J Clin Periodontol 2015; 42: 998–1005 doi: 10.1111/jcpe.

12471

The association of hypertension Yoo-Been Ahn1,*, Myung-Seop

Shin1,*, Jong-Seok Byun2 and
Hyun-Duck Kim1,3

with periodontitis is highlighted in 1

Department of Preventive and Social
Dentistry, School of Dentistry, Seoul National
University, Seoul, Korea; 2Department of

female adults: results from the Applied Statistics, College of IT, Hanshin
University, Osan-Si, Gyeonggi-Do, Korea;
3
Dental Research Institute, School of

Fourth Korea National Health Dentistry, Seoul National University, Seoul,

Korea

*Dr Ahn and Dr Shin are co-first authors who

and Nutrition Examination contributed equally to this work.

Survey
Ahn Y-B, Shin M-S, Byun J-S, Kim H-D. The association of hypertension
with periodontitis is highlighted in female adults: results from the Fourth Korea
National Health and Nutrition Examination Survey. J Clin Periodontol 2015; 42:
998–1005. doi: 10.1111/jcpe.12471.

Abstract
Aim: To evaluate the association of hypertension and high systolic and diastolic
blood pressure (SBP and DBP) with periodontitis in a nationally representative
Korean adult population.
Materials and Methods: Total of 14,625 participants of Fourth Korea National
Health and Nutrition Examination Survey (KNHANES IV) aged over 19 years
were cross-sectionally surveyed. Periodontitis was defined as CPI score of 3 or 4.
Hypertension was categorized as: normotensive (SBP < 120 mmHg and
DBP < 80 mmHg), pre-hypertensive (120 < SBP < 140 mmHg or
80 < DBP < 90 mmHg) and hypertensive (SBP ≥ 140 mmHg or
DBP ≥ 90 mmHg or taking antihypertensive medication). Multivariate Poisson
regression analyses were performed controlling for age, sex, household income,
drinking, smoking, physical activity, obesity, hypercholesterolaemia and diabetes
mellitus. Stratified analyses were performed to identify specific risk groups.
Results: Hypertension showed a significant positive association with periodontitis
in the fully adjusted model in female adults with a dose–response relationship.
This association was highlighted in females aged 30–59 years (prevalence
Key words: epidemiology; females;
ratio = 1.25; 95% confidence interval: 1.11–1.40). The strength of the association
hypertension; KNHANES; periodontitis
was highest in females aged 30–39 years and decreased with increasing age.
Among females aged 30–59 years, high-risk groups of this link were lower middle Accepted for publication 8 October 2015

Conflict of interest and source of funding statement

The authors declare no conflicts of interest. The data from the Fourth Korea National Health and Nutrition Examination Sur-
vey were provided by the Korea Centers for Disease Control and Prevention. This work was supported by a grant from the
Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Edu-
cation, Science and Technology (No. 2013-062881) and the NRF Grant through the Oromaxillofacial Dysfunction Research
Center for the Elderly (No. 2014-050477) at Seoul National University of Korea. Dr Ahn was supported by the Brain Korea
21 grant from Seoul National University, School of Dentistry of Korea.

998 © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

income quartile, never drinker and non-diabetes groups for both pre-hypertension
and hypertension.
Conclusion: Our data showed that hypertension was associated with periodontitis
in Korean female adults independent of known confounders.
Periodontal disease has drawn
increasing attention for its associa-
tion with cardiovascular disease
(CVD), as a chronic multifactorial
condition linked with systemic
inflammatory markers and endothe-
lial dysfunction. In 2013, a consen-
sus report of the joint EFP/AAP
Workshop was published to address
that the current state of the evidence
supports a positive and significant
association between periodontitis
and atherosclerotic CVD (Tonetti
et al. 2013). Known as a major risk
factor for CVD, hypertension is also
considered to play a role as a risk
factor for periodontitis. World
Health Organization (WHO) reports
that periodontitis and hypertension
affect approximately one third of the
world’s adult population, the latter
of which accounts for 51% of deaths
from stroke and 45% of CVD mor-
tality (WHO, 2014). Similarly, peri-
odontitis and hypertension are
highly prevalent in Korea, affecting
one third of adults aged over 30
(KCDC, 2014). As such, hyperten-
sion and periodontitis are major
health problems and the elucidation
of their association is of public
health concern.
Several potential mechanisms of
hypertension-induced periodontal
deterioration have been proposed.
Endothelial dysfunction of small
arterioles and the subsequent gingi-
val arteriolar wall thickening and
microcirculatory dysfunction caused
by high blood pressure have been
suggested as possible mechanisms
(Tsioufis et al. 2011). In an experi-
mental study, heightened levels of
inflammatory mediators were found
in the gingival tissue of sponta-
neously hypertensive rats, suggesting
that hypertensive condition favours
the inflammatory process which can
affect the periodontium peripherally
(Bonato et al. 2012). Several epi-
demiological data have suggested a
positive association of hypertension
with periodontitis. A cross-sectional
study of 99 Polanders found a crude
association of elevated aortic systolic
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Hypertension and periodontitis
and diastolic pressure (SBP and
DBP) with periodontitis (Franek
et al. 2009). In a subsequent study
of 155 type 2 diabetes individuals,
central SBP and DBP were reported
to be associated with periodontitis
severity (Franek et al. 2010). In
another cross-sectional study of 79
Brazilians, DBP was associated with
severe periodontitis among individu-
als with heterozygous familial hyper-
cholesterolaemia, after adjusting for
traditional risk factors for
atherosclerosis (Vieira et al. 2011).
To date, however, no nationally rep-
resentative epidemiological study has
reported on the role of high blood
pressure on periodontitis pathogene-
sis.
In the lack of evidence on the
association of hypertension with
periodontitis in Koreans, the authors
explored this potential link in a
nationally representative sample of
Korean population, using the Fourth
Korea National Health and Nutri-
tion Examination Survey
(KNHANES IV) data. The aim of
this study was to test the hypothesis
that hypertension is associated with
periodontitis.
Materials and Methods
Study design and subjects
To test the hypothesis that hyperten-
sion is associated with periodontitis,
cross-sectional analyses were per-
formed using a dataset of nationally
representative Korean population.
The data were derived from the
KNHANES IV, conducted between
2007 and 2009 by the Korea Centers
for Disease Control and Prevention
(KCDC). A detailed description of
the sampling methods and survey
contents is described in previous
publications (Lee et al. 2013, Kim
et al. 2014), and in the KNHANES
IV report (KCDC, 2009). In the
KNHANES, physical and dental
examinations and blood sampling
were performed at a mobile exami-
nation centre and all clinical mea-
999
surements were taken by trained
staff members. Face-to-face inter-
views were conducted with a struc-
tured questionnaire by trained
interviewers. Out of the 24,871 par-
ticipants of this survey, only those
individuals aged over 19 who had
complete datasets were included in
the analysis, which constituted a
total of 14,625 participants (6247
males and 8378 females) (Table 1).
Assessment of hypertension
A standard mercury sphygmo-
manometer (Baumanometer, W.A.
Baum, Copiague, NY, USA) was
used to measure SBP and DBP on the
participants’ right arm in a seated
position after at least 5 min. of rest
before the initial measurement. The
blood pressure measurements were
taken twice at a 5-min. interval and
the average values were used for the
analysis. For our analyses, pre-hyper-
tension was defined as having either
120 ≤ SBP < 140 mmHg or 80 ≤
DBP < 90 mmHg and hypertension
was defined as having an average SBP
over 140 mmHg or DBP over
90 mmHg or medicated for hyperten-
sion. This classification was based on
the SBP and DBP cut-off points sug-
gested by the JNC7 report (Choba-
nian et al. 2003).
Assessment of periodontitis
Periodontal status of the participants
was assessed by dentists using the
Community Periodontal Index of
Treatment Needs (CPITN). Accord-
ing to the WHO guidelines, a CPI
probe with a 0.5-mm ball tip was
used with an approximately 20 g
probing force. Periodontal pocket
depths (PD) were measured at six
sites (mesio-buccal, mid-buccal,
disto-buccal, disto-lingual, mid-
lingual and mesio-lingual) per tooth.
Ten index teeth selected for the
examination were: the first and sec-
ond molars in each posterior sextant,
the upper right incisor in upper
middle sextant and the lower left
1000 Ahn et al.

Table 1. Characteristics of the participants by periodontitis (CPI 3–4) (n = 14,625) ing on probing), 2 (presence of cal-
Variable N Periodontitis (CPI 3–4) p Value* culus), 3 (PD ≥ 3.5 mm) and 4
(PD ≥ 5.5 mm). Training and cali-
No Yes bration procedure preceded each
annual survey in accordance with
Age (years), n (%) the KNHANES standards. The
19–29 2010 1871 (19.8) 139 (2.7) <0.001 Kappa value means for inter-exami-
30–39 3107 2489 (26.3) 618 (11.9) ner reliability were 0.71 (0.69–0.77)
40–49 3048 1914 (20.2) 1134 (21.9)
in 2007, 0.89 (0.55–1.00) in 2008 and
50–59 2557 1291 (13.7) 1266 (24.5)
≥60 3903 1887 (20.0) 2016 (39.0)
0.75 (0.53–0.94) in 2009 (KCDC,
Sex, n (%) 2009). For the analysis, periodontal
Female 8378 5889 (62.3) 2489 (48.1) <0.001 status was dichotomized into peri-
Male 6247 3563 (37.7) 2684 (51.9) odontitis negative (CPI score of 0–2,
Household income, n (%) including normal and gingivitis) and
Lowest quartile 2811 1528 (16.2) 1283 (24.8) <0.001 periodontitis positive (CPI score of
Lower middle quartile 3645 2250 (23.8) 1395 (27.0) 3–4).
Upper middle quartile 4032 2701 (28.6) 1331 (25.7)
Highest quartile 4137 2973 (31.5) 1164 (22.5)
Drinking, n (%) Assessment of potential confounders
Never 2003 1203 (12.7) 800 (15.5) <0.001
Ever in lifetime 12,622 8249 (87.3) 4373 (84.5)
The authors considered the following
Smoking, n (%) as potential confounders: (1) age, (2)
Never 8626 6046 (64.0) 2580 (49.9) <0.001 sex, (3) household income, (4)
Ever in lifetime 5999 3406 (36.0) 2593 (50.1) drinking, (5) smoking, (6) physical
Physical activity, n (%) activity, (7) obesity, (8) hypercholes-
None 9699 6142 (65.0) 3557 (68.8) <0.001 terolaemia and (9) diabetes mellitus
≥1 day/week 4926 3310 (35.0) 1616 (31.2) (Tsioufis et al. 2011).
Obesity†, n (%) Information on age, sex, income
Non-obese 9954 6662 (70.5) 3292 (63.6) <0.001 and such lifestyle variables as smok-
Obese 4671 2790 (29.5) 1881 (36.4)
ing and drinking habits, and physical
Hypercholesterolaemia‡, n (%)
No 13,037 8567 (90.6) 4470 (86.4) <0.001
activity was collected from the par-
Yes 1588 885 (9.4) 703 (13.6) ticipants’ responses to a standardized
Diabetes§, n (%) questionnaire through in-person
Non-diabetic 13,293 8824 (93.4) 4469 (86.4) <0.001 interviews. Participants were catego-
Diabetic 1332 628 (6.6) 704 (13.6) rized into five age groups: 19–29,
Hypertension¶, n (%) 30–39, 40–49, 50–59 and over
Normal 6942 5122 (54.2) 1820 (35.2) <0.001 60 years. Income status was mea-
Pre-hypertension 3573 2204 (23.3) 1369 (26.5) sured by the household income and
Hypertension 4110 2126 (22.5) 1984 (38.4) was categorized into quartiles. Self-
Systolic blood pressure (SBP), n (%)
<120 mmHg 8552 6193 (65.6) 2359 (45.6) <0.001
reported alcohol consumption was
120 ≤ SBP < 140 mmHg 2834 1663 (17.6) 1171 (22.6) dichotomized into none or ever in
≥140 mmHg†† 3239 1596 (16.9) 1643 (31.8) lifetime. Self-reported smoking status
Diastolic blood pressure (DBP), n (%) was similarly dichotomized into
<80 mmHg 8829 6245 (66.1) 2584 (50.0) <0.001 never smokers or ever a smoker in
80 ≤ DBP < 90 mmHg 2389 1477 (15.6) 912 (17.6) lifetime. Information on physical
≥90 mmHg†† 3407 1730 (18.3) 1677 (32.4) activity was assessed by the number
*Obtained from chi-square test.
of days per week strenuous activities
†
Obesity is defined as body mass index (BMI, kg/m2) ≥ 25. are conducted and grouped as none
‡
Hypercholesterolaemia: total cholesterol in blood (TC) ≥ 240 mg/dl or medicated for or more than 1 day per week. Body
hypercholesterolaemia; normal: TC < 240 mg/dl. weight and height were measured to
§
Diabetes: fasting plasma glucose (FPG) ≥ 126 mg/dl or medicated for diabetes; pre-dia- the nearest 0.1 kg and 0.1 cm,
betes: 100 ≤ FPG < 126 mg/dl; normal: FPG < 100 mg/dl. respectively, with the participants in
Hypertension: SBP ≥ 140 mmHg or DBP ≥ 90 mmHg or medicated for hypertension; light in-door clothing without shoes.
pre-hypertension: 120 ≤ SBP < 140 mmHg or 80 ≤ DBP < 90 mmHg; normal: SBP < 120 Body mass index (BMI: kg/m2) was
mmHg and DBP < 80 mmHg. calculated using the formula weight/
††
Includes individuals medicated for hypertension.
height2 (kg/m2). Obesity was defined
as having BMI over 25 kg/m2. Blood
samples were collected from the
central incisor in lower middle sex- examined. If no adjacent tooth was antecubital vein of each participant
tant. A sextant was examined only if present, all remaining teeth were after at least 8 h of fasting and anal-
there were two or more teeth present examined and the highest score was ysed within 24 h of collection. Con-
that were not scheduled for extrac- recorded as the score for that sex- centrations of total cholesterol (TC)
tion. If the index tooth was absent tant. CPI was scored from 0 to 4: 0 and fasting plasma glucose (FPG)
in a sextant, the adjacent tooth was (normal), 1 (gingivitis with bleed- were measured in an automatic
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Hypertension and periodontitis 1001

analyser using commercially avail-
able enzymatic assay kits (1470
Wizard; PerkinElmer, Wallac:
Waltham, Massachusetts, USA).
Hypercholesterolaemia was defined
as having TC over 240 mg/dl or
medicated for hypercholesterolaemia.
Diabetes was defined as FPG over
126 mg/dl or medicated for diabetes,
according to the WHO criteria
(WHO, 2006).
Statistical analyses
In sequential analyses, the hyperten-
sion variable of Model III was sub-
stituted with ternary SBP and DBP
variables to test for the association
of these components with periodon-
titis individually in SBP and DBP
models. The ternary SBP and DBP
variables adopted the diagnostic cri-
teria as suggested by the JNC7
report (Chobanian et al. 2003): SBP
cut-offs were 120 and 140 mmHg
while those of DBP were 80 and
90 mmHg for pre-hypertensive and
hypertensive criteria respectively.
The hypertensive SBP and DBP cat-
egories included those individuals
medicated for hypertension.
Evaluation of the interaction
effects between hypertension and
confounders on the association of
hypertension with periodontitis were
performed for drinking, smoking,
exercise, obesity and diabetes vari-
ables.
Finally, to investigate high-
risk group of the link between

In the analysis, the outcome variable

was periodontitis and the main
explanatory variable was hyperten- Table 2. Adjusted association of hypertension with periodontitis (CPI 3–4) in multiple
sion status. Summary statistics of models (n = 14,625)
the population characteristics were Variable N Prevalence ratio (95% confidence interval)
calculated as frequencies and per-
centages. Any statistically significant Model I Model II Model III
differences between the periodontitis
Hypertension
positive and negative groups, in
Normal 6942 1 1 1
terms of the socio-economic, beha- Pre-hypertension 3573 1.10 (1.04–1.16) 1.10 (1.04–1.16) 1.09 (1.03–1.15)
vioural and health-related factors, Hypertension 4110 1.12 (1.07–1.18) 1.13 (1.07–1.19) 1.10 (1.04–1.16)
were examined using chi-square test. Trend-p < 0.001 Trend-p < 0.001 Trend-p = 0.001
Multiple multivariate Poisson Age (years)
regression models were applied to 19–29 2010 1 1 1
evaluate the adjusted prevalence 30–39 3107 2.90 (2.43–3.45) 2.85 (2.39–3.39) 2.84 (2.38–3.38)
ratios (PRs) of the association of 40–49 3048 5.32 (4.50–6.28) 5.26 (4.45–6.22) 5.22 (4.42–6.16)
hypertension with periodontitis while 50–59 2557 6.87 (5.82–8.11) 6.82 (5.77–8.05) 6.72 (5.69–7.93)
adjusting for potential confounders. ≥60 3903 6.71 (5.68–7.93) 6.62 (5.60–7.82) 6.53 (5.52–7.72)
Trend-p < 0.001 Trend-p < 0.001 Trend-p < 0.001
Model I was adjusted for socio-
Sex
economic variables including age Female 8378 1 1 1
group, sex and household income. Male 6247 1.43 (1.38–1.50) 1.13 (1.15–1.30) 1.23 (1.15–1.30)
Model II was adjusted for socio-eco- Household income
nomic variables and health-related Lowest quartile 2811 1 1 1
behavioural variables including Lower middle quartile 3645 1.00 (0.94–1.06) 1.01 (0.95–1.07) 1.01 (0.95–1.06)
drinking, smoking and physical Upper middle quartile 4032 0.95 (0.90–1.01) 0.96 (0.91–1.02) 0.96 (0.91–1.02)
activity. Model III and the final Highest quartile 4137 0.80 (0.75–0.86) 0.82 (0.77–0.88) 0.82 (0.77–0.88)
model, was adjusted for all the Trend-p < 0.001 Trend-p < 0.001 Trend-p < 0.001
Drinking
aforementioned variables and sys-
Never 2003 1 1
temic health-related variables includ- Ever in lifetime 12,622 0.99 (0.93–1.05) 0.99 (0.93–1.05)
ing obesity, hypercholesterolaemia Smoking
and diabetes. For each model, the Never 8626 1 1
adjusted PRs, confidence intervals Ever in lifetime 5999 1.25 (1.18–1.33) 1.25 (1.18–1.33)
(CI) and the trend p-values for mul- Physical activity
ti-category variables were calculated. None 9699 1 1
In accordance with the age group ≥1 day/week 4926 0.96 (0.92–1.01) 0.96 (0.92–1.01)
and sex-stratified design of Obesity
KNHANES sampling (KCDC, Non-obese 9954 1
Obese 4671 1.05 (1.01–1.10)
2009), age group (five groups: 19–29,
Hypercholesterolaemia
30–39, 40–49, 50–59 or over No 13,037 1
60 years) and sex-stratified analyses Yes 1588 1.03 (0.97–1.09)
were performed both individually Diabetes
and in combination to adjust for the Non-diabetic 13,293 1
residual decrease in p-value due to Diabetic 1332 1.10 (1.04–1.16)
the big sample size of over 10,000.
Model I: adjusted for socio-economic factors including age group, sex and household
For the age and sex groups in income. Model II: adjusted for all variables in Model I and behavioural factors including
which the association of hyperten- drinking, smoking and physical activity. Model III: adjusted for all variables in Model II
sion with periodontitis was found and systemic health-related factors including obesity, hypercholesterolaemia and diabetes
significant, PRs for periodontitis was mellitus.
estimated using the same Model III. Bold denotes statistical significance at p < 0.05.

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
1002 Ahn et al.

hypertension and periodontitis,
stratified analyses by economic,
behavioural and systemic factors
were performed using the Model
III in the subgroup of females aged
30–59 years in which significant
association was found. Stratification
groups were as follows: (1) income
quartiles, (2) physical activity (two
groups: none or ≥1 day per week),
(3) drinking (two groups: never or
ever in lifetime), (4) smoking (two
groups: never or ever in lifetime),
(5) obesity (two groups: non-obese
or obese), (6) hypercholesterolaemia
(two groups: normal or hyperc-
holesterolemia) and (7) diabetes
mellitus (two groups: normal or
diabetic).
For the analyses, statistical signif-
icance was set at p-values < 0.05.
Results
General characteristics
Compared to the participants with-
out periodontitis, those with peri-
odontitis were significantly older
and more represented by males,
smokers, never drinkers and indi-
viduals with lower household
income (Table 1). Higher prevalence
of obesity, hypercholesterolaemia,
diabetes, pre-hypertension, hyper-
tension and higher SBP and DBP
was observed among individuals
with periodontitis.
Age group and sex-stratified association
of hypertension with periodontitis
The link of hypertension on peri-
odontitis was highlighted in the fol-
lowing age and sex groups (Table 3):
40–49 years group (PR = 1.13; 95%
CI: 1.00–1.28) and females (PR =
1.19; 95% CI: 1.09–1.29). The asso-
ciation was strongest in the 30–39
years group (PR = 1.64; 95% CI:
1.08–2.48), which gradually
decreased with increasing age to
reach the null in the over 60 years
group (PR = 1.10; 95% CI: 0.97–
1.24). For the 19–29 years female
group, the PR of hypertension could
not be estimated due to the small
sample size of 19.
Relationship between hypertension, high
SBP and high DBP and periodontitis in
females aged 30–59 years
In females aged 30–59 years
(n = 5010), the association of hyper-
tension with periodontitis was stron-
ger than that of total population
(Fig. 1). The fully adjusted PR was
1.13 (95% CI: 1.01–1.26) for pre-
hypertension and 1.25 (95% CI:
1.11–1.40) for hypertension with a
dose–response relationship (trend
Table 3. Age and sex-stratified adjusted association of hypertension with periodontitis (CPI
3–4) (n = 14,625)
Stratum N Prevalence ratio (95% confidence interval)
Normal
p < 0.001). Increasing SBP and DBP
also showed independent association
with periodontitis (PR: 1.24; 95%
CI: 1.10–1.39 for hypertensive SBP
and PR: 1.25; 95% CI: 1.11–1.40 for
hypertensive DBP) with a dose–
response relationship (trend p < 0.001)
for both models.
Effect of interaction terms between
hypertension and confounders in females
aged 30–59 years
The interaction effect between
hypertension and confounders on
the association of hypertension with
periodontitis was not significant for
drinking, smoking, physical activity,
obesity or diabetes in females aged
30–59 years. However, the fully
adjusted PR was increased from
1.25 (95% CI: 1.11–1.40) to 1.40
(95% CI: 1.11–1.77) for interaction
with drinking and 1.34 (95% CI:
1.16–1.55) for interaction with
obesity.
Stratified association of hypertension with
periodontitis in females aged 30–59 years
In terms of socio-economic and
health-related factors, the link of
Pre-hypertension Hypertension†

Age (years)
Relationship between hypertension and 19–29 2010 1 1.30 (0.85–1.97) 0.76 (0.30–1.94)
periodontitis 30–39 3107 1 0.89 (0.74–1.06) 1.00 (0.79–1.26)
Hypertension was consistently asso- 40–49 3048 1 1.14 (1.02–1.27) 1.13 (1.00–1.28)
50–59 2557 1 1.10 (1.00–1.22) 1.09 (0.99–1.20)
ciated with periodontitis throughout
≥60 3903 1 1.05 (0.96–1.15) 1.08 (0.99–1.17)
the adjustment process in Models I, Sex
II and III with a dose–response rela- Female 8378 1 1.15 (1.05–1.25) 1.19 (1.09–1.29)
tionship (Table 2). The positive asso- Male 6247 1 1.01 (0.94–1.08) 1.00 (0.93–1.07)
ciation of pre-hypertension and Age and sex
hypertension with periodontitis 19- to 29-year-old female 1142 1 2.19 (1.25–3.84) –
found in the age-, sex- and income- 30- to 39-year-old female 1813 1 0.94 (0.68–1.31) 1.64 (1.08–2.48)
adjusted Model I was consistent in 40- to 49-year-old female 1735 1 1.10 (0.91–1.32) 1.34 (1.10–1.63)
Model II, which was further 50- to 59-year-old female 1462 1 1.17 (1.00–1.36) 1.18 (1.02–1.36)
≥60-year-old female 2226 1 1.08 (0.94–1.25) 1.10 (0.97–1.24)
adjusted for lifestyle variables. In the
19- to 29-year-old male 868 1 0.95 (0.57–1.59) 0.89 (0.34–2.33)
final Model III, after the inclusion of 30- to 39-year-old male 1294 1 0.84 (0.68–1.03) 0.87 (0.67–1.13)
obesity, hypercholesterolaemia and 40- to 49-year-old male 1313 1 1.12 (0.98–1.28) 1.02 (0.88–1.18)
diabetes variables, the strength of 50- to 59-year-old male 1095 1 1.04 (0.91–1.18) 1.00 (0.88–1.13)
the association of hypertension with ≥60-year-old male 1677 1 1.03 (0.91–1.16) 1.05 (0.94–1.17)
periodontitis was slightly attenuated,
nonetheless, remained significant Prevalence ratios are adjusted for age groups, sex, household income, drinking, smoking,
physical activity, obesity, hypercholesterolaemia and diabetes except the stratum.
(PR = 1.09; 95% CI: 1.03–1.15 for †
Hypertension: either SBP ≥ 140 mmHg or DBP ≥ 90 mmHg or medicated for hyperten-
pre-hypertension; PR = 1.10; 95% sion; pre-hypertension: 120 ≤ SBP < 140 mmHg or 80 ≤ DBP < 90 mmHg; normal:
CI: 1.04–1.16 for hypertension; SBP < 120 mmHg and DBP < 80 mmHg.
trend-p = 0.001). Bold denotes statistical significance at p < 0.05.

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Hypertension and periodontitis 1003

Fig. 1. Adjusted association of hypertension, systolic and diastolic blood pressure (SBP and DBP) with periodontitis (CPI 3–4) in
females aged 30–59 years (n = 5010): (a) prevalence ratio (PR) of hypertension on periodontitis; (b) PR of SBP on periodontitis; (c)
PR of DBP on periodontitis. Adjusted PRs are controlled for age group, sex, household income, drinking, smoking, physical activ-
ity, obesity, hypercholesterolaemia and diabetes mellitus. Diamond denotes PR and bar denotes 95% confidence interval. Diamond
with value 1 represents the reference. Bold denotes statistical significance at p < 0.05.

hypertension on periodontitis in
females aged 30–59 years was high-
lighted in the following subgroups
(Table 4): lower middle income
quartile (PR = 1.71; 95% CI: 1.25–
2.33), highest income quartile
(PR = 1.29 (1.01–1.65; 95% CI:
1.01–1.65), never drinker (PR = 1.51;
95% CI: 1.16–1.98), never smoker
(PR = 1.27; 95% CI: 1.12–1.43),
physically active (PR = 1.33; 95%
CI: 1.06–1.66), non-obese (PR =
1.32; 95% CI: 1.14–1.53), hyperc-
holesterolaemia (PR = 1.68; 95% CI:
1.23–2.29) and non-diabetes (PR =
1.28; 95% CI: 1.13–1.44). Also, the
link of pre-hypertension on peri-
odontitis was highlighted in the fol-
lowing subgroups: lower middle
income quartile (PR = 1.30; 95% CI:
1.07–1.58), never drinker (PR = 1.31;
95% CI: 1.02–1.70) and non-diabetes
(PR = 1.14; 95% CI: 1.02–1.28).
Discussion
Our results demonstrated that hyper-
tension is associated with periodonti-
tis among Korean female adults,
independent of the effects of age,
sex, income, drinking, smoking,
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
physical activity, obesity, hyperc-
holesterolaemia and diabetes, based
on a Korean national data. To the
best of our knowledge, this study
presents the first evidence that
hypertension is associated with high
prevalence of periodontitis in mid-
dle-aged females.
The major strengths of our study
are fourfold. First, the KNHANES
data used for this study are a large-
scale national survey of representa-
tive Korean population. Second, we
used the Poisson model and
reported PRs instead of odds ratio.
The frequently used odds ratios
from logistic regression analysis
overestimate the PR. PRs are the
measure of choice in the analysis of
cross-sectional survey data and pro-
vide more robust results (Barros &
Hirakata 2003). Third, currently
known confounders of periodontitis
have shown statistically significant
independent association with peri-
odontitis in our data, hence corrob-
orating our data reliable. Finally,
the association of hypertension with
periodontitis was assessed by age
group and sex-stratified analyses to
minimize the residual false-positive
effect as a result of the decreased
standard error due to the large sam-
ple greater than 10,000.
The findings of our study high-
light the importance of female sex in
the relationship between hyperten-
sion and periodontal disease.
Females have higher risk of develop-
ing CVD than males (Appelman
et al. 2015). Females may have lower
threshold blood pressure for devel-
oping peripheral vascular diseases,
possibly due to the female-specific
higher prevalence of arterial stiffness
(Coutinho 2014). The higher suscep-
tibility of females to peripheral vas-
cular disease at lower blood pressure
could contribute to the higher preva-
lence of hypertension-related peri-
odontal disease in females. Further
studies are needed to clarify the
underlying mechanisms of this phe-
nomenon.
Interestingly, the association of
hypertension with periodontitis in
females was highlighted in younger
age group. The chronic nature of
periodontitis and hypertension
means that a period of time is
required for the risk factors to con-
tribute to the development of these
1004 Ahn et al.

Table 4. Stratified association of hypertension with periodontitis (CPI 3–4) in females aged reduced blood supply to periodontal
30–59 years (n = 5010) tissues could lead to increased sus-
Variable N Prevalence ratio (95% confidence interval) ceptibility to periodontal inflamma-
tion (Higashi et al. 2008). In
Category Normal Pre-hypertension Hypertension† addition, hypertension contributes to
systemic diseases such as metabolic
Household income syndrome which are risk factors for
Lowest quartile 501 1 1.25 (0.95–1.63) 1.10 (0.83–1.45) periodontitis (Kim et al. 2010, Han
Lower middle quartile 1217 1 1.30 (1.07–1.58) 1.48 (1.22–1.80)
et al. 2012a).
Upper middle quartile 1628 1 0.94 (0.76–1.17) 1.13 (0.90–1.41)
Highest quartile 1664 1 1.10 (0.88–1.37) 1.29 (1.01–1.65)
In the stratified analyses, those
Drinking with hypercholesterolaemia, lower
Never 710 1 1.31 (1.02–1.70) 1.51 (1.16–1.98) middle income, highest income and
Ever in lifetime 4300 1 1.09 (0.97–1.23) 1.20 (1.05–1.36) never drinking, never smoking, phys-
Smoking ically active, non-obese and non-dia-
Never 4510 1 1.13 (1.01–1.27) 1.27 (1.12–1.43) betic showed highlighted association
Ever in lifetime 500 1 1.13 (0.83–1.54) 1.11 (0.81–1.52) between hypertension and periodon-
Physical activity titis. Alcohol drinking, smoking,
None 3485 1 1.09 (0.96–1.24) 1.22 (1.07–1.39) non-exercise, obesity and diabetes
≥1 day/week 1525 1 1.22 (0.99–1.50) 1.33 (1.06–1.66)
Obesity
are well-known confounders (Tsiou-
Non-obese 3653 1 1.09 (0.95–1.25) 1.32 (1.14–1.53) fis et al. 2011) of the relationship
Obese 1357 1 1.16 (0.97–1.40) 1.18 (0.99–1.41) between hypertension and periodon-
Hypercholesterolaemia titis. Since periodontitis is a multi-
No 4532 1 1.12 (0.99–1.26) 1.19 (1.04–1.35) factorial disease, when the
Yes 478 1 1.37 (0.96–1.95) 1.68 (1.23–2.29) confounding effects of the risk fac-
Diabetes tors are removed, the link between
No 4761 1 1.14 (1.02–1.28) 1.28 (1.13–1.44) hypertension and periodontitis
Yes 249 1 0.85 (0.58–1.26) 1.04 (0.74–1.46) becomes highlighted. Since highest
Prevalence ratios are adjusted for age group, household income, drinking, smoking, physical income group are usually less
activity, obesity, hypercholesterolaemia and diabetes except the stratum. exposed to common risk factors, the
†
Hypertension: either SBP ≥ 140 mmHg or DBP ≥ 90 mmHg or medicated for hyperten- effect of hypertension on periodonti-
sion; pre-hypertension: 120 ≤ SBP < 140 mmHg or 80 ≤ DBP < 90 mmHg; normal: tis would be emphasized in this
SBP < 120 mmHg and DBP < 80 mmHg. group. The link of association
Bold denotes statistical significance at p < 0.05 and prevalence ratios greater than 1.13 for between hypertension and periodon-
pre-hypertension or 1.25 for hypertension. titis was also highlighted in females
with lower middle income. Consider-
ing that prevalence of hypertension
chronic diseases. The exposure time 2012). Therefore, the relatively lower in Korean female adults is highest in
to the risk factors in younger indi- level of female sex hormones in old the lower middle income group
viduals is considerably shorter than women could mean highlighted (26.3%) (KCDC, 2014), further
that in the older. As such, the longer effect of common risk factors of studies are needed to clarify the link.
exposure time to the common risk periodontitis and hypertension. Fur- Moreover, our data support the
factors for periodontitis and hyper- ther studies including sex hormones previous report that high blood
tension in older women means that and immune functions will clarify pressure is associated with high
the contribution of hypertension on the link. prevalence of periodontitis among
the development of periodontitis The mechanism of how hyperten- individuals with hypercholestero-
could be masked by the influence of sion induces periodontitis remains laemia (Franek et al. 2009, 2010,
these common risk factors. There- largely unknown. A possible linkage Vieira et al. 2011).
fore, high blood pressure in younger between hypertension and periodon- Our study has some limitations.
women may have played a more sig- titis is inflammation (Bonato et al. Owing to the limitations of the
nificant role in developing periodon- 2012). Both diseases are chronic cross-sectional design of the survey,
titis than that in older women. inflammatory diseases and are asso- no inference on the causality could
Similarly, the association of hyper- ciated with oxidative stress and pro- be made. Also, as the KNHANES
tension with periodontitis was gener- inflammatory cytokines (Han et al. employs CPITN index as a peri-
ally highlighted in never drinkers, 2012b, 2013). Systemic circulation of odontal assessment tool, our
never smokers and physically active, theses inflammatory products could periodontitis cases could have been
non-obese and non-diabetic individu- play a part in the link between underestimated. This could be a
als who were less exposed to these hypertension and periodontitis. non-differential bias and could have
common risk factors. Moreover, sev- Increased peripheral resistance, mea- diluted the estimated association.
eral female sex hormones including sured by pulse wave velocity was Notwithstanding these limitations,
oestrogen, progesterone and pro- also associated with periodontitis the results of our study are reliable
lactin influence the development of T (Shanker et al. 2013). Endothelial enough to test the hypothesis that
and B cells, the major players of cel- dysfunction caused by elevated high blood pressure is associated
lular immune response (Pennell et al. blood pressure and the subsequent with periodontitis.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Overall, hypertension was associ-
ated with higher prevalence of peri-
odontitis among middle-aged
Korean females independent of
known confounders. Dentists should
take precautions for individuals with
hypertension to prevent and control
for periodontitis. Further research is
indicated to confirm this association
in other ethnic population. Also,
studies with prospective or experi-
mental design will aid the clarifica-
tion of the causality and mechanism
of this link.
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Address:
Hyun-Duck Kim
Department of Preventive and Social
Dentistry
School of Dentistry
Seoul National University
Yeongun-dong, Jongno-gu
Seoul110-749
Korea
E-mail: hyundkim@snu.ac.kr
needs to be confirmed in different
ethnic populations. Nonetheless,
periodontists may incorporate
blood pressure screening into regu-
lar dental checkups to help identify
patients with higher risk of peri-
odontitis.