Background
Dental caries (tooth decay) and periodontal diseases (gingivitis and periodontitis) affect the majority of people worldwide, and treatment costs place a significant burden on health ...services. Decay and gum disease can cause pain, eating and speaking difficulties, low self‐esteem, and even tooth loss and the need for surgery. As dental plaque is the primary cause, self‐administered daily mechanical disruption and removal of plaque is important for oral health. Toothbrushing can remove supragingival plaque on the facial and lingual/palatal surfaces, but special devices (such as floss, brushes, sticks, and irrigators) are often recommended to reach into the interdental area.
Objectives
To evaluate the effectiveness of interdental cleaning devices used at home, in addition to toothbrushing, compared with toothbrushing alone, for preventing and controlling periodontal diseases, caries, and plaque. A secondary objective was to compare different interdental cleaning devices with each other.
Search methods
Cochrane Oral Health’s Information Specialist searched: Cochrane Oral Health’s Trials Register (to 16 January 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 12), MEDLINE Ovid (1946 to 16 January 2019), Embase Ovid (1980 to 16 January 2019) and CINAHL EBSCO (1937 to 16 January 2019). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication.
Selection criteria
Randomised controlled trials (RCTs) that compared toothbrushing and a home‐use interdental cleaning device versus toothbrushing alone or with another device (minimum duration four weeks).
Data collection and analysis
At least two review authors independently screened searches, selected studies, extracted data, assessed studies' risk of bias, and assessed evidence certainty as high, moderate, low or very low, according to GRADE. We extracted indices measured on interproximal surfaces, where possible. We conducted random‐effects meta‐analyses, using mean differences (MDs) or standardised mean differences (SMDs).
Main results
We included 35 RCTs (3929 randomised adult participants). Studies were at high risk of performance bias as blinding of participants was not possible. Only two studies were otherwise at low risk of bias. Many participants had a low level of baseline gingival inflammation.
Studies evaluated the following devices plus toothbrushing versus toothbrushing: floss (15 trials), interdental brushes (2 trials), wooden cleaning sticks (2 trials), rubber/elastomeric cleaning sticks (2 trials), oral irrigators (5 trials). Four devices were compared with floss: interdental brushes (9 trials), wooden cleaning sticks (3 trials), rubber/elastomeric cleaning sticks (9 trials) and oral irrigators (2 trials). Another comparison was rubber/elastomeric cleaning sticks versus interdental brushes (3 trials).
No trials assessed interproximal caries, and most did not assess periodontitis. Gingivitis was measured by indices (most commonly, Löe‐Silness, 0 to 3 scale) and by proportion of bleeding sites. Plaque was measured by indices, most often Quigley‐Hein (0 to 5).
Primary objective: comparisons against toothbrushing alone
Low‐certainty evidence suggested that flossing, in addition to toothbrushing, may reduce gingivitis (measured by gingival index (GI)) at one month (SMD ‐0.58, 95% confidence interval (CI) ‐1.12 to ‐0.04; 8 trials, 585 participants), three months or six months. The results for proportion of bleeding sites and plaque were inconsistent (very low‐certainty evidence).
Very low‐certainty evidence suggested that using an interdental brush, plus toothbrushing, may reduce gingivitis (measured by GI) at one month (MD ‐0.53, 95% CI ‐0.83 to ‐0.23; 1 trial, 62 participants), though there was no clear difference in bleeding sites (MD ‐0.05, 95% CI ‐0.13 to 0.03; 1 trial, 31 participants). Low‐certainty evidence suggested interdental brushes may reduce plaque more than toothbrushing alone (SMD ‐1.07, 95% CI ‐1.51 to ‐0.63; 2 trials, 93 participants).
Very low‐certainty evidence suggested that using wooden cleaning sticks, plus toothbrushing, may reduce bleeding sites at three months (MD ‐0.25, 95% CI ‐0.37 to ‐0.13; 1 trial, 24 participants), but not plaque (MD ‐0.03, 95% CI ‐0.13 to 0.07).
Very low‐certainty evidence suggested that using rubber/elastomeric interdental cleaning sticks, plus toothbrushing, may reduce plaque at one month (MD ‐0.22, 95% CI ‐0.41 to ‐0.03), but this was not found for gingivitis (GI MD ‐0.01, 95% CI ‐0.19 to 0.21; 1 trial, 12 participants; bleeding MD 0.07, 95% CI ‐0.15 to 0.01; 1 trial, 30 participants).
Very‐low certainty evidence suggested oral irrigators may reduce gingivitis measured by GI at one month (SMD ‐0.48, 95% CI ‐0.89 to ‐0.06; 4 trials, 380 participants), but not at three or six months. Low‐certainty evidence suggested that oral irrigators did not reduce bleeding sites at one month (MD ‐0.00, 95% CI ‐0.07 to 0.06; 2 trials, 126 participants) or three months, or plaque at one month (SMD ‐0.16, 95% CI ‐0.41 to 0.10; 3 trials, 235 participants), three months or six months, more than toothbrushing alone.
Secondary objective: comparisons between devices
Low‐certainty evidence suggested interdental brushes may reduce gingivitis more than floss at one and three months, but did not show a difference for periodontitis measured by probing pocket depth. Evidence for plaque was inconsistent.
Low‐ to very low‐certainty evidence suggested oral irrigation may reduce gingivitis at one month compared to flossing, but very low‐certainty evidence did not suggest a difference between devices for plaque.
Very low‐certainty evidence for interdental brushes or flossing versus interdental cleaning sticks did not demonstrate superiority of either intervention.
Adverse events
Studies that measured adverse events found no severe events caused by devices, and no evidence of differences between study groups in minor effects such as gingival irritation.
Authors' conclusions
Using floss or interdental brushes in addition to toothbrushing may reduce gingivitis or plaque, or both, more than toothbrushing alone. Interdental brushes may be more effective than floss. Available evidence for tooth cleaning sticks and oral irrigators is limited and inconsistent. Outcomes were mostly measured in the short term and participants in most studies had a low level of baseline gingival inflammation. Overall, the evidence was low to very low‐certainty, and the effect sizes observed may not be clinically important. Future trials should report participant periodontal status according to the new periodontal diseases classification, and last long enough to measure interproximal caries and periodontitis.
Reason for withdrawal from publication
Withdrawn from the Cochrane Library in Issue 7, 2019 as out of date. Topic area to be included in a new review of Interventions for treating cavitated or ...dentine carious lesions.
Background
Many dentists or hygienists provide scaling and polishing for patients at regular intervals, even for those at low risk of developing periodontal disease. There is debate over the clinical ...and cost effectiveness of 'routine scaling and polishing' and the optimal frequency at which it should be provided for healthy adults.
A 'routine scale and polish' treatment is defined as scaling or polishing, or both, of the crown and root surfaces of teeth to remove local irritational factors (plaque, calculus, debris and staining), which does not involve periodontal surgery or any form of adjunctive periodontal therapy such as the use of chemotherapeutic agents or root planing. Routine scale and polish treatments are typically provided in general dental practice settings. The technique may also be referred to as prophylaxis, professional mechanical plaque removal or periodontal instrumentation.
This review updates a version published in 2013.
Objectives
1. To determine the beneficial and harmful effects of routine scaling and polishing for periodontal health.
2. To determine the beneficial and harmful effects of routine scaling and polishing at different recall intervals for periodontal health.
3. To determine the beneficial and harmful effects of routine scaling and polishing for periodontal health when the treatment is provided by dentists compared with dental care professionals (dental therapists or dental hygienists).
Search methods
Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health’s Trials Register (to 10 January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 12), MEDLINE Ovid (1946 to 10 January 2018), and Embase Ovid (1980 to 10 January 2018). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.
Selection criteria
Randomised controlled trials of routine scale and polish treatments, with or without oral hygiene instruction, in healthy dentate adults without severe periodontitis. We excluded split‐mouth trials.
Data collection and analysis
Two review authors screened the results of the searches against inclusion criteria, extracted data and assessed risk of bias independently and in duplicate. We calculated mean differences (MDs) (or standardised mean differences (SMDs) when different scales were reported) and 95% confidence intervals (CIs) for continuous data. We calculated risk ratios (RR) and 95% CIs for dichotomous data. We used a fixed‐effect model for meta‐analyses. We contacted study authors when necessary to obtain missing information. We rated the certainty of the evidence using the GRADE approach.
Main results
We included two studies with 1711 participants in the analyses. Both studies were conducted in UK general dental practices and involved adults without severe periodontitis who were regular attenders at dental appointments. One study measured outcomes at 24 months and the other at 36 months. Neither study measured adverse effects, changes in attachment level, tooth loss or halitosis.
Comparison 1: routine scaling and polishing versus no scheduled scaling and polishing
Two studies compared planned, regular interval (six‐ and 12‐monthly) scale and polish treatments versus no scheduled treatment. We found little or no difference between groups over a two‐ to three‐year period for gingivitis, probing depths, oral health‐related quality of life (all high‐certainty evidence) and plaque (low‐certainty evidence). The SMD for gingivitis when comparing six‐monthly scale and polish treatment versus no scheduled treatment was –0.01 (95% CI –0.13 to 0.11; two trials, 1087 participants), and for 12‐monthly scale and polish versus no scheduled treatment was –0.04 (95% CI –0.16 to 0.08; two trials, 1091 participants).
Regular planned scale and polish treatments produced a small reduction in calculus levels over two to three years when compared with no scheduled scale and polish treatments (high‐certainty evidence). The SMD for six‐monthly scale and polish versus no scheduled treatment was –0.32 (95% CI –0.44 to –0.20; two trials, 1088 participants) and for 12‐monthly scale and polish versus no scheduled treatment was –0.19 (95% CI –0.31 to –0.07; two trials, 1088 participants). The clinical importance of these small reductions is unclear.
Participants' self‐reported levels of oral cleanliness were higher when receiving six‐ and 12‐monthly scale and polish treatments compared to no scheduled treatment, but the certainty of the evidence is low.
Comparison 2: routine scaling and polishing at different recall intervals
Two studies compared routine six‐monthly scale and polish treatments versus 12‐monthly treatments. We found little or no difference between groups over two to three years for the outcomes of gingivitis, probing depths, oral health‐related quality of life (all high‐certainty evidence) and plaque (low‐certainty evidence). The SMD for gingivitis was 0.03 (95% CI ‐0.09 to 0.15; two trials, 1090 participants; I2 = 0%). Six‐ monthly scale and polish treatments produced a small reduction in calculus levels over a two‐ to three‐year period when compared with 12‐monthly treatments (SMD –0.13 (95% CI –0.25 to –0.01; 2 trials, 1086 participants; high‐certainty evidence). The clinical importance of this small reduction is unclear.
The comparative effects of six‐ and 12‐monthly scale and polish treatments on patients' self‐reported levels of oral cleanliness were uncertain (very low‐certainty evidence).
Comparison 3: routine scaling and polishing provided by dentists compared with dental care professionals (dental therapists or hygienists)
No studies evaluated this comparison.
The review findings in relation to costs were uncertain (very low‐certainty evidence).
Authors' conclusions
For adults without severe periodontitis who regularly access routine dental care, routine scale and polish treatment makes little or no difference to gingivitis, probing depths and oral health‐related quality of life over two to three years follow‐up when compared with no scheduled scale and polish treatments (high‐certainty evidence). There may also be little or no difference in plaque levels over two years (low‐certainty evidence). Routine scaling and polishing reduces calculus levels compared with no routine scaling and polishing, with six‐monthly treatments reducing calculus more than 12‐monthly treatments over two to three years follow‐up (high‐certainty evidence), although the clinical importance of these small reductions is uncertain. Available evidence on the costs of the treatments is uncertain. The studies did not assess adverse effects.
Background
Glycaemic control is a key component in diabetes mellitus (diabetes) management. Periodontitis is the inflammation and destruction of the underlying supporting tissues of the teeth. Some ...studies have suggested a bidirectional relationship between glycaemic control and periodontitis.
Treatment for periodontitis involves subgingival instrumentation, which is the professional removal of plaque, calculus, and debris from below the gumline using hand or ultrasonic instruments. This is known variously as scaling and root planing, mechanical debridement, or non‐surgical periodontal treatment. Subgingival instrumentation is sometimes accompanied by local or systemic antimicrobials, and occasionally by surgical intervention to cut away gum tissue when periodontitis is severe.
This review is part one of an update of a review published in 2010 and first updated in 2015, and evaluates periodontal treatment versus no intervention or usual care.
Objectives
To investigate the effects of periodontal treatment on glycaemic control in people with diabetes mellitus and periodontitis.
Search methods
An information specialist searched six bibliographic databases up to 7 September 2021 and additional search methods were used to identify published, unpublished, and ongoing studies.
Selection criteria
We searched for randomised controlled trials (RCTs) of people with type 1 or type 2 diabetes mellitus and a diagnosis of periodontitis that compared subgingival instrumentation (sometimes with surgical treatment or adjunctive antimicrobial therapy or both) to no active intervention or 'usual care' (oral hygiene instruction, education or support interventions, and/or supragingival scaling (also known as PMPR, professional mechanical plaque removal)). To be included, the RCTs had to have lasted at least 3 months and have measured HbA1c (glycated haemoglobin).
Data collection and analysis
At least two review authors independently examined the titles and s retrieved by the search, selected the included trials, extracted data from included trials, and assessed included trials for risk of bias. Where necessary and possible, we attempted to contact study authors.
Our primary outcome was blood glucose levels measured as glycated (glycosylated) haemoglobin assay (HbA1c), which can be reported as a percentage of total haemoglobin or as millimoles per mole (mmol/mol).
Our secondary outcomes included adverse effects, periodontal indices (bleeding on probing, clinical attachment level, gingival index, plaque index, and probing pocket depth), quality of life, cost implications, and diabetic complications.
Main results
We included 35 studies, which randomised 3249 participants to periodontal treatment or control. All studies used a parallel‐RCT design and followed up participants for between 3 and 12 months. The studies focused on people with type 2 diabetes, other than one study that included participants with type 1 or type 2 diabetes. Most studies were mixed in terms of whether metabolic control of participants at baseline was good, fair, or poor. Most studies were carried out in secondary care.
We assessed two studies as being at low risk of bias, 14 studies at high risk of bias, and the risk of bias in 19 studies was unclear. We undertook a sensitivity analysis for our primary outcome based on studies at low risk of bias and this supported the main findings.
Moderate‐certainty evidence from 30 studies (2443 analysed participants) showed an absolute reduction in HbA1c of 0.43% (4.7 mmol/mol) 3 to 4 months after treatment of periodontitis (95% confidence interval (CI) ‐0.59% to ‐0.28%; ‐6.4 mmol/mol to ‐3.0 mmol/mol). Similarly, after 6 months, we found an absolute reduction in HbA1c of 0.30% (3.3 mmol/mol) (95% CI ‐0.52% to ‐0.08%; ‐5.7 mmol/mol to ‐0.9 mmol/mol; 12 studies, 1457 participants), and after 12 months, an absolute reduction of 0.50% (5.4 mmol/mol) (95% CI ‐0.55% to ‐0.45%; ‐6.0 mmol/mol to ‐4.9 mmol/mol; 1 study, 264 participants).
Studies that measured adverse effects generally reported that no or only mild harms occurred, and any serious adverse events were similar in intervention and control arms. However, adverse effects of periodontal treatments were not evaluated in most studies.
Authors' conclusions
Our 2022 update of this review has doubled the number of included studies and participants, which has led to a change in our conclusions about the primary outcome of glycaemic control and in our level of certainty in this conclusion. We now have moderate‐certainty evidence that periodontal treatment using subgingival instrumentation improves glycaemic control in people with both periodontitis and diabetes by a clinically significant amount when compared to no treatment or usual care. Further trials evaluating periodontal treatment versus no treatment/usual care are unlikely to change the overall conclusion reached in this review.
Background
There is ongoing debate about the frequency with which patients should attend for a dental check‐up and the effects on oral health of the interval between check‐ups. Recommendations ...regarding optimal recall intervals vary between countries and dental healthcare systems, but 6‐month dental check‐ups have traditionally been advocated by general dental practitioners in many high‐income countries.
This review updates a version first published in 2005, and updated in 2007 and 2013.
Objectives
To determine the optimal recall interval of dental check‐up for oral health in a primary care setting.
Search methods
Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 17 January 2020), the Cochrane Central Register of Controlled Trials (CENTRAL; in the Cochrane Library, 2019, Issue 12), MEDLINE Ovid (1946 to 17 January 2020), and Embase Ovid (1980 to 17 January 2020). We also searched the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication when searching.
Selection criteria
We included randomised controlled trials (RCTs) assessing the effects of different dental recall intervals in a primary care setting.
Data collection and analysis
Two review authors screened search results against inclusion criteria, extracted data and assessed risk of bias, independently and in duplicate. We contacted study authors for clarification or further information where necessary and feasible. We expressed the estimate of effect as mean difference (MD) with 95% confidence intervals (CIs) for continuous outcomes and risk ratios (RR) with 95% CIs for dichotomous outcomes. We assessed the certainty of the evidence using GRADE.
Main results
We included two studies with data from 1736 participants. One study was conducted in a public dental service clinic in Norway and involved participants under 20 years of age who were regular attenders at dental appointments. It compared 12‐month with 24‐month recall intervals and measured outcomes at two years. The other study was conducted in UK general dental practices and involved adults who were regular attenders, which was defined as having attended the dentist at least once in the previous two years. It compared the effects of 6‐month, 24‐month and risk‐based recall intervals, and measured outcomes at four years. The main outcomes we considered were dental caries, gingival bleeding and oral‐health‐related quality of life. Neither study measured other potential adverse effects.
24‐month versus 12‐month recall at 2 years' follow‐up
Due to the very low certainty of evidence from one trial, it is unclear if there is an important difference in caries experience between assignment to a 24‐month or a 12‐month recall. For 3‐ to 5‐year‐olds with primary teeth, the mean difference (MD) in dmfs (decayed, missing, and filled tooth surfaces) increment was 0.90 (95% CI −0.16 to 1.96; 58 participants). For 16‐ to 20‐year‐olds with permanent teeth, the MD in DMFS increment was 0.86 (95% CI −0.03 to 1.75; 127 participants). The trial did not assess other clinical outcomes of relevance to this review.
Risk‐based recall versus 6‐month recall at 4 years' follow‐up
We found high‐certainty evidence from one trial of adults that there is little to no difference between risk‐based and 6‐month recall intervals for the outcomes: number of tooth surfaces with any caries (ICDAS 1 to 6; MD 0.15, 95% CI −0.77 to 1.08; 1478 participants); proportion of sites with gingival bleeding (MD 0.78%, 95% CI −1.17% to 2.73%; 1472 participants); oral‐health‐related quality of life (MD in OHIP‐14 scores −0.35, 95% CI −1.02 to 0.32; 1551 participants). There is probably little to no difference in the prevalence of moderate to extensive caries (ICDAS 3 to 6) between the groups (RR 1.04, 95% CI 0.99 to 1.09; 1478 participants; moderate‐certainty evidence).
24‐month recall versus 6‐month recall at 4 years' follow‐up
We found moderate‐certainty evidence from one trial of adults that there is probably little to no difference between 24‐month and 6‐month recall intervals for the outcomes: number of tooth surfaces with any caries (MD −0.60, 95% CI −2.54 to 1.34; 271 participants); percentage of sites with gingival bleeding (MD −0.91%, 95% CI −5.02% to 3.20%; 271 participants). There may be little to no difference between the groups in the prevalence of moderate to extensive caries (RR 1.05, 95% CI 0.92 to 1.20; 271 participants; low‐certainty evidence). We found high‐certainty evidence that there is little to no difference in oral‐health‐related quality of life between the groups (MD in OHIP‐14 scores −0.24, 95% CI −1.55 to 1.07; 305 participants).
Risk‐based recall versus 24‐month recall at 4 years' follow‐up
We found moderate‐certainty evidence from one trial of adults that there is probably little to no difference between risk‐based and 24‐month recall intervals for the outcomes: prevalence of moderate to extensive caries (RR 1.06, 95% CI 0.95 to 1.19; 279 participants); number of tooth surfaces with any caries (MD 1.40, 95% CI −0.69 to 3.49; 279 participants). We found high‐certainty evidence that there is no important difference between the groups in the percentage of sites with gingival bleeding (MD −0.07%, 95% CI −4.10% to 3.96%; 279 participants); or in oral‐health‐related quality of life (MD in OHIP‐14 scores −0.37, 95% CI −1.69 to 0.95; 298 participants).
Authors' conclusions
For adults attending dental check‐ups in primary care settings, there is little to no difference between risk‐based and 6‐month recall intervals in the number of tooth surfaces with any caries, gingival bleeding and oral‐health‐related quality of life over a 4‐year period (high‐certainty evidence). There is probably little to no difference between the recall strategies in the prevalence of moderate to extensive caries (moderate‐certainty evidence).
When comparing 24‐month with either 6‐month or risk‐based recall intervals for adults, there is moderate‐ to high‐certainty evidence that there is little to no difference in the number of tooth surfaces with any caries, gingival bleeding and oral‐health‐related quality of life over a 4‐year period.
The available evidence on recall intervals between dental check‐ups for children and adolescents is uncertain.
The two trials we included in the review did not assess adverse effects of different recall strategies.
Background
Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety ...of agents to prevent them. One of these side effects is oral mucositis (mouth ulcers).
Objectives
To evaluate the effectiveness of prophylactic agents for oral mucositis in patients with cancer receiving treatment, compared with other potentially active interventions, placebo or no treatment.
Search methods
Electronic searches of Cochrane Oral Health Group and PaPaS Trials Registers (to 16 February 2011), CENTRAL (The Cochrane Library 2011, Issue 1), MEDLINE via OVID (1950 to 16 February 2011), EMBASE via OVID (1980 to 16 February 2011), CINAHL via EBSCO (1980 to 16 February 2011), CANCERLIT via PubMed (1950 to 16 February 2011), OpenSIGLE (1980 to 2005) and LILACS via the Virtual Health Library (1980 to 16 February 2011) were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information.
Selection criteria
Randomised controlled trials of interventions to prevent oral mucositis in patients receiving treatment for cancer.
Data collection and analysis
Information regarding methods, participants, interventions, outcome measures, results and risk of bias were independently extracted, in duplicate, by two review authors. Authors were contacted for further details where these were unclear. The Cochrane Collaboration statistical guidelines were followed and risk ratios calculated using random‐effects models.
Main results
A total of 131 studies with 10,514 randomised participants are now included. Overall only 8% of these studies were assessed as being at low risk of bias. Ten interventions, where there was more than one trial in the meta‐analysis, showed some statistically significant evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis, compared to either a placebo or no treatment. These ten interventions were: aloe vera, amifostine, cryotherapy, granulocyte‐colony stimulating factor (G‐CSF), intravenous glutamine, honey, keratinocyte growth factor, laser, polymixin/tobramycin/amphotericin (PTA) antibiotic pastille/paste and sucralfate.
Authors' conclusions
Ten interventions were found to have some benefit with regard to preventing or reducing the severity of mucositis associated with cancer treatment. The strength of the evidence was variable and implications for practice include consideration that benefits may be specific for certain cancer types and treatment. There is a need for further well designed, and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent.
Background
Caries is one of the most prevalent, preventable conditions worldwide. A wide variety of management options are available at different thresholds of disease, ranging from non‐operative ...preventive strategies such as improved oral hygiene, reduced sugar diet, and application of topical fluoride, to minimally invasive treatments for early lesions which are limited to enamel, through to selective removal and restoration for extensive lesions. The cornerstone of caries detection is a visual and tactile dental examination, however, an increasing array of methods of caries lesion detection have been proposed that could potentially support traditional methods of detection and diagnosis. Earlier identification of disease could afford patients the opportunity of less invasive treatment with less destruction of tooth tissue, reduce the need for treatment with aerosol‐generating procedures, and potentially result in a reduced cost of care to the patient and to healthcare services.
Objectives
Our primary objective was to determine the diagnostic accuracy of different electrical conductance devices for the detection and diagnosis of non‐cavitated coronal dental caries in different populations (children, adolescents, and adults) and when tested against different reference standards.
Search methods
Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 26 April 2019); Embase Ovid (1980 to 26 April 2019); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 26 April 2019); and the World Health Organization International Clinical Trials Registry Platform (to 26 April 2019). We studied reference lists as well as published systematic review articles.
Selection criteria
We included diagnostic accuracy studies that compared electrical conductance devices with a reference standard of histology or an enhanced visual examination. This included prospective studies that evaluated the diagnostic accuracy of single index tests and studies that directly compared two or more index tests. We included studies using previously extracted teeth or those that recruited participants with teeth believed to be sound or with early lesions limited to enamel.
Studies that explicitly recruited participants with more advanced lesions that were obviously into dentine or frankly cavitated were excluded.
Data collection and analysis
Two review authors extracted data independently using a piloted study data extraction form based on the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS‐2). Sensitivity and specificity with 95% confidence intervals (CIs) were reported for each study. This information was displayed as coupled forest plots, and plotted as summary receiver operating characteristic (SROC) plots, displaying the sensitivity‐specificity points for each study. Due to variability in thresholds we estimated diagnostic accuracy using hierarchical summary receiver operating characteristic (HSROC) methods.
Main results
We included seven studies reporting a total of 719 tooth sites or surfaces, with an overall prevalence of the target condition of 73% (528 tooth sites or surfaces). The included studies evaluated two index tests: the electronic caries monitor (ECM) (four studies, 475 tooth surfaces) and CarieScan Pro (three studies, 244 tooth surfaces). Six studies used histology as the reference standard, one used an enhanced visual examination. No study was considered to be at low risk of bias across all four domains or low concern for applicability or both. All studies were at high (five studies) or unclear (two studies) risk of bias for the patient selection domain. We judged two studies to be at unclear risk of bias for the index test domain, and one study to be at high risk of bias for the reference standard and flow and timing domains. We judged three studies to be at low concern for applicability for patient selection, and all seven studies to be of low concern for reference standard and flow and timing domains.
Studies were synthesised using a hierarchical method for meta‐analysis. There was variability in the results of the individual studies, with sensitivities which ranged from 0.55 to 0.98 and specificities from 0 to 1.00. These extreme values of specificity may be explained by a low number of healthy tooth surfaces in the included samples. The diagnostic odds ratio (DOR) was 15.65 (95% CI 1.43 to 171.15), and indicative of the variability in the included studies. Through meta‐regression we observed no meaningful difference in accuracy according to device type or dentition. Due to the small number of studies we were unable to formally investigate other potential sources of heterogeneity.
We judged the certainty of the evidence as very low, and downgraded for risk of bias due to limitations in the design and conduct of the included studies, imprecision arising from the relatively small number of surfaces studied, and inconsistency due to the variability of results.
Authors' conclusions
The design and conduct of studies to determine the diagnostic accuracy of methods to detect and diagnose caries in situ is particularly challenging. The evidence base to support the detection and diagnosis of caries with electrical conductance devices is sparse. Newer electrical conductance devices show promise and further research at the enamel caries threshold using a robust study design to minimise bias is warranted. In terms of applicability, any future studies should be carried out in a clinical setting to provide a realistic assessment within the oral cavity where plaque, staining, and restorations can be problematic.
Background
Effective oral hygiene measures carried out on a regular basis are vital to maintain good oral health. One‐to‐one oral hygiene advice (OHA) within the dental setting is often provided as a ...means to motivate individuals and to help achieve improved levels of oral health. However, it is unclear if one‐to‐one OHA in a dental setting is effective in improving oral health and what method(s) might be most effective and efficient.
Objectives
To assess the effects of one‐to‐one OHA, provided by a member of the dental team within the dental setting, on patients' oral health, hygiene, behaviour, and attitudes compared to no advice or advice in a different format.
Search methods
Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 10 November 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 10) in the Cochrane Library (searched 10 November 2017); MEDLINE Ovid (1946 to 10 November 2017); and Embase Ovid (1980 to 10 November 2017). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were also searched for ongoing trials (10 November 2017). No restrictions were placed on the language or date of publication when searching the electronic databases. Reference lists of relevant articles and previously published systematic reviews were handsearched. The authors of eligible trials were contacted, where feasible, to identify any unpublished work.
Selection criteria
We included randomised controlled trials assessing the effects of one‐to‐one OHA delivered by a dental care professional in a dental care setting with a minimum of 8 weeks follow‐up. We included healthy participants or participants who had a well‐defined medical condition.
Data collection and analysis
At least two review authors carried out selection of studies, data extraction and risk of bias independently and in duplicate. Consensus was achieved by discussion, or involvement of a third review author if required.
Main results
Nineteen studies met the criteria for inclusion in the review with data available for a total of 4232 participants. The included studies reported a wide variety of interventions, study populations, clinical outcomes and outcome measures. There was substantial clinical heterogeneity amongst the studies and it was not deemed appropriate to pool data in a meta‐analysis. We summarised data by categorising similar interventions into comparison groups.
Comparison 1: Any form of one‐to‐one OHA versus no OHA
Four studies compared any form of one‐to‐one OHA versus no OHA.
Two studies reported the outcome of gingivitis. Although one small study had contradictory results at 3 months and 6 months, the other study showed very low‐quality evidence of a benefit for OHA at all time points (very low‐quality evidence).
The same two studies reported the outcome of plaque. There was low‐quality evidence that these interventions showed a benefit for OHA in plaque reduction at all time points.
Two studies reported the outcome of dental caries at 6 months and 12 months respectively. There was very low‐quality evidence of a benefit for OHA at 12 months.
Comparison 2: Personalised one‐to‐one OHA versus routine one‐to‐one OHA
Four studies compared personalised OHA versus routine OHA.
There was little evidence available that any of these interventions demonstrated a difference on the outcomes of gingivitis, plaque or dental caries (very low quality).
Comparison 3: Self‐management versus professional OHA
Five trials compared some form of self‐management with some form of professional OHA.
There was little evidence available that any of these interventions demonstrated a difference on the outcomes of gingivitis or plaque (very low quality). None of the studies measured dental caries.
Comparison 4: Enhanced one‐to‐one OHA versus one‐to‐one OHA
Seven trials compared some form of enhanced OHA with some form of routine OHA.
There was little evidence available that any of these interventions demonstrated a difference on the outcomes of gingivitis, plaque or dental caries (very low quality).
Authors' conclusions
There was insufficient high‐quality evidence to recommend any specific one‐to‐one OHA method as being effective in improving oral health or being more effective than any other method. Further high‐quality randomised controlled trials are required to determine the most effective, efficient method of one‐to‐one OHA for oral health maintenance and improvement. The design of such trials should be cognisant of the limitations of the available evidence presented in this Cochrane Review.
Background
Root caries is a well‐recognised disease, with increasing prevalence as populations age and retain more of their natural teeth into later life. Like coronal caries, root caries can be ...associated with pain, discomfort, tooth loss, and contribute significantly to poorer oral health‐related quality of life in the elderly. Supplementing the visual‐tactile examination could prove beneficial in improving the accuracy of early detection and diagnosis. The detection of root caries lesions at an early stage in the disease continuum can inform diagnosis and lead to targeted preventive therapies and lesion arrest.
Objectives
To assess the diagnostic test accuracy of index tests for the detection and diagnosis of root caries in adults, used alone or in combination with other tests.
Search methods
Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 31 December 2018); Embase Ovid (1980 to 31 December 2018); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 31 December 2018); and the World Health Organization International Clinical Trials Registry Platform (to 31 December 2018). We studied reference lists as well as published systematic review articles.
Selection criteria
We included diagnostic accuracy study designs that compared one or more index tests (laser fluorescence, radiographs, visual examination, electronic caries monitor (ECM), transillumination), either independently or in combination, with a reference standard. This included prospective studies that evaluated the diagnostic accuracy of single index tests and studies that directly compared two or more index tests. In vitro and in vivo studies were eligible for inclusion but studies that artificially created carious lesions were excluded.
Data collection and analysis
Two review authors extracted data independently and in duplicate using a standardised data extraction and quality assessment form based on the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS‐2) specific to the review context. Estimates of diagnostic test accuracy were expressed as sensitivity and specificity with 95% confidence intervals (CI) for each dataset. We planned to use hierarchical models for data synthesis and explore potential sources of heterogeneity through meta‐regression.
Main results
Four cross‐sectional diagnostic test accuracy studies providing eight datasets with data from 4997 root surfaces were analysed. Two in vitro studies evaluated secondary root caries lesions on extracted teeth and two in vivo studies evaluated primary root caries lesions within the oral cavity. Four studies evaluated laser fluorescence and reported estimates of sensitivity ranging from 0.50 to 0.81 and specificity ranging from 0.40 to 0.80. Two studies evaluated radiographs and reported estimates of sensitivity ranging from 0.40 to 0.63 and specificity ranging from 0.31 to 0.80. One study evaluated visual examination and reported sensitivity of 0.75 (95% CI 0.48 to 0.93) and specificity of 0.38 (95% CI 0.14 to 0.68). One study evaluated the accuracy of radiograph and visual examination in combination and reported sensitivity of 0.81 (95% CI 0.54 to 0.96) and specificity of 0.54 (95% CI 0.25 to 0.81). Given the small number of studies and important differences in the clinical and methodological characteristics of the studies we were unable to pool the results. Consequently, we were unable to formally evaluate the comparative accuracy of the different tests considered in this review. Using QUADAS‐2 we judged all four studies to be at overall high risk of bias, but only two to have applicability concerns (patient selection domain). Reasons included bias in the selection process, use of post hoc (data driven) positivity thresholds, use of an imperfect reference standard, and use of extracted teeth.
We downgraded the certainty of the evidence due to study limitations and serious imprecision of the results (downgraded two levels), and judged the certainty of the evidence to be very low.
Authors' conclusions
Visual‐tactile examination is the mainstay of root caries detection and diagnosis; however, due to the paucity of the evidence base and the very low certainty of the evidence we were unable to determine the additional benefit of adjunctive diagnostic tests for the detection and diagnosis of root caries.
Background
The detection and diagnosis of caries at the earliest opportunity is fundamental to the preservation of tooth tissue and maintenance of oral health. Radiographs have traditionally been ...used to supplement the conventional visual‐tactile clinical examination. Accurate, timely detection and diagnosis of early signs of disease could afford patients the opportunity of less invasive treatment with less destruction of tooth tissue, reduce the need for treatment with aerosol‐generating procedures, and potentially result in a reduced cost of care to the patient and to healthcare services.
Objectives
To determine the diagnostic accuracy of different dental imaging methods to inform the detection and diagnosis of non‐cavitated enamel only coronal dental caries.
Search methods
Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 31 December 2018); Embase Ovid (1980 to 31 December 2018); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 31 December 2018); and the World Health Organization International Clinical Trials Registry Platform (to 31 December 2018). We studied reference lists as well as published systematic review articles.
Selection criteria
We included diagnostic accuracy study designs that compared a dental imaging method with a reference standard (histology, excavation, enhanced visual examination), studies that evaluated the diagnostic accuracy of single index tests, and studies that directly compared two or more index tests. Studies reporting at both the patient or tooth surface level were included. In vitro and in vivo studies were eligible for inclusion. Studies that explicitly recruited participants with more advanced lesions that were obviously into dentine or frankly cavitated were excluded. We also excluded studies that artificially created carious lesions and those that used an index test during the excavation of dental caries to ascertain the optimum depth of excavation.
Data collection and analysis
Two review authors extracted data independently and in duplicate using a standardised data extraction form and quality assessment based on QUADAS‐2 specific to the clinical context. Estimates of diagnostic accuracy were determined using the bivariate hierarchical method to produce summary points of sensitivity and specificity with 95% confidence regions. Comparative accuracy of different radiograph methods was conducted based on indirect and direct comparisons between methods. Potential sources of heterogeneity were pre‐specified and explored visually and more formally through meta‐regression.
Main results
We included 104 datasets from 77 studies reporting a total of 15,518 tooth sites or surfaces. The most frequently reported imaging methods were analogue radiographs (55 datasets from 51 studies) and digital radiographs (42 datasets from 40 studies) followed by cone beam computed tomography (CBCT) (7 datasets from 7 studies). Only 17 studies were of an in vivo study design, carried out in a clinical setting. No studies were considered to be at low risk of bias across all four domains but 16 studies were judged to have low concern for applicability across all domains. The patient selection domain had the largest number of studies judged to be at high risk of bias (43 studies); the index test, reference standard, and flow and timing domains were judged to be at high risk of bias in 30, 12, and 7 studies respectively.
Studies were synthesised using a hierarchical bivariate method for meta‐analysis. There was substantial variability in the results of the individual studies, with sensitivities that ranged from 0 to 0.96 and specificities from 0 to 1.00. For all imaging methods the estimated summary sensitivity and specificity point was 0.47 (95% confidence interval (CI) 0.40 to 0.53) and 0.88 (95% CI 0.84 to 0.92), respectively. In a cohort of 1000 tooth surfaces with a prevalence of enamel caries of 63%, this would result in 337 tooth surfaces being classified as disease free when enamel caries was truly present (false negatives), and 43 tooth surfaces being classified as diseased in the absence of enamel caries (false positives). Meta‐regression indicated that measures of accuracy differed according to the imaging method (Chi2(4) = 32.44, P < 0.001), with the highest sensitivity observed for CBCT, and the highest specificity observed for analogue radiographs. None of the specified potential sources of heterogeneity were able to explain the variability in results. No studies included restored teeth in their sample or reported the inclusion of sealants.
We rated the certainty of the evidence as low for sensitivity and specificity and downgraded two levels in total for risk of bias due to limitations in the design and conduct of the included studies, indirectness arising from the in vitro studies, and the observed inconsistency of the results.
Authors' conclusions
The design and conduct of studies to determine the diagnostic accuracy of methods to detect and diagnose caries in situ are particularly challenging. Low‐certainty evidence suggests that imaging for the detection or diagnosis of early caries may have poor sensitivity but acceptable specificity, resulting in a relatively high number of false‐negative results with the potential for early disease to progress. If left untreated, the opportunity to provide professional or self‐care practices to arrest or reverse early caries lesions will be missed. The specificity of lesion detection is however relatively high, and one could argue that initiation of non‐invasive management (such as the use of topical fluoride), is probably of low risk.
CBCT showed superior sensitivity to analogue or digital radiographs but has very limited applicability to the general dental practitioner. However, given the high‐radiation dose, and potential for caries‐like artefacts from existing restorations, its use cannot be justified in routine caries detection. Nonetheless, if early incidental carious lesions are detected in CBCT scans taken for other purposes, these should be reported. CBCT has the potential to be used as a reference standard in diagnostic studies of this type.
Despite the robust methodology applied in this comprehensive review, the results should be interpreted with some caution due to shortcomings in the design and execution of many of the included studies. Future research should evaluate the comparative accuracy of different methods, be undertaken in a clinical setting, and focus on minimising bias arising from the use of imperfect reference standards in clinical studies.
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