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KSR Number: KSRA89490

Routine scale and polish for periodontal health in adults

  • Cochrane Database Syst Rev 2018, 12, CD004625, 10.1002/14651858.CD004625.pub5
  • Full report

Risk of Bias Assessment

Overall summary: Low risk of bias in the review

Bottom Line

Limited evidence suggests that regular scale and polish treatments (at 6-month or 12-month intervals) may reduce the level of calculus on teeth compared to no treatment, and that these reductions may be more substantial with a shorter interval between treatments (6-months instead of 12-months). Participants' self-reported perception of oral cleanliness appears to be higher for regular scale and polish treatment compared to no treatment. There was little to no difference reported in gingivitis/gingival bleeding, plaque, probing depths, oral health-related quality of life or costs from an NHS perspective for regular scale and polish treatment compared to no treatment. However, these conclusions should be interpreted with some caution, as the involvement of only one reviewer in some data extractions means reviewer error and bias cannot be ruled out. Further large, high-quality studies are required to provide additional evidence to support these conclusions, particularly with respect to adverse events.

Risk of Bias Assessment

Overall summary Low risk of bias in the review

Low

One or two review authors were involved in data extraction; this was considered inadequate to minimise error and bias. However, all other domains were considered to be at low risk.

A. Did the interpretation of findings address all of the concerns identified in Domains 1 to 4? Probably no
B. Was the relevance of identified studies to the review's research question appropriately considered? Probably yes
C. Did the reviewers avoid emphasizing results on the basis of their statistical significance? Probably yes
Risk of bias in the review Low

Details of Review

Number of studies 2
Number of participants 1711
Last search date 10 January 2018
Review type Intervention
Objective To determine the beneficial and harmful effects of routine scaling and polishing for periodontal health, including at different recall intervals and when provided by dentists compared with dental care professionals (dental therapists or dental hygienists).
Population Dentate adults regularly attending for dental care in primary settings.

Studies in patients with severe peridontal disease (such as alveolar bone loss involving most teeth, or people requiring referral for specialist (surgical) periodontal treatment) or patients who had previously undergone specialist periodontal treatment and were in the post-treatment ’maintenance phase’ were excluded.
Interventions Routine scale and polish treatment with or without oral hygiene instruction that was provided by a dentist, dental hygienist or therapist at a planned, regular interval.
Comparator No scheduled scale and polish treatment; a scale and polish treatment given at a different planned, regular interval; a scale and polish treatment performed by a different type of dental professional.
Outcome Primary outcome: periodontal disease, assessed by gingivitis indices (both inflammatory and bleeding on probing).

Secondary outcomes: clinical status factors (calculus and plaque indices, changes in probing depths, changes in attachment level, periodontal indices, tooth loss or adverse events); participant-centred factors (Halitosis), participant satisfaction (for example, with oral comfort, oral cleanliness, appearance (including gingival recession), care received and provider of care (i.e. dentist, therapist or hygienist), oral-health related quality of life); economic cost factors (i.e. the costs of a scale and polish).
Study design Randomised controlled trials (RCTs) with at least six months of follow-up.

Split-mouth studies were excluded, as this does not reflect the manner in which a routine scale and polish is delivered in practice.

Results

In the comparison between planned, regular scale and polish (S&P) at 6- or 12-month intervals compared with no S&P, pooled analysis reported little to no difference in gingivitis/gingival bleeding for the duration of the trial (at 6-month intervals: standardised mean difference (SMD) -0.01, 95% confidence interval (CI) -0.13 to 0.11, 2 trials, n=1087 participants; at 12-month intervals: SMD -0.04, 95% CI -0.16 to 0.08, 2 trials, n=1091 participants). One study reported little to no difference in plaque (at 6-month intervals: mean difference (MD) -0.04%, 95% CI -0.13 to 0.05, 1 trial, n=207 participants; at 12-month intervals: MD 0.00%, 95% CI -0.10 to 0.09, 1 trial, n=200 participants), probing depths (at 6-month intervals: MD 0.00 mm, 95% CI -0.04 to 0.04, 1 trial, n=880 participants; at 12-month intervals: MD 0.00 mm, 95% CI -0.04 to 0.04, 1 trial, n=890 participants), oral health-related quality of life (at 6-month intervals: MD -0.30, 95% CI -1.24 to 0.64, 1 trial, n=795 participants; at 12-month intervals: MD 0.10, 95% CI (0.83 to 1.03, 1 trial, n=807 participants) or costs from an NHS perspective (at 6-month intervals: MD £0.52, 95% CI £-18.10 to £19.14, 1 trial, n=554 participants; at 12-month intervals: MD £8.14, 95% CI £-13.76 to £30.04, 1 trial, n=544 participant) for the duration of the trial.

Pooled analysis reported small reductions in calculus levels for planned, regular scale and polish (S&P) at 6- or 12-month intervals compared to no S&P (at 6-month intervals: SMD -0.32, 95% CI -0.44 to -0.20, 2 trials, n=1084 participants; at 12-month intervals: SMD -0.19, 95% CI -0.31 to -0.07, 2 trials, n=1088 participants). One study reported higher patient perception of oral cleanliness for planned, regular scale and polish (S&P) at 6- or 12-month intervals compared to no S&P (at 6-month intervals: risk ratio (RR) 1.83, 95% CI 1.28 to 2.63, 1 trial, n=205 participants; at 12-month intervals: RR 1.65, 95% CI 1.13 to 2.40, 1 trial, n=200 participants).

In the comparison between planned, regular scale and polish (S&P) at 6- or 12-month intervals vs. S&P at a different planned, regular interval, pooled analysis reported little or no difference in gingivitis/gingival bleeding (SMD -0.03, 95% CI -0.09 to 0.15, 2 trials, n=1090 participants) at 6-month intervals compared to 12-month intervals at 24 to 36 months of follow-up. One study reported little to no difference in plaque (MD -0.04%, 95% CI -0.13 to 0.05, 1 trial, n=207 participants), probing depths (MD 0.00 mm, 95% CI -0.04 to 0.04, 1 trial, n=882 participants), patient perception of oral cleanliness (RR 1.11, 95% CI 0.85 to 1.47, 1 trial, n=207 participants), oral health-related quality of life (MD -0.40, 95% CI -1.34 to 0.54, 1 trial, n=786 participants) or costs from an NHS perspective (MD £-7.62, 95% CI £-28.39 to £13.15, 1 trial, n=556 participants) at 6-month intervals compared to 12-month intervals at 24 to 36 months of follow up.

Pooled analysis reported small reductions in calculus levels for 6-month interval S&P compared to 12-month interval S&P (SMD -0.13, 95% CI -0.25 to -0.01, 2 trials, n=1086 participants) at 24 to 36 months of follow up.

No studies reported a comparison between S&P treatment provided by a dentist compared with a dental care professional (dental therapist or dental hygienist).

Full Risk of Bias Assessment

The objectives and eligibility criteria were clearly defined and appeared appropriate for the review question. No restrictions were placed on language, publication date or publication format. Restrictions were placed on outcomes; however, these were considered appropriate.

1.1 Did the review adhere to pre-defined objectives and eligibility criteria? Probably yes
1.2 Were the eligibility criteria appropriate for the review question? Probably yes
1.3 Were eligibility criteria unambiguous? Probably yes
1.4 Were all restrictions in eligibility criteria based on study characteristics appropriate (e.g. date, sample size, study quality, outcomes measured)? Probably yes
1.5 Were any restrictions in eligibility criteria based on sources of information appropriate (e.g. publication status or format, language, availability of data)? Probably yes
Concerns regarding specification of study eligibility criteria Low

Cochrane Oral Health's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid and Embase Ovid databases were searched to identify relevant literature. Clinicaltrials.gov and the World Health Organisation (WHO) clinical trials registry platform were searched to identify ongoing studies. The reference lists of all related review articles and all included full text articles were checked to identify additional studies. The authors of eligible studies and researchers in the field were contacted, where possible and necessary, to obtain information on additional unpublished or published studies. The search strategy was reported in full and appeared to be appropriate. No search restrictions were placed on date, publication format or language. Two authors were independently involved in title and abstract screening, and at least two authors were independently involved in screening at the full text stage; any disagreements were resolved through mutual discussion with additional team members.

2.1 Did the search include an appropriate range of databases/electronic sources for published and unpublished reports? Probably yes
2.2 Were methods additional to database searching used to identify relevant reports? Probably yes
2.3 Were the terms and structure of the search strategy likely to retrieve as many eligible studies as possible? Probably yes
2.4 Were restrictions based on date, publication format, or language appropriate? Probably yes
2.5 Were efforts made to minimise error in selection of studies? Probably yes
Concerns regarding methods used to identify and/or select studies Low

One or two review authors were involved in data extraction; this was considered inadequate to minimise error and bias. Sufficient study characteristics were provided to enable interpretation of the results. All relevant study results appear to have been collected for the synthesis. Risk of bias was assessed using the Cochrane tool for assessing risk of bias in randomised trials for standard randomised controlled trials; and further risk of bias domains were assessed for trials involving cluster randomisation. Two authors were independently involved in the risk of bias assessment.

3.1 Were efforts made to minimise error in data collection? Probably no
3.2 Were sufficient study characteristics considered for both review authors and readers to be able to interpret the results? Probably yes
3.3 Were all relevant study results collected for use in the synthesis? Probably yes
3.4 Was risk of bias (or methodological quality) formally assessed using appropriate criteria? Probably yes
3.5 Were efforts made to minimise error in risk of bias assessment? Probably yes
Concerns regarding methods used to collect data and appraise studies High

The synthesis appeared to included all relevant studies. All pre-defined analyses appeared to be reported. The synthesis appeared to be appropriate; meta-analysis was performed to pool studies where possible and appropriate, Heterogeneity was assessed using the I2 statistic, and was found to be low for all outcomes. Sensitivity or sub-group analyses were planned, but could not be performed due to the small number of included studies (<10); this was considered to be appropriate. Publication bias was not formally assessed due to the small number of included studies (<10); this was considered to be appropriate.

4.1 Did the synthesis include all studies that it should? Probably yes
4.2 Were all pre-defined analyses reported or departures explained? Probably yes
4.3 Was the synthesis appropriate given the degree of similarity in the research questions, study designs and outcomes across included studies? Probably yes
4.4 Was between-study variation minimal or addressed in the synthesis? Probably yes
4.5 Were the findings robust, e.g. as demonstrated through funnel plot or sensitivity analyses? Probably yes
4.6 Were biases in primary studies minimal or addressed in the synthesis? Probably yes
Concerns regarding synthesis and findings Low

Abstract

Abstract - 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; I 2 = 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. Plain language summary Routine scale and polish for periodontal health in adults Review question This review examined evidence for effects of routine scale and polish treatment. It was carried out by authors working with Cochrane Oral Health to assess the effects of routine scale and polish treatments for healthy adults; to establish whether different time intervals between treatments influence these effects; and to compare the effectiveness of the treatment when given by a dentist compared to a dental therapist or hygienist. This review updates the version published in 2013 and the evidence was up‐to‐date as of 10 January 2018. Background Scaling and polishing removes deposits such as plaque and calculus (tartar) from tooth surfaces. Over time, the regular removal of these deposits may reduce gingivitis (a mild form of gum disease) and prevent progression to periodontitis (severe gum disease). Routine scale and polish treatment is sometimes referred to as "prophylaxis", "professional mechanical plaque removal" or "periodontal instrumentation". Many dentists or hygienists provide scaling and polishing for most patients at regular i tervals even if the patients are considered to be at low risk of developing gum disease. There is debate about whether scaling and polishing is effective and the best interval between treatments. Scaling is an invasive procedure and has been associated with a number of negative side effects including damage to tooth surfaces and tooth sensitivity. For the purposes of this review, a 'routine scale and polish' was scaling and polishing of both the tooth and the root of the tooth to remove plaque deposits (mainly bacteria), and calculus. Calculus is so hard it cannot be removed by toothbrushing alone and this along with plaque, other debris and staining on the teeth is removed by the scale and polish treatment. Scaling or removal of hardened deposits is done with specially designed dental instruments or ultrasonic scalers, and polishing is done mechanically with special pastes. In this review, we included scaling above and below the gum level; however, we excluded any surgical procedure on the gums, any chemical washing of the space between gum and tooth (pocket) and root planing, which is more intense scraping of the root than simple scaling. Study characteristics We included two studies with a total of 1711 participants in our review. Both studies involved adults without severe periodontitis who were regular attenders at dental appointments in the UK. The studies were conducted in general dental practices, which is the most appropriate setting to evaluate 'routine scale and polish' treatments. One study measured outcomes at 24 months and one study at 36 months. Key results The studies found little or no difference between regular planned scale and polish treatments compared with no scheduled scale and polish for the early signs of gum disease (gingivitis or bleeding gums; plaque deposits; and probing depths or gum pockets). There was a small reduction in calculus (tartar) levels, but it was uncertain if this is important for patients or their dentists. Participants receiving six‐monthly and 12‐monthly scale and polish treatments reported feeling that their teeth were cleaner than those who were scheduled to receive no treatment. However, there did not seem to be a difference between groups in terms of quality of life. Available evidence on the costs of the treatments was uncertain. Neither of the studies measured side effects (such as damage to tooth surfaces and tooth sensitivity), changes in attachment level, tooth loss or halitosis (bad breath). Neither study compared scale and polish treatments provided by different professionals, e.g. dentists, dental therapists and hygienists. Certainty of the evidence We judged the certainty of the evidence to be high for gingivitis, probing depths, calculus and quality of life, but low for plaque, and low to very low for patient perception of oral cleanliness. The certainty of evidence for costs was very low. The high‐certainty evidence for gingivitis means that we can be confident that routine scale and polish does not significantly reduce the signs of mild gum disease when measured up to three years.