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BACKGROUND This study assesses the association between periodontal pathogen colonization and the potential risk of developing precancerous lesions of gastric cancer (PLGC) in a clinical setting. METHODS Included were 35 newly diagnosed patients with PLGC and 70 age-matched individuals without PLGC. A full-mouth intraoral examination was performed to assess periodontal conditions. Stimulated whole saliva and pooled plaque samples were collected to evaluate colonization by Porphyromonas gingivalis, Treponema denticola, Tannerella forsythia, and Aggregatibacter actinomycetemcomitans and to characterize oral microbial diversity in saliva and dental plaque. RESULTS Compared with the control group, patients with PLGC experienced higher prevalence of bleeding on probing (31.5% versus 22.4%; P <0.05), higher levels of T. denticola (P <0.01) and A. actinomycetemcomitans (P <0.01), and less bacterial diversity in their saliva (P <0.01). The final multivariate logistic regression model consisting of all key sociodemographic characteristics, oral health behavioral factors, and periodontal assessments revealed that elevated colonization with periodontal pathogens, specifically T. forsythia, T. denticola, and A. actinomycetemcomitans, decreased bacterial diversity in dental plaque, and not flossing teeth regularly was a significant predictor of increased risk of PLGC (P = 0.022). CONCLUSION Findings of the present study provide new evidence suggesting that periodontal pathogen burdens and bacterial diversity in the oral cavity are important factors contributing to a potentially increased risk of developing precancerous gastric lesions.