Improved oral hygiene is associated with decreased risk of new-onset diabetes: a nationwide population-based cohort study



Inflammation plays an important role in the development of diabetes, a major global health problem. Periodontal disease is also common in the general population. Because periodontal disease and poor oral hygiene can provoke transient bacteraemia and systemic inflammation, we hypothesised that periodontal disease and oral hygiene indicators would be associated with the occurrence of new-onset diabetes.


In this study we analysed data collected between 2003 and 2006 on 188,013 subjects from the National Health Insurance System-Health Screening Cohort (NHIS-HEALS) in Korea who had no missing data for demographics, past medical history, oral hygiene indicators or laboratory findings. The presence of periodontal disease was defined on the basis of a modified version of ICD-10 codes (Korean Classification of Disease, sixth edition), if claims for treatment for acute periodontitis (K052), chronic periodontitis (K053) and periodontosis (K054) were made more than two times by a dentist, or if, according to medical records, subjects received treatment by a dentist for periodontal disease with ICD-10 codes K052, K053 or K054. Oral hygiene behaviours (number of tooth brushings, a dental visit for any reason and professional dental cleaning) were collected as self-reported data of dental health check-ups. Number of missing teeth was ascertained by dentists during oral health examination. The incidence of new-onset diabetes was defined according to ICD-10 codes E10–E14. The criterial included at least one claim per year for both visiting an outpatient clinic and admission accompanying prescription records for any glucose-lowering agent, or was based on a fasting plasma glucose ≥7 mmol/l from NHIS-HEALS.


Of the included subjects, 17.5% had periodontal disease. After a median follow-up of 10.0 years, diabetes developed in 31,545 (event rate: 16.1%, 95% CI 15.9%, 16.3%) subjects. In multivariable models, after adjusting for demographics, regular exercise, alcohol consumption, smoking status, vascular risk factors, history of malignancy and laboratory findings, the presence of periodontal disease (HR 1.09, 95% CI 1.07, 1.12, p < 0.001) and number of missing teeth (≥15 teeth) remained positively associated with occurrence of new-onset diabetes (HR 1.21, 95% CI 1.09, 1.33, p < 0.001, p for trend <0.001). Frequent tooth brushing (≥3 times/day) was negatively associated with occurrence of new-onset diabetes (HR 0.92, 95% CI 0.89, 0.95, p < 0.001, p for trend <0.001).


Frequent tooth brushing may be an attenuating factor and the presence of periodontal disease and an increased number of missing teeth may be augmenting factors for the occurrence of new-onset diabetes. Improving oral hygiene may be associated with a decreased risk of occurrence of new-onset diabetes.

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Data availability

The data that support the findings of this study are available from NHIS-HEALS, but restrictions apply to the availability of these data, which were used under licence for the current study and so are not publicly available. Data are, however, available from the authors upon reasonable request and with permission from the National Health Insurance System.





National Health Insurance System


National Health Insurance System-National Health Screening Cohort


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This project was supported by a grant from the Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Education (2018R1D1A1B07040959 to T-JS). The funders had no role in study design, data collection and analysis, the decision to publish, or preparation of the manuscript.

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YC, KJL, HGW, and TJS, contributed to conception and design of the study, data acquisition, analysis and interpretation of results, and drafted and critically revised the manuscript; JSL, contributed to design of the study, data acquisition and interpretation, and critically revised the manuscript. TJS accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. All authors gave final approval for the manuscript to be published.

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Correspondence to Tae-Jin Song.

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Chang, Y., Lee, J.S., Lee, KJ. et al. Improved oral hygiene is associated with decreased risk of new-onset diabetes: a nationwide population-based cohort study. Diabetologia 63, 924–933 (2020).

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  • Diabetes mellitus
  • Epidemiology
  • Oral hygiene
  • Periodontal diseases
  • Periodontitis
  • Tooth loss
  • Toothbrushing