Oral Health and Its Association with Systolic Blood Pressure Among Women in Rural Nepal: A Cross-Sectional Study

Oral Health and Its Association with Systolic Blood Pressure Among Women in Rural Nepal: A Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Oral Health and Its Association with Systolic Blood Pressure Among Women in Rural Nepal: A Cross-Sectional Study Astrid Kamilla Stunes, Chandra Yogal, Dilip Prajapati, Unni Syversen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8114872/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background: Oral diseases are a significant yet under-recognized public health issue, particularly in low-resource settings. In Nepal, rural women face health inequities and limited access to general and oral healthcare. Emerging evidence suggests a bidirectional relationship between hypertension and poor oral health, but data from South Asia are limited. The object of the current study was to assess the oral health status and examine the potential associations of systolic blood pressure (SBP) with caries experience (Decayed, Missing, and Filled Teeth (DMFT)), and severe periodontitis, among women in rural Nepal. Methods: This cross-sectional study included 691 non-pregnant women from the Kavre District, Nepal, recruited in 2019 as part of a larger health survey. Blood pressure was measured using standardized protocols and clinical oral assessments were conducted using the WHO Oral Health Assessment Form for Adults. Associations between SBP and oral health outcomes were analyzed using negative binomial and logistic regression models, adjusting for sociodemographic, behavioral, and biological factors. Results: The mean age of the participants was 48.4 ± 11.7 years. Decayed teeth were present in 58.6% of the women, only five participants (0.6%) had any restorative dental treatment, and the overall mean DMFT index was 5.07 ± 6.04. Bleeding on probing was observed in 81.6% of the participants, and 12.7% presented with severe periodontitis. Hypertension affected 29.8% of the women. While unadjusted analyses showed associations between SBP and both DMFT and severe periodontitis, these associations were not significant after adjusting for variables such as age, body mass index, smoking, vitamin D levels, and other factors. Conclusions: This study shows a relatively high burden of oral health issues among rural Nepalese women along a high prevalence of hypertension. Although elevated SBP appeared to be linked with poor oral health, adjusted analyses suggest that shared risk factors, such as age, comorbidities, and behavioral practices, may play a more prominent role in this population. These findings underscore the need for integrated health strategies addressing both oral and systemic health in marginalized populations. Figures Figure 1 Introduction Oral diseases constitute a major public health burden, with a global prevalence surpassing the combined prevalence of the five leading noncommunicable diseases (NCDs): cardiovascular diseases (CVDs), diabetes mellitus, chronic respiratory diseases, mental disorders, and cancers [1]. Despite their widespread impact, oral diseases often receive limited attention in health policy due to their typically non-fatal nature. Caries and periodontal disease are the primary contributors to this burden, with substantial implications for individual health, economic productivity, and healthcare systems. According to a systematic analysis from the 2021 Global Burden of Disease study, the South-East Asian region has the highest prevalence of untreated dental caries and severe periodontitis in the world [2]. Within this region, Nepal ranks at an intermediate level, with prevalence rates that fall between the highest- and lowest-burden countries [1]. In developing countries such as Nepal, residents of rural areas typically experience significantly reduced access to both oral and general healthcare services compared to their urban counterparts, thereby contributing to an exacerbation of the overall disease burden. Particularly women in rural Nepal lag behind their urban counterparts in the Human Development and Gender Inequality Indexes [3]. There are limited national data on oral health in Nepal and significant disparities in access and outcomes, particularly among vulnerable populations such as rural women. The WHO emphasizes the urgent need for more comprehensive surveillance and country-specific data to support fair oral health policies and ensure integration into universal health coverage [1, 4]. Hypertension is a prevalent and life-threatening condition that significantly increases the risk of CVDs. In South-East Asia, the number of individuals with uncontrolled hypertension increased by 144% between 1990 and 2019, underscoring the urgent need for effective management [5]. Hypertension and poor oral health share many risk factors, and studies have described bidirectional relationships between elevated blood pressure (BP), a high Decayed, Missing and Filled Teeth (DMFT) index, and periodontitis. In addition to shared risk factors, elevated BP may also contribute to an increase in DMFT index due to systemic inflammation and potential medication-induced reduction in saliva flow. Several recent studies describe a significantly higher DMFT index among those with hypertension [6, 7]. Elevated BP may contribute to periodontitis by impairment of gingival microcirculation and promotion of chronic tissue ischemia [8, 9]. In addition, systemic inflammation and side effects of antihypertensive medications may further exacerbate the risk for periodontitis [8-10]. In the current study we wanted to describe oral health, applying the WHO Oral Health Assessment Form for Adults, among women in a rural area of Nepal. Additionally, we wanted to examine the associations between systolic BP and two key oral health indicators, the DMFT index and severe periodontitis. Methods Study design, setting and participants This is a cross-sectional oral health study conducted among women in a rural setting of Nepal in October to November 2019. The study is part of a larger survey with the primary aim to assess the prevalence of diabetes and the vitamin D status among women in the rural Kavre District [11, 12]. The participants were recruited from a study population of 1498 married, non-pregnant women, assessed for reproductive health and non-communicable diseases in 2012–2013 [12-14]. The inclusion criteria were: married women ≥ 15 years of age, and exclusion criteria were: pregnancy and physical and/or mental conditions that made it challenging to participate. Recruitment of study participants and data collection Government-appointed Female Community Health Volunteers (FCHVs) played a crucial role in recruiting participants and collecting data for the current study. The FCHVs reached out to the women who participated in the 2012–2013 survey, informed them about the new study and invited them to take part. One-day screening sites were set up at health centers, local schools, and village halls. Informed consent was obtained from all women who agreed to participate, either through a signature or a thumbprint. Questionnaires and physical measurements Data collection by interview using questionnaires, physical measurements and blood sampling has previously been described [11]. Briefly, the open data kit free software (V1.4.11, University of Washington, USA) was used to collect data. A comprehensive questionnaire addressing socioeconomic and lifestyle factors was administered through structured interviews conducted by four trained health workers, who also performed physical assessments including measurements of weight, height, and BP. Body weight (kg) was measured using a portable digital weighing scale (Seca 220, Germany). Height (cm) was measured with a stadiometer. Systolic and diastolic BP (SBP and DBP) were measured twice in the left arm, in a seated position, using a digital BP monitor (Omron 5 Series). Measurements were taken 15–30 minutes into the interview and again at the end. The average of the two readings was used for analysis. Blood sampling and analysis Fasting blood samples were collected by standard venipuncture, and a portion of whole blood was transported on ice the same day to the Department of Biochemistry, Dhulikhel Hospital, Kathmandu University Hospital, for analysis of glycosylated hemoglobin (HbA1c) using Hb-Vario (Erba Mannheim, Germany). The remaining blood was centrifuged, and serum samples were stored at -30°C at the study site before being transported to Dhulikhel Hospital in cold boxes and thereafter stored at -80°C until further analyses. Analyses of serum 25-hydroxycholecalciferol (25(OH)D) were performed with a chemiluminescence immunoassay (CLIA) using a LIAISON analyzer (DiaSorian, Italy). Clinical oral health and saliva flow rate assessments A total of six Bachelor of Dental Surgery interns, undertaking a mandatory one-month community placement, were trained in the use of oral health assessment tools and techniques under the supervision of an expert community dentist from Dhulikhel Hospital, Kathmandu University School of Medical Sciences, Nepal. The interns were responsible for clinical assessments of oral health and saliva sampling. Clinical oral health assessments were performed using natural light and/or a headlight, a plain mouth mirror, disposable tongue depressor, and a WHO Community Periodontal Index (CPI) probe. Dental and periodontal measurements were performed in accordance with the WHO Oral Health Assessment Form for Adults [15]. Decayed, missing and filled teeth were registered and bleeding on probing, shallow (4-5 mm probing depth (PD)) and deep (≥ 6 mm PD) periodontal pockets, were measured at multiple sites for 28 teeth. Participants were instructed to refrain from eating, drinking, or smoking for at least 30 minutes prior to saliva collection. Unstimulated Whole Saliva Flow Rate (UWSFR) was performed by collecting saliva over a period of five minutes without swallowing. The total saliva volume was transferred into a standard calibrated measuring tube and UWSFR in mL/minute was calculated. Classifications and definitions of variables Socioeconomic status Socioeconomic status (SES) was calculated according to Kuppuswamy’s Socioeconomic Status Scale in the context of Nepal, 2019 [16]. This scale uses a combined score including education, occupation and total household income per month, and categorizes SES into five classes: upper class, upper middle class, lower middle class, upper lower class, and lower class. Anthropometrics Body Mass Index (BMI) was calculated in kg/m 2 , and categorized according to the WHO recommendations for Asian populations [17], as underweight: < 18.5 kg/m 2 , normal weight: 18.5 – < 23.0 kg/m 2 , overweight: 23.0 – < 27.5 kg/m 2 , and obesity: ≥ 27.5 kg/m 2 . Blood pressure status BP among participants was categorized as normal if SBP < 120 and DBP < 80 mm Hg, elevated if SBP ≥ 120 – < 140 mm Hg or DBP ≥ 80 – < 90 mm and as hypertension if SBP ≥ 140 mmHg and/or DBP ≥ 90 mm Hg and/or participant used BP medication [5]. Glycemic status The participants were assigned to have normal glycemic status if they had HbA1c < 5.7% (< 39 mmol/mol), prediabetes if they had HbA1c ≥ 5.7% – < 6.5% (≥ 39 – < 48 mmol/mol) and as having diabetes if they had a history of diabetes and/or used antidiabetic medication and/or had a HbA1c of ≥ 6.5% (≥ 48 mmol/mol), in accordance with the WHO classification [18]. Caries experience The total number of decayed, missing and filled teeth (DMFT) was registered for 28 teeth. Based on the WHO guidelines [15], the caries experience by the DMFT index was categorized as follows; very low: 13.9. Gingival status Full mouth bleeding status (FMBS) was calculated as the number of sites bleeding on probing in percentages of recorded sites. Gingival status, irrespective of absence or presence of periodontal pockets, was categorized by FMBS as; healthy gingiva: 30%, in accordance with guidelines [19]. Periodontal status Classification of periodontal status was conducted in the following manner; healthy / no periodontitis: ≤ 1 pocket 4–5 mm, mild to moderate periodontitis: ≥ 2 pockets 4–5 mm (not on the same tooth), and severe periodontitis: ≥ 1 pocket ≥ 6 mm and ≥ 1 pocket 4–5 mm (not on the same tooth), the latter in accordance with WHOs definition of severe periodontitis [20]. Saliva flow rate Unstimulated whole saliva flow rate (UWSFR) was classified as: normal: ≥ 0.2 mL/minute, low: > 0.1 ­­– < 0.2 mL/minute and very low (hyposalivation): ≤ 0.1 mL/minute in accordance with pervious defined categories [21]. Statistics Descriptive characteristics are summarized as mean ± standard deviation or as frequency in numbers with percentage (n [%]). Normality of data distribution and homogeneity of variance were tested by Shapiro-Wilk test and Levene’s test for equality of variance, respectively. Differences in continuous variables were analyzed by an independent Student’s t -tests or by a Mann-Whitney U -Test, depending on the distribution. Differences in categorical variables were analyzed by Chi-Square tests. The associations between SBP and DMFT were assessed using negative binomial regression models, which are appropriate for count data exhibiting overdispersion, such as DMFT. Results are presented as Incident Rate Ratio (IRR) with the corresponding 95% confidence intervals (CIs). Variable selection and model structure were guided by a Directed Acyclic Graph (DAG) (Supplementary Figure 1), constructed based on theoretical and empirical evidence of relationships between exposure and outcome. Confounders were defined as variables that influence both exposure and outcome, mediators as those lying on the causal pathway, and covariates as variables associated with the outcome, but not necessarily with the exposure. Model 1 included age (years), BMI (kg/m²), and SES (middle and low). Model 2 extended Model 1 by additionally adjusting for DBP (mm Hg), smoking status (never, former, current), tooth brushing frequency (≥ 1/day vs < 1/day), serum vitamin D levels (nmol/L), and UWSFR (mL/minute). The association between SBP and severe periodontitis was evaluated using binary logistic regression analyses. Variable selection and model specification were informed by a DAG (Supplementary Figure 2). Model 1adjusted for the potential confounders: age (years), BMI (kg/m²), SES, and smoking status. Model 2 further adjusted for the potential mediators: DBP (mm Hg), serum vitamin D (nmol/L), and glycemic status (normal, pre-diabetes, and diabetes). Results from the logistic regression are reported as crude and adjusted odds ratios (ORs and AORs) with corresponding 95% CIs. Statistical significance was set at p < 0.05. Results Participants A total of 691 women, who completed both BP measurements and clinical oral assessments, were included in this cross-sectional oral health study. The study was conducted as part of a larger population-based follow-up survey [11, 12], and a flow chart of study participants is shown in Figure 1. Sociodemographic and clinical characteristics of the study participants are summarized in Table 1. The mean age of the participants was 48.4 ± 11. 7 years. Most women had no formal education (88.2%), and 73.8% were classified as having low SES. Previous or current smoking were reported among 35.0% of the women, and 27.3% informed to brush their teeth less than once per day. Blood pressure, glycemic status and vitamin D status The mean SBP was 126.3 ± 19.1 mm Hg and the mean DBP was 82.0 ± 10.7 mm Hg, with 43% and 29.8% meeting the criteria for elevated BP and hypertension, respectively. Among those with hypertension, the use of blood pressure medication was reported by 43 of the women, of whom 25 still had hypertension, 17 had elevated BP and only one participant had normal BP. Pre-diabetes or diabetes was identified in 37.9% of participants. A total of 44.3% of the participants had serum vitamin D below 50 nmol/L. Data collection and blood sampling were conducted over a two-month period (October and November) and no monthly variation in serum vitamin D concentrations was observed. Oral health characteristics Comprehensive clinical oral health characteristics are summarized in Table 2 and in Supplementary Table 1. Overall, 85.4% of the participants had 20 or more natural teeth, which is the WHO definition of having a functional dentition [15]. Decayed teeth were present in 58.6% of the participants (mean 1.77 ± 2.37), while missing teeth were observed in 56.3% (mean 3.29 ± 5.22). Restorative treatment was rare, with only five (0.6%) of the participants presented with any filled teeth. The mean DMFT index for the study population was 5.07 ± 6.04 and was highest (8.87 ± 7.38) among women ≥ 55 years of age. The mean DMFT among participants in the WHO reference group aged 35–44 years was 2.83 ± 4.14. Based on the DMFT index classification [15], 12.2% of the study participants were in the high DMFT group (> 13.9), 8.7% were in the moderate group (9.0–13.9), and 79.2% were in the very low to low group (< 9.0). Bleeding on probing was present in 81.6% of the participants. Gingivitis was found in 77.4% of the participants, including 47.6% with generalized gingivitis. The prevalence of gingivitis was similar across all age groups. Periodontitis was observed in 35.9% of the participants, classified as mild to moderate in 23.2% and as severe in 12.7% of the population. The prevalence of severe periodontitis increased with age, from 7.5% in participants < 35 years to 21.9% in those ≥ 55 years. Among participants in the WHO reference group aged 35–44 years, 8.7% had severe periodontitis. The mean UWSFR among the women was 0.51 ± 0.30 mL/min. Hyposalivation (UWSFR ≤ 0.1 mL/minute) was observed in 9.8% of the participants, and the saliva flow rate was observed to progressively decline with age. Associations between SBP, DMFT, and severe periodontitis Selected variables based on the DAG model (Supplementary Figure 1) stratified by DMFT status is shown in Supplementary Table 2. SBP was positively associated with an increase in DMFT scores (IRR: 1.071, 95% CI: 1.025–1.119; p = 0.002) as shown in Table 3. This association was no longer significant after adjusting for variables such as age, BMI, tooth brushing frequency, serum vitamin D levels, and saliva flow rate, which appear to have a stronger influence on DMFT (Table 3). Selected variables based on the DAG model (Supplementary Figure 2) stratified by periodontal status are shown in Supplementary Table 3. SBP was positively associated with an increased risk for severe periodontitis (OR: 1.115, 95% CI: 1.001–1.242, p = 0.047) as shown in Table 4. After adjusting for the potential confounders age, BMI, smoking and SES and the potential mediators DBP, serum vitamin D levels, and glycemic status, the association was no longer significant (Table 4). Discussion In this cross-sectional study of 691 women in rural Nepal, we observed a relatively high prevalence of oral health issues, including decayed teeth, gingivitis, and periodontitis, alongside systemic health concerns such as elevated BP. Although initial analyses showed associations between SBP and both DMFT scores and severe periodontitis, these associations were no longer evident after adjusting for variables like age, BMI, smoking, and vitamin D levels. Blood pressure A total of 29.8% of the women were found to have hypertension. This prevalence was lower than the 34% reported by WHO for Nepalese women [5], yet notably higher than the 17.9% reported in the 2022 Nepal Demographic and Health Survey [22]. In accordance with the latter study, the use of antihypertensives was low in this population [22]. Elevated BMI is a well-established risk factor for hypertension, and the high proportion of participants with overweight or obesity (63.1%) in this study likely contributed to the relatively high prevalence of hypertension. Oral health A functional dentition, here defined as having 20 or more natural teeth, was present in 85.4% of the women. This proportion declined with age and among women aged 55 years and older, only 68.6% retained a functional dentition. This age-related decrease is of concern, as the preservation of a functional dentition in older adults is associated with improved general health, enhanced quality of life, and a reduced risk of adverse health outcomes [23]. Decayed teeth were present in 58.6% of the participants, with small variations across the age groups. The observed prevalence of untreated caries was lower in the current study compared to two previous studies among women in Nepal, which reported prevalences of 69.8% and 69.6%, respectively [24, 25]. Missing teeth were observed in all age groups. The presence and number of missing teeth increased significantly with age, reaching a prevalence of 83.3% among women aged 55 and older. Only five participants (0.6%) had evidence of restorative dental treatment (filled teeth), suggesting that this component had minimal impact on the overall DMFT index in this study. Nevertheless, it was included in the calculation for completeness. The low prevalence of restorative care indicates limited access to dental care, with oral health issues likely progressing untreated until extraction is required. This interpretation is supported by the finding that nearly half of the women reported never having visited a dental health worker. Because the DMFT index represents a cumulative measure of caries experience, it was, as anticipated, highest among participants in the oldest age group (≥ 55 years). However, the prevalence and mean number of decayed teeth, and consequently the DMFT index, were higher in the youngest age group (< 35 years) compared to the WHO reference group aged 35–44 years. This may reflect the recent dietary transition in Nepal, characterized by increased consumption of processed foods high in sugar and fat, disproportionately affecting younger individuals. Previous findings from this population have also demonstrated a high prevalence of overweight, obesity, and central obesity, also among the younger age groups [26]. Among women in the WHO reference age group of 35–44 years, the mean DMFT was 2.83. This value is lower than the DMFT of 4.0 reported for Nepal in the WHO Global Oral Health Data Bank [27], and also lower than the mean DMFT of 3.18 reported among females in a recent study of a comparable Nepalese population [28]. Although most participants reported brushing their teeth, 27.3% did so less than once per day, and participants who did not brush daily had significantly higher DMFT scores. Infrequent brushing, possibly combined with suboptimal technique, may contribute to increased caries and subsequently tooth loss. Bleeding on probing is known to be highly prevalent during pregnancy, due to hormonal changes. This is supported by two studies from Nepal, reporting that 79.3% and 100% of the participants exhibited bleeding on probing during pregnancy [24, 29]. In contrast to studies involving pregnant women, the present study, conducted exclusively among non-pregnant women, found bleeding on probing in 81.6% the of participants, with 77.6% exhibiting gingivitis (FMBS ≥ 10%). These findings indicate an alarmingly high prevalence of gingival inflammation in this population, independent of pregnancy-related physiological changes. Despite the high prevalence of bleeding on probing among women in the present study, the prevalence of severe periodontitis was 12.7%, which is relatively low compared to other reports from Nepal. The WHO estimates a national prevalence of 14.8% for severe periodontal disease among individuals aged 15 years and older [4]. Additionally, a 2021 cross-sectional study from rural eastern Nepal, involving 440 adults aged 20–65 years, found a prevalence of 31.7% using the same diagnostic criteria as in the current study [30]. Among participants in the WHO reference age group of 34–44 years, the prevalence was 8.7%, which is markedly lower than the 34% previously reported for Nepal [31]. Associations We found an initial positive association between SBP and DMFT, but this was not present in the adjusted analyses. Previous research, including a large cross-sectional study of 10,520 individuals aged 35–70 in Iran, reported significantly higher DMFT indices among participants with hypertension in an unadjusted model [6]. Further, a cross-sectional group comparison study from Pakistan, including 108 adults aged 24–69 found that individuals with undiagnosed and untreated hypertension had nearly double the DMFT scores compared to those with normal BP [7]. On the other hand, no significant association was found between blood pressure and adolescents in the National Health and Nutrition Examination Survey (NHANES) study, including 2861 participants aged 13–17 years [32]. Elevated BP may raise DMFT scores through systemic inflammation, vascular changes, and medication-induced dry mouth. This association may be less relevant in adolescents due to fewer comorbidities, limited medication use, and greater oral and vascular resilience. The observation of no association between SBT and DMFT after adjusting for other variables in the current study suggests that established factors like age, BMI, tooth brushing frequency, saliva flow rate, and possibly vitamin D levels, were more decisive in determining DMFT scores in the current population. We observed that SBT was associated with severe periodontitis in the crude analysis. Several studies have previously identified a bidirectional link between periodontitis and elevated BP. Data from the NHANES study, which included 5,396 individuals over the age of 30, showed that people with active periodontitis or bleeding on probing, an early sign of periodontal disease, had significantly higher SBP independent of other factors [33]. These findings were supported by a 2021 case-control study from Great Britain, which found that individuals with periodontitis had higher SBP and DBP compared to healthy controls, regardless of other cardiovascular risk factors [34]. Additionally, this study described that SBP was associated with bleeding on probing, even in individuals without diagnosed periodontitis [34]. Periodontal inflammation may contribute to elevated BP through systemic inflammatory pathways and endothelial dysfunction, while antihypertensive medications and vascular changes associated with hypertension can impair oral health by reducing salivary flow and gingival perfusion. In the current study, the association between SBP and severe periodontitis was not significant in adjusted analyses, indicating that other established risk factors like BMI, SES, smoking, diabetes, and serum vitamin D [31, 35], were more decisive determinants of severe periodontitis in this population. Strengths and limitations This study has several strengths, including a relatively large cohort of rural Nepalese women, representing a vulnerable population with limited data on oral health outcomes. Further, we collected extensive biological specimens and detailed data on sociodemographic characteristics, anthropometric and physiological measurements, and oral health parameters. Clinical oral health assessments were performed by Dental Surgery interns, in accordance with the WHO Oral Health Assessment Form for Adults [15], facilitating comparisons with other populations. On the other hand, even though the examiners were trained under the supervision of an expert community dentist, the oral health assessments were not calibrated between the examiners, causing a risk for individual discrepancies. Further, as the present study population was recruited from an initial survey focused on reproductive health, only women were included. This might result in an overestimation of oral health problems, as women in Nepal generally experience poorer health than men due to gender norms, social inequities, and limited healthcare access. Although less studied, similar disparities are seen in oral health, with higher DMFT scores reported among females in some studies [25, 36]. The calculation of SES according to the Kuppuswamy [16], the participants’ own occupations, rather than those of the household heads, were used. This approach was necessary due to limited information on husbands’ occupations and may have led to a slight underestimation of SES in this study. Additionally, self-reported behaviors such as smoking and the frequency of tooth brushing may be subject to recall bias and misestimation, potentially affecting the results. Finally, the cross-sectional design limits the ability to draw causal inferences from the observed associations. Conclusion This cross-sectional study among rural Nepalese women describes the prevalence of oral diseases, including caries, gingivitis and periodontitis. Of notice, only 0.6% of the population presented with any dental restoration. We also observed a relatively high prevalence of elevated blood pressure. Although initial analyses showed associations between SBP and both DMFT index and severe periodontitis, these relationships were not evident after adjusting for factors such as age, BMI, comorbidities and behavioral and oral hygiene practices. These findings support the integration of oral health into broader public health strategies, particularly in underserved communities. Declarations Ethics approval and consent to participate Ethical approval was obtained from the National Health Research Council, Nepal (Reg.no. 744/2018), the Institutional Review Committee of Kathmandu University School of Medical Sciences, Dhulikhel Hospital (approval no. 124/19) and Regional Committees for Medical and Health Research Ethics, Norway (REK no. 13003). Informed consent was obtained from all participants, by signature or thumbprint. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. All data generated during this study are included in this published article and its supplementary files. Competing interests The authors declare that the research was conducted without interference from commercial or financial relationships. The authors declare that they have no competing interests. Funding This study was supported by grants from the Liaison Committee between the Central Norway Regional Health Authority (RHA) and the Norwegian University of Science and Technology (NTNU). The funding body did not have a role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. Authors' contributions All authors made substantial contributions before submission, and all authors have read and approved the final manuscript. AKS analysed and interpreted the data and was the major contributor in writing the manuscript. CY, DP and US planned the original study and was responsible for participant recruitment, health assessments and analyses. US and AKS conceived the idea of the present study and were involved in data interpretation, and supervision of the study. Acknowledgements The authors would like to thank all the women who volunteered to participate, the female volunteer health workers and the dental intern students. Without their dedication, this research would not be possible. The author also like to thank Hedda Høvik, Center for Oral Health Services and Research, Mid-Norway (TkMidt), Trondheim, Norway, for valuable input and revision. References WHO: Global oral health status report: towards universal health coverage for oral health by 2030: regional summary of the South-East Asia Region . In . ; 2023. 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Herrera D, Tonetti MS, Chapple I, Kebschull M, Papapanou PN, Sculean A, Abusleme L, Aimetti M, Belibasakis G, Blanco J et al : Consensus Report of the 20th European Workshop on Periodontology: Contemporary and Emerging Technologies in Periodontal Diagnosis . J Clin Periodontol 2025, 52 Suppl 29 (Suppl 29):4–33. World Health Organization, Oral health: Prevalence of severe periodontal disease in people 15+ years [https://www.who.int/data/gho/indicator-metadata-registry/imr-details/6104] Flink H, Tegelberg A, Lagerlöf F: Influence of the time of measurement of unstimulated human whole saliva on the diagnosis of hyposalivation . Arch Oral Biol 2005, 50 (6):553–559. Dhungana RR, Pedisic Z, Dhimal M, Bista B, de Courten M: Hypertension screening, awareness, treatment, and control: a study of their prevalence and associated factors in a nationally representative sample from Nepal . Glob Health Action 2022, 15 (1):2000092. 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Tables Table 1 : Characteristics of study population N = 691 Age, yrs 48.4 ± 11.7 < 35 yrs 80 [11.6] 35–44 yrs 183 [26.5] 45–54 yrs 218 [31.5] ≥ 55 yrs 210 [30.4] Ethnicity Brahmin/Chhetri 84 [12.2] Newar/Tamang 549 [79.5] Dalit 32 [4.5] Others 26 [3.8] Education Bachelor degree 7 [1.0] Higher secondary school, PCL 17 [2.5] Secondary school 20 [2.9] Primary school 28 [4.1] No formal education 610 [88.2] Missing 9 [1.3] Household income per month, NPR 25 454 ± 38 348 < 5 000 42 [6.1] 5 000 – < 20 000 277 [40.1] 20 000 – < 50 000 277 [40.1] ≥ 50 000 95 [13.7] Work status, last 12 months Government employee 25 [3.6] Non-government employee 8 [1.2] Self-employee (agriculture, animal husbandry, business and others) 528 [76.4] Homemaker 101 [14.6] Missing 29 [4.2] SES Upper middle 81 [11.7] Lower middle 63 [9.1] Upper lower 42 [6.1] Lower 468 [67.7] Missing 37 [5.4] Smoking status Never 448 [64.9] Previous 106 [15.3] Current 136 [19.7] Missing 1 [0.1] Tooth brushing frequency ≥ 2 times/day 30 [4.4] Once/day 467 [67.6] Weekly 170 [24.6] Monthly or never 19 [2.7] Missing 5 [0.7] Anthropometrics a Weight, kg 54.8 ± 10.3 Height, m 1.49 ± 0.06 BMI, kg/m 2 24.8 ± 4.3 Underweight, BMI < 18.5 kg/m 2 38 [5.5] Normal weight, BMI: ≥ 18.5 – < 23 kg/m 2 214 [31.0] Overweight, BMI: ≥ 23 – < 27.5 kg/m 2 265 [38.4] Obesity, BMI ≥ 27.5 kg/m 2 171 [24.7] Missing 3 [0.4] SBP, mm Hg 126.3 ± 19.1 DBP, mm Hg 82.0 ± 10.7 BP status* Normal 188 [27.2] Elevated 297 [43.0] Hypertension 206 [29.8] HbA1c, mmol/mol b 37.52 ± 8.59 Glycemic status** Normal 409 [59.2] Pre-diabetes 231 [33.4] Diabetes 31 [4.5] Missing 20 [2.9] Serum 25(OH)D, nmol/L c 52.3 ± 15.5 ≥ 50 nmol/L 355 [51.4] < 50 nmol/L 306 [44.3] Missing 30 [4.3] Data are in mean ± standard deviation or number [percentage] PCL = Proficiency Certificate Level, NPR = Nepalese Rupee, SES = Socioeconomic Status, BMI = Body Mass Index, SBP/DBP = Systolic/Diastolic Blood Pressure. HbA1c = glycated hemoglobin * BP status: Normal: SBP < 120 mm Hg and DBP < 80 mm Hg, Elevated: SBP ≥ 120 to < 140 mm Hg or DBP ≥ 80 to < 90 mm Hg, Hypertension: SBP ≥ 140 mm Hg and/or DBP ≥ 90 mm Hg and/or use BP medication ** Glycemic status: Normal: HbA1c < 39 mmol/mol, Pre-diabetes: HbA1c ≥ 39 to < 48 mmol/mol, Diabetes: diabetes history/medication/HbA1c ≥ 48 mmol/mol) a missing data from N = 3 b missing data from N = 20 c missing data from N = 30 Table 2: Clinical oral health characteristics Total, N = 691 < 35 yrs, N = 80 35–44 yrs, N = 183 45–54 yrs, N = 218 ≥ 55 yrs, N = 210 Number of natural teeth 1–9 teeth 15 [2.2] - - - 15 [7.1] 10–19 teeth 86 [12.4] 5 [6.3] 10 [5.5] 20 [9.2] 51 [24.3] ≥ 20 teeth 590 [85.4] 75 [93.7] 173 [94.5] 198 [90.8] 144 [68.6] Decayed teeth Present in 405 [58.6] 45 [56.3] 91 [49.7] 130 [59.6] 139 [66.2] Mean + SD 1.77 ± 2.37 1.54 ± 1.97 1.35 ± 2.06 1.67 ± 1.90 2.33 ± 3.02 Missing teeth Present in 389 [56.3] 28 [35.0] 66 [36.1] 120 [55.0] 175 [83.3] Mean ± SD 3.29 ± 5.22 1.45 ± 3.58 1.46 ± 3.33 2.36 ± 3.81 6.54 ± 6.67 Filled teeth Present in 5 [0.6] DMFT Mean ± SD 5.07 ± 6.04 3.01 ± 4.52 2.83 ± 4.14 4.04 ± 4.55 8.87 ± 7.38 DMFT status* Low 547 [79.2] 73 [91.3] 168 [91.8] 186 [85.3] 120 [57.1] Moderate 60 [8.7] 2 [2.5] 6 [3.3] 21 [9.6] 31 [14.8] High 84 [12.2] 5 [6.3] 9 [4.9] 11 [5.0] 59 [28.1] Gingival status** Healthy 156 [22.6] 17 [21.3] 33 [18.0] 41 [18.8] 65 [31.0] Localized 206 [29.8] 28 [35.0] 60 [32.8] 71 [32.6] 47 [22.4] Generalized 329 [47.6] 35 [43.7] 90 [49.2] 106 [48.6] 98 [46.6] Periodontal status*** Healthy 443 [64.1] 68 [85.0] 134 [73.2] 142 [65.1] 99 [47.1] Mild to moderate 160 [23.2] 6 [7.5] 33 [18.0] 56 [25.7] 65 [31.0] Severe 88 [12.7] 6 [7.5] 16 [8.7] 20 [9.2] 46 [21.9] Total, N = 650 < 35 yrs, N = 77 35–44 yrs, N = 172 45–54 yrs, N = 206 ≥ 55 yrs, N = 195 UWSFR status**** Normal 569 [87.5] 71 [92.2] 158 [91.9] 175 [84.9] 165 [84.6] Low 17 [2.6] 2 [2.6] 4 [2.3] 3 [1.5] 8 [4.1] Hyposalvation 64 [9.8] 4 [5.2] 10 [5.8] 28 [13.6] 22 [11.3] Data are in numbers [%] or mean ± standard deviation DMFT = Decayed, Missing and Filled Teeth, UWSFR = Unstimulated Whole Saliva Flow Rate *DMFT status: Low: 13.9 **Gingival status: Healthy gingiva: Full Mouth Bleeding Status (FMBS) 30% ***Periodontal status: Healthy: no or 1 pocket 4–5 mm, Mild to moderate: ≥ 2 pockets 4–5 mm (not on the same tooth), Severe: ≥ 2 pockets 4–5 mm and ≥ 1 pocket ≥ 6 mm (not on the same tooth) ***UWSFR status: Normal: ≥ 0.2 mL/minute, Low: > 0.1 – < 0.2 mL/minute and Hyposalivation: ≤ 0.1 mL/minute Table 3: Associations between Systolic Blood Pressure (SBP) and the Decayed, Missing and Filled Teeth (DMFT) index SBP, per 10 mm Hg IRR DMFT index 95% CI p N Crude 1.071 1.025–1.119 0.002 691 Model 1 0.995 0.995–1.044 0.833 651 Model 2 1.058 0.980–1.143 0.150 590 IRR = Incident Rate Ratio Model 1: Age, Body Mass Index, SES, Model 2: Model 1 + Diastolic Blood Pressure, Smoking status, Frequency of tooth brushing, serum 25(OH)D and Unstimulated Whole Saliva Flow Rate Table 4: Associations between Systolic Blood Pressure (SBP) and severe periodontitis Healthy, mild to moderate periodontitis Severe periodontitis SBP, per 10 mm Hg OR 95% CI p N Crude Reference 1.115 1.001–1.242 0.047 691 AOR Model 1 Reference 1.054 0.931–1.193 0.405 650 Model 2 Reference 1.012 0.840–1.219 0.903 614 OR = Odds Ratio, AOR = Adjusted Odds Ratio Model 1: Age, Body Mass Index, SES and Smoking status, Model 2: Model 1 + Diastolic Blood Pressure, serum 25(OH)D and Glycemic status Additional Declarations No competing interests reported. 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diseases constitute a major public health burden, with a global prevalence surpassing the combined prevalence of the five leading noncommunicable diseases (NCDs): cardiovascular diseases (CVDs), diabetes mellitus, chronic respiratory diseases, mental disorders, and cancers [1]. Despite their widespread impact, oral diseases often receive limited attention in health policy due to their typically non-fatal nature. Caries and periodontal disease are the primary contributors to this burden, with substantial implications for individual health, economic productivity, and healthcare systems.\u003c/p\u003e\n\u003cp\u003eAccording to a systematic analysis from the 2021 Global Burden of Disease study, the South-East Asian region has the highest prevalence of untreated dental caries and severe periodontitis in the world [2]. Within this region, Nepal ranks at an intermediate level, with prevalence rates that fall between the highest- and lowest-burden countries [1].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn developing countries such as Nepal, residents of rural areas typically experience significantly reduced access to both oral and general healthcare services compared to their urban counterparts, thereby contributing to an exacerbation of the overall disease burden. Particularly women in rural Nepal lag behind their urban counterparts in the Human Development and Gender Inequality Indexes [3]. There are limited national data on oral health in Nepal and significant disparities in access and outcomes, particularly among vulnerable populations such as rural women. The WHO emphasizes the urgent need for more comprehensive surveillance and country-specific data to support fair oral health policies and ensure integration into universal health coverage [1, 4].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHypertension is a prevalent and life-threatening condition that significantly increases the risk of CVDs. In South-East Asia, the number of individuals with uncontrolled hypertension increased by 144% between 1990 and 2019, underscoring the urgent need for effective management [5]. Hypertension and poor oral health share many risk factors, and studies have described bidirectional relationships between elevated blood pressure (BP), a high Decayed, Missing and Filled Teeth (DMFT) index, and periodontitis. In addition to shared risk factors, elevated BP may also contribute to an increase in DMFT index due to systemic inflammation and potential medication-induced reduction in saliva flow. Several recent studies describe a significantly higher DMFT index among those with hypertension [6, 7]. Elevated BP may contribute to periodontitis by impairment of gingival microcirculation and promotion of chronic tissue ischemia [8, 9]. In addition, systemic inflammation and side effects of antihypertensive medications may further exacerbate the risk for periodontitis [8-10].\u003c/p\u003e\n\u003cp\u003eIn the current study we wanted to describe oral health, applying the WHO Oral Health Assessment Form for Adults, among women in a rural area of Nepal. Additionally, we wanted to examine the associations between systolic BP and two key oral health indicators, the DMFT index and severe periodontitis.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design, setting and participants\u003c/p\u003e\n\u003cp\u003eThis is a cross-sectional\u0026nbsp;oral health study conducted among women in a rural setting of Nepal in October to November 2019. The study is part of a larger survey with the primary aim to assess the prevalence of diabetes and the vitamin D status among women in the rural Kavre District [11, 12].\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe participants were recruited from a study population of 1498 married, non-pregnant women, assessed for reproductive health and non-communicable diseases in 2012\u0026ndash;2013 [12-14]. The inclusion criteria were: married women \u0026ge; 15 years of age, and exclusion criteria were: pregnancy and physical and/or mental conditions that made it challenging to participate.\u003c/p\u003e\n\u003cp\u003eRecruitment of study participants and data collection\u003c/p\u003e\n\u003cp\u003eGovernment-appointed Female Community Health Volunteers (FCHVs) played a crucial role in recruiting participants and collecting data for the current study. The FCHVs reached out to the women who participated in the 2012\u0026ndash;2013 survey, informed them about the new study and invited them to take part. One-day screening sites were set up at health centers, local schools, and village halls. Informed consent was obtained from all women who agreed to participate, either through a signature or a thumbprint.\u003c/p\u003e\n\u003cp\u003eQuestionnaires and physical measurements\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData collection by interview using questionnaires, physical measurements and blood sampling has previously been described [11]. Briefly, the open data kit free software (V1.4.11, University of Washington, USA) was used to collect data. A comprehensive questionnaire addressing socioeconomic and lifestyle factors was administered through structured interviews conducted by four trained health workers, who also performed physical assessments including measurements of weight, height, and BP. Body weight (kg) was measured using a portable digital weighing scale (Seca 220, Germany). Height (cm) was measured with a stadiometer. Systolic and diastolic BP (SBP and DBP) were measured twice in the left arm, in a seated position, using a digital BP monitor (Omron 5 Series). Measurements were taken 15\u0026ndash;30 minutes into the interview and again at the end. The average of the two readings was used for analysis.\u003c/p\u003e\n\u003cp\u003eBlood sampling and analysis\u003c/p\u003e\n\u003cp\u003eFasting blood samples were collected by standard venipuncture, and a portion of whole blood was transported on ice the same day to the Department of Biochemistry, Dhulikhel Hospital, Kathmandu University Hospital, for analysis of glycosylated hemoglobin (HbA1c) using Hb-Vario (Erba Mannheim, Germany). The remaining blood was centrifuged, and serum samples were stored at -30\u0026deg;C at the study site before being transported to Dhulikhel Hospital in cold boxes and thereafter stored at -80\u0026deg;C until further analyses. Analyses of serum 25-hydroxycholecalciferol (25(OH)D) were performed with a chemiluminescence immunoassay (CLIA) using a LIAISON\u0026nbsp;analyzer (DiaSorian, Italy).\u003c/p\u003e\n\u003cp\u003eClinical oral health and saliva flow rate assessments\u003c/p\u003e\n\u003cp\u003eA total of six Bachelor of Dental Surgery interns, undertaking a mandatory one-month community placement, were trained in the use of oral health assessment tools and techniques under the supervision of an expert community dentist from Dhulikhel Hospital, Kathmandu University School of Medical Sciences, Nepal. The interns were responsible for clinical assessments of oral health and saliva sampling.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClinical oral health assessments were performed using natural light and/or a headlight, a plain mouth mirror, disposable tongue depressor, and a WHO Community Periodontal Index (CPI) probe. Dental and periodontal measurements were performed in accordance with the WHO Oral Health Assessment Form for Adults [15]. Decayed, missing and filled teeth were registered and bleeding on probing, shallow (4-5 mm probing depth (PD)) and deep (\u0026ge; 6 mm PD) periodontal pockets, were measured at multiple sites for 28 teeth.\u003c/p\u003e\n\u003cp\u003eParticipants were instructed to refrain from eating, drinking, or smoking for at least 30 minutes prior to saliva collection. Unstimulated Whole Saliva Flow Rate (UWSFR) was performed by collecting saliva over a period of five minutes without swallowing. The total saliva volume was transferred into a standard calibrated measuring tube and UWSFR in mL/minute was calculated.\u003c/p\u003e\n\u003cp\u003eClassifications and definitions of variables\u003c/p\u003e\n\u003cp\u003eSocioeconomic status\u003c/p\u003e\n\u003cp\u003eSocioeconomic status (SES) was calculated according to Kuppuswamy\u0026rsquo;s Socioeconomic Status Scale in the context of Nepal, 2019 [16]. This scale uses a combined score including education, occupation and total household income per month, and categorizes SES into five classes: upper class, upper middle class, lower middle class, upper lower class, and lower class.\u003c/p\u003e\n\u003cp\u003eAnthropometrics\u003c/p\u003e\n\u003cp\u003eBody Mass Index (BMI) was calculated in kg/m\u003csup\u003e2\u003c/sup\u003e, and categorized according to the WHO recommendations for Asian populations [17], as underweight: \u0026lt; 18.5 kg/m\u003csup\u003e2\u003c/sup\u003e, normal weight: 18.5 \u0026ndash; \u0026lt; 23.0 kg/m\u003csup\u003e2\u003c/sup\u003e, overweight: 23.0 \u0026ndash; \u0026lt; 27.5 kg/m\u003csup\u003e2\u003c/sup\u003e, and obesity: \u0026ge; 27.5 kg/m\u003csup\u003e2\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eBlood pressure status\u003c/p\u003e\n\u003cp\u003eBP among participants was categorized as normal if SBP \u0026lt; 120 and DBP \u0026lt; 80 mm Hg, elevated if SBP \u0026ge; 120 \u0026ndash; \u0026lt; 140 mm Hg or DBP \u0026ge; 80 \u0026ndash; \u0026lt; 90 mm and\u003c/p\u003e\n\u003cp\u003eas hypertension if SBP \u0026ge; 140 mmHg and/or DBP \u0026ge; 90 mm Hg and/or participant used BP medication [5].\u003c/p\u003e\n\u003cp\u003eGlycemic status\u003c/p\u003e\n\u003cp\u003eThe participants were assigned to have normal glycemic status if they had HbA1c \u0026lt; 5.7% (\u0026lt; 39 mmol/mol), prediabetes if they had HbA1c \u0026ge; 5.7% \u0026ndash; \u0026lt; 6.5% (\u0026ge; 39 \u0026ndash; \u0026lt; 48 mmol/mol) and as having diabetes if they had a history of diabetes and/or used antidiabetic medication and/or had a HbA1c of \u0026ge; 6.5% (\u0026ge; 48 mmol/mol),\u0026nbsp;in accordance with the WHO classification [18].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCaries experience\u003c/p\u003e\n\u003cp\u003eThe total number of decayed, missing and filled teeth (DMFT) was registered for 28 teeth. Based on the WHO guidelines [15], the caries experience by the DMFT index was categorized as follows; very low: \u0026lt; 5, low:\u0026nbsp;5\u0026nbsp;\u0026ndash;\u0026nbsp;\u0026le;\u0026nbsp;8.9, moderate: 9 \u0026ndash;\u0026nbsp;\u0026le;\u0026nbsp;13.9 and high: \u0026gt; 13.9.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGingival status\u003c/p\u003e\n\u003cp\u003eFull mouth bleeding status (FMBS) was calculated as the number of sites bleeding on probing in percentages of recorded sites. Gingival status, irrespective of absence or presence of periodontal pockets, was categorized by FMBS as; healthy gingiva: \u0026lt; 10%, localized gingivitis: 10% \u0026ndash; 30% and generalized gingivitis: \u0026gt; 30%, in accordance with guidelines [19].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePeriodontal status\u003c/p\u003e\n\u003cp\u003eClassification of periodontal status was conducted in the following manner; healthy / no periodontitis:\u0026nbsp;\u0026le;\u0026nbsp;1 pocket 4\u0026ndash;5 mm, mild to moderate periodontitis:\u0026nbsp;\u0026ge; 2 pockets 4\u0026ndash;5 mm (not on the same tooth), and severe periodontitis: \u0026ge; 1 pocket \u0026ge; 6 mm and \u0026ge; 1 pocket 4\u0026ndash;5 mm (not on the same tooth), the latter in accordance with WHOs definition of severe periodontitis [20].\u003c/p\u003e\n\u003cp\u003eSaliva flow rate\u003c/p\u003e\n\u003cp\u003eUnstimulated whole saliva flow rate (UWSFR) was classified as: normal: \u0026ge; 0.2 mL/minute, low: \u0026gt; 0.1 \u0026shy;\u0026shy;\u0026ndash; \u0026lt; 0.2 mL/minute and very low (hyposalivation): \u0026le; 0.1 mL/minute in accordance with\u0026nbsp;pervious defined categories\u0026nbsp;[21].\u003c/p\u003e\n\u003cp\u003eStatistics\u003c/p\u003e\n\u003cp\u003eDescriptive characteristics are summarized as mean \u0026plusmn; standard deviation or as frequency in numbers with percentage (n [%]). Normality of data distribution and homogeneity of variance were tested by Shapiro-Wilk test and Levene\u0026rsquo;s test for equality of variance, respectively. Differences in continuous variables were analyzed by an independent Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e-tests or\u0026nbsp;by a\u0026nbsp;Mann-Whitney \u003cem\u003eU\u003c/em\u003e-Test, depending on the distribution. Differences in categorical variables were analyzed by Chi-Square tests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe associations between SBP and DMFT were assessed using negative binomial regression models, which are appropriate for count data exhibiting overdispersion, such as DMFT. Results are presented as Incident Rate Ratio (IRR) with the corresponding 95% confidence intervals (CIs). Variable selection and model structure were guided by a Directed Acyclic Graph (DAG) (Supplementary Figure 1), constructed based on theoretical and empirical evidence of relationships between exposure and outcome. Confounders were defined as variables that influence both exposure and outcome, mediators as those lying on the causal pathway, and covariates as variables associated with the outcome, but not necessarily with the exposure. Model 1 included age (years), BMI (kg/m\u0026sup2;), and SES (middle and low). Model 2 extended Model 1 by additionally adjusting for DBP (mm Hg), smoking status (never, former, current), tooth brushing frequency (\u0026ge; 1/day vs \u0026lt; 1/day), serum vitamin D levels (nmol/L), and UWSFR (mL/minute).\u003c/p\u003e\n\u003cp\u003eThe association between SBP and severe periodontitis was evaluated using binary logistic regression analyses. Variable selection and model specification were informed by a DAG (Supplementary Figure 2). Model 1adjusted for the potential confounders: age (years), BMI (kg/m\u0026sup2;), SES, and smoking status. Model 2 further adjusted for the potential mediators: DBP (mm Hg), serum vitamin D (nmol/L), and glycemic status (normal, pre-diabetes, and diabetes). Results from the logistic regression are reported as crude and adjusted odds ratios (ORs and AORs) with corresponding 95% CIs. Statistical significance was set at p \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eParticipants\u003c/p\u003e\n\u003cp\u003eA total of 691 women, who completed both BP measurements and clinical oral assessments, were included in this cross-sectional oral health study. The study was conducted as part of a larger population-based follow-up survey [11, 12], and a flow chart of study participants is shown in Figure 1. Sociodemographic and clinical characteristics of the study participants are summarized in Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe mean age of the participants was 48.4 \u0026plusmn; 11. 7 years. Most women had no formal education (88.2%), and 73.8% were classified as having low SES. Previous or current smoking were reported among 35.0% of the women, and 27.3% informed to brush their teeth less than once per day.\u003c/p\u003e\n\u003cp\u003eBlood pressure, glycemic status and vitamin D status\u003c/p\u003e\n\u003cp\u003eThe mean SBP was 126.3 \u0026plusmn; 19.1 mm Hg and the mean DBP was 82.0 \u0026plusmn; 10.7 mm Hg, with 43% and 29.8% meeting the criteria for elevated BP and hypertension, respectively. Among those with hypertension, the use of blood pressure medication was reported by 43 of the women, of whom 25 still had hypertension, 17 had elevated BP and only one participant had normal BP.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePre-diabetes or diabetes was identified in 37.9% of participants. A total of 44.3% of the participants had serum vitamin D below 50 nmol/L. Data collection and blood sampling were conducted over a two-month period (October and November) and no monthly variation in serum vitamin D concentrations was observed.\u003c/p\u003e\n\u003cp\u003eOral health characteristics\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eComprehensive clinical oral health characteristics are summarized in Table 2 and in Supplementary Table 1. Overall, 85.4% of the participants had 20 or more natural teeth, which is the WHO definition of having a functional dentition [15]. Decayed teeth were present in 58.6% of the participants (mean 1.77 \u0026plusmn; 2.37), while missing teeth were observed in 56.3% (mean 3.29 \u0026plusmn; 5.22). Restorative treatment was rare, with only five (0.6%) of the participants presented with any filled teeth. The mean DMFT index for the study population was 5.07 \u0026plusmn; 6.04 and was highest (8.87 \u0026plusmn; 7.38) among women\u0026nbsp;\u0026ge;\u0026nbsp;55 years of age. The mean DMFT among participants in the WHO reference group aged 35\u0026ndash;44 years was 2.83 \u0026plusmn; 4.14. Based on the DMFT index classification\u0026nbsp;[15], 12.2% of the study participants were in the high DMFT group (\u0026gt; 13.9), 8.7% were in the moderate group (9.0\u0026ndash;13.9), and 79.2% were in the very low to low group (\u0026lt; 9.0).\u003c/p\u003e\n\u003cp\u003eBleeding on probing was present in 81.6% of the participants. Gingivitis was found in 77.4% of the participants, including 47.6% with generalized gingivitis. The prevalence of gingivitis was similar across all age groups.\u003c/p\u003e\n\u003cp\u003ePeriodontitis was observed in 35.9% of the participants, classified as mild to moderate in 23.2% and as severe in 12.7% of the population.\u0026nbsp;The prevalence of severe periodontitis increased with age, from 7.5% in participants \u0026lt; 35 years to 21.9% in those \u0026ge; 55 years. Among participants in the WHO reference group aged 35\u0026ndash;44 years, 8.7% had severe periodontitis.\u003c/p\u003e\n\u003cp\u003eThe mean UWSFR among the women was 0.51 \u0026plusmn; 0.30 mL/min. Hyposalivation (UWSFR \u0026le; 0.1 mL/minute) was observed in 9.8% of the participants, and the saliva flow rate was observed to progressively decline with age.\u003c/p\u003e\n\u003cp\u003eAssociations between SBP, DMFT, and severe periodontitis\u003c/p\u003e\n\u003cp\u003eSelected variables based on the DAG model (Supplementary Figure 1) stratified by DMFT status is shown in Supplementary Table 2. SBP was positively associated with an increase in DMFT scores (IRR: 1.071, 95% CI: 1.025\u0026ndash;1.119; p = 0.002) as shown in Table 3. This association was no longer significant after adjusting for variables such as age, BMI, tooth brushing frequency, serum vitamin D levels, and saliva flow rate, which appear to have a stronger influence on DMFT (Table 3).\u003c/p\u003e\n\u003cp\u003eSelected variables based on the DAG model (Supplementary Figure 2) stratified by periodontal status are shown in Supplementary Table 3. SBP was positively associated with an increased risk for severe periodontitis (OR: 1.115, 95% CI: 1.001\u0026ndash;1.242, p = 0.047) as shown in Table 4. After adjusting for the potential confounders age, BMI, smoking and SES and the potential mediators DBP, serum vitamin D levels, and glycemic status, the association was no longer significant (Table 4).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this cross-sectional study of 691 women in rural Nepal, we observed a relatively high prevalence of oral health issues, including decayed teeth, gingivitis, and periodontitis, alongside systemic health concerns such as elevated BP. Although initial analyses showed associations between SBP and both DMFT scores and severe periodontitis, these associations were no longer evident after adjusting for variables like age, BMI, smoking, and vitamin D levels.\u003c/p\u003e\n\u003cp\u003eBlood pressure\u003c/p\u003e\n\u003cp\u003eA total of 29.8% of the women were found to have hypertension. This prevalence was lower than the 34% reported by WHO for Nepalese women [5], yet notably higher than the 17.9% reported in the 2022 Nepal Demographic and Health Survey [22]. In accordance with the latter study, the use of antihypertensives was low in this population [22]. Elevated BMI is a well-established risk factor for hypertension, and the high proportion of participants with overweight or obesity (63.1%) in this study likely contributed to the relatively high prevalence of hypertension.\u003c/p\u003e\n\u003cp\u003eOral health\u003c/p\u003e\n\u003cp\u003eA functional dentition, here defined as having 20 or more natural teeth, was present in 85.4% of the women. This proportion declined with age and among women aged 55 years and older, only 68.6% retained a functional dentition. This age-related decrease is of concern, as the preservation of a functional dentition in older adults is associated with improved general health, enhanced quality of life, and a reduced risk of adverse health outcomes [23].\u003c/p\u003e\n\u003cp\u003eDecayed teeth were present in 58.6% of the participants, with small variations across the age groups. The observed prevalence of untreated caries was lower in the current study compared to two previous studies among women in Nepal, which reported prevalences of 69.8% and 69.6%, respectively [24, 25]. Missing teeth were observed in all age groups. The presence and number of missing teeth increased significantly with age, reaching a prevalence of 83.3% among women aged 55 and older. Only five participants (0.6%) had evidence of restorative dental treatment (filled teeth), suggesting that this component had minimal impact on the overall DMFT index in this study. Nevertheless, it was included in the calculation for completeness. The low prevalence of restorative care indicates limited access to dental care, with oral health issues likely progressing untreated until extraction is required. This interpretation is supported by the finding that nearly half of the women reported never having visited a dental health worker.\u003c/p\u003e\n\u003cp\u003eBecause the DMFT index represents a cumulative measure of caries experience, it was, as anticipated, highest among participants in the oldest age group (\u0026ge; 55 years). However, the prevalence and mean number of decayed teeth, and consequently the DMFT index, were higher in the youngest age group (\u0026lt; 35 years) compared to the WHO reference group aged 35\u0026ndash;44 years. This may reflect the recent dietary transition in Nepal, characterized by increased consumption of processed foods high in sugar and fat, disproportionately affecting younger individuals. Previous findings from this population have also demonstrated a high prevalence of overweight, obesity, and central obesity, also among the younger age groups [26].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong women in the WHO reference age group of 35\u0026ndash;44 years, the mean DMFT was 2.83. This value is lower than the DMFT of 4.0 reported for Nepal in the WHO Global Oral Health Data Bank [27], and also lower than the mean DMFT of 3.18 reported among females in a recent study of a comparable Nepalese population [28]. Although most participants reported brushing their teeth, 27.3% did so less than once per day, and participants who did not brush daily had significantly higher DMFT scores. Infrequent brushing, possibly combined with suboptimal technique, may contribute to increased caries and subsequently tooth loss.\u003c/p\u003e\n\u003cp\u003eBleeding on probing is known to be highly prevalent during pregnancy, due to hormonal changes. This is supported by two studies from Nepal, reporting that 79.3% and 100% of the participants exhibited bleeding on probing during pregnancy [24, 29]. In contrast to studies involving pregnant women, the present study, conducted exclusively among non-pregnant women, found bleeding on probing in 81.6% the of participants, with 77.6% exhibiting gingivitis (FMBS \u0026ge; 10%). These findings indicate an alarmingly high prevalence of gingival inflammation in this population, independent of pregnancy-related physiological changes.\u003c/p\u003e\n\u003cp\u003eDespite the high prevalence of bleeding on probing among women in the present study, the prevalence of severe periodontitis was 12.7%, which is relatively low compared to other reports from Nepal. The WHO estimates a national prevalence of 14.8% for severe periodontal disease among individuals aged 15 years and older [4]. Additionally, a 2021 cross-sectional study from rural eastern Nepal, involving 440 adults aged 20\u0026ndash;65 years, found a prevalence of 31.7% using the same diagnostic criteria as in the current study [30]. Among participants in the WHO reference age group of 34\u0026ndash;44 years, the prevalence was 8.7%, which is markedly lower than the 34% previously reported for Nepal [31].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAssociations\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe found an initial positive association between SBP and DMFT, but this was not present in the adjusted analyses. Previous research, including a large cross-sectional study of 10,520 individuals aged 35\u0026ndash;70 in Iran, reported significantly higher DMFT indices among participants with hypertension in an unadjusted model [6]. Further, a cross-sectional group comparison study from Pakistan, including 108 adults aged 24\u0026ndash;69 found that individuals with undiagnosed and untreated hypertension had nearly double the DMFT scores compared to those with normal BP [7]. On the other hand, no significant association was found between blood pressure and adolescents in the National Health and Nutrition Examination Survey (NHANES) study, including 2861 participants aged 13\u0026ndash;17 years [32]. Elevated BP may raise DMFT scores through systemic inflammation, vascular changes, and medication-induced dry mouth. This association may be less relevant in adolescents due to fewer comorbidities, limited medication use, and greater oral and vascular resilience.\u003c/p\u003e\n\u003cp\u003eThe observation of no association between SBT and DMFT after adjusting for other variables in the current study suggests that established factors like age, BMI, tooth brushing frequency, saliva flow rate, and possibly vitamin D levels, were more decisive in determining DMFT scores in the current population.\u003c/p\u003e\n\u003cp\u003eWe observed that SBT was associated with severe periodontitis in the crude analysis. Several studies have previously identified a bidirectional link between periodontitis and elevated BP. Data from the NHANES study, which included 5,396 individuals over the age of 30, showed that people with active periodontitis or bleeding on probing, an early sign of periodontal disease, had significantly higher SBP independent of other factors [33]. These findings were supported by a 2021 case-control study from Great Britain, which found that individuals with periodontitis had higher SBP and DBP compared to healthy controls, regardless of other cardiovascular risk factors [34]. Additionally, this study described that SBP was associated with bleeding on probing, even in individuals without diagnosed periodontitis [34]. Periodontal inflammation may contribute to elevated BP through systemic inflammatory pathways and endothelial dysfunction, while antihypertensive medications and vascular changes associated with hypertension can impair oral health by reducing salivary flow and gingival perfusion. In the current study, the association between SBP and severe periodontitis was not significant in adjusted analyses, indicating that other established risk factors like BMI, SES, smoking, diabetes, and serum vitamin D [31, 35], were more decisive determinants of severe periodontitis in this population.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStrengths and limitations\u003c/p\u003e\n\u003cp\u003eThis study has several strengths, including a relatively large cohort of rural Nepalese women, representing a vulnerable population with limited data on oral health outcomes. Further, we collected extensive biological specimens and detailed data on sociodemographic characteristics, anthropometric and physiological measurements, and oral health parameters. Clinical oral health assessments were performed by Dental Surgery interns, in accordance with the WHO Oral Health Assessment Form for Adults [15], facilitating comparisons with other populations. On the other hand, even though the examiners were trained under the supervision of an expert community dentist, the oral health assessments were not calibrated between the examiners, causing a risk for individual discrepancies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurther, as the present study population was recruited from an initial survey focused on reproductive health, only women were included. This might result in an overestimation of oral health problems, as women in Nepal generally experience poorer health than men due to gender norms, social inequities, and limited healthcare access. Although less studied, similar disparities are seen in oral health, with higher DMFT scores reported among females in some studies [25, 36]. The calculation of SES according to the Kuppuswamy [16], the participants\u0026rsquo; own occupations, rather than those of the household heads, were used. This approach was necessary due to limited information on husbands\u0026rsquo; occupations and may have led to a slight underestimation of SES in this study. Additionally, self-reported behaviors such as smoking and the frequency of tooth brushing may be subject to recall bias and misestimation, potentially affecting the results. Finally, the cross-sectional design limits the ability to draw causal inferences from the observed associations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis cross-sectional study among rural Nepalese women describes the prevalence of oral diseases, including caries, gingivitis and periodontitis. Of notice, only 0.6% of the population presented with any dental restoration. We also observed a relatively high prevalence of elevated blood pressure. Although initial analyses showed associations between SBP and both DMFT index and severe periodontitis, these relationships were not evident after adjusting for factors such as age, BMI, comorbidities and behavioral and oral hygiene practices. These findings support the integration of oral health into broader public health strategies, particularly in underserved communities.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the National Health Research Council, Nepal (Reg.no. 744/2018), the Institutional Review Committee of Kathmandu University School of Medical Sciences, Dhulikhel Hospital (approval no. 124/19) and Regional Committees for Medical and Health Research Ethics, Norway (REK no. 13003). Informed consent was obtained from all participants, by signature or thumbprint.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. All data generated during this study are included in this published article and its supplementary files.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that the research was conducted without interference from commercial or financial relationships. The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was supported by grants from the Liaison Committee between the Central Norway Regional Health Authority (RHA) and the Norwegian University of Science and Technology (NTNU). The funding body did not have a role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eAll authors made substantial contributions before submission, and all authors have read and approved the final manuscript. AKS analysed and interpreted the data and was the major contributor in writing the manuscript. CY, DP and US planned the original study and was responsible for participant recruitment, health assessments and analyses. US and AKS conceived the idea of the present study and were involved in data interpretation, and supervision of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all the women who volunteered to participate, the female volunteer health workers and the dental intern students. Without their dedication, this research would not be possible. The author also like to thank Hedda H\u0026oslash;vik, Center for Oral Health Services and Research, Mid-Norway (TkMidt), Trondheim, Norway, for valuable input and revision. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO: \u003cstrong\u003eGlobal oral health status report: towards universal health coverage for oral health by 2030: regional summary of the South-East Asia Region\u003c/strong\u003e. 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gender and oral health knowledge on DMFT index: a cross sectional study among school children in Kaski District, Nepal\u003c/strong\u003e. \u003cem\u003eBMC Oral Health \u003c/em\u003e2023, \u003cstrong\u003e23\u003c/strong\u003e(1):59.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e: Characteristics of study population\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN = 691\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge, yrs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e48.4 \u0026plusmn; 11.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u0026lt; 35 yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e80 [11.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e35\u0026ndash;44 yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e183 [26.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e45\u0026ndash;54 yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e218 [31.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u0026ge; 55 yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e210 [30.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eBrahmin/Chhetri\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e84 [12.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eNewar/Tamang\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e549 [79.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eDalit\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e32 [4.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e26 [3.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eBachelor degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e7 [1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eHigher secondary school, PCL\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e17 [2.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eSecondary school\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e20 [2.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003ePrimary school\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e28 [4.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eNo formal education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e610 [88.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e9 [1.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousehold income per month, NPR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e25 454 \u0026plusmn; 38\u0026nbsp;348\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u0026lt; 5 000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e42 [6.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e5 000 \u0026ndash; \u0026lt; 20 000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e277 [40.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e20 000 \u0026ndash; \u0026lt; 50 000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e277 [40.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u0026ge; 50 000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e95 [13.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWork status, last 12 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eGovernment employee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e25 [3.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eNon-government employee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e8 [1.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eSelf-employee (agriculture, animal husbandry, business and others)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e528 [76.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eHomemaker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e101 [14.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e29 [4.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSES\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eUpper middle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e81 [11.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eLower middle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e63 [9.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eUpper lower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e42 [6.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eLower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e468 [67.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e37 [5.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e448 [64.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003ePrevious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e106 [15.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eCurrent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e136 [19.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1 [0.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTooth brushing frequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u0026ge; 2 times/day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e30 [4.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u0026nbsp;Once/day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e467 [67.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eWeekly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e170 [24.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eMonthly or never\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e19 [2.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e5 [0.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnthropometrics\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eWeight, kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e54.8 \u0026plusmn; 10.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eHeight, m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1.49 \u0026plusmn; 0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e24.8 \u0026plusmn; 4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eUnderweight, BMI \u0026lt; 18.5 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e38 [5.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eNormal weight, BMI: \u0026ge; 18.5 \u0026ndash; \u0026lt; 23 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e214 [31.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eOverweight, BMI: \u0026ge; 23 \u0026ndash; \u0026lt; 27.5 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e265 [38.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eObesity, BMI \u0026ge; 27.5 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e171 [24.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e3 [0.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSBP, mm Hg\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e126.3 \u0026plusmn; 19.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDBP, mm Hg\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e82.0 \u0026plusmn; 10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBP status*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e188 [27.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eElevated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e297 [43.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e206 [29.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHbA1c, mmol/mol\u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e37.52 \u0026plusmn; 8.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGlycemic status**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e409 [59.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003ePre-diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e231 [33.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e31 [4.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e20 [2.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSerum 25(OH)D, nmol/L\u003csup\u003ec\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e52.3 \u0026plusmn; 15.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u0026ge; 50 nmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e355 [51.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u0026lt; 50 nmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e306 [44.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e30 [4.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are in mean \u0026plusmn; standard deviation or number [percentage]\u003c/p\u003e\n\u003cp\u003ePCL = Proficiency Certificate Level, NPR = Nepalese Rupee, SES = Socioeconomic Status, BMI = Body Mass Index, SBP/DBP = Systolic/Diastolic Blood Pressure. HbA1c = glycated hemoglobin\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003eBP status: Normal: SBP \u0026lt; 120 mm Hg and DBP \u0026lt; 80 mm Hg, Elevated: SBP \u0026ge; 120 to \u0026lt; 140 mm Hg or DBP \u0026ge; 80 to \u0026lt; 90 mm Hg, Hypertension: SBP \u0026ge; 140 mm Hg and/or DBP \u0026ge; 90 mm Hg and/or use BP medication\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e**\u003c/strong\u003eGlycemic status: Normal: HbA1c \u0026lt; 39 mmol/mol, Pre-diabetes: HbA1c \u0026ge; 39 to \u0026lt; 48 mmol/mol, Diabetes: diabetes history/medication/HbA1c \u0026ge; 48 mmol/mol)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003emissing data from N = 3\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003emissing data from N = 20\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003ec\u003c/sup\u003e\u003c/strong\u003emissing data from N = 30\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Clinical oral health characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"601\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal,\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN = 691\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 35 yrs,\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN = 80\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e35\u0026ndash;44 yrs,\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN = 183\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e45\u0026ndash;54 yrs,\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN = 218\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ge; 55 yrs,\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;N = 210\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of natural teeth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e1\u0026ndash;9 teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e15 [2.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e15 [7.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e10\u0026ndash;19 teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e86 [12.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e5 [6.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e10 [5.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e20 [9.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e51 [24.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026ge; 20 teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e590 [85.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e75 [93.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e173 [94.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e198 [90.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e144 [68.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDecayed teeth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003ePresent in\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e405 [58.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e45 [56.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e91 [49.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e130 [59.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e139 [66.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eMean + SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e1.77 \u0026plusmn; 2.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e1.54 \u0026plusmn; 1.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e1.35 \u0026plusmn; 2.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e1.67 \u0026plusmn; 1.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e2.33 \u0026plusmn; 3.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMissing teeth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003ePresent in\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e389 [56.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e28 [35.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e66 [36.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e120 [55.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e175 [83.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e3.29 \u0026plusmn; 5.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e1.45 \u0026plusmn; 3.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e1.46 \u0026plusmn; 3.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e2.36 \u0026plusmn; 3.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e6.54 \u0026plusmn; 6.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFilled teeth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003ePresent in\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e5 [0.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDMFT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e5.07 \u0026plusmn; 6.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e3.01 \u0026plusmn; 4.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e2.83 \u0026plusmn; 4.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e4.04 \u0026plusmn; 4.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e8.87 \u0026plusmn; 7.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDMFT status*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e547 [79.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e73 [91.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e168 [91.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e186 [85.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e120 [57.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e60 [8.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e2 [2.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e6 [3.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e21 [9.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e31 [14.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e84 [12.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e5 [6.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e9 [4.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e11 [5.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e59 [28.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGingival status**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eHealthy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e156 [22.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e17 [21.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e33\u0026nbsp;[18.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e41 [18.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e65 [31.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eLocalized\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e206 [29.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e28 [35.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e60 [32.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e71 [32.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e47 [22.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eGeneralized\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e329 [47.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e35 [43.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e90 [49.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e106 [48.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e98 [46.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeriodontal status***\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eHealthy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e443 [64.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e68 [85.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e134 [73.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e142 [65.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e99 [47.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eMild to moderate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e160 [23.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e6 [7.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e33 [18.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e56 [25.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e65 [31.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eSevere\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e88 [12.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e6 [7.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e16 [8.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e20 [9.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e46 [21.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal,\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN = 650\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 35 yrs,\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN = 77\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e35\u0026ndash;44 yrs,\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN = 172\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e45\u0026ndash;54 yrs,\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN = 206\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ge; 55 yrs,\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;N = 195\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUWSFR status****\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e569 [87.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e71 [92.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e158 [91.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e175 [84.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e165 [84.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e17 [2.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e2 [2.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e4 [2.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e3 [1.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e8 [4.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eHyposalvation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e64 [9.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e4 [5.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e10 [5.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e28 [13.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e22 [11.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are in numbers [%] or mean \u0026plusmn; standard deviation\u003c/p\u003e\n\u003cp\u003eDMFT = Decayed, Missing and Filled Teeth, UWSFR = Unstimulated Whole Saliva Flow Rate\u003c/p\u003e\n\u003cp\u003e*DMFT status: Low: \u0026lt; 9.0, Moderate: 9.0\u0026ndash;13.9. High: \u0026gt; 13.9\u003c/p\u003e\n\u003cp\u003e**Gingival status: Healthy gingiva: Full Mouth Bleeding Status (FMBS) \u0026lt; 10%, Localized gingivitis: 10% \u0026ndash; 30%, Generalized gingivitis: \u0026gt; 30%\u003c/p\u003e\n\u003cp\u003e***Periodontal status: Healthy: no or 1 pocket 4\u0026ndash;5 mm, Mild to moderate: \u0026ge; 2 pockets 4\u0026ndash;5 mm (not on the same tooth), Severe: \u0026ge; 2 pockets 4\u0026ndash;5 mm and \u0026ge; 1 pocket \u0026ge; 6 mm (not on the same tooth)\u003c/p\u003e\n\u003cp\u003e***UWSFR status: Normal: \u0026ge; 0.2 mL/minute, Low: \u0026gt; 0.1 \u0026ndash; \u0026lt; 0.2 mL/minute and Hyposalivation: \u0026le; 0.1 mL/minute\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Associations between Systolic Blood Pressure (SBP) and the Decayed, Missing and Filled Teeth (DMFT) index\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSBP, \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eper 10 mm Hg\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIRR DMFT index\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCrude\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.071\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.025\u0026ndash;1.119\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e691\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0.995\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.995\u0026ndash;1.044\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.833\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e651\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.980\u0026ndash;1.143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e590\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIRR = Incident Rate Ratio\u003c/p\u003e\n\u003cp\u003eModel 1: Age, Body Mass Index, SES, Model 2: Model 1 + Diastolic Blood Pressure, Smoking status, Frequency of tooth brushing, serum 25(OH)D and Unstimulated Whole Saliva Flow Rate\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Associations between Systolic Blood Pressure (SBP) and severe periodontitis\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealthy, mild to moderate periodontitis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSevere periodontitis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSBP,\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eper 10 mm Hg\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCrude\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1.115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e1.001\u0026ndash;1.242\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.047\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e691\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1.054\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e0.931\u0026ndash;1.193\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.405\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e650\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e0.840\u0026ndash;1.219\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.903\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e614\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eOR = Odds Ratio, AOR = Adjusted Odds Ratio\u003c/p\u003e\n\u003cp\u003eModel 1: Age, Body Mass Index, SES and Smoking status, Model 2: Model 1 + Diastolic Blood Pressure, serum 25(OH)D and Glycemic status\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8114872/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8114872/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eOral diseases are a significant yet under-recognized public health issue, particularly in low-resource settings. In Nepal, rural women face health inequities and limited access to general and oral healthcare. Emerging evidence suggests a bidirectional relationship between hypertension and poor oral health, but data from South Asia are limited. The object of the current study was to assess the oral health status and examine the potential associations of systolic blood pressure (SBP) with caries experience (Decayed, Missing, and Filled Teeth (DMFT)), and severe periodontitis, among women in rural Nepal.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eThis cross-sectional study included 691 non-pregnant women from the Kavre District, Nepal, recruited in 2019 as part of a larger health survey. Blood pressure was measured using standardized protocols and clinical oral assessments were conducted using the WHO Oral Health Assessment Form for Adults. Associations between SBP and oral health outcomes were analyzed using negative binomial and logistic regression models, adjusting for sociodemographic, behavioral, and biological factors.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eThe mean age of the participants was 48.4\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7 years. Decayed teeth were present in 58.6% of the women, only five participants (0.6%) had any restorative dental treatment, and the overall mean DMFT index was 5.07\u0026thinsp;\u0026plusmn;\u0026thinsp;6.04. Bleeding on probing was observed in 81.6% of the participants, and 12.7% presented with severe periodontitis. Hypertension affected 29.8% of the women. While unadjusted analyses showed associations between SBP and both DMFT and severe periodontitis, these associations were not significant after adjusting for variables such as age, body mass index, smoking, vitamin D levels, and other factors.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eThis study shows a relatively high burden of oral health issues among rural Nepalese women along a high prevalence of hypertension. Although elevated SBP appeared to be linked with poor oral health, adjusted analyses suggest that shared risk factors, such as age, comorbidities, and behavioral practices, may play a more prominent role in this population. These findings underscore the need for integrated health strategies addressing both oral and systemic health in marginalized populations.\u003c/p\u003e","manuscriptTitle":"Oral Health and Its Association with Systolic Blood Pressure Among Women in Rural Nepal: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 08:54:24","doi":"10.21203/rs.3.rs-8114872/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"58145883395629288696861790966548334525","date":"2025-12-14T05:44:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-12T05:29:26+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-18T09:42:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-14T13:23:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-14T13:20:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-11-14T12:47:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0ec86e2d-7522-4026-b04d-747fc35764a6","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T08:54:29+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-22 08:54:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8114872","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8114872","identity":"rs-8114872","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}