Original Article
Relationship Between Prehypertension/Hypertension and
Periodontal Disease: A Prospective Cohort Study
Yuya Kawabata,1 Daisuke Ekuni,1 Hisataka Miyai,1 Kota Kataoka,1 Mayu Yamane,1
Shinsuke Mizutani,1 Koichiro Irie,1 Tetsuji Azuma,1 Takaaki Tomofuji,1,2 Yoshiaki Iwasaki,3 and
Manabu Morita1
BACKGROUND
Most cross-sectional studies have found a significant positive relation-
ship between periodontal disease and prehypertension/hypertension.
However, these studies had limitations and there are few prospective
cohort studies in young adults. The purpose of this prospective cohort
study was to investigate whether periodontal disease was related to
prehypertension/hypertension in Japanese university students.
METHODS
Students (n  =  2,588), who underwent health examinations before
entering university and before graduation, were included in the analy-
sis. The association between periodontal disease such as the percent-
age of bleeding on probing (BOP) and community periodontal index
(CPI) scores, and change in blood pressure status was determined.
RESULTS
At the reexamination, the numbers of participants with prehyperten-
sion (systolic blood pressure 120–139 mm Hg or diastolic blood pres-
sure 80–89 mm Hg) and hypertension (≥140/90 mm Hg) were 882
Hypertension is a major cause of premature death and dis-
ability in the world mainly as a result of cardiovascular
disease including coronary heart disease and stroke and
other vascular diseases.1 Hypertension is also highly preva-
lent affecting about 30% of adults as reported by the World
Health Organization and the prevalence of hypertension
in the Western Pacific and South-East Asian regions range
from 5 to 47% in men and 7 to 38% in women.2 In addition
to many dietary and lifestyle factors including smoking and
alcohol consumption,3–5 the role of chronic inflammation
has been implicated in the etiology of hypertension.6
Periodontal disease is one of the most widespread chronic
diseases and a highly prevalent chronic inflammatory con-
dition associated with an increase in circulating levels of
inflammatory biomarkers.7 Most cross-sectional studies
have found significant positive relationships between peri-
odontal disease, blood pressure, and possibly hyperten-
sion.8–17 However, these studies have limitations and vary in
Correspondence: Daisuke Ekuni (dekuni7@md.okayama-u.ac.jp).
Initially submitted April 13, 2015; date of first revision April 29, 2015;
accepted for publication June 26, 2015; online publication July 23, 2015.
388  American Journal of Hypertension  29(3)  March 2016
(34.1%) and 109 (4.2%), respectively. In a logistic regression model, the
risk of hypertension was significantly associated with male (odds ratio
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(OR): 6.31; 95% confidence interval (CI): 2.63–15.13; P < 0.001), no habit-
ual physical activity at baseline (OR: 2.90; 95% CI: 1.56–5.38; P < 0.01)
and periodontal disease defined as the presence of both probing
pocket depth (PPD) ≥ 4 mm and BOP ≥ 30% at baseline (OR: 2.74; 95%
CI: 1.19–6.29; P = 0.02) in participants with prehypertension at baseline.
On the other hand, the risk of prehypertension was not associated with
presence of periodontal disease (OR: 0.93; 95% CI: 0.51–1.70; P = 0.82).
CONCLUSION
In the short-term prospective cohort study, a significant associa-
tion between presence of periodontal disease and hypertension was
observed in Japanese university students.
Keywords: blood pressure; cohort studies; hypertension; periodontal
disease; university students.
doi:10.1093/ajh/hpv117
design, participants, and definition of periodontal disease.
A review also points out that prospective cohort studies are
needed to determine the impact of periodontitis on blood
pressure regulation and incident hypertension.18 Only 2 pro-
spective cohort studies have been conducted so far, and their
findings varied.19,20 These studies were carried out among
adult and elderly participants, and there are few studies that
assessed the relationship between hypertension and peri-
odontal disease in young adults.
It is important to evaluate the relationship between hyper-
tension and periodontal disease in young adults, as control
of the risk factors for hypertension at an early stage is essen-
tial to prevent its occurrence. Furthermore, since prehyper-
tension predicts an increased risk for the development of
hypertension and confers an increased risk for cardiovascu-
lar events,21,22 we focused on not only hypertension but also
prehypertension. We hypothesized that presence of peri-
odontal disease may predict prehypertension/hypertension
1Department of Preventive Dentistry, Okayama University Graduate
School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama,
Japan; 2Advanced Research Center for Oral and Craniofacial Sciences,
Okayama University Dental School, Okayama, Japan; 3Health Service
Center, Okayama University, Okayama, Japan.
© American Journal of Hypertension, Ltd 2015. All rights reserved.
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in young adults. The aim of the present prospective cohort
study was to explain the relationship between prehyperten-
sion/hypertension and periodontal disease in university
students.
METHODS
Study population
Of first-year students (n  =  4,516) who underwent both
general health and oral examinations (preuniversity) at
the Health Service Center of Okayama University in April
2010 or 2011, 3,011 students volunteered to receive a 3-year
follow-up examination before graduation in April 2013 or
2014 (follow-up rate; 66.7%). The participants included in
the study had no self-reported history of hypertension and
no medication history. After excluding participants who
were ≥30 years old (n = 14) and who did not complete ques-
tionnaires (n = 409), data from 2,588 students (1,278 males,
1,310 females) aged 18.2 ± 0.7 years (range, 18–27 years) were
analyzed. The study was approved by the Ethics Committee
of Okayama University Graduate School of Medicine,
Dentistry and Pharmaceutical Sciences (No. 1039). Written
consent was obtained from all participants.
Assessment of resting blood pressure
Hypertension was defined by systolic blood pressure
≥140 mm Hg or diastolic blood pressure ≥90 mm Hg, mean-
while prehypertension was defined by systolic blood pres-
sure 120–139 mm Hg or diastolic blood pressure 80–89 mm
Hg.22 Peripheral blood pressure of the upper arm as well as
heart rate was obtained by using an automatic oscillomet-
ric device (BP-203RVII; Omron, Tokyo, Japan) in accord-
ance with the Japanese Society of Hypertension guidelines
for blood pressure monitoring and the American Heart
Association recommendations.23 Briefly, under the super-
vision of public nurses, the participants sat in a chair with
their legs uncrossed and their feet flat on the floor. They were
instructed to avoid talking during the procedure and to posi-
tion the upper arm at their heart level. Single resting blood
pressure measurement was obtained. A  second or third
measure was taken if blood pressure values were greater than
140/90 mm Hg. The mean values of the 2 or 3 measurements
on each blood pressure recording were calculated and used
in the results presented here.
Assessment of body mass index
During the general health examination, the participant’s
height and body weight were measured by public health
nurses using Tanita body fat analyser (Model No. BF-220;
Tanita, Tokyo, Japan).24 Body mass index (BMI) was com-
puted as weight in kilograms divided by the square of height
in meters. Categories of BMI were determined based on the
accepted cutoff values of underweight (BMI < 18.5 kg/m2),
normal weight (18.5–24.9 kg/m2), overweight (25–29.9 kg/
m2), and obesity (≥30 kg/m2)25 and were used to represent
body composition. However, since the number of obese
Hypertension and Periodontal Disease
participants was too low, we combined overweight and obe-
sity for the analysis.
Oral examination
Six dentists (D.E., K.K., K.I., M.Y., S.M., and T.A.) exam-
ined the oral health status of the subjects. The teeth present
were counted. Periodontal condition was assessed using
the community periodontal index (CPI).26 Ten teeth were
selected for periodontal examination: 2 molars in each pos-
terior sextant, and the upper right and lower left central inci-
sors. Measurements were made using a CPI probe (YDM,
Tokyo, Japan) at 6 sites (mesio-buccal, mid-buccal, disto-
buccal, disto-lingual, mid-lingual, and mesio-lingual) per
tooth. The percentage of teeth exhibiting bleeding on prob-
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ing (%BOP: number of BOP-positive teeth per total number
of teeth) was calculated. BOP is an earlier and more sensitive
indicator of inflammation than visual signs of inflammation
(redness and swelling).27 Thus, we also assessed %BOP as
an indicator of periodontal disease in this study.26 Levels of
dental plaque and calculus were assessed using the simpli-
fied oral hygiene index.28 Good intra- and inter-examiner
agreement was achieved for repeated probing pocket depth
(PPD) measurements in the 10 teeth used for CPI (kappa
statistic >0.8).
Questionnaire
A questionnaire was used to assess general and oral health
behavior. In addition to gender, age, and general health con-
dition, the questionnaire included the following items: (i)
frequently consuming fatty foods (yes/no); (ii) frequently
eating green vegetables (yes/no); (iii) frequently eating
sweets (yes/no); (iv) frequently drinking (sugar-sweetened)
soft drinks (yes/no); (v) habitual physical activity (everyday/
sometimes/never); (vi) habitual drinking of alcohol (every-
day/sometimes/never); (vii) smoking status (current/past/
never); (viii) daily frequency of tooth brushing (1/2/≥3); (ix)
use of dental floss (yes/no); and (x) regular visits to dental
clinics for checkups once or more a year (yes/no).29–31 Since
the numbers of participants who drink alcohol everyday and
get physical activity everyday were too low, we combined the
2 categories “everyday” and “sometimes” for the analysis.
There were no past smokers in this study.
Statistical analysis
Because we considered that both prehypertension and
hypertension were important for young adults to keep their
health, 3 subgroup analyses were performed: (i) a change
from normal blood pressure to prehypertension/hyperten-
sion during 3  years, (ii) a change from prehypertension to
hypertension during 3 years, and (iii) keeping hypertension
during 3 years.
Periodontal disease was defined using 2 criteria: (i) pres-
ence of PPD ≥ 4 mm (CPI score  =  3 or 4)24 or (ii) pres-
ence of PPD ≥ 4 mm and BOP ≥ 30% (active periodontal
pocket).32 We selected these 2 categories in order to avoid
underestimation.
American Journal of Hypertension  29(3)  March 2016  389
Kawabata et al.

Paired t, unpaired t, and chi-square tests were used to
determine whether there were any significant differences
between baseline and reexamination or 2 groups accord-
ing to blood pressure category. Using a logistic regression
model, both odds ratio (OR) and 95% confidence interval
(CI) were calculated. Change to prehypertension/hyper-
tension during the 3-year follow-up was used as a depend-
ent variable. Age, gender, smoking status, BMI, frequently
consuming fatty foods, number of teeth present, simplified
oral hygiene index, and the presence of periodontal disease
at baseline were added as independent variables in the mul-
tivariate analysis. We also performed multiple imputation
with 5 different values for handling missing data. A statisti-
cal program (PASW version 18.0; IBM, Tokyo, Japan) was
used for statistical analyses.
prehypertension/hypertension groups at the follow-up. In
participants with prehypertension at baseline, there were
significant differences in the gender (P < 0.001), number
of subjects frequently consuming fatty foods (P  =  0.04),
and habitual physical activity (P  <  0.01) between the
normal blood pressure/prehypertension and hyperten-
sion groups at the 3-year-follow up. In participants with
hypertension at baseline, there was only a significant dif-
ference in the heart rate (P = 0.01) between normal blood
pressure/prehypertension and hypertension groups at the
3-year follow-up.
In the logistic regression analyses, the risk of having prehy-
pertension/hypertension after 3 years was significantly asso-
ciated with “male” (OR: 4.03; 95% CI: 2.95–5.49; P < 0.001)
and “overweight” (OR: 2.72; 95% CI: 1.06–7.00; P = 0.04) at

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RESULTS
The blood pressure and body mass values of the 2,588
participants at baseline and follow-up are shown in Table 1.
There were significant differences in both systolic and dias-
tolic blood pressure values between baseline and follow-up
(P < 0.001). The number of participants with prehyperten-
sion/hypertension significantly decreased after the 3-year-
follow-up (P < 0.001).
Table  2 shows the characteristics at baseline based
on blood pressure. Among participants with normal
blood pressure at baseline (n  =  1,287), there were sig-
nificant differences in the gender (P  <  0.001), BMI cat-
egory (P  <  0.01), number of teeth present (P  =  0.01),
simplified oral hygiene index (P  =  0.02), and BOP cat-
egory (P = 0.04) between the normal blood pressure and
baseline in the participants with normal blood pressure at
baseline (Table  3). However, there was no significant rela-
tionship between periodontal disease and prehypertension/
hypertension after 3 years (Tables 3 and 4). In participants
with prehypertension at baseline, the risk of having hyper-
tension was significantly associated with “male” (OR: 6.31;
95% CI: 2.63–15.13; P  <  0.001) and “no habitual physical
activity” (OR: 2.90; 95% CI: 1.56–5.38; P < 0.01) at baseline
(Table  4). Furthermore, the risk of hypertension was sig-
nificantly associated with periodontal disease defined as the
presence of PPD ≥ 4 mm and BOP ≥ 30% (active periodontal
pocket) at baseline (OR: 2.74; 95% CI: 1.19–6.29; P = 0.02)
(Table 4). In participants with hypertension at baseline, the
risk of keeping hypertension was significantly associated
with “overweight” (OR: 2.41; 95% CI: 1.06–5.47; P = 0.04) at
baseline when periodontal disease was defined as presence
of PPD ≥ 4 mm (Table 3).

Table 1.  Participant characteristics (n = 2,588)

Parameters Baseline After 3 years P value

Systolic blood pressure (mm Hg) 120.0 ± 13.1a 115.8 ± 14.0 <0.001

Diastolic blood pressure (mm Hg) 72.2 ± 8.3 69.4 ± 9.2 <0.001
Heart rate (number) 82.6 ± 13.1 77.2 ± 13.4 <0.001
Body mass index (BMI) (kg/m2) 20.7 ± 2.8 20.9 ± 2.7 <0.001
Blood pressure category <0.001
  Normal blood pressure 1,287 (49.7)b 1,597 (61.7)
  (<120/80 mm Hg)
 Prehypertension 1,150 (44.4) 882 (34.1)
  (120–139/80–89 mm Hg)
 Hypertension 151 (5.8) 109 (4.2)
  (≥140/90 mm Hg)
BMI category 0.31
 Underweight 461 (17.8) 438 (16.9)
  (BMI < 18.5 kg/m2)
  Normal weight 1,956 (75.6) 1,971 (76.2)
  (BMI 18.5–24.9 kg/m2)
 Overweight 144 (5.6) 155 (6.0)
  (BMI 25–29.9 kg/m2)
 Obesity 27 (1.0) 24 (0.9)
  (BMI ≥ 30 kg/m2)

aMean ± SD. bn (%).

390  American Journal of Hypertension  29(3)  March 2016

 Table 2.  Relationship between prehypertension/hypertension and related factors

Prehypertension
Normal blood pressure (120–139/80–89 mm Hg) Hypertension
(<120/80 mm Hg) at baseline at baseline (≥140/90 mm Hg) at baseline
(n = 1,287) (n = 1,150) (n = 151)

Normal blood Normal blood

Normal blood Prehypertension/ pressure/ pressure/
pressure after hypertension after P value (χ2 prehypertension Hypertension P value (χ2 prehypertension Hypertension P value (χ2
3 years 3 years or unpaired after 3 years after 3 years or unpaired after 3 years after 3 years or unpaired
Parameters at baseline (n = 1,060) (n = 227) t test) (n = 1,094) (n = 56) t test ) (n = 103) (n = 48) t test)

Age (years) 18.2 ± 0.5a 18.2 ± 0.8 0.21 18.3 ± 0.7 18.2 ± 0.4 0.071 18.4 ± 1.0 18.9 ± 2.0 0.09
Male 263 (24.8)b 131 (57.7) <0.001 699 (63.9) 50 (89.3) <0.001 91 (88.3) 44 (91.7) 0.54
Heart rate (number) 79.6 ± 11.9 80.3 ± 11.1 0.45 84.8 ± 13.5 85.6 ± 14.2 0.66 88.7 ± 13.9 95.1 ± 15.3 0.01
Body mass index category <0.01 0.76 0.26
Underweight 250 (23.6) 33 (14.5) 166 (15.2) 7 (12.5) 3 (2.9) 2 (4.2)
Normal weight 796 (75.1) 186 (81.9) 835 (76.3) 43 (76.8) 70 (68.0) 26 (54.2)
Overweight 14 (1.3) 8 (3.5) 93 (8.5) 6 (10.7) 30 (29.1) 20 (41.7)
Frequently consuming fatty foods Yes 280 (26.4) 61 (26.9) 0.89 307 (28.1) 23 (41.1) 0.04 36 (35.0) 18 (37.5) 0.76
Frequently eating green vegetables Yes 744 (70.2) 168 (74.0) 0.25 706 (64.5) 36 (64.3) 0.97 67 (65.0) 34 (70.8) 0.48
Frequently eating sweets Yes 281 (26.5) 54 (23.8) 0.40 296 (27.1) 19 (33.9) 0.26 27 (26.2) 17 (35.4) 0.25
Frequently drinking (sweetened) soft drinks Yes 273 (25.8) 61 (26.9) 0.73 293 (26.8) 15 (26.8) 1.00 28 (27.2) 13 (27.1) 0.99
Habitual physical activity Yes 416 (39.2) 105 (46.3) 0.051 511 (46.7) 15 (26.8) <0.01 40 (38.8) 20 (41.7) 0.74
Habitual drinking Yes 52 (4.9) 18 (7.9) 0.07 47 (4.3) 3 (5.4) 0.70 6 (5.8) 1 (2.1) 0.31
Current smoker Yes 4 (0.4) 1 (0.4) 0.89 4 (0.4) 0 (0) 0.65 0 (0) 0 (0) —
Number of teeth present 28.2 ± 1.3 28.5 ± 1.4 0.01 28.6 ± 1.4 28.5 ± 1.2 0.60 28.6 ± 1.4 29.1 ± 1.5 0.06
Oral hygiene index-simplified 0.6 ± 0.5 0.7 ± 0.6 0.02 0.7 ± 0.5 0.7 ± 0.5 0.81 0.8 ± 0.9 0.8 ± 0.5 0.82
Percentage of bleeding on probing (BOP) 27.5 ± 27.1 30.0 ± 27.3 0.19 30.7 ± 27.0 29.8 ± 23.3 0.82 36.3 ± 28.1 34.8 ± 28.7 0.76
Presence of BOP ≥ 30% Yes 457 (43.1) 115 (50.7) 0.04 546 (49.9) 34 (60.7) 0.13 58 (56.3) 30 (62.5) 0.63
Presence of probing pocket depth ≥4 mm Yes 121 (11.4) 25 (11.0) 0.86 131 (12.0) 10 (17.9) 0.19 17 (16.5) 7 (14.6) 0.76
Presence of probing pocket depth ≥4 mm Yes 74 (7.0) 18 (7.9) 0.62 98 (9.0) 9 (16.1) 0.07 15 (14.6) 7 (14.6) 1.00
and BOP ≥ 30%
Brushing frequency (times/day) 3 129 (12.2) 26 (11.5) 0.95 97 (8.9) 6 (10.7) 0.10 8 (7.8) 2 (4.2) 0.71
2 774 (73.0) 168 (74.0) 784 (71.7) 33 (58.9) 70 (68.0) 34 (70.8)
1 157 (14.8) 33 (14.5) 213 (19.5) 17 (30.4) 25 (24.3) 12 (25.0)
Dental floss use Yes 51 (4.8) 13 (5.7) 0.57 48 (4.4) 4 (7.1) 0.33 3 (2.9) 1 (2.1) 0.77
Regular checkup Yes 232 (21.9) 55 (24.2) 0.44 215 (19.7) 15 (26.8) 0.19 16 (15.5) 9 (18.8) 0.62

aMean ± SD. bn (%).

American Journal of Hypertension  29(3)  March 2016  391

Hypertension and Periodontal Disease

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Kawabata et al.

Table 3.  Adjusted odds ratios and 95% CIs for prehypertension/hypertension when periodontal disease was defined as having probing
pocket depth ≥4 mm

Parameters Odds ratioa 95% CI P value

Normal blood pressure (<120/80 mm Hg) at baseline (n = 1,287)

Age 1.18 0.93–1.48 0.17
Gender Female 1
Male 4.03 2.95–5.49 <0.001
Current smoker No 1
Yes 1.49 0.15–14.79 0.73
Body mass index Normal weight 1
Underweight 0.52 0.34–0.78 <0.01

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Overweight 2.72 1.06–7.00 0.04
Frequently consuming fatty foods No 1
Yes 0.96 0.68–1.36 0.83
Habitual physical activity Yes 1
No 1.06 0.78–1.44 0.73
Number of teeth present 1.08 0.97–1.21 0.17
Oral hygiene index-simplified 1.24 0.94–1.65 0.13
Presence of probing pocket depth ≥4 mm No 1
Yes 0.95 0.54–1.56 0.83
Prehypertension (120–139/80–89 mm Hg) at baseline (n = 1,150)b
Age 0.21 0.35–1.26 0.21
Gender Female 1
Male 6.14 2.56–14.70 <0.001
Body mass index Normal weight 1
Underweight 0.77 0.33–1.77 0.53
Overweight 1.30 0.52–3.26 0.58
Frequently consuming fatty foods No 1
Yes 1.57 0.89–2.76 0.12
Habitual physical activity Yes 1
No 2.82 1.52–5.22 <0.01
Number of teeth present 0.88 0.71–1.08 0.20
Oral hygiene index-simplified 0.74 0.43–1.27 0.27
Presence of probing pocket depth ≥4 mm No 1
Yes 0.52 0.24–1.11 0.09
Hypertension (≥140/90 mm Hg) at baseline (n = 151)b
Age 1.28 0.99–1.64 0.06
Gender Female 1
Male 1.38 0.38–4.95 0.62
Body mass index Normal weight 1
Underweight 1.83 0.27–12.68 0.54
Overweight 2.41 1.06–5.47 0.04
Frequently consuming fatty foods No 1
Yes 1.27 0.60–2.72 0.53
Habitual physical activity Yes 1
No 0.92 0.44–1.93 0.82

392  American Journal of Hypertension  29(3)  March 2016


Table 3.  Continued
Parameters
Number of teeth present
Oral hygiene index-simplified
Presence of probing pocket depth ≥4 mm No
Yes
aAdjusted for age, gender, smoking status, body mass index, frequently consuming fatty foods, number of teeth present, oral hygiene index-
simplified, presence of probing pocket depth ≥4 mm. bSmoking status was omitted from independent variables because there was no current
smoker in the case.
DISCUSSION
Most cross-sectional studies have found significant posi-
tive relationships between periodontal disease, blood pres-
sure, and possibly hypertension.9–18 In the present study,
the numbers of participants with presence of PPD ≥ 4 mm
and BOP ≥ 30% in the normal blood pressure, prehyperten-
sion, and hypertension groups at baseline were 92 (7.1%),
107 (9.3%), and 22 (14.6%), respectively, with significant
difference between the groups (chi-square tests, P  <  0.01;
cross-sectional analysis). In this prospective study among
Japanese university students, the risk of having hypertension
after 3  years was significantly associated with periodontal
disease defined as the presence of PPD ≥ 4 mm and BOP
≥ 30% (active periodontal pocket) at baseline after adjust-
ing for confounding factors. Our results were supported by
a previous prospective cohort study among 1,023 Japanese
employees (mean age: 37.3 years, range: 20–56 years).19 The
results suggest that the presence of periodontal disease may
be a risk factor for developing hypertension in people with
prehypertension.
In another prospective cohort of 31,543 male profession-
als (dentists, pharmacists, optometrists, podiatrists, osteo-
paths, and veterinarians) aged 40–75  years in the United
States,20 there was no significant relationship between self-
reported periodontal disease at baseline and incident hyper-
tension during 20 years of follow-up.20 In contrast with the
previous report, our results showed a significant relationship
between the presence of periodontal disease and hyperten-
sion. The discrepancy between our study and the previous
study could possibly be explained by the difference in age
at baseline (18–27 vs. 40–75 years), follow-up period (3 vs.
20 years) and definition of periodontal disease (presence of
PPD ≥ 4 mm and BOP ≥ 30% vs. self-reported periodontal
disease).
Periodontal disease has been suggested as a risk factor for
stroke, coronary heart disease, peripheral arterial disease,
and hypertension.18,33,34 A  recent review suggests that the
causal relation has been considered to be both direct and
indirect, and there is a pathophysiological link of periodon-
titis to hypertension.18 Our results support the causal rela-
tionship between periodontal disease and hypertension. The
presence of periodontal disease defined as the presence of
PPD ≥ 4 mm and BOP ≥ 30% was associated with hyperten-
sion in this study. BOP is an earlier and sensitive indicator of
inflammation,27 and deepened PPD with BOP (+) increase
a risk of progression of periodontal disease.32 It should be
noted that progression of periodontal disease during these
Table 4. Continued
Hypertension and Periodontal Disease
Odds ratioa 95% CI P value
1.24 0.98–1.58 0.08
0.87 0.43–1.79 0.71
1
0.62 0.20–1.96 0.42
3  years may be associated with blood pressure, since peri-
odontal status can change during the 3-year university life.31
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In this study, the risk of having prehypertension/hyper-
tension after 3 years was significantly associated with over-
weight at baseline in the participants with normal blood
pressure (<120/80 mm Hg). A  previous study reports that
BMI is an independent and important predictor of blood
pressure among young individuals (25–55  years),35 which
supported our results. On the other hand, in participants
with prehypertension at baseline, the risk of having hyper-
tension was significantly associated with no habitual physi-
cal activity at baseline. The American Heart Relationship
promotes primordial prevention for keeping blood pressure
<120/80 mm Hg to achieve cardiovascular health.36 Taken
together, maintenance of normal weight and habitual physi-
cal activity are important factors for young adults in keep-
ing normal blood pressure and preventing hypertension and
future diseases.
Of 151 participants with hypertension at baseline, 48
participants (31.8%) still had hypertension in this study.
The risk of keeping hypertension was significantly associ-
ated with overweight at baseline when periodontal disease
was defined as the presence of PPD ≥ 4 mm. Weight loss is a
valuable treatment goal in hypertensive patients.37 Thus, we
should encourage participants with hypertension to improve
overweight during undergraduate days.
We focused on both prehypertension and hypertension,
and then 3 subgroup analyses were performed: (i) a change
from normal blood pressure to prehypertension/hyperten-
sion during 3  years, (ii) a change from prehypertension to
hypertension during 3 years, and (iii) having hypertension
during 3 years. Because only 5 participants developed hyper-
tension and 222 developed prehypertension from normal
blood pressure, we combined these 2 cases (the change to
prehypertension and that to hypertension). On the other
hand, when we used another definition, a change from
normal blood pressure/prehypertension to hypertension,
the risk of hypertension, was significantly associated with
periodontal disease defined as the presence of PPD ≥ 4 mm
and BOP ≥ 30% at baseline (OR: 2.63; 95% CI: 1.18–5.88;
P = 0.02), which also supported our hypothesis.
The present study had other limitations. First, blood
pressure was measured only one time if the value was lower
than 140/90 mm Hg, because of a limited amount of time
to measure it in our routine health screening. According
to the American Heart Association recommendation, a
minimum of 2 readings should be taken at intervals of at
least 1 minute, and the average of those readings should be
American Journal of Hypertension  29(3)  March 2016  393
Kawabata et al.

Table 4.  Adjusted odds ratios and 95% CIs for prehypertension/hypertension when periodontal disease was defined as having probing
pocket depth ≥4 mm and BOP ≥30%

Parameters Odds ratioa 95% CI P value

Normal blood pressure (<120/80 mm Hg) at baseline (n = 1,287)

Age 1.18 0.93–1.48 0.17
Gender Female 1
Male 4.03 2.96–5.49 <0.001
Current smoker No 1
Yes 1.49 0.15–14.87 0.73
Body mass index Normal weight 1
Underweight 0.52 0.34–0.78 <0.01

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Overweight 2.73 1.06–7.03 0.04
Frequently consuming fatty foods No 1
Yes 0.96 0.68–1.36 0.83
Habitual physical activity Yes 1
No 0.95 0.70–1.29 0.73
Number of teeth present 1.08 0.97–1.21 0.17
Oral hygiene index-simplified 1.25 0.93–1.70 0.14
Presence of probing pocket depth ≥4 mm No 1
Presence of BOP ≥30% Yes 0.93 0.51–1.70 0.82
Prehypertension (120–139/80–89 mm Hg) at baseline (n = 1,150)b
Age 0.67 0.36–1.26 0.21
Gender Female 1
Male 6.31 2.63–15.13 <0.001
Body mass index Normal weight 1
Underweight 0.79 0.34–1.80 0.56
Overweight 1.25 0.50–3.15 0.64
Frequently consuming fatty foods No 1
Yes 1.58 0.90–2.77 0.12
Habitual physical activity Yes 1
No 2.90 1.56–5.38 <0.01
Number of teeth present 0.88 0.72–1.08 0.22
Oral hygiene index-simplified 0.67 0.38–1.18 0.16
Presence of probing pocket depth ≥4 mm No 1
Presence of BOP ≥30% Yes 2.74 1.19–6.29 0.02
Hypertension (≥140/90 mm Hg) at baseline (n = 151)b
Age 1.27 0.99–1.63 0.06
Gender Female 1
Male 1.44 0.40–5.14 0.58
Body mass index Normal weight 1
Underweight 1.90 0.28–13.08 0.52
Overweight 2.21 0.99–4.96 0.053
Frequently consuming fatty foods No 1
Yes 1.29 0.61–2.76 0.51
Habitual physical activity Yes 1
No 0.92 0.43–1.93 0.82
Number of teeth present 1.24 0.97–1.57 0.08

394  American Journal of Hypertension  29(3)  March 2016


Table 4.  Continued
Parameters
Oral hygiene index-simplified
Presence of probing pocket depth ≥4 mm No
Presence of BOP ≥30% Yes
aAdjusted for age, gender, smoking status, body mass index, frequently consuming fatty foods, number of teeth present, oral hygiene index-
simplified, presence of probing pocket depth ≥4 mm and BOP ≥30%. bSmoking status was omitted from independent variables because there
was no current smoker in the case.
used to represent the blood pressure.23 Second, all partici-
pants were recruited from students at Okayama University.
This may limit the ability to extrapolate these findings to
the general population. Third, we should consider a selec-
tion bias, which may lead to over- or underestimation of
the true relationship since the follow-up rate (66.7%) was
low in this study. We performed multiple imputation with 5
different values, because, in recent years, multiple imputa-
tion has emerged as a methodology for handling missing
data. The trend of results was similar with original find-
ings. In the logistic regression analyses, the risk of having
hypertension after 3 years was significantly associated with
periodontal disease defined as the presence of PPD ≥ 4 mm
and BOP ≥ 30% (active periodontal pocket) at baseline in
the participants with prehypertension at baseline (OR: 2.52;
95% CI: 1.11–5.71; P = 0.03), which supported our conclu-
sion. However, there were statistically significant differences
in both systolic and diastolic blood pressure at baseline
between participants who were followed up in this study
and subjects who were not (120.0 ± 13.1 vs. 122.1 ± 13.6 mm
Hg and 72.3  ± 8.4 vs. 73.3  ± 8.8 
mm Hg, respectively)
(P  <  0.001). The participants who were followed up may
have been healthier than the whole population; therefore,
the results of this single study should be interpreted with
some caution. Fourth, the number of incident cases and the
total sample size of the study population were rather small
particularly in the short follow-up. In fact, the short follow-
up is potentially the major issue of why an association was
not found. Finally, we cannot deny the possibility that other
potential confounding factors, such as dietary salt intake38
and delayed heart rate recovery,39 may have affected the
observed relationships, because our study was combined
with routine health screening and the data obtained were
limited.
In conclusion, within the limitations of this short-term
prospective cohort study, a significant association between
the presence of periodontal disease and hypertension was
observed in Japanese university students.
ACKNOWLEDGMENTS
This study was self-supported.
DISCLOSURE
The authors declared no conflict of interest.
Hypertension and Periodontal Disease
Odds ratioa 95% CI P value
0.82 0.39–1.71 0.59
1 0.77
0.84 0.26–2.73 0.83
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