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Toothbrushing, inflammation, and risk of cardiovascular disease: results from Scottish Health Survey

BMJ 2010; 340 doi: (Published 27 May 2010) Cite this as: BMJ 2010;340:c2451
  1. Cesar de Oliveira, research fellow in epidemiology and public health,
  2. Richard Watt, professor and honorary consultant in dental public health,
  3. Mark Hamer, senior research fellow in epidemiology and public health
  1. 1Department of Epidemiology and Public Health, University College London, London WC1E 6BT
  1. Correspondence to: R Watt r.watt{at}
  • Accepted 12 April 2010


Objective To examine if self reported toothbrushing behaviour is associated with cardiovascular disease and markers of inflammation (C reactive protein) and coagulation (fibrinogen).

Design National population based survey.

Setting Scottish Health Survey, which draws a nationally representative sample of the general population living in households in Scotland.

Participants 11 869 men and women, mean age 50 (SD 11).

Main outcome measures Oral hygiene assessed from self reported frequency of toothbrushing. Surveys were linked prospectively to clinical hospital records, and Cox proportional hazards models were used to estimate the risk of cardiovascular disease events or death according to oral hygiene. The association between oral hygiene and inflammatory markers and coagulation was examined in a subsample of participants (n=4830) by using general linear models with adjustments.

Results There were a total of 555 cardiovascular disease events over an average of 8.1 (SD 3.4) years of follow-up, of which 170 were fatal. In about 74% (411) of cardiovascular disease events the principal diagnosis was coronary heart disease. Participants who reported poor oral hygiene (never/rarely brushed their teeth) had an increased risk of a cardiovascular disease event (hazard ratio 1.7, 95% confidence interval 1.3 to 2.3; P<0.001) in a fully adjusted model. They also had increased concentrations of both C reactive protein (β 0.04, 0.01 to 0.08) and fibrinogen (0.08, −0.01 to 0.18).

Conclusions Poor oral hygiene is associated with higher levels of risk of cardiovascular disease and low grade inflammation, though the causal nature of the association is yet to be determined.


  • Contributors: CdeO conceived and designed the study, interpreted the data, drafted the article, and is guarantor. MH analysed the data. RW and MH interpreted the data and revised the article. All authors approved the final version.

  • Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. CdeO is funded by the National Institute of Aging/National Institute of Health and British government departments. MH is funded by the British Heart Foundation. The Scottish Health Survey is funded by the Scottish Executive. The funders had no role in the present study.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare (1) No financial support for the submitted work from anyone other than their employer; (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; (4) No non-financial interests that may be relevant to the submitted work.

  • Ethical approval: This study was approved by the London research ethics council and informed consent was given by all participants.

  • Data sharing: The Scottish Health Survey dataset is openly available at the UK Data Archive ( The follow-up data on hospital admissions can be made available on request from the Information Services Division, Edinburgh (

  • Accepted 12 April 2010

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