Background

Implantable devices are an important part of treatment regimens for serious cardiovascular disordersand their use has steadily increased since the original development of vascular grafts and artificial heart valves in the 1950s. Implantable pacemakers were first used in the early 1960sand a steady progression of increasingly sophisticated and effective devices have been introduced up until the present. Although relatively rareinfection of implanted devices can be a very serious complicationand prevention of infection is an important clinical priority.¹ Such infections are believed to be caused by seeding of the devices by bacteria that enter the body from other sites.^2–4

Disorders of the teethgumsand their supporting structures are important threats to a person’s overall health.⁵ The mouth is colonized with a large number of bacterial speciesand several of these have been identified as being the source of infection in patients with underlying structural defects of the heartincluding prosthetic heart valves and other prosthetic materials.^{2, 4, 6, 7} The identification and targeted treatment of foci of infection of the mouth potentially can reduce the incidence of infection of implanted cardiovascular devices. Some implantable devices also require routine anticoagulationwith a corresponding increased risk of bleeding complications. Bleeding is a potential complication of dental procedures such as tooth extractionsand anticoagulation increases the probability of bleeding following these procedures.⁸

Dental evaluation and treatment are carried out by healthcare professionalsbut financial barriers can impede access to dental services. In 2015the percentage of people in the United States with no dental insurance was 29% overall and 62% for older adults.⁹ The number of people lacking dental insurance is triple the rate of those lacking medical insuranceand there are serious gaps in the U.S. safety net system for providing dental care to uninsured adults and children.¹⁰ Optimizing insurance coverage for necessary clinical and dental services is an important priority.¹¹

Programs overseen by the Centers for Medicare & Medicaid Services (CMS) are major components of the U.S. health insurance system. Medicaid and the Children's Health Insurance Program (CHIP) are administered by States under broad Federal guidelines. States are required to provide dental benefits to Medicaid and CHIP-enrolled childrenbut States choose whether to provide dental benefits for adults. Medicare generally does not cover most dental services. While the statutes that define Medicare policies do not permit payment for most types of dental carethey have allowed some exceptions when dental care is closely tied to the outcomes of complex medical procedures.¹² For examplein the CY 2023 Physician Fee Schedule Final Rule (87 FR 70198)CMS finalized a policy to permit payment for certain dental servicessuch as dental examinationsincluding necessary treatmentperformed as part of a comprehensive workup prior to organ transplant surgeryor prior to cardiac valve replacement or valvuloplasty proceduresthat are similarly inextricably linked to certain other covered medical services.¹³ Howeverthis payment policy does not authorize payment for dental care administered to patients who receive implanted cardiac devices other than prosthetic valves.

The rationale for performing a thorough dental evaluation before implantation of cardiac devices is twofold. The first is that examination by a dentist can identify local sources of active infectionsuch as oral abscesses or infected teeth or gums. By then treating those focithe bacterial load in the mouth can be reduced. The second rationale is to provide teaching to the patient on proper daily self-care of the teeth and gums through brushing and flossing. Such daily maintenance can minimize the overgrowth of pathogenic bacteria in the mouth and deter progression of dental disease that could contribute to transient bacteremia and seeding of the implanted device. Unless there is great urgency to insert the deviceit can be safe and feasible to incorporate a dental examinationlocal treatmentand patient education components into one or two dental visits prior to the implantation procedure.^14–16

We sought to assemble and evaluate the published evidence supporting the efficacy of specific types of dental care that are intended to reduce adverse event rates in patients who receive implanted cardiac devices other than surgical prosthetic valves. If the evidence base is judged to be sufficientthis information potentially can inform policy initiatives (including changes to Medicare payment policies) that can improve access to specific dental services for people with serious or life-threatening cardiac disorders. The primary question for this review is: For those undergoing insertion of implantable cardiovascular devicesdoes dental care prior to the treatment improve adverse event rates and other relevant outcomes?

Methods

The goal of this Rapid Response report was to identify evidence pertinent to the efficacy of dental evaluation prior to the insertion of certain kinds of medical devices used to treat cardiovascular conditions. The medical devices addressed in this report include:

• Ventricular assist devices
• Artificial pacemakers
• Implantable defibrillators
• Transcatheter artificial heart valves
• Synthetic vascular grafts and patches
• Coronary and vascular stents

We reviewed peer-reviewed literature and professional guidelines from the last 50 years to identify research and standards of practice on the need for and effectiveness of dental screening and pretreatment prior to the insertion of cardiovascular devices. A medical librarian with extensive experience conducting searches for systematic and rapid reviews developed and conducted a literature search of Ovid MEDLINE ALL in March 2023 (Appendix A). Our review of the search results focused on identifying primary research studiessystematic reviewsand clinical guidelines published by professional societies. We also scanned the reference lists of all included studies.

One team member reviewed each title and abstract. A comparison group (patients who did not receive pre-treatment dental care) was not a criterion for including a study. We excluded reports of small numbers of patients (such as case reports) and studies that reported on patients treated only with surgically implanted cardiac valves. We included systematic reviews that addressed the effectiveness of dental care prior to insertion of cardiovascular devices. Each study included at the abstract review stage was then reviewed in full text to determine its final suitability for inclusion in this report.

Any published papers on clinical practice guidelines pertaining to the use of implantable cardiac devices were identified in review of the MEDLINE search results. We also searched for practice guidelines through review of the literature references of all included primary studies and systematic reviews. To find additional relevant practice guidelineswe conducted a gray literature search using the websites of the American College of CardiologyAmerican Dental AssociationAmerican Heart AssociationCenters for Disease Control and Prevention (CDC)CochraneEuropean Society of CardiologyHeart Rhythm SocietyNational Heart Lung and Blood Institute (NHLBI)National Institute for Health and Care Excellence (NICE)and Society for Cardiovascular Angiography & Interventions. Because it is a repository of evidence syntheses on a variety of clinical topicswe also searched Cochrane for evidence summaries. All sites were searched for the following terms: dentaldentistryoralteethgingivitiscavitiescavityand caries. All results of these searches were reviewed at the title/abstract leveland any potentially relevant guidelines were then reviewed at the full-text level by one reviewer.

We evaluated each included primary research study for its study designusing the categories of randomized controlled trial (RCT)prospective cohortretrospective cohortor registry-based study. For studies that were not RCTswe recorded whether the statistical analysis had used methods to adjust for confoundingsuch as matching or propensity score methods. For systematic reviewswe summarized the date ranges of the searchthe primary conclusionsand any strength of evidence assessments that were performed.

All reported patient outcomes in the included studies were recorded. We did not perform quantitative meta-analysis of the included primary research studies. Insteadwe conducted a narrative synthesis of all included studies for this report.

Results

The literature search yielded 386 records. The review of titlesabstractsand full-text yielded two primary research studies and four systematic reviews.^17–23 All of the included articles were published since 2017. One primary study¹⁷ was funded by the Japan Society for Promotion of Science; the other primary study¹⁸ reported no source of funding. One systematic review¹⁹ was funded by the American Dental Association; the other three systematic reviews reported no funding source.^{20, 22, 23} Table 1 summarizes the research designsmajor resultsand patient populations of the two included primary studies. No randomized controlled trials were identifiedand the two included primary studies both had retrospective cohort designs. One study was conducted in the United States,¹⁸ and one was conducted in Japan.¹⁷ Neither study used statistical methods to control for confounding between the comparison groups.

The gray literature search identified 41 practice guidelines or recommendationsof which 19 addressed patient populations and devices relevant to the topic of this report (Appendix B).^24–42

Both of the primary research studies^{17, 18} and two systematic reviews^{19, 23} examined the association between dental problems and clinical outcomes in patients who received ventricular assist devices (VADs). The primary research studies both had modest sample sizes (Table 1). Both studies examined rates of intraoral bleeding occurring after dental treatment and also after the implantation of VADs. The study conducted in Japan¹⁷ compared 17 patients who underwent tooth extractions prior to insertion of the VAD with 11 patients who underwent tooth extractions after the VAD insertion. Only bleeding that persisted after the day of the tooth extraction was counted as a bleeding complicationand the study did not report how long the patients were monitored for bleeding beyond the first postoperative day. The rate of bleeding was significantly (p = 0.001) lower in the group who had the dental procedure prior to VAD insertion (13% versus 67%). In the U.S. study,¹⁸ all 88 patients underwent dental examinations prior to VAD insertion and then were stratified by whether invasive dental treatment was required and performed. The patients were monitored for signs of bleeding during the 31 days following the initial dental evaluation. Of the patients who underwent dental treatmentthe mean time between dental treatment and VAD insertion was 19.87 daysso anticoagulation regimens may have varied during the 31-day followup period. Intraoral bleeding was higher in the group who received dental treatment (7% rate). Because it did not include a comparison group of patients with similar dental disordersthis second study does not define whether the dental treatment affected rates of adverse events following VAD insertion.

A systematic review¹⁹ sought studies examining the efficacy of dental care prior to either surgical cardiac valve replacement or VAD insertion. While the review identified six studies addressing valve replacementit identified no relevant studies addressing VAD insertion. In its evaluation of the evidence on dental care prior to surgical valve replacementthis review found that evidence was inconsistent on whether dental care prior to surgical valve replacement lowered rates of mortalityinfectious endocarditispostsurgical infectionor hospital length of stay.^{23, 43} Surgically implanted cardiac valves have mechanical characteristics similar to valves that are inserted using a transcatheter technique.²¹ A systematic review has examined strategies for preventing infectious endocarditis in patients who undergo transcatheter aortic valve implantation (TAVI).²⁰ It describes consensus on use of prophylactic antibiotics during the TAVI procedure but does not address evidence on the efficacy of dental care prior to the procedure.^{19, 21}

A systematic review²³ examined whether standardized protocols for dental evaluation have been defined for patients who will undergo VAD insertion. It found that only one published study had described a protocol. That study⁴³ was published in 2002and no other studies have described adoption of its protocol for use prior to VAD insertion. Another systematic review²² searched for articles describing outcomesguidelinesor protocols for dental care prior to a wide range of cardiovascular procedures. It included 44 publications in its analysisbut these included narrative reviews and letters to the editor as well as primary studies. Only two of the publications were primary studies examining dental care prior to cardiac procedures addressed in this review.^{44, 45} These studies reported the results of the dental evaluations but provided no data on clinical outcomes after the patients underwent vascular procedures. The systematic review concluded that there is some evidence supporting recommendations for pre-treatment dental care for surgical valve replacement and cardiac transplantation but no evidence supporting pre-treatment dental care prior to insertion of other cardiovascular devices.

Table 1

Table of included studies.

Our searches identified 19 practice guidelines or recommendations that address relevant cardiac conditions and procedures.^24–42 Of theseeight provide recommendations on the prevention of serious infection for patients with implantable cardiac devices and other cardiac conditions that are susceptible to serious infection (Appendix B).^{24, 27, 30–35} The cardiac conditions addressed in the guidelines include congenital heart diseasevalvular heart diseaseinfective endocarditisvascular graft infectionscardiac arrhythmiasheart failureand other less common conditions.

Five guidelines were produced for the American Heart Association.^{24, 26, 29, 34, 35} Topics for these clinical practice guidelines were prevention of viridans group streptococcal infective endocarditismanagement of cardiovascular implantable electronic device infectionsand vascular graft infections. Three guidelines were produced jointly between the American College of Cardiology and the American Heart Association.^{32, 33, 38} Topics for these clinical practice guidelines were the management of patients with valvular heart disease and adults with congenital heart disease. Three guidelines were produced for a collaboration between the American College of Cardiologythe American Heart Associationand the Heart Rhythm Society.^{36, 37, 39} All of these addressed cardiac rhythm abnormalities. Two guidelines were produced for the European Society of Cardiology.^{25, 28} These addressed cardiac pacing and emergency management of patients with left ventricular assist devices (LVADs). One guideline addressing medical clearance for common dental procedures was produced for the American Academy of Family Physicians.³⁰ One guideline addressing heart failure was produced by a collaboration of the American Heart Associationthe American College of Cardiologyand the Heart Failure Society of America.⁴² One guideline was produced jointly for the American College of Cardiologythe American Heart Associationand the North American Society for Pacing and Electrophysiology.⁴¹ This guideline addressed pacemaker implantation. One guideline on transcatheter mitral valve interventions was produced by the American Association for Thoracic Surgerythe American College of Cardiologythe Society for Cardiovascular Angiography and Interventionsand the Society for Thoracic Surgeons.⁴⁰ A guideline and a related evidence summary were produced for Cochrane and NICE in the UK.^{27, 31} These addressed antibiotic prophylaxis use for the prevention of infective endocarditis.

Authors of all of the guidelines cited a lack of clinical trial evidence on which to base their recommendations. Thereforeguideline writing groups identified case seriesobservational studiesand expert opinion as the basis for their recommendations. None of the guidelines recommend specific dental treatments prior to insertion of cardiovascular devices. Howeverfour guidelines and an evidence summary called for improved oral health overalland education and instruction of cardiac patients in routine oral health practices.^{27, 31–33, 35} Two guidelines also recommended regular or biannual dental examinations as a strategy for preventing infectious endocarditis.^{32, 35}

Discussion

To prepare this Rapid Responsea thorough search of the MEDLINE database compiled all relevant published studies through March 2023. The evidence base includes two primary research studies that have relatively small sample sizes and used retrospective cohort designs.^{17, 18} Both of these studies examined the relationship between dental procedures and bleeding occurrence among patients who receive ventricular assist devices. At this timereduction of bleeding from dental work is the strongest evidence-based rationale for provision of dental care immediately prior to the insertion of VADs. Our MEDLINE search also identified one systematic review addressing dental care in patients who undergo insertion of transcatheter prosthetic heart valves and one other systematic review that synthesized evidence for surgically implanted prosthetic valves.^{19, 20} These reviews did not identify strong evidence supporting the necessity of dental care (other than routine prophylactic antibiotics) prior to the valve procedures.

A frequently used category of implanted cardiac devices is artificial pacemakers and implantable defibrillatorsof which more than one million are inserted worldwide every year.²⁸ A cross-sectional analysis using a large nationwide database in South Korea found that dental procedures following implantation of the devices are associated with new episodes of endocarditis.⁴⁶ Howeverour MEDLINE search identified no studies evaluating the efficacy of pre-insertion dental care for patients receiving these devicesand recently published guidelines do not include recommendations for such dental care.²⁸

Artificial materials are also used in the treatment of other vascular disorders. These devices include vascular stents and grafts. Our MEDLINE search identified no primary studies or systematic reviews on the efficacy of dental care for preventing complications in patients receiving these devices. Dental care has been addressed in a recently published clinical practice guideline that included the following position statement:

A variety of other prosthetic cardiovascular devices deserve comment. These include cardiovascular implantable electronic devices; septal defect closure devices (when there is complete defect closure); peripheral vascular grafts and patchesincluding those used for hemodialysis and coronary and other vascular stents; central nervous system ventriculoatrial shunts; vena caval filters; and pledgets. Infections of these devices are rareand when they occurmost cases are caused by staphylococci. ThereforeAP [antibiotic prophylaxis] for a dental procedure in these patients is not suggested.³⁵

While this statement does not directly address dental care prior to procedures for implanting these devicesit implies that the efficacy of such dental care is likely to be low.

Cardiac transplantation is a definitive treatment for end-stage heart failureand evidence supports the efficacy of pre-transplant dental evaluation and treatment for preventing complications following the transplant.^{22, 47} An important difference between heart transplantation and the use of artificial cardiovascular devices is that immunosuppressive drugs are used to prevent organ rejection after the transplant procedure. Impaired immunity increases the risk of serious infections that can lead to prolonged hospitalizations and patient morbidity.⁴⁸ Two comparative studies have examined the impact of pre-treatment dental care on the rate of serious infections in patients administered immunosuppressive drugs for treatment of malignanciesand both showed a significantly lower infection rate in the patients who had received pre-treatment dental care.^{14, 49} Immunosuppression may be an important mediating factor for demonstrating the efficacy of pre-treatment dental care in patients who receive various invasive treatments for their cardiac conditions.

After implantation of cardiovascular devicesthere is an ongoing risk of device infection,⁷ and prophylactic antibiotics have often been recommended for patients who undergo subsequent dental procedures.³ This Rapid Response was not scoped to evaluate primary research studies on the efficacy of prophylactic antibioticsbut our guideline review highlighted a long-standing controversy in the field regarding which patients should and should not be provided a course of prophylactic antibiotics prior to dental treatment. Historicallyprophylactic antibiotics were used for the majority of patients perceived to be at risk for infective endocarditis. In the last 15 yearsNICEin the UKhas recommended ceasing all such prophylaxis,³¹ while others have focused on identifying which patients may actually benefit from this practice.^{27, 33, 35} Most guideline writing groups now agree that only those patients at highest risk of developing infective endocarditis should be given prophylaxis prior to elective dental interventions,^{27, 32, 35} yet there is still professional debate as to which patients are actually high risk.

Dental care can include a fairly broad range of dental services as part of pre-treatment dental programs. Practice guidelines addressing pre-treatment dental care for patients with cancer have advocated a combination of services that include thorough examinationsimmediate treatment of serious abnormalitiesand patient education.^{50, 51} Howeverit has not been possible to determine which of the components of the dental programs had greater or lesser impact. Systematic reviews addressing both ventricular assist devices and hematological cancers^{23, 52} noted the lack of consistency across studies in the specific components of recommended patient evaluation and dental treatments. Howeverthe recommended regimens have generally included physical examinations by a dentistplaque removalother treatments that are targeted at local foci of infectionand training of patients on daily dental hygiene.

This Rapid Response has addressed bleeding and infectious outcomes whose incidence or severity potentially can be reduced by an episode of pre-treatment dental care. While the current evidence base has limitationsit does provide guidance on when dental care may be beneficial in the care of people with certain types of cardiovascular disorders that are treated with artificial devices. The linkages between dental care and treatment with implantable cardiovascular devices (and the benefits of linking such care) are summarized in Appendix C. While the evidence of efficacy for dental care prior to device insertion is limited to a narrow segment of the devices (VADs and transcutaneous artificial heart valves)clinical practice guidelines suggest that ongoing oral hygiene regimens and routine dental examinations after the implantation procedures can be beneficial.

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Gregoratos GAbrams JEpstein AEet al ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines). J Cardiovasc Electrophysiol. 2002 Nov;13(11):1183–99. doi: 10.1046/j.1540-8167.2002.01183.x. PMID: 12475117. [PubMed: 12475117] [CrossRef]

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Kuderer NMDale DCCrawford Jet al Mortalitymorbidityand cost associated with febrile neutropenia in adult cancer patients. Cancer. 2006 May 15;106(10):2258–66. doi: 10.1002/cncr.21847. PMID: 16575919. [PubMed: 16575919] [CrossRef]

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Afterword

Recognized for excellence in conducting comprehensive systematic reviewsthe Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) Program is developing a range of rapid evidence products to assist end-users in making specific decisions in a limited timeframe.

To shorten timelinesreviewers make strategic choices about which review processes to abridge. Howeverthe adaptations made for expediency may limit the certainty and generalizability of the findings from the reviewparticularly in areas with a large literature base. Transparent reporting of the methods used and the resulting limitations of the evidence synthesis are extremely important.

AHRQ expects that these rapid evidence products will be helpful to health plansproviderspurchasersgovernment programsand the healthcare system as a whole. Transparency and stakeholder input are essential to the Effective Health Care Program.

If you have comments on this reportthey may be sent by mail to the Task Order Officer named below at: Agency for Healthcare Research and Quality5600 Fishers LaneRockvilleMD 20857or by email to vog.shh.qrha@cpe.

• Robert Otto ValdezPh.D.M.H.S.A.
  Director
  Agency for Healthcare Research and Quality
• Craig A. UmscheidM.D.M.S.
  Director
  Evidence-based Practice Center Program
  Center for Evidence and Practice Improvement
  Agency for Healthcare Research and Quality
• Therese MillerDr.P.H.
  Acting Director
  Center for Evidence and Practice Improvement
  Agency for Healthcare Research and Quality
• Christine S. ChangM.D.M.P.H.
  Task Order Officer
  Associate Director
  Evidence-based Practice Center Program
  Center for Evidence and Practice Improvement
  Agency for Healthcare Research and Quality

Appendix A. MEDLINE Search Strategy

Search preformed on March 92023:

Ovid MEDLINE ALL 1946 to March 082023

1 Heart Failure/su or AngioplastyBalloonCoronary/ or AtherectomyCoronary/ or Cardiac Surgical Procedures/ or exp Coronary Artery Bypass/ or Arterial Switch Operation/ or Cardiomyoplasty/ or exp Heart ArrestInduced/ or Heart BypassRight/ or Fontan Procedure/ or Heart Massage/ or Heart Transplantation/ or Heart-Lung Transplantation/ or Maze Procedure/ or Myocardial Revascularization/ or AngioplastyBalloonCoronary/ or AtherectomyCoronary/ or exp Coronary Artery Bypass/ or Transmyocardial Laser Revascularization/ or Norwood Procedures/ or Pericardial Window Techniques/ or Pericardiectomy/ or Pericardiocentesis/ or Percutaneous Coronary Intervention/ or ((arter* or cardia* or cardio* or coronary or heart).hw. and su.fs.) (477123)

2 (arter* or atria$1 or CABG or cardia* or cardio* or coronary or heart*).ti,kf. (1619523)

3 Cardiac Resynchronization Therapy Devices/ or DefibrillatorsImplantable/ or HeartArtificial/ or Heart-Assist Devices/ or PacemakerArtificial/ (66879)

4 (((arter* or vascular) adj2 stent*) or defibrillat* or pacemaker$1 or pace-maker$1 or "ventricular assist*").ti,kf. (51579)

5 or/1-4 (1837393)

6 (Dental Prophylaxis/ or Dental Scaling/ or Periodontal Debridement/ or Periodontal Diseases/ or Root Planing/) and (Perioperative Care/ or Perioperative Period/ or Preoperative Care/ or Preoperative Period/) (69)

7 ((dental or periodont* or "oral care" or "oral disease*" or "oral health" or "oral hygiene" or "oral infection*" or teeth or tooth) and (advance or ahead or before or caries or cavity or cavities or early or initial* or "medically necessary" or prehabilitation or preliminary or periimplant or "peri-implant*" or preimplant* or "pre-implant*" or perioperat* or "peri-operat*" or preoperat* or "pre-operat*" or preparat* or periprocedur* or "peri-procedur*" or post* or preprocedur* or "pre-procedur*" or perisurg* or "peri-surg*" or presurg* or "pre-surg*" or peritherap* or "peri-therap*" or pretherap* or "pre-therap*" or peritransplant* or "peri-transplant*" or pretransplant* or "pre-transplant* or peritreat* or peri-treat* or pretreat*" or "pre-treat*" or preventive or prior or prophyl* or screen* or time* or timing or undergoing)).ti,kf. (41360)

8 ((dental or periodont* or "oral care" or "oral disease*" or "oral health" or "oral hygiene" or "oral infection*" or teeth or tooth) adj5 (advance or ahead or before or caries or cavity or cavities or early or initial* or "medically necessary" or prehabilitation or preliminary or periimplant or "peri-implant*" or preimplant* or "pre-implant*" or perioperat* or "peri-operat*" or preoperat* or "pre-operat*" or preparat* or periprocedur* or "peri-procedur*" or post* or preprocedur* or "pre-procedur*" or perisurg* or "peri-surg*" or presurg* or "pre-surg*" or peritherap* or "peri-therap*" or pretherap* or "pre-therap*" or peritransplant* or "peri-transplant*" or pretransplant* or "pre-transplant* or peritreat* or peri-treat* or pretreat*" or "pre-treat*" or preventive or prior or prophyl* or screen* or time* or timing or undergoing)).ab. (63593)

9 or/6-8 (89857)

10 and/5,9 (882)

11 10 not ((exp Animals/ not Humans/) or (animal model* or bitch$2 or bovine or canine or capra or cat or cats or cattle or cow$1 or dog$1 or equine or ewe$1 or feline or goat$1 or hamster$1 or horse$1 or invertebrate$1 or macaque$1 or mare$1 or mice or monkey$1 or mouse or murine or nonhuman or non-human or ovine or pig or pigs or porcine or primate$1 or rabbit$1 or rat$1 or rattus or rhesus or rodent* or sheep or simian or sow$1 or vertebrate$1 or zebrafish).ti. or ("case report$1" or comment).ti.) (815)

12 limit 11 to english language (740)

13 12 not (case reports or comment or editorial or letter or news).pt. (647)

14 13 and ((meta-analysis or "systematic review").pt. or (meta-anal* or metaanal* or ((evidence or review or scoping or systematic or umbrella) adj3 (review or synthesis))).ti.) (34)

15 13 and ((controlled clinical trial or randomized controlled trial).pt. or (control* or random* or trial*).ti,ab,kf.) (212)

16 15 not 14 (200)

17 13 and (Case-Control Studies/ or Cohort Studies/ or Comparative Study/ or Controlled Before-After Studies/ or Cross-Sectional Studies/ or Epidemiologic Studies/ or exp Evaluation Studies as Topic/ or Follow-Up Studies/ or Historically Controlled Study/ or Interrupted Time Series Analysis/ or Longitudinal Studies/ or Prospective Studies/ or Retrospective Studies/ or ("case-control" or cohort$1 or "before-after" or ((comparative or epidemiologic or evaluation) adj3 study) or cross-sectional or follow-up or (historic* adj4 control*) or "interrupted time" or longitudinal$2 or prospective$2 or retrospective$2).ti.) (260)

18 17 not (14 or 16) (148)

Supplemental search performed on March 282023

Ovid MEDLINE ALL 1946 to March 272023

1 heart septal defects/ or aortopulmonary septal defect/ or truncus arteriosuspersistent/ or endocardial cushion defects/ or heart septal defectsatrial/ or foramen ovalepatent/ or lutembacher syndrome/ or heart septal defectsventricular/ or double outlet right ventricle/ (32819)

2 ((atrial or ventricular) adj "septal defect*").ti,ab,kf. (24288)

3 or/1-2 (42677)

4 (Dental Prophylaxis/ or Dental Scaling/ or Periodontal Debridement/ or Periodontal Diseases/ or Root Planing/) and (Perioperative Care/ or Perioperative Period/ or Preoperative Care/ or Preoperative Period/) (69)

5 ((dental or periodont* or "oral care" or "oral disease*" or "oral health" or "oral hygiene" or "oral infection*" or teeth or tooth) and (advance or ahead or before or caries or cavity or cavities or early or initial* or "medically necessary" or prehabilitation or preliminary or periimplant or "peri-implant*" or preimplant* or "pre-implant*" or perioperat* or "peri-operat*" or preoperat* or "pre-operat*" or preparat* or periprocedur* or "peri-procedur*" or post* or preprocedur* or "pre-procedur*" or perisurg* or "peri-surg*" or presurg* or "pre-surg*" or peritherap* or "peri-therap*" or pretherap* or "pre-therap*" or peritransplant* or "peri-transplant*" or pretransplant* or "pre-transplant* or peritreat* or peri-treat* or pretreat*" or "pre-treat*" or preventive or prior or prophyl* or screen* or time* or timing or undergoing)).ti,kf. (41477)

6 ((dental or periodont* or "oral care" or "oral disease*" or "oral health" or "oral hygiene" or "oral infection*" or teeth or tooth) adj5 (advance or ahead or before or caries or cavity or cavities or early or initial* or "medically necessary" or prehabilitation or preliminary or periimplant or "peri-implant*" or preimplant* or "pre-implant*" or perioperat* or "peri-operat*" or preoperat* or "pre-operat*" or preparat* or periprocedur* or "peri-procedur*" or post* or preprocedur* or "pre-procedur*" or perisurg* or "peri-surg*" or presurg* or "pre-surg*" or peritherap* or "peri-therap*" or pretherap* or "pre-therap*" or peritransplant* or "peri-transplant*" or pretransplant* or "pre-transplant* or peritreat* or peri-treat* or pretreat*" or "pre-treat*" or preventive or prior or prophyl* or screen* or time* or timing or undergoing)).ab. (63769)

7 or/4-6 (90105)

8 and/3,7 (36)

9 8 not ((exp Animals/ not Humans/) or (animal model* or bitch$2 or bovine or canine or capra or cat or cats or cattle or cow$1 or dog$1 or equine or ewe$1 or feline or goat$1 or hamster$1 or horse$1 or invertebrate$1 or macaque$1 or mare$1 or mice or monkey$1 or mouse or murine or nonhuman or non-human or ovine or pig or pigs or porcine or primate$1 or rabbit$1 or rat$1 or rattus or rhesus or rodent* or sheep or simian or sow$1 or vertebrate$1 or zebrafish).ti. or ("case report$1" or comment).ti.) (29)

10 limit 9 to english language (27)

11 10 not (case reports or comment or editorial or letter or news).pt. (13)

12 11 and ((meta-analysis or "systematic review").pt. or (meta-anal* or metaanal* or ((evidence or review or scoping or systematic or umbrella) adj3 (review or synthesis))).ti.) (1)

13 11 and ((controlled clinical trial or randomized controlled trial).pt. or (control* or random* or trial*).ti,ab,kf.) (2)

14 13 not 12 (1)

15 11 and (Case-Control Studies/ or Cohort Studies/ or Comparative Study/ or Controlled Before-After Studies/ or Cross-Sectional Studies/ or Epidemiologic Studies/ or exp Evaluation Studies as Topic/ or Follow-Up Studies/ or Historically Controlled Study/ or Interrupted Time Series Analysis/ or Longitudinal Studies/ or Prospective Studies/ or Retrospective Studies/ or ("case-control" or cohort$1 or "before-after" or ((comparative or epidemiologic or evaluation) adj3 study) or cross-sectional or follow-up or (historic* adj4 control*) or "interrupted time" or longitudinal$2 or prospective$2 or retrospective$2).ti.) (3)

16 15 not (12 or 14) (2)

Appendix B. Relevant Guideline Recommendations

Appendix C. Linkages Between Certain Medical and Dental Services

Acknowledgments: The authors thank Dr. Jonathan Treadwellwho served as Associate Editor for this review.

Suggested citation:

Hickam DHGordon CJArmstrong CEPaynter R. Efficacy of Dental Services for Reducing Adverse Events in Those Undergoing Insertion of Implantable Cardiovascular Devices. Rapid Response. (Prepared by the Scientific Resource Center under Contract No. 75Q80122C00002.) AHRQ Publication No. 23-EHC020. RockvilleMD: Agency for Healthcare Research and Quality; July 2023. DOI: https://doi.org/10.23970/AHRQEPCRAPIDDENTALCARDIO. Posted final reports are located on the Effective Health Care Program search page.

Disclosures: This report is based on research conducted by the Scientific Resource Center for the Agency for Healthcare Research and Quality (AHRQ) Effective Health Care Program under contract to AHRQRockvilleMD (Contract No. 75Q80122C00002). The findings and conclusions in this document are those of the authorswho are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Thereforeno statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

This Rapid Response was prepared by the AHRQ Evidence-based Practice Center (EPC) Program using streamlined literature review methods to assist end-users in making specific decisions in a limited timeframe. To shorten timelinesreviewers made strategic choices about which processes to abridge compared to a comprehensive systematic review. The adaptations made for expediency may limit the certainty and generalizability of the findings from the review.

None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.

The information in this report is intended to help healthcare decision makers—patients and clinicianshealth system leadersand policymakersamong others—make well-informed decisions and thereby improve the quality of healthcare services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent informationi.e.in the context of available resources and circumstances presented by individual patients.

This report is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. Most AHRQ documents are publicly available to use for noncommercial purposes (researchclinical or patient educationquality improvement projects) in the United Statesand do not need specific permission to be reprinted and used unless they contain material that is copyrighted by others. Specific written permission is needed for commercial use (reprinting for saleincorporation into softwareincorporation into for-profit training courses) or for use outside of the U.S. If organizational policies require permission to adapt or use these materialsAHRQ will provide such permission in writing.

AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this reportsuch as clinical practice guidelinesother quality enhancement toolsor reimbursement or coverage policiesmay not be stated or implied.

Role of the Funding Source: Funding for this review was provided by AHRQ. The funding source assigned the topic and provided comments on draft manuscripts but was not involved in data collectionanalysismanuscript preparationor addressing comments from reviewers.

AHRQ appreciates appropriate acknowledgment and citation of its work. Suggested language for acknowledgment: This work was based on an evidence reportEfficacy of Dental Services for Reducing Adverse Events in Those Undergoing Insertion of Implantable Cardiovascular Devicesby the Scientific Resource Center for the AHRQ EPC Program.