App-Guided Exercise Improves Periodontal Status in Periodontitis Treatment – A Pilot Randomized Clinical Trial

ABSTRACT

Objective:  To compare two protocols for adjunctive exercise prescription – before or after subgingival instrumentation (SI) – during periodontal therapy.

Material and Methods:  Twenty-four patients were randomly allocated into two groups and evaluated at 3-time points (T0 – Baseline, T1 – 45 days, T2 – 90 days). Group 1 (n=10) received SI at T0, re-evaluation and exercise at T1, and final re-evaluation at T2. Group 2 (n=14) started exercising at T0, received re-evaluation and SI at T1, and final re-evaluation at T2. Clinical parameters included probing depth (PD), clinical attachment loss (CAL), bleeding on probing (BoP), and plaque index. Crevicular fluid was analyzed by multiplex immunoassay. The exercise lasted 7 minutes and was performed 3 times/week using an app.

Results:  Twenty-four patients completed the study. All clinical parameters improved at T2. Group 2, but not Group 1, significantly improved BoP and CAL at T1. There was no significant interaction or intergroup differences for any clinical parameter. For initial PD≥4mm sites, both groups showed significant reductions in PD and CAL at both time points. Only IL-1β and IFN-γ were significantly reduced for both groups at T2.

Conclusion:  Both exercise/SI protocols improved periodontal parameters after 90 days.

Keywords:
Periodontal Diseases; Exercise; Periodontics

Introduction

Periodontitis is the second most prevalent oral disease in humans, affecting 50% of the world’s population [¹]. It is characterized by progressive destruction of the tooth-supporting apparatus and may lead to tooth loss if untreated [²]. Additionally, severe periodontitis is the sixth most common non-communicable disease (NCD) in humans [³]. As a significant public health problem [⁴,⁵], periodontitis shares common risk factors with other NCDs and may also negatively impact systemic health, being independently associated with cardiovascular diseases [⁶], diabetes [⁷], and adverse pregnancy outcomes [⁸]. Moreover, obesity, poor nutrition, tobacco smoking, and physical inactivity have been associated with an increase in periodontitis risk [⁹], although multidisciplinary treatment within primary health care is generally underperformed [¹⁰].

Physical exercise is a planned, structured, and repetitive activity to improve or maintain one or more components of physical fitness, performance, or health [¹¹,¹²]. When individuals transition from inactivity to an active lifestyle, the general effects of exercise are more significant. Physical inactivity has been associated with the development of 40 chronic diseases. Active individuals have lower mortality rates, cardiovascular disease, metabolic disease, depression, colon and breast cancer [¹³]. Moreover, physical exercise may protect against the development of diabetes mellitus, osteoporosis, arterial hypertension, obesity, anxiety, and stress [¹⁴], in addition to being associated with a lower systemic inflammatory profile [¹⁵].

Some observational studies have shown that exercise may be associated with a reduced prevalence of periodontitis [¹⁴,16,¹⁷]. Longitudinal interventional studies have demonstrated potentially beneficial effects of physical exercise on the periodontium [¹⁸,¹⁹]. In addition, a systematic review and meta-analysis revealed that the frequency of physical exercise – a routine of exercises between three and five times a week – was associated with a lower prevalence of periodontitis compared to inactive individuals [²⁰]. Two potential explanations for this association are 1) a reduced systemic inflammatory burden and 2) a positive patient attitude to behavior change in general [²⁰,²¹].

The modern world is characterized by an increasingly sedentary lifestyle, with limited access to exercise facilities [²¹,²²]. Circuit training has been proposed as a quick way of improving fitness levels since it can be undertaken anywhere and without specialist equipment [²³]. One regime for circuit interval training consists of performing as many repetitions as possible in 30 seconds, followed by a 10 to 15-second recovery [²⁴]. Such a training protocol has also been reported to maximize fitness outcomes with minimal investment [²³].

In the treatment of several chronic inflammatory diseases, such as diabetes, hypertension, and obesity, non-pharmacological self-care interventions for a healthier lifestyle, including physical exercise, need to be embraced [²⁵]. The current guideline for treating Stage I-III periodontitis states that ‘perhaps’ physical exercise should be prescribed during the initial phase of periodontal treatment [²⁶]. Therefore, this randomized pilot clinical trial aimed to compare two protocols for prescribing adjunctive physical exercise before or after subgingival instrumentation using a smartphone circuit training app to guide exercise training during non-surgical periodontal therapy.

Materials and Methods

Study Design and Ethical Clearance

This randomized parallel-arm pilot clinical trial was approved by the Institutional Ethics Committee (Opinion no. # 3.129.897) and registered at the Brazilian Registry of Clinical Trials (ReBEC #RBR-5jxh6c). It was performed according to the Declaration of Helsinki as revised in 2013 and reported according to CONSORT guidelines [²⁷].

Population and Eligibility Criteria

All participants were selected at the Dental Clinic of the Federal University of Paraná and provided informed consent to participate. Inclusion criteria were: 1) having at least 20 teeth, excluding third molars, with at least two non-adjacent teeth with interproximal sites showing probing depth (PD) ≥4mm, bleeding on probing (BoP) and clinical attachment loss (CAL); 2) 30-50 years old; 3) non-practitioners of exercise for at least one year; 4) no contraindication to exercise; 5) body mass index (BMI) ranging from 18.5 to 29.9 (kg/m²); and 6) having a smartphone. Exclusion criteria: 1) history of periodontal therapy within the previous 6 months; 2) smokers; 3) having a systemic NCD; 4) taking any medication that may influence the inflammatory, immunological, microbiological, and clinical condition of the periodontium.

Clinical Examination

All patients underwent complete periodontal examination at each time point using the same-batch standardized manual probes (CPUNC 15, Hu-Friedy, Chicago, IL, USA). Two previously trained and calibrated researchers (GG and PR, Kappa ± 1mm>0.9) performed a full mouth clinical examination by assessing O’Leary’s plaque index (PI) at four sites per tooth and PD, BoP, and CAL at six sites per tooth. All patients received oral hygiene instruction (OHI). Repeated clinical examinations occurred after 45 days (T1) and 90 days (T2) by the same baseline examiners, blinded to treatment allocation.

Experimental Design and Treatment Protocol

Following the initial clinical examination at T0, participants were randomly assigned into two groups - using computer-generated random numbers – and followed for 3 months. Group 1 (G1) received, at baseline (T0): subgingival instrumentation (SI); at T1: periodontal re-evaluation, repeated SI, and started exercising; and at T2: final periodontal re-evaluation. Group 2 (G2), at T0: started exercising; at T1: received periodontal reevaluation and SI; and at T2: received final periodontal re-evaluation. The allocation sequence was generated and implemented by a researcher who was not the examiner (RF, HV, NG, MB, or HT).

Subgingival Instrumentation (SI)

SI was performed quadrant-wise using hand curettes under local anesthesia (Mepivacaine 2% with 1:100,000 epinephrine) within one week. At the first round of SI (T0 for G1 and T1 for G2), all PD>3mm sites were instrumented. Repeated SI was restricted to sites with no closed pockets (defined as PD≥4mm and no BoP if PD = 4 mm) [²⁶].

Exercise Training Protocol

Patients were asked to complete a seven-minute circuit training workout using only bodyweight resistance 3 times/week [²³]. A free smartphone application (Seven, 2018, Perigee AB, Malmö, Sweden) guided the volunteers through the exercises. The exercise circuit included two sequential rounds of pushups, abdominal crunches, squats, planks, high knees, lunges, and side planks. Exercises were performed for 30 seconds, followed by a 10-second rest [²⁸]. All participants received a video tutorial to ensure proper performance, and compliance was assessed through weekly screenshots of the app’s calendar interface that records each training session.

Inflammatory Profile Analysis

Gingival crevicular fluid samples were collected from the initially deepest PD site showing attachment loss in each individual at all time points, as previously described [²⁹,³⁰]. One paper point was inserted in each collection site for 10 seconds, then removed and stored in 200mL phosphate-buffered saline (PBS) supplemented with protease inhibitors. Blood-contaminated samples were discarded. After three minutes, the procedure was repeated until four paper points were collected from the same site, representing 40s of exposition, as previously reported [²⁹,³⁰]. Samples were stored at -80°C until analysis using a multiplex immunoassay (HCYTOMAG-60K, Merck KGaA, Darmstadt, Germany), to determine the concentration of Interferon (IFN)-γ, Interleukin (IL)-1 receptor antagonist (IL-1ra), IL-1β, IL-4, IL-6, IL-10, Tumor Necrosis Factor (TNF) and Vascular Endothelial Growth Factor (VEGF). All procedures were conducted according to the manufacturer’s instructions.

Sample Size and Statistical Analysis

The primary outcome was the mean PD reduction in sites with PD≥4mm. Since this pilot trial was intended to validate an innovative proposed exercise training protocol, we anticipated a minimum final sample size of 10 individuals per group. This sample size allowed 60% power for detecting a mean intergroup difference of 1 mm, considering a standard deviation of 1 and an alpha of 5%. Statistical analysis was performed using JAMOVI (https://jamovi.org). For baseline intergroup comparisons of continuous variables, an unpaired t-test was used after confirming normal distribution and homogeneity of variances, and frequency distribution was assessed using Fisher’s exact test. Mixed analysis of variance (mixed ANOVA) was used for all numerical clinical and immunological parameters. The chi-square test was used to test the frequency distribution of closed pockets at T1 and T2. To rule out the possibility of local behavior modification (resulting in lower plaque levels) influencing the results in G2, we tested the association between PI and BoP / PI and PD using linear regression. For all analyses, statistical significance was set at p<0.05.

Results

A total of 157 individuals were screened from 2019 to 2023. After the invitation to participate and applying inclusion and exclusion criteria, 33 patients were enrolled in the study and randomized to one of the two groups. Eight participants (five from G1 and three from G2) dropped out of the study during follow-up, and 1 (G1) was excluded due to an allergic reaction to local anesthesia. Twenty-four individuals were included in the final analysis (G1: n=10; G2: n=14) (Figure 1). None of the participants reported any side effects related to physical exercise.

Figure 1
The study flowchart.

The mean age of the participants was 40.6 ± 7 years in G1 and 41.9 ± 7 years in G2, with most white female participants in both groups. The groups had no significant differences in baseline characteristics or clinical parameters (Table 1).

Table 1
The baseline sociodemographic and periodontal characteristics of participants.

Variables	G1	G2	p-value*
Sex (Male, %)	40%	35.7%	1.00
Skin color (White, %)	80%	91%	0.59
Age (Years)	40.6 ± 6.62	41.9 ± 6.67	0.63
Height (m)	1.65 ± 0.10	1.65 ± 0.08	0.96
Weight (kg)	68.5 ± 12.10	62.6 ± 10.26	0.24
Probing depth (mm)	2.36 ± 0.31	2.27 ± 0.28	0.48
Clinical Attachment Loss (mm)	2.35 ± 0.56	2.60 ± 0.68	0.34
Bleeding on Probing (Yes, %)	17.3 ± 5.93	19.2 ± 9.01	0.56
Plaque (Yes, %)	57.4 ± 16.6	47.0 ± 15.7	0.13

• *t-test, except for sex and skin color (Fisher’s exact test).

Overall, subgingival instrumentation at T0 (G1) improved all clinical parameters, with a statistically significant reduction in mean PD and plaque at T1; and showed a further statistically substantial reduction at T2, after physical exercise was added (p<0.001). In G2, physical exercise without SI significantly reduced all clinical parameters at T1, and that reduction was even greater in T2 after SI was delivered (except for mean CAL). There was no statistically significant interaction between time and grouping or differences between G1 and G2 for any full-mouth clinical parameter (Table 2).

Table 2
Periodontal clinical parameters of Group 1 and Group 2 patients at different time points (T0, T1, and T2).

Variables	Group	Baseline (T0)	45 Days (T1)	90 Days (T2)	p-value*
					Time	Group	Int.
PD (mm)	1	2.36 ± 0.31A	2.17 ± 0.26B	1.93 ± 0.20C	<0.001	0.62	0.66
	2	2.27 ± 0.28A	2.11 ± 0.34B	1.91 ± 0.30C
CAL (mm)	1	2.35 ± 0.56A	2.19 ± 0.38A,B	2.05 ± 0.34B	<0.001	0.48	0.38
	2	2.60 ± 0.68A	2.34 ± 0.73B	2.17 ± 0.65B
BoP (%)	1	17.26 ± 5.93A	10.14 ± 4.30A	3.27 ± 2.25B	<0.001	0.59	0.87
	2	19.20 ± 9.01A	10.49 ± 7.83B	4.11 ± 4.38C
Plaque (%)	1	57.37 ± 16.65A	35.91 ± 13.85B	22.57 ± 8.04C	<0.001	0.07	0.63
	2	47.00 ± 15.70A	30.47 ± 12.36B	18.64 ± 8.47C

• PD: Probing Depth; CAL: Clinical Attachment Loss; BoP: Bleeding on Probing; Int: Interaction; Different capital letters in each row indicate statistically significant differences in time points; *Mixed ANOVA; There was no statistically significant interaction or intergroup difference for any parameter.

The associations between PI and PD or BoP improvement (T0-T1) in group 2 were not statistically significant (r²= 0.08, p=0.33 and r²= 0.14, p=0.19, respectively) (Figure 2).

Figure 2
Associations between A) Bleeding on probing (BoP, %) and B) Probing Depth (PD, mm) improvement and plaque reduction (%) in T1 compared to T0 in Group 2.

A statistically significant reduction in mean PD and CAL of initially moderate to deep pockets through different time points was observed in both groups (p<0.05), except for mean CAL between T1 and T2 in group 1. Although CAL reduction was statistically significant with exercise (G2; p<0.001), an inter-group statistically significant difference for mean CAL at T1 could still be observed (p<0.05; Figure 3).

Figure 3
Mean probing depth (PD, mm) and clinical attachment loss (CAL, mm) in initially moderate to deep sites (PD>3mm) at the patient level for group 1 (G1) and group 2 (G2).

The percentage of closed pockets was approximately 60% at T1 and 80% at T2, with no statistically significant difference between groups at either time point (0.71 and 0.25, respectively) (Table 3).

Table 3
Frequency of closed pockets.

Group (Non-Closed Pockets)	45 Days (T1)	90 Days (T2)
	N (%)	N (%)
G1 (n=144)	87 (60.4)	121 (84.0)
G2 (n=151)	88 (58.3)	119 (78.8)
P-value (χ2)	0.71	0.25

All inflammatory markers analyzed showed significant intra-group variability. When the impact of either SI (G1) or exercise (G2) alone was considered, considering from T0 to T1, divergent trends were observed for IL-4 (decreased by exercise and increased after SI) and VEGF (increased by exercise and decreased by SI). However, those differences were not statistically significant. At T2, only IL-1ß and IFN-γ were significantly reduced (p<0.05) (Figure 4). IL-6 levels were below the detection limits of the assay.

Figure 4
Mean (SD) concentration of inflammation-related markers in gingival crevicular fluid according to time point (T0, T1, or T2) and group (1 and 2).

Discussion

Physical exercise has been recommended as an intervention in managing several inflammatory diseases, and emerging data suggest that it could also be the case for periodontitis [¹⁸,¹⁹]. This randomized clinical trial evaluated the optimal timing for prescribing physical exercise as an adjunct to non-surgical periodontal therapy. Overall, our results demonstrated a beneficial impact of physical exercise on all periodontal clinical parameters, as well as a significant reduction in mean PD of initially moderate to deep pockets (>3mm), and no difference between the timing of exercise prescription on periodontal clinical parameters after 3 months.

Physical exercise (G2) significantly reduced mean PD, BoP, and plaque percentage after 45 days (T1). As there was no significant association between PD and BoP improvement, or between PD and PI reduction (although PI reduction was observed in both groups), we suggest these observations signify biological mechanisms independent of the reduction in plaque levels, and that physical exercise may play an essential role in reduced inflammation, as previously described [¹⁵,²⁰]. Previous studies have demonstrated that physical exercise is potentially protective against gingival bleeding [¹⁵,¹⁸]. Furthermore, starting a physical exercise routine produced results similar to periodontal parameters to SI after 45 days. This follows Omori et al. [¹⁸], who presumed that a routine of appropriate exercises had a similar effect to non-surgical periodontal treatment in people with obesity.

When SI was associated with a physical exercise routine (G1, at T2), PD reduction in moderate to deep sites was higher than in SI alone (G1, at T1). These findings are consistent with those of Sudhanshu et al. [¹⁹], who showed that a routine of yoga exercises adjunctive to periodontal treatment yielded better results for PI, PD reduction, and CAL gain compared to periodontal treatment alone [¹⁹].

A training protocol that includes exercising thrice a week is under previously reported methods for specific health benefits [²¹]. Moreover, it has been shown that two consecutive days of extreme conditioning program training led to a significant decrease in anti-inflammatory cytokines and could suppress the immune system [³¹]. Our physical exercise model was based on circuit training using only bodyweight, a recognized alternative for maintaining physical fitness [²²], and has become popular due to its time-effectiveness. Additionally, this approach combines aerobic and resistance training into a single exercise bout lasting 7 minutes [²³]. Previous studies have shown that aerobic and resistance exercises could modulate systemic inflammation, but aerobic exercise is more effective in modulating inflammatory markers, such as IL-2, IL-4, IL-6, and TNF, than resistance training [³²,³³]. In our study, the significant intra-group variability precluded definite conclusions on regulating inflammatory markers, but only IL-1ß and IFN-γ were significantly reduced at the end of the experiment (p<0.05). Additionally, total crevicular fluid volume was not used to normalize the results due to structural limitations in our laboratory, but the method was standardized as in previous studies [²⁹,³⁰].

Using a cost-free smartphone application to assist in the practice of a physical exercise routine seems simple and widely applicable. Such technologies represent promising tools for motivation and improvement in patients' knowledge and compliance [³⁴,³⁵]. In addition, a systematic review with meta-analysis showed that smartphone applications effectively increase physical exercise in short periods (up to 3 months) [³⁶], per our study design.

The World Health Organization recommends 150 minutes of moderate-intensity physical activity weekly for health benefits [¹³]. Another study showed that 90 minutes a week of moderate-intensity exercise might have health benefits compared to inactive people [³⁷]. However, a previous study from our group showed that even 1 to 75 min/per week of leisure exercise may improve the odds of better self-perception of oral health by 20% [³⁸]. In this pilot study, we prescribed a routine of 21 min/week exercise and demonstrated positive results on periodontal treatment. These findings suggest that increased physical exercise may benefit individuals, and oral health professionals should encourage their patients to improve their time with physical activities [¹⁴,²⁶]. It remains debatable, however, if our findings are solely related to physical exercise or are influenced by confounders, such as stress management and control, or improved self-care (especially oral health care following OHI, which was performed due to ethical issues) due to enrollment in research (Hawthorne effect) [³⁹].

Our study was designed to address two central questions: 1) What is the optimal timing for exercise prescription during the active phase of periodontal treatment? and 2) What is the impact of exercise alone compared to a positive control (SI) on clinical periodontal parameters? A negative control was not included for ethical reasons. Despite having positive effects, exercising alone is not intended to replace periodontal treatment but rather to help improve periodontal parameters in the short and long term. One possible advantage of starting an exercise routine earlier in periodontal treatment (Step 1) could be the reduced need for subgingival instrumentation or even periodontal surgery. In our study, G1 received two possible subgingival interventions (if the endpoints of periodontal therapy were not achieved at the site level) during the 90 days, while G2 received only one.

Although consistent evidence from other studies supports the benefits of physical exercise interventions in periodontal treatment [¹⁸,¹⁹,⁴⁰], this is one of the few longitudinal studies that confirm these findings. There are limitations to this pilot trial: in a definitive study the aim would be to achieve 80% power; for ethical reasons, both groups received baseline OHI, and this is a confounding factor for the improvements seen for G2 in PD and CAL at T1 – there would be merit in a definitive study following G1 and G2 having OHI at T0, but G2 only undertaking the exercise for 3-months; recruiting participants who were willing to start an exercise routine was challenging; control of other cofounders was limited, since individuals who start training may also improve self-care through diet and oral hygiene, for example. However, this study suggests a beneficial impact of a circuit training protocol on periodontal parameters as part of steps one and two of periodontal care. Moreover, not allowing behavior modification would also limit the extrapolation of these findings to real patients in daily clinical practice. In vivo studies in pre-clinical models could assist in ruling out biases related to behavioral modification in human clinical trials.

Conclusion

Both exercise prescription protocols, either before or after subgingival instrumentation, significantly improved periodontal parameters after 90 days. Additionally, physical exercise alongside oral hygiene instruction significantly reduced probing depth in initially moderate to deep pockets, suggesting that early prescription could facilitate periodontal treatment.

Acknowledgments

We want to thank Prof. Dr. Tácito Pessoa de Souza Júnior, the Department of Physical Education staff, and the Department of Stomatology of the Federal University of Paraná for their support.

• Financial Support
  The authors would like to thank the Paraná State Research Foundation (Fundação Araucária, Curitiba, PR, Brazil) and the National Council for Research and Technological Development (CNPq, Brasília, DF, Brazil) for partially funding this study (#70/2021). One of the researchers (GG) was awarded a scholarship from the Coordination for the Improvement of Higher Education Personnel (CAPES, Brasília, DF, Brazil).

Data Availability

The data used to support the findings of this study can be made available upon request to the corresponding author.

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Edited by

• Academic Editor:
  Alessandro Leite Cavalcanti

Publication Dates

• Publication in this collection
  28 Nov 2025
• Date of issue
  2026

History

• Received
  22 July 2024
• Accepted
  21 Feb 2025