Non-Cochrane · umbrella · PM41265469
Effect of Adjunctive Use of Commercial Daily Mouthwashes on Periodontal Health: An Umbrella Review.
Koromantzos Panagiotis A, Bobetsis Yiorgos A, Giota Chrysoula, et al. · Journal of clinical periodontology · 2026 · PubMed · doi:10.1111/jcpe.70061
Findings
41 findings
| Population | ||||
|---|---|---|---|---|
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Essential oil (EO) mouthrinse adjunct to mechanical oral hygiene | Placebo, vehicle or negative control rinse plus mechanical oral hygiene | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Figuero 2019; pairwise MA, EO in alcoholic solution (EEOO) | The first group (11 RCTs, 1009 participants) had an alcoholic solution of EO; in both EO groups, GI improved, but not significantly High Downgraded: inconsistency 11 studies · 1009 participants |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Essential oil (EO) mouthrinse adjunct to mechanical oral hygiene | Placebo, vehicle or negative control rinse plus mechanical oral hygiene | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Van Leeuwen 2014; 4 RCTs; EOMW versus V-Sol; Loe and Silness GI | MD 0.36 [0.26, 0.62] High 4 studies |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Essential oil (EO) mouthrinse adjunct to mechanical oral hygiene | Placebo, vehicle or negative control rinse plus mechanical oral hygiene | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Figuero 2019; pairwise MA, EO in non-alcoholic solution (EEOO_noAlc) | The second group (one RCT, 107 subjects) had a non-alcoholic solution of EO; in both EO groups, GI improved, but not significantly High Downgraded: inconsistency 1 study · 107 participants |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Essential oil (EO) mouthrinse adjunct to mechanical oral hygiene | Placebo, vehicle or negative control rinse plus mechanical oral hygiene | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Figuero 2019; network MA, EO (EEOO) | Statistically significant differences were found between EO and EO in no-alcohol solution versus placebo both in MA and NMA High Downgraded: inconsistency Studies not reported |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Essential oil (EO) mouthrinse adjunct to mechanical oral hygiene | Placebo, vehicle or negative control rinse plus mechanical oral hygiene | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Van Leeuwen 2014; EOMW versus V-Sol; modified gingival index (MGI) | MD 0.17 [0.08, 0.25] High Studies not reported |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Essential oil (EO) mouthrinse adjunct to mechanical oral hygiene | Placebo, vehicle or negative control rinse plus mechanical oral hygiene | Plaque index 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Haas 2016; 14 RCTs, proximal area (Table 4) | MD -0.95 [-1.26, -0.63] Low Downgraded: risk of bias, inconsistency, publication bias 14 studies |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Essential oil (EO) mouthrinse adjunct to mechanical oral hygiene | Placebo, vehicle or negative control rinse plus mechanical oral hygiene | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Gunsolley 2006; 17 RCTs, EO agents only | SMD 0.762 Moderate Downgraded: risk of bias, publication bias 17 studies |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Essential oil (EO) mouthrinse adjunct to mechanical oral hygiene | Placebo, vehicle or negative control rinse plus mechanical oral hygiene | Plaque index 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Gunsolley 2006; 20 RCTs (25 arms), EO agents only | SMD 0.852 Moderate Downgraded: risk of bias, publication bias 20 studies |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Essential oil (EO) mouthrinse adjunct to mechanical oral hygiene | Placebo, vehicle or negative control rinse plus mechanical oral hygiene | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Haas 2016; 11 RCTs, MGI, proximal area (Table 4) | MD -0.34 [-0.53, -0.15] Low Downgraded: risk of bias, inconsistency, publication bias 11 studies |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Essential oil (EO) mouthrinse adjunct to mechanical oral hygiene | Placebo, vehicle or negative control rinse plus mechanical oral hygiene | Plaque index 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Van Leeuwen 2014; 4 RCTs; EO mouthrinse (EOMW) versus vehicle solution V-Sol; 6-month brushing studies, Turesky-modified QH | MD 0.39 [0.3, 0.47] High 4 studies |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Essential oil (EO) mouthrinse adjunct to mechanical oral hygiene | Placebo, vehicle or negative control rinse plus mechanical oral hygiene | Plaque index 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Haas 2016; relative extra reduction | Relative reduction (%) 32 Low Downgraded: risk of bias, inconsistency, publication bias 14 studies |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Essential oil (EO) mouthrinse adjunct to mechanical oral hygiene | Placebo, vehicle or negative control rinse plus mechanical oral hygiene | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Figuero 2019; network MA, EO in no-alcohol solution (EEOO_noAlc) | Statistically significant differences were found between EO and EO in no-alcohol solution versus placebo both in MA and NMA High Downgraded: inconsistency Studies not reported |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Essential oil (EO) mouthrinse adjunct to mechanical oral hygiene | Placebo, vehicle or negative control rinse plus mechanical oral hygiene | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Haas 2016; relative extra reduction | Relative reduction (%) 24 Low Downgraded: risk of bias, inconsistency, publication bias 11 studies |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | EO mouthrinse plus mechanical plaque control | Mechanical plaque control alone | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Araujo 2015; responder analysis, at least 50% healthy sites | 44.8% of participants using an EO-containing mouthwash achieved at least 50% healthy sites versus 14.4% in subjects performing only mechanical plaque control 14.4% vs 44.8% High 29 studies · 5106 participants |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | EO mouthrinse plus mechanical plaque control | Mechanical plaque control alone | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Araujo 2015; healthy sites (healthier mouth) | OR 7.8 [5.4, 11.2] High 29 studies · 5106 participants |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | EO mouthrinse plus mechanical plaque control | Mechanical plaque control alone | Plaque index 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Araujo 2015; plaque-free sites (cleaner mouth) | OR 5.0 [3.3, 7.5] High 29 studies · 5106 participants |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | EO mouthrinse plus mechanical plaque control | Mechanical plaque control alone | Plaque index 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Araujo 2015; responder analysis, at least 50% plaque-free sites Unresolved: the two extractors disagree on this row. | 36.9% of participants using an EO-containing mouthwash achieved at least 50% plaque-free sites versus 5.5% in subjects performing only mechanical plaque control 5.5% vs 36.9% GRADE not reported Studies not reported |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | EO mouthrinse plus mechanical plaque control | Mechanical plaque control alone | Plaque index 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Araujo 2015; percentage reduction in plaque at 6 months | Percentage reduction (%) 27.7 [22.4, 32.9] High Downgraded: inconsistency 29 studies · 5106 participants |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | EO mouthrinse plus mechanical plaque control | Mechanical plaque control alone | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Araujo 2015; percentage reduction in gingivitis at 6 months (point estimate as printed is inconsistent with its CI) | The percentage reductions in gingivitis and plaque at 6 months were 6.0 (95% CI: 11.3-20.7) and 27.7 (95% CI: 22.4-32.9), respectively High 29 studies · 5106 participants |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | EO mouthrinse adjunct to mechanical plaque control | Cetylpyridinium chloride (CPC) mouthrinse adjunct to mechanical plaque control | Plaque index 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Haas 2016; MA comparing EO and CPC, Quigley-Hein | MD -0.75 Low Downgraded: risk of bias, inconsistency, publication bias Studies not reported |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | EO mouthrinse adjunct to mechanical plaque control | Cetylpyridinium chloride (CPC) mouthrinse adjunct to mechanical plaque control | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Haas 2016; MA comparing EO and CPC, MGI | MD -0.52 Low Downgraded: risk of bias, inconsistency, publication bias Studies not reported |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | EO mouthrinse adjunct to mechanical plaque control | Flossing adjunct to toothbrushing | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Haas 2016; interproximal area | When EO was compared to brushing and flossing ... there was no significant difference regarding gingivitis Low Downgraded: risk of bias, inconsistency, publication bias Studies not reported |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | EO mouthrinse adjunct to mechanical plaque control | Flossing adjunct to toothbrushing | Plaque index 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Haas 2016; interproximal area | When EO was compared to brushing and flossing regarding levels of plaque in the interproximal area, there was significantly lower levels in favour of EO Low Downgraded: risk of bias, inconsistency, publication bias Studies not reported |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | CPC mouthrinse adjunct to toothbrushing | Toothbrushing alone or with placebo rinse | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Gunsolley 2006; CPC agents, 7 RCTs (4 of 7 significant) Unresolved: the two extractors disagree on this row. | Four out of seven RCTs showed a statistically significant improvement in GI for the CPC group; concentrations varied (0.045%-0.07%) GRADE not reported 7 studies |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | CPC mouthrinse adjunct to toothbrushing | Toothbrushing alone or with placebo rinse | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Figuero 2019; pairwise MA, CPC concentration <=0.05% (CPC_L) | In four RCTs (429 participants), CPC concentration was <=0.05% (CPC_L)... In all RCTs, CPC reduced the GI but failed to reach statistical significance High Downgraded: inconsistency 4 studies · 429 participants |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | CPC mouthrinse adjunct to toothbrushing | Toothbrushing alone or with placebo rinse | Plaque index 6 weeks to 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Haps 2008; 6 RCTs, end scores, Quigley-Hein | MD 0.5 Low Downgraded: risk of bias, imprecision, inconsistency, publication bias 6 studies |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | CPC mouthrinse adjunct to toothbrushing | Toothbrushing alone or with placebo rinse | Plaque index 6 weeks to 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Langa 2021; 9 RCTs, Turesky-modified QH | MD -0.7 [-0.83, -0.57] Low Downgraded: risk of bias, inconsistency, publication bias 9 studies · 720 participants |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | CPC mouthrinse adjunct to toothbrushing | Toothbrushing alone or with placebo rinse | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Figuero 2019; pairwise MA, CPC concentration >0.05% (CPC_H) | In three RCTs (292 participants) the concentration was > 0.05% (CPC_H)... In all RCTs, CPC reduced the GI but failed to reach statistical significance High Downgraded: inconsistency 3 studies · 292 participants |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | CPC mouthrinse adjunct to toothbrushing | Toothbrushing alone or with placebo rinse | Gingival inflammation (gingival index) 6 weeks to 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Langa 2021; 9 RCTs, Loe and Silness GI | MD -0.38 [-0.47, -0.28] Low Downgraded: risk of bias, inconsistency, publication bias 9 studies · 720 participants |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | CPC mouthrinse adjunct to toothbrushing | Toothbrushing alone or with placebo rinse | Gingival inflammation (gingival index) 6 weeks to 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Haps 2008; 6 RCTs, end scores | MD 0.25 Low Downgraded: risk of bias, imprecision, inconsistency, publication bias 6 studies |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Low-concentration chlorhexidine (CHX, <0.10%) mouthrinse | Placebo or negative control rinse | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Figuero 2019; pairwise MA, CHX_L | A reduction, although not statistically significant, in GI was reported; however, the data were derived only from a single RCT including 33 participants High Downgraded: inconsistency 1 study · 33 participants |
| Adults with gingivitis (periodontal status not always reported) | Sodium fluoride (NaF) mouthrinse as adjunct to mechanical oral hygiene | Placebo or negative control | Gingival index (GI) Figuero et al. 2019 SR | Non-significant benefit in reducing the GI (3 RCTs, 732 participants) High 3 studies · 732 participants |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Thiocyanate/carbamide peroxide (SCN_H2O2) mouthrinse | Placebo or negative control rinse | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Figuero 2019; pairwise MA, SCN_H2O2 | For both antimicrobial agents, there was only a non-significant benefit in reducing the GI; one RCT (140 participants) for SCN_H2O2 High Downgraded: inconsistency 1 study · 140 participants |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Vehicle solution (V-Sol, hydro-alcohol) mouthrinse | Water control (negative control) | Plaque index 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Van Leeuwen 2014; V-Sol versus water control (WC) | MD 0.04 GRADE not reported Studies not reported |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Vehicle solution (V-Sol, hydro-alcohol) mouthrinse | Water control (negative control) | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Van Leeuwen 2014; V-Sol versus water control (WC) | MD 0.03 GRADE not reported Studies not reported |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Commercial daily mouthrinse agents (network: EO, CPC, CHX, AmF_SnF, alexidine, delmopinol and others) | Placebo or negative control rinse | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Figuero 2019; network meta-analysis, GI, SUCRA ranking | The ranking of treatments according to SUCRA results from best to worst was as follows: EO in no-alcohol solution, EO, high-concentration CPC, low-concentration CHX, AmF_SnF, low-concentration CPC, alexidine,… High Downgraded: inconsistency 21 studies · 5775 participants |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Commercial daily mouthrinse agents (network: EO, CPC, CHX, AmF_SnF, alexidine, delmopinol and others) | Placebo or negative control rinse | Plaque index 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Figuero 2019; plaque control (SR-level GRADE only; no estimate in the umbrella review) Unresolved: the two extractors disagree on this row. | no estimate extracted High Studies not reported |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | High-concentration CHX (>=0.12%) mouthrinse | Placebo or negative control rinse | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Figuero 2019; network MA, CHX_H | Statistically significant differences were found between CHX_H, EEOO, EEOO_noAlc and tric_cop versus placebo both in the PMA and in the NMA High Downgraded: inconsistency Studies not reported |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | High-concentration CHX (>=0.12%) mouthrinse | Placebo or negative control rinse | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Figuero 2019; pairwise MA, CHX_H | Statistically significant differences were found between CHX_H, EEOO, EEOO_noAlc and tric_cop versus placebo both in the PMA and in the NMA High Downgraded: inconsistency Studies not reported |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Triclosan/copolymer mouthrinse | Placebo or negative control rinse | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Figuero 2019; network MA, triclosan/copolymer (tric_cop) | Statistically significant differences were found between CHX_H, EEOO, EEOO_noAlc and tric_cop versus placebo both in the PMA and in the NMA High Downgraded: inconsistency Studies not reported |
| Adults with gingivitis or no periodontal diagnosis, not under periodontal therapy | Triclosan/copolymer mouthrinse | Placebo or negative control rinse | Gingival inflammation (gingival index) 6 months · Umbrella review of SRs/MAs of RCTs; adjunct to mechanical plaque control · Included SR: Figuero 2019; pairwise MA, triclosan/copolymer (tric_cop) | Statistically significant differences were found between CHX_H, EEOO, EEOO_noAlc and tric_cop versus placebo both in the PMA and in the NMA High Downgraded: inconsistency Studies not reported |
Included primary studies 7
Open in Studies| Study | Year | Also included by | Outcomes it informs here | Trial data |
|---|---|---|---|---|
| Araujo 2015 Meta-analysis of the effect of an essential oil-containing mouthrinse on gingivitis and plaque. PMID:26227646 | 2015 | this review only | not stated | not extracted yet |
| Figuero 2019 Efficacy of adjunctive anti-plaque chemical agents in managing gingivitis: A systematic review and network meta-analyses. PMID:31058336 | 2019 | this review only | not stated | not extracted yet |
| Gunsolley 2006 A meta-analysis of six-month studies of antiplaque and antigingivitis agents. PMID:17138709 | 2006 | this review only | not stated | not extracted yet |
| Haas 2016 Essential oils-containing mouthwashes for gingivitis and plaque: Meta-analyses and meta-regression. PMID:27628316 | 2016 | this review only | not stated | not extracted yet |
| Haps 2008 The effect of cetylpyridinium chloride-containing mouth rinses as adjuncts to toothbrushing on plaque and parameters of gingival… PMID:19138180 | 2008 | this review only | not stated | not extracted yet |
| Langa 2021 The effect of cetylpyridinium chloride mouthrinse as adjunct to toothbrushing compared to placebo on interproximal plaque and gingival… PMID:33185736 | 2021 | this review only | not stated | not extracted yet |
| Van Leeuwen 2014 The effect of an essential-oils mouthrinse as compared to a vehicle solution on plaque and gingival inflammation: a systematic review and… PMID:24720368 | 2014 | this review only | not stated | not extracted yet |
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | Adults not currently under periodontal treatment, any periodontal diagnosis (gingivitis or periodontitis) | Adults, mostly systemically healthy with gingivitis; some SRs did not report periodontal status (7 SRs, 62 primary RCTs appearing 110 times) |
| Intervention | Commercially available over-the-counter daily mouthwash as adjunct to mechanical plaque control | Low-concentration CHX (n=1 SR), CPC (n=4 SRs), essential oil mouthwashes (n=5 SRs), fluoride (n=1), oxygen-releasing (n=1) |
| Comparison | Placebo mouthwash or mechanical oral hygiene alone (not a positive control such as CHX 0.12%) | Placebo, vehicle solution, water control, mechanical plaque control alone |
| Outcomes | Plaque index (PI); gingival index (GI) or bleeding index (BI, modified BI) | Plaque index and gingival or bleeding indices |
| Study designs | Systematic reviews/meta-analyses of randomized controlled trials | 7 systematic reviews/meta-analyses of RCTs (n=7) |
| Timing | No time limit on mouthwash use | Follow-up 3 weeks to 6 months or longer |
AMSTAR 2 items
Two independent extractors rated each item. Their ratings are shown side by side because they have not been reconciled yet. The overall rating follows Shea et al. 2017: one critical flaw gives Low, more than one gives Critically Low.
| Item | Extractor A | Extractor B | Agree |
|---|---|---|---|
| 1Research question includes PICO components | NR | Yes | no |
| 2Protocol established before the reviewcritical | NR | Partial Yes | no |
| 3Choice of study designs explained | NR | No | no |
| 4Comprehensive literature searchcritical | NR | Partial Yes | no |
| 5Study selection in duplicate | NR | Yes | no |
| 6Data extraction in duplicate | NR | No | no |
| 7List of excluded studies with reasonscritical | NR | Yes | no |
| 8Included studies described in detail | NR | Yes | no |
| 9Risk of bias assessed satisfactorilycritical | NR | RCT: Yes · NRSI: N/A | no |
| 10Funding of included studies reported | NR | No | no |
| 11Appropriate meta-analysis methodscritical | NR | RCT: N/A · NRSI: N/A | no |
| 12Impact of risk of bias on the pooled results | NR | N/A | no |
| 13Risk of bias accounted for in interpretationcritical | NR | Yes | no |
| 14Heterogeneity explained | NR | Yes | no |
| 15Publication bias investigatedcritical | NR | N/A | no |
| 16Conflicts of interest reported | NR | No | no |
| Overall | NR | Moderate | no |