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09.03.2026 - minute readminutes read

Physical Activity and Periodontitis: How Moving Your Body Shapes the Oral Microbiome and Affects Periodontal Health

Why does physical activity matter for periodontitis?
Over the last few years, our Italian research group has focused on the lifestyle determinants of periodontal health, and on how they significantly affect the likelihood of disease onset, disease progression, as well as the outcomes of periodontal therapy.

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Article written by Dr. Crystal Marruganti, a periodontal specialist, clinical researcher and educator working at the intersection of periodontal science, oral-systemic health and advanced surgical care, recognized by Forbes in its 30 Under 30 list.

Lifestyle is one of the most powerful, and often overlooked, determinants of periodontal health.

Lifestyle behaviours include daily habits that affect overall health and wellbeing including nutrition, physical exercise, sleep quality and stress levels, among others.

Unhealthy lifestyle behaviours have been recognized as the common risk factor for multiple non-communicable diseases (NCDs) as well as periodontitis (Marruganti et al., 2023).

Indeed, over the last 30 years, the management of NCDs has dramatically changed in approach. Evidence of the important role of common risk factors has emerged, therefore shifting from a medication-based treatment to a more comprehensive approach including behaviour change interventions for risk-factor modifications (Sayburn 2018).

The increasing prevalence of NCDs, despite improved treatments and the global efforts to tackle them, suggests this alarming rise may be due to the simultaneous advent of the “modern lifestyle”, which is characterized by the increased consumption of ultra-processed foods as well as smoking and alcohol, long sitting hours, and the combination of high stress and poor sleep quality (Yang et al, 2019; Mireku et al., 2019; Harb et al., 2023).

Among these lifestyle behaviours, physical activity stands out as a major modifiable factor with well-established systemic health benefits, influencing cardiometabolic function, immune regulation, and inflammatory balance; all mechanisms that are also critically involved in the onset and progression of periodontitis (Thyfault et al., 2021).

Is there an association between physical activity and periodontitis?

Multiple epidemiological studies have focused on the association between physical activity and periodontitis (Al-Zahrani et al., 2005; Bawadi et al., 2011; S.J. Han et al., 2019), although with conflicting results.

Specifically, a cross-sectional study, employing a partial periodontal examination protocol of NHANES III, noted that subjects with normal weight, regular levels of bodily movement, and a better diet quality were 40% less likely to have periodontitis compared to individuals presenting none of these healthy lifestyles (Al-Zahrani et al., 2005).

Similar results were obtained by a more recent large-scale study performed on more than two thousand Japanese adults, showing that total physical activity levels were inversely associated with periodontitis in women, but not in men, potentially due to hormonal differences (Iwasaki et al., 2023).

Along the same lines, sedentary behaviour (more than 7.5h/day) was found to be associated with higher odds of periodontal disease in a large-scale study of US adults (Almohamad et al., 2022).

From a mechanistic point of view, a cross-sectional study performed on more than five thousand adults evaluated the association between physical activity and serum IgG antibodies against selected periodontal microorganisms. Results showed that physical activity was positively associated with the antibodies in the Orange-Blue cluster (E. nodatum, A. naeslundii), i.e., a cluster that is associated with healthy periodontal states, although without reaching statistical significance (Anderson et al., 2018).

Similarly, a more recent large-scale study performed on UK adults showed no significant associations between genetic variants associated with self-reported and accelerometer-assessed physical activity and periodontitis (Baumeister et al., 2023).

In a nutshell, despite the large number of studies performed, there seems to be no clear significant trend in the association between overall physical activity and the periodontal status.

Not all types of physical activity are the same: the ‘Physical Activity Paradox’

Although the idea that not all types of bodily movements exert the same health effects traces back to the 1950s, it was not until 2017 that the concept of the ‘Physical Activity Paradox’ was firstly defined in relation to cardiovascular benefits (Holtermann et al., 2018).

In particular, the ‘Physical Activity Paradox’ refers to the divergent impact of the two different types of physical activity, occupational (OPA) and leisure-time (LTPA), on health outcomes.

Leisure-time physical activity (LTPA)

Leisure-time physical activity (LTPA) refers to bodily movements performed during free time and not required as part of the essential activities of daily living. It is performed at the subject's discretion and includes activities such as sports, exercise, and recreational walking. LTPA-associated dynamic movements and psychological well-being have been linked with improved cardiometabolic function and reduced state of low-grade systemic inflammation (Hamer et al., 2012; H. Li et al., 2021).

Occupational physical activity (OPA)

Occupational physical activity (OPA) refers, instead, to bodily movements made as part of the subject's professional tasks (e.g., carrying/lifting heavy loads, digging or construction work, household chores, etc.). OPA often involves long-lasting static load and repetitive working postures, with detrimental consequences on psycho-physical health and on the low-grade systemic inflammation balance (Holtermann et al., 2013; Hallman et al., 2017; Holtermann et al., 2021).

Does the physical activity paradox apply to periodontitis?

The physical activity paradox has been identified in multiple studies for several NCDs, including cardiovascular diseases and diabetes. In particular, a large-scale study conducted on Danish adults aged 20–100 years suggested that high LTPA was associated with a significantly reduced risk of major cardiovascular events and all-cause mortality over a period of 10-year follow-up, as opposed to OPA which associated with increased risks, even after adjusting for relevant factors such as lifestyle, general health, living conditions, and socioeconomic factors (Halle et al., 2021).

A similar trend was noted for type 2 diabetes mellitus (T2DM), where the combination of low LTPA and high OPA levels was associated with significantly higher risk of T2DM (Stage et al., 2025).

Given the multiple shared aetiopathological pathways between cardiovascular diseases, T2DM, and periodontitis, our research group started to question whether the physical activity paradox could also apply to periodontal diseases. Indeed, we hypothesized that the conflicting evidence present on the topic could actually be underpinned by the lack of discrimination between PA type (namely, LTPA and OPA).

Hence, we analysed the data coming from a large-scale, population-based study conducted on more than ten thousand US adults (NHANES 2009–2014). Periodontitis was clinically assessed using a full mouth periodontal examination, while PA levels were self-reported using the World Health Organisation-validated “Global Physical Activity Questionnaire”.

Participants were then categorized according to their PA levels, separately for LTPA and OPA, as being inactive, insufficiently active (<150 min/week), sufficiently active (150–300 min/week), or highly active (>300 min/week).

Results from this epidemiological study identified high LTPA as a protective indicator for both periodontitis and severe periodontitis, while high OPA resulted as a significant risk indicator. When considering the four combinations of LTPA/OPA, the prevalence of both periodontitis and severe periodontitis gradually increased when shifting from the lowest risk group, that is high LTPA/low OPA, to the highest risk group, that is low LTPA/high OPA (Figure 1).

Accordingly, the increased odds of periodontitis and severe periodontitis in the low LTPA/high OPA group further corroborate the cumulative association between LTPA and OPA on the periodontal status. Moreover, the sensitivity analyses showed a dose-response relationship, according to which the higher the frequency/intensity of LTPA, the lower the odds of periodontitis/severe periodontitis, while, on the other hand, the higher the frequency/duration of OPA, the higher the odds of periodontitis/severe periodontitis.

These independent associations resulted partially mediated by systemic inflammation, elevated BMI, and comorbidities (such as diabetes and hypertension) (Marruganti et al., 2023).

Thus, in line with the physical-activity paradox, our findings suggest a simple yet ironic truth: for periodontal health, it is essential not only to stay active, but to choose the right kind of activity

Biological mechanisms & how physical activity shapes oral microbiome composition

The mechanisms with which physical activity can affect periodontal health are not clearly understood yet, but they include both direct and indirect effects. While the indirect effects relate to the modulation of shared risk factors (like diabetes and obesity), the direct effects include the reduction of systemic inflammation as well as changes in the microbiome composition (Marruganti et al., 2023).

Plenty of evidence has underlined how physical exercise protects against all-cause mortality and contributes to the reduction of overall low-grade systemic inflammation (Mathur et al., 2009).

When considering the different types of physical activity and periodontitis, high LTPA had been previously found to be associated with a reduction in the levels of both systemic and local (i.e., within the gingival crevicular fluid) inflammatory biomarkers (Kasapis & Thompson, 2005; Sanders et al., 2009; Rombaldi et al., 2015).

On the other hand, a high occupational workload may contribute to physical deterioration, leading to chronic stimulation of the hypothalamic–pituitary–adrenal axis and resulting in the release of high levels of cortisol, pro-inflammatory cytokines, and oxidative stress markers (Tatzber et al., 2022). These blueprints of low-grade systemic inflammation have been significantly associated with the incidence and progression of periodontitis (D'Aiuto et al., 2004; Baima et al., 2022).

However, OPA is also related to heavy physical labour, which, in turn, is associated with socioeconomic disadvantage, a well-established risk indicator for periodontitis and other NCDs (Borrell et al., 2006). Overall, physical exercise (LTPA in particular) may be considered as a mean to control periodontitis as well as its associated NCDs.

In addition to the low-grade systemic inflammation pathway, recent evidence suggests that regular physical exercise can induce a significant shift in the oral microbiome, toward a more nitrate-reducing profile, which in turn was found to exert an anti-inflammatory effect due to the increase in nitric oxide, as reported by some clinical studies (Simpson et al., 2025; Uchida et al., 2021).

Indeed, the nitrate–nitrite–nitric oxide (NO) pathway is crucial for many physiological functions, helping to lower blood pressure and improve blood flow, as it represents an alternative pathway for NO production especially under hypoxic conditions where the common NO production pathways falter (Ma et al., 2018).

In particular, Simpson et al. (2025) demonstrated a significant shift in the tongue microbial composition, along with higher nitrate and nitrite salivary levels, after an 8-week intervention of High Intensity Interval Training (HIIT). Similarly, a 12-week supervised exercise program (aerobic plus resistance) was shown to shift the salivary microbiome away from dysbiosis in a cohort of adults affected by non-alcoholic fatty liver disease (Uchida et al., 2021).

All in all, physical exercise was found to be associated with improved immunologic surveillance, increased salivary flow, together with overall systemic metabolic improvements (Sant’Anna et al., 2019; Thyfault et al., 2020; Warnberg et al., 2010). Hence, exercise may help shift from a disease-promoting microbial community to a health-promoting one, thus reducing the risk of periodontitis onset and progression.

Conclusions

Physical activity represents a major modifiable risk factor for periodontitis as well as other chronic non-communicable diseases, mainly through the mechanisms of modulation of systemic inflammation and shift in the oral microbiome composition. However, not all types of physical activity are the same. Indeed, while leisure-time physical activity exerts a protective effect, occupational physical activity was found to be a risk indicator for periodontitis

Article written by Dr. Crystal Marruganti, a periodontal specialist, clinical researcher and educator working at the intersection of periodontal science, oral-systemic health and advanced surgical care.

Disclaimer: Images and bold formatting included in this article were added by SUNSTAR for editorial purposes and do not reflect the views or involvement of the author. These elements may include illustrative or commercial content with which the author is not affiliated.

 

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