Skip to main content

Oral health and 10-year cardiovascular risk in US adults: mediating role of inflammatory diet and vitamin D



To investigate whether E-DII or vitamin D mediates the relationship between oral health and cardiovascular disease (CVD) risk.


This study involved 6616 participants aged over 30 years old from the National Health and Nutrition Examination Survey (NHANES) in 2009–2014. Dietary inflammation and 10-year CVD risk were evaluated via the Energy-adjusted Dietary Inflammatory Index (E-DII) and the Framingham Risk Score (FRS), respectively. We used correlation analysis and mediation analysis to investigate the role of dietary inflammation and vitamin D in the relationship between oral health and CVD risk.


Oral health indicators and CVD risk were positively correlated with E-DII (r > 0, P < 0.001) and negatively correlated with vitamin D levels (r < 0, P < 0.001). The estimated mediating role of E-DII and vitamin D in the overall association between oral health and 10-year risk of CVD ranged from 4.9 to 7.5% and 6.6 to 11.6%, respectively. Furthermore, the mediation proportion of E-DII and vitamin D levels in the total association between oral health indicators and FRS were increased in participants without periodontitis.


Both E-DII and serum vitamin D were mediated the association between oral problems and 10-year CVD risk, especially in participants without periodontitis. Among them, E-DII played a positive mediating role, and serum vitamin D levels was a negative mediator.

Clinical relevance

Anti-inflammatory diet and prevention of vitamin D deficiency might reduce the impact of oral problems on cardiovascular disease risk to some extent. The study highlights the important role of oral health and dietary inflammation and vitamin D in primary prevention of cardiovascular disease.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2

Data availability

All data extracted in this study are included in this article.


  1. Richards NC et al (2016) Disability, noncommunicable disease and health information. Bull World Health Organ 94(3):230–232

    Article  PubMed  PubMed Central  Google Scholar 

  2. Virani SS et al (2020) Heart disease and stroke statistics-2020 update: a report from the American Heart Association. Circulation 141(9):e139–e596

    Article  PubMed  Google Scholar 

  3. Ritchey MD et al (2018) Vital signs: state-level variation in nonfatal and fatal cardiovascular events targeted for prevention by million hearts 2022. MMWR Morb Mortal Wkly Rep 67(35):974–982

    Article  PubMed  PubMed Central  Google Scholar 

  4. D’Agostino RB Sr et al (2008) General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation 117(6):743–753

    Article  PubMed  Google Scholar 

  5. Kassebaum NJ et al (2014) Global burden of severe periodontitis in 1990–2010: a systematic review and meta-regression. J Dent Res 93(11):1045–1053

    Article  PubMed  PubMed Central  Google Scholar 

  6. Monsarrat P et al (2016) Clinical research activity in periodontal medicine: a systematic mapping of trial registers. J Clin Periodontol 43(5):390–400

    Article  PubMed  Google Scholar 

  7. Romandini M et al (2021) Periodontitis, edentulism, and risk of mortality: a systematic review with meta-analyses. J Dent Res 100(1):37–49

    Article  PubMed  Google Scholar 

  8. Johansson-Persson A et al (2014) A high intake of dietary fiber influences C-reactive protein and fibrinogen, but not glucose and lipid metabolism, in mildly hypercholesterolemic subjects. Eur J Nutr 53(1):39–48

    Article  PubMed  Google Scholar 

  9. Shivappa N et al (2014) Designing and developing a literature-derived, population-based dietary inflammatory index. Public Health Nutr 17(8):1689–1696

    Article  PubMed  Google Scholar 

  10. O’Neil A et al (2015) Pro-inflammatory dietary intake as a risk factor for CVD in men: a 5-year longitudinal study. Br J Nutr 114(12):2074–2082

    Article  PubMed  PubMed Central  Google Scholar 

  11. Ji M et al (2020) Dietary inflammatory index and cardiovascular risk and mortality: a meta-analysis of cohort studies. Medicine (Baltimore) 99(20):e20303

    Article  PubMed  Google Scholar 

  12. Woelber JP et al (2016) An oral health optimized diet can reduce gingival and periodontal inflammation in humans - a randomized controlled pilot study. BMC Oral Health 17(1):28

    Article  PubMed  PubMed Central  Google Scholar 

  13. Guo J et al (2017) Vitamin D intake and risk of CVD and all-cause mortality: evidence from the Caerphilly Prospective Cohort Study. Public Health Nutr 20(15):2744–2753

    Article  PubMed  PubMed Central  Google Scholar 

  14. Fry CM, Sanders TA (2015) Vitamin D and risk of CVD: a review of the evidence. Proc Nutr Soc 74(3):245–257

    Article  PubMed  Google Scholar 

  15. USC, B (2008) Current Population Survey(CPS) - definitions and explanations

  16. Wong ND (2020) Cardiovascular risk assessment: the foundation of preventive cardiology. Am J Prev Cardiol 1:100008

    Article  PubMed  PubMed Central  Google Scholar 

  17. Eke PI et al (2010) Accuracy of NHANES periodontal examination protocols. J Dent Res 89(11):1208–1213

    Article  PubMed  Google Scholar 

  18. Eke PI et al (2012) Update of the case definitions for population-based surveillance of periodontitis. J Periodontol 83(12):1449–1454

    Article  PubMed  PubMed Central  Google Scholar 

  19. Mora JR, Iwata M, von Andrian UH (2008) Vitamin effects on the immune system: vitamins A and D take centre stage. Nat Rev Immunol 8(9):685–698

    Article  PubMed  PubMed Central  Google Scholar 

  20. Strozyk D, Gress TM, Breitling LP (2018) Smoking and bone mineral density: comprehensive analyses of the third National Health and Nutrition Examination Survey (NHANES III). Arch Osteoporos 13(1):16

    Article  PubMed  Google Scholar 

  21. Aldosari M, Helmi M, Kennedy EN, Badamia R, Odani S, Agaku I, Vardavas C (2020) Depression, periodontitis, caries and missing teeth in the USA, NHANES 2009-2014. Fam Med Community Health 8(4):e000583

  22. Feng Q et al (2021) The role of body mass index in the association between dietary sodium intake and blood pressure: a mediation analysis with NHANES. Nutr Metab Cardiovasc Dis 31(12):3335–3344

    Article  PubMed  Google Scholar 

  23. Sanz M et al (2020) Periodontitis and cardiovascular diseases: consensus report. J Clin Periodontol 47(3):268–288

    Article  PubMed  PubMed Central  Google Scholar 

  24. Liljestrand JM et al (2015) Missing teeth predict incident cardiovascular events, diabetes, and death. J Dent Res 94(8):1055–1062

    Article  PubMed  Google Scholar 

  25. Loos BG et al (2000) Elevation of systemic markers related to cardiovascular diseases in the peripheral blood of periodontitis patients. J Periodontol 71(10):1528–1534

    Article  PubMed  Google Scholar 

  26. Paul O et al (2020) Inflammation in periodontal disease: possible link to vascular disease. Front Physiol 11:609614

    Article  PubMed  Google Scholar 

  27. Genco RJ, Sanz M (2020) Clinical and public health implications of periodontal and systemic diseases: An overview. Periodontology 2000 83(1):7–13

    Article  PubMed  Google Scholar 

  28. Desvarieux M et al (2003) Relationship between periodontal disease, tooth loss, and carotid artery plaque: the Oral Infections and Vascular Disease Epidemiology Study (INVEST). Stroke 34(9):2120–2125

    Article  PubMed  PubMed Central  Google Scholar 

  29. Salas-Salvadó J et al (2008) Components of the Mediterranean-type food pattern and serum inflammatory markers among patients at high risk for cardiovascular disease. Eur J Clin Nutr 62(5):651–659

    Article  PubMed  Google Scholar 

  30. Ramallal R et al (2017) Inflammatory potential of diet, weight gain, and incidence of overweight/obesity: The SUN cohort. Obesity (Silver Spring) 25(6):997–1005

    Article  PubMed  Google Scholar 

  31. Tyrovolas S et al (2017) Dietary inflammatory potential is linked to cardiovascular disease risk burden in the US adult population. Int J Cardiol 240:409–413

    Article  PubMed  PubMed Central  Google Scholar 

  32. Asadi Z et al (2020) Association between dietary inflammatory index and risk of cardiovascular disease in the Mashhad stroke and heart atherosclerotic disorder study population. IUBMB Life 72(4):706–715

    Article  PubMed  Google Scholar 

  33. Moreira AP et al (2012) Influence of a high-fat diet on gut microbiota, intestinal permeability and metabolic endotoxaemia. Br J Nutr 108(5):801–809

    Article  PubMed  Google Scholar 

  34. Bayston KF, Cohen J (1990) Bacterial endotoxin and current concepts in the diagnosis and treatment of endotoxaemia. J Med Microbiol 31(2):73–83

    Article  PubMed  Google Scholar 

  35. Laugerette F et al (2011) Emulsified lipids increase endotoxemia: possible role in early postprandial low-grade inflammation. J Nutr Biochem 22(1):53–59

    Article  PubMed  Google Scholar 

  36. Crowley SD (2014) The cooperative roles of inflammation and oxidative stress in the pathogenesis of hypertension. Antioxid Redox Signal 20(1):102–120

    Article  PubMed  PubMed Central  Google Scholar 

  37. Messner B, Bernhard D (2014) Smoking and cardiovascular disease: mechanisms of endothelial dysfunction and early atherogenesis. Arterioscler Thromb Vasc Biol 34(3):509–515

    Article  PubMed  Google Scholar 

  38. Botelho J, Machado V, Proença L, Delgado AS, Mendes JJ (2020) Vitamin D deficiency and oral health: a comprehensive review. Nutrients 12(5):1471

  39. Parikh S et al (2012) Circulating 25-hydroxyvitamin D concentrations are correlated with cardiometabolic risk among American black and white adolescents living in a year-round sunny climate. Diabetes Care 35(5):1133–1138

    Article  PubMed  PubMed Central  Google Scholar 

  40. Calton EK, Keane KN, Soares MJ (2015) The potential regulatory role of vitamin D in the bioenergetics of inflammation. Curr Opin Clin Nutr Metab Care 18(4):367–373

    Article  PubMed  Google Scholar 

Download references


This work was supported by the National Natural Science Foundation of China (No.81973129).

Author information

Authors and Affiliations



Bo Li and Ling Wang made the study design; Ling Wang, Xuanzhi Wang, Mengzi Sun conducted the study; Ling Wang and Mengzi Sun analyzed the data and wrote the manuscript; Xuanzhi Wang, Mengzi Sun, Xuhan Wang, Xiaotong Li, Wenyu Hu, Yixue Yang, Jing Li and Yibo Dong participated amending the manuscript. All authors agreed with the final version of the manuscript. Bo Li are the guarantors.

Corresponding author

Correspondence to Bo Li.

Ethics declarations

Ethics approval and consent to participate

The protocols of NHANES were approved by the institutional review board of the National Center for Health Statistics, CDC. Written informed consent was obtained from each participant before participation in this study.

Consent for publication

All authors have seen and approved the final version of the manuscript being submitted. This work was original research that has not been published previously, and not under consideration for publication elsewhere, in whole or in part.

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wang, L., Wang, X., Sun, M. et al. Oral health and 10-year cardiovascular risk in US adults: mediating role of inflammatory diet and vitamin D. Clin Oral Invest 27, 3405–3413 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: