Regular Dental Check-ups Are Independently Associated With Insulin Resistance in Japanese Type 2 Diabetes Patients (JDCP study 17)

Regular Dental Check-ups Are Independently Associated With Insulin Resistance in Japanese Type 2 Diabetes Patients (JDCP study 17) | 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 Article Regular Dental Check-ups Are Independently Associated With Insulin Resistance in Japanese Type 2 Diabetes Patients (JDCP study 17) Yui Tsuji, Koji Inagaki, Keiko Naruse, Takeshi Kikuchi, Tsuyoshi Fujita, and 19 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7448584/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Despite the well-established bidirectional relationship between periodontal disease and diabetes, limited research has examined the role of regular dental check-ups in patients with type 2 diabetes. This study analyzed the relationship between periodontal disease status, dental visit patterns, and diabetes status using baseline data from the Japan Diabetes Complication and its Prevention (JDCP) prospective study. Among 6,099 patients with diabetes (aged 40–75 years), 685 with type 2 diabetes who underwent dental examinations were included. Trained dentists collected periodontal disease data using self-report questionnaires and periodontal examination. Insulin resistance was evaluated using the homeostasis model assessment of insulin resistance (HOMA-IR). Participants who did not undergo regular dental check-ups exhibited higher HOMA-IR values than those who did. Logistic regression analyses revealed a significant association between insulin resistance and regular dental check-ups (odds ratio = 2.33, 95% confidence interval = 1.07–5.09, P = 0.034). Approximately 50% of the respondents did not undergo regular dental check-ups. Individuals who undergo dental check-ups may experience improved local periodontal inflammation through treatment, potentially reducing systemic inflammation and infection compared to those who do not. This reduction in systemic inflammation and infection could contribute to improved insulin resistance. Health sciences/Diseases Health sciences/Endocrinology Health sciences/Health care Health sciences/Medical research Health sciences/Risk factors Periodontal disease Diabetes Insulin resistance Dental check-ups HOMA-IR Periodontal treatment Figures Figure 1 Introduction Periodontitis is a chronic multifactorial inflammatory disease associated with dysbiotic plaque biofilm formation 1 , 2 . It is characterized by progressive destruction of periodontal tissue and is the primary cause of tooth loss in adults 3 . The onset and the progression of periodontal disease are influenced not only by oral hygiene but also by lifestyle factors, such as dietary habits and smoking, as well as genetic and environmental factors 4 , which has led to its classification as a lifestyle-related disease. In 2021, over 1 billion people were affected by severe periodontitis, with South Asia having the highest prevalence rate at 17.6% 5 . A 2022 survey conducted in Japan revealed a high prevalence of periodontal disease, with approximately 50% of individuals aged 55 years and older strongly suspected of having the condition, with an increase to over 60% among those aged 75 years and older 6 . Diabetes is a characterized by chronic hyperglycemia resulting from defects in insulin secretion, insulin action, or both 7 . It is associated with various metabolic disorders, with approximately 1 billion individuals projected to be affected by diabetes by 2050 8 . A 2023 survey conducted in Japan reported that 12.3% of individuals were strongly suspected of having diabetes, with the prevalence increasing with age, reaching 19.5% among those aged ≥ 70 years 9 . Previous studies have revealed the association between diabetes, obesity, and periodontal disease, with particular emphasis on the well-established bidirectional relationship between diabetes and periodontal disease 10 – 12 . Periodontal disease is defined as a recognized comorbidity of diabetes 13 , with diabetic patients having a higher frequency of periodontal disease 12 and an increased risk of tooth loss 14 , 15 . Conversely, periodontal disease is a risk factor for worsening glycemic control and may influence the risk for diabetic complications 16 , 17 . Moreover, periodontal treatment in patients with diabetes reportedly reduces glycosylated hemoglobin A1c (HbA1c) levels by approximately 0.5% 18 . Clinical guidelines strongly recommend periodontal treatment for patients with diabetes 19 . However, the rate of dental visits among patients with diabetes is reportedly low, and their awareness of periodontal disease also remains limited 20 . Despite the established bidirectional relationship between periodontal disease and diabetes, limited research has focused on regular dental check-ups in patients with diabetes in Japan. This study aimed to analyze the relationship between periodontal disease status, dental visit patterns, and diabetes status in Japanese patients with diabetes using baseline data from the Japan Diabetes Complication and its Prevention (JDCP) prospective study, a large-scale, prospective observational study of Japanese diabetes patients launched by the Japan Diabetes Society in 2007. Results Participant characteristics The characteristics of the participants presented in Table 1 , the study included 421 male (61.5%) and 264 (38.5%) female participants, and the mean participant age was 61.5 ± 8.1 years. The median HbA1c level was 7.3 ± 1.3%, the median HOMA-IR was 2.0 (1.3–3.1), and the median BMI was 23.9 (22.0–26.6) kg/m 2 . The HbA1c levels and HOMA-IR were higher among female participants than among male participants. Table 1 Baseline characteristics and clinical variables of JDCP subjects All (685) Male (421) Female(264) P value Age (years) 61.5 ± 8.1 (684) 60.8 ± 8.2 (420) 62.6 ± 7.8 (264) 0.004 Alcohol consumption (n, %) 680 418 262 Yes 288 (42.4%) 251 (60.0%) 37 (14.1%) < 0.001 No 392 (57.6%) 167 (40.0%) 225 (85.9%) Current smoking status (n, %) 683 420 263 Yes 249 (36.5%) 156 (37.1%) 93 (35.4%) 0.638 No 434 (63.5%) 264 (62.9%) 170 (64.6%) Duration of diabetes (years) 9.0 (5.0–16.0) (676) 10.0 (6.0–17.0) (414) 9.0 (4.0–15.0) (262) 0.430 Height (cm) 161.9 ± 9.1 (684) 167.3 ± 6.3 (420) 153.2 ± 5.7 (264) < 0.001 Weight (kg) 64.7 ± 12.8 (678) 68.7 ± 12.2 (416) 58.4 ± 11.1 (262) < 0.001 Maximum weight (kg) 71.5 ± 13.7 (683) 75.8 ± 13.4(420) 64.7 ± 11.2 (263) < 0.001 Age at maximum weight (years) 49.0 (40.0–57.0) (679) 46.5 (36.0–55.0) (418) 51.0 (40.0–59.0) (261) < 0.001 Waist circumference (cm) 87.1 ± 10.5 (631) 87.9 ± 9.7 (384) 86.0 ± 11.5 (247) 0.032 BMI (kg/m 2 ) 23.9 (22.0-26.6) (677) 23.8 (22.1–26.2) (415) 24.0 (21.8–27.3) (262) 0.487 HbA1c (%) 7.2 (6.7–7.8) (682) 7.1 (6.6–7.6) (418) 7.3 (6.8-8.0) (264) 0.002 FPG (mg/dL) 132.5 (114.0-155.3) (302) 130.5 (114.0-153.8) (176) 135.0 (114.8-156.3) (126) 0.220 Fasting IRI (µU/mL) 6.0 (4.1–10.0) (182) 5.7 (3.8–9.1) (113) 7.4 (4.7–11.3) (69) 0.026 *HOMA-IR 2.0 (1.3-3.0) (172) 1.8 (1.2-3.0) (107) 2.2 (1.5–3.4) (65) 0.047 *HOMA-IR ≥ 2.5 61 (35.5%) 36 (33.6%) 25 (38.5%) Systolic BP (mmHg) 130.0 (120.0-140.0) (660) 130.0 (120.0-140.0) (403) 130.0 (121.0-139.0) (257) 0.592 Diastolic BP (mmHg) 74.8 ± 10.2 (660) 76.0 ± 10.3 (403) 72.8 ± 9.7 (257) < 0.001 Total cholesterol (mg/dL) 195.6 ± 32.3 (666) 191.6 ± 32.7 (406) 201.8 ± 30.6 (260) < 0.001 LDL cholesterol (mg/dL) 113.0 ± 26.2 (652) 110.4 ± 25.7 (402) 117.1 ± 26.5 (250) 0.001 HDL cholesterol (mg/dL) 56.0 (46.0–67.0) (669) 53.1 (44.0-64.3) (414) 60.0 (51.0–72.0) (255) < 0.001 Triglycerides (mg/dL) 107.5 (76.0-162.0) (360) 112.0 (76.0-167.0) (203) 104.0 (75.0-154.5) (157) 0.484 Serum creatinine (mg/dL) 0.8 (0.6–0.9) (665) 0.8 (0.7–0.9) (409) 0.6 (0.5–0.7) (256) < 0.001 eGFR (mL/min/1.73 m 2 ) 74.6 (63.7–86.4) (665) 74.4 (64.3–85.8) (409) 74.9 (63.5–89.5) (256) 0.560 Serum albumin (g/dL) 4.3 (4.1–4.5) (630) 4.3 (4.1–4.5) (388) 4.3 (4.1–4.5) (242) 0.436 Types of diabetes medication (n, %) 683 420 263 Oral hypoglycemic agents 450 (65.9%) 282 (67.1%) 168 (63.9%) Insulin 73 (10.7%) 46 (11.0%) 27 (10.3%) Both 90 (13.2%) 49 (11.7%) 41 (15.6%) Assesments of Periodontal disease The results of the periodontal examination based on the HbA1c level are summarized in Table 2 . The median number of present teeth was 24.0 (17.0–27.0), the rate of probing PD ≥ 4 mm was 11.1% (0.0–33.3), the rate of CAL ≥ 4 mm was 26.7% (6.2–50.0), the rate of BOP was 16.7% (3.3–33.3), and the mean bone loss was 1.8 mm (1.2–2.3). A comparison by sex revealed that females had significantly fewer teeth and a higher rate of BOP than males ( P = 0.01). Comparison of the findings of periodontal examinations across HbA1c levels revealed no significant differences. Table 2 Baseline results of periodontal examination of JDCP subjects by HbA1c All(685) HbA1c (%) n < 6.5(101) 6.5–6.9(169) 7.0-7.9(272) ≥ 8.0(140) P value Present teeth 24.0 (17.0–27.0) 682 23.0 (17.5–27.0) 23.0 (17.0–27.0) 24.0 (18.0–26.0) 24.0 (16.0–26.0) 0.98 (682) (270) (139) Male 24.0 (18.0–27.0)* a 418 24.0 (20.0–27.0) 24.0 (18.0–27.0) 24.0 (19.0–27.0)* b 24.0 (14.8–26.0) 0.695 (421) (64) (119) (165) (70) Female 22.0 (16.0–26.0)* a 261 22.0 (14.5–26.5) 20.0 (14.8–26.3) 22.0 (17.0–26.0)* b 24.0 (17.5–27.0) 0.625 (261) (37) (50) (105) (69) More than 28 tooth (n, %) 98 (14.3%) 97 17 (16.8%) 31 (18.3%) 34 (12.5%) 15 (10.7%) More than 20 tooth (n, %) 469 (68.5%) 466 74 (73.3%) 109 (64.5%) 191 (70.2%) 92 (65.7%) Mean probing depth 2.7 (2.2–3.2) 606 2.8 (2.4–3.5) 2.6 (2.2–3.3) 2.6 (2.1–3.2) 2.6 (2.2–3.1) 0.343 (mm) (609) (86) (153) (244) (123) Percentage of sites with 11.1 (0.0-33.3) 606 16.7 (2.1–34.0) 12.5 (0.0-28.9) 10.0 (0.0-27.2) 10.0 (0.0-33.3) 0.532 PD ≥ 4 mm (%) (609) (86) (153) (244) (123) Male 11.1 (0.0–32.0) 378 12.7 (0.0–34.0) 11.1 (0.0-25.9)* c 9.2 (0.0-33.3) 16.7 (2.8–33.3) 0.665 (381) (54) (109) (150) (65) Female 13.9 (0.0-33.3) 228 22.2 (6.7–42.7) 21.7 (6.7–41.0)* c 11.1 (0.0-22.2) 8.3 (0.0-29.6) 0.008 (228) (32) (44) (94) (58) Mean clinical attachment 3.1 (2.4-4.0) 398 3.3 (2.7-4.0) 3.2 (2.5-4.0) 3.0 (2.4–3.7) 2.9 (2.4-4.0) 0.441 level (CAL)(mm) (401) (60) (96) (154) (88) Percentage of sites with 26.7 (6.2–50.0) 398 33.3 (7.0–50.0) 30.0 (6.9–52.5) 22.8 (4.0–50.0) 25.0 (6.7–52.1) 0.806 CAL ≥ 4 mm (%) (401) (60) (96) (154) (88) Male 30.0 (8.3–58.3) 236 33.3 (11.1–50.0) 30.3 (10.4–56.0) 24.2 (2.8–55.6) 25.0 (8.3–65.6) 0.771 (239) (35) (66) (90) (45) Female 23.4 (2.8–50.0) 162 33.3 (2.8–50.0) 26.3 (0.0-46.2) 22.2 (4.6–47.2) 22.2 (0.0–55.0) 0.061 (162) (25) (30) (64) (43) Percentage of sites with bleeding on probing 16.7 (3.3–33.3) 586 18.1 (2.8–41.7) 16.7 (3.1–33.3) 16.7 (3.2–33.3) 19.4 (5.6–41.7) 0.495 (BOP)(%) (589) (80) (149) (234) (123) Male 13.9 (2.8–33.3)* d 366 8.3 (2.8–30.6)** e 13.6 (2.8–31.3) 13.9 (2.8–32.6) 19.4 (5.6–50.0) 0.24 (369) (51) (106) (144) (65) Female 20.8 (56-37.3)* d 220 33.3 (13.9–61.2)** e 22.2 (5.6–50.0) 19.4 (5.3–34.0) 18.1 (5.6–33.3) 0.112 (220) (29) (43) (90) (58) Mean alveolar bone 1.8 (1.2–2.3) 539 2.0 (1.0-2.3) 1.8 (1.3–2.3) 1.6 (1.2–2.2) 1.8 (1.2–2.3) 0.765 score (%) (541) (78) (141) (212) (108) Patient responses to the questionnaires on periodontal disease The results based on the responses to the periodontal disease questionnaire are summarized in Supplementary Table 1. More than 50% of the respondents reported using interdental cleaning tools very rarely. Furthermore, approximately 50% of the respondents reported not undergoing regular dental check-ups. A comparison by sex showed that females were more likely than males to use interdental cleaning aids and had a higher frequency of tooth brushing ( P = 0.005). Characteristics of participants with and without regular dental check-ups The characteristics of the participants in the groups with and without regular dental check-ups are presented in Table 3 . Compared with participants with regular dental check-ups, those without regular dental check-ups had higher fasting immunoreactive insulin (IRI) (median = 7.5 [interquartile range = 4.5–11.0] vs. 5.6 [3.7–9.0]; P = 0.025), higher HOMA-IR (2.3 [1.4–3.7] vs. 1.8 [1.2–2.7]; P = 0.025), higher triglyceride levels (121.0 [82.5–179.0] vs. 101.0 [75.0–148.0]; P = 0.017), higher serum creatinine levels (0.8 [0.7–0.9] vs. 0.7 [0.6–0.9]; P = 0.049), and lower high-density lipoprotein cholesterol levels (54.7 [46.0–65.0] vs. 57.0 [46.0–70.0]; P = 0.045). Table 3 Baseline characteristics and clinical variables of JDCP subjects by regular dental check ups n = 678 Regular dental check ups P value With （365, 53.8%） Without （313, 46.2% ） Age (years) 61.8 ± 7.9 （364） 61.1 ± 8.3 0.231 Alcohol consumption (n，%) 362 311 Yes 216 (59.7%) 171 (55.0%) 0.220 No 146 (40.3%) 140 (45.0%) Current smoking status (n，%) 365 311 Yes 239 (65.5%) 189 (60.8%) 0.206 No 126 (34.5%) 122 (39.2%) Duration of diabetes (years) 10.0 (5.0-17.0) （361） 9.0 (5.0-16.0) （309） 0.755 Height (cm) 161.7 ± 9.5 （365） 162.1 ± 8.6 （312） 0.595 Weight (kg) 64.1 ± 13.7 （362） 64.4 ± 11.6 （310） 0.164 Maximum weight (kg) 70.7 ± 14.4 （363） 72.4 ± 12.9 （313） 0.106 Age at maximum weight (years) 49.0 (40.0-57.0) （360） 49.0 (39.0-57.0) （312） 0.096 Waist circumference (cm) 86.4 ± 10.4 （335） 87.9 ± 10.5 （291） 0.075 BMI (kg/m 2 ) 23.7 (21.9-26.2) （362） 24.0 (22.0-27.1) （309） 0.105 HbA1c (%) 7.1 (6.6-7.7) （364） 7.2 (6.7-7.8) （312） 0.180 FPG (mg/dL) 132.0 (115.0-153.0) （175） 133.0 (112.5-156.0) （125） 0.976 Fasting IRI (µU/mL) 5.6 (3.7-9.0) （102） 7.5 (4.5-11.0) （78） 0.025 HOMA-IR 1.8 (1.2-2.7) （94） 2.3 (1.4-3.7) （76） 0.025 Systolic BP (mmHg) 130.0 (120.0-140.0) （353） 129.0 (120.0-139.5) （301） 0.100 Diastolic BP (mmHg) 75.0 ± 10.0 （353） 74.5 ± 10.4 （301） 0.522 Total cholesterol (mg/dL) 195.0 ± 30.9 （353） 195.7 ± 33.5 （306） 0.770 LDL cholesterol (mg/dL) 112.1 ± 25.5 （345） 113.3 ± 26.5 （300） 0.576 HDL cholesterol (mg/dL) 57.0 (46.0-70.0) （357） 54.7 (46.0-65.0) （305） 0.045 Triglycerides (mg/dL) 101.0 (75.0-148.0) （206） 121.0 (82.5-179.0) （149） 0.017 Serum creatinine (mg/dL) 0.7 (0.6-0.9) （354） 0.8 (0.7-0.9) （304） 0.049 eGFR (mL/min/1.73 m 2 ) 74.9 (64.9-87.3) （354) 73.8 (62.2-85.3) (304) 0.231 Serum albumin (g/dL) 4.3 (4.1-4.5) （335） 4.3 (4.1-4.5) （292） 0.218 Factors associated with insulin resistance Based on the characteristics identified in the univariate analysis, a multiple logistic regression model was used for identification of factors independently associated with insulin resistance (Fig. 1 ). In addition to higher BMI, Regular dental check-ups were found to be independently associated with insulin resistance even after the adjustment of age, sex, smoking, alcohol consumption, duration of diabetes, BMI, regular dental checkups, use of interdental cleaning aids (odds ratio [OR] = 2.33, 95% confidence interval [CI] = 1.07–5.09, P = 0.034). Discussion This study aimed to examine the relationship between periodontal disease status, dental visit patterns, and diabetes status in Japanese patients with type 2 diabetes. The present study suggests that participants who did not undergo regular dental check-ups exhibited higher fasting IRI and HOMA-IR compared with those who did. Although studies on insulin resistance and periodontal disease in non-diabetic patients have been conducted 21 , to the best our knowledge, this is the first study which demonstrated the independent association between regular dental checkups and insulin resistande in the large-scale study in Japanese patients with diabetes. The reduced risk of insulin resistance associated with regular dental check-ups could be explained by the presence of systemic inflammation related to periodontal disease 22 . Insulin resistance is a primary factor in diabetes, and it has been widely reported to elevate levels of inflammatory cytokines and markers 23 . It is well established that these inflammatory cytokines are elevated during local inflammation of periodontal tissues caused by periodontal disease 24 , 25 . Moreover, the systemic inflammatory burden increases with the extent and severity of periodontal disease 23 , contributing to insulin resistance and worsening glycemic control 26 , 27 . Kiyowa et al. reported that participants with periodontal disease were three and a half times more likely to have insulin resistance than those without periodontal disease 28 . Treatment of periodontitis results in reduction of both local and systematic inflammation 29 . Periodontal treatment involves the professional removal of supragingival and subgingival bacterial plaque, biofilm, and calculus, along with oral hygiene instructions 30 . The primary goal of periodontitis treatment is to reduce swelling and infection and to stabilize the condition of the periodontal tissue. Sun et al. reported that periodontal treatment can improve HbA1c levels, lipid profiles, and HOMA-IR, while significantly reducing serum inflammatory cytokine levels in patients with type 2 diabetes 31 . Furthermore, Mammen et al. documented a significant decrease in HOMA-IR 3 months after non-surgical periodontal therapy, which included oral hygiene instructions, in patients with type 2 diabetes and chronic periodontitis 32 . Therefore, individuals who attend dental check-ups may experience improved local periodontal inflammation through periodontal treatment, which, in turn, could reduce systemic inflammation and infection compared to those who do not undergo regular dental check-ups. This reduction in systemic inflammation and infection may also contribute to improved insulin resistance. The latest systematic review and meta-analysis indicated that periodontal treatment may be more beneficial than existing pharmacotherapy for diabetes, both in terms of side effects and medical economics 18 . A 2024 survey conducted in Japan, 62.0% of individuals aged 60 to 69 reported regular dental check-ups 33 . The present study suggests that approximately 50% of respondents did not receive regular dental check-ups. Despite clinical guidelines strongly recommending periodontal treatment for patients with diabetes 19 , only 40.5% of 1,101 patients with diabetes (mean age: 69.5 ± 11.9 years) regularly attended dental check-ups, as reported in the 2024 Japan Medical Association Database of Clinical Medicine 34 . Poudel et al. reported that individuals with diabetes have inadequate oral health knowledge, poor oral health attitudes, and low compliance with recommended oral hygiene behaviors and dental visits 20 . These findings highlight a low level of awareness regarding periodontal disease, underscoring the need for appropriate interventions. The results from this study indicate a statistically significant association between regular dental check-ups and insulin resistance in patients with diabetes, using the baseline data of the JDCP study. However, it is important to acknowledge that this is a cross-sectional study, which does not fully support the association between dental visits and insulin resistance in a long-term follow-up. Further studies should be conducted using prospective follow-up data from the JDCP study to determine whether periodontal treatment is associated with decreased insulin resistance in patients with type 2 diabetes mellitus in Japan. Methods Study population The JDCP study participants were outpatients with type 1 and type 2 diabetes, aged 40 to 74 years, receiving treatment at university hospitals, core local hospitals, and specialized diabetes clinics nationwide in Japan. The study initially included 7,700 patients who met the inclusion criteria and provided informed consent during the 30-month period from June 2007 to November 2009. Ultimately, 6,338 patients were included after excluding those who met the following criteria: (1) inability to make regular outpatient visits; (2) progression to diabetic proliferative retinopathy; (3) ongoing dialysis therapy; (4) diagnosis of malignancy in the previous 5 years; and (5) other conditions deemed ineligible by the study investigators. Of these, 685 patients with type 2 diabetes who underwent dental examinations by a dentist were included in the final analysis (Supplementary Fig. 1). The Declaration of Helsinki and the Ethical Guidelines for Clinical/ Epidemiological Studies of the Japanese Ministry of Health Labor and Welfare were followed. This study was conducted with approval from the Japan Diabetes Society Research Ethics Committee and the institutional review board of each participating facility and registered with the UMIN Clinical Trial Registry (Registry ID, UMIN 000016519). All participants provided written informed consent. Periodontal assessment and oral health information The data of periodontal disease were collected from self-reported questionnaires and the periodontal examinations, including radiographic assessments, with patient consent performed by trained dentists. The self-report questionnaire gathered information on tooth loss within the previous year, the self-reported number of teeth, history of gingival swelling, frequency of daily toothbrushing, use of interdental cleaning aids, and frequency of regular dental check-ups. The periodontal examination included tooth count and tooth mobility measurements of the present teeth, excluding third molars. Probing pocket depth (PD), bleeding on probing (BOP) and clinical attachment level (CAL) assessments were made at the 6 sites of each tooth using a periodontal pocket probe. Radiographic assessments were examined to evaluate alveolar bone loss as an indicator of periodontal tissue destruction. If the first molars were missing, second molars were assessed instead. Alveolar bone loss was categorized as follows: 75% (score IV). Insulin resistance assessment Insulin resistance was evaluated using HOMA-IR, calculated as fasting insulin (µU/mL) × fasting glucose (mmol/L)/22.5. A HOMA-IR value greater than 2.5 was considered indicative of insulin resistance 13 . Other assessments Additional assessments included physical examinations, blood pressure measurements, and laboratory tests for HbA1c, fasting plasma glucose, fasting immunoreactive insulin, serum lipids, creatinine, estimated glomerular filtration rate, and serum albumin. Surveys were conducted regarding the duration of diabetes, alcohol consumption, smoking status, and the use of oral hypoglycemic agents and insulin therapy. Statistical analysis Statistical analyses were performed using SPSS version 29 (IBM Corp., Armonk, NY, USA). Continuous variables were presented as means ± standard deviation (S,D,) and analyzed using Student’s t-test for normally distributed variables. Non-normally distributed variables were expressed as medians (interquartile ranges) and analyzed using the Mann–Whitney U test. Categorical variables were presented as percentages and analyzed using the χ 2 test. Multiple logistic regression analyses were conducted to explore the association between insulin resistance and periodontal disease, adjusting for sex (male/female), age (< 60 years/≥60 years), smoking history (yes/no), alcohol consumption (yes/no), duration of diabetes (< 10 years/≥10 years), body mass index (BMI) (< 25/≥25 kg/m 2 ), regular dental check-ups (yes/no), and use of interdental cleaning aids (yes/no). HOMA-IR (< 2.5/≥2.5) was used as the dependent variable to calculate ORs and 95% CIs. ORs and CIs were adjusted for age, sex, and explanatory variables to determine associations between insulin resistance and periodontal disease. Statistical significance was set at P < 0.05. All data analyses were independently performed at least twice by multiple investigators to ensure accuracy. Abbreviations JDCP Japan Diabetes Complication and its Prevention prospective study HbA1c hemoglobin A1c Declarations Acknowledgments The authors would like to express their sincere thanks to all physicians and medical staff at the 464 participating facilities for their cooperation and to all diabetic patients for their participation in the study. The authors would also like to thank Editage (https://www.editage.jp/) for English language editing. Author contributions Y.T. and K.I. study design and study, data analysis and writing of original draft. T.K., T.F., A.M., J.N., E.N., S.Y., K.T., S.T., A.S., S.K., H.N., T.I., Y.N., M.Y., N.Y., N.M., F.N., H.Y., and T.N. data collection. K.I., K.N., R.N. and N.T. reviewed the manuscript and provided critical advice. All authors read and approved the final version of the manuscript. Data availability statement All data are available in the manuscript and associated supplementary files. Funding The Authors received no funding for this work. Competing interests The authors declare no competing interests. References Papapanou, P. N. et al. Periodontitis: consensus report of workgroup 2 of the 2017 world workshop on the classification of periodontal and Peri-Implant diseases and conditions. J. Periodontol . 89 , S173–S182 (2018). Kinane, D. F., Stathopoulou, P. G. & Papapanou, P. N. Periodontal diseases. Nat. Rev. Dis. Primers . 3 , 17038 (2017). Suzuki, S. et al. Reasons for Tooth Extractions in Japan: The Second Nationwide Survey. Int. Dent. J. 72 , 366–372 (2022). Kwon, T., Lamster, I. B. & Levin, L. Current Concepts in the Management of Periodontitis. Int. Dent. J. 71 , 462–476 (2021). Nascimento, G. G., Alves-Costa, S. & Romandini, M. Burden of severe periodontitis and edentulism in 2021, with projections up to 2050: the global burden of disease 2021 study. J. Periodontal Res. 59 , 823–867 (2024). Ministry of Health Labour and Welfare. 2022 Survey of Dental Diseases . (2023). https://www.mhlw.go.jp/content/10804000/001112405.pdf Schuster, D. P. & Duvuuri, V. Diabetes mellitus. Clin. Podiatr. Med. Surg. 19 , 79–107 (2002). GBD 2021 Diabetes Collaborators. Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021. Lancet 402 , 203–234 (2023). Ministry of Health Labour and Welfare. 2023 National Health and Nutrition Survey . (2024). https://www.mhlw.go.jp/content/10900000/001338334.pdf Rosário et al. Periodontitis severity relationship with metabolic syndrome: A systematic review with meta-analysis. Oral Dis. 29 , 2512–2520 (2023). Stohr, J., Barbaresko, J., Neuenschwander, M. & Schlesinger, S. Bidirectional association between periodontal disease and diabetes mellitus: A systematic review and meta-analysis of cohort studies. Sci. Rep. 11 , 13686 (2021). Graziani, F., Gennai, S., Solini, A. & Petrini, M. A systematic review and meta-analysis of epidemiologic observational evidence on the effect of periodontitis on diabetes. An update of the EFP-AAP review. J. Clin. Periodontol . 45 , 167–187 (2018). The Japan Diabetes Society. Guide for Treatment of Diabetes (Bunkodo Co., Ltd., 2024). Ahmadinia, A. R. et al. Association between type 2 diabetes (T2D) and tooth loss: a systematic review and meta-analysis. BMC Endocr. Disord . 22 , 100 (2022). Weijdijk, L. P. M., Ziukaite, L., Van der Weijden, G. A., Fridus), Bakker, E. W. P., Slot, D. E. & (& The risk of tooth loss in patients with diabetes: A systematic review and meta-analysis. Int. J. Dent. Hyg. 20 , 145–166 (2022). Genco, R. J., Graziani, F. & Hasturk, H. Effects of periodontal disease on glycemic control, complications, and incidence of diabetes mellitus. Periodontol 2000 . 83, 59–65 (2020). Wu, C. Z. et al. Epidemiologic relationship between periodontitis and type 2 diabetes mellitus. BMC Oral Health . 20 , 204 (2020). Umezaki, Y., Yamashita, A., Nishimura, F. & Naito, T. The role of periodontal treatment on the reduction of hemoglobinA1c, comparing with existing medication therapy: A systematic review and meta-analysis. Front. clin. diabetes healthc. 6 https://doi.org/10.3389/fcdhc.2025.1541145 (2025). The Japanese Society of Periodontology. 2023 Periodontal Treatment Guidelines for Patients with Diabetes (Revised Version 3) (Ishiyaku Publishers,Inc., 2023). Poudel, P. et al. Oral health knowledge, attitudes and care practices of people with diabetes: a systematic review. BMC Public. Health . 18 , 577 (2018). Andriankaja, O. M. et al. Insulin resistance predicts the risk of gingival/periodontal inflammation. J. Periodontol . 89 , 549–557 (2018). Martínez-García, M. & Hernández-Lemus, E. Periodontal inflammation and systemic diseases: an overview. Front. Physiol. 12 , 709438 (2021). Borst, S. E. The role of TNF-alpha in insulin resistance. Endocrine 23 , 177–182 (2004). Cecoro, G., Annunziata, M., Iuorio, M. T., Nastri, L. & Guida, L. Periodontitis, low-grade inflammation and systemic health: a scoping review. Medicina (Kaunas) 56 , (2020). Polak, D. & Shapira, L. An update on the evidence for pathogenic mechanisms that may link periodontitis and diabetes. J. Clin. Periodontol . 45 , 150–166 (2018). Miyazawa, I., Morino, K., Harada, K., Ishikado, A. & Kume, S. The relationship among obesity, diabetes, and oral fealth: a narrative review of real-world evidence. Curr. Oral Health Rep. 12 , 1–6 (2025). Song, I. S. et al. Severe periodontitis is associated with insulin resistance in non-abdominal obese adults. J. Clin. Endocrinol. Metab. 101 , 4251–4259 (2016). Kiryowa, H. M. et al. Periodontitis is associated with insulin resistance in adults living with diabetes mellitus in Uganda: a cross- sectional study. BMC Res. Notes 16 , (2023). Luthra, S. et al. Treatment of periodontitis and C-reactive protein: A systematic review and meta-analysis of randomized clinical trials. J. Clin. Periodontol . 50 , 45–60 (2023). American Dental Association. Periodontitis. https://www.ada.org/resources/ada-library/oral-health-topics/periodontitis Sun, W. L. et al. Inflammatory cytokines, adiponectin, insulin resistance and metabolic control after periodontal intervention in patients with type 2 diabetes and chronic periodontitis. Intern. Med. 50 , 1569–1574 (2011). Mammen, J., Vadakkekuttical, R. J., George, J. M., Kaziyarakath, J. A. & Radhakrishnan, C. Effect of non-surgical periodontal therapy on insulin resistance in patients with type II diabetes mellitus and chronic periodontitis, as assessed by C-peptide and the Homeostasis Assessment Index. J Investig Clin. Dent 8 , (2017). Ministry of Health Labour and Welfare. 2024 Survey of Dental Diseases . (2025). https://www.mhlw.go.jp/content/10804000/001512690.pdf The Japan Medical Association Research Institute. The Fifth J-DOME Report . (2024). https://www.jdome.jp/doc/jdome-report2024-5th.pdf Additional Declarations No competing interests reported. Supplementary Files SupplementaryInformation250804.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7448584","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":516128676,"identity":"225a58fa-65da-4c7a-86fb-4ff9bb2fbaf3","order_by":0,"name":"Yui Tsuji","email":"","orcid":"","institution":"Aichi Gakuin University Junior College","correspondingAuthor":false,"prefix":"","firstName":"Yui","middleName":"","lastName":"Tsuji","suffix":""},{"id":516128678,"identity":"84904d5b-d959-4303-ab69-1b07f8c74cd7","order_by":1,"name":"Koji Inagaki","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIie3QsYrCMBzH8V9wuCV6a0Wsr1Dp6MtEbuiiIAjOASEuPWd9C32DlD/oIs6CDhbBycVNpMKlhxxOsW7C5TuFkg/kV8DlesM8QCQS8KEfvgZFSPgSATOkLbXt2mPVkUyTqdpF4+1wj8uV8DnS6PcspMa1SObq2J3uFgH7HhO8lUA4sRDfEyJJFXVnmw5QjgnYmGW8AIkCQ9jNkMYzUsvJXJHISYlfCMEzUo3NlsmamvkWqsuIN1dtad3iLeOvczygRmU7TNNT1vL9JS1C2x8DuLhjQDMF8ySmQqvAh/4jQPZ7LB3sxOVyuf5ZP4Z9WGrw8BmnAAAAAElFTkSuQmCC","orcid":"","institution":"Aichi Gakuin University Junior College","correspondingAuthor":true,"prefix":"","firstName":"Koji","middleName":"","lastName":"Inagaki","suffix":""},{"id":516128680,"identity":"8fc9f5cc-c39a-4a0c-bb85-fcca3eee1465","order_by":2,"name":"Keiko Naruse","email":"","orcid":"","institution":"Aichi Gakuin University","correspondingAuthor":false,"prefix":"","firstName":"Keiko","middleName":"","lastName":"Naruse","suffix":""},{"id":516128682,"identity":"43a4d2f5-bd3b-4352-bebd-36cf5d13ebde","order_by":3,"name":"Takeshi Kikuchi","email":"","orcid":"","institution":"Aichi Gakuin University","correspondingAuthor":false,"prefix":"","firstName":"Takeshi","middleName":"","lastName":"Kikuchi","suffix":""},{"id":516128684,"identity":"088b11c9-8711-4e07-8d5c-3952e119408d","order_by":4,"name":"Tsuyoshi Fujita","email":"","orcid":"","institution":"Aichi Gakuin University","correspondingAuthor":false,"prefix":"","firstName":"Tsuyoshi","middleName":"","lastName":"Fujita","suffix":""},{"id":516128685,"identity":"454ab2cb-9f66-4494-9d7e-71d005a97c52","order_by":5,"name":"Akio Mitani","email":"","orcid":"","institution":"Aichi Gakuin University","correspondingAuthor":false,"prefix":"","firstName":"Akio","middleName":"","lastName":"Mitani","suffix":""},{"id":516128686,"identity":"71a74d05-adbc-4166-b0b9-6d1d4e743533","order_by":6,"name":"Jun Negishi","email":"","orcid":"","institution":"Hokkaido University Hospital Center for Advanced Oral Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Negishi","suffix":""},{"id":516128687,"identity":"7a721f9a-49f9-4587-b601-212926f863f2","order_by":7,"name":"Eiji Nemoto","email":"","orcid":"","institution":"Tohoku University Graduate School of Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Eiji","middleName":"","lastName":"Nemoto","suffix":""},{"id":516128688,"identity":"8bf1e9d5-37a4-4692-8836-8a04afdc7522","order_by":8,"name":"Satoru Yamada","email":"","orcid":"","institution":"Tohoku University Graduate School of Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Satoru","middleName":"","lastName":"Yamada","suffix":""},{"id":516128689,"identity":"79f6ccff-ff4c-4b56-b1ae-16c63b0029b3","order_by":9,"name":"Koichi Tabeta","email":"","orcid":"","institution":"Niigata University Graduate School of Medical and Dental Sciences","correspondingAuthor":false,"prefix":"","firstName":"Koichi","middleName":"","lastName":"Tabeta","suffix":""},{"id":516128690,"identity":"f5a15643-ba29-4dc2-8e61-3cd921f21891","order_by":10,"name":"Sachiyo Tomita","email":"","orcid":"","institution":"Tokyo Dental College","correspondingAuthor":false,"prefix":"","firstName":"Sachiyo","middleName":"","lastName":"Tomita","suffix":""},{"id":516128691,"identity":"d7257613-6858-4d7e-929b-8a38923128c5","order_by":11,"name":"Atsushi Saito","email":"","orcid":"","institution":"Tokyo Dental College","correspondingAuthor":false,"prefix":"","firstName":"Atsushi","middleName":"","lastName":"Saito","suffix":""},{"id":516128692,"identity":"f688313d-0087-46fe-88b3-62406a941ce5","order_by":12,"name":"Sayaka Katagiri","email":"","orcid":"","institution":"Institute of Science Tokyo","correspondingAuthor":false,"prefix":"","firstName":"Sayaka","middleName":"","lastName":"Katagiri","suffix":""},{"id":516128693,"identity":"7128ccfd-d899-44da-8e12-ea6a2c3c1fd7","order_by":13,"name":"Hiroshi Nitta","email":"","orcid":"","institution":"Institute of Science Tokyo","correspondingAuthor":false,"prefix":"","firstName":"Hiroshi","middleName":"","lastName":"Nitta","suffix":""},{"id":516128694,"identity":"b4f16ddf-9cf2-4fd5-9d65-65598d68cca4","order_by":14,"name":"Takanori Iwata","email":"","orcid":"","institution":"Institute of Science Tokyo","correspondingAuthor":false,"prefix":"","firstName":"Takanori","middleName":"","lastName":"Iwata","suffix":""},{"id":516128695,"identity":"b3300d91-4dec-4e45-8a36-cc278caebc5d","order_by":15,"name":"Yukihiro Numabe","email":"","orcid":"","institution":"The Nippon Dental University","correspondingAuthor":false,"prefix":"","firstName":"Yukihiro","middleName":"","lastName":"Numabe","suffix":""},{"id":516128696,"identity":"915484c4-1476-45dc-ab6e-3caac028c571","order_by":16,"name":"Matsuo Yamamoto","email":"","orcid":"","institution":"Showa University School of Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Matsuo","middleName":"","lastName":"Yamamoto","suffix":""},{"id":516128697,"identity":"d6c3473f-06f3-419b-9932-f56a17e4a2fd","order_by":17,"name":"Nobuo Yoshinari","email":"","orcid":"","institution":"Matsumoto Dental University","correspondingAuthor":false,"prefix":"","firstName":"Nobuo","middleName":"","lastName":"Yoshinari","suffix":""},{"id":516128698,"identity":"5c7b1be1-10fa-45e7-97bf-23c57abea008","order_by":18,"name":"Noriyoshi Mizuno","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Noriyoshi","middleName":"","lastName":"Mizuno","suffix":""},{"id":516128699,"identity":"c3a278d5-4176-4c64-ad09-a0dcb7412820","order_by":19,"name":"Fusanori Nishimura","email":"","orcid":"","institution":"Kyushu University Faculty of Dental Science","correspondingAuthor":false,"prefix":"","firstName":"Fusanori","middleName":"","lastName":"Nishimura","suffix":""},{"id":516128700,"identity":"9bacc580-0718-4743-9a6d-0a32ddc6771e","order_by":20,"name":"Hiromichi Yumoto","email":"","orcid":"","institution":"Tokushima University Graduate school","correspondingAuthor":false,"prefix":"","firstName":"Hiromichi","middleName":"","lastName":"Yumoto","suffix":""},{"id":516128701,"identity":"bd5ccbb3-d7ee-4f1b-9a95-c3b433173912","order_by":21,"name":"Toru Naito","email":"","orcid":"","institution":"Fukuoka Dental College","correspondingAuthor":false,"prefix":"","firstName":"Toru","middleName":"","lastName":"Naito","suffix":""},{"id":516128702,"identity":"97f7a17d-b129-4bbf-90c5-8048b6927b0f","order_by":22,"name":"Rimei Nishimura","email":"","orcid":"","institution":"Japan Diabetes Society","correspondingAuthor":false,"prefix":"","firstName":"Rimei","middleName":"","lastName":"Nishimura","suffix":""},{"id":516128703,"identity":"106572c6-984e-4b00-b147-88e47dc7e2a5","order_by":23,"name":"Naoko Tajima","email":"","orcid":"","institution":"Japan Diabetes Society","correspondingAuthor":false,"prefix":"","firstName":"Naoko","middleName":"","lastName":"Tajima","suffix":""}],"badges":[],"createdAt":"2025-08-25 00:23:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7448584/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7448584/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91830283,"identity":"0340cd9d-8a77-4958-b81f-f57c9095ba65","added_by":"auto","created_at":"2025-09-22 09:01:23","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":180309,"visible":true,"origin":"","legend":"","description":"","filename":"jdcp250829.docx","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/fe9bbca0944b3d0a6674fc9e.docx"},{"id":91827075,"identity":"4356acb7-e4fb-46d5-9180-557fb19555e4","added_by":"auto","created_at":"2025-09-22 08:45:23","extension":"jpg","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":658676,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/a80cb38444585b25c9737409.jpg"},{"id":91825854,"identity":"b53f3578-7899-44db-a51a-f3a5317f0f7e","added_by":"auto","created_at":"2025-09-22 08:37:23","extension":"xlsx","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":28848,"visible":true,"origin":"","legend":"","description":"","filename":"Table13.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/84b0c63c58a5dcb197b60a3e.xlsx"},{"id":91825855,"identity":"0bc61712-699d-45cc-8072-2180cb972210","added_by":"auto","created_at":"2025-09-22 08:37:23","extension":"json","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":20991,"visible":true,"origin":"","legend":"","description":"","filename":"2f6cb88bf54c4f238e3ef23370299f95.json","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/977cd7b2b88d8c5bf049c3de.json"},{"id":91825858,"identity":"83dc2dbe-d298-41ba-88ed-7c92481576ab","added_by":"auto","created_at":"2025-09-22 08:37:23","extension":"jpg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":656116,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFigure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/4abc9e588cfc7d749dfc1a77.jpg"},{"id":91825853,"identity":"89102d9c-3238-43c7-983e-6d9f81a56dca","added_by":"auto","created_at":"2025-09-22 08:37:23","extension":"xlsx","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":16946,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/abf66b8b993a6bb3b6d34694.xlsx"},{"id":91828393,"identity":"b691c998-df1d-4c36-9373-b6f42fbd71fe","added_by":"auto","created_at":"2025-09-22 08:53:23","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":40591,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryInformation250804.docx","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/64224eb78892197834c3bcad.docx"},{"id":91825865,"identity":"6408d07b-75c0-4b8d-8aa3-66bc9eef811d","added_by":"auto","created_at":"2025-09-22 08:37:23","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":141538,"visible":true,"origin":"","legend":"","description":"","filename":"2f6cb88bf54c4f238e3ef23370299f951enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/5c94fefcde8dbed594669246.xml"},{"id":91827077,"identity":"0c551e4f-431c-4bfd-aa88-0c7bd8f58c5b","added_by":"auto","created_at":"2025-09-22 08:45:23","extension":"jpg","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":658676,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/aa09aeed338f432eb8da0f70.jpg"},{"id":91827079,"identity":"4e14951d-cccf-49e9-a953-b76ee2f7621e","added_by":"auto","created_at":"2025-09-22 08:45:23","extension":"eps","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":66530,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage1.eps","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/f90184e90267a90113dbefca.eps"},{"id":91825862,"identity":"87a3b8cc-0b13-4692-b5c3-2016a9981ae1","added_by":"auto","created_at":"2025-09-22 08:37:23","extension":"eps","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":399,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage2.eps","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/01abd05170c75138b1518f8c.eps"},{"id":91825866,"identity":"9abb8372-0c48-40f6-a971-223517d6594f","added_by":"auto","created_at":"2025-09-22 08:37:23","extension":"eps","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":66505,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage3.eps","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/83c3b8a5ba4198a718190d57.eps"},{"id":91825860,"identity":"8c8c5dd1-8889-4464-9b2b-1f6e7c712f6c","added_by":"auto","created_at":"2025-09-22 08:37:23","extension":"eps","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":399,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage2.eps","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/281648594bade05bb4adbeac.eps"},{"id":91827080,"identity":"c25c6d27-9853-463c-8a35-788ac53b427a","added_by":"auto","created_at":"2025-09-22 08:45:23","extension":"eps","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":66530,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage5.eps","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/79bc44c3e08100579737fcdb.eps"},{"id":91828395,"identity":"7901b4a1-1878-408a-9a9d-71fe43b903b1","added_by":"auto","created_at":"2025-09-22 08:53:23","extension":"eps","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":399,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage2.eps","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/4a2a5d9f9ff738821fe953a2.eps"},{"id":91825869,"identity":"f0d8b8ae-3899-45e0-b0a0-6446798c8e11","added_by":"auto","created_at":"2025-09-22 08:37:23","extension":"png","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":180161,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/86b4ee14c4621487eff38d58.png"},{"id":91825868,"identity":"1726f229-5976-41c2-9c71-9c7c71d23c16","added_by":"auto","created_at":"2025-09-22 08:37:23","extension":"xml","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":139264,"visible":true,"origin":"","legend":"","description":"","filename":"2f6cb88bf54c4f238e3ef23370299f951structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/8821aa3f19763661913e35a4.xml"},{"id":91825870,"identity":"b8559c0d-13cd-4d89-9e7c-739d432f8006","added_by":"auto","created_at":"2025-09-22 08:37:24","extension":"html","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":149264,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/514a1aed9e162bece7f8ecca.html"},{"id":91825851,"identity":"394b8b53-c604-48a4-973c-32084e0709a6","added_by":"auto","created_at":"2025-09-22 08:37:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":27107,"visible":true,"origin":"","legend":"\u003cp\u003eMultiple logistic regression analysis for the odds ratio (OR) of HOMA-IR ＜2.5 of JDCP subjects at baseline\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/3a1ca140dd28c6f337a6b247.png"},{"id":94489628,"identity":"0cbc7b81-2b0d-460f-a621-6637e4c27596","added_by":"auto","created_at":"2025-10-27 17:05:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1381020,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/965b068c-925e-4f4e-91c3-142ec05019f9.pdf"},{"id":91825852,"identity":"5ab95c47-99d0-4630-af2f-7b3bd3d2a085","added_by":"auto","created_at":"2025-09-22 08:37:23","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":40591,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryInformation250804.docx","url":"https://assets-eu.researchsquare.com/files/rs-7448584/v1/93cb5f4c9a5206937aa2c0ed.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Regular Dental Check-ups Are Independently Associated With Insulin Resistance in Japanese Type 2 Diabetes Patients (JDCP study 17)","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePeriodontitis is a chronic multifactorial inflammatory disease associated with dysbiotic plaque biofilm formation\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. It is characterized by progressive destruction of periodontal tissue and is the primary cause of tooth loss in adults\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. The onset and the progression of periodontal disease are influenced not only by oral hygiene but also by lifestyle factors, such as dietary habits and smoking, as well as genetic and environmental factors\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e, which has led to its classification as a lifestyle-related disease. In 2021, over 1\u0026nbsp;billion people were affected by severe periodontitis, with South Asia having the highest prevalence rate at 17.6%\u003csup\u003e5\u003c/sup\u003e. A 2022 survey conducted in Japan revealed a high prevalence of periodontal disease, with approximately 50% of individuals aged 55 years and older strongly suspected of having the condition, with an increase to over 60% among those aged 75 years and older \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eDiabetes is a characterized by chronic hyperglycemia resulting from defects in insulin secretion, insulin action, or both\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. It is associated with various metabolic disorders, with approximately 1\u0026nbsp;billion individuals projected to be affected by diabetes by 2050\u003csup\u003e8\u003c/sup\u003e. A 2023 survey conducted in Japan reported that 12.3% of individuals were strongly suspected of having diabetes, with the prevalence increasing with age, reaching 19.5% among those aged\u0026thinsp;\u0026ge;\u0026thinsp;70 years \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003ePrevious studies have revealed the association between diabetes, obesity, and periodontal disease, with particular emphasis on the well-established bidirectional relationship between diabetes and periodontal disease\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Periodontal disease is defined as a recognized comorbidity of diabetes\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e, with diabetic patients having a higher frequency of periodontal disease\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e and an increased risk of tooth loss\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Conversely, periodontal disease is a risk factor for worsening glycemic control and may influence the risk for diabetic complications \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Moreover, periodontal treatment in patients with diabetes reportedly reduces glycosylated hemoglobin A1c (HbA1c) levels by approximately 0.5%\u003csup\u003e18\u003c/sup\u003e. Clinical guidelines strongly recommend periodontal treatment for patients with diabetes\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. However, the rate of dental visits among patients with diabetes is reportedly low, and their awareness of periodontal disease also remains limited\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eDespite the established bidirectional relationship between periodontal disease and diabetes, limited research has focused on regular dental check-ups in patients with diabetes in Japan. This study aimed to analyze the relationship between periodontal disease status, dental visit patterns, and diabetes status in Japanese patients with diabetes using baseline data from the Japan Diabetes Complication and its Prevention (JDCP) prospective study, a large-scale, prospective observational study of Japanese diabetes patients launched by the Japan Diabetes Society in 2007.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eParticipant characteristics\u003c/h2\u003e\u003cp\u003eThe characteristics of the participants presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the study included 421 male (61.5%) and 264 (38.5%) female participants, and the mean participant age was 61.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1 years. The median HbA1c level was 7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3%, the median HOMA-IR was 2.0 (1.3\u0026ndash;3.1), and the median BMI was 23.9 (22.0\u0026ndash;26.6) kg/m\u003csup\u003e2\u003c/sup\u003e. The HbA1c levels and HOMA-IR were higher among female participants than among male participants.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline characteristics and clinical variables of JDCP subjects\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAll (685)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale (421)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFemale(264)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1 (684)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2 (420)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e62.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8 (264)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlcohol consumption (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e680\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e418\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e262\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e288 (42.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e251 (60.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37 (14.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e392 (57.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e167 (40.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e225 (85.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCurrent smoking status (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e683\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e420\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e263\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e249 (36.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e156 (37.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e93 (35.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.638\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e434 (63.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e264 (62.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e170 (64.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of diabetes (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.0 (5.0\u0026ndash;16.0) (676)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.0 (6.0\u0026ndash;17.0) (414)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.0 (4.0\u0026ndash;15.0) (262)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.430\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e161.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1 (684)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e167.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3 (420)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e153.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7 (264)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight (kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e64.7\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8 (678)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68.7\u0026thinsp;\u0026plusmn;\u0026thinsp;12.2 (416)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e58.4\u0026thinsp;\u0026plusmn;\u0026thinsp;11.1 (262)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaximum weight (kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71.5\u0026thinsp;\u0026plusmn;\u0026thinsp;13.7 (683)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75.8\u0026thinsp;\u0026plusmn;\u0026thinsp;13.4(420)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e64.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.2 (263)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge at maximum weight (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e49.0 (40.0\u0026ndash;57.0) (679)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46.5 (36.0\u0026ndash;55.0) (418)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e51.0 (40.0\u0026ndash;59.0) (261)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWaist circumference (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e87.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5 (631)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7 (384)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e86.0\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5 (247)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.032\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.9 (22.0-26.6) (677)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.8 (22.1\u0026ndash;26.2) (415)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24.0 (21.8\u0026ndash;27.3) (262)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.487\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHbA1c (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.2 (6.7\u0026ndash;7.8) (682)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.1 (6.6\u0026ndash;7.6) (418)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.3 (6.8-8.0) (264)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFPG (mg/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e132.5 (114.0-155.3) (302)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e130.5 (114.0-153.8) (176)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e135.0 (114.8-156.3) (126)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.220\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFasting IRI (\u0026micro;U/mL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.0 (4.1\u0026ndash;10.0) (182)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.7 (3.8\u0026ndash;9.1) (113)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.4 (4.7\u0026ndash;11.3) (69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.026\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e*HOMA-IR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.0 (1.3-3.0) (172)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.8 (1.2-3.0) (107)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.2 (1.5\u0026ndash;3.4) (65)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.047\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e*HOMA-IR\u0026thinsp;\u0026ge;\u0026thinsp;2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61 (35.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36 (33.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 (38.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSystolic BP (mmHg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e130.0 (120.0-140.0) (660)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e130.0 (120.0-140.0) (403)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e130.0 (121.0-139.0) (257)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.592\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiastolic BP (mmHg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2 (660)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.3 (403)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e72.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7 (257)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal cholesterol (mg/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e195.6\u0026thinsp;\u0026plusmn;\u0026thinsp;32.3 (666)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e191.6\u0026thinsp;\u0026plusmn;\u0026thinsp;32.7 (406)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e201.8\u0026thinsp;\u0026plusmn;\u0026thinsp;30.6 (260)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDL cholesterol (mg/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e113.0\u0026thinsp;\u0026plusmn;\u0026thinsp;26.2 (652)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e110.4\u0026thinsp;\u0026plusmn;\u0026thinsp;25.7 (402)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e117.1\u0026thinsp;\u0026plusmn;\u0026thinsp;26.5 (250)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHDL cholesterol (mg/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56.0 (46.0\u0026ndash;67.0) (669)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53.1 (44.0-64.3) (414)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e60.0 (51.0\u0026ndash;72.0) (255)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTriglycerides (mg/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e107.5 (76.0-162.0) (360)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e112.0 (76.0-167.0) (203)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e104.0 (75.0-154.5) (157)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.484\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSerum creatinine (mg/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.8 (0.6\u0026ndash;0.9) (665)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.8 (0.7\u0026ndash;0.9) (409)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.6 (0.5\u0026ndash;0.7) (256)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eeGFR (mL/min/1.73 m\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74.6 (63.7\u0026ndash;86.4) (665)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74.4 (64.3\u0026ndash;85.8) (409)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e74.9 (63.5\u0026ndash;89.5) (256)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.560\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSerum albumin (g/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.3 (4.1\u0026ndash;4.5) (630)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.3 (4.1\u0026ndash;4.5) (388)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.3 (4.1\u0026ndash;4.5) (242)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.436\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTypes of diabetes medication\u003c/p\u003e\u003cp\u003e (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e683\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e420\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e263\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOral hypoglycemic agents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e450 (65.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e282 (67.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e168 (63.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInsulin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e73 (10.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46 (11.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27 (10.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90 (13.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (11.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e41 (15.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAssesments of Periodontal disease\u003c/h3\u003e\n\u003cp\u003eThe results of the periodontal examination based on the HbA1c level are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The median number of present teeth was 24.0 (17.0\u0026ndash;27.0), the rate of probing PD\u0026thinsp;\u0026ge;\u0026thinsp;4 mm was 11.1% (0.0\u0026ndash;33.3), the rate of CAL\u0026thinsp;\u0026ge;\u0026thinsp;4 mm was 26.7% (6.2\u0026ndash;50.0), the rate of BOP was 16.7% (3.3\u0026ndash;33.3), and the mean bone loss was 1.8 mm (1.2\u0026ndash;2.3). A comparison by sex revealed that females had significantly fewer teeth and a higher rate of BOP than males (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01). Comparison of the findings of periodontal examinations across HbA1c levels revealed no significant differences.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline results of periodontal examination of JDCP subjects by HbA1c\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAll(685)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e\u003cp\u003eHbA1c (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;6.5(101)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.5\u0026ndash;6.9(169)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7.0-7.9(272)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;8.0(140)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePresent teeth\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24.0 (17.0\u0026ndash;27.0)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e682\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23.0 (17.5\u0026ndash;27.0)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23.0 (17.0\u0026ndash;27.0)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e24.0 (18.0\u0026ndash;26.0)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e24.0 (16.0\u0026ndash;26.0)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.98\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(682)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(270)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(139)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e24.0 (18.0\u0026ndash;27.0)*\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e418\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24.0 (20.0\u0026ndash;27.0)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24.0 (18.0\u0026ndash;27.0)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e24.0 (19.0\u0026ndash;27.0)*\u003c/b\u003e\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e24.0 (14.8\u0026ndash;26.0)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.695\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e(421)\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(64)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(119)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e(165)\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(70)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e22.0 (16.0\u0026ndash;26.0)*\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e261\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22.0 (14.5\u0026ndash;26.5)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20.0 (14.8\u0026ndash;26.3)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e22.0 (17.0\u0026ndash;26.0)*\u003c/b\u003e\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e24.0 (17.5\u0026ndash;27.0)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.625\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e(261)\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(37)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(50)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e(105)\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(69)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMore than 28 tooth (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e98 (14.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17 (16.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e31 (18.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e34 (12.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e15 (10.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMore than 20 tooth (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e469 (68.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e466\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e74 (73.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e109 (64.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e191 (70.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e92 (65.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean probing depth\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.7 (2.2\u0026ndash;3.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e606\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.8 (2.4\u0026ndash;3.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.6 (2.2\u0026ndash;3.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.6 (2.1\u0026ndash;3.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.6 (2.2\u0026ndash;3.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.343\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e(mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(609)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(86)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(153)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(244)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(123)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePercentage of sites with\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11.1 (0.0-33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e606\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16.7 (2.1\u0026ndash;34.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12.5 (0.0-28.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10.0 (0.0-27.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e10.0 (0.0-33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.532\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePD\u0026thinsp;\u0026ge;\u0026thinsp;4 mm (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(609)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(86)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(153)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(244)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(123)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11.1 (0.0\u0026ndash;32.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e378\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.7 (0.0\u0026ndash;34.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e11.1 (0.0-25.9)*\u003c/b\u003e\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e9.2 (0.0-33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e16.7 (2.8\u0026ndash;33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.665\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(381)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e(109)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(150)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(65)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13.9 (0.0-33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e228\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22.2 (6.7\u0026ndash;42.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e21.7 (6.7\u0026ndash;41.0)*\u003c/b\u003e\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11.1 (0.0-22.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e8.3 (0.0-29.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(228)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e(44)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(58)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean clinical attachment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.1 (2.4-4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e398\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.3 (2.7-4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.2 (2.5-4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3.0 (2.4\u0026ndash;3.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.9 (2.4-4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.441\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003elevel (CAL)(mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(401)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(96)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(154)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(88)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePercentage of sites with\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26.7 (6.2\u0026ndash;50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e398\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33.3 (7.0\u0026ndash;50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30.0 (6.9\u0026ndash;52.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e22.8 (4.0\u0026ndash;50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e25.0 (6.7\u0026ndash;52.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.806\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCAL\u0026thinsp;\u0026ge;\u0026thinsp;4 mm (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(401)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(96)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(154)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(88)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30.0 (8.3\u0026ndash;58.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e236\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33.3 (11.1\u0026ndash;50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30.3 (10.4\u0026ndash;56.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e24.2 (2.8\u0026ndash;55.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e25.0 (8.3\u0026ndash;65.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.771\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(239)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(45)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.4 (2.8\u0026ndash;50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e162\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33.3 (2.8\u0026ndash;50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e26.3 (0.0-46.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e22.2 (4.6\u0026ndash;47.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e22.2 (0.0\u0026ndash;55.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.061\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(162)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(43)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePercentage of sites with bleeding on probing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16.7 (3.3\u0026ndash;33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e586\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18.1 (2.8\u0026ndash;41.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16.7 (3.1\u0026ndash;33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e16.7 (3.2\u0026ndash;33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e19.4 (5.6\u0026ndash;41.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.495\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e(BOP)(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(589)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(149)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(234)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(123)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e13.9 (2.8\u0026ndash;33.3)*\u003c/b\u003e\u003csup\u003e\u003cb\u003ed\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e366\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e8.3 (2.8\u0026ndash;30.6)**\u003c/b\u003e\u003csup\u003e\u003cb\u003ee\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13.6 (2.8\u0026ndash;31.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.9 (2.8\u0026ndash;32.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e19.4 (5.6\u0026ndash;50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e(369)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e(51)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(106)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(144)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(65)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e20.8 (56-37.3)*\u003c/b\u003e\u003csup\u003e\u003cb\u003ed\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e220\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e33.3 (13.9\u0026ndash;61.2)**\u003c/b\u003e\u003csup\u003e\u003cb\u003ee\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22.2 (5.6\u0026ndash;50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e19.4 (5.3\u0026ndash;34.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e18.1 (5.6\u0026ndash;33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.112\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e(220)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e(29)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(43)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(58)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean alveolar bone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.8 (1.2\u0026ndash;2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e539\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.0 (1.0-2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.8 (1.3\u0026ndash;2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.6 (1.2\u0026ndash;2.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.8 (1.2\u0026ndash;2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.765\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003escore (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(541)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(141)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(212)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(108)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003ePatient responses to the questionnaires on periodontal disease\u003c/h3\u003e\n\u003cp\u003eThe results based on the responses to the periodontal disease questionnaire are summarized in Supplementary Table\u0026nbsp;1. More than 50% of the respondents reported using interdental cleaning tools very rarely. Furthermore, approximately 50% of the respondents reported not undergoing regular dental check-ups. A comparison by sex showed that females were more likely than males to use interdental cleaning aids and had a higher frequency of tooth brushing (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005).\u003c/p\u003e\n\u003ch3\u003eCharacteristics of participants with and without regular dental check-ups\u003c/h3\u003e\n\u003cp\u003eThe characteristics of the participants in the groups with and without regular dental check-ups are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Compared with participants with regular dental check-ups, those without regular dental check-ups had higher fasting immunoreactive insulin (IRI) (median\u0026thinsp;=\u0026thinsp;7.5 [interquartile range\u0026thinsp;=\u0026thinsp;4.5\u0026ndash;11.0] vs. 5.6 [3.7\u0026ndash;9.0]; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.025), higher HOMA-IR (2.3 [1.4\u0026ndash;3.7] vs. 1.8 [1.2\u0026ndash;2.7]; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.025), higher triglyceride levels (121.0 [82.5\u0026ndash;179.0] vs. 101.0 [75.0\u0026ndash;148.0]; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.017), higher serum creatinine levels (0.8 [0.7\u0026ndash;0.9] vs. 0.7 [0.6\u0026ndash;0.9]; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.049), and lower high-density lipoprotein cholesterol levels (54.7 [46.0\u0026ndash;65.0] vs. 57.0 [46.0\u0026ndash;70.0]; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.045).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003eBaseline characteristics and clinical variables of JDCP subjects by regular dental check ups\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"586\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"bottom\" style=\"width: 191px;\"\u003e\n \u003cp\u003en = 678\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 338px;\"\u003e\n \u003cp\u003eRegular dental check ups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003eWith\u0026nbsp;（365, 53.8%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003eWithout\u0026nbsp;（313, 46.2%\u0026nbsp;）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e61.8 \u0026plusmn; 7.9\u0026nbsp;（364）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e61.1 \u0026plusmn; 8.3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.231\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 191px;\"\u003e\n \u003cp\u003eAlcohol consumption (n，%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e362\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e311\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e216 (59.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e171 (55.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.220\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e146 (40.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e140 (45.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 191px;\"\u003e\n \u003cp\u003eCurrent smoking status (n，%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e365\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e311\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e239 (65.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e189 (60.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.206\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e126 (34.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e122 (39.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 191px;\"\u003e\n \u003cp\u003eDuration of diabetes (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e10.0 (5.0-17.0)\u0026nbsp;（361）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e9.0 (5.0-16.0)\u0026nbsp;（309）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.755\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003eHeight (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e161.7 \u0026plusmn; 9.5\u0026nbsp;（365）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e162.1 \u0026plusmn; 8.6\u0026nbsp;（312）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.595\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003eWeight (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e64.1 \u0026plusmn; 13.7\u0026nbsp;（362）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e64.4 \u0026plusmn; 11.6\u0026nbsp;（310）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.164\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003eMaximum weight (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e70.7 \u0026plusmn; 14.4\u0026nbsp;（363）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e72.4 \u0026plusmn; 12.9\u0026nbsp;（313）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.106\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 191px;\"\u003e\n \u003cp\u003eAge at maximum weight (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e49.0 (40.0-57.0)\u0026nbsp;（360）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e49.0 (39.0-57.0)\u0026nbsp;（312）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.096\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 191px;\"\u003e\n \u003cp\u003eWaist circumference (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e86.4 \u0026plusmn; 10.4\u0026nbsp;（335）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e87.9 \u0026plusmn; 10.5\u0026nbsp;（291）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.075\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e23.7 (21.9-26.2)\u0026nbsp;（362）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e24.0 (22.0-27.1)\u0026nbsp;（309）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.105\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003eHbA1c (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e7.1 (6.6-7.7)\u0026nbsp;（364）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e7.2 (6.7-7.8)\u0026nbsp;（312）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.180\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003eFPG (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e132.0 (115.0-153.0)\u0026nbsp;（175）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e133.0 (112.5-156.0)\u0026nbsp;（125）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.976\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003eFasting IRI (\u0026micro;U/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e5.6 (3.7-9.0)\u0026nbsp;（102）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e7.5 (4.5-11.0)\u0026nbsp;（78）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.025\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003eHOMA-IR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e1.8 (1.2-2.7)\u0026nbsp;（94）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e2.3 (1.4-3.7)\u0026nbsp;（76）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.025\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003eSystolic BP (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e130.0 (120.0-140.0)\u0026nbsp;（353）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e129.0 (120.0-139.5)\u0026nbsp;（301）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003eDiastolic BP (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e75.0 \u0026plusmn; 10.0\u0026nbsp;（353）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e74.5 \u0026plusmn; 10.4\u0026nbsp;（301）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.522\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 191px;\"\u003e\n \u003cp\u003eTotal cholesterol (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e195.0 \u0026plusmn; 30.9\u0026nbsp;（353）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e195.7 \u0026plusmn; 33.5\u0026nbsp;（306）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.770\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003eLDL cholesterol (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e112.1 \u0026plusmn; 25.5\u0026nbsp;（345）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e113.3 \u0026plusmn; 26.5\u0026nbsp;（300）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.576\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 191px;\"\u003e\n \u003cp\u003eHDL cholesterol (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e57.0 (46.0-70.0)\u0026nbsp;（357）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e54.7 (46.0-65.0)\u0026nbsp;（305）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.045\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003eTriglycerides (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e101.0 (75.0-148.0)\u0026nbsp;（206）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e121.0 (82.5-179.0)\u0026nbsp;（149）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.017\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 191px;\"\u003e\n \u003cp\u003eSerum creatinine (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e0.7 (0.6-0.9)\u0026nbsp;（354）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e0.8 (0.7-0.9)\u0026nbsp;（304）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.049\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003eeGFR (mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e74.9 (64.9-87.3)\u0026nbsp;（354)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e73.8 (62.2-85.3)\u0026nbsp;(304)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.231\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003eSerum albumin (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e4.3 (4.1-4.5)\u0026nbsp;（335）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e4.3 (4.1-4.5)\u0026nbsp;（292）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.218\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003c/BR\u003e\n\u003ch3\u003eFactors associated with insulin resistance\u003c/h3\u003e\n\u003cp\u003eBased on the characteristics identified in the univariate analysis, a multiple logistic regression model was used for identification of factors independently associated with insulin resistance\u003c/p\u003e\u003cp\u003e(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In addition to higher BMI, Regular dental check-ups were found to be independently associated with insulin resistance even after the adjustment of age, sex, smoking, alcohol consumption, duration of diabetes, BMI, regular dental checkups, use of interdental cleaning aids (odds ratio [OR]\u0026thinsp;=\u0026thinsp;2.33, 95% confidence interval [CI]\u0026thinsp;=\u0026thinsp;1.07\u0026ndash;5.09, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.034).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to examine the relationship between periodontal disease status, dental visit patterns, and diabetes status in Japanese patients with type 2 diabetes. The present study suggests that participants who did not undergo regular dental check-ups exhibited higher fasting IRI and HOMA-IR compared with those who did. Although studies on insulin resistance and periodontal disease in non-diabetic patients have been conducted\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e, to the best our knowledge, this is the first study which demonstrated the independent association between regular dental checkups and insulin resistande in the large-scale study in Japanese patients with diabetes.\u003c/p\u003e\u003cp\u003eThe reduced risk of insulin resistance associated with regular dental check-ups could be explained by the presence of systemic inflammation related to periodontal disease\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Insulin resistance is a primary factor in diabetes, and it has been widely reported to elevate levels of inflammatory cytokines and markers\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. It is well established that these inflammatory cytokines are elevated during local inflammation of periodontal tissues caused by periodontal disease\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Moreover, the systemic inflammatory burden increases with the extent and severity of periodontal disease\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e, contributing to insulin resistance and worsening glycemic control\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Kiyowa et al. reported that participants with periodontal disease were three and a half times more likely to have insulin resistance than those without periodontal disease\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Treatment of periodontitis results in reduction of both local and systematic inflammation\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003ePeriodontal treatment involves the professional removal of supragingival and subgingival bacterial plaque, biofilm, and calculus, along with oral hygiene instructions\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. The primary goal of periodontitis treatment is to reduce swelling and infection and to stabilize the condition of the periodontal tissue. Sun et al. reported that periodontal treatment can improve HbA1c levels, lipid profiles, and HOMA-IR, while significantly reducing serum inflammatory cytokine levels in patients with type 2 diabetes\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Furthermore, Mammen et al. documented a significant decrease in HOMA-IR 3 months after non-surgical periodontal therapy, which included oral hygiene instructions, in patients with type 2 diabetes and chronic periodontitis\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. Therefore, individuals who attend dental check-ups may experience improved local periodontal inflammation through periodontal treatment, which, in turn, could reduce systemic inflammation and infection compared to those who do not undergo regular dental check-ups. This reduction in systemic inflammation and infection may also contribute to improved insulin resistance. The latest systematic review and meta-analysis indicated that periodontal treatment may be more beneficial than existing pharmacotherapy for diabetes, both in terms of side effects and medical economics\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eA 2024 survey conducted in Japan, 62.0% of individuals aged 60 to 69 reported regular dental check-ups\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. The present study suggests that approximately 50% of respondents did not receive regular dental check-ups. Despite clinical guidelines strongly recommending periodontal treatment for patients with diabetes\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e, only 40.5% of 1,101 patients with diabetes (mean age: 69.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.9 years) regularly attended dental check-ups, as reported in the 2024 Japan Medical Association Database of Clinical Medicine\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. Poudel et al. reported that individuals with diabetes have inadequate oral health knowledge, poor oral health attitudes, and low compliance with recommended oral hygiene behaviors and dental visits\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. These findings highlight a low level of awareness regarding periodontal disease, underscoring the need for appropriate interventions.\u003c/p\u003e\u003cp\u003eThe results from this study indicate a statistically significant association between regular dental check-ups and insulin resistance in patients with diabetes, using the baseline data of the JDCP study. However, it is important to acknowledge that this is a cross-sectional study, which does not fully support the association between dental visits and insulin resistance in a long-term follow-up. Further studies should be conducted using prospective follow-up data from the JDCP study to determine whether periodontal treatment is associated with decreased insulin resistance in patients with type 2 diabetes mellitus in Japan.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eStudy population\u003c/h2\u003e\u003cp\u003eThe JDCP study participants were outpatients with type 1 and type 2 diabetes, aged 40 to 74 years, receiving treatment at university hospitals, core local hospitals, and specialized diabetes clinics nationwide in Japan. The study initially included 7,700 patients who met the inclusion criteria and provided informed consent during the 30-month period from June 2007 to November 2009. Ultimately, 6,338 patients were included after excluding those who met the following criteria: (1) inability to make regular outpatient visits; (2) progression to diabetic proliferative retinopathy; (3) ongoing dialysis therapy; (4) diagnosis of malignancy in the previous 5 years; and (5) other conditions deemed ineligible by the study investigators. Of these, 685 patients with type 2 diabetes who underwent dental examinations by a dentist were included in the final analysis (Supplementary Fig.\u0026nbsp;1).\u003c/p\u003e\u003cp\u003e The Declaration of Helsinki and the Ethical Guidelines for Clinical/ Epidemiological Studies of the Japanese Ministry of Health Labor and Welfare were followed. This study was conducted with approval from the Japan Diabetes Society Research Ethics Committee and the institutional review board of each participating facility and registered with the UMIN Clinical Trial Registry (Registry ID, UMIN 000016519). All participants provided written informed consent.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003ePeriodontal assessment and oral health information\u003c/h2\u003e\u003cp\u003eThe data of periodontal disease were collected from self-reported questionnaires and the periodontal examinations, including radiographic assessments, with patient consent performed by trained dentists. The self-report questionnaire gathered information on tooth loss within the previous year, the self-reported number of teeth, history of gingival swelling, frequency of daily toothbrushing, use of interdental cleaning aids, and frequency of regular dental check-ups. The periodontal examination included tooth count and tooth mobility measurements of the present teeth, excluding third molars. Probing pocket depth (PD), bleeding on probing (BOP) and clinical attachment level (CAL) assessments were made at the 6 sites of each tooth using a periodontal pocket probe. Radiographic assessments were examined to evaluate alveolar bone loss as an indicator of periodontal tissue destruction. If the first molars were missing, second molars were assessed instead. Alveolar bone loss was categorized as follows: \u0026lt;25% (score I), 25\u0026ndash;50% (score II), 50\u0026ndash;75% (score III), and \u0026gt;\u0026thinsp;75% (score IV).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eInsulin resistance assessment\u003c/h2\u003e\u003cp\u003eInsulin resistance was evaluated using HOMA-IR, calculated as fasting insulin (\u0026micro;U/mL) \u0026times; fasting glucose (mmol/L)/22.5. A HOMA-IR value greater than 2.5 was considered indicative of insulin resistance \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eOther assessments\u003c/h2\u003e\u003cp\u003eAdditional assessments included physical examinations, blood pressure measurements, and laboratory tests for HbA1c, fasting plasma glucose, fasting immunoreactive insulin, serum lipids, creatinine, estimated glomerular filtration rate, and serum albumin. Surveys were conducted regarding the duration of diabetes, alcohol consumption, smoking status, and the use of oral hypoglycemic agents and insulin therapy.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eStatistical analyses were performed using SPSS version 29 (IBM Corp., Armonk, NY, USA). Continuous variables were presented as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (S,D,) and analyzed using Student\u0026rsquo;s t-test for normally distributed variables. Non-normally distributed variables were expressed as medians (interquartile ranges) and analyzed using the Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e test. Categorical variables were presented as percentages and analyzed using the χ\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e test. Multiple logistic regression analyses were conducted to explore the association between insulin resistance and periodontal disease, adjusting for sex (male/female), age (\u0026lt;\u0026thinsp;60 years/\u0026ge;60 years), smoking history (yes/no), alcohol consumption (yes/no), duration of diabetes (\u0026lt;\u0026thinsp;10 years/\u0026ge;10 years), body mass index (BMI) (\u0026lt;\u0026thinsp;25/\u0026ge;25 kg/m\u003csup\u003e2\u003c/sup\u003e), regular dental check-ups (yes/no), and use of interdental cleaning aids (yes/no). HOMA-IR (\u0026lt;\u0026thinsp;2.5/\u0026ge;2.5) was used as the dependent variable to calculate ORs and 95% CIs. ORs and CIs were adjusted for age, sex, and explanatory variables to determine associations between insulin resistance and periodontal disease. Statistical significance was set at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. All data analyses were independently performed at least twice by multiple investigators to ensure accuracy.\u003c/p\u003e\u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eJDCP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eJapan Diabetes Complication and its Prevention prospective study\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHbA1c\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ehemoglobin A1c\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their sincere thanks to all physicians and medical staff at the 464 participating facilities for their cooperation and to all diabetic patients for their participation in the study. The authors would also like to thank Editage (https://www.editage.jp/) for English language editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eY.T. and K.I. study design and study, data analysis and writing of original draft. T.K., T.F., A.M., J.N., E.N., S.Y., K.T., S.T., A.S., S.K., H.N., T.I., Y.N., M.Y., N.Y., N.M., F.N., H.Y., and T.N. data collection. K.I., K.N., R.N. and N.T. reviewed the manuscript and provided critical advice. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data are available in the manuscript and associated supplementary files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Authors received\u0026nbsp;no funding\u0026nbsp;for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePapapanou, P. N. et al. Periodontitis: consensus report of workgroup 2 of the 2017 world workshop on the classification of periodontal and Peri-Implant diseases and conditions. \u003cem\u003eJ. Periodontol\u003c/em\u003e. \u003cb\u003e89\u003c/b\u003e, S173\u0026ndash;S182 (2018).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKinane, D. F., Stathopoulou, P. G. \u0026amp; Papapanou, P. N. Periodontal diseases. \u003cem\u003eNat. Rev. Dis. Primers\u003c/em\u003e. \u003cb\u003e3\u003c/b\u003e, 17038 (2017).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSuzuki, S. et al. Reasons for Tooth Extractions in Japan: The Second Nationwide Survey. \u003cem\u003eInt. Dent. J.\u003c/em\u003e \u003cb\u003e72\u003c/b\u003e, 366\u0026ndash;372 (2022).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKwon, T., Lamster, I. B. \u0026amp; Levin, L. Current Concepts in the Management of Periodontitis. \u003cem\u003eInt. Dent. J.\u003c/em\u003e \u003cb\u003e71\u003c/b\u003e, 462\u0026ndash;476 (2021).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNascimento, G. G., Alves-Costa, S. \u0026amp; Romandini, M. Burden of severe periodontitis and edentulism in 2021, with projections up to 2050: the global burden of disease 2021 study. \u003cem\u003eJ. Periodontal Res.\u003c/em\u003e \u003cb\u003e59\u003c/b\u003e, 823\u0026ndash;867 (2024).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health Labour and Welfare. \u003cem\u003e2022 Survey of Dental Diseases\u003c/em\u003e. (2023). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/content/10804000/001112405.pdf\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/content/10804000/001112405.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchuster, D. P. \u0026amp; Duvuuri, V. Diabetes mellitus. \u003cem\u003eClin. Podiatr. Med. Surg.\u003c/em\u003e \u003cb\u003e19\u003c/b\u003e, 79\u0026ndash;107 (2002).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGBD 2021 Diabetes Collaborators. Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021. \u003cem\u003eLancet\u003c/em\u003e \u003cb\u003e402\u003c/b\u003e, 203\u0026ndash;234 (2023).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health Labour and Welfare. \u003cem\u003e2023 National Health and Nutrition Survey\u003c/em\u003e. (2024). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/content/10900000/001338334.pdf\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/content/10900000/001338334.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRos\u0026aacute;rio et al. Periodontitis severity relationship with metabolic syndrome: A systematic review with meta-analysis. \u003cem\u003eOral Dis.\u003c/em\u003e \u003cb\u003e29\u003c/b\u003e, 2512\u0026ndash;2520 (2023).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStohr, J., Barbaresko, J., Neuenschwander, M. \u0026amp; Schlesinger, S. Bidirectional association between periodontal disease and diabetes mellitus: A systematic review and meta-analysis of cohort studies. \u003cem\u003eSci. Rep.\u003c/em\u003e \u003cb\u003e11\u003c/b\u003e, 13686 (2021).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGraziani, F., Gennai, S., Solini, A. \u0026amp; Petrini, M. A systematic review and meta-analysis of epidemiologic observational evidence on the effect of periodontitis on diabetes. An update of the EFP-AAP review. \u003cem\u003eJ. Clin. Periodontol\u003c/em\u003e. \u003cb\u003e45\u003c/b\u003e, 167\u0026ndash;187 (2018).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThe Japan Diabetes Society. \u003cem\u003eGuide for Treatment of Diabetes\u003c/em\u003e (Bunkodo Co., Ltd., 2024).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAhmadinia, A. R. et al. Association between type 2 diabetes (T2D) and tooth loss: a systematic review and meta-analysis. \u003cem\u003eBMC Endocr. Disord\u003c/em\u003e. \u003cb\u003e22\u003c/b\u003e, 100 (2022).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWeijdijk, L. P. M., Ziukaite, L., Van der Weijden, G. A., Fridus), Bakker, E. W. P., Slot, D. E. \u0026amp; (\u0026amp; The risk of tooth loss in patients with diabetes: A systematic review and meta-analysis. \u003cem\u003eInt. J. Dent. Hyg.\u003c/em\u003e \u003cb\u003e20\u003c/b\u003e, 145\u0026ndash;166 (2022).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGenco, R. J., Graziani, F. \u0026amp; Hasturk, H. Effects of periodontal disease on glycemic control, complications, and incidence of diabetes mellitus. \u003cem\u003ePeriodontol 2000\u003c/em\u003e. 83, 59\u0026ndash;65 (2020).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWu, C. Z. et al. Epidemiologic relationship between periodontitis and type 2 diabetes mellitus. \u003cem\u003eBMC Oral Health\u003c/em\u003e. \u003cb\u003e20\u003c/b\u003e, 204 (2020).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUmezaki, Y., Yamashita, A., Nishimura, F. \u0026amp; Naito, T. The role of periodontal treatment on the reduction of hemoglobinA1c, comparing with existing medication therapy: A systematic review and meta-analysis. \u003cem\u003eFront. clin. diabetes healthc.\u003c/em\u003e \u003cb\u003e6\u003c/b\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fcdhc.2025.1541145\u003c/span\u003e\u003cspan address=\"10.3389/fcdhc.2025.1541145\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2025).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThe Japanese Society of Periodontology. \u003cem\u003e2023 Periodontal Treatment Guidelines for Patients with Diabetes (Revised Version 3)\u003c/em\u003e (Ishiyaku Publishers,Inc., 2023).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePoudel, P. et al. Oral health knowledge, attitudes and care practices of people with diabetes: a systematic review. \u003cem\u003eBMC Public. Health\u003c/em\u003e. \u003cb\u003e18\u003c/b\u003e, 577 (2018).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAndriankaja, O. M. et al. Insulin resistance predicts the risk of gingival/periodontal inflammation. \u003cem\u003eJ. Periodontol\u003c/em\u003e. \u003cb\u003e89\u003c/b\u003e, 549\u0026ndash;557 (2018).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMart\u0026iacute;nez-Garc\u0026iacute;a, M. \u0026amp; Hern\u0026aacute;ndez-Lemus, E. Periodontal inflammation and systemic diseases: an overview. \u003cem\u003eFront. Physiol.\u003c/em\u003e \u003cb\u003e12\u003c/b\u003e, 709438 (2021).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBorst, S. E. The role of TNF-alpha in insulin resistance. \u003cem\u003eEndocrine\u003c/em\u003e \u003cb\u003e23\u003c/b\u003e, 177\u0026ndash;182 (2004).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCecoro, G., Annunziata, M., Iuorio, M. T., Nastri, L. \u0026amp; Guida, L. Periodontitis, low-grade inflammation and systemic health: a scoping review. \u003cem\u003eMedicina (Kaunas)\u003c/em\u003e \u003cb\u003e56\u003c/b\u003e, (2020).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePolak, D. \u0026amp; Shapira, L. An update on the evidence for pathogenic mechanisms that may link periodontitis and diabetes. \u003cem\u003eJ. Clin. Periodontol\u003c/em\u003e. \u003cb\u003e45\u003c/b\u003e, 150\u0026ndash;166 (2018).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMiyazawa, I., Morino, K., Harada, K., Ishikado, A. \u0026amp; Kume, S. The relationship among obesity, diabetes, and oral fealth: a narrative review of real-world evidence. \u003cem\u003eCurr. Oral Health Rep.\u003c/em\u003e \u003cb\u003e12\u003c/b\u003e, 1\u0026ndash;6 (2025).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSong, I. S. et al. Severe periodontitis is associated with insulin resistance in non-abdominal obese adults. \u003cem\u003eJ. Clin. Endocrinol. Metab.\u003c/em\u003e \u003cb\u003e101\u003c/b\u003e, 4251\u0026ndash;4259 (2016).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKiryowa, H. M. et al. Periodontitis is associated with insulin resistance in adults living with diabetes mellitus in Uganda: a cross- sectional study. \u003cem\u003eBMC Res. Notes\u003c/em\u003e \u003cb\u003e16\u003c/b\u003e, (2023).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLuthra, S. et al. Treatment of periodontitis and C-reactive protein: A systematic review and meta-analysis of randomized clinical trials. \u003cem\u003eJ. Clin. Periodontol\u003c/em\u003e. \u003cb\u003e50\u003c/b\u003e, 45\u0026ndash;60 (2023).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmerican Dental Association. Periodontitis. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ada.org/resources/ada-library/oral-health-topics/periodontitis\u003c/span\u003e\u003cspan address=\"https://www.ada.org/resources/ada-library/oral-health-topics/periodontitis\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSun, W. L. et al. Inflammatory cytokines, adiponectin, insulin resistance and metabolic control after periodontal intervention in patients with type 2 diabetes and chronic periodontitis. \u003cem\u003eIntern. Med.\u003c/em\u003e \u003cb\u003e50\u003c/b\u003e, 1569\u0026ndash;1574 (2011).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMammen, J., Vadakkekuttical, R. J., George, J. M., Kaziyarakath, J. A. \u0026amp; Radhakrishnan, C. Effect of non-surgical periodontal therapy on insulin resistance in patients with type II diabetes mellitus and chronic periodontitis, as assessed by C-peptide and the Homeostasis Assessment Index. \u003cem\u003eJ Investig Clin. Dent\u003c/em\u003e \u003cb\u003e8\u003c/b\u003e, (2017).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health Labour and Welfare. \u003cem\u003e2024 Survey of Dental Diseases\u003c/em\u003e. (2025). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/content/10804000/001512690.pdf\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/content/10804000/001512690.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThe Japan Medical Association Research Institute. \u003cem\u003eThe Fifth J-DOME Report\u003c/em\u003e. (2024). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.jdome.jp/doc/jdome-report2024-5th.pdf\u003c/span\u003e\u003cspan address=\"https://www.jdome.jp/doc/jdome-report2024-5th.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Periodontal disease, Diabetes, Insulin resistance, Dental check-ups, HOMA-IR, Periodontal treatment","lastPublishedDoi":"10.21203/rs.3.rs-7448584/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7448584/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDespite the well-established bidirectional relationship between periodontal disease and diabetes, limited research has examined the role of regular dental check-ups in patients with type 2 diabetes. This study analyzed the relationship between periodontal disease status, dental visit patterns, and diabetes status using baseline data from the Japan Diabetes Complication and its Prevention (JDCP) prospective study. Among 6,099 patients with diabetes (aged 40\u0026ndash;75 years), 685 with type 2 diabetes who underwent dental examinations were included. Trained dentists collected periodontal disease data using self-report questionnaires and periodontal examination.\u003c/p\u003e\u003cp\u003eInsulin resistance was evaluated using the homeostasis model assessment of insulin resistance (HOMA-IR). Participants who did not undergo regular dental check-ups exhibited higher HOMA-IR values than those who did. Logistic regression analyses revealed a significant association between insulin resistance and regular dental check-ups (odds ratio\u0026thinsp;=\u0026thinsp;2.33, 95% confidence interval\u0026thinsp;=\u0026thinsp;1.07\u0026ndash;5.09, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.034). Approximately 50% of the respondents did not undergo regular dental check-ups. Individuals who undergo dental check-ups may experience improved local periodontal inflammation through treatment, potentially reducing systemic inflammation and infection compared to those who do not. This reduction in systemic inflammation and infection could contribute to improved insulin resistance.\u003c/p\u003e","manuscriptTitle":"Regular Dental Check-ups Are Independently Associated With Insulin Resistance in Japanese Type 2 Diabetes Patients (JDCP study 17)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-22 08:37:18","doi":"10.21203/rs.3.rs-7448584/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cdacc713-2309-4e3a-8063-16ca09001c6f","owner":[],"postedDate":"September 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":54834652,"name":"Health sciences/Diseases"},{"id":54834653,"name":"Health sciences/Endocrinology"},{"id":54834654,"name":"Health sciences/Health care"},{"id":54834655,"name":"Health sciences/Medical research"},{"id":54834656,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2025-10-27T15:06:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-22 08:37:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7448584","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7448584","identity":"rs-7448584","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}