The ESP Coordinating Center (ESP CC) is responding to a request from the Partnered Evidence-Based Policy Resource Center (PEPReC) for an evidence brief on the relation between receipt of preventive dental care and chronic disease-related benefits, harms, and costs. Findings from this evidence brief will be used to inform implementation and evaluation of the Veterans Innovation Center (VIC) Care Coordination for Dental Benefits demonstration program.

PREFACE

The VA Evidence Synthesis Program (ESP) was established in 2007 to provide timely and accurate syntheses of targeted healthcare topics of importance to clinicians, managers, and policymakers as they work to improve the health and healthcare of Veterans. These reports help:

• Develop clinical policies informed by evidence;
• Implement effective services to improve patient outcomes and to support VA clinical practice guidelines and performance measures; and
• Set the direction for future research to address gaps in clinical knowledge.

The program comprises three ESP Centers across the US and a Coordinating Center located in Portland, Oregon. Center Directors are VA clinicians and recognized leaders in the field of evidence synthesis with close ties to the AHRQ Evidence-based Practice Center Program and Cochrane. The Coordinating Center was created to manage program operations, ensure methodological consistency and quality of products, and interface with stakeholders. To ensure responsiveness to the needs of decision-makers, the program is governed by a Steering Committee composed of health system leadership and researchers. The program solicits nominations for review topics several times a year via the program website.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, Deputy Director, ESP Coordinating Center at vog.av@dyolF.elociN.

Executive Summary

Poor dental health in the form of periodontal disease (a gum infection typically caused by poor oral hygiene) is a widespread issue in the United States. Nearly half of US adults aged 30 and older have periodontal disease, and prevalence is highest among older adults (70% of those 65 or older), men (56%), smokers (64%), and those below the federal poverty level (65%). In the last 2 decades, growing evidence has suggested periodontal disease is associated with chronic diseases such as heart disease, lung disease, stroke, and type 2 diabetes. The pathway between periodontal disease and chronic diseases is not well understood, but periodontal disease may trigger an inflammatory response in the body that leads to high blood pressure, vascular inflammation, and/or atherosclerosis; these processes then contribute to the etiology and severity of certain chronic diseases. Bacteria in the oral cavity may also be inhaled into the lower respiratory tract, leading to exacerbations of chronic obstructive pulmonary disease (COPD).

Detection and initial treatment of dental problems, including periodontal disease, is commonly implemented through the provision of preventive dental services such as routine exams, cleanings, and education on oral hygiene. Treatment of more advanced forms of periodontal disease typically consists of scaling and root planing, with or without the use of antibiotics. Currently, few Veterans receive these services: only 8% of Veterans have a dental issue that is service-connected, or meet other criteria required to receive dental care through the Department of Veterans Affairs (VA). In 2019, the VA initiated the Veterans Innovation Center (VIC) Care Coordination for Dental Benefits program to increase Veterans’ access to community-based, pro bono or discounted dental service providers. Although the intended purpose of the program is to reduce the use of VA emergency care for dental conditions by providing Veterans with access to routine dental care, the program may also improve Veterans’ chronic disease outcomes, given the link between periodontal disease treatment and chronic disease outcomes. The purpose of the current ESP review is to synthesize evidence on benefits and harms of detection and treatment of dental problems (specifically, periodontal disease) among those with type 2 diabetes, cardiovascular disease, cerebrovascular disease, or COPD. Evidence on chronic disease outcomes, health care utilization, and costs associated with periodontal treatment will be used to inform the implementation and evaluation of the VA Care Coordination for Dental Benefits program.

Using rapid review methods, we prioritized evidence from the most recent and relevant systematic reviews (SRs) and only included primary studies when they addressed gaps in higher-level evidence and when they were published after the search dates of prioritized SRs. From 1,768 possible citations, we included 46 studies; from these, we prioritized 8 SRs and included 21 primary studies that addressed gaps or updated evidence from SRs. Highlighted findings from these 29 studies appears in Table 1.

For those with COPD, evidence from 3 controlled trials suggests that periodontal treatment improves certain chronic disease outcomes. One fair-quality RCT and 1 fair-quality non-randomized, controlled trial indicate periodontal treatment may improve lung function and reduce the frequency of exacerbations at 1 and 2 years compared to no treatment. Another fair-quality RCT found no adverse events within a month of periodontal treatment. However, in this short study, periodontal treatment did not reduce the number of doctor’s visits after treatment, nor did it improve quality of life, self-assessment of health, or illness severity. An additional poor-quality retrospective cohort study indicated those with COPD who receive periodontal treatment have lower annual medical costs than those who do not receive treatment.

Results from moderate- and high-quality SRs suggest periodontal treatment improves some chronic disease and inflammatory indicators in the short term for people with type 2 diabetes (eg, HbA1c, fasting blood glucose, total cholesterol, CRP) or cardiovascular disease (eg, TNF-α, IL-6, CRP, LDL cholesterol) with only minor adverse events. However, improvements do not seem to last beyond 6 months. The impact of periodontal treatment on chronic disease indicators for those with cerebrovascular disease is unclear.

Table 1

Highlighted Review Findings.

Evidence is also unclear on whether periodontal treatment reduces the risk of diabetes and cardiovascular disease-related complications. For those with type 2 diabetes, evidence from a single fair-quality retrospective cohort study indicates periodontal treatment may reduce the risk of heart failure compared to no treatment. Findings on stroke and myocardial infarction are unclear, with some studies finding lower risk among people with type 2 diabetes who receive periodontal treatment compared to no treatment and others finding no difference in risk between groups. For those with hypertension or atherosclerosis, evidence from a single, poor-quality retrospective cohort study indicates periodontal treatment is associated with a reduced risk of stroke. However, a self-controlled case series indicates that individuals’ risk for stroke and myocardial infarction actually increased after periodontal treatment when compared to baseline. It is possible the results of this study were influenced by patients discontinuing NSAIDS, blood thinners, or antiplatelet medications due to periodontal treatment, which could have caused an increase in cardiovascular risk. In this study, the risk of MI decreased over time, while for stroke, the pattern of resolution was unclear.

Findings on costs of periodontal treatment versus no treatment for people with type 2 diabetes, coronary artery disease (CAD), or cerebrovascular disease are similarly unclear, with some studies indicating periodontal treatment contributes to lower medical costs and other studies indicating periodontal treatment has no effect or contributes to higher health care costs. One poor-quality retrospective cohort study found those with congestive heart failure who undergo periodontal treatment have lower medical costs than those who do not receive treatment. In terms of health care utilization, 1 poor-quality retrospective cohort study reported periodontal treatment was associated with lower inpatient admissions for those with type 2 diabetes, CAD, or cerebrovascular disease, while another found no significant difference in health care utilization in those with type 2 diabetes who do and do not receive periodontal treatment.

There is some evidence that the balance of benefits and costs of periodontal treatment may differ by individual patient characteristics. For example, in 1 study that reported periodontal treatment was associated with higher medical costs compared to no treatment, authors noted that periodontal treatment was most cost-effective among those with higher HbA1c (who may have more to gain from periodontal treatment-associated improvements in HbA1c) and those who are older (who may have lower lifetime costs of periodontal treatment). Another found savings due to periodontal treatment were limited to those who did not initiate diabetes-related medications after diagnosis.

There are limitations to our rapid review methodology and of our included studies. We used rapid review methods to prioritize synthesis of the best available evidence, rather than all available evidence. These methods included: 1) synthesizing the most recent and relevant SRs, 2) conducting primary study searches to address gaps in the systematic review literature and to identify evidence published after SRs, and 3) having a single reviewer assess study eligibility, study quality, and strength of evidence with second reviewer checking. Common limitations of prioritized SRs included not searching for grey literature, having no publicly available protocol, and lacking discussion of individual studies’ risk of bias. Common limitations of included primary studies were lack of patient and provider blinding in RCTs, and, in controlled observational studies, poorly defined treatment and control groups and the presence of important differences between groups at baseline.

As we primarily found unclear results from studies with methodological limitations, there is a need for better-conducted studies on this topic. Future research should evaluate the effect of periodontal treatment on a broad range of clinically relevant outcomes (including quality of life, diabetes and cardiovascular disease-related complications, and potential harms) measured at shorter (3-6 months) and longer-term (1+ years) time points. VA researchers may additionally wish to use a hybrid effectiveness-implementation study design to evaluate clinically relevant questions around whether referral to dental care improves outcomes.

In conclusion, among people with COPD, periodontal treatment may improve lung function and reduce exacerbations at 1-2 years and reduce annual medical costs. Among people with diabetes or cardiovascular disease, periodontal treatment likely improves some measures of chronic disease severity and inflammation at 3-4 months, but benefits do not appear to persist beyond 6 months. Results are unclear on the relation between periodontal treatment and chronic disease outcomes for those with cerebrovascular disease. Results are also unclear on the relation between periodontal treatment, medical costs, and risk of chronic disease complications among those with diabetes, cardiovascular disease, or cerebrovascular disease.

INTRODUCTION

BACKGROUND

Poor dental health in the form of periodontal disease is a widespread issue in the United States. Nearly half of US adults aged 30 and older have periodontal disease, and prevalence is highest among older adults (70% of those 65 or older), men (56%), smokers (64%), and those below the federal poverty level (65%).¹ While periodontitis and related conditions such as tooth decay compromise oral health and oral quality of life, there is increasing evidence that oral health impacts non-oral chronic diseases such as heart disease, lung disease, stroke, and diabetes. Early evidence of this association was summarized in a 2000 report from United States Surgeon General,² and in the decades since that report, research on the topic has accelerated.

Most research to date has examined the relation of periodontal disease with cardiovascular disease (CVD) and type 2 diabetes (T2D) outcomes. A 2012 systematic review (SR) by the American Heart Association concluded there is an association between periodontal disease and atherosclerotic vascular disease (ASVD) that is independent of known risk factors.³ In this SR, 18 out of 26 relevant studies reported poor periodontal status was associated with increased risk of ASVD-related outcomes (such as coronary heart disease [CHD], coronary artery disease [CAD], and mortality from ASVD and CHD causes). Eleven out of 14 relevant studies found poor periodontal status was linked with increased risk of stroke. Along the same lines, a 2013 SR by the European Federation of Periodontology and the American Academy of Periodontology found a “small body of evidence [that] supports significant, adverse effects of periodontal disease on glycaemic control, diabetes complications, and development of type 2 (and possibly gestational) diabetes.”⁴ Additionally, a 2006 SR⁵ and several subsequent observational studies^6,7 have suggested there may be a relation between periodontal disease and respiratory diseases such as chronic obstructive pulmonary disease (COPD).

Periodontal disease (which includes gingivitis and periodontitis) is a gum infection that typically results from poor oral hygiene. Symptoms include bleeding or receding gums in mild cases and painful abscesses and loss of teeth in severe cases.⁸ Because periodontal disease triggers an inflammatory response in the body, it may contribute to worsening of diseases whose etiology or severity are in part driven by chronic inflammation.^4,9 Importantly, however, this pathway is not fully understood and may differ by chronic disease. For instance, it is possible that periodontal disease may cause or worsen some chronic diseases, but it may also be the case that the conditions have 1 or more shared causes, such as smoking, alcohol misuse, overweight/obesity, or socioeconomic factors. For T2D in particular, there is considerable evidence that while periodontal disease may impact glycemic control, T2D itself likely worsens oral health (periodontal disease has been recently described as the “sixth complication of diabetes”).^3,10,11

There are several plausible biological mechanisms that may explain the link between periodontal disease and chronic disease outcomes. One possibility is that periodontal disease-related inflammation causes the destruction of endothelial cells that line the walls of blood vessels and maintain normal blood pressure.⁹ High blood pressure is a risk factor for development of CVD and cerebrovascular diseases as well as adverse events such as myocardial infarction and stroke.¹² A second potential pathway is that oral bacteria such as porphyromonas gingivalis directly invade arterial walls through the breakdown of gum tissue, causing vascular inflammation and atherosclerosis.⁹ For those with COPD, oral bacteria can be inhaled into the lower respiratory tract, which can eventually trigger COPD-related exacerbations.⁷ Finally, periodontal disease may trigger production of highly reactive chemical molecules that cause oxidative stress throughout the body.⁹ For people with T2D, oxidative stress may contribute to vascular complications such as retinopathy, nephropathy, and cardiomyopathy.¹³

Despite growing evidence linking periodontal disease to chronic disease outcomes, it is unclear whether interventions that have been shown to successfully treat periodontal disease can also lead to clinically meaningful improvement in CVD, T2D, or other chronic disease outcomes. There is a pressing need to address this question given the high comorbidity of chronic diseases among those with, or at risk for, periodontal disease. For example, in a recent case-control study of 1,199 people with periodontal disease, 19% had comorbid hypertension, 9.7% had comorbid endocrine disorders, and 8.5% had comorbid pulmonary disorders.¹⁴ Chronic conditions are especially prevalent among Veterans: it has been estimated that 43% of Veterans have hypertension, 25% have T2D,^15,16 10% have coronary heart disease,¹⁶ 5% have experienced stroke,¹⁶ and 8% have experienced myocardial infarction.¹⁶ Although the prevalence of COPD among Veterans is unknown, it is thought to be increasing, particularly among Operation Enduring Freedom/Operation Iraqi Freedom Veterans.¹⁷

Currently, only 8% of Veterans have a dental issue that is service-connected, or meet other criteria required to receive dental care through the Department of Veterans Affairs (VA).¹⁸ To help address this issue, the VA initiated the Veterans Innovation Center (VIC) Care Coordination for Dental Benefits program. This demonstration program is designed to increase Veteran access to dental health care by connecting them with community-based, pro bono, or discounted dental service providers.¹⁸ The goal of the program is to improve Veterans’ health while also decreasing health care-related costs from emergency dental-related care by enabling VA administrative staff to coordinate community-based care for Veterans that are otherwise ineligible to receive dental care at the VA. In 2020, the VA Partnered Evidence-Based Policy Resource Center (PEPReC) was tasked with evaluating the impact of the program on Veterans’ health and health care utilization, and requested a rapid review of the impact of detection and treatment of dental problems on chronic disease outcomes to help inform this evaluation.

Detection and early treatment of dental problems, including periodontal disease, is commonly carried out through the provision of preventive dental services such as routine exams, cleanings, and education on oral hygiene. Regular access to these services may reduce painful and costly dental complications, and conceivably routine dental care and detection of dental problems may positively impact chronic disease outcomes (Figure 1). Consequently, the VA’s demonstration program could impact Veterans’ health beyond reducing dental-related emergency care if it leads to improved oral health and successful treatment of periodontal disease, and if that treatment results in improvement in chronic disease outcomes. The purpose of the current ESP review is to evaluate whether detection and treatment of dental problems has an impact on chronic disease-related outcomes for those with CVD, cerebrovascular disease, T2D, or COPD. Specifically, we focused on the detection and treatment of periodontal disease, as the link between periodontal disease and chronic disease is well evidenced and represents the area where the VA pilot program could have meaningful clinical impact.

Figure 1

Conceptual Pathway between Receipt of Preventive Dental Services and Improvement in Chronic Disease Outcomes.

ELIGIBILITY CRITERIA

The ESP included studies that met the following criteria:

• Population: Adults (excluding pregnant women) with CVD, cerebrovascular disease, T2D, and/or COPD
• Intervention: Detection and treatment of dental problems (ie, use of preventive dental services such as regular oral exams, detection of dental problems, and treatment of dental problems detected during exams)
• Comparator: No detection or treatment of dental problems
• Outcomes:

  • Clinical outcomes (eg, patient-reported symptoms, complications of chronic diseases)
  • Chronic disease indicators (eg, HbA1c, blood pressure, cholesterol)
  • Quality of life (eg, oral health-related quality of life, overall quality of life)
  • Healthcare utilization (eg, emergency department visits for non-traumatic dental conditions or non-dental conditions, health care visits associated with chronic disease management, direct costs)
  • Harms (Any)
• Timing: Any
• Setting: Any
• Study design: Using a best-evidence approach, we prioritized evidence from systematic reviews (SRs) and multisite comparative studies that adequately controlled for potential patient-, provider-, and system-level confounding factors. Inferior study designs (eg, single-site, inadequate control for confounding, noncomparative) were only included when they filled gaps in higher-level evidence

Figure 2

Analytic Framework of Key Questions and PICOs.

METHODS

RESULTS

The literature flow diagram (Figure 3) summarizes the results of the search and study selection processes. Among 520 potentially relevant SR citations and 1,248 potentially relevant primary study citations, we included 46 studies (25 SRs^24–48 and 21 primary studies^49–69). Of the 25 included SRs, we prioritized 8 that were the most recent and relevant: 2 review of reviews^25,30 (1 with meta-analysis), 2 Cochrane SRs^38,43 (1 with meta-analysis), and 4 other SRs^26,32,37,48 (2 with meta-analysis). The remaining 17 SRs were not prioritized because they were already included in a prioritized review of reviews, their PICOs of interest were otherwise covered by more recent or relevant reviews, or they did not report data on clinically relevant outcomes (see Supplementary Materials for a list of these 17 SRs and specific reasons why each was not prioritized). The 21 primary studies included from our gap search and update search consisted of 8 RCTs,^{49,50,60,65–69} 1 non-randomized controlled trial,⁵⁶ 8 retrospective cohort studies,^{52,53,55,57,59,61,62,64} 1 case-control study,⁵⁸ 2 modeling studies,^51,63 and 1 self-controlled case-series.⁵⁴

We found the largest volume of evidence for people with T2D (6 reviews plus 17 primary studies), followed by CVD (2 reviews plus 5 primary studies), cerebrovascular disease (3 primary studies), and COPD (4 primary studies). Most SRs and primary studies examined non-surgical periodontal treatment (eg, scaling and root planing with or without adjunctive treatments such as antibiotics or oral hygiene instructions) although a few SRs included studies that looked at surgical treatment. Comparators generally consisted of no periodontal treatment, delayed treatment, or less-intensive forms of care (eg, oral health instructions only or community care). Across studies, outcomes relevant to all 4 of our key questions were assessed, including 1) patient-reported symptoms and complications of chronic disease (eg, oral health-related quality of life [OHRQoL], frequency of COPD exacerbations, risk of stroke or myocardial infarction); 2) markers of inflammation and chronic disease severity (eg, HbA1c, fasting blood glucose, cholesterol, triglycerides, IL-6, and CRP); 3) health care utilization and costs (eg, inpatient admissions, medical costs); and 4) harms of periodontal treatment.

In terms of quality assessment, 2 SRs (both Cochrane reviews) were high quality, 4 were moderate quality, 1 was low quality, and 1 was critically low quality. Among moderate-quality reviews, common methodological limitations included lack of grey literature searches, absence of a publicly available review protocol, and failure to discuss individual studies’ risks of bias when interpreting results. Low- and critically low-quality reviews also provided insufficient information on data extraction or quality assessment processes. The quality of primary studies ranged from fair to low-quality. Among RCTs, patients and providers were commonly aware of group assignment (ie, unblinded), half of RCTs did not have a publicly available protocol, and there was a lack of information on cointerventions that may have affected results (ie, tooth brushing). Among cohort studies and other types of controlled, observational studies, limitations included poorly defined treatment or control groups (ie, it was often unclear if people who did not receive periodontal treatment had periodontal disease or were periodontally healthy), inadequate adjustment for differences between treatment and control groups at baseline, and a high likelihood that measured or unmeasured confounders could have influenced results.

A list of excluded studies and study-level data abstraction and quality assessment for included studies appear in the Supplementary Materials.

LITERATURE FLOW

Figure 3

Literature Flowchart.

TYPE 2 DIABETES

Overview

Six SRs^{25,26,30,32,37,43} provide the best available evidence on the link between periodontal treatment and chronic disease indicators for those with T2D, as well as some limited information on other clinically important outcomes (Table 2). Overall, periodontal treatment was associated with small improvements in HbA1c,^25,26,30,43 fasting blood glucose,²⁵ triglycerides,³² total cholesterol,³² and CRP²⁶ for those with T2D for up to 4 months compared to no or control treatment; however, improvements in most outcomes did not persist at 6 months. Periodontal treatment was not associated with improvements in LDL or HDL cholesterol at 3 or 6 months³² compared to no or control treatment in patients with T2D, and had mixed results (ranging from no improvement to small improvement favoring periodontal treatment) on other markers of systemic inflammation compared to no or control treatment.^30,43 One SR looked at diabetes-related complications, quality of life, and cost outcomes, but found no evidence.⁴³ Data on harms were sparse but suggested that periodontal treatment may be associated with minor adverse events (eg, diarrhea, headaches, and nausea/vomiting).

Seventeen primary studies^{50–53,55,57–59,61–69} (6 RCTs, 8 retrospective cohort, 1 case-control, and 2 modeling studies) address gaps in SRs or update evidence from SRs (Table 2). Overall, 5 RCTs provided updated data on chronic disease indicators and were generally in agreement with findings from SRs. The remaining 12 studies (1 RCT, 8 retrospective cohort, 1 case-control, and 2 modeling studies) examined outcomes not covered by SRs and generally had unclear results, with some studies reporting periodontal treatment is associated with improvements in oral health-related quality of life (OHRQoL),⁵⁸ decreased medical costs,^51,57,59,52 and decreased risk of stroke and myocardial infarction, while others reported no improvements in OHRQoL,⁵⁰ increased or no change in medical costs,^51,59 and no significant difference in stroke or myocardial infarction risk compared to no treatment. A single retrospective cohort study⁵³ reported periodontal treatment is associated with reduced risk of heart failure compared to no treatment. Two studies had conflicting results on health care utilization, with one⁵⁷ finding periodontal treatment was associated with lower rates of inpatient admissions for those who received periodontal treatment compared to no treatment, and another⁶¹ finding no significant difference in health care utilization between groups. Finally, a simulation study⁶³ projected that expanding periodontal treatment coverage would lead to lower risk of diabetes-related complications.

Patient-reported Symptoms and Complications

A high-quality Cochrane review⁴³ found no studies that reported on diabetes-related complications or quality of life. No other SRs examined this outcome.

Table 2

Overview of Best Available Evidence on Periodontal Treatment vs No Treatment Among Adults With T2 Diabetes.

A fair-quality RCT⁵⁰ found that among those with T2D, there were no significant differences in OHRQoL (measured by the General Oral Health Assessment) between periodontal treatment and no treatment at 3 months, and another⁶⁹ found no difference in diabetes treatment-related QoL between groups at 3 months. By contrast, a fair-quality case-control study⁵⁸ found that patients with poorly-controlled T2D (HbA1c ≥ 7%) who received periodontal treatment had better OHRQoL compared to those who did not receive treatment (6.05 vs 9.02 on the Oral Health Impact Profile-14; p<.05). However, among those with well-controlled diabetes (HbA1c < 7%), there was no significant difference between groups. A major limitation of this study is that it was unclear what type of periodontal treatment patients received or how long after receiving treatment outcomes were measured. There was also no significant difference between groups on measures of functionality (SF-36) for any patients in the RCT.⁵⁰

In terms of complications, a fair-quality retrospective cohort study⁵³ found that advanced periodontal treatment was associated with a reduction in the rates of myocardial infarction (hazard ratio [HR] = 0.92, 95% CI [0.85, 0.99]) and heart failure (HR = 0.60, 95% CI [0.45, 0.80]) but not stroke (HR = 0.95, 95% CI [0.85, 1.06]) compared to non-advanced periodontal treatment over a maximum follow-up of 3 years. By contrast, a poor-quality retrospective cohort study⁵⁵ found that among those with diabetes mellitus and periodontal disease, the stroke incidence rate was significantly lower in the intensive treatment (.88%/yr) than the no treatment group (1.08%/yr) over a maximum follow-up of 10 years (p<.001). A study⁶³ that used a computer-based simulation model to project reductions of complications when periodontal treatment coverage is expanded among those with T2 diabetes (from 28% to 88% coverage) found expanded periodontal treatment coverage was associated with 7.3% reduced nephropathy incidence (95% CI [−20.3, −0.3]), 17.7% reduced neuropathy incidence (95% CI [−32.7, −4.7%]), and 18.4% reduced retinopathy incidence (95% CI [−34.5, −3.5%]) among those with T2 diabetes. Stroke and myocardial infarction incidence were also projected to be reduced by 5% (95% CI [−20.8, 3.9%]) but the difference was not statistically significant.

Overall, findings on the relation between periodontal treatment and patient-reported symptoms and complications for those with T2D are supported by low strength of evidence, as results were inconsistent across studies and studies were primarily observational with important methodological limitations. Additionally, results from the simulation study should be interpreted with caution because they were projected using a mathematical model that required the authors to make a number of assumptions about the link between periodontal treatment and diabetes-related complications that have not been directly evaluated.

Chronic Disease Indicators

A moderate-quality review of reviews²⁵ found periodontal treatment was associated with a small but significant improvement in mean HbA1c levels at 3-6 months when compared to no treatment (weighted mean difference [WMD] = −0.32%, 95% CI [−0.5, −0.15]). A high-quality Cochrane review⁴³ of RCTs found similar results for HbA1c at 3-4 months (MD = −0.29%, 95% CI [−0.48, −0.10]) but noted mean HbA1c levels were no longer significantly different between groups at 6 months. The review of reviews²⁵ also reported periodontal treatment was associated with improvements in fasting blood glucose at 3-6 months when compared to no treatment (WMD = −11.59 ml/dl, 95% CI [−15.2, −8.0]), but did not evaluate whether outcomes differed at 3 or 6 months. Five RCTs^65–69 published after these SRs found similar results for HbA1c.

Periodontal treatment was also associated with shorter-term improvements in total cholesterol, triglycerides, and CRP levels when compared to no or control treatment. A moderate-quality review³² reported periodontal treatment was associated with improvements in total cholesterol (mean difference [MD] = −0.47 mmol/L, 95% CI [−0.75, −0.18]) and triglycerides (MD = −0.2 mmol/L, 95% CI [−0.24, −0.16]) levels compared to no or control treatment, while the control arm was associated with improvements in HDL cholesterol (MD = 0.06 mmol/L, 95% CI [0.03, 0.08]) levels compared to periodontal treatment, all at 3 months. However, the review found no significant differences between groups at 6 months. Another moderate-quality review²⁶ found a significant reduction in mean CRP level from baseline among those receiving periodontal treatment compared to no treatment (difference in mean change scores = 1.89 mg/L, 95% CI [1.70, 2.08]) at 3-6 months. This SR did not evaluate whether outcomes differed at 3 or 6 months. However, an RCT⁶⁸ published after this SR found no significant improvements in CRP between the treatment and no treatment groups at 6 months. Individual, fair-quality RCTs additionally found periodontal treatment was associated with significantly better post-prandial glucose (PPG) at 3 months,⁶⁵ improvements in oxidative stress at 3 months,⁶⁹ and improvement in some measures of cardiac health (E/e’ ratio) but not others (left ventricle mass index and NT-proBNP) at 6 months⁶⁸ compared to no treatment.

Finally, a moderate-quality review³² found no significant differences in mean LDL cholesterol levels between periodontal treatment and no treatment or control treatment groups at 3 or 6 months. A low-quality review³⁷ reported that 7 studies found periodontal treatment was associated with improvements in mean IL-6 levels, while 9 studies did not find any impact (follow-up time not reported). An RCT⁶⁸ published since the review found no significant difference in IL-6 between periodontal treatment and no treatment at 6 months. Finally, a critically low-quality review of reviews³⁰ found mixed results on the relation of periodontal therapy to measures of systematic inflammation (follow-up time not reported).

Overall, findings on the relation between periodontal treatment and chronic disease indicators for those with T2D are supported by moderate strength of evidence. Although we identified several moderate- and high-quality SRs of RCTs examining these outcomes, SR authors noted that the RCTs that composed the reviews had some methodological limitations including a lack of masking of participants and study personnel as well as incomplete outcome data.

Health Care Utilization and Costs

A high-quality Cochrane review⁴³ found no studies that reported data on costs. No other SRs examined this outcome, and no SRs examined health care utilization. Findings on costs from primary studies of primarily insurance claims data have mixed results, with studies indicating that periodontal treatment was associated with higher, lower, and no significant differences in costs compared to no periodontal treatment.

First, 5 studies^{52,57,61,62,64} found periodontal treatment was associated with lower costs compared to no treatment. A fair-quality retrospective cohort study⁵² conducted in the Netherlands found a small reduction in diabetes-related health care costs per quarter per year (−€12.03, 95% CI [−15.77, −8.29]) following periodontal treatment compared with no periodontal treatment. Several additional, poor-quality retrospective studies^61,62,64 based on claims data found similar results. One of these was a US-based retrospective cohort study⁶¹ that found that, among those with newly diagnosed T2D, periodontal treatment was associated with lower healthcare costs compared to no treatment ($1,799 lower over 2 years, p=.01), although benefits were limited to those who did not initiate diabetes medications after diagnosis. Another was a US-based retrospective cohort study⁶² that found that people with T2D who received periodontal care had $1,750 lower annual medical costs than those who did not (statistical significance not evaluated). A third was a retrospective cohort study⁵⁷ based in the US which found that those with T2D who received periodontal treatment had significantly lower mean annual medical costs than those who did not receive treatment ($4,216 vs $7,056; p<.04). A final study⁶³ that used a computer-based simulation model to project costs of expanding periodontal treatment coverage among those with T2D (from 28% to 88% coverage) found that expanded coverage was associated with savings of $5,904 (95% CI [−6,039, −5,769]) per capita.

By contrast, 2 studies^51,59 found periodontal treatment was associated with higher costs compared to no treatment. A fair-quality, retrospective cohort study based on claims data⁵⁹ conducted in the US found that after adjusting for disease burden, those with diabetes mellitus who received periodontitis or gingivitis treatment had higher per-member per-year medical costs than those who received other dental services or no dental services (adjusted costs not reported). This finding was echoed by a second modeling study⁵¹ conducted in the UK that found medical costs for people with T2D who received periodontal treatment was higher than those that did not receive treatment (incremental costs ranged from £504 to £1,056). Authors pointed out that the intervention was most cost-effective for those who are older and who have higher HbA1c. A final, poor-quality retrospective cohort study⁶⁴ found no significant differences in medical costs for those with newly diagnosed T2D who undergo periodontal treatment versus those who do not.

Studies also had unclear results in terms of health care utilization. One poor-quality retrospective cohort study⁵⁷ found that receipt of periodontal treatment was associated with lower rates of inpatient admissions compared to controls (40.4 vs 66.6 inpatient admissions/1,000 subjects/year; p<.05), while another⁶¹ found no significant difference between groups in number of outpatient physician visits, probability of hospitalization, or occurrence of an emergency room visits.

These studies had major limitations which reduce our certainty in the findings. First, for most studies based on claims data, it was unclear whether people in the control group who did not receive periodontal treatment had periodontal disease or were periodontally healthy. It is therefore possible that confounders associated with periodontal disease – rather than periodontal treatment itself – influenced the results. One study⁵⁷ attempted to control for periodontal disease status by including people who had received 1, 2, or 3 sessions of periodontal treatment in the control group (compared to 4 sessions in the intervention group). Consequently, study groups may actually represent levels of adherence to treatment rather than a comparison between receipt versus no receipt of treatment. A second limitation of the studies of claims data is that most only evaluated data from participants who were continually enrolled in both medical and dental insurance and who were alive for the duration of the study. Authors of 1 study⁶⁴ commented that this may have excluded younger patients (who may have changed their health insurance) and older patients (who may have died during the study). Authors of another study⁶¹ explicitly stated that selection bias could have influenced their results, given that limiting participants to those continually enrolled in insurance reduced the sample size to around 15% of the total sample.

Overall, findings on the relation between periodontal treatment and health care utilization and costs for those with T2D are supported by low strength of evidence, because results were inconsistent across studies and studies were primarily observational with important methodological limitations.

Harms

A high-quality Cochrane review⁴³ found that most of its included studies (20/35) did not report on adverse events, and several others (11/35) reported that either no adverse events or no major adverse events occurred. Of the remaining 4 studies, 1 study reported no adverse events occurred from use of doxycycline and 3 studies reported minor adverse events due to treatment in both groups (including diarrhea, headaches, nausea/vomiting) or due to doxycycline or chlorhexidine (including diarrhea, pain, nausea, taste change, and tooth stain). None of the included studies in another moderate-quality review²⁶ reported on the occurrence of adverse effects or complications of periodontal treatment. Two fair-quality RCTs^66,69 published since these reviews also reported there were no harms of periodontal treatment. Overall, findings on the relation between periodontal treatment and harms for those with T2D are supported by moderate strength of evidence. Importantly, although evidence is available on harms from a high-quality SR and 2 additional fair-quality RCTs, only half the studies in the included SR reported on this outcome.

CARDIOVASCULAR DISEASE

Overview

Two SRs provide the best available evidence on the link between periodontal treatment and chronic disease indicators among those CVD (Table 3). Overall, for those which chronic heart disease, periodontal treatment was associated with improvements in TNF-α, IL-6 and CRP at 3 months compared to no treatment. For those with hyperlipidemia, periodontal treatment was also associated with improvements in LDL and CRP at 3 months compared to no treatment. Although additional clinically relevant outcomes (ie, all-cause and CVD-related mortality, cardiovascular events, and adverse events) were examined by 1 review, authors did not find sufficient data to draw conclusions.

Four primary studies (4 retrospective cohort and 1 self-controlled case series) addressed gaps in SR evidence by examining the association between periodontal treatment and cardiovascular events, health care utilization, and costs (Table 3). Overall, data on complications of CVD are unclear. One retrospective cohort study⁵⁵ indicated those with hypertension and atherosclerosis who received periodontal treatment had a lower risk of stroke than those who did not receive treatment, while a self-controlled case series⁵⁴ indicated the risk of myocardial infarction increased in the 4 weeks after intensive dental treatment compared to baseline then decreased over the next 20 weeks. Results on costs are also unclear, with 1 retrospective cohort study⁵⁹ indicating those with coronary artery disease (CAD) had higher per-member per-month medical costs than those who did not receive treatment and 2 others^57,62 indicating those with CAD had lower annual medical costs. One of these studies⁶² reported those with CHD similarly had lower annual medical costs than those who did not receive treatment, and the other⁵⁷ reported lower inpatient admissions among those with CAD who received treatment. No SRs or primary studies reported on harms.

Patient-reported Symptoms and Complications

A high-quality Cochrane review³⁸ looked for data on all-cause and CVD-related mortality and cardiovascular events but found only a single relevant study with high attrition. A poor-quality, retrospective cohort study⁵⁵ identified in the gap search found that among those with periodontal disease and hypertension, the stroke incident rate was lower in the intensive treatment group (.83%/yr) than in the no treatment group (1.09%/yr) over a maximum follow-up of 10 years (p<.001). This study found similar results for those with atherosclerosis (incident rate of intensive treatment = 1.00%/yr vs IR of no treatment = 1.18%/yr; p<.001). A self-controlled case-series⁵⁴ reported the rate of myocardial infarction was higher in the first 4 weeks after an invasive dental treatment compared with baseline (incident ratio [IR] = 1.56, 95% CI [0.98, 2.47]), but noted that this rate decreased over the subsequent 20 weeks. Overall, findings on the relation between periodontal treatment and patient-reported symptoms and complications for those with CVD are supported by insufficient strength of evidence, as studies reported conflicting results and either were poor quality or did not have a separate control group.

Chronic Disease Indicators

A moderate-quality review⁴⁸ included 3 studies of periodontal treatment compared to no treatment for those with CVD. One study found those with chronic heart disease who received periodontal treatment experienced improvements in TNF-α, IL-6, and CRP levels at 3 months compared to no treatment. The second found that those with refractory hypertension who received periodontal treatment experienced improvements in IL-6 and CRP levels at 6 months, although it is unclear whether control groups also improved. The final study found that those with hyperlipidemia who received periodontal treatment experienced improvements in LDL and CRP levels compared to no treatment at 3 months. By contrast, a high-quality Cochrane review³⁸ looked for data on blood test results for those with CVD undergoing periodontal treatment but found no usable data due to substantial attrition in the single relevant study. Overall, findings on the relation between periodontal treatment and chronic disease indicators for those with CVD are supported by low strength of evidence. Although findings are supported by a high- and a moderate-quality SR, the SRs came to different conclusions based on the small number of available studies that had important methodological limitations including high attrition.

Table 3

Overview of Best Available Evidence on Periodontal Treatment vs No Treatment Among Adults With Cardiovascular Disease.

Health Care Utilization and Costs

A poor-quality retrospective cohort study⁵⁷ reported that receipt of periodontal treatment was associated with significantly lower rates of inpatient admissions compared to no treatment among people with coronary artery disease (CAD) (46.6 vs 65.2 inpatient admissions/1,000 subjects/year; p<.01). As noted above, a major limitation of this study was that the control group was active (control participants received 1, 2, or 3 sessions of periodontal treatment compared to 4 sessions in the intervention group), which could have attenuated observed treatment effects.

In terms of costs, a fair-quality retrospective cohort study⁵⁹ reported that after adjusting for disease burden, people with CAD who received periodontal treatment incurred higher per-member per-month medical costs than those who received no dental services (adjusted costs not reported). By contrast, a poor-quality retrospective cohort study⁵⁷ found that those with CAD who received periodontal treatment had significantly lower annual medical costs than those who did not receive treatment ($9,133 vs $10,222; p<.04). A second poor-quality retrospective cohort study⁶² conducted in the US found that people with CAD who received periodontal treatment had lower annual medical costs compared to those who did not receive periodontal treatment (average $15,549-$16,271 in periodontal treatment group vs $20,502-$21,202 in no treatment group depending on compliance with medical care). Authors noted similar results for those with congestive heart disease (average $35,669-$36,172 in periodontal treatment group vs $47,332-$49,064 in no treatment group depending on compliance with medical care). Differences were not evaluated for statistical significance in this study, which was published as a report by United Healthcare.

Overall, findings on the relation between periodontal treatment and healthcare utilization and costs for those with CVD are supported by low strength of evidence, as studies reported conflicting results and were all observational with important methodological limitations.

Harms

A high-quality Cochrane review³⁸ looked for data on harms but found no usable data due to high attrition in the single relevant study. No primary studies identified in the gap search reported on harms.

CEREBROVASCULAR DISEASE

Overview

We did not identify any SRs examining the link between periodontal treatment and any outcomes of interest for those with cerebrovascular disease. Three primary studies^54,57,59 (2 retrospective cohort and 1 self-controlled case series) conducted in those with cerebrovascular disease reported similar findings as those with CVD (Table 4). One retrospective cohort study⁵⁹ found that after adjusting for disease burden, people with cerebrovascular disease who underwent periodontal treatment had higher medical costs than those who did not receive dental services, while another⁵⁷ found they have lower annual medical costs and lower rates of inpatient admissions. A third self-controlled case series⁵⁴ found that the risk of ischemic stroke was higher in the 4 weeks after intensive dental therapy than at baseline.

Patient-reported Symptoms and Complications

A self-controlled case series⁵⁴ reported that the risk of stroke was slightly elevated in the 4 weeks after an invasive dental treatment (IR = 1.39, 95% CI [0.89, 2.15]) with an unclear pattern of resolution in the following weeks. Overall, this finding is supported by insufficient strength of evidence as the single observational study did not have a separate control group.

Chronic Disease Indicators

No studies reported on chronic disease indicators.

Health Care Utilization and Costs

One fair-quality retrospective cohort study⁵⁹ found that after adjusting for disease burden, people with cerebrovascular disease who underwent periodontal treatment had higher medical costs than those who did not receive dental services (adjusted costs not reported). By contrast, a poor-quality retrospective cohort study⁵⁷ indicated people with cerebrovascular disease who received periodontal treatment had lower mean annual medical costs compared to those who did not receive dental services ($8,214 vs $13,895; p<.04). This study also reported lower rates of inpatient admissions in the periodontal treatment group compared to the no treatment group (350.0 vs 444.4 inpatient admissions/1,000 subjects/year; p<.002). Overall, findings are supported by low strength of evidence, as studies reported conflicting results and were observational with important methodological limitations, including 1 study whose comparison group was composed of those who received 1, 2, or 3 sessions of periodontal therapy and another whose comparison group was composed of people who may have been periodontally healthy.

Harms

No primary studies reported on harms.

Table 4

Overview of Best Available Evidence on Periodontal Treatment vs No Treatment Among Adults With Cerebrovascular Disease.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Overview

We did not identify any SRs examining the link between periodontal treatment and any outcomes of interest for those with COPD. Four primary studies^49,56,60 (2 RCTs, 1 non-randomized, controlled trial, and 1 retrospective cohort study) examined outcomes of periodontal treatment versus no treatment among people with COPD (Table 5). One RCT⁴⁹ and 1 non-randomized controlled trial⁵⁶ found that periodontal treatment was associated with reductions in the frequency of COPD exacerbations at 1 and 2 years, while another, shorter RCT⁶⁰ indicated that periodontal treatment had no significant effect on COPD-related quality of life, self-assessment of health, or illness severity at 1 month. This RCT⁶⁰ also found a reduction in doctor visits in both treatment and control groups (significance not assessed) and no adverse events in either group. The retrospective cohort study⁶² found lower annual medical costs among those who received periodontal treatment compared to those who did not.

Patient-reported Symptoms and Complications

A fair-quality RCT⁴⁹ (N=60) and another fair-quality, non-randomized controlled trial⁵⁶ (N=40) found that periodontal treatment was associated with significant reductions in the mean frequency of COPD exacerbations at 1 year (1.95 vs 3.25 exacerbations/patient-year) and 2 years (30% of patients experiencing frequent/70% experiencing infrequent exacerbations vs 66.7% frequent/33.3% infrequent) compared to no treatment. A shorter and smaller fair-quality RCT⁶⁰ (N=30) did not find significant differences between treatment groups in COPD-related quality of life (measured by SGRQ-A), self-assessment of health, or illness severity at 1 month. These findings are supported by low strength of evidence, as evidence on short- and long-term findings conflict, and RCTs were small with important methodological limitations including 1 study that did not describe how patients were allocated to treatment versus control groups.

Chronic Disease Indicators

A fair-quality RCT⁴⁹ (N=60) with 2 periodontal treatment groups (scaling and root planing or supragingival scaling treatment) found both forms of treatment had a significant, positive effect on measures of lung function (including forced expiratory volume in the first second [FEV1] and forced vital capacity [FEV1/FVC]) compared with no treatment at 2 years. These findings are supported by low strength of evidence, as evidence comes from a single, small RCT that did not mask participants and had no publicly available protocol.

Health Care Utilization, Costs, and Harms

A fair-quality RCT⁶⁰ (N=30) found a reduction in doctor visits in both treatment and control groups and no adverse events in either group at 1 month. A poor-quality retrospective cohort study⁶² found that those with COPD who received periodontal treatment had lower annual medical costs than those who did not receive treatment ($12,938-$38,450 vs $15,817-$52,484 depending on medical compliance). These findings are supported by low strength of evidence, as evidence comes from a single, small RCT that did not mask participants and had no publicly available protocol, as well as a retrospective cohort study that did not clearly report whether people in the no treatment group had periodontal disease or were periodontally healthy.

Table 5

Overview of Best Available Evidence on Periodontal Treatment vs No Treatment Among Adults With Chronic Obstructive Pulmonary Disease.

SUMMARY AND DISCUSSION

We conducted a rapid review to synthesize evidence on benefits and harms of detection and treatment of dental problems (specifically, periodontal disease) among those with T2D, CVD, cerebrovascular disease, or COPD. Although multiple reviews^3–5 have found a link between periodontal disease and chronic disease, it remains unclear whether treatment for periodontal disease can meaningfully improve chronic disease outcomes and reduce healthcare utilization and associated costs.

This review found that periodontal disease treatment may improve chronic disease outcomes for those with COPD. Results from 1 fair-quality RCT⁴⁹ and 1 fair-quality non-randomized, controlled trial⁵⁷ suggest periodontal treatment may improve lung function and reduce the frequency of exacerbations at 1 and 2 years compared to no treatment. Another fair-quality RCT⁶⁰ found no adverse events within a month of periodontal treatment. However, in this short study, periodontal treatment did not reduce the number of doctor’s visits after treatment, nor did it appear to improve quality of life, self-assessment of health, or illness severity. It is possible that these discordant findings are due to the shorter follow-up period of this study (ie, the effect of periodontal treatment on some COPD outcomes may take longer than 1 month to become apparent). A poor-quality retrospective cohort study⁶² adds additional evidence indicating those who receive periodontal treatment have lower annual medical costs than those who do not receive treatment; however, results may have been confounded if the control group included people who were periodontally healthy.

Results from moderate- and high-quality SRs^{25,26,32,43,48} indicate periodontal treatment likely improves measures of chronic disease severity and inflammation (eg, HbA1c, fasting blood glucose, total cholesterol, triglycerides, CRP) compared to no treatment among those with T2D or cardiovascular disease in the short term (3-4 months). However, improvements do not seem to persist beyond 6 months. This may be due to the fact that periodontal treatment is meant to be a continuous preventive intervention (ie, scaling and root planing followed by routine check-ups and addressing subsequent problems that arise). A single periodontal treatment session or group of sessions may therefore be insufficient to produce durable improvement in chronic disease indicators.

Evidence is unclear on whether periodontal treatment reduces the risk of diabetes and CVD-related complications. For those with T2D, evidence from a single fair-quality retrospective cohort study⁵³ indicates that periodontal treatment may reduce the risk of heart failure compared to no treatment. However, studies^53,55,63 on myocardial infarction and stroke risk among those with T2D found conflicting results, with some studies indicating no difference in risk and others indicating lower risk among who received periodontal treatment. Additionally, a simulation study⁶³ of people with T2 diabetes projected that expanding periodontal treatment would lead to improvements in diabetes-related complications. Authors of this study made important assumptions about the connection between periodontal treatment and diabetes outcomes that have not been directly evaluated. These assumptions could have led to findings that were favorable towards periodontal treatment.

For those with hypertension or atherosclerosis, evidence from a single, poor-quality retrospective cohort study⁵⁵ indicates that periodontal treatment may reduce stroke risk. However, a self-controlled case series⁵⁴ indicated that individuals’ risk for stroke and myocardial infarction increased after periodontal treatment when compared to baseline. It is possible the invasive nature of periodontal disease treatment triggers inflammation or releases bacteria into the blood stream, the effect of which is a temporary increase in vascular inflammation and/or atherosclerosis that leads to higher risk of cardiovascular-related adverse events.^54,70 However, a 2011 letter published by Harvard Health that discusses this study pointed out that although the relative risk of stroke and myocardial infarction was higher after periodontal treatment than at baseline, the absolute risk of these events was low.^70,71 Both this letter and a 2010 news article by Consumer Reports⁷⁰ also pointed out that participants may have discontinued the use of NSAIDS, blood thinners, or antiplatelet medications to reduce bleeding due to periodontal treatment, and consequently these patients’ cardiovascular risk may have been heightened. Authors of the case series conducted sensitivity analyses to assess whether medication use may have confounded results but acknowledged their data on medications may have been insufficient to rule out confounding.

Findings on costs of periodontal treatment versus no treatment for people with T2D, coronary artery disease, or cerebrovascular disease are also unclear, with some studies^{52,57,61–63} indicating periodontal treatment contributes to reductions in costs and other studies^51,59,64 finding no significant difference or higher medical costs associated with periodontal treatment. One poor-quality retrospective cohort study⁵⁷ reported periodontal treatment was associated with lower inpatient admissions for those with T2D, coronary artery disease, or cerebrovascular disease, while another⁶¹ conducted in those with T2D found no significant differences between groups in total outpatient physician visits, likelihood of a hospitalization, or occurrences of emergency room visits. A major limitation of many of these studies is that the purportedly “no treatment” control groups were poorly described and may have included people who were periodontally healthy. It is reasonable to expect people who are periodontally healthy to have lower health care costs than those who have periodontal disease, and the inclusion of healthy individuals in control groups assumed to represent individuals with periodontal disease not receiving treatment could leads to biased or inaccurate findings. An additional consideration in the applicability of these studies is that several included the costs of providing periodontal treatment. Within the VA’s current pilot program, the VA would not bear the costs of periodontal treatment, which means that the costs measured in included studies are not the same as those incurred by the VA (eg, the costs associated with facilitating access to periodontal treatment or treating dental emergencies subsequent to untreated dental conditions).

Finally, we found some evidence that the balance of benefits and costs may differ by individual patient characteristics. For example, in 1 study⁵¹ that reported periodontal treatment was associated with higher medical costs compared to no treatment, authors noted that periodontal treatment was most cost-effective in those with higher HbA1c (who have more to gain from periodontal treatment-associated improvements in HbA1c) and those who are older (who have lower lifetime costs of periodontal treatment). Another study⁵⁸ found that those with poorly controlled T2D (HbA1c ≥ 7%) who underwent periodontal treatment experienced significant improvements in OHRQoL compared to controls, while those with well-controlled T2D (HbA1c<7%) who underwent periodontal treatment experienced no improvements compared to controls.

CONCLUSIONS

Among people with COPD, periodontal treatment may improve lung function and reduce exacerbations at 1-2 years, as well as reduce annual medical costs. Among people with diabetes or cardiovascular disease, periodontal treatment likely leads to improvements in some measures of chronic disease severity and inflammation at 3-4 months, but benefits do not seem to persist beyond 6 months. Results are unclear on the relation between periodontal treatment and chronic disease outcomes for those with cerebrovascular disease. Results are also unclear on the relation between periodontal treatment and medical costs and risk of chronic disease complications among those with diabetes, cardiovascular disease, or cerebrovascular disease.

ACKNOWLEDGMENTS

This topic was developed in response to a nomination by the Partnered Evidence-Based Policy Resource Center (PEPReC) for the purpose of informing the implementation and evaluation of the Veterans Innovation Center (VIC) Care Coordination for Dental Benefits demonstration program. The scope was further developed with input from the topic nominators (ie, Operational Partners) and the ESP Coordinating Center.

In designing the study questions and methodology at the outset of this report, the ESP consulted several technical and content experts. Broad expertise and perspectives were sought. Divergent and conflicting opinions are common and perceived as healthy scientific discourse that results in a thoughtful, relevant systematic review. Therefore, in the end, study questions, design, methodologic approaches, and/or conclusions do not necessarily represent the views of individual technical and content experts.

The authors gratefully acknowledge Mark Helfand, MD, MPH, MS for input on review scope, Payten Sonnen for help with data extraction and editorial review, and Julia Haskin, MA for her editorial review, as well as the following individuals for their contributions to the project:

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Supplementary Materials

Suggested citation:

Veazie S, Vela K, Parr NJ. Evidence Brief: Detection and Treatment of Dental Problems on Chronic Disease Outcomes. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-009; 2021. Available at: https://www.hsrd.research.va.gov/publications/esp/reports.cfm.

This report is based on research conducted by the Evidence Synthesis Program (ESP) Center located at the VA Portland Health Care System funded by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development. The findings and conclusions in this document are those of the author(s) who are responsible for its contents; the findings and conclusions do not necessarily represent the views of the Department of Veterans Affairs or the United States government. Therefore, no statement in this article should be construed as an official position of the Department of Veterans Affairs. No investigators have any affiliations or financial involvement (eg, employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in the report.