J Clin Periodontol 2014; 41: 31–37 doi: 10.1111/jcpe.

12183

Moderate and severe € rg Eberhard1,#, Meike Stiesch1,#,

Jo
Arno Kerling2, Christoph Bara3,
Christine Eulert4, Denise

periodontitis are independent Hilfiker-Kleiner4, Andres Hilfiker3,

Eva Budde5, Johann Bauersachs4,
Momme Kück2, Axel Haverich3,

risk factors associated with low Anette Melk6,# and Uwe Tegtbur2,#
1
Department of Prosthetic Dentistry and
Biomedical Materials Science, Hannover

cardiorespiratory fitness in Medical School, Hannover, Germany;

2
Institute of Sports Medicine, Hannover
Medical School, Hannover, Germany;

sedentary non-smoking men

3
Department of Cardiothoracic,
Transplantation and Vascular Surgery,
Hannover Medical School, Hannover,
Germany; 4Department of Cardiology and

aged between 45 and 65 years Angiology, Hannover Medical School,

Hannover, Germany; 5Institute of Biometry,
Hannover Medical School, Hannover,
Germany; 6Department for Paediatric
Nephrology, Hepatology and Metabolic
Eberhard J, Stiesch M, Kerling A, Bara C, Eulert C, Hilfiker-Kleiner D, Disorders, Hannover Medical School,
Hilfiker A, Budde E, Bauersachs J, Kück M, Haverich A, Melk A, Tegtbur U. Hannover, Germany
Moderate and severe periodontitis are independent risk factors associated with low
cardiorespiratory fitness in sedentary non-smoking men aged between 45 and
#
65 years. Journal of Clinical Periodontology 2014; 41: 31–37. doi: 10.1111/ These authors contributed equally.
jcpe.12183.

Abstract
Aim: To investigate the association between periodontal disease severity and
cardiorespiratory fitness (CRF) in a cross-sectional study of sedentary men.
Materials & Methods: Seventy-two healthy men (45–65 years) who did not join
any sport activity and had a preferentially sitting working position were recruited.
Periodontal status was recorded and CRF was measured by peak oxygen uptake
(VO2peak) during exercise testing on a cycle ergometer. Physical activity was
assessed by a validated questionnaire and data were transformed to metabolic
equivalent of task scores. Univariate and multivariate regression analyses were
performed to investigate associations.
Results: Differences between VO2peak levels in subjects with no or mild, moderate or
severe periodontitis were statistically significant (p = 0.026). Individuals with low
VO2peak values showed high BMI scores, high concentrations of high-sensitive C-
reactive protein, low levels of high-density lipoprotein-cholesterol, and used more
glucocorticoids compared to individuals with high VO2peak levels. Multivariate
regression analysis showed that high age (p = 0.090), high BMI scores (p < 0.001),
low levels of physical activity (p = 0.031) and moderate (p = 0.087), respectively,
Key words: cardiorespiratory fitness;
severe periodontitis (p = 0.033) were significantly associated with low VO2peak levels. periodontitis; physical activity; risk factor;
Conclusions: This study demonstrated that moderate and severe periodontitis systemic health
were independently associated with low levels of CRF in sedentary men aged
between 45 and 65 years. Accepted for publication 14 October 2013

Conflict of interest and source of funding statement

The authors declare no conflicts of interests.
This study was funded in part by the Cluster of Excellence “rebirth” Hannover and the Cordis Foundation.

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 31
32 Eberhard et al.
Recently, several publications reviewed
the evidence regarding potential asso-
ciations between periodontitis and ath-
erosclerotic vascular diseases, diabetes
mellitus or child low-birth weight,
showing that oral health affects that
of the entire body (Chambrone et al.
2011, Lalla & Papapanou 2011,
Lockhart et al. 2012). In addition,
Linden et al. reported in an excellent
review modest associations between
periodontitis and respiratory disease,
chronic kidney disease, obesity, met-
abolic syndrome and cancer (Linden
et al. 2013). Investigators proposed
periodic transient bacteraemia or
increased levels of circulating cyto-
kines to accelerate pathological pro-
cesses relevant for the systemic
pathologies associated with peri-
odontitis (Bahrani-Mougeot et al.
2008, Schenkein & Loos 2013).
Cardiorespiratory fitness (CRF)
is a surrogate measure of the func-
tional status of the respiratory, car-
diovascular and skeletal muscle
system. There is convincing evidence
that low CRF is associated with
increased cardiovascular morbidity
and mortality in both men and
women, independent of classical risk
factors (for review see Swift et al.,
2013). CRF is usually expressed in
metabolic equivalents or maximal
oxygen uptake (VO2peak), as mea-
sured during incremental exercise
testing, using treadmill or cycle
ergometers. In an early attempt to
explore systemic effects of periodon-
tal diseases, Wakai et al. investigated
the relationship between CRF and
periodontal health (Wakai et al.
1999). These authors were not able
to show a clear correlation between
VO2peak and periodontal health
scores. In contrast, Shimazaki et al.
showed that subjects with high Com-
munity Periodontal Index scores
exhibited significantly lower levels of
VO2peak than subjects with low index
scores (Shimazaki et al. 2010).
Individual levels of CRF depend
on non-modifiable (age, gender and
genotype) and modifiable (physical
activity, smoking, obesity and medi-
cal condition) determinants. How-
ever, CRF levels are predominately
determined by physical activity and
exercise training (Lee et al. 2010);
therefore, the scientific values of
both aforementioned studies are
somewhat limited due to the fact
that they did not report the quantity
of physical activity of the subjects
under investigation. In addition,
periodontal disease assignment was
drawn in both studies by the Com-
munity Periodontal Index, which
was originally not designed to assess
the prevalence of periodontal disease
in a population (Page & Eke 2007).
Based on these limitations, it was
obvious to investigate the association
between periodontitis and CRF
including data of routine physical
activity and using a valid case defini-
tion of periodontitis. The investiga-
tion of a correlation between
periodontitis and CRF was of spe-
cial concern, because in contrast to
the repeatedly described associations
with the cardiovascular system, CRF
addresses several organ systems. The
present cross-sectional study was
conducted in a cohort of physically
inactive men aged between 45 and
65 years, with the simultaneous
assessment of CRF, physical activity
and their periodontal conditions. It
was our hypothesis that periodontal
disease severity is negatively associ-
ated with CRF.
Methods
Study subjects
We recruited between 15th May and
30th July 2011 by advertisement for
otherwise healthy men aged between
45 and 65 years within our own
institution (Hannover Medical
School), who had not joined any
exercise programme or sports activi-
ties, did not have any physical
activity at leisure, and had a prefer-
entially sitting working position
during the last 3 years. To make an
enquiry about physical and work
place activity a questionnaire was
sent to all male employees at Han-
nover Medical School. Employees
who self-reported no physical activ-
ity and had a preferentially sitting
working position during the last
3 years were invited for the inter-
view. A comprehensive medical his-
tory including anti-hypertensive
medications, glucocorticoids and
lipid-lowering agents was recorded
by interview. Subjects with known
cardiac diseases, diabetes mellitus,
cancer and current or former (last
cigarette >3 years) cigarette smokers
were excluded. Subjects were also
excluded if they had less than
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
eight teeth, received antibiotics within
3 months prior to the study or peri-
odontal treatment within 6 months
prior to the study. The subjects were
subsequently included and provided
informed consent in accordance with
the policies of the institutional
Review Board of Hannover Medical
School (no. 5909). The study was
registered at the WHO trials registry
(DRKS00003097).
Periodontal examination
An experienced periodontist (JE)
assessed each subject for the pres-
ence and severity of periodontal
disease. For all measurements, a
pressure calibrated periodontal
probe was used (Florida Probe Sys-
tem, Florida Probe). This evaluation
included the measurement of the
probing depth (PD) and clinical
attachment level (CAL) at six sides
per tooth. The presence of no or
mild, moderate or severe periodontal
conditions were classified by the clin-
ical case definitions of periodontitis
introduced by the Centres for
Disease Control and Prevention and
the American Academy of Periodon-
tology (CDC-AAP) (Page & Eke
2007, Eke et al. 2012). Subjects were
classified as moderate periodontitis
by ≥2 interproximal sides with CAL
≥4 mm, or by ≥2 interproximal sides
with PD ≥5 mm (not at the same
tooth). Severe periodontitis was
characterized by ≥2 interproximal
sides with CAL ≥6 mm and ≥1 inter-
proximal side with PD ≥5 mm (not
at the same tooth). No or mild peri-
odontitis was specified if neither
moderate nor severe periodontitis
was diagnosed.
Analysis of oxygen consumption (VO2peak)
Cardiorespiratory fitness was mea-
sured directly from respiratory gas
exchange during a standardized
cardiopulmonary stepwise exercise
testing on a cycle ergometer (Ergo-
line, Bitz, Germany). Maximum oxy-
gen consumption was defined as the
maximum mean value over a period
of 30 s during the test. For this
study, the term VO2peak instead of
VO2max was used because it was
uncertain how close to their maxi-
mum the subjects would cycle. All
tests have been stopped with the
onset of dyspnoea and/or peripheral

muscle fatigue. The resulting VO2peak
value in ml O2 per kg body weight
per minute allowed a direct compari-
son of individuals regardless of body
weight.
Assessment of activity
Subjects were selected according to a
low status of physical activity with
respect to sport and leisure activities
or work conditions; however, for all
analyses physical activity was
assessed by a validated questionnaire
that evaluates activities during nor-
mal daily routine and leisure time
(Frey et al. 1999). This questionnaire
included an extensive array of ques-
tions related to daily activities,
leisure-time activities and sedentary
activities at home. Frequency (times
per day, week or month) and dura-
tion per session (min or hours per
day) were reported for each activity.
Frequency and duration of participa-
tion in activities within each intensity
category were summarized to create
estimates for daily physical activity.
Physical activity data were trans-
formed to represent metabolic equiv-
alent of task scores (MET = 3.5 ml/
min./kg body weight representing
resting energy expenditure). Weekly
average time spent on activities was
calculated by adding the MET-
weighted hours for each leisure time
activity and daily activities, divided
by 60 and multiplied by 7 days.
Assessment of blood pressure
Blood pressure was recorded before
any intervention or measurement by
an experienced cardiologist (CE)
using sphygmomanometric measure-
ments on a rested participant prior to
treadmill testing. Measurements were
taken with a blood pressure cuff
adapted to the broadness of the par-
ticipant’s upper arm (boso manuell;
Bosch & Sohn, Jungingen, Germany).
Participants actively treated with
antihypertensive drugs or exhibiting a
systolic and/or diastolic blood pres-
sure equal or greater than 140/
90 mmHg were designated as being
hypertensive.
Laboratory assessments
Blood samples were obtained after
an overnight fasting period at
8:00 a.m. from all subjects. Measure-
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Periodontitis is associated with CRF
ments of lipid levels, glucose concen-
tration, etc., were done by standard
laboratory testing (Modularâ ana-
lytic eco analyser; Roche Diagnostic
GmbH, Mannheim, Germany).
Serum concentrations of high-sensi-
tive C-reactive protein (hsCRP) were
determined by immunonephelome-
try (Cardiophase hsCRP; Siemens
AG, Erlangen, Germany).
Statistical analysis
For all statistical analyses the statis-
tical software package SPSS 19.0
(IBM Corp., Armonk, NY, USA)
was used. Descriptive statistics
included calculation of mean values
and standard deviations for quanti-
tative variables. Qualitative variables
were expressed as frequency and
percentage.
Differences between individual
VO2peak-groups (25%-percentiles) for
single variables were tested using
ANOVA for continuous variables and
the Chi-Square or Fischer exact test,
respectively, for categorical vari-
ables. A p-value (≤0.05) was consid-
ered significant.
The influences of each variable
were investigated with univariate
regression models, considering the
mean VO2peak as the outcome vari-
able. All variables with a p-value
p < 0.2 were considered significant
and investigated in a multivariate
regression model. Correlations
between variables were tested using
Pearson correlation coefficient and
highly dependent variables were
excluded from analysis. A multivari-
ate analysis (backward stepwise lin-
ear regression with p = 0.10 to enter
and p = 0.05 to leave) was per-
formed. Possible predictor variables
were age, weight, BMI, physical
activity, heart rate, diastolic blood
pressure, anti-hypertensive medica-
tion, glucocorticoids and periodontal
disease severity (no/mild, moderate
or severe periodontitis according to
Table 1. Cardiorespiratory fitness significantly decreased with periodontal disease severity
(p = 0.026)
CDC-AAP No/mild
Moderate
Severe
CI, confidence interval.
33
the CDC-AAP classification). The
estimates for each variable were
derived from SPSS output, as well as
standard deviation and correspond-
ing 95% confidence interval.
Results
Eighty-three subjects were screened
and a total of 72 healthy eligible men
(mean age: 52.7  5.4 years) were
included. Eleven subjects did not
comply with the inclusion criteria.
Thirty subjects were classified as no/
mild periodontitis, 30 were classified
as moderate periodontitis and 12
participants were classified with
severe periodontitis. Descriptive
statistics for clinical case definitions
and VO2peak levels are summarized in
Table 1. The differences between
VO2peak levels in subjects with no or
mild periodontitis, moderate or severe
periodontitis were statistically signifi-
cant (p = 0.026). Individuals with
VO2peak values in the lower quartile
showed higher weight (p < 0.001) and
BMI (p < 0.001) scores, low levels of
high-density lipoprotein (HDL)-
cholesterol (p = 0.036), high serum
concentrations of hsCRP (p = 0.045)
and used more glucocorticoids
(p = 0.027) compared to individuals
with VO2peak levels in the upper 25%
quartile of the study population
(Table 2). No differences were
observed between different VO2peak
quartiles for age, physical activity,
heart rate, systolic or diastolic blood
pressure, serum glucose, total choles-
terol, triglycerides and low-density
lipoprotein-cholesterol. In addition,
no significant differences were found
between VO2peak-quartiles with respect
to anti-hypertensive medication and
lipid-lowering agents.
Univariate regression analysis
showed that age, BMI and no or
mild periodontitis (CDC-AAP) were
significantly associated with VO2peak.
Variables retained in the multivariate
model after the stepwise selection
VO2peak (ml/min./kg)
Mean  SD 95% CI
30.5  5.3 28.6; 32.5
27.9  4.9 26.1; 29.7
25.8  6.6 21.6; 30.0
34 Eberhard et al.

Table 2. Descriptive statistics (mean  SD) for participating subjects and ANOVA analysis for quartiles of VO2peak (ml/min./kg)
All participants VO2peak p
(n = 72)
First Quartile Second Quartile Third Quartile Fourth Quartile

Age, year 52.7  5.4 53.8  4.5 54.4  6.2 51.1  5.2 51.0  5.2 0.115
Weight, kg 87.6  12.1 95.7  13.5 91.1  12.8 84.5  7.6 79.6  7.3 <0.001
BMI 27.2  3.5 29.8  4.2 27.7  3.4 26.7  2.6 24.8  1.3 <0.001
VO2peak, ml/min. 2495.8  430.7 2094.5  367.4 2418.6  336.2 2550.6  257.0 2897.0  308.9 <0.001
VO2peak, ml/min./kg 28.9  5.8 22.0  2.7 26.6  0.9 30.2  1.4 36.5  2.7 <0.001
Physical activity, MET 29.2  18.8 21.7  14.3 27.3  15.0 29.6  21.3 38.1  22.1 0.070
Heart rate, bpm 74.6  12.3 77.2  13.8 72.0  9.7 77.3  10.4 71.3  13.2 0.266
Systolic blood pressure, mmHg 122.2  14.1 123.6  14.0 123.17  16.4 122.0  13.6 118.72  12.5 0.729
Diastolic blood pressure, mmHg 83.3  9.7 86.9  8.4 84.4  11.6 82.3  10.9 79.4  7.1 0.129
Maximum power, Watt 227.9  33.4 207.3  24.9 218.4  27.7 227.8  35.0 256.9  25.9 <0.001
Maximum systolic blood 207.3  24.1 216.1  26.5 205.6  21.3 206.8  26.4 202.8  21.3 0.380
pressure, mmHg
Maximum diastolic blood 88.2  12.9 90.2  13.5 90.2  12.7 86.9  16.9 85.8  7.3 0.658
pressure, mmHg
Serum glucose, mmol/l 5.3  0.4 5.4  0.4 5.4  0.5 5.3  0.5 5.3  0.4 0.874
Total cholesterol, mg/dl 215.9  33.5 213.0  26.2 218.8  38.1 219.7  38.6 208.8  32.1 0.750
Triglycerides, mg/dl 135.8  93.5 166.5  85.7 166.2  145.9 121.2  51.7 96.2  46.9 0.062
LDL cholesterol, mmol/l 146.5  28.0 143.9  18.6 147.1  30.8 151.1  33.5 141.2  28.7 0.752
HDL cholesterol, mmol/l 50.8  10.6 45.5  9.4 48.8  9.0 52.9  13.0 54.7  8.3 0.036
hsCRP, mg/l 1.7  2.9 2.7  3.9 1.0  0.7 2.6  4.0 0.6  0.84 0.045
Anti-hypertensive medication (C07)*, n 20 8 6 4 2 0.211
Lipid-lowering agents (C10A)*, n 4 0 1 2 1 0.519
Glucocorticoids (H02)*, n 3 3 0 0 0 0.027

*ATC code in parenthesis.

LDL, low-density lipoprotein; HDL, high-density lipoprotein; hsCRP, high-sensitive C-reactive protein.

Table 3. Uni- and multivariate regression analysis with VO2peak (ml/min./kg) as the depen-
procedures were age, BMI, physical
dent variable. The regression coefficient corresponds to a one-unit change of the dependent
activity, and moderate or severe variable.
periodontitis (Table 3). High age
(p = 0.090), high BMI scores Regression coefficient 95% CI p-value
(p < 0.001), low levels of physical
Univariate regression
activity (p = 0.031), and moderate Age, year 0.257 0.495; 0.018 0.036
(p = 0.087), respectively, severe peri- BMI 0.588 1.056; 0.121 0.015
odontitis (p = 0.033) were signifi- Physical activity, MET 0.049 0.016; 0.114 0.135
cantly associated with low VO2peak Heart rate, bpm 0.033 0.152; 0.085 0.574
levels. Systolic blood pressure, mmHg 0.084 0.046; 0.215 0.201
Diastolic blood pressure, mmHg 0.029 0.207; 0.149 0.742
Serum glucose, mmol/l 0.751 2.170; 3.673 0.608
Discussion Total cholesterol, mg/dl 0.153 0.428; 0.122 0.270
Triglycerides, mg/dl 0.028 0.022; 0.077 0.266
The results of this study showed an
LDL cholesterol, mmol/l 0.131 0.146; 0.407 0.347
association between periodontal HDL cholesterol, mmol/l 0.241 0.092; 0.574 0.153
disease severity and the functional hsCRP, mg/l 0.052 0.381; 0.485 0.809
status of the respiratory, cardiovascu- Clinical case definition, CDC-AAP
lar and skeletal muscle system in No or mild periodontitis 4.110 0.215; 8.004 0.039
sedentary non-smoking men aged Moderate periodontitis 1.811 1.925; 5.547 0.335
between 45 and 65 years; stepwise Severe periodontitis 2.753 6.404; 0.897 0.136
regression analysis showed that mod- Multivariate regression
erate and severe periodontitis are risk Age, year 0.173 0.374; 0.027 0.090
factors for reduced CRF. This associ- BMI 0.702 0.981; 0.323 <0.001
Physical activity, MET 0.062 0.006; 0.119 0.031
ation was independent of other
Clinical case definition, CDC-AAP
known risk factors for CRF and indi- Moderate periodontitis 2.008 4.313; 0.297 0.087
cated a yet not documented adverse Severe periodontitis 3.431 6.568; 0.294 0.033
systemic health effect of periodontal
diseases affecting a combined param- CI, confidence interval; LDL, low-density lipoprotein; HDL, high-density lipoprotein;
eter of systemic health integrating hsCRP, high-sensitive C-reactive protein.
several organ systems of the body.
Cardiorespiratory fitness was and obesity (Lee et al. 2010). The BMI has been confirmed in the pres-
found to be associated with age, associations between CRF and age ent study. Ageing is a confounding
gender, physical activity, smoking as well as body weight, respectively, factor for both the prevalence of
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

periodontal disease and CRF; how-
ever, the statistical analyses revealed
periodontal disease severity as an
independent risk factor. The negative
association between BMI and CRF
observed in the present study has
also been demonstrated in US obese
individuals who had approximately
10–15% lower CRF values than
non-obese individuals (Wang et al.
2010). The risk for obesity is reduced
by physical activity (Coakley et al.
1998) and longitudinal studies sup-
ported a weak association between
overweight or obesity and periodon-
tal infections (Saxlin et al. 2010). In
this regard, metabolic disorders like
diabetes, hypercholesterolemia and
low HDL-cholesterol levels have also
been associated with impaired skele-
tal muscle functions including CRF
or cardiovascular disease (Carnethon
et al. 2005). In this study, ANOVA
analysis found differences between
quartiles of CRF regarding triglyce-
rides (p = 0.062) and HDL-choles-
terol, however, both parameters were
highly correlated to BMI scores and
were therefore eliminated from uni-
and multivariate regression analyses.
Basically CRF is determined by
the extent of physical activity
(Church et al. 2007), this association
was also confirmed in the present
regression analyses. Subjects in the
lowest quartile of VO2peak presented
low levels of physical activity com-
pared to subjects in the highest
VO2peak quartile. Physical activity is
regarded as the main confounding
factor for the observed association
between CRF and periodontal dis-
ease severity in the present study,
because both variables showed a few
interdependent associations. For
example, several studies showed an
independent association between low
levels of physical activity and an
increased frequency of periodontitis
(Merchant et al. 2003, Al-Zahrani
et al. 2005, Bawadi et al. 2011). Of
importance is that improved oral
hygiene, which someone might sug-
gest be associated with increased
physical activity, did not necessarily
account for lower frequencies of
periodontal disease (Bawadi et al.
2011). The link between physical
activity and periodontitis is an anti-
inflammatory effect of regular exer-
cise and this anti-inflammatory effect
might also result in a suppressive
effect on periodontal disease (Peter-
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Periodontitis is associated with CRF
sen & Pedersen 2005). Another sys-
temic effect of physical activity is the
reduction of high blood pressure,
which is also associated to low CRF
(Sawada et al. 1993). In addition,
high blood pressure was found to be
associated with periodontal disease
(Howell et al. 2001, D’Aiuto et al.
2006, Franek et al. 2009, Rivas-Tu-
manyan et al. 2012). These contrary
effects may at least in part explain
that no association was observed
between blood pressure, respectively,
physical activity and CRF in this
study. In addition, the high fre-
quency of anti-hypertensive drug use
in subjects belonging to the lower
25% quartile of VO2peak levels did
not allow any reliable calculation of
an association between these vari-
ables. However, based on the associ-
ation between high blood pressure
and low CRF, VO2peak values in
subjects in the lowest quartile may
even be worse without using anti-
hypertensive medications.
C-reactive protein concentration
is, a strong predictor for myocardial
infarction and stroke risk (Ridker
et al. 1997). In this study, CRP con-
centrations were significant higher in
subjects with low CRF compared to
subjects with high CRF, the former
also suffering more frequently from
moderate or severe periodontitis.
This observation is in accordance
with studies showing that periodon-
tal disease was associated with acute
phase response and changes in serum
C-reactive protein levels (Whelton
et al. 2002, D’Aiuto et al. 2004).
Again, physical activity may be a
confounding factor for the observed
associations, because C-reactive pro-
tein concentrations in individuals
were also determined by the level of
physical activity (Andersson et al.
2008).
The findings of this study fit well
with prior clinical studies linking
periodontal and systemic diseases
(Lockhart et al. 2012, Linden et al.
2013). Although the outcome mea-
sure CRF is a compound parameter
including several organ systems of
the body, CRF is associated with
increased cardiovascular morbidity
and mortality in both men and
women (Swift et al. 2013). In a
recent meta-analysis Kodama et al.
(2009) calculated that a one-MET
increase in CRF was associated with
a 13% reduction in cardiovascular
35
mortality. The difference between sub-
jects with no or mild periodontitis and
subjects with severe periodontitis was
approximately one MET (based on a
regression coefficient of 3.431 ml/
min./kg), representing a significant
reduced cardiovascular mortality in
subjects with no or mild periodontitis
compared to subjects with severe peri-
odontitis. The magnitude of the effect
and the clinical significance of the pre-
sented data is illustrated by a recent
publication that reported an immedi-
ate 14% reduction in cardiovascular
mortality rate following the national
workplace smoking ban in 2004 in the
Republic of Ireland (Stallings-Smith
et al. 2013).
Limitations of the study are
related to sample size and selection
criteria. A power calculation was not
done in advance because of the
explorative character to this study.
Especially the exclusion of women
from the study restricted generaliza-
tion of the results. The reasons to
include only men were existing sex
differences in cardiovascular aging
and adaptive responses to physical
activity, as well as hormonal differ-
ences in pre- and postmenopausal
women (Parker et al. 2010). Another
limitation of the study is that infor-
mation of the socio-economic status
or education levels were not
recorded. However, the socio-eco-
nomic status with respect to years of
education, employment status and
income was quite similar within the
population, because the occupational
situation of all included subjects did
show only minor differences.
Strength of the study is that subjects
with diabetes or current smokers
were excluded to reduce confounding
from these established risk factors
for periodontal disease (Hujoel et al.
2002, Mealey & Oates 2006). In
addition, this study accurately deter-
mined and characterized physical
activity levels of the selected subjects
by self-assessment and by an exten-
sive questionnaire (Frey et al. 1999)
confirming the sedentary lifestyle of
the subjects.
Summary
In summary, the presented study
demonstrated that moderate and
severe periodontitis were associated
with reduced levels of CRF in seden-
tary men. It appeared that this study
36 Eberhard et al.
highlight strong confounding effects
between physical activity, periodon-
tal disease and systemic health that
should take into consideration in
future research design.
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Address:
Jörg Eberhard
Periimplant and Oral Infections
Department of Prosthetic Dentistry and
Biomedical Materials Science
Hannover Medical School
Carl-Neuberg-Str. 1
30625 Hannover
Germany
E-mail: eberhard.joerg@mh-hannover.de
 Periodontitis is associated with CRF 37

Clinical Relevance
Scientific rationale for the study: To
investigate the association between
periodontitis and a surrogate mea-
sure of the functional status of the
respiratory, cardiovascular and
skeletal muscle system.
Principle findings: In this study peri- between periodontal and cardiovas-
odontal disease severity was associ- cular diseases should include data of
ated with low cardiorespiratory physical activity and capacity.
fitness in sedentary men aged
between 45 and 65 years.
Practical implications: Future research
aimed to investigate the association

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd