI only, without longitudinal assessment, is not sufficiently complete to diagnose periodontitis.
There are also limitations, in that the design of the
present study was cross-sectional. An obvious problem with cross-sectional studies is that exposure and
outcome are measured at the same time, while their
interrelated sequences are unknown. In addition, the
authors did not measure inflammatory markers such as
interleukin-6, tumor necrosis factor-a, and C-reactive
protein; therefore, this study is limited in its description
of inflammatory factors associated with oral health
behaviors and hypertension. Despite these limitations,
the present study has important implications in that it
provides epidemiologic evidence demonstrating an
association between oral behavior and hypertension.
CONCLUSIONS
Individuals with poor oral hygiene habits were more
likely to have higher hypertension prevalence. Within
the limits of this study, oral hygiene behavior may
be considered an independent risk indicator for hypertension, and maintaining good oral hygiene may help
prevent and control hypertension. A longitudinal study
or an intervention trial would be necessary to ascertain
the role of oral hygiene behavior in hypertension.
ACKNOWLEDGMENTS
This research was supported by Basic Science
Research Program through the National Research
Foundation (NRF) of Korea funded by the Ministry of
Science, Information Communication Technology &
Future Planning (NRF-2014R1A1A1003106; Seoul,
Republic of Korea). The authors thank the Korea
Centers for Disease Control and Prevention for providing the data. The authors report no conflicts of interest related to this study.
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Correspondence: Dr. Jun-Beom Park, Department of
Periodontics, Seoul St. Marys Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero,
Seocho-gu, Seoul 137-701, Republic of Korea. E-mail:
jbassoonis@yahoo.co.kr.
Submitted January 14, 2015; accepted for publication
February 17, 2015.

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