To evaluate the longitudinal association of combined healthy lifestyle factors with incidence or progression of periodontitis and tooth loss in older adults. This 6-year study included 374 Japanese 70-year olds with 7,157 teeth, from a source eligible baseline population of 554 individuals. Four lifestyle factors-cigarette smoking, physical activity, relative weight, and dietary quality-were scored as healthy (1 point) or unhealthy (0 point). Adding the individual scores generated the "healthy lifestyle score" (0-4 points). Multilevel mixed-effects logistic regression models were applied to evaluate tooth-specific associations between the baseline healthy lifestyle score and the incidence or progression of periodontitis (increase in clinical attachment loss ≥3mm) and tooth loss. After 6years, 19.0% of the teeth exhibited periodontitis incidence or progression and 8.2% were lost. Compared with a healthy lifestyle score of 0-1 (least healthy), the highest score (4 points) was associated with a significantly lower tooth-specific risk of periodontitis (adjusted odds ratio=0.32; 95% confidence interval: 0.16-0.62) and tooth loss (adjusted odds ratio=0.42; 95% confidence interval: 0.23-0.77). Simultaneous adherence to multiple healthy lifestyle factors significantly lowers the risk of incidence or progression of periodontitis and tooth loss in older adults.