Providing patients with proper oral hygiene instruction is recognized as an important part of dental hygiene appointments – but should we also be encouraging patients to exercise for oral health benefits? The Canadian 24-Hour Movement Guidelines recommend adults accumulate at least 150 minutes of moderate to vigorous aerobic activity each week.1 You have likely heard of the benefits of physical activity for the prevention and management of chronic diseases such as cardiovascular disease, diabetes, cancer, hypertension, and metabolic syndrome – exercise helps to regulate blood sugar, lower blood pressure, reduce inflammation, and improve the function of many organs. (Fig. 1) Is physical activity also important for the prevention and management of periodontal disease?
Benefits of physical activity. Regular physical activity has been associated with decreased risk of numerous chronic conditions, and many of these chronic conditions are also positively associated with periodontal disease. In addition to reduced risk of chronic disease, there are numerous other benefits of regular physical activity as well.
A recent systematic review and meta-analysis found an association between higher frequency of physical activity and lower occurrence of periodontal disease.2 This systematic review included seven studies, of which two were large cross-sectional studies using subsets of national surveys in the United States (n = 12110 and n = 2521) and defined periodontal disease as at least one site with probing depth ≥ 4 mm and clinical attachment loss of ≥ 3 mm.3,4 The findings of the review state that adults who achieved a frequency of ≥ 5 episodes of moderate or ≥ 3 episodes of vigorous-intensity physical activity per week were less likely to experience periodontal disease. Physical activity was measured through surveys and included a broad range of activities such as walking to work, aerobic exercise, swimming, garden and yard work, and weightlifting. The results of this systematic review could not provide specific recommendations for intensity and type of physical activity, but one study did find individuals with higher metabolic equivalent tasks (METs) – a measure of exercise intensity (Table 1) – had lower relative risk of periodontal disease.5 Meta-analysis also revealed a significant association between sedentary behavior and increased odds of periodontal disease.2 This finding aligns with the recent Canadian 24-Hour Movement Guidelines1 that support ‘moving more’ – with light physical activity including standing as an example–along with reducing sedentary time for overall health. Another study published after the systematic review reported that adults (n = 9500) who walked at least 30 minutes a day, 5 days a week were less likely to have periodontal disease. In this study, periodontal disease was defined using the community periodontal index from the World Health Organization.6 Given that walking is considered to have a MET value approximately equal to many other moderate intensity activities, activities at the same or higher intensity level than walking may be beneficial for periodontal health.
Adapted from (Scheinowitz, 2018).22
The link between periodontal disease and physical activity is hypothesized to be a result of reductions in chronic low-grade inflammation resulting from increased frequency of physical activity.7,8 Physical activity plays a particularly important role in immune health during aging9, and is known to alter the modulation and production of pro-inflammatory cytokines, including C-reactive protein (CRP).10,11 In a case-control study of 751 subjects, it was found that more time spent exercising was associated with decreasing levels of CRP in patients with periodontal disease.12 Increased levels of CRP are associated with worsening of periodontal condition, and elevated serum CRP is also associated with other systemic disorders, such as coronary heart disease, stroke, and diabetes.13,14
Physical activity may also have indirect effects on periodontal health through its shared relationships with other chronic diseases. For example, poorly controlled diabetes is known to compromise periodontal health15,16 and physical activity improves blood glucose control.8 Another example is cardiovascular disease (CVD) – aerobic exercise directly combats the development of CVD and could therefore have indirect benefits for periodontal disease in those living with CVD. The same is true of obesity and metabolic syndrome.17,18 In an intervention study, obese women with chronic periodontal disease who participated in a 12-week aerobic exercise program (1-hour session, 3 days a week with a fitness instructor) achieved a significant decrease in BMI, probing depth and clinical attachment loss.19 Even in the absence of weight loss, increasing levels of physical activity have numerous benefits for individuals who are obese or have metabolic syndrome. This can be a result of improvements in cardiometabolic health seen with exercise; cardiovascular risk markers can be significantly improved by changes in diet and exercise in the absence of fat loss.20,21
Since the publication of the review previously discussed2 a randomized control trial reported the effects of a physical activity intervention on periodontal health and HbA1c levels in patient with type 2 diabetes mellitus (T2DM) over a 6-month period.8 The intervention group had significantly reduced severity of periodontal disease and bleeding on probing, and significantly reduced HbA1c levels compared to the control group at the end of the trial. The intervention group was further divided into 3 groups – one group completed a strength-endurance training program, the second group completed an endurance program, and the third group completed a combination of both programs. Overall, all participants in the intervention group participated in two training sessions per week for 26 weeks at a gym facility. They were supervised by trained exercise professionals and each session began with a 10-minute warm-up, followed by either two sets of 8 strength exercises using weight machines (strength-endurance program) or 30-minute treadmill or bicycle ergometer session (endurance program). The third intervention group completed one strength-endurance and one endurance training session per week. Training duration and intensity progressed gradually after weeks 4 and 13. Regardless of which training program was used, bleeding on probing and severity of periodontal disease were significantly reduced in the intervention group. These findings emphasize the potential benefits of physical activity in supporting periodontal health in the context of T2DM.
While relatively few studies of physical activity and periodontal disease exist, current evidence supports an association between higher levels of physical activity and better periodontal health. While many patients with periodontal disease also suffer from additional chronic diseases such as CVD, diabetes, or metabolic syndrome – the benefits of physical activity for these conditions and reduced inflammation suggest that periodontal health can be supported by meeting the 24-Hour Movement Guidelines. These guidelines (see link below) are based on strong evidence demonstrating a dose-response relationship between physical activity and premature all-cause mortality, and when the recommended levels of physical activity are met, can confer protection from several chronic diseases.18
Guidance for Patients
- You don’t need to participate in high-intensity activities to experience health benefits. Starting with moderate-intensity activities and gradually progressing to higher intensity will improve health.
- Gradually increase your activity – if you are completely sedentary, 150 minutes of moderate exercise a week might be too much to start. Encourage patients to start where they are at and slowly increase activity over time.
- During moderate-intensity physical activity (e.g. brisk walking, bike riding), you should be able to talk, your heart rate will be elevated, and you may be breathing a bit harder and normal. During vigorous-intensity physical activity (e.g. jogging, dancing, cross-country skiing), you will sweat and be ‘out of breath’; you shouldn’t be able to hold a conversation or sing during vigorous activities.
- Choose activities that you enjoy doing. Hiking, biking, running, golfing, swimming, aerobics classes, or anything else that gets you moving.
- Even tasks such as gardening, yard work, or housework can be beneficial for your health so long as they are done in bouts of 10 minutes or longer.
- If you are living with a chronic disease such as heart disease, diabetes, or osteoporosis, physical activity may be especially important for your health. If you are hesitant to start exercising due to health concerns, please consult with your physician or a trained exercise professional such as a kinesiologist or
- Adding in strength and balance exercises in addition to aerobic activity is especially important as we age, and can help prevent falls, ultimately reducing your risk of osteoporotic fracture. Exercise recommendations for patients with osteoporosis can be found at https://osteoporosis.ca/health-care-professionals/clinical-practice-guidelines/exercise-recommendations/
- Break up long periods of sitting time with movement breaks. In addition to the benefits of regular physical activity, there are also many benefits of reducing sedentary time.
- To view the Canadian 24-Hour Movement Guidelines, visit csepguidelines.ca/
Oral Health welcomes this original article.
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About the Author
Hannah Young holds a BKin from the University of the Fraser Valley and is completing a MSc in the Faculty of Applied Health Sciences at Brock University. Hannah’s research focuses on women’s health, physical activity and periodontal disease for which she was awarded an Ontario Graduate Scholarship.
Wendy Ward is a Professor and Canada Research Chair in the Department of Kinesiology in the Faculty of Applied Health Sciences at Brock University. Her team’s overall research goal within the Nutrition, Bone and Oral Health Research Group is to develop dietary strategies that help protect against osteoporosis and related fractures while also understanding the complex relationships with other health conditions such as periodontal disease.