Cochrane · intervention · CD012628
Oral hygiene interventions for people with intellectual disabilities
Waldron, C, Nunn, J, Mac Giolla Phadraig, C, et al. · Cochrane Database of Systematic Reviews · 2019 · Cochrane Library
Full textEvery question was extracted from the full review (methods and results), not only its Summary of Findings table.
Questions
31
current version
GRADE rated
27
No studies
2
Included studies
34
as reported
No studies 2 · 6.5%Ungraded 2 · 6.5%Very low 14 · 45.2%Low 12 · 38.7%Moderate 1 · 3.2%High 0 · 0%
Ungraded means an effect was reported without a GRADE rating; it is not a gap. No studies means the review found nothing to answer the question. The six categories are a display order, not a score.
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | People with an ID, living at home, in day care, in hospital or in a residential care setting; all intellectual disabilities as defined by ICD-10 | 1795 people with ID and 354 carers across 34 studies; children and adults with mild to profound ID; settings home, residential, day care, school (n=34) |
| Intervention | Oral hygiene-related knowledge-based interventions for participants or their carers; Oral hygiene-related behavioural interventions for participants or their carers; Oral hygiene-related skills training for participants; Oral hygiene-related skills training for carers | Special manual toothbrush (n=7); Electric toothbrush (n=13); Oral hygiene care training of carers (n=7); Oral hygiene training of people with ID (n=6); Scheduled dental recall intervals plus supervised toothbrushing (n=1); Discussion of clinical photographs as motivator (n=1); Daily/twice-weekly/once-weekly toothbrushing frequency (n=1); Toothpaste with a plaque-disclosing agent (n=1); Individualised oral care plan (n=1) |
| Comparison | Usual care; No care; Similar alternative intervention | Conventional manual toothbrush (n=7); Manual toothbrush (n=13); No training of carers (n=7); No oral hygiene training (n=6); Usual care (n=3); No discussion of photographs (n=1); Conventional toothpaste (n=1) |
| Outcomes | Primary: Gingival health of people with ID. Secondary: Oral hygiene skills acquisition; Oral hygiene knowledge acquisition; Adherence to oral hygiene routines; Quality of life or long-term patient-centred outcomes (e.g. tooth retention); Dental caries levels; Any unintended (positive or negative) effects | Gingival inflammation; Plaque; Gingival bleeding; Gingival pocketing; Calculus; Oral health assessment and bacteria levels; Oral health knowledge; Behaviour, attitude and self-efficacy; Quality of life (n=0); Dental caries (n=0) |
| Study designs | Randomised controlled trials (including cluster-RCTs); non-randomised studies (non-randomised controlled trials, controlled before-after studies, interrupted time series studies, repeated measures studies) | 19 RCTs including cluster-RCTs and cross-over trials (n=19); 15 non-randomised studies: non-randomised controlled trials, controlled before-after, interrupted time series (n=15) |
| Timing | Short-term follow-up (<6 weeks); Medium-term follow-up (6 weeks to 12 months); Long-term follow-up (>12 months) | Short term (<6 weeks); Medium term (6 weeks to 12 months); Long term (>12 months) |
Search date: 2019-02. Databases: Cochrane Oral Health's Trials Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE Ovid (from 1946 onwards); Embase Ovid (previous six months to date); PsycINFO Ovid (from 1806 onwards)
Questions and results
Current version onlyOral hygiene interventions (mechanical plaque removal): knowledge-based, behavioural, or skills training for people with ID or their carers vs Usual care, no care, or a similar alternative intervention
Population: People with intellectual disabilities (ID), living at home, in day care, in hospital or in a residential care setting; all levels of ID as defined by ICD-10
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Any unintended (positive or negative) effects of the interventions | Adverse/unintended effects addressed narratively: 10 of 34 studies investigated or reported negative unintended or adverse effects (e.g. difficulty with the electric or 3-headed toothbrushes, being frightened by the… | 10 studies | Ungraded |
Dental caries levels of people with ID | No studies measured dental caries levels. One RCT (Shaw 1991, Comparison 5) assessed DMFT at baseline only and did not report caries at any later time point. | 0 studies | No studies |
Quality of life changes or long-term, patient-centred outcomes (e.g. tooth retention) | No studies measured quality of life changes or long-term, patient-centred outcomes as formal outcomes; some studies commented on quality of life only in the discussion or conclusion sections. | 0 studies | No studies |
Special manual toothbrush (self, carer or carer-assisted brushing) vs Conventional manual toothbrush (self, carer or carer-assisted brushing)
Population: Children and adults with mixed levels of ID; setting home, residential, day care, school, mixed or not specified
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Behaviour, attitude and self-efficacy (carer experience) (medium term) Medium term (6 weeks to 12 months) | Comparison 1.6 (graded in the Effects of interventions text; not tabulated in the SoF). Bildt 2010, Superbrush vs conventional, 4 months, 18 participants (1 RCT): carer handling of toothbrush MD 0.50 (95% CI -0.35 to… | 1 study · 18 participants | Very low Downgraded: risk of bias, imprecision |
Oral health assessment and oral bacteria levels (medium term) Medium term (6 weeks to 12 months) | Comparison 1.5 (graded in the Effects of interventions text; not tabulated in the SoF). Single-use suction toothbrush vs standard manual toothbrush (both with a chemical agent), 90 days, Ferozali 2007: Total Oral… | 1 study · 22 participants | Very low Downgraded: risk of bias, imprecision |
Plaque (short term) Short term (<6 weeks) | MD 0.20 [-0.45, 0.85] | 1 study · 25 participants | Very low Downgraded: imprecision |
Gingival inflammation (short term) Short term (<6 weeks) | MD -0.10 [-0.77, 0.57] | 1 study · 25 participants | Low Downgraded: imprecision |
Plaque (medium term) Medium term (6 weeks to 12 months) | MD -0.44 [-0.93, 0.05] | 1 study · 18 participants | Very low Downgraded: risk of bias, imprecision |
Gingival inflammation (medium term) Medium term (6 weeks to 12 months) | MD -12.40 [-24.31, -0.49] | 1 study · 18 participants | Very low Downgraded: risk of bias, imprecision |
Electric toothbrush (self, carer or carer-assisted brushing) vs Manual toothbrush (self, carer or carer-assisted brushing)
Population: Children and adults with mixed levels of ID; setting home, residential, day care, school, mixed or not specified
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Plaque (medium term) Medium term (6 weeks to 12 months) | SMD 0.29 [-0.07, 0.65] | 2 studies · 120 participants | Low Downgraded: risk of bias, imprecision |
Behaviour, attitude and self-efficacy (participant/carer preference) Long term (>12 months) | Comparison 2.8 (reported; not GRADE-rated). One NRS (Bratel 1991, 23 participants), self-efficacy at 16 months: 10/12 people with ID using the electric toothbrush reported a preference for it, finding it easier to use… | 1 study · 23 participants | Ungraded |
Gingival inflammation (short term) Short term (<6 weeks) | Electric vs manual toothbrush. Assorted gingival indices scale 0-4, 2-4 weeks; 252 participants (4 RCTs); Low. Four studies showed no significant differences for gingival inflammation short term; data could not be… | 4 studies · 252 participants | Low Downgraded: risk of bias |
Gingival inflammation (medium term) Medium term (6 weeks to 12 months) | MD 0.02 [-0.06, 0.09] | 2 studies · 120 participants | Moderate Downgraded: risk of bias |
Plaque (short term) Short term (<6 weeks) | Assorted plaque indices scale 0-5, 1-4 weeks; 247 participants (4 RCTs); Very Low. Uncertain effect on plaque short term: 2 studies (69 participants) favoured the electric toothbrush; 2 studies (178 participants)… | 4 studies · 247 participants | Very low Downgraded: risk of bias, inconsistency |
Calculus (medium term) Medium term (6 weeks to 12 months) | SMD -0.04 [-0.40, 0.32] | 2 studies · 120 participants | Low Downgraded: risk of bias, imprecision |
Oral hygiene care training of carers vs No training (or a placebo training session) of carers
Population: People with mixed levels of ID (age range unclear); setting residential
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Plaque (medium term) Medium term (6 weeks to 12 months) | MD -0.07 [-0.26, 0.13] | 2 studies · 99 participants | Low Downgraded: risk of bias |
Behaviour, attitude and self-efficacy of carers (medium term) Medium term (6 weeks to 12 months) | MD 0.15 [-0.80, 1.10] | 2 studies · 189 participants | Very low Downgraded: risk of bias, inconsistency |
Oral health knowledge of carers (medium term) Medium term (6 weeks to 12 months) | MD 0.69 [0.31, 1.06] | 2 studies · 189 participants | Low Downgraded: risk of bias |
Gingival inflammation (medium term) Medium term (6 weeks to 12 months) | MD -0.09 [-0.63, 0.45] | 2 studies · 99 participants | Low Downgraded: risk of bias, inconsistency |
Oral hygiene training (toothbrushing routine) of people with ID vs No oral hygiene training of people with ID
Population: Children and adults with mild to profound ID; setting residential or school
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Plaque (short term) Short term (<6 weeks) | MD -0.47 [-0.92, -0.02] | 1 study · 10 participants | Very low Downgraded: risk of bias, imprecision |
Behaviour, attitude and self-efficacy (toothbrushing behaviour) (medium and long term) Long term (>12 months) | Behaviour, attitude and self-efficacy (steps achieved in a toothbrushing routine), 100 days to 19 months; 59 participants (4 NRS); Very Low. Results not in a format for meta-analysis: 3 NRS (56 participants) reported… | 4 studies · 59 participants | Very low Downgraded: risk of bias |
Gingival inflammation (short term) Short term (<6 weeks) | MD -0.28 [-0.90, 0.34] | 1 study · 10 participants | Very low Downgraded: risk of bias, imprecision |
Scheduled dental recall intervals (1-, 3- or 6-monthly; oral hygiene instruction with or without scale and polish) plus daily supervised toothbrushing by carers vs Usual care (no specific treatment)
Population: Adults (mean age 30.9 years), level of ID unclear; setting day centre
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Gingival pocketing (long term) Long term (>12 months) | MD -0.60 [-0.97, -0.23] | 1 study · 304 participants | Low Downgraded: risk of bias, imprecision |
Plaque (long term) Long term (>12 months) | MD -0.70 [-1.28, -0.12] | 1 study · 304 participants | Low Downgraded: risk of bias, imprecision |
Calculus (long term) Long term (>12 months) | MD -2.00 [-2.64, -1.36] | 1 study · 304 participants | Low Downgraded: risk of bias, imprecision |
Gingival bleeding (long term) Long term (>12 months) | MD -0.20 [-0.86, 0.46] | 1 study · 304 participants | Low Downgraded: risk of bias, imprecision |
Discussion of individual clinical photographs (plaque highlighted by a disclosing agent) as an oral hygiene motivator, plus oral hygiene instruction vs No discussion of clinical photographs, but received the same oral hygiene instruction
Population: People with ID (level of ID and age unclear); setting day centre
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Plaque (medium term) Medium term (6 weeks to 12 months) | MD -0.10 [-0.85, 0.65] | 1 study · 29 participants | Very low Downgraded: risk of bias, imprecision |
Daily toothbrushing by a dental student vs Twice-weekly or once-weekly toothbrushing by a dental student
Population: People aged 15 to 30 years with mixed levels of ID; setting residential
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Gingival inflammation (short term) Short term (<6 weeks) | Daily vs twice-weekly or once-weekly toothbrushing by dental students. Buccal and labial Loe & Silness index, mean 21 days; 80 participants (1 RCT); Low. Brushing daily most likely reduced gingival inflammation more… | 1 study · 80 participants | Low Downgraded: imprecision |
Toothpaste with a plaque-disclosing agent vs Conventional toothpaste
Population: Children aged 7 to 13 years with Down syndrome (mild to moderate ID); setting residential
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Plaque (short term) Short term (<6 weeks) | Simplified Green & Vermillion Oral Hygiene Index (plaque), mean 10 days; percent mean difference 65 (intervention) vs 15 (control), P<0.0001 favouring the disclosing-agent toothpaste; 40 participants (SoF states 80,… | 1 study · 40 participants | Very low Downgraded: risk of bias |
Gingival inflammation (short term) Short term (<6 weeks) | Toothpaste with a plaque-disclosing agent vs conventional toothpaste, children with Down syndrome. Ainamo & Bay Gingival Bleeding Index, mean 10 days; percent mean difference 18 (intervention) vs 8 (control), P<0.001… | 1 study · 40 participants | Very low Downgraded: risk of bias |
Individualised oral care plan based on a multidisciplinary assessment vs Usual care (regular oral hygiene care following the institution's standard guidelines)
Population: Adults aged 22 to 57 years with mixed levels of ID; setting residential
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Plaque (medium term) Medium term (6 weeks to 12 months) | Individualised oral care plan vs usual care. Subjective Oral Hygiene Rating scale 1-5 and Improvement Differential, mean 12 months; SOHR 2.97 (intervention) vs 3.10 (control); improvement differential 38% vs 5%; 79… | 1 study · 79 participants | Very low Downgraded: risk of bias |
Oral hygiene interventions (mechanical plaque removal): knowledge-based, behavioural, or skills training for people with ID or their carers vs Usual care, no care, or a similar alternative intervention
Population: People with intellectual disabilities (ID), living at home, in day care, in hospital or in a residential care setting; all levels of ID as defined by ICD-10
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Oral hygiene knowledge acquisition by people with ID, or by their carers | Protocol stage (Waldron 2017): planned secondary outcome (oral hygiene knowledge acquisition); no eligible studies or results reported at protocol stage. | 0 studies | No studies |
Adherence to oral hygiene routines by people with ID or their carers | Protocol stage (Waldron 2017): planned secondary outcome (adherence to oral hygiene routines); no eligible studies or results reported at protocol stage. | 0 studies | No studies |
Dental caries levels of people with ID | Protocol stage (Waldron 2017): planned secondary outcome (dental caries levels); no eligible studies or results reported at protocol stage. | 0 studies | No studies |
Any unintended (positive or negative) effects of the interventions | Protocol stage (Waldron 2017): planned secondary outcome (unintended / adverse effects); no eligible studies or results reported at protocol stage. | 0 studies | No studies |
Oral hygiene skills acquisition by people with ID, or by their carers | Protocol stage (Waldron 2017): planned secondary outcome (oral hygiene skills acquisition); no eligible studies or results reported at protocol stage. | 0 studies | No studies |
Quality of life changes or long-term, patient-centred outcomes (e.g. tooth retention) | Protocol stage (Waldron 2017): planned secondary outcome (quality of life / long-term patient-centred outcomes); no eligible studies or results reported at protocol stage. | 0 studies | No studies |
Gingival health of people with ID (primary outcome) | Protocol stage (Waldron 2017): planned primary outcome (gingival health); no eligible studies or results reported at protocol stage. | 0 studies | No studies |