Association between oral health and bowel habits: a cross-sectional study

Association between oral health and bowel habits: a cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Association between oral health and bowel habits: a cross-sectional study Zuhong Ji, Jianwen Mei, Youjian Li, Zijie Wang, Zhirui Guo, Lin Miao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5733361/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Apr, 2025 Read the published version in BMC Public Health → Version 1 posted 9 You are reading this latest preprint version Abstract Background Oral diseases affect approximately 3.5 billion people worldwide, disproportionately burdening populations in developing countries. Chronic diarrhea and constipation, as common intestinal disorders, may interact bidirectionally with oral health, though their population-level associations remain unexamined. Methods We analyzed data from the National Health and Nutrition Examination Surveys (NHANES) 2005–2008, selecting participants based on inclusion criteria. Chronic diarrhea and constipation were defined based on the bowel health questionnaire. Oral health indicators (teeth condition and oral pain frequency) were derived from the oral health questionnaire. Covariates selected by Lasso regression were analyzed through adjusted logistic regression to examine associations between bowel habits and oral health. Restricted cubic splines (RCS), subgroup stratification, and sensitivity analyses were also used. Results A total of 7512 participants aged ≥ 20 with complete information were included. Multivariable logistic regression revealed a significant association between chronic constipation and poor teeth condition (OR:1.45, 95% CI: 1.05–2.01, P = 0.029). A U-shaped dose-response relationship was observed between stool frequency and poor teeth condition (nonlinear P -value = 0.002) using RCS analysis, with both abnormally low and high bowel frequencies correlating with increased oral health risks. No significant association was identified between oral pain frequency and abnormal bowel habits after full covariate adjustment. Stratified analyses indicated that daily dietary fiber intake ≥ 25 g was associated with reduced risks of poor teeth condition (chronic diarrhea OR: 0.40, 95% CI: 0.12–0.98; chronic constipation OR: 0.44, 95% CI: 0.13–1.09), whereas higher income (PIR > 3.5) correlated with elevated risks (chronic diarrhea OR: 2.38, 95% CI: 1.35–3.98; chronic constipation OR: 2.18, 95% CI: 1.22–3.70). Sensitivity analyses supported the stability of associations between abnormal bowel habits and poor teeth condition. Conclusions Both chronic constipation and diarrhea were associated with higher risk of poor teeth condition. In the general population and subgroup analyses, individuals with stool frequency around 8–10 times per week demonstrated the lowest risk of poor teeth condition. Stratified analysis indicates that dietary fiber intake and PIR might modify the observed relationship between abnormal bowel habits and teeth condition. Chronic diarrhea Chronic constipation Oral health NHANES Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Oral health has emerged as a critical global health challenge, with approximately 3.5 billion people worldwide affected by oral diseases that create striking health disparities between and within nations, particularly burdening developing countries[ 1 , 2 ]. The consequences of untreated oral conditions extend beyond localized infections—they correlate with systemic inflammation, psychological distress, and elevated all-cause mortality[ 3 – 5 ]. Despite these profound implications, population-level preventive strategies remain inadequately implemented[ 6 , 7 ]. Two fundamental indicators of oral health—teeth condition and oral pain frequency—have recently gained recognition as biomarkers reflecting not only oral cavity integrity but also broader physiological and psychological wellbeing[ 8 ]. Parallel to this oral health crisis, chronic bowel disorders impose a growing disease burden. Chronic constipation (14% global prevalence) and diarrhea (5%) frequently coexist with metabolic disorders, neurological conditions, and mental health comorbidities[ 9 , 10 ]. Compared with acute symptoms, chronic diarrhea and chronic constipation usually last for more than four weeks and are associated with a variety of other diseases[ 11 – 13 ]. Emerging evidence suggests bidirectional crosstalk between the gut and oral ecosystems, mediated through microbial translocation, metabolites, and immune modulation[ 14 , 15 ]. For example, Nakajima et al. discovered that P. gingivalis , the primary pathogen of chronic periodontitis, induces intestinal inflammation by altering the gut microbiota and downregulating tjp-1 and occludin[ 16 ]. However, existing research predominantly focuses on unidirectional oral-to-gut microbial transmission and periodontitis-inflammatory bowel disease associations[ 17 , 18 ], leaving a critical knowledge gap regarding how chronic bowel habit alterations might reciprocally impact oral health outcomes. Notably, Jiang et al. employed Mendelian randomization analysis to reveal significant associations between gut microbial taxa (Christensenellaceae, Erysipelotrichia, etc.) and dental caries risk, suggesting gut microbiota may exert bidirectional effects on oral health[ 19 ]. This gap motivates our population-based investigation into the relationship between bowel habits and oral health. Based on the theory that the gut and oral cavity are closely related, we hypothesize that compared to individuals with normal bowel habits, those suffering from chronic constipation or diarrhea exhibit a higher prevalence of oral problems (manifested as poor teeth condition and frequent oral pain). We predict that this manifestation is also reflected in bowel frequency: too few or too many bowel movements per week simultaneously implicate an increased risk of poor teeth condition and a higher frequency of oral pain. To validate these hypotheses, this study collected and analyzed data from the National Health and Nutrition Examination Survey (NHANES). The NHANES, which is a major program in the US, assesses the health and nutritional status of the civilian non-institutionalized population via interviews and physical exams and is widely used for epidemiological research and health policy formulation. By establishing a population-level association between bowel habits patterns and oral health, this study fills a critical evidentiary gap in the gut-mouth axis paradigm, while providing new insights for future oral disease prevention and screening strategies. Materials and methods Study population The NHANES database serves as a cross-sectional survey with a two-year cycle. For the present study, both the bowel health and oral health questionnaire components were required. The analysis focused on NHANES cycles from 2005 to 2008 because bowel-related interview data were available through 2010, while the oral health questionnaire underwent a substantive revision in 2009, including updated question codes and content. The inclusion criteria for the study are: (1) age ≥ 20 years, (2) complete responses to oral health and bowel health questionnaires, and (3) availability of comprehensive covariate data such as demographic characteristics and dietary intake profiles. Participants with missing data were excluded from the study. Bowel health assessment Bowel habit classification was performed using participant responses from the bowel health questionnaire, with chronic diarrhea and constipation defined through standardized criteria. To evaluate stool consistency, participants were presented with the Bristol Stool Form Scale (BSFS) card depicting seven stool types through illustrations and descriptors. Each individual was instructed to identify their most representative stool pattern by selecting the corresponding BSFS number. Weekly bowel movement frequency was determined through the question: “How many times per week do you usually have a bowel movement?” Diagnostic thresholds were applied as follows: Chronic diarrhea: (a) Predominant stool type categorized as BSFS type 6 (fluffy pieces with ragged edges, a mushy stool) or type 7 (watery, no solid pieces), or (b) Exceeding 21 bowel movements weekly (> 3/day); Chronic constipation: Predominant stool type classified as BSFS type 1 (separate hard lumps, like nuts) or type 2 (sausage-like, but lumpy), or (b) Fewer than 3 bowel movements weekly[ 12 , 20 ]. Oral health assessment Previous studies have demonstrated that self-rated oral health, as an indicator to measure oral conditions, exhibits strong reliability and validity[ 21 , 22 ]. In addition, it can serve as a predictor for potential oral diseases and subsequent oral health development trends to some extent[ 23 ]. The oral health questionnaire in the NHANES database from 2005 to 2008 included key questions related to oral health-related quality of life and perceived teeth conditions. This study focused on teeth conditions and the frequency of oral pain in the past year as the primary endpoints. The questions were: “Now I have some questions about the condition of your teeth and gums. How would you describe the condition of your teeth?” and “How often during the last year have you had painful aching anywhere in your mouth?”. The oral health questionnaire was completed at home prior to the physical examination, using the Computer-Assisted Personal Interviewing (CAPI) system, which was managed by interviewers. Covariates In this study, to reduce potential bias, we included covariates that have been previously identified in prior researches and other factors that may influence the relationship between bowel habits and oral health[ 12 , 13 , 24 ]. These covariates included demographic factors such as age (continuous), gender, ethnicity (Mexican American, other Hispanic, non-Hispanic white, non-Hispanic black, and other races), education level (high school), poverty-to-income ratio ( 3.5), marital status (divorced/separated/widowed, married/living with a partner, never married), and body mass index (BMI) ( 24). Given the significant regulatory effect of lifestyle habits on bowel frequency, lifestyle factors were incorporated into the study, including vigorous activities (yes, no, unknown), smoking (never, past, current), and alcohol consumption (yes, no). We also referenced the commonly used depression questionnaire score classification to eliminate the interference of psychiatric factors, where scores of 0–10 were considered as no depression, and scores ≥ 10 were regarded as having depression[ 12 ]. Diabetes, as a comorbidity, was determined based on fasting blood glucose levels, glycated hemoglobin, history of diabetes, and whether insulin was used. Additionally, dietary fiber, water intake, total sugar intake, white blood cell (WBC) count, neutrophil percentage, C-reactive protein (CRP), and serum calcium were also included as covariates. In the subsequent stratified analysis, age was grouped into three categories with 20-year intervals (20–39 years, 40–59 years, and 60–85 years). Blood-related markers were divided into two groups based on normal range boundaries: WBC count was split into 10, neutrophil percentage into 75, CRP into 0.01–0.99 and 1.00–20.00, and serum calcium into 7.0–9.0 and 9.1–11.5. Statistical analysis Given the complexity of the sampling design in the NHANES database, appropriate weighting was applied to the data during analysis in this study. Participants were grouped based on their bowel habits, and baseline characteristics were described for each group. Continuous variables were expressed as mean ± SE, while categorical variables were presented as percentages. Spearman correlation analysis was used to test the monotonic relationship (monotonic decrease or increase) between independent variables, and the correlation strength was judged by the correlation coefficient ρ. Generally, we consider |ρ|≥0.8 as strong correlation, 0.5≤|ρ|<0.8 as moderate correlation, 0.3≤|ρ|<0.5 as weak correlation, and |ρ|<0.3 indicates that the two variables are basically uncorrelated. Survey-weighted analysis of variance (ANOVA) was used to compare differences in continuous variables among groups, and survey-weighted chi-square tests were employed to evaluate differences in categorical variables. To address multicollinearity and optimize feature selection, least absolute shrinkage and selection operator (Lasso) regression with 10-fold cross-validation was first applied to identify covariates most predictive of the oral health outcomes. The optimal penalty parameter (λ) was determined by minimizing the binomial deviance through iterative validation. Covariates retaining non-zero coefficients under the optimal λ were subsequently entered into multivariable logistic regression models to estimate adjusted odds ratios. Weighted logistic regression analysis was conducted to examine the association between oral health and diarrhea, as well as constipation. The initial crude model did not adjust for any potential confounding factors. Model 1 included adjustments for age, sex, race, education, poverty-to-income ratio, and marital status. Model 2 further adjusted for BMI, smoking, alcohol consumption, vigorous activities, depression score, diabetes, dietary fiber intake, CRP, and serum calcium. Subsequently, we conducted stratified analysis and interactive effect analysis to further identify the variables that influence the relationship between bowel habits and teeth condition, as well as the relationship between the bowel and oral health in various subgroups. Given the potential bidirectional influences between bowel habits and oral health, restricted cubic spline (RCS) curves were implemented to characterize nonlinear dose-response relationship between teeth condition and bowel frequency. Subsequent stratified RCS curves were constructed to evaluate potential effect modification by age categories and depression status. To evaluate the robustness of primary findings, several sensitivity analyses were implemented: First, missing covariates were multiple imputed via the R mice package using predictive mean matching. Estimates from multiply imputed models were contrasted against complete-case analyses to evaluate missing data impacts. Second, we excluded participants with diabetes, depression, or elevated CRP (≥ 1.00 mg/dL) to test associations in a low-comorbidity subsample. Statistical analyses in this study were performed using R version 4.4.2 (R Foundation for Statistical Computing, Vienna, Austria). A two-tailed P -value < 0.05 was considered statistically significant. Results Baseline characteristics of participants A total of 20,497 participants were recruited for the survey between 2005 and 2008. Based on our inclusion and exclusion criteria, 7,512 eligible participants (aged ≥ 20 years with no missing data on variables; see Fig. 1 for details) were finally included in our study. Among them, 535 reported chronic diarrhea, 589 reported chronic constipation, and the remaining 6,388 had no significant abnormalities in defecation. After weighting the sample data, there were 3,877 (51.87%) females and 3,635 (48.13%) males. It is worth noting that the proportion of females in the chronic constipation group was significantly higher than that of males (73.30% vs. 26.70%). The average age of participants in the total sample was 46.67 ± 0.48, but this value increased to 50.26 ± 0.94 in the chronic diarrhea group. In terms of sociodemographic characteristics, compared to the two groups with abnormal bowel habits, normal individuals were more likely to be non-Hispanic white, have a higher level of education, be more affluent, and be married/living with a partner. Additionally, significant differences were observed in lifestyle behaviors among the three groups: the diarrhea group had the highest proportions of alcohol consumption, current smoking, and no vigorous physical activity. Individuals with chronic constipation exhibited significantly lower daily water intake (793.40 ± 53.44) and dietary fiber intake (14.30 ± 0.34) than both diarrhea (water: 927.64 ± 62.70; fiber: 15.33 ± 0.64) and normal bowel habit groups (water: 985.24 ± 25.99; fiber: 16.54 ± 0.22). We found that participants with abnormal bowel habits had a significantly higher probability of poor teeth condition compared to normal participants (16.58% and 16.14% vs. 10.20%). Similarly, normal individuals had a lower probability of experiencing frequent oral pain compared to participants with diarrhea or constipation (6.68% vs. 9.80% and 8.43%). Regarding laboratory tests, participants with chronic diarrhea had higher CRP levels (0.54mg/dL) and lower serum calcium levels (9.41mg/dL) (Table 1 ). Figure 2 illustrates the correlation between baseline variables: there is a weak negative correlation between age and marital status (ρ= -0.42), a weak positive correlation between educational level and poverty-income ratio (ρ = 0.41), and no correlation is observed among other independent variables. Table 1 Characteristics of participatants stratified by bowel conditions: NHANES 2005–2008, weighted. Total Normal bowel Chronic diarrhea Chronic constipation P -value No. of participatants 7512 6388 535 589 Age, y, means (SE) 46.67 (0.48) 46.48 (0.51) 50.26 (0.94) 45.78 (0.77) < 0.001 Sex, N (%) < 0.001 Female 3877 (51.87) 3149 (50.29) 304 (57.39) 424 (73.30) Male 3635 (48.13) 3239 (49.71) 231 (42.61) 165 (26.70) Race, N (%) 0.013 Mexican American 1355 (7.58) 1142 (7.43) 100 (8.32) 113 (8.72) Other Hispanic 500 (3.69) 414 (3.60) 43 (4.62) 43 (3.99) Non-Hispanic White 3874 (73.74) 3348 (74.30) 251 (71.30) 275 (69.13) Non-Hispanic Black 1522 (10.19) 1254 (9.73) 125 (11.65) 143 (14.49) Other race 261 (4.80) 230 (4.95) 16 (4.11) 15 (3.67) Education, N (%) < 0.001 High School 3674 (58.06) 3236 (59.51) 203 (49.16) 235 (48.30) Poverty-to-income ratio, N (%) < 0.001 3.5 2545 (46.19) 2261 (47.58) 141 (40.70) 143 (34.26) Marital status, N (%) 0.001 Divorced/Separated/Widowed 1623 (18.16) 1335 (17.51) 138 (21.44) 150 (23.23) Married/Living with a partner 4767 (66.62) 4101(67.30) 329 (65.98) 337 (58.88) Never married 1122 (15.22) 952 (15.19) 68 (12.58) 102 (17.90) BMI, N (%) < 0.001 24 5864 (75.85) 5007 (76.31) 434 (78.80) 423 (67.58) Smoking, N (%) < 0.001 Never 3911 (51.65) 3304 (51.58) 246 (42.57) 361 (60.61) Fomer 1983 (25.67) 1700 (25.77) 160 (30.17) 123 (20.41) Current 1618 (22.68) 1384 (22.65) 129 (27.26) 105 (18.98) Alcohol consumption, N (%) < 0.001 No 2242 (25.01) 1801 (23.72) 191(29.32) 250 (36.98) Yes 5270 (74.99) 4587 (76.28) 344 (70.68) 339 (63.02) Vigorous activities, N (%) < 0.001 No 3044 (35.07) 2516(33.72) 268 (44.09) 260 (43.61) Yes 744 (11.58) 658 (11.90) 36 (8.07) 50 (10.85) Unknown 3724 (53.35) 3214 (54.39) 231 (47.84) 279 (45.54) Depression, N (%) < 0.001 No 6936 (92.33) 5961 (93.32) 456 (85.23) 519 (97.01) Yes 576 (7.67) 427 (6.68) 79 (14.77) 70 (2.99) Diabetes, N (%) < 0.001 No 6521 (90.53) 5575 (90.87) 427 (84.57) 519 (91.65) Yes 991 (9.47) 813 (9.13) 108 (15.43) 70 (8.35) Water intake, gm, means (SE) 967.98 (25.20) 985.24 (25.99) 927.64 (62.70) 793.40 (53.44) 0.002 Total sugars, gm, means (SE) 115.38 (1.33) 116.14 (1.32) 109.80 (3.73) 111.05 (3.57) 0.045 Dietary fiber intake, gm, means (SE) 16.10 (0.21) 16.54 (0.22) 15.33 (0.64) 14.30 (0.34) < 0.001 WBC count, 1000 cells/uL, means (SE) 7.32 (0.04) 7.32 (0.05) 7.51 (0.13) 7.21 (0.15) 0.407 Neutrophils percent, N (%) 58.48 (0.16) 58.50 (0.17) 58.39 (0.46) 58.52 (0.61) 0.607 CRP, mg/dL 0.41 (0.01) 0.40 (0.01) 0.54 (0.05) 0.42 (0.03) 0.012 Serum Calcium, mg/dL, means (SE) 9.45 (0.02) 9.46 (0.02) 9.41 (0.02) 9.45 (0.02) 0.019 Stool frequency, means (SE) 9.17 (0.07) 9.04 (0.09) 7.74 (0.20) 12.51 (0.44) < 0.001 Condition of teeth, N (%) < 0.001 Excellent/Very good, N (%) 2327 (36.98) 2034 (38.00) 129 (29.17) 164 (31.47) Good 2428 (33.16) 2108 (33.34) 146 (32.84) 174 (31.25) Fair 1650 (18.84) 1359 (18.46) 140 (21.42) 151 (21.13) Poor 1107 (11.03) 887 (10.20) 120 (16.58) 100 (16.14) Frequency of oral pain, N (%) 0.001 Often 569 (7.00) 459 (6.68) 57 (9.80) 53 (8.43) Occasionally 1211 (14.88) 1002 (14.45) 95 (16.69) 114 (18.53) Never 5732 (78.12) 4927 (78.87) 383 (73.50) 422 (73.04) Lasso regression for variable selection To avoid potential overfitting issues in the subsequent weighted logistic regression model, we employed Lasso regression to select covariates from among 20 candidate confounding factors. In the analysis of teeth condition, no covariates were excluded based on the optimal penalty parameter (λ = 0.0007) determined by the minimum binomial deviation criterion, indicating that all pre-specified variables made meaningful contributions to the model (Fig. 3 B). By contrast, in the analysis of oral pain frequency, 17 covariates were retained (excluding alcohol consumption, diabetes, and WBC count) at the minimum penalty parameter (λ = 0.0013) for inclusion in the multivariable logistic regression analysis (Fig. 3 D). Logistic regression analysis of oral health Using normal participants as the control group, we investigated the relationship between abnormal bowel habits and oral health through weighted logistic regression models. In the crude model, both chronic constipation and diarrhea showed significant association with higher prevalence of poor teeth condition ( P for trend < 0.001) and frequent oral pain ( P for trend = 0.009) (Table 2 ). After fully adjustment for sociodemographic, lifestyle, and clinical covariates (Model 2), chronic constipation remained associated with 45% higher odds of poor teeth condition (OR = 1.45, 95% CI: 1.05–2.01), while chronic diarrhea showed a 24% elevation (OR = 1.24, 95% CI: 0.94–1.65) ( P for trend = 0.006). However, no statistically significant correlation was observed between bowel habits and the frequency of oral pain in Model 1 (adjusted for sociodemographic variables) ( P for trend = 0.070), or Model 2 (adjusted for all covariates) ( P for trend = 0.337). Table 2 Weighted univariate and multivariate analyses showing the relationship between oral health and bowel conditions. Crude model Model1 Model2 OR (95% CI) P value OR (95% CI) P value OR (95% CI) P value Condition of teeth Bowel habits Normal Ref Ref Ref Chronic constipation 1.69 (1.27–2.26) < 0.001 1.39 (1.01–1.91) 0.042 1.45 (1.05–2.01) 0.029 Chronic diarrhea 1.75 (1.35–2.27) < 0.001 1.41 (1.08–1.84) 0.015 1.24 (0.94–1.65) 0.119 P for trend < 0.001 0.001 0.006 Frequency of oral pain Bowel habits Normal Ref Ref Ref Chronic constipation 1.29 (0.89–1.85) 0.172 1.01 (0.69–1.48) 0.976 0.98 (0.67–1.44) 0.927 Chronic diarrhea 1.52 (1.03–2.24) 0.036 1.45 (0.97–2.17) 0.067 1.28 (0.83–1.98) 0.233 P for trend 0.009 0.070 0.377 Association between teeth condition and stool frequency Based on the previous logistic regression analysis, both chronic diarrhea and constipation were associated with an elevated risk of poor teeth condition. RCS regression further demonstrated a significant nonlinear U-shaped relationship between stool frequency and poor teeth condition (nonlinear P -value = 0.002, Fig. 4 A). The risk of poor teeth condition decreased with increasing weekly stool frequency until reaching a minimum at 9.241 bowel movements per week, beyond which the risk progressively rose. Subgroup RCS analysis across different age groups revealed minimal variation in optimal bowel movement frequency: 9.844/week (20–39 years), 9.543/week (40–59 years), and 8.462/week (60–85 years) (Fig. 4 B-D). Notably, non-depressed individuals exhibited a U-shaped association, with the lowest adjusted odds ratio (OR) for poor teeth condition observed at 9.201 bowel movements/week. In contrast, no significant association emerged between stool frequency and teeth condition in the depression subgroup (nonlinear P -value = 0.677), suggesting potential effect modification by mental health status that warrants further investigation (Fig. 4 F). Stratified analysis and interaction test We further conducted stratified logistic regression analysis with adjusted covariates and interaction tests to determine the variables influencing the relationship between bowel habits and teeth condition. As shown in Fig. 5 , both chronic diarrhea and constipation were generally linked to a higher prevalence of poor teeth condition, reflected by the overall rightward shift of effect estimates (OR values). Notably, participants with daily dietary fiber intake ≥ 25 g had a significantly reduced risk of poor teeth condition compared to those with lower intake (chronic constipation: OR: 0.44, 95% CI: 0.13–1.09; chronic diarrhea: OR: 0.40, 95% CI: 0.12–0.98). Conversely, the risk of poor teeth condition significantly increased in the PIR > 3.5 subgroup, with OR values of 2.38 (95% CI: 1.35–3.98) for chronic diarrhea and 2.18 (95% CI: 1.22–3.70) for chronic constipation. Interaction tests showed that diabetes ( P for interaction = 0.092) and dietary fiber intake ( P for interaction = 0.061) presented trends in influencing the associations, though the P -value did not reach statistical significance ( Supplementary Table S1 ). Sensitivity analysis For sensitivity analysis, we re-included 9,337 participants previously excluded due to covariate missing data, imputed missing values via multiple imputation, and performed weighted logistic regression ( Supplementary Table S2 ). Results demonstrated significant associations between chronic constipation, chronic diarrhea, and poor teeth condition ( P for trend = 0.005) as well as frequent oral pain ( P for trend = 0.007). Subsequently, we excluded individuals with diabetes (n = 991), depression (n = 576), or CRP ≥ 1 mg/dL (n = 847) from the complete-case dataset and repeated the weighted logistic regression ( Supplementary Table S3 ). Findings were consistent with prior conclusions: both chronic diarrhea and constipation were closely associated with a higher risk of poor teeth condition across Model 1 ( P for trend < 0.001), Model 2 ( P for trend = 0.022), and Model 3 ( P for trend = 0.014). Although chronic diarrhea was linked to frequent oral pain in the crude model, this association no longer reached statistical significance after covariate adjustment ( P for trend = 0.148). Discussion This cross-sectional study aimed to explore the association between chronic diarrhea, constipation, and oral health using data from the NHANES during 2005–2008. The results indicated that both chronic constipation and diarrhea were associated with a higher risk of poor teeth condition. A significant U-shaped dose-response relationship was observed between poor teeth condition and stool frequency. It is noteworthy that both the general population and age-specific subgroups exhibited optimal teeth condition when maintaining 8–10 bowel movements weekly, with progressively elevated risks observed at both lower and higher extremes of stool frequency. Although there was a positive correlation between the frequency of oral pain and abnormal bowel habits in the crude model, the association was no longer statistically significant after adjusting for all covariates. Futhermore, stratified analyses demonstrated higher dietary fiber intake was associated with lower risks of poor teeth condition in both constipation and diarrhea populations, while elevated PIR correlated with reduced risks. These differential associations suggest that dietary nutrient intake and socioeconomic status may also indirectly affect teeth condition. The relationship between oral health and gastrointestinal disorders has been increasingly explored, yet direct evidence linking abnormal bowel movements to oral health issues remains incomplex. A Japanese study on lifestyle diseases conducted between 2013 and 2017 revealed an association between low occlusal bite force and an increased risk of developing Irritable Bowel Syndrome (IBS)[ 25 ]. Baseline variables such as the number of remaining teeth, tooth loss, and the presence of dentures differed between the IBS and non-IBS groups. Unfortunately, subsequent logistic regression analysis did not show a significant association between teeth condition and IBS risk. In a cross-sectional study conducted by Amiri M et al. among elderly individuals in Iran, a significant relationship was observed between teeth problems and functional constipation[ 26 ]. The underlying mechanism is primarily attributed to the significant impact of oral health on general well-being and dietary intake among the elderly. However, this conclusion cannot be extended to younger populations, and it also fails to explain the association between chronic diarrhea and teeth conditions. In contrast, our study observed an association between abnormal bowel movements and poor dental conditions across different age groups. Furthermore, we identified a relatively low-risk weekly frequency of bowel movements. These findings provide new insights for future screening of high-risk populations for oral diseases and daily life management strategies. In the subgroup analysis, participants with dietary fiber intake ≥ 25 g had a significantly lower risk of poor teeth condition, which may be related to changes in food choices when oral health is impaired. The study indicated that individuals with fewer than 28 teeth had significantly lower dietary fiber intake compared to those with complete dentition, and their serum levels of nutrients such as folate and vitamin C were also lower[ 27 ]. Even among those wearing full dentures, their dietary fiber intake remained significantly lower than those with all natural teeth[ 28 ]. In rat models of periodontitis, there was a dose-dependent relationship between increased dietary fiber intake and reduced alveolar bone loss and decreased proinflammatory markers, suggesting that dietary fiber intake holds promise as an intervention to reduce oral infectious diseases such as periodontitis[ 29 ]. This viewpoint was further supported by subsequent researches indicating that dietary fiber may restrict the progression of periodontal diseases by regulating gut microbiota and pH levels[ 30 , 31 ]. It is well-known that although the oral and gut microbiota compositions are relatively independent, microorganisms can spread from the oral cavity to the intestine when the efficiency of the oral-intestinal barrier is reduced[ 32 , 33 ]. Previous researches have indicated that poor oral health can exacerbate intestinal inflammation[ 34 , 35 ], suggesting that abnormal bowel movements are more likely caused by the migration of oral pathogens to the intestine, rather than vice versa. Similarly, a multicenter study involving hospitalized patients with swallowing difficulties found a higher proportion of fecal incontinence among those with poor oral health[ 36 ]. Additionally, the mechanisms by which oral bacteria cause gastrointestinal dysfunction include Toll-like receptor activation, changes in oxidative stress, inflammasome activation, release of proinflammatory cytokines, and modulation of the complement system[ 37 , 38 ]. These complex factors collectively contribute to the synergistic pathological effects of oral infections on the intestine. Although gut microorganisms can also affect the oral cavity, current evidence primarily focuses on the fecal-oral route, often occurring in situations with inadequate public health systems or compromised immune function[ 39 ]. Aggor et al. demonstrated that colonizing germ-free mice with segmented filamentous bacteria effectively alleviated antibiotic-induced oropharyngeal candidiasis[ 40 ], indicating that the gut microbiota can also affect oral health through immune modulation. This reverse regulatory mechanism from the gut to the oral cavity is most commonly observed in inflammatory bowel disease (IBD). Approximately 10–30% of IBD patients exhibit oral manifestations of the disease, including aphthous ulcers, pyostomatitis vegetans, and periodontitis[ 41 – 43 ]. The mechanism by which IBD causes oral manifestations is not fully understood, but it is currently believed to involve multiple factors such as immune dysregulation, genetics, and microbiome alterations[ 44 , 45 ]. Whether other gastrointestinal diseases, especially chronic constipation and diarrhea, have a definite impact on oral health still requires further investigation. This study, for the first time, untangles the correlation between abnormal bowel habits and oral health, providing empirical support for the oral-gut axis theory in the context of chronic intestinal insufficiency. From a clinical perspective, chronic constipation is significantly associated with an elevated risk of poor teeth condition, necessitating the implementation of interdisciplinary therapeutic approaches. Clinicians should consider conducting routine oral health screenings for patients with persistent intestinal abnormalities, particularly those with weekly bowel movement frequencies of less than 8 or more than 10 times. Although there are variations in stool frequency across different age groups, maintaining a weekly bowel movement frequency of 8 to 10 times may represent the optimal range for minimizing the risk of oral health issues. Meanwhile, adequate dietary fiber intake may offer protective effects on dental health, suggesting that dietary intervention could serve as an effective strategy for addressing gut-oral comorbidities. The stable association observed in the sensitivity analysis validates the robustness of using self-reported bowel patterns as epidemiological markers for oral health monitoring, paving new avenues for future oral health screenings. However, this study has several limitations. First, as a cross-sectional study based on NHANES, it cannot determine causality. Prospective cohort studies are needed to clarify the temporal relationship between oral and bowel indicators. Second, the oral and bowel data relied on self-reported questionnaires, which are susceptible to recall bias. Future studies should combine objective methods such as microbial metagenomic sequencing and quantitative radiographic accessment of oral pathologies to build multi-omics networks linking the oral cavity and intestine. Additionally, animal models (such as ligature-induced periodontitis and DSS-induced colitis) should be designed to investigate mechanistic interactions involving microbial translocation, immune regulation, and metabolomic remodeling. Thirdly, despite adjusting for major confounding factors, potential unmeasured variables (such as epigenetic factors and dietary patterns) may influence the results. Due to data availability limitations, drug usage (such as laxatives, antibiotics, antidepressants) and biomarkers reflecting oral/intestinal function (such as lipopolysaccharide binding protein, short-chain fatty acids) were not included. Conclusion This study revealed a U-shaped relationship between stool frequency and poor teeth condition, with the lowest risk observed at 8–10 times/week. Both chronic constipation and diarrhea were associated with higher risks of teeth problems, but no significant correlation was found with self-reported oral pain frequency. Stratified analyses suggested dietary fiber intake and PIR may modulate the gut-oral interaction. The underlying mechanisms linking bowel abnormalities to oral health risks require further experimental and longitudinal investigation. Abbreviations NHANES National Health and Nutrition Examination Surveys NCHS National Center for Health Statistics BSFS Bristol Stool Form Scale WBC white blood cell CRP C-reactive protein BMI Body mess index OR Odds ratio SE Means and standard errors Declarations Ethics approval and consent to participate NHANES data has been approved by the NCHS Research Ethics Review Committee. Research using public databases does not require ethical approval. Consent for publication Not applicable. Availability of data and materials Research related data can be found or downloaded on the NHANES official website: https://www.cdc.gov/nchs/nhanes/site.html. Competing interests The author declares that there is no conflict of interest. Funding This study was not supported by funding. Authors’ contributions LM and ZRG conceptualized and designed this study. ZHJ, JWM extracted data from the database. ZHJ, JWM, YJL, and ZJW analyzed and explained the data. ZHJ drafted the initial manuscript. LM and ZRG revised the manuscript. All authors acknowledge the final manuscript as submitted. Acknowledgement The author thanks the Second Affiliated Hospital of Nanjing Medical University for its support of this study. References Kassebaum NJ, Smith A, Bernabe E, Fleming TD, Reynolds AE, Vos T, Murray C, Marcenes W: Global, Regional, and National Prevalence, Incidence, and Disability-Adjusted Life Years for Oral Conditions for 195 Countries, 1990-2015: A Systematic Analysis for the Global Burden of Diseases, Injuries, and Risk Factors . J DENT RES 2017, 96 (4):380-387. Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C: The global burden of oral diseases and risks to oral health . Bull World Health Organ 2005, 83 (9):661-669. Yu YH, Steffensen B, Chasman DI, Buring JE: Self-reported oral health is associated with systemic health outcomes and all-cause mortality . J AM DENT ASSOC 2024, 155 (3):233-243. Kisely S, Sawyer E, Siskind D, Lalloo R: The oral health of people with anxiety and depressive disorders - a systematic review and meta-analysis . J Affect Disord 2016, 200 :119-132. Kalaigian A, Chaffee BW: Mental Health and Oral Health in a Nationally Representative Cohort . J DENT RES 2023, 102 (9):1007-1014. Thwin KM, Ogawa H, Phantumvanit P, Miyazaki H, Songpaisan Y: Oral health-related quality of life in the Myanmar population: The first national oral health survey 2016 - 2017 . Community Dent Health 2024, 41 (3):158-163. Wong ML, Lee YH, Sim YF, Wong TJ, Soh SH, Goh BT, Poon CY, Allen PF, Chia KS, Sim C: Oral health knowledge, attitudes and behaviours of adults: Findings from a National Oral Health Survey in Singapore . Community Dent Oral Epidemiol 2024, 52 (3):292-301. Dibello V, Lobbezoo F, Solfrizzi V, Custodero C, Lozupone M, Pilotto A, Dibello A, Santarcangelo F, Grandini S, Daniele A et al : Oral health indicators and bone mineral density disorders in older age: A systematic review . AGEING RES REV 2024, 100 :102412. Suares NC, Ford AC: Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis . AM J GASTROENTEROL 2011, 106 (9):1582-1591, 1581, 1592. Schiller LR: Chronic diarrhea . GASTROENTEROLOGY 2004, 127 (1):287-293. Black CJ, Drossman DA, Talley NJ, Ruddy J, Ford AC: Functional gastrointestinal disorders: advances in understanding and management . LANCET 2020, 396 (10263):1664-1674. Ballou S, Katon J, Singh P, Rangan V, Lee HN, McMahon C, Iturrino J, Lembo A, Nee J: Chronic Diarrhea and Constipation Are More Common in Depressed Individuals . Clin Gastroenterol Hepatol 2019, 17 (13):2696-2703. Sommers T, Mitsuhashi S, Singh P, Hirsch W, Katon J, Ballou S, Rangan V, Cheng V, Friedlander D, Iturrino J et al : Prevalence of Chronic Constipation and Chronic Diarrhea in Diabetic Individuals in the United States . AM J GASTROENTEROL 2019, 114 (1):135-142. Newman KL, Kamada N: Pathogenic associations between oral and gastrointestinal diseases . TRENDS MOL MED 2022, 28 (12):1030-1039. Kunath BJ, De Rudder C, Laczny CC, Letellier E, Wilmes P: The oral-gut microbiome axis in health and disease . NAT REV MICROBIOL 2024, 22 (12):791-805. Nakajima M, Arimatsu K, Kato T, Matsuda Y, Minagawa T, Takahashi N, Ohno H, Yamazaki K: Oral Administration of P. gingivalis Induces Dysbiosis of Gut Microbiota and Impaired Barrier Function Leading to Dissemination of Enterobacteria to the Liver . PLOS ONE 2015, 10 (7):e134234. Bao J, Li L, Zhang Y, Wang M, Chen F, Ge S, Chen B, Yan F: Periodontitis may induce gut microbiota dysbiosis via salivary microbiota . INT J ORAL SCI 2022, 14 (1):32. Lee YC, Liu CY, Lee CL, Zhang RH, Huang CJ, Yen TL: The Periodontopathic Pathogen, Porphyromonas gingivalis, Involves a Gut Inflammatory Response and Exacerbates Inflammatory Bowel Disease . Pathogens 2022, 11 (1). Jiang Y, Jin H, Liang Q, Zhu X: Causal relationship between gut microbiota and dental caries: A Mendelian randomization analysis . Medicine (Baltimore) 2025, 104 (8):e41555. Wang Y, Wang Z: Association between ideal cardiovascular health and bowel conditions among US adults . Front Nutr 2024, 11 :1473531. Atala-Acevedo C, McGrath R, Glenister K, Capurro D, Bourke L, Simmons D, Morgan M, Marino R: Self-Rated Oral Health as a Valid Measure of Oral Health Status in Adults Living in Rural Australia . Healthcare (Basel) 2023, 11 (12). Yin N, Li W, Zhou H, Zhang Y, Zhang W, Ding W, Ge H, Zhang S, Liao S: Associations Among Self-rated Oral Health, Subjective Oral Conditions, Oral Health Behaviours, and Oral Healthrelated Quality of Life (OHRQoL) . Oral Health Prev Dent 2023, 21 :25-32. Meisel P, Holtfreter B, Volzke H, Kocher T: Self-reported oral health predicts tooth loss after five and ten years in a population-based study . J CLIN PERIODONTOL 2018, 45 (10):1164-1172. Cao H, Wang M, Duan M, Wang S, Zhang H: Association of serum calcium level with periodontitis: a cross-sectional study from NHANES 2009-2014 . Front Nutr 2024, 11 :1520639. Okuyama Y, Matsui D, Ozaki E, Watanabe Y: Association of low occlusal force as an oral hypofunction with the prevalence of irritable bowel syndrome in Japanese adults . J Gastroenterol Hepatol 2023, 38 (8):1269-1276. Amiri M, Hassanzadeh A, Rahimi M: A survey on functional constipation and its risk factors in older people in Shahreza, Iran . J Educ Health Promot 2024, 13 :118. Nowjack-Raymer RE, Sheiham A: Numbers of natural teeth, diet, and nutritional status in US adults . J DENT RES 2007, 86 (12):1171-1175. Nowjack-Raymer RE, Sheiham A: Association of edentulism and diet and nutrition in US adults . J DENT RES 2003, 82 (2):123-126. Tailor R, Medara N, Chopra A, Swarnamali H, Eberhard J, Jayasinghe TN: Role of prebiotic dietary fiber in periodontal disease: A systematic review of animal studies . Front Nutr 2023, 10 :1130153. Sun Y, Zhang S, Nie Q, He H, Tan H, Geng F, Ji H, Hu J, Nie S: Gut firmicutes: Relationship with dietary fiber and role in host homeostasis . Crit Rev Food Sci Nutr 2023, 63 (33):12073-12088. Fernandez CE, Maturana-Valenzuela C, Rojas-Castillo N, Rosier B: Potential effects of prebiotic fibers on dental caries: a systematic review . J Sci Food Agric 2025. Schmidt TS, Hayward MR, Coelho LP, Li SS, Costea PI, Voigt AY, Wirbel J, Maistrenko OM, Alves RJ, Bergsten E et al : Extensive transmission of microbes along the gastrointestinal tract . ELIFE 2019, 8 . Kunath BJ, Hickl O, Queiros P, Martin-Gallausiaux C, Lebrun LA, Halder R, Laczny CC, Schmidt T, Hayward MR, Becher D et al : Alterations of oral microbiota and impact on the gut microbiome in type 1 diabetes mellitus revealed by integrated multi-omic analyses . MICROBIOME 2022, 10 (1):243. Kitamoto S, Nagao-Kitamoto H, Jiao Y, Gillilland MR, Hayashi A, Imai J, Sugihara K, Miyoshi M, Brazil JC, Kuffa P et al : The Intermucosal Connection between the Mouth and Gut in Commensal Pathobiont-Driven Colitis . CELL 2020, 182 (2):447-462. Atarashi K, Suda W, Luo C, Kawaguchi T, Motoo I, Narushima S, Kiguchi Y, Yasuma K, Watanabe E, Tanoue T et al : Ectopic colonization of oral bacteria in the intestine drives T(H)1 cell induction and inflammation . SCIENCE 2017, 358 (6361):359-365. Shimizu A, Maki H, Ohno T, Nomoto A, Fujishima I, Kayashita J, Momosaki R, Nishioka S, Wakabayashi H: Association of poor oral health status and faecal incontinence in patients with dysphagia: A cross-sectional analysis from the Sarcopenic Dysphagia Database . J ORAL REHABIL 2023, 50 (4):286-292. Mukherjee S, Chopra A, Karmakar S, Bhat SG: Periodontitis increases the risk of gastrointestinal dysfunction: an update on the plausible pathogenic molecular mechanisms . CRIT REV MICROBIOL 2025, 51 (1):187-217. Zhang C, Xu C, Gao L, Li X, Zhao C: Porphyromonas gingivalis lipopolysaccharide promotes T-hel per17 cell differentiation by upregulating Delta-like ligand 4 expression on CD14(+) monocytes . PEERJ 2021, 9 :e11094. Park SY, Hwang BO, Lim M, Ok SH, Lee SK, Chun KS, Park KK, Hu Y, Chung WY, Song NY: Oral-Gut Microbiome Axis in Gastrointestinal Disease and Cancer . Cancers (Basel) 2021, 13 (9). Aggor FE, Bertolini M, Zhou C, Taylor TC, Abbott DA, Musgrove J, Bruno VM, Hand TW, Gaffen SL: A gut-oral microbiome-driven axis controls oropharyngeal candidiasis through retinoic acid . JCI Insight 2022, 7 (18). Baima G, Muwalla M, Testa G, Mazza F, Bebars A, Perotto S, Vernero M, Massano A, Romano F, Ribaldone DG et al : Periodontitis prevalence and severity in inflammatory bowel disease: A case-control study . J PERIODONTOL 2023, 94 (3):313-322. Lauritano D, Boccalari E, Di Stasio D, Della VF, Carinci F, Lucchese A, Petruzzi M: Prevalence of Oral Lesions and Correlation with Intestinal Symptoms of Inflammatory Bowel Disease: A Systematic Review . Diagnostics (Basel) 2019, 9 (3). Katz J, Shenkman A, Stavropoulos F, Melzer E: Oral signs and symptoms in relation to disease activity and site of involvement in patients with inflammatory bowel disease . ORAL DIS 2003, 9 (1):34-40. Lankarani KB, Sivandzadeh GR, Hassanpour S: Oral manifestation in inflammatory bowel disease: a review . World J Gastroenterol 2013, 19 (46):8571-8579. Vasovic M, Gajovic N, Brajkovic D, Jovanovic M, Zdravkovaic N, Kanjevac T: The relationship between the immune system and oral manifestations of inflammatory bowel disease: a review . CENT EUR J IMMUNOL 2016, 41 (3):302-310. Additional Declarations No competing interests reported. Supplementary Files SupplementaryTableS1.docx SupplementaryTableS2.docx SupplementaryTableS3.docx Cite Share Download PDF Status: Published Journal Publication published 21 Apr, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 09 Apr, 2025 Editor assigned by journal 09 Apr, 2025 Reviews received at journal 03 Apr, 2025 Reviews received at journal 03 Apr, 2025 Reviewers agreed at journal 03 Apr, 2025 Reviewers agreed at journal 02 Apr, 2025 Reviewers invited by journal 02 Apr, 2025 Submission checks completed at journal 24 Mar, 2025 First submitted to journal 20 Mar, 2025 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-5733361","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":437704350,"identity":"4f645713-d90c-4557-ba52-ab3a30c85ef8","order_by":0,"name":"Zuhong Ji","email":"","orcid":"","institution":"The Second Affiliated Hospital of Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zuhong","middleName":"","lastName":"Ji","suffix":""},{"id":437704352,"identity":"fa4fc522-891d-4f0e-85be-4529344fb326","order_by":1,"name":"Jianwen Mei","email":"","orcid":"","institution":"The Second Affiliated Hospital of Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jianwen","middleName":"","lastName":"Mei","suffix":""},{"id":437704354,"identity":"ce2a82dc-ee91-4041-9644-c49603e915a5","order_by":2,"name":"Youjian Li","email":"","orcid":"","institution":"The Second Affiliated Hospital of Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Youjian","middleName":"","lastName":"Li","suffix":""},{"id":437704355,"identity":"c9b532fa-6df7-43b6-bff2-b20a0e27b90f","order_by":3,"name":"Zijie Wang","email":"","orcid":"","institution":"Qinghefang Community Health Service Station, Changshu Fifth People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zijie","middleName":"","lastName":"Wang","suffix":""},{"id":437704356,"identity":"ec379598-39b9-4eeb-bb53-96f3764a27e0","order_by":4,"name":"Zhirui Guo","email":"","orcid":"","institution":"The Second Affiliated Hospital of Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhirui","middleName":"","lastName":"Guo","suffix":""},{"id":437704357,"identity":"df391a03-6944-49ce-a732-7120575904ae","order_by":5,"name":"Lin Miao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYBACPmYgkcDAIMfAcADEZyashQ2qxZgELVA6sQFCE6OFnffohgc1NunbGU+nSTBUWCc2sJ89QMBhfGk3Eo6l5e5sOLtNguFMemIDT14CAS08ZjcS2A7nbjgA1MLYdjixQYLHgAgt/w6nG4C1/CNWS2Lb4QSIlgaitfSlGQIdttki4Vi6cRtPDn4t/PxnzG7++GYjb3Dj7MYbH2qsZfvZz+DXggASB8BxCo8pIgB/A/FqR8EoGAWjYGQBANPJRIYh/XNhAAAAAElFTkSuQmCC","orcid":"","institution":"The Second Affiliated Hospital of Nanjing Medical University","correspondingAuthor":true,"prefix":"","firstName":"Lin","middleName":"","lastName":"Miao","suffix":""}],"badges":[],"createdAt":"2024-12-30 07:08:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5733361/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5733361/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-22747-8","type":"published","date":"2025-04-21T15:57:21+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":80069231,"identity":"9cee4b43-00d5-4993-ba9a-eef538e8fa13","added_by":"auto","created_at":"2025-04-07 13:48:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":143445,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of eligible patients selected from NHANES 2005-2008.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5733361/v1/750ef83325f40a134e6d5069.png"},{"id":80069265,"identity":"9191784e-c586-4122-998d-2e78f4848425","added_by":"auto","created_at":"2025-04-07 13:48:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":518730,"visible":true,"origin":"","legend":"\u003cp\u003eSpearman correlation analysis of baseline variables.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5733361/v1/fb841a287e9318bc3a2c9256.png"},{"id":80072231,"identity":"3473a9b8-a6b0-4839-986b-808d85254f83","added_by":"auto","created_at":"2025-04-07 14:12:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":633096,"visible":true,"origin":"","legend":"\u003cp\u003eLasso regression for covariate screening in oral health outcomes. (A) Lasso coefficient plot for teeth condition. (B) Cross-validation curves for teeth condition. (C) Lasso coefficient plot for oral pain frequency. (D) Cross-validation curves for oral pain frequency.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-5733361/v1/a79cff1cc9742446e287ed0d.png"},{"id":80070153,"identity":"38214a89-6a5e-4260-b61f-20843d919ec3","added_by":"auto","created_at":"2025-04-07 13:56:05","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":381060,"visible":true,"origin":"","legend":"\u003cp\u003eAfter adjusting for all covariates, the relationship between teeth condition and stool frequency was analyzed using restricted cubic spline regression. (A)\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-5733361/v1/40a8a072bc230f2ff81b0f2a.png"},{"id":80069260,"identity":"8d5c14ea-a28b-4fdd-a1ed-fb6945c9de86","added_by":"auto","created_at":"2025-04-07 13:48:05","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":703807,"visible":true,"origin":"","legend":"\u003cp\u003eStratified analysis and interactive testing based on the relationship between teeth condition and bowel habits.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-5733361/v1/c05e89b9e0e3f60a1981094e.png"},{"id":81569829,"identity":"77f685c1-3411-4d0d-a46b-3d61faf61791","added_by":"auto","created_at":"2025-04-28 16:11:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5274370,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5733361/v1/0bb086fb-0e27-4032-a3c0-e9a283422436.pdf"},{"id":80070149,"identity":"6975244f-c013-4f15-81e1-3ceb21d7cd79","added_by":"auto","created_at":"2025-04-07 13:56:05","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21685,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTableS1.docx","url":"https://assets-eu.researchsquare.com/files/rs-5733361/v1/ef366d5a8408e2a04d9152e8.docx"},{"id":80070854,"identity":"057703b4-bcab-4051-8772-387edee120b6","added_by":"auto","created_at":"2025-04-07 14:04:05","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":14652,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTableS2.docx","url":"https://assets-eu.researchsquare.com/files/rs-5733361/v1/343457577abcddb3cdcad860.docx"},{"id":80070858,"identity":"fc344812-410d-4910-984a-8b5930606789","added_by":"auto","created_at":"2025-04-07 14:04:06","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":14979,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTableS3.docx","url":"https://assets-eu.researchsquare.com/files/rs-5733361/v1/ef70e0fe9a4457925644a49f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association between oral health and bowel habits: a cross-sectional study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOral health has emerged as a critical global health challenge, with approximately 3.5\u0026nbsp;billion people worldwide affected by oral diseases that create striking health disparities between and within nations, particularly burdening developing countries[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The consequences of untreated oral conditions extend beyond localized infections\u0026mdash;they correlate with systemic inflammation, psychological distress, and elevated all-cause mortality[\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Despite these profound implications, population-level preventive strategies remain inadequately implemented[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Two fundamental indicators of oral health\u0026mdash;teeth condition and oral pain frequency\u0026mdash;have recently gained recognition as biomarkers reflecting not only oral cavity integrity but also broader physiological and psychological wellbeing[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParallel to this oral health crisis, chronic bowel disorders impose a growing disease burden. Chronic constipation (14% global prevalence) and diarrhea (5%) frequently coexist with metabolic disorders, neurological conditions, and mental health comorbidities[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Compared with acute symptoms, chronic diarrhea and chronic constipation usually last for more than four weeks and are associated with a variety of other diseases[\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Emerging evidence suggests bidirectional crosstalk between the gut and oral ecosystems, mediated through microbial translocation, metabolites, and immune modulation[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. For example, Nakajima et al. discovered that \u003cem\u003eP. gingivalis\u003c/em\u003e, the primary pathogen of chronic periodontitis, induces intestinal inflammation by altering the gut microbiota and downregulating tjp-1 and occludin[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, existing research predominantly focuses on unidirectional oral-to-gut microbial transmission and periodontitis-inflammatory bowel disease associations[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], leaving a critical knowledge gap regarding how chronic bowel habit alterations might reciprocally impact oral health outcomes. Notably, Jiang et al. employed Mendelian randomization analysis to reveal significant associations between gut microbial taxa (Christensenellaceae, Erysipelotrichia, etc.) and dental caries risk, suggesting gut microbiota may exert bidirectional effects on oral health[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This gap motivates our population-based investigation into the relationship between bowel habits and oral health.\u003c/p\u003e \u003cp\u003e Based on the theory that the gut and oral cavity are closely related, we hypothesize that compared to individuals with normal bowel habits, those suffering from chronic constipation or diarrhea exhibit a higher prevalence of oral problems (manifested as poor teeth condition and frequent oral pain). We predict that this manifestation is also reflected in bowel frequency: too few or too many bowel movements per week simultaneously implicate an increased risk of poor teeth condition and a higher frequency of oral pain. To validate these hypotheses, this study collected and analyzed data from the National Health and Nutrition Examination Survey (NHANES). The NHANES, which is a major program in the US, assesses the health and nutritional status of the civilian non-institutionalized population via interviews and physical exams and is widely used for epidemiological research and health policy formulation. By establishing a population-level association between bowel habits patterns and oral health, this study fills a critical evidentiary gap in the gut-mouth axis paradigm, while providing new insights for future oral disease prevention and screening strategies.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eThe NHANES database serves as a cross-sectional survey with a two-year cycle. For the present study, both the bowel health and oral health questionnaire components were required. The analysis focused on NHANES cycles from 2005 to 2008 because bowel-related interview data were available through 2010, while the oral health questionnaire underwent a substantive revision in 2009, including updated question codes and content. The inclusion criteria for the study are: (1) age\u0026thinsp;\u0026ge;\u0026thinsp;20 years, (2) complete responses to oral health and bowel health questionnaires, and (3) availability of comprehensive covariate data such as demographic characteristics and dietary intake profiles. Participants with missing data were excluded from the study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eBowel health assessment\u003c/h3\u003e\n\u003cp\u003eBowel habit classification was performed using participant responses from the bowel health questionnaire, with chronic diarrhea and constipation defined through standardized criteria. To evaluate stool consistency, participants were presented with the Bristol Stool Form Scale (BSFS) card depicting seven stool types through illustrations and descriptors. Each individual was instructed to identify their most representative stool pattern by selecting the corresponding BSFS number. Weekly bowel movement frequency was determined through the question: \u0026ldquo;How many times per week do you usually have a bowel movement?\u0026rdquo; Diagnostic thresholds were applied as follows: Chronic diarrhea: (a) Predominant stool type categorized as BSFS type 6 (fluffy pieces with ragged edges, a mushy stool) or type 7 (watery, no solid pieces), or (b) Exceeding 21 bowel movements weekly (\u0026gt;\u0026thinsp;3/day); Chronic constipation: Predominant stool type classified as BSFS type 1 (separate hard lumps, like nuts) or type 2 (sausage-like, but lumpy), or (b) Fewer than 3 bowel movements weekly[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eOral health assessment\u003c/h3\u003e\n\u003cp\u003ePrevious studies have demonstrated that self-rated oral health, as an indicator to measure oral conditions, exhibits strong reliability and validity[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In addition, it can serve as a predictor for potential oral diseases and subsequent oral health development trends to some extent[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The oral health questionnaire in the NHANES database from 2005 to 2008 included key questions related to oral health-related quality of life and perceived teeth conditions. This study focused on teeth conditions and the frequency of oral pain in the past year as the primary endpoints. The questions were: \u0026ldquo;Now I have some questions about the condition of your teeth and gums. How would you describe the condition of your teeth?\u0026rdquo; and \u0026ldquo;How often during the last year have you had painful aching anywhere in your mouth?\u0026rdquo;. The oral health questionnaire was completed at home prior to the physical examination, using the Computer-Assisted Personal Interviewing (CAPI) system, which was managed by interviewers.\u003c/p\u003e\n\u003ch3\u003eCovariates\u003c/h3\u003e\n\u003cp\u003eIn this study, to reduce potential bias, we included covariates that have been previously identified in prior researches and other factors that may influence the relationship between bowel habits and oral health[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. These covariates included demographic factors such as age (continuous), gender, ethnicity (Mexican American, other Hispanic, non-Hispanic white, non-Hispanic black, and other races), education level (\u0026lt;\u0026thinsp;high school, high school, \u0026gt;high school), poverty-to-income ratio (\u0026lt;\u0026thinsp;1.3, 1.3\u0026ndash;3.5, \u0026gt;\u0026thinsp;3.5), marital status (divorced/separated/widowed, married/living with a partner, never married), and body mass index (BMI) (\u0026lt;\u0026thinsp;18.5, 18.5\u0026ndash;24, \u0026gt;\u0026thinsp;24). Given the significant regulatory effect of lifestyle habits on bowel frequency, lifestyle factors were incorporated into the study, including vigorous activities (yes, no, unknown), smoking (never, past, current), and alcohol consumption (yes, no). We also referenced the commonly used depression questionnaire score classification to eliminate the interference of psychiatric factors, where scores of 0\u0026ndash;10 were considered as no depression, and scores\u0026thinsp;\u0026ge;\u0026thinsp;10 were regarded as having depression[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Diabetes, as a comorbidity, was determined based on fasting blood glucose levels, glycated hemoglobin, history of diabetes, and whether insulin was used. Additionally, dietary fiber, water intake, total sugar intake, white blood cell (WBC) count, neutrophil percentage, C-reactive protein (CRP), and serum calcium were also included as covariates. In the subsequent stratified analysis, age was grouped into three categories with 20-year intervals (20\u0026ndash;39 years, 40\u0026ndash;59 years, and 60\u0026ndash;85 years). Blood-related markers were divided into two groups based on normal range boundaries: WBC count was split into \u0026lt;\u0026thinsp;10 and \u0026gt;\u0026thinsp;10, neutrophil percentage into \u0026lt;\u0026thinsp;75 and \u0026gt;\u0026thinsp;75, CRP into 0.01\u0026ndash;0.99 and 1.00\u0026ndash;20.00, and serum calcium into 7.0\u0026ndash;9.0 and 9.1\u0026ndash;11.5.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eGiven the complexity of the sampling design in the NHANES database, appropriate weighting was applied to the data during analysis in this study. Participants were grouped based on their bowel habits, and baseline characteristics were described for each group. Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SE, while categorical variables were presented as percentages. Spearman correlation analysis was used to test the monotonic relationship (monotonic decrease or increase) between independent variables, and the correlation strength was judged by the correlation coefficient ρ. Generally, we consider |ρ|\u0026ge;0.8 as strong correlation, 0.5\u0026le;|ρ|\u0026lt;0.8 as moderate correlation, 0.3\u0026le;|ρ|\u0026lt;0.5 as weak correlation, and |ρ|\u0026lt;0.3 indicates that the two variables are basically uncorrelated. Survey-weighted analysis of variance (ANOVA) was used to compare differences in continuous variables among groups, and survey-weighted chi-square tests were employed to evaluate differences in categorical variables. To address multicollinearity and optimize feature selection, least absolute shrinkage and selection operator (Lasso) regression with 10-fold cross-validation was first applied to identify covariates most predictive of the oral health outcomes. The optimal penalty parameter (λ) was determined by minimizing the binomial deviance through iterative validation. Covariates retaining non-zero coefficients under the optimal λ were subsequently entered into multivariable logistic regression models to estimate adjusted odds ratios. Weighted logistic regression analysis was conducted to examine the association between oral health and diarrhea, as well as constipation. The initial crude model did not adjust for any potential confounding factors. Model 1 included adjustments for age, sex, race, education, poverty-to-income ratio, and marital status. Model 2 further adjusted for BMI, smoking, alcohol consumption, vigorous activities, depression score, diabetes, dietary fiber intake, CRP, and serum calcium. Subsequently, we conducted stratified analysis and interactive effect analysis to further identify the variables that influence the relationship between bowel habits and teeth condition, as well as the relationship between the bowel and oral health in various subgroups. Given the potential bidirectional influences between bowel habits and oral health, restricted cubic spline (RCS) curves were implemented to characterize nonlinear dose-response relationship between teeth condition and bowel frequency. Subsequent stratified RCS curves were constructed to evaluate potential effect modification by age categories and depression status. To evaluate the robustness of primary findings, several sensitivity analyses were implemented: First, missing covariates were multiple imputed via the R mice package using predictive mean matching. Estimates from multiply imputed models were contrasted against complete-case analyses to evaluate missing data impacts. Second, we excluded participants with diabetes, depression, or elevated CRP (\u0026ge;\u0026thinsp;1.00 mg/dL) to test associations in a low-comorbidity subsample.\u003c/p\u003e \u003cp\u003eStatistical analyses in this study were performed using R version 4.4.2 (R Foundation for Statistical Computing, Vienna, Austria). A two-tailed \u003cem\u003eP\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics of participants\u003c/h2\u003e \u003cp\u003eA total of 20,497 participants were recruited for the survey between 2005 and 2008. Based on our inclusion and exclusion criteria, 7,512 eligible participants (aged\u0026thinsp;\u0026ge;\u0026thinsp;20 years with no missing data on variables; see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for details) were finally included in our study. Among them, 535 reported chronic diarrhea, 589 reported chronic constipation, and the remaining 6,388 had no significant abnormalities in defecation. After weighting the sample data, there were 3,877 (51.87%) females and 3,635 (48.13%) males. It is worth noting that the proportion of females in the chronic constipation group was significantly higher than that of males (73.30% vs. 26.70%). The average age of participants in the total sample was 46.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48, but this value increased to 50.26\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94 in the chronic diarrhea group. In terms of sociodemographic characteristics, compared to the two groups with abnormal bowel habits, normal individuals were more likely to be non-Hispanic white, have a higher level of education, be more affluent, and be married/living with a partner. Additionally, significant differences were observed in lifestyle behaviors among the three groups: the diarrhea group had the highest proportions of alcohol consumption, current smoking, and no vigorous physical activity. Individuals with chronic constipation exhibited significantly lower daily water intake (793.40\u0026thinsp;\u0026plusmn;\u0026thinsp;53.44) and dietary fiber intake (14.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34) than both diarrhea (water: 927.64\u0026thinsp;\u0026plusmn;\u0026thinsp;62.70; fiber: 15.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.64) and normal bowel habit groups (water: 985.24\u0026thinsp;\u0026plusmn;\u0026thinsp;25.99; fiber: 16.54\u0026thinsp;\u0026plusmn;\u0026thinsp;0.22). We found that participants with abnormal bowel habits had a significantly higher probability of poor teeth condition compared to normal participants (16.58% and 16.14% vs. 10.20%). Similarly, normal individuals had a lower probability of experiencing frequent oral pain compared to participants with diarrhea or constipation (6.68% vs. 9.80% and 8.43%). Regarding laboratory tests, participants with chronic diarrhea had higher CRP levels (0.54mg/dL) and lower serum calcium levels (9.41mg/dL) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates the correlation between baseline variables: there is a weak negative correlation between age and marital status (ρ= -0.42), a weak positive correlation between educational level and poverty-income ratio (ρ\u0026thinsp;=\u0026thinsp;0.41), and no correlation is observed among other independent variables.\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\u003eCharacteristics of participatants stratified by bowel conditions: NHANES 2005\u0026ndash;2008, weighted.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\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\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNormal bowel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChronic diarrhea\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChronic constipation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\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\u003eNo. of participatants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7512\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6388\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e535\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e589\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, y, means (SE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.67 (0.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.48 (0.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.26 (0.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45.78 (0.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\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\u003e3877 (51.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3149 (50.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e304 (57.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e424 (73.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\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\u003e3635 (48.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3239 (49.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e231 (42.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e165 (26.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMexican American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1355 (7.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1142 (7.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100 (8.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e113 (8.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e500 (3.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e414 (3.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43 (4.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43 (3.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Hispanic White\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3874 (73.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3348 (74.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e251 (71.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e275 (69.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Hispanic Black\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1522 (10.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1254 (9.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e125 (11.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e143 (14.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther race\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e261 (4.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e230 (4.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (4.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (3.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; High School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2023 (17.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1634 (16.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e202 (24.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e187 (21.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1815 (24.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1518 (24.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e130 (26.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e167 (29.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt; High School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3674 (58.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3236 (59.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e203 (49.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e235 (48.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoverty-to-income ratio, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2052 (17.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1672 (16.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e187 (23.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e193 (23.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.3\u0026ndash;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2915 (36.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2455 (35.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e207 (35.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e253 (42.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2545 (46.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2261 (47.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e141 (40.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e143 (34.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced/Separated/Widowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1623 (18.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1335 (17.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e138 (21.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e150 (23.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried/Living with a partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4767 (66.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4101(67.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e329 (65.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e337 (58.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1122 (15.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e952 (15.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68 (12.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e102 (17.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114 (1.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88 (1.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11(1.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (2.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18.5\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1534 (22.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1293 (22.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90 (19.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e151 (30.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5864 (75.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5007 (76.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e434 (78.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e423 (67.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3911 (51.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3304 (51.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e246 (42.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e361 (60.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFomer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1983 (25.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1700 (25.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e160 (30.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e123 (20.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1618 (22.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1384 (22.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e129 (27.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e105 (18.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\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\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\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\u003e2242 (25.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1801 (23.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e191(29.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e250 (36.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\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\u003e5270 (74.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4587 (76.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e344 (70.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e339 (63.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVigorous activities, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\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\u003e3044 (35.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2516(33.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e268 (44.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e260 (43.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\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\u003e744 (11.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e658 (11.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36 (8.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50 (10.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3724 (53.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3214 (54.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e231 (47.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e279 (45.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\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\u003e6936 (92.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5961 (93.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e456 (85.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e519 (97.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\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\u003e576 (7.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e427 (6.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79 (14.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70 (2.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\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\u003e6521 (90.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5575 (90.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e427 (84.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e519 (91.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\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\u003e991 (9.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e813 (9.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e108 (15.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70 (8.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWater intake, gm, means (SE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e967.98 (25.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e985.24 (25.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e927.64 (62.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e793.40 (53.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal sugars, gm, means (SE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115.38 (1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e116.14 (1.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e109.80 (3.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e111.05 (3.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.045\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDietary fiber intake, gm, means (SE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.10 (0.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.54 (0.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.33 (0.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.30 (0.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC count, 1000 cells/uL, means (SE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.32 (0.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.32 (0.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.51 (0.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.21 (0.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.407\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeutrophils percent, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58.48 (0.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.50 (0.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.39 (0.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58.52 (0.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.607\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP, mg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.41 (0.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.40 (0.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.54 (0.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.42 (0.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum Calcium, mg/dL, means (SE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.45 (0.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.46 (0.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.41 (0.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.45 (0.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStool frequency, means (SE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.17 (0.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.04 (0.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.74 (0.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.51 (0.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCondition of teeth, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcellent/Very good, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2327 (36.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2034 (38.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e129 (29.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e164 (31.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2428 (33.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2108 (33.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e146 (32.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e174 (31.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1650 (18.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1359 (18.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e140 (21.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e151 (21.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1107 (11.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e887 (10.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e120 (16.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100 (16.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of oral pain, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOften\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e569 (7.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e459 (6.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57 (9.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53 (8.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccasionally\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1211 (14.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1002 (14.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95 (16.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e114 (18.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5732 (78.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4927 (78.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e383 (73.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e422 (73.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eLasso regression for variable selection\u003c/h3\u003e\n\u003cp\u003eTo avoid potential overfitting issues in the subsequent weighted logistic regression model, we employed Lasso regression to select covariates from among 20 candidate confounding factors. In the analysis of teeth condition, no covariates were excluded based on the optimal penalty parameter (λ\u0026thinsp;=\u0026thinsp;0.0007) determined by the minimum binomial deviation criterion, indicating that all pre-specified variables made meaningful contributions to the model (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). By contrast, in the analysis of oral pain frequency, 17 covariates were retained (excluding alcohol consumption, diabetes, and WBC count) at the minimum penalty parameter (λ\u0026thinsp;=\u0026thinsp;0.0013) for inclusion in the multivariable logistic regression analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eD).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLogistic regression analysis of oral health\u003c/h2\u003e \u003cp\u003e Using normal participants as the control group, we investigated the relationship between abnormal bowel habits and oral health through weighted logistic regression models. In the crude model, both chronic constipation and diarrhea showed significant association with higher prevalence of poor teeth condition (\u003cem\u003eP\u003c/em\u003e for trend\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and frequent oral pain (\u003cem\u003eP\u003c/em\u003e for trend\u0026thinsp;=\u0026thinsp;0.009) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). After fully adjustment for sociodemographic, lifestyle, and clinical covariates (Model 2), chronic constipation remained associated with 45% higher odds of poor teeth condition (OR\u0026thinsp;=\u0026thinsp;1.45, 95% CI: 1.05\u0026ndash;2.01), while chronic diarrhea showed a 24% elevation (OR\u0026thinsp;=\u0026thinsp;1.24, 95% CI: 0.94\u0026ndash;1.65) (\u003cem\u003eP\u003c/em\u003e for trend\u0026thinsp;=\u0026thinsp;0.006). However, no statistically significant correlation was observed between bowel habits and the frequency of oral pain in Model 1 (adjusted for sociodemographic variables) (\u003cem\u003eP\u003c/em\u003e for trend\u0026thinsp;=\u0026thinsp;0.070), or Model 2 (adjusted for all covariates) (\u003cem\u003eP\u003c/em\u003e for trend\u0026thinsp;=\u0026thinsp;0.337).\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\u003eWeighted univariate and multivariate analyses showing the relationship between oral health and bowel conditions.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\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=\"char\" char=\".\" 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=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCrude model\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eModel1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eModel2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\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\u003eCondition of teeth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBowel habits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic constipation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.69 (1.27\u0026ndash;2.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.39 (1.01\u0026ndash;1.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.45 (1.05\u0026ndash;2.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic diarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.75 (1.35\u0026ndash;2.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.41 (1.08\u0026ndash;1.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.24 (0.94\u0026ndash;1.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.119\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e for trend\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of oral pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBowel habits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic constipation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.29 (0.89\u0026ndash;1.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.01 (0.69\u0026ndash;1.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.976\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.98 (0.67\u0026ndash;1.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.927\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic diarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.52 (1.03\u0026ndash;2.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.45 (0.97\u0026ndash;2.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.067\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.28 (0.83\u0026ndash;1.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.233\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e for trend\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.070\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.377\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 \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAssociation between teeth condition and stool frequency\u003c/h2\u003e \u003cp\u003eBased on the previous logistic regression analysis, both chronic diarrhea and constipation were associated with an elevated risk of poor teeth condition. RCS regression further demonstrated a significant nonlinear U-shaped relationship between stool frequency and poor teeth condition (nonlinear \u003cem\u003eP\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.002, Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA). The risk of poor teeth condition decreased with increasing weekly stool frequency until reaching a minimum at 9.241 bowel movements per week, beyond which the risk progressively rose. Subgroup RCS analysis across different age groups revealed minimal variation in optimal bowel movement frequency: 9.844/week (20\u0026ndash;39 years), 9.543/week (40\u0026ndash;59 years), and 8.462/week (60\u0026ndash;85 years) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB-D). Notably, non-depressed individuals exhibited a U-shaped association, with the lowest adjusted odds ratio (OR) for poor teeth condition observed at 9.201 bowel movements/week. In contrast, no significant association emerged between stool frequency and teeth condition in the depression subgroup (nonlinear \u003cem\u003eP\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.677), suggesting potential effect modification by mental health status that warrants further investigation (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eF).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStratified analysis and interaction test\u003c/h2\u003e \u003cp\u003eWe further conducted stratified logistic regression analysis with adjusted covariates and interaction tests to determine the variables influencing the relationship between bowel habits and teeth condition. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, both chronic diarrhea and constipation were generally linked to a higher prevalence of poor teeth condition, reflected by the overall rightward shift of effect estimates (OR values). Notably, participants with daily dietary fiber intake\u0026thinsp;\u0026ge;\u0026thinsp;25 g had a significantly reduced risk of poor teeth condition compared to those with lower intake (chronic constipation: OR: 0.44, 95% CI: 0.13\u0026ndash;1.09; chronic diarrhea: OR: 0.40, 95% CI: 0.12\u0026ndash;0.98). Conversely, the risk of poor teeth condition significantly increased in the PIR\u0026thinsp;\u0026gt;\u0026thinsp;3.5 subgroup, with OR values of 2.38 (95% CI: 1.35\u0026ndash;3.98) for chronic diarrhea and 2.18 (95% CI: 1.22\u0026ndash;3.70) for chronic constipation. Interaction tests showed that diabetes (\u003cem\u003eP\u003c/em\u003e for interaction\u0026thinsp;=\u0026thinsp;0.092) and dietary fiber intake (\u003cem\u003eP\u003c/em\u003e for interaction\u0026thinsp;=\u0026thinsp;0.061) presented trends in influencing the associations, though the \u003cem\u003eP\u003c/em\u003e-value did not reach statistical significance (\u003cb\u003eSupplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e\u003c/b\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSensitivity analysis\u003c/h2\u003e \u003cp\u003eFor sensitivity analysis, we re-included 9,337 participants previously excluded due to covariate missing data, imputed missing values via multiple imputation, and performed weighted logistic regression (\u003cb\u003eSupplementary Table \u003cspan refid=\"MOESM2\" class=\"InternalRef\"\u003eS2\u003c/span\u003e\u003c/b\u003e). Results demonstrated significant associations between chronic constipation, chronic diarrhea, and poor teeth condition (\u003cem\u003eP\u003c/em\u003e for trend\u0026thinsp;=\u0026thinsp;0.005) as well as frequent oral pain (\u003cem\u003eP\u003c/em\u003e for trend\u0026thinsp;=\u0026thinsp;0.007). Subsequently, we excluded individuals with diabetes (n\u0026thinsp;=\u0026thinsp;991), depression (n\u0026thinsp;=\u0026thinsp;576), or CRP\u0026thinsp;\u0026ge;\u0026thinsp;1 mg/dL (n\u0026thinsp;=\u0026thinsp;847) from the complete-case dataset and repeated the weighted logistic regression (\u003cb\u003eSupplementary Table \u003cspan refid=\"MOESM3\" class=\"InternalRef\"\u003eS3\u003c/span\u003e\u003c/b\u003e). Findings were consistent with prior conclusions: both chronic diarrhea and constipation were closely associated with a higher risk of poor teeth condition across Model 1 (\u003cem\u003eP\u003c/em\u003e for trend\u0026thinsp;\u0026lt;\u0026thinsp;0.001), Model 2 (\u003cem\u003eP\u003c/em\u003e for trend\u0026thinsp;=\u0026thinsp;0.022), and Model 3 (\u003cem\u003eP\u003c/em\u003e for trend\u0026thinsp;=\u0026thinsp;0.014). Although chronic diarrhea was linked to frequent oral pain in the crude model, this association no longer reached statistical significance after covariate adjustment (\u003cem\u003eP\u003c/em\u003e for trend\u0026thinsp;=\u0026thinsp;0.148).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis cross-sectional study aimed to explore the association between chronic diarrhea, constipation, and oral health using data from the NHANES during 2005\u0026ndash;2008. The results indicated that both chronic constipation and diarrhea were associated with a higher risk of poor teeth condition. A significant U-shaped dose-response relationship was observed between poor teeth condition and stool frequency. It is noteworthy that both the general population and age-specific subgroups exhibited optimal teeth condition when maintaining 8\u0026ndash;10 bowel movements weekly, with progressively elevated risks observed at both lower and higher extremes of stool frequency. Although there was a positive correlation between the frequency of oral pain and abnormal bowel habits in the crude model, the association was no longer statistically significant after adjusting for all covariates. Futhermore, stratified analyses demonstrated higher dietary fiber intake was associated with lower risks of poor teeth condition in both constipation and diarrhea populations, while elevated PIR correlated with reduced risks. These differential associations suggest that dietary nutrient intake and socioeconomic status may also indirectly affect teeth condition.\u003c/p\u003e \u003cp\u003e The relationship between oral health and gastrointestinal disorders has been increasingly explored, yet direct evidence linking abnormal bowel movements to oral health issues remains incomplex. A Japanese study on lifestyle diseases conducted between 2013 and 2017 revealed an association between low occlusal bite force and an increased risk of developing Irritable Bowel Syndrome (IBS)[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Baseline variables such as the number of remaining teeth, tooth loss, and the presence of dentures differed between the IBS and non-IBS groups. Unfortunately, subsequent logistic regression analysis did not show a significant association between teeth condition and IBS risk. In a cross-sectional study conducted by Amiri M et al. among elderly individuals in Iran, a significant relationship was observed between teeth problems and functional constipation[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The underlying mechanism is primarily attributed to the significant impact of oral health on general well-being and dietary intake among the elderly. However, this conclusion cannot be extended to younger populations, and it also fails to explain the association between chronic diarrhea and teeth conditions. In contrast, our study observed an association between abnormal bowel movements and poor dental conditions across different age groups. Furthermore, we identified a relatively low-risk weekly frequency of bowel movements. These findings provide new insights for future screening of high-risk populations for oral diseases and daily life management strategies. In the subgroup analysis, participants with dietary fiber intake\u0026thinsp;\u0026ge;\u0026thinsp;25 g had a significantly lower risk of poor teeth condition, which may be related to changes in food choices when oral health is impaired. The study indicated that individuals with fewer than 28 teeth had significantly lower dietary fiber intake compared to those with complete dentition, and their serum levels of nutrients such as folate and vitamin C were also lower[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Even among those wearing full dentures, their dietary fiber intake remained significantly lower than those with all natural teeth[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In rat models of periodontitis, there was a dose-dependent relationship between increased dietary fiber intake and reduced alveolar bone loss and decreased proinflammatory markers, suggesting that dietary fiber intake holds promise as an intervention to reduce oral infectious diseases such as periodontitis[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This viewpoint was further supported by subsequent researches indicating that dietary fiber may restrict the progression of periodontal diseases by regulating gut microbiota and pH levels[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is well-known that although the oral and gut microbiota compositions are relatively independent, microorganisms can spread from the oral cavity to the intestine when the efficiency of the oral-intestinal barrier is reduced[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Previous researches have indicated that poor oral health can exacerbate intestinal inflammation[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], suggesting that abnormal bowel movements are more likely caused by the migration of oral pathogens to the intestine, rather than vice versa. Similarly, a multicenter study involving hospitalized patients with swallowing difficulties found a higher proportion of fecal incontinence among those with poor oral health[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Additionally, the mechanisms by which oral bacteria cause gastrointestinal dysfunction include Toll-like receptor activation, changes in oxidative stress, inflammasome activation, release of proinflammatory cytokines, and modulation of the complement system[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. These complex factors collectively contribute to the synergistic pathological effects of oral infections on the intestine. Although gut microorganisms can also affect the oral cavity, current evidence primarily focuses on the fecal-oral route, often occurring in situations with inadequate public health systems or compromised immune function[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Aggor et al. demonstrated that colonizing germ-free mice with segmented filamentous bacteria effectively alleviated antibiotic-induced oropharyngeal candidiasis[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], indicating that the gut microbiota can also affect oral health through immune modulation. This reverse regulatory mechanism from the gut to the oral cavity is most commonly observed in inflammatory bowel disease (IBD). Approximately 10\u0026ndash;30% of IBD patients exhibit oral manifestations of the disease, including aphthous ulcers, pyostomatitis vegetans, and periodontitis[\u003cspan additionalcitationids=\"CR42\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The mechanism by which IBD causes oral manifestations is not fully understood, but it is currently believed to involve multiple factors such as immune dysregulation, genetics, and microbiome alterations[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Whether other gastrointestinal diseases, especially chronic constipation and diarrhea, have a definite impact on oral health still requires further investigation.\u003c/p\u003e \u003cp\u003eThis study, for the first time, untangles the correlation between abnormal bowel habits and oral health, providing empirical support for the oral-gut axis theory in the context of chronic intestinal insufficiency. From a clinical perspective, chronic constipation is significantly associated with an elevated risk of poor teeth condition, necessitating the implementation of interdisciplinary therapeutic approaches. Clinicians should consider conducting routine oral health screenings for patients with persistent intestinal abnormalities, particularly those with weekly bowel movement frequencies of less than 8 or more than 10 times. Although there are variations in stool frequency across different age groups, maintaining a weekly bowel movement frequency of 8 to 10 times may represent the optimal range for minimizing the risk of oral health issues. Meanwhile, adequate dietary fiber intake may offer protective effects on dental health, suggesting that dietary intervention could serve as an effective strategy for addressing gut-oral comorbidities. The stable association observed in the sensitivity analysis validates the robustness of using self-reported bowel patterns as epidemiological markers for oral health monitoring, paving new avenues for future oral health screenings.\u003c/p\u003e \u003cp\u003eHowever, this study has several limitations. First, as a cross-sectional study based on NHANES, it cannot determine causality. Prospective cohort studies are needed to clarify the temporal relationship between oral and bowel indicators. Second, the oral and bowel data relied on self-reported questionnaires, which are susceptible to recall bias. Future studies should combine objective methods such as microbial metagenomic sequencing and quantitative radiographic accessment of oral pathologies to build multi-omics networks linking the oral cavity and intestine. Additionally, animal models (such as ligature-induced periodontitis and DSS-induced colitis) should be designed to investigate mechanistic interactions involving microbial translocation, immune regulation, and metabolomic remodeling. Thirdly, despite adjusting for major confounding factors, potential unmeasured variables (such as epigenetic factors and dietary patterns) may influence the results. Due to data availability limitations, drug usage (such as laxatives, antibiotics, antidepressants) and biomarkers reflecting oral/intestinal function (such as lipopolysaccharide binding protein, short-chain fatty acids) were not included.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study revealed a U-shaped relationship between stool frequency and poor teeth condition, with the lowest risk observed at 8\u0026ndash;10 times/week. Both chronic constipation and diarrhea were associated with higher risks of teeth problems, but no significant correlation was found with self-reported oral pain frequency. Stratified analyses suggested dietary fiber intake and PIR may modulate the gut-oral interaction. The underlying mechanisms linking bowel abnormalities to oral health risks require further experimental and longitudinal investigation.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eNHANES \u0026nbsp;National Health and Nutrition Examination Surveys\u003c/p\u003e\n\u003cp\u003eNCHS \u0026nbsp; \u0026nbsp; \u0026nbsp;National Center for Health Statistics\u003c/p\u003e\n\u003cp\u003eBSFS \u0026nbsp; \u0026nbsp; \u0026nbsp; Bristol Stool Form Scale\u003c/p\u003e\n\u003cp\u003eWBC \u0026nbsp; \u0026nbsp; \u0026nbsp; white blood cell\u003c/p\u003e\n\u003cp\u003eCRP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C-reactive protein\u003c/p\u003e\n\u003cp\u003eBMI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Body mess index\u003c/p\u003e\n\u003cp\u003eOR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Odds ratio\u003c/p\u003e\n\u003cp\u003eSE \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Means and standard errors\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNHANES data has been approved by the NCHS Research Ethics Review Committee. Research using public databases does not require ethical approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch related data can be found or downloaded on the NHANES official website: https://www.cdc.gov/nchs/nhanes/site.html.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares that there is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not supported by funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLM and ZRG conceptualized and designed this study. ZHJ, JWM extracted data from the database. ZHJ, JWM, YJL, and ZJW analyzed and explained the data. ZHJ drafted the initial manuscript. LM and ZRG revised the manuscript. All authors acknowledge the final manuscript as submitted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author thanks the Second Affiliated Hospital of Nanjing Medical University for its support of this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKassebaum NJ, Smith A, Bernabe E, Fleming TD, Reynolds AE, Vos T, Murray C, Marcenes W: \u003cstrong\u003eGlobal, Regional, and National Prevalence, Incidence, and Disability-Adjusted Life Years for Oral Conditions for 195 Countries, 1990-2015: A Systematic Analysis for the Global Burden of Diseases, Injuries, and Risk Factors\u003c/strong\u003e. \u003cem\u003eJ DENT RES\u003c/em\u003e 2017, \u003cstrong\u003e96\u003c/strong\u003e(4):380-387.\u003c/li\u003e\n \u003cli\u003ePetersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C: \u003cstrong\u003eThe global burden of oral diseases and risks to oral health\u003c/strong\u003e. \u003cem\u003eBull World Health Organ\u003c/em\u003e 2005, \u003cstrong\u003e83\u003c/strong\u003e(9):661-669.\u003c/li\u003e\n \u003cli\u003eYu YH, Steffensen B, Chasman DI, Buring JE: \u003cstrong\u003eSelf-reported oral health is associated with systemic health outcomes and all-cause mortality\u003c/strong\u003e. \u003cem\u003eJ AM DENT ASSOC\u003c/em\u003e 2024, \u003cstrong\u003e155\u003c/strong\u003e(3):233-243.\u003c/li\u003e\n \u003cli\u003eKisely S, Sawyer E, Siskind D, Lalloo R: \u003cstrong\u003eThe oral health of people with anxiety and depressive disorders - a systematic review and meta-analysis\u003c/strong\u003e. \u003cem\u003eJ Affect Disord\u003c/em\u003e 2016, \u003cstrong\u003e200\u003c/strong\u003e:119-132.\u003c/li\u003e\n \u003cli\u003eKalaigian A, Chaffee BW: \u003cstrong\u003eMental Health and Oral Health in a Nationally Representative Cohort\u003c/strong\u003e. \u003cem\u003eJ DENT RES\u003c/em\u003e 2023, \u003cstrong\u003e102\u003c/strong\u003e(9):1007-1014.\u003c/li\u003e\n \u003cli\u003eThwin KM, Ogawa H, Phantumvanit P, Miyazaki H, Songpaisan Y: \u003cstrong\u003eOral health-related quality of life in the Myanmar population: The first national oral health survey 2016 - 2017\u003c/strong\u003e. \u003cem\u003eCommunity Dent Health\u003c/em\u003e 2024, \u003cstrong\u003e41\u003c/strong\u003e(3):158-163.\u003c/li\u003e\n \u003cli\u003eWong ML, Lee YH, Sim YF, Wong TJ, Soh SH, Goh BT, Poon CY, Allen PF, Chia KS, Sim C: \u003cstrong\u003eOral health knowledge, attitudes and behaviours of adults: Findings from a National Oral Health Survey in Singapore\u003c/strong\u003e. \u003cem\u003eCommunity Dent Oral Epidemiol\u003c/em\u003e 2024, \u003cstrong\u003e52\u003c/strong\u003e(3):292-301.\u003c/li\u003e\n \u003cli\u003eDibello V, Lobbezoo F, Solfrizzi V, Custodero C, Lozupone M, Pilotto A, Dibello A, Santarcangelo F, Grandini S, Daniele A\u003cem\u003e\u0026nbsp;et al\u003c/em\u003e: \u003cstrong\u003eOral health indicators and bone mineral density disorders in older age: A systematic review\u003c/strong\u003e. \u003cem\u003eAGEING RES REV\u003c/em\u003e 2024, \u003cstrong\u003e100\u003c/strong\u003e:102412.\u003c/li\u003e\n \u003cli\u003eSuares NC, Ford AC: \u003cstrong\u003ePrevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis\u003c/strong\u003e. \u003cem\u003eAM J GASTROENTEROL\u003c/em\u003e 2011, \u003cstrong\u003e106\u003c/strong\u003e(9):1582-1591, 1581, 1592.\u003c/li\u003e\n \u003cli\u003eSchiller LR: \u003cstrong\u003eChronic diarrhea\u003c/strong\u003e. \u003cem\u003eGASTROENTEROLOGY\u003c/em\u003e 2004, \u003cstrong\u003e127\u003c/strong\u003e(1):287-293.\u003c/li\u003e\n \u003cli\u003eBlack CJ, Drossman DA, Talley NJ, Ruddy J, Ford AC: \u003cstrong\u003eFunctional gastrointestinal disorders: advances in understanding and management\u003c/strong\u003e. \u003cem\u003eLANCET\u003c/em\u003e 2020, \u003cstrong\u003e396\u003c/strong\u003e(10263):1664-1674.\u003c/li\u003e\n \u003cli\u003eBallou S, Katon J, Singh P, Rangan V, Lee HN, McMahon C, Iturrino J, Lembo A, Nee J: \u003cstrong\u003eChronic Diarrhea and Constipation Are More Common in Depressed Individuals\u003c/strong\u003e. \u003cem\u003eClin Gastroenterol Hepatol\u003c/em\u003e 2019, \u003cstrong\u003e17\u003c/strong\u003e(13):2696-2703.\u003c/li\u003e\n \u003cli\u003eSommers T, Mitsuhashi S, Singh P, Hirsch W, Katon J, Ballou S, Rangan V, Cheng V, Friedlander D, Iturrino J\u003cem\u003e\u0026nbsp;et al\u003c/em\u003e: \u003cstrong\u003ePrevalence of Chronic Constipation and Chronic Diarrhea in Diabetic Individuals in the United States\u003c/strong\u003e. \u003cem\u003eAM J GASTROENTEROL\u003c/em\u003e 2019, \u003cstrong\u003e114\u003c/strong\u003e(1):135-142.\u003c/li\u003e\n \u003cli\u003eNewman KL, Kamada N: \u003cstrong\u003ePathogenic associations between oral and gastrointestinal diseases\u003c/strong\u003e. \u003cem\u003eTRENDS MOL MED\u003c/em\u003e 2022, \u003cstrong\u003e28\u003c/strong\u003e(12):1030-1039.\u003c/li\u003e\n \u003cli\u003eKunath BJ, De Rudder C, Laczny CC, Letellier E, Wilmes P: \u003cstrong\u003eThe oral-gut microbiome axis in health and disease\u003c/strong\u003e. \u003cem\u003eNAT REV MICROBIOL\u003c/em\u003e 2024, \u003cstrong\u003e22\u003c/strong\u003e(12):791-805.\u003c/li\u003e\n \u003cli\u003eNakajima M, Arimatsu K, Kato T, Matsuda Y, Minagawa T, Takahashi N, Ohno H, Yamazaki K: \u003cstrong\u003eOral Administration of P. gingivalis Induces Dysbiosis of Gut Microbiota and Impaired Barrier Function Leading to Dissemination of Enterobacteria to the Liver\u003c/strong\u003e. \u003cem\u003ePLOS ONE\u003c/em\u003e 2015, \u003cstrong\u003e10\u003c/strong\u003e(7):e134234.\u003c/li\u003e\n \u003cli\u003eBao J, Li L, Zhang Y, Wang M, Chen F, Ge S, Chen B, Yan F: \u003cstrong\u003ePeriodontitis may induce gut microbiota dysbiosis via salivary microbiota\u003c/strong\u003e. \u003cem\u003eINT J ORAL SCI\u003c/em\u003e 2022, \u003cstrong\u003e14\u003c/strong\u003e(1):32.\u003c/li\u003e\n \u003cli\u003eLee YC, Liu CY, Lee CL, Zhang RH, Huang CJ, Yen TL: \u003cstrong\u003eThe Periodontopathic Pathogen, Porphyromonas gingivalis, Involves a Gut Inflammatory Response and Exacerbates Inflammatory Bowel Disease\u003c/strong\u003e. \u003cem\u003ePathogens\u003c/em\u003e 2022, \u003cstrong\u003e11\u003c/strong\u003e(1).\u003c/li\u003e\n \u003cli\u003eJiang Y, Jin H, Liang Q, Zhu X: \u003cstrong\u003eCausal relationship between gut microbiota and dental caries: A Mendelian randomization analysis\u003c/strong\u003e. \u003cem\u003eMedicine (Baltimore)\u003c/em\u003e 2025, \u003cstrong\u003e104\u003c/strong\u003e(8):e41555.\u003c/li\u003e\n \u003cli\u003eWang Y, Wang Z: \u003cstrong\u003eAssociation between ideal cardiovascular health and bowel conditions among US adults\u003c/strong\u003e. \u003cem\u003eFront Nutr\u003c/em\u003e 2024, \u003cstrong\u003e11\u003c/strong\u003e:1473531.\u003c/li\u003e\n \u003cli\u003eAtala-Acevedo C, McGrath R, Glenister K, Capurro D, Bourke L, Simmons D, Morgan M, Marino R: \u003cstrong\u003eSelf-Rated Oral Health as a Valid Measure of Oral Health Status in Adults Living in Rural Australia\u003c/strong\u003e. \u003cem\u003eHealthcare (Basel)\u003c/em\u003e 2023, \u003cstrong\u003e11\u003c/strong\u003e(12).\u003c/li\u003e\n \u003cli\u003eYin N, Li W, Zhou H, Zhang Y, Zhang W, Ding W, Ge H, Zhang S, Liao S: \u003cstrong\u003eAssociations Among Self-rated Oral Health, Subjective Oral Conditions, Oral Health Behaviours, and Oral Healthrelated Quality of Life (OHRQoL)\u003c/strong\u003e. \u003cem\u003eOral Health Prev Dent\u003c/em\u003e 2023, \u003cstrong\u003e21\u003c/strong\u003e:25-32.\u003c/li\u003e\n \u003cli\u003eMeisel P, Holtfreter B, Volzke H, Kocher T: \u003cstrong\u003eSelf-reported oral health predicts tooth loss after five and ten years in a population-based study\u003c/strong\u003e. \u003cem\u003eJ CLIN PERIODONTOL\u003c/em\u003e 2018, \u003cstrong\u003e45\u003c/strong\u003e(10):1164-1172.\u003c/li\u003e\n \u003cli\u003eCao H, Wang M, Duan M, Wang S, Zhang H: \u003cstrong\u003eAssociation of serum calcium level with periodontitis: a cross-sectional study from NHANES 2009-2014\u003c/strong\u003e. \u003cem\u003eFront Nutr\u003c/em\u003e 2024, \u003cstrong\u003e11\u003c/strong\u003e:1520639.\u003c/li\u003e\n \u003cli\u003eOkuyama Y, Matsui D, Ozaki E, Watanabe Y: \u003cstrong\u003eAssociation of low occlusal force as an oral hypofunction with the prevalence of irritable bowel syndrome in Japanese adults\u003c/strong\u003e. \u003cem\u003eJ Gastroenterol Hepatol\u003c/em\u003e 2023, \u003cstrong\u003e38\u003c/strong\u003e(8):1269-1276.\u003c/li\u003e\n \u003cli\u003eAmiri M, Hassanzadeh A, Rahimi M: \u003cstrong\u003eA survey on functional constipation and its risk factors in older people in Shahreza, Iran\u003c/strong\u003e. \u003cem\u003eJ Educ Health Promot\u003c/em\u003e 2024, \u003cstrong\u003e13\u003c/strong\u003e:118.\u003c/li\u003e\n \u003cli\u003eNowjack-Raymer RE, Sheiham A: \u003cstrong\u003eNumbers of natural teeth, diet, and nutritional status in US adults\u003c/strong\u003e. \u003cem\u003eJ DENT RES\u003c/em\u003e 2007, \u003cstrong\u003e86\u003c/strong\u003e(12):1171-1175.\u003c/li\u003e\n \u003cli\u003eNowjack-Raymer RE, Sheiham A: \u003cstrong\u003eAssociation of edentulism and diet and nutrition in US adults\u003c/strong\u003e. \u003cem\u003eJ DENT RES\u003c/em\u003e 2003, \u003cstrong\u003e82\u003c/strong\u003e(2):123-126.\u003c/li\u003e\n \u003cli\u003eTailor R, Medara N, Chopra A, Swarnamali H, Eberhard J, Jayasinghe TN: \u003cstrong\u003eRole of prebiotic dietary fiber in periodontal disease: A systematic review of animal studies\u003c/strong\u003e. \u003cem\u003eFront Nutr\u003c/em\u003e 2023, \u003cstrong\u003e10\u003c/strong\u003e:1130153.\u003c/li\u003e\n \u003cli\u003eSun Y, Zhang S, Nie Q, He H, Tan H, Geng F, Ji H, Hu J, Nie S: \u003cstrong\u003eGut firmicutes: Relationship with dietary fiber and role in host homeostasis\u003c/strong\u003e. \u003cem\u003eCrit Rev Food Sci Nutr\u003c/em\u003e 2023, \u003cstrong\u003e63\u003c/strong\u003e(33):12073-12088.\u003c/li\u003e\n \u003cli\u003eFernandez CE, Maturana-Valenzuela C, Rojas-Castillo N, Rosier B: \u003cstrong\u003ePotential effects of prebiotic fibers on dental caries: a systematic review\u003c/strong\u003e. \u003cem\u003eJ Sci Food Agric\u003c/em\u003e 2025.\u003c/li\u003e\n \u003cli\u003eSchmidt TS, Hayward MR, Coelho LP, Li SS, Costea PI, Voigt AY, Wirbel J, Maistrenko OM, Alves RJ, Bergsten E\u003cem\u003e\u0026nbsp;et al\u003c/em\u003e: \u003cstrong\u003eExtensive transmission of microbes along the gastrointestinal tract\u003c/strong\u003e. \u003cem\u003eELIFE\u003c/em\u003e 2019, \u003cstrong\u003e8\u003c/strong\u003e.\u003c/li\u003e\n \u003cli\u003eKunath BJ, Hickl O, Queiros P, Martin-Gallausiaux C, Lebrun LA, Halder R, Laczny CC, Schmidt T, Hayward MR, Becher D\u003cem\u003e\u0026nbsp;et al\u003c/em\u003e: \u003cstrong\u003eAlterations of oral microbiota and impact on the gut microbiome in type 1 diabetes mellitus revealed by integrated multi-omic analyses\u003c/strong\u003e. \u003cem\u003eMICROBIOME\u003c/em\u003e 2022, \u003cstrong\u003e10\u003c/strong\u003e(1):243.\u003c/li\u003e\n \u003cli\u003eKitamoto S, Nagao-Kitamoto H, Jiao Y, Gillilland MR, Hayashi A, Imai J, Sugihara K, Miyoshi M, Brazil JC, Kuffa P\u003cem\u003e\u0026nbsp;et al\u003c/em\u003e: \u003cstrong\u003eThe Intermucosal Connection between the Mouth and Gut in Commensal Pathobiont-Driven Colitis\u003c/strong\u003e. \u003cem\u003eCELL\u003c/em\u003e 2020, \u003cstrong\u003e182\u003c/strong\u003e(2):447-462.\u003c/li\u003e\n \u003cli\u003eAtarashi K, Suda W, Luo C, Kawaguchi T, Motoo I, Narushima S, Kiguchi Y, Yasuma K, Watanabe E, Tanoue T\u003cem\u003e\u0026nbsp;et al\u003c/em\u003e: \u003cstrong\u003eEctopic colonization of oral bacteria in the intestine drives T(H)1 cell induction and inflammation\u003c/strong\u003e. \u003cem\u003eSCIENCE\u003c/em\u003e 2017, \u003cstrong\u003e358\u003c/strong\u003e(6361):359-365.\u003c/li\u003e\n \u003cli\u003eShimizu A, Maki H, Ohno T, Nomoto A, Fujishima I, Kayashita J, Momosaki R, Nishioka S, Wakabayashi H: \u003cstrong\u003eAssociation of poor oral health status and faecal incontinence in patients with dysphagia: A cross-sectional analysis from the Sarcopenic Dysphagia Database\u003c/strong\u003e. \u003cem\u003eJ ORAL REHABIL\u003c/em\u003e 2023, \u003cstrong\u003e50\u003c/strong\u003e(4):286-292.\u003c/li\u003e\n \u003cli\u003eMukherjee S, Chopra A, Karmakar S, Bhat SG: \u003cstrong\u003ePeriodontitis increases the risk of gastrointestinal dysfunction: an update on the plausible pathogenic molecular mechanisms\u003c/strong\u003e. \u003cem\u003eCRIT REV MICROBIOL\u003c/em\u003e 2025, \u003cstrong\u003e51\u003c/strong\u003e(1):187-217.\u003c/li\u003e\n \u003cli\u003eZhang C, Xu C, Gao L, Li X, Zhao C: \u003cstrong\u003ePorphyromonas gingivalis lipopolysaccharide promotes T-hel per17 cell differentiation by upregulating Delta-like ligand 4 expression on CD14(+) monocytes\u003c/strong\u003e. \u003cem\u003ePEERJ\u003c/em\u003e 2021, \u003cstrong\u003e9\u003c/strong\u003e:e11094.\u003c/li\u003e\n \u003cli\u003ePark SY, Hwang BO, Lim M, Ok SH, Lee SK, Chun KS, Park KK, Hu Y, Chung WY, Song NY: \u003cstrong\u003eOral-Gut Microbiome Axis in Gastrointestinal Disease and Cancer\u003c/strong\u003e. \u003cem\u003eCancers (Basel)\u003c/em\u003e 2021, \u003cstrong\u003e13\u003c/strong\u003e(9).\u003c/li\u003e\n \u003cli\u003eAggor FE, Bertolini M, Zhou C, Taylor TC, Abbott DA, Musgrove J, Bruno VM, Hand TW, Gaffen SL: \u003cstrong\u003eA gut-oral microbiome-driven axis controls oropharyngeal candidiasis through retinoic acid\u003c/strong\u003e. \u003cem\u003eJCI Insight\u003c/em\u003e 2022, \u003cstrong\u003e7\u003c/strong\u003e(18).\u003c/li\u003e\n \u003cli\u003eBaima G, Muwalla M, Testa G, Mazza F, Bebars A, Perotto S, Vernero M, Massano A, Romano F, Ribaldone DG\u003cem\u003e\u0026nbsp;et al\u003c/em\u003e: \u003cstrong\u003ePeriodontitis prevalence and severity in inflammatory bowel disease: A case-control study\u003c/strong\u003e. \u003cem\u003eJ PERIODONTOL\u003c/em\u003e 2023, \u003cstrong\u003e94\u003c/strong\u003e(3):313-322.\u003c/li\u003e\n \u003cli\u003eLauritano D, Boccalari E, Di Stasio D, Della VF, Carinci F, Lucchese A, Petruzzi M: \u003cstrong\u003ePrevalence of Oral Lesions and Correlation with Intestinal Symptoms of Inflammatory Bowel Disease: A Systematic Review\u003c/strong\u003e. \u003cem\u003eDiagnostics (Basel)\u003c/em\u003e 2019, \u003cstrong\u003e9\u003c/strong\u003e(3).\u003c/li\u003e\n \u003cli\u003eKatz J, Shenkman A, Stavropoulos F, Melzer E: \u003cstrong\u003eOral signs and symptoms in relation to disease activity and site of involvement in patients with inflammatory bowel disease\u003c/strong\u003e. \u003cem\u003eORAL DIS\u003c/em\u003e 2003, \u003cstrong\u003e9\u003c/strong\u003e(1):34-40.\u003c/li\u003e\n \u003cli\u003eLankarani KB, Sivandzadeh GR, Hassanpour S: \u003cstrong\u003eOral manifestation in inflammatory bowel disease: a review\u003c/strong\u003e. \u003cem\u003eWorld J Gastroenterol\u003c/em\u003e 2013, \u003cstrong\u003e19\u003c/strong\u003e(46):8571-8579.\u003c/li\u003e\n \u003cli\u003eVasovic M, Gajovic N, Brajkovic D, Jovanovic M, Zdravkovaic N, Kanjevac T: \u003cstrong\u003eThe relationship between the immune system and oral manifestations of inflammatory bowel disease: a review\u003c/strong\u003e. \u003cem\u003eCENT EUR J IMMUNOL\u003c/em\u003e 2016, \u003cstrong\u003e41\u003c/strong\u003e(3):302-310.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Chronic diarrhea, Chronic constipation, Oral health, NHANES","lastPublishedDoi":"10.21203/rs.3.rs-5733361/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5733361/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cb\u003eBackground\u003c/b\u003e Oral diseases affect approximately 3.5\u0026nbsp;billion people worldwide, disproportionately burdening populations in developing countries. Chronic diarrhea and constipation, as common intestinal disorders, may interact bidirectionally with oral health, though their population-level associations remain unexamined.\u003c/p\u003e \u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e We analyzed data from the National Health and Nutrition Examination Surveys (NHANES) 2005\u0026ndash;2008, selecting participants based on inclusion criteria. Chronic diarrhea and constipation were defined based on the bowel health questionnaire. Oral health indicators (teeth condition and oral pain frequency) were derived from the oral health questionnaire. Covariates selected by Lasso regression were analyzed through adjusted logistic regression to examine associations between bowel habits and oral health. Restricted cubic splines (RCS), subgroup stratification, and sensitivity analyses were also used.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResults\u003c/b\u003e A total of 7512 participants aged\u0026thinsp;\u0026ge;\u0026thinsp;20 with complete information were included. Multivariable logistic regression revealed a significant association between chronic constipation and poor teeth condition (OR:1.45, 95% CI: 1.05\u0026ndash;2.01, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029). A U-shaped dose-response relationship was observed between stool frequency and poor teeth condition (nonlinear \u003cem\u003eP\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.002) using RCS analysis, with both abnormally low and high bowel frequencies correlating with increased oral health risks. No significant association was identified between oral pain frequency and abnormal bowel habits after full covariate adjustment. Stratified analyses indicated that daily dietary fiber intake\u0026thinsp;\u0026ge;\u0026thinsp;25 g was associated with reduced risks of poor teeth condition (chronic diarrhea OR: 0.40, 95% CI: 0.12\u0026ndash;0.98; chronic constipation OR: 0.44, 95% CI: 0.13\u0026ndash;1.09), whereas higher income (PIR\u0026thinsp;\u0026gt;\u0026thinsp;3.5) correlated with elevated risks (chronic diarrhea OR: 2.38, 95% CI: 1.35\u0026ndash;3.98; chronic constipation OR: 2.18, 95% CI: 1.22\u0026ndash;3.70). Sensitivity analyses supported the stability of associations between abnormal bowel habits and poor teeth condition.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusions\u003c/b\u003e Both chronic constipation and diarrhea were associated with higher risk of poor teeth condition. In the general population and subgroup analyses, individuals with stool frequency around 8\u0026ndash;10 times per week demonstrated the lowest risk of poor teeth condition. Stratified analysis indicates that dietary fiber intake and PIR might modify the observed relationship between abnormal bowel habits and teeth condition.\u003c/p\u003e","manuscriptTitle":"Association between oral health and bowel habits: a cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-07 13:48:01","doi":"10.21203/rs.3.rs-5733361/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-09T06:30:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-09T06:25:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-03T15:45:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-03T05:46:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"255404900247825539032547511443813594557","date":"2025-04-03T04:55:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"323472340056362804539990565081571338295","date":"2025-04-03T03:32:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-02T17:16:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-24T05:32:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-03-20T12:52:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9b684aa8-5488-426c-a117-ce9862dcc2d3","owner":[],"postedDate":"April 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-28T16:05:02+00:00","versionOfRecord":{"articleIdentity":"rs-5733361","link":"https://doi.org/10.1186/s12889-025-22747-8","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-04-21 15:57:21","publishedOnDateReadable":"April 21st, 2025"},"versionCreatedAt":"2025-04-07 13:48:01","video":"","vorDoi":"10.1186/s12889-025-22747-8","vorDoiUrl":"https://doi.org/10.1186/s12889-025-22747-8","workflowStages":[]},"version":"v1","identity":"rs-5733361","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5733361","identity":"rs-5733361","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}