Periodontal treatment and subsequent clinical outcomes and medical care costs: A retrospective cohort study

PLOS ONE RESEARCH ARTICLE Periodontal treatment and subsequent clinical outcomes and medical care costs: A retrospective cohort study Bryan S. Michalowicz1, Jeffrey P. Anderson2, Thomas E. Kottke1, Steven P. Dehmer ID1, Donald C. Worley1, Sheryl Kane1, Sarah Basile1, D. Brad Rindal ID1* 1 HealthPartners Institute, Bloomington, Minnesota, United States of America, 2 Genesis Research, Hoboken, New Jersey, United States of America a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 * Abstract Introduction OPEN ACCESS Citation: Michalowicz BS, Anderson JP, Kottke TE, Dehmer SP, Worley DC, Kane S, et al. (2023) Periodontal treatment and subsequent clinical outcomes and medical care costs: A retrospective cohort study. PLoS ONE 18(8): e0290028. https:// doi.org/10.1371/journal.pone.0290028 Editor: Gustavo G. Nascimento, National Dental Research Institute Singapore / Duke NUS Medical School Singapore, SINGAPORE Received: December 13, 2022 Accepted: July 31, 2023 Published: August 14, 2023 Copyright: © 2023 Michalowicz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: The data used for this study were collected for routine clinical (nonresearch) purposes under the protections of HIPAA and state health record statutes. We had IRB permission to use these data for research purposes, but because patients did not have an opportunity to provide prospective informed consent about sharing these data publicly, we are not at liberty to submit study data files to a research data repository. This response is consistent with NIH and PCORI policies which have Periodontitis is a common oral disease associated with coronary artery disease (CAD), cerebrovascular disease (CBVD) and type 2 diabetes (T2D). We studied if periodontitis treatment improves clinical outcomes and reduces medical care costs in patients with CAD, CBVD or T2D. Methods We used clinic records and claims data from a health care system to identify patients with periodontitis and CAD, CBVD or T2D, and to assess periodontal treatments, hospitalizations, medical costs (total, inpatient, outpatient, pharmacy), glycated hemoglobin, cardiovascular events, and death following concurrent disease diagnoses. We compared clinical outcomes according to receipt of periodontal treatment and/or maintenance care in the follow-up period, and care costs according to treatment status within one year following concurrent disease diagnoses, while adjusting for covariates. The data were analyzed in 2019–21. Results We identified 9,503 individuals, 4,057 of whom were in the CAD cohort; 3,247 in the CBVD cohort; and 4,879 in the T2D cohort. Patients who were selected and elected to receive treatment and maintenance care were less likely to be hospitalized than untreated individuals (CAD: OR = 0.71 (95% CI: 0.55, 0.92); CBVD: OR = 0.73 (0.56, 0.94); T2D: OR = 0.80 (0.64, 0.99)). Selection to treatment and/or maintenance care was not significantly associated with cardiovascular events, mortality, or glycated hemoglobin change. Total care costs did not differ significantly between treated and untreated groups over 4 years. Treated patients experienced lower inpatient costs but higher pharmacy costs. PLOS ONE | https://doi.org/10.1371/journal.pone.0290028 August 14, 2023 1 / 16 PLOS ONE had input from patient stakeholder groups. The following is the contact information for the for the individual holding the data and responding to external requests for data access: Richard Paskach, Sr. Director, Research Informatics & Technology Email: Richard.R. Tel. 952-967-5531. Funding: This study was funded by a grant from the National Institute of Dental and Craniofacial Research to BSM and DBR (DE026797). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. https://www.nidcr.nih.gov/. Competing interests: The authors have declared that no competing interests exist. Periodontal treatment and subsequent clinical outcomes and costs Conclusions Patients with periodontitis and CAD, CBVD or T2D who were selected and elected to undergo periodontal treatment or maintenance care had lower rates of hospitalizations, but did not differ significantly from untreated individuals in terms of clinical outcomes or total medical care costs. Introduction Periodontitis is a chronic multifactorial inflammatory disease associated with dysbiotic plaque biofilms and characterized by progressive destruction of the tooth-supporting apparatus [1]. It is highly prevalent and a major cause of tooth loss in adults [2, 3]. Periodontitis has been associated with myriad non-oral diseases, including coronary artery disease (CAD), cerebrovascular disease (CBVD), and type 2 diabetes (T2D) [4]. The putative mechanisms linking these conditions include immune responses to bacteria that have translocated through inflamed periodontal tissues to distant organs, and the systemic action of locally (orally)-produced inflammatory mediators [5]. Thus, treatment of periodontitis has been studied as a means of mitigating the incidence and progression of non-oral diseases. Periodontal treatment in adults with T2D yields modest, short-term improvements in glycated hemoglobin (HbA1c), although the sustainability of this effect is uncertain [6]. Treatment may improve brachial artery compliance and endothelial cell activity but has not been shown to improve clinical outcomes in patients with cardiovascular disease [7–9]. To date, large randomized controlled trials are lacking for CAD and CBVD. Periodontitis, but not its treatment, is consistently associated with increases in all-cause mortality and death due to CAD and CBVD [10]. Health insurance claims data have been used to explore relationships between periodontitis, its treatment and non-oral diseases [11–15]. This approach, however, is limited by concerns with misclassification bias and confounding [16]. Use of integrated medical and dental records can circumvent some of the limitations inherent in claims data [17]. Few studies have examined the relationship between periodontal treatment and medical care costs [18–22]. Jeffcoat et al. reported substantial care costs savings for CAD, CBVD and T2D patients following periodontal treatment [20]. Although some have advocated for Medicare to include dental services, in part to help reduce medical care costs for seniors, at present there is insufficient evidence that periodontal treatment reduces medical care costs [23–25]. We sought to address some of the shortcomings of prior investigations by leveraging multiple data systems. We used medical and dental clinic records and insurance plan and claims data and a retrospective cohort study design to explore associations between receipt of periodontal treat (...truncated)