Cochrane · intervention · CD013826
Preprocedural mouth rinses for preventing transmission of infectious diseases through aerosols in dental healthcare providers
Kumbargere Nagraj, S, Eachempati, P, Paisi, M, et al. · Cochrane Database of Systematic Reviews · 2022 · Cochrane Library
Full textEvery question was extracted from the full review (methods and results), not only its Summary of Findings table.
Questions
56
current version
GRADE rated
40
No studies
5
Included studies
17
as reported
No studies 5 · 8.9%Ungraded 11 · 19.6%Very low 35 · 62.5%Low 5 · 8.9%Moderate 0 · 0%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 | Dental patients undergoing aerosol-generating procedures | 17 studies with 830 participants aged 18 to 70 years. Eleven trials from India; three from the USA; two from Brazil; one from Puerto Rico. All published in English. |
| Intervention | Any preprocedural rinse that aimed to reduce contaminated aerosols in dental clinics | Chlorhexidine (n=10); Cetylpyridinium chloride (n=4); Essential oils/herbal mouthwash (n=5); Povidone iodine (n=3); Boric acid (n=1) |
| Comparison | Placebo, no mouth rinse or another mouth rinse | No rinsing (n=4); Water (n=9); Saline (n=3); Ozonated water (n=1) |
| Outcomes | Incidence of infection of dental healthcare providers; Reduction in the level of contamination by particles larger than 5 µm (droplets) at distances of less than 2 m from patient's oral cavity; Reduction in the level of contamination by particles of 5 µm or less (droplet nuclei) at distances of 2 m or more from patient's oral cavity; Cost; Change of microbiota in the patient's mouth; Adverse events; Acceptability and feasibility of the intervention | Incidence of infection of dental healthcare providers (n=0); Reduction in the level of contamination by particles larger than 5 µm at distances of less than 2 m (n=16); Reduction in the level of contamination by particles 5 µm or less at distances of 2 m or more (n=3); Cost (n=0); Change of microbiota in the patient's mouth (n=0); Adverse events (n=0); Acceptability and feasibility of the intervention (n=0) |
| Study designs | Randomized controlled trials (parallel-arm or cluster-RCT) in dental patients; cross-over trials included for secondary objectives with first-period data as parallel-arm | Not reported |
| Timing | Not specified | Not reported |
Search date: 2022-02. Databases: Cochrane Oral Health's Trials Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE Ovid; Embase Ovid; WHO COVID-19 Global literature on coronavirus disease database; Cochrane COVID-19 Study Register
Questions and results
Current version onlyAny preprocedural mouth rinse vs Placebo, no rinsing or control
Population: Dental patients undergoing aerosol-generating procedures (AGPs)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Adverse events such as transient discolouration, altered taste, allergic reaction, hypersensitivity | SoF tables state 'Not reported'; no included study reported adverse events. | 0 studies | No studies |
Change of microbiota in the patient's mouth | No included study reported change of oral microbiota. | 0 studies | No studies |
Incidence of infection of dental healthcare providers | Primary outcome. Not measured by any of the 17 included studies (SoF tables state 'Not reported'); remained a total evidence gap from the protocol. | 0 studies | No studies |
Acceptability and feasibility of the intervention to patients and dental healthcare providers | No included study assessed acceptability or feasibility. | 0 studies | No studies |
Cost | No included study reported cost. | 0 studies | No studies |
Chlorhexidine (CHX) vs No rinsing
Population: Dental patients undergoing aerosol-generating procedures (AGPs) and the dental healthcare providers treating them
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity operator level | At operator level, because of high heterogeneity (I2 = 89%), which could not be explained, the results were not meta-analysed (2 studies, 60 participants; Feres 2010, Retamal-Valdes 2017). No pooled estimate or GRADE… | 2 studies · 60 participants | Ungraded |
Chlorhexidine (CHX) vs Water (distilled)
Population: Dental patients undergoing aerosol-generating procedures (AGPs) and the dental healthcare providers treating them
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity operator level | At operator level, because of high heterogeneity (I2 = 98%), the results were not meta-analysed (6 studies, 196 participants). No pooled estimate or GRADE rating. | 6 studies · 196 participants | Ungraded |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity combined patient and operator level | MD -632.94 [-1267.33, 1.45] -632.94 [-1267.33, 1.45] CFUs | 3 studies · 80 participants | Very low Downgraded: risk of bias, imprecision, inconsistency |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity tempered CHX; combined operator, assistant and patient level | MD -101.1 [-107.01, -95.19] -101.1 [-107.01, -95.19] CFUs | 1 study · 20 participants | Low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity patient level (pharynx; not analysed) | Bay 1993 compared 0.12% CHX with distilled water (30-second rinse) and evaluated the outcome at patient level (Andersen's level 2, oropharynx); the data were not included in the meta-analysis. No pooled estimate or… | 1 study | Ungraded |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity assistant level | At assistant level, because of high heterogeneity (I2 = 96%), the results were not meta-analysed (4 studies, 136 participants). No pooled estimate or GRADE rating. | 4 studies · 136 participants | Ungraded |
Chlorhexidine (CHX) vs Saline
Population: Dental patients undergoing aerosol-generating procedures (AGPs) and the dental healthcare providers treating them
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity 3 feet from patient's mouth | MD -668.4 [-1044.45, -292.35] | 1 study · 20 participants | Ungraded |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity operator level | MD -21.33 [-36.8, -5.86] -21.33 [-36.8, -5.86] CFUs | 1 study · 12 participants | Very low Downgraded: risk of bias, imprecision |
Chlorhexidine (CHX) vs Essential oils/herbal mouthwash
Population: Dental patients undergoing aerosol-generating procedures (AGPs) and the dental healthcare providers treating them
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity 15 cm from mouth (essential oil mouthwash B) | MD -44.1 [-59.12, -29.08] | 1 study · 20 participants | Ungraded |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity pharynx level (patient level; not analysed) | Bay 1993 compared 0.12% CHX with essential oil mouthwash C (Listerine) at pharynx level (Andersen's level 2), which was considered patient level and hence was not analysed. No pooled estimate or GRADE rating. | 1 study | Ungraded |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity assistant level | MD -12.21 [-15.58, -8.83] -12.21 [-15.58, -8.83] CFUs | 3 studies · 76 participants | Low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity operator level | MD -23.09 [-34.4, -11.78] -23.09 [-34.4, -11.78] CFUs | 3 studies · 76 participants | Low Downgraded: risk of bias, imprecision |
Chlorhexidine (CHX) vs Povidone iodine
Population: Dental patients undergoing aerosol-generating procedures (AGPs) and the dental healthcare providers treating them
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Reduction in level of contamination by particles <=5 um (droplet nuclei) at >=2 m from patient's oral cavity droplet nuclei; aerobic cultures (9 feet behind patient) | MD 0.2 [-7.28, 7.68] 0.2 [-7.28, 7.68] CFUs | 1 study · 40 participants | Very low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity operator level; aerobic and anaerobic cultures combined | MD -4.7 [-7.01, -2.39] -4.7 [-7.01, -2.39] CFUs | 1 study · 30 participants | Very low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles <=5 um (droplet nuclei) at >=2 m from patient's oral cavity droplet nuclei; anaerobic cultures (9 feet behind patient) | MD -0.8 [-11.65, 10.05] -0.8 [-11.65, 10.05] CFUs | 1 study · 40 participants | Very low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity operator level; aerobic cultures | MD -10.75 [-26.24, 4.74] -10.75 [-26.24, 4.74] CFUs | 2 studies · 52 participants | Very low Downgraded: risk of bias, imprecision |
Chlorhexidine (CHX) vs Cetylpyridinium chloride (CPC)
Population: Dental patients undergoing aerosol-generating procedures (AGPs) and the dental healthcare providers treating them
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity cold CHX vs tempered CPC; assistant level | MD 17.4 [11.3, 23.5] 17.4 [11.3, 23.5] CFUs | 1 study · 20 participants | Very low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity cold CHX vs cold CPC; assistant level | MD 8.8 [2.7, 14.9] 8.8 [2.7, 14.9] CFUs | 1 study · 20 participants | Very low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity tempered CHX vs cold CPC; operator level | MD -11.5 [-18.37, -4.63] -11.5 [-18.37, -4.63] CFUs | 1 study · 20 participants | Very low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity tempered CHX vs tempered CPC; operator level | MD -2.2 [-9.07, 4.67] -2.2 [-9.07, 4.67] CFUs | 1 study · 20 participants | Very low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity tempered CHX vs cold CPC; assistant level | MD -8.8 [-14.9, -2.7] -8.8 [-14.9, -2.7] CFUs | 1 study · 20 participants | Very low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity CHX 0.12% vs CPC+Zn+F; operator level | MD -30 [-85.86, 25.86] -30 [-85.86, 25.86] CFUs | 1 study · 30 participants | Very low Downgraded: imprecision, inconsistency |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity tempered CHX vs tempered CPC; assistant level | MD -0.2 [-6.3, 5.9] -0.2 [-6.3, 5.9] CFUs | 1 study · 20 participants | Very low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity cold CHX vs tempered CPC; operator level | MD 13.6 [6.73, 20.47] 13.6 [6.73, 20.47] CFUs | 1 study · 20 participants | Very low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity cold CHX vs cold CPC; operator level | MD 4.43 [-2.27, 11.13] 4.43 [-2.27, 11.13] CFUs | 2 studies · 50 participants | Very low Downgraded: risk of bias, imprecision |
Tempered chlorhexidine vs Non-tempered chlorhexidine
Population: Dental patients undergoing aerosol-generating procedures (AGPs) and the dental healthcare providers treating them
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity combined operator, assistant and patient level | MD -10.8 [-15.15, -6.45] -10.8 [-15.15, -6.45] CFUs | 1 study · 20 participants | Very low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity assistant level | MD -17.6 [-23.7, -11.5] -17.6 [-23.7, -11.5] CFUs | 1 study · 20 participants | Very low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity operator level | MD -15.8 [-22.67, -8.93] -15.8 [-22.67, -8.93] CFUs | 1 study · 20 participants | Very low Downgraded: risk of bias, imprecision |
Cetylpyridinium chloride (CPC) vs No rinsing
Population: Dental patients undergoing aerosol-generating procedures (AGPs) and the dental healthcare providers treating them
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity CPC vs no rinsing; operator level | MD -34.8 [-65.92, -3.68] -34.8 [-65.92, -3.68] CFUs | 1 study · 30 participants | Very low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity CPC+Zn+F vs no rinsing; operator level | MD -583 [-958.36, -207.64] -583 [-958.36, -207.64] CFUs | 1 study · 30 participants | Low Downgraded: imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity CPC + domiphen bromide + quaternary ammonium vs no rinsing; combined | MD -0.75 [-1.32, -0.18] -0.75 [-1.32, -0.18] CFUs | 2 studies · 200 participants | Very low Downgraded: risk of bias, imprecision |
Cetylpyridinium chloride (CPC) vs Water
Population: Dental patients undergoing aerosol-generating procedures (AGPs) and the dental healthcare providers treating them
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity CPC+Zn+F vs water; operator level | MD -246 [-437.96, -54.04] -246 [-437.96, -54.04] CFUs | 1 study · 30 participants | Low Downgraded: imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity CPC + domiphen bromide + quaternary ammonium vs water; combined | MD -0.78 [-1.24, -0.31] -0.78 [-1.24, -0.31] CFUs | 1 study · 105 participants | Very low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity CPC vs water; operator level | MD -48.7 [-67.82, -29.58] -48.7 [-67.82, -29.58] CFUs | 1 study · 30 participants | Very low Downgraded: risk of bias, imprecision |
Tempered cetylpyridinium chloride vs Cold cetylpyridinium chloride
Population: Dental patients undergoing aerosol-generating procedures (AGPs) and the dental healthcare providers treating them
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity operator level | MD -9.3 [-16.17, -2.43] -9.3 [-16.17, -2.43] CFUs | 1 study · 20 participants | Very low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity assistant level | MD -8.6 [-14.7, -2.5] -8.6 [-14.7, -2.5] CFUs | 1 study · 20 participants | Very low Downgraded: risk of bias, imprecision |
Povidone iodine vs Saline
Population: Dental patients undergoing aerosol-generating procedures (AGPs) and the dental healthcare providers treating them
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity operator level | MD -16.5 [-32.65, -0.35] -16.5 [-32.65, -0.35] CFUs | 1 study · 12 participants | Very low Downgraded: risk of bias, imprecision |
Essential oil/herbal mouthwash vs Water
Population: Dental patients undergoing aerosol-generating procedures (AGPs) and the dental healthcare providers treating them
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity patient level (pharynx; not analysed) | Bay 1993 compared essential oil mouthwash C (Listerine) with distilled water and reported combined CFUs at different levels using Andersen's air sampler; level 2 (pharynx) was considered patient level and was not… | 1 study | Ungraded |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity operator level | At operator level, because of high heterogeneity (I2 = 98%), the results were not meta-analysed (3 studies; Gupta 2014, Nayak 2020, Shetty 2013). No pooled estimate or GRADE rating. | 3 studies | Ungraded |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity assistant level | At assistant level, because of high heterogeneity (I2 = 99%), the results were not meta-analysed (3 studies; Gupta 2014, Nayak 2020, Shetty 2013). No pooled estimate or GRADE rating. | 3 studies | Ungraded |
Chlorhexidine (CHX) vs Ozonated water
Population: Dental patients undergoing aerosol-generating procedures (AGPs) and the dental healthcare providers treating them
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Reduction in level of contamination by particles <=5 um (droplet nuclei) at >=2 m from patient's oral cavity droplet nuclei; anaerobic cultures | MD -3.4 [-14.66, 7.86] -3.4 [-14.66, 7.86] CFUs | 1 study · 40 participants | Very low Downgraded: risk of bias, imprecision, inconsistency |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity operator level; aerobic cultures | MD -17.8 [-33.7, -1.9] -17.8 [-33.7, -1.9] CFUs | 1 study · 40 participants | Very low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles <=5 um (droplet nuclei) at >=2 m from patient's oral cavity droplet nuclei; aerobic cultures | MD -12.3 [-27.12, 2.52] -12.3 [-27.12, 2.52] CFUs | 1 study · 40 participants | Very low Downgraded: risk of bias, imprecision, inconsistency |
Povidone iodine vs Ozonated water
Population: Dental patients undergoing aerosol-generating procedures (AGPs) and the dental healthcare providers treating them
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Reduction in level of contamination by particles <=5 um (droplet nuclei) at >=2 m from patient's oral cavity droplet nuclei; aerobic cultures | MD -12.5 [-26.33, 1.33] -12.5 [-26.33, 1.33] CFUs | 1 study · 40 participants | Very low Downgraded: risk of bias, imprecision, inconsistency |
Reduction in level of contamination by particles <=5 um (droplet nuclei) at >=2 m from patient's oral cavity droplet nuclei; anaerobic cultures | MD -2.6 [-9.54, 4.34] -2.6 [-9.54, 4.34] CFUs | 1 study · 40 participants | Very low Downgraded: risk of bias, imprecision, inconsistency |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity operator level; aerobic cultures | MD 3.5 [-17.1, 24.1] 3.5 [-17.1, 24.1] CFUs | 1 study · 40 participants | Very low Downgraded: risk of bias, imprecision, inconsistency |
Chlorhexidine (CHX) vs Boric acid
Population: Dental patients undergoing aerosol-generating procedures (AGPs) and the dental healthcare providers treating them
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity operator level | MD -26.6 [-28.24, -24.96] -26.6 [-28.24, -24.96] CFUs | 1 study · 60 participants | Very low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity assistant level | MD -8.03 [-9.65, -6.41] -8.03 [-9.65, -6.41] CFUs | 1 study · 60 participants | Very low Downgraded: risk of bias, imprecision |
Boric acid vs Water
Population: Dental patients undergoing aerosol-generating procedures (AGPs) and the dental healthcare providers treating them
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity operator level | MD -29.3 [-32.65, -25.95] -29.3 [-32.65, -25.95] CFUs | 1 study · 60 participants | Very low Downgraded: risk of bias, imprecision |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity assistant level | MD -14.04 [-16.47, -11.61] -14.04 [-16.47, -11.61] CFUs | 1 study · 60 participants | Very low Downgraded: risk of bias, imprecision |
Essential oil mouthwash C (Listerine) vs Coloured and flavoured 5% hydroalcohol mouthwash
Population: Dental patients undergoing aerosol-generating procedures (AGPs) and the dental healthcare providers treating them
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity operator level; aerobic culture (cross-over; graph-only, not analysed) | One study (Fine 1993a) compared essential oil mouthwash C (Listerine) with coloured and flavoured 5% hydroalcohol mouthwash in a cross-over design for reduction in contamination by particles >5 um at operator level… | 1 study | Ungraded |
Any preprocedural mouth rinse vs Placebo, no rinsing or control
Population: Dental patients undergoing aerosol-generating or aerosol-inducing procedures (AGPs/AIPs) randomised to mouth rinses
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Cost | Protocol only: planned outcome; no studies included (protocol stage). | NR | No studies |
Adverse events such as transient discolouration, altered taste, allergic reaction, hypersensitivity | Protocol only: planned outcome; no studies included (protocol stage). | NR | No studies |
Incidence of infection of dental healthcare providers (dentists, dental surgery assistants, dental hygienists, dental technologists, dental laboratory staff, dental aides or trainee students) | Protocol only: planned outcome; no studies included (protocol stage). | NR | No studies |
Reduction in level of contamination by particles <=5 um (droplet nuclei) at >=2 m from patient's oral cavity | Protocol only: planned outcome; no studies included (protocol stage). | NR | No studies |
Acceptability and feasibility of the intervention to patients and dental healthcare providers | Protocol only: planned outcome; no studies included (protocol stage). | NR | No studies |
Reduction in level of contamination by particles >5 um (droplets) at <2 m from patient's oral cavity | Protocol only: planned outcome; no studies included (protocol stage). | NR | No studies |
Change of microbiota in the patient's mouth | Protocol only: planned outcome; no studies included (protocol stage). | NR | No studies |