Teeth and gums: periodontal treatment and daily oral hygiene

Marinho et al. (2003; PMID 12535435): 70 randomized or quasi-randomized trials with blind outcome assessment, 42,300 children; fluoride toothpaste prevented 24% of new decayed, missing and filled surfaces (95% CI 21 to 28%). In populations with 2.6 new surfaces a year, 1.6 children brushing with fluoride toothpaste for 3 years prevented one decayed, missing or filled surface; with 1.1 a year, 3.7 children did. Walsh et al. (2019; PMID 30829399): 1,000 to 1,250 ppm against non-fluoride toothpaste, SMD -0.28 (55 studies, high and moderate certainty). Rule et al. (1984; PMID 6088166) and Murray and Shaw (1980; PMID 6989549) are two independent trials. Hard endpoint An outcome that matters directly to a person and is counted without judgment, such as death, heart attack, stroke or fracture. counted by examiners, replicated The same finding reproduced by a separate research group. A result seen once can be chance or bias; a replicated one is harder to explain away.: A.

Walsh et al. (2019; PMID 30829399): in adults of all ages, 1,000 or 1,100 ppm fluoride toothpaste reduced the decayed, missing and filled surfaces increment against non-fluoride toothpaste (mean difference -0.53, 95% CI -1.02 to -0.04; 3 studies, 2,162 participants, moderate certainty). Jensen and Kohout (1988; PMID 3204243): double-blind Neither the participants nor the people assessing them know who received the real treatment until the trial ends. trial in 810 healthy adults aged 54 and older; 1,100 ppm fluoride toothpaste lowered coronal caries by 41% and root surface caries by 67% over 1 year against a control toothpaste. Only three adult trials, with a small pooled difference, and the indexed records do not show two independent groups: B.

Simpson et al. (2022; PMID 35420698): 35 trials, 3,249 participants; HbA1c 0.43% lower 3 to 4 months after treatment (95% CI -0.59% to -0.28%; 30 studies, moderate certainty), 0.30% lower at 6 months (12 studies) and 0.50% lower at 12 months (1 study, 264 participants). D'Aiuto et al. (2018; PMID 30472992): 264 adults with type 2 diabetes, HbA1c 0.6% lower after 12 months of intensive treatment against supragingival cleaning. Against this, DPTT (Engebretson et al., 2013; PMID 24346989), 514 participants at 5 academic centers, was stopped early for futility: HbA1c difference -0.05% at 6 months (P = .55). The Veterans Affairs trial (Jones et al., 2007; PMID 17137468), 165 veterans, found no significant benefit at 4 months. HbA1c is a surrogate, which caps the row at B; one large trial was null.

Yaacob et al. (2014; PMID 24934383): 56 trials, 51 with data (4,624 participants). Powered brushes reduced plaque (short term SMD -0.50, 40 trials; long term SMD -0.47, 14 trials) and gingivitis (short term SMD -0.43, 44 trials; long term SMD -0.21, 16 trials), moderate quality evidence, corresponding to an 11% and 21% plaque reduction and a 6% and 11% gingivitis reduction. Heterogeneity How much the results of the pooled trials differ from each other. High heterogeneity makes a combined estimate less reliable. was high and the review states the clinical importance remains unclear. Plaque and gum indices stand in for tooth loss, which was not measured: B.

Worthington et al. (2019; PMID 30968949): 35 trials, 3,929 adults. Flossing plus toothbrushing may reduce gingivitis at one month (SMD -0.58, 8 trials, 585 participants, low certainty); bleeding and plaque results were inconsistent (very low certainty). Interdental brushes may reduce plaque more than toothbrushing alone (2 trials, 93 participants, low certainty). No trial assessed cavities between teeth and most did not assess periodontitis; the review states the effect sizes How large a difference the treatment made, as distinct from whether the difference could be detected at all. may not be clinically important. The earlier review (Sambunjak et al., 2011; PMID 22161438; 12 trials) found a 0.13 point reduction at 1 month on the 0 to 3 gingivitis scale. Low and very low certainty, small effects: C.

Luo et al. (2021; PMID 34897644), Cochrane review of 8 trials: no evidence of a difference in blood pressure for most comparisons. Artery function (flow-mediated dilatation): Tonetti et al. (2007; PMID 17329698; 120 patients) found it worse 24 hours after treatment and better at 60 and 180 days (difference 2.0% at 180 days); Lobo et al. (2020; PMID 31810741; 48 patients after heart attack) found improvement at 6 months; Saffi et al. (2018; PMID 29873864; 69 patients with coronary disease) found no difference at 3 months. Surrogate endpoints A lab value or measurement used in place of the outcome that matters, such as LDL cholesterol standing in for heart attacks. Moving a surrogate does not always move the outcome., mixed results: C.

Sen et al., PREMIERS (2023; PMID 37548008): 280 patients after stroke or transient ischemic attack; death, myocardial infarction and recurrent stroke occurred in 8% with intensive and 12% with standard periodontal treatment, hazard ratio How often an event happened in the treated group compared with the control group over the same period. A ratio of 0.80 means 20 percent fewer events. 0.65 (95% CI 0.30 to 1.38), not superior. Ye et al. (2022; PMID 36194420), Cochrane: two trials, both at high risk of bias, no new trials since 2019; no reliable evidence for secondary prevention and very low certainty for primary prevention. The PAVE pilot (Couper et al., 2008; PMID 18166096) randomized 303 patients with coronary heart disease to test feasibility. Trials run, no benefit shown on events: D on Route 2 Human randomized trials have been run and did not show benefit on the stated outcome. One of the two routes to the lowest letter on EBL's scale..

Three large independent trials found no reduction in preterm birth: Michalowicz et al. (2006; PMID 17079762), Offenbacher et al., MOTOR (2009; PMID 19701034) and Newnham et al. (2009; PMID 19935025). Iheozor-Ejiofor et al. (2017; PMID 28605006), Cochrane, 15 trials: no clear difference in preterm birth; low-quality evidence that treatment may reduce low birth weight (9.70% against 12.60%; RR 0.67). Polyzos et al. (2010; PMID 21190966): low-quality trials supported a benefit while high-quality trials showed none (preterm birth OR 1.15; low birth weight OR 1.07). Gum health improved in every trial. Replicated null on preterm birth: D on Route 2.

Yoneyama et al. (2002; PMID 11943036): 417 residents of 11 Japanese nursing homes; toothbrushing after each meal plus weekly professional care reduced pneumonia, febrile days and death from pneumonia. Larger later trials did not repeat this: Juthani-Mehta et al. (2015; PMID 25520333; 834 residents, 36 Connecticut nursing homes), brushing plus chlorhexidine plus upright feeding, stopped for futility (first pneumonia 27.4% against 23.5%, HR 1.12); Zimmerman et al. (2020; PMID 32558913; 2,152 residents, 14 North Carolina homes), no significant reduction over 2 years; Hollaar et al. (2017; PMID 28629318; 103 residents with swallowing problems), chlorhexidine rinse did not reduce aspiration pneumonia. Cao et al. (2022; PMID 36383760), Cochrane, 6 trials (6,244 participants), all at high risk of bias: insufficient evidence of a difference in pneumonia (low certainty); pneumonia deaths lower in two small trials (RR 0.43, 95% CI 0.25 to 0.76; 454 participants, low certainty); no difference in all-cause death. Early positive trials, failed replication: C.