Full‐mouth treatment modalities (within 24 hours) for chronic periodontitis in adults

Joerg Eberhard; Sören Jepsen; Pia‐Merete Jervøe‐Storm; Ian Needleman; Helen V Worthington

doi:10.1002/14651858.CD004622.pub3

. 2015 Apr 17;2015(4):CD004622. doi: 10.1002/14651858.CD004622.pub3

Full‐mouth treatment modalities (within 24 hours) for chronic periodontitis in adults

Joerg Eberhard ^1,^✉, Sören Jepsen ², Pia‐Merete Jervøe‐Storm ², Ian Needleman ³, Helen V Worthington ⁴

Editor: Cochrane Oral Health Group

PMCID: PMC8687876 PMID: 25884249

Abstract

Background

Periodontitis is chronic inflammation that causes damage to the soft tissues and bones supporting the teeth. Mild to moderate periodontitis affects up to 50% of adults. Conventional treatment is quadrant scaling and root planing. In an attempt to enhance treatment outcomes, alternative protocols for anti‐infective periodontal therapy have been introduced: full‐mouth scaling (FMS) and full‐mouth disinfection (FMD), which is scaling plus use of an antiseptic. This review updates our previous review of full‐mouth treatment modalities, which was published in 2008.

Objectives

To evaluate the clinical effects of 1) full‐mouth scaling (over 24 hours) or 2) full‐mouth disinfection (over 24 hours) for the treatment of chronic periodontitis compared to conventional quadrant scaling and root planing (over a series of visits at least one week apart). A secondary objective was to evaluate whether there was a difference in clinical effect between full‐mouth disinfection and full‐mouth scaling.

Search methods

The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 26 March 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2015, Issue 2), MEDLINE via OVID (1946 to 26 March 2015), EMBASE via OVID (1980 to 26 March 2015) and CINAHL via EBSCO (1937 to 26 March 2015). We searched the US National Institutes of Health Trials Register (ClinicalTrials.gov) and the WHO International Clinical Trials Registry Platform for ongoing studies. There were no restrictions regarding language or date of publication in the searches of the electronic databases. We scanned reference lists from relevant articles and contacted the authors of eligible studies to identify trials and obtain additional information.

Selection criteria

We included randomised controlled trials (RCTs) with at least three months of follow‐up that evaluated full‐mouth scaling and root planing within 24 hours with adjunctive use of an antiseptic such as chlorhexidine (FMD) or without the use of antiseptic (FMS), compared to conventional quadrant scaling and root planing (control). Participants had a clinical diagnosis of chronic periodontitis according to the International Classification of Periodontal Diseases. We excluded studies of people with aggressive periodontitis, systemic disorders or who were taking antibiotics.

Data collection and analysis

Several review authors independently conducted data extraction and risk of bias assessment (which focused on method of randomisation, allocation concealment, blinding of examiners and completeness of follow‐up). Our primary outcome was tooth loss and secondary outcomes were change in probing pocket depth (PPD), bleeding on probing (BOP) and probing attachment (i.e. clinical attachment level; CAL), and adverse events. We followed the methodological guidelines of The Cochrane Collaboration.

Main results

We included 12 trials, which recruited 389 participants. No studies assessed the primary outcome tooth loss.

Ten trials compared FMS and control; three of these were assessed as being at high risk of bias, three as unclear risk and four as low risk. There was no evidence for a benefit for FMS over the control for change in probing pocket depth (PPD), gain in probing attachment (i.e. clinical attachment level; CAL) or bleeding on probing (BOP). The difference in changes between FMS and control for whole mouth PPD at three to four months was 0.01 mm higher (95% CI ‐0.17 to 0.19, three trials, 82 participants). There was no evidence of heterogeneity. The difference in changes for CAL was 0.02 mm lower (95% CI ‐0.26 to 0.22, three trials, 82 participants), and the difference in change in BOP was 2.86 per cent of sites lower (95% CI ‐7.65 to 1.93, four trials, 120 participants).

We included six trials in the meta‐analyses comparing FMD and control, with two trials assessed as being at high risk of bias, one as low and three as unclear. The analyses did not indicate a benefit for FMD over the control for PPD, CAL or BOP. The difference in changes for whole‐mouth PPD between FMD and control at three to four months was 0.13 mm higher (95% CI ‐0.09 to 0.34, two trials, 44 participants). There was no evidence of heterogeneity. The difference in changes for CAL was 0.04mm higher (95% CI ‐0.25 to 0.33, two trials, 44 participants) and the difference in change in BOP being 12.59 higher for FMD (95% CI ‐8.58 to 33.77, three trials, 68 participants).

Three trials were included in the analyses comparing FMS and FMD. The mean difference in PPD change at three to four months was 0.11 mm lower (‐0.34 to 0.12, two trials, 45 participants) indicating no evidence of a difference between the two interventions. There was a difference in the gain in CAL at three to four months (‐0.25 mm, 95% CI ‐0.42 to ‐0.07, two trials, 45 participants), favouring FMD but this was not found at six to eight months. There was no evidence for a difference between FMS and FMD for BOP (‐1.59, 95% CI ‐9.97 to 6.80, two trials, 45 participants).

Analyses were conducted for different teeth types (single‐ or multi‐rooted) and for teeth with different levels of probing depth at baseline, for PPD, CAL and BOP. There was insufficient evidence of a benefit for either FMS or FMD.

Harms and adverse events were reported in eight studies. The most important harm identified was an increased body temperature after FMS or FMD treatments.

We assessed the quality of the evidence for each comparison and outcome as 'low' because of design limitations leading to risk of bias and because of the small number of trials and participants, which led to imprecision in the effect estimates.

Authors' conclusions

The inclusion of five additional RCTs in this updated review comparing the clinical effects of conventional mechanical treatment with FMS and FMD approaches for the treatment of chronic periodontitis has not changed the conclusions of the original review. From the twelve included trials there is no clear evidence that FMS or FMD provide additional benefit compared to conventional scaling and root planing. In practice, the decision to select one approach to non‐surgical periodontal therapy over another should include patient preference and the convenience of the treatment schedule.

Plain language summary

Treating all teeth (full mouth) within 24 hours for chronic gum disease (periodontitis) in adults

Review question

Long lasting (chronic) gum disease causes damage to the gums and soft tissue structures around teeth. This review seeks to evaluate the effectiveness of full‐mouth treatments carried out within 24 hours compared to the more conventional treatment of partial mouth scaling and root planing (SRP) usually done over a number of weeks. The treatments being reviewed are full‐mouth scaling (FMS) and full‐mouth disinfection (FMD). A secondary aim was to establish if there was a difference in effectiveness between FMS and FMD. This review updates our previous review published in 2008.

Background

Gum disease or periodontitis is a chronic inflammatory disease that causes damage to the soft tissue and bone around the teeth. Mild periodontitis is common in adults with severe periodontitis occurring in up to 20% of the population. Non‐surgical treatments based on the mechanical removal of bacteria from infected root surfaces are used in order to arrest and control the loss of the bone and tissue that support the tooth in adults suffering from chronic gum disease. These treatments can be carried out in a different area of the mouth in separate sessions over a period of several weeks (SRP), which is the conventional method, or alternatively, can be done within 24 hours in one or two sessions, which is termed 'full‐mouth scaling' (FMS). When an antiseptic agent (such as chlorhexidine for example) is added to the full‐mouth scaling the intervention is called 'full‐mouth disinfection' (FMD). The rationale for full‐mouth approaches is that they may reduce the likelihood of re‐infection in already treated sites.

Study characteristics

This review, carried out within the Cochrane Oral Health Group, is an update of one we published in 2008 and the evidence is current up to March 2015. We identified another five relevant studies for inclusion in this review and therefore this review includes 12 studies, which involved 389 participants. There is one Chinese study awaiting classification. Participants in the included studies were aged between 27 and 78 years, and there were roughly the same number of men and women involved.

The studies we included had to be randomised controlled trials with at least three months of follow‐up that evaluated full‐mouth scaling and root planing within 24 hours. Both FMS and FMD were compared to conventional quadrant scaling and root planing, which was the control group. Participants had to have a clinical diagnosis of chronic periodontitis according to the International Classification of Periodontal Diseases. We excluded studies of people with aggressive periodontitis, systemic disorders or who were taking antibiotics.

Key results

Treatment effects of FMS and FMD compared to conventional scaling and root planing (SRP) are modest and there are no clear implications for periodontal care. Harms and adverse events were reported in eight studies. The most important harm identified was an increased body temperature after FMS or FMD treatments. In practice, the decision to select one approach to non‐surgical periodontal therapy over another can include patient preference and the convenience of the treatment schedule.

Quality of the evidence

The quality of the evidence is low for all treatment comparisons and outcomes. This is due to the small number of studies and participants involved and limitations in the study designs. Future research is likely to change findings.

Summary of findings

Background

Description of the condition

Periodontitis is a chronic inflammatory disease affecting the tissues surrounding the teeth characterised by a progressive loss of the alveolar bone. Periodontitis is caused by microorganisms that adhere to and grow on the tooth surfaces. Some 5% to 20% of the population suffer from severe, generalised periodontitis, though mild to moderate periodontitis affects the majority of adults (AAP 2005; Oliver 1991).

Periodontitis is seen as resulting from a complex interplay of bacterial infection and host response, modified by behavioural and systemic risk factors. In people with periodontitis, key pathogens such as Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis and Prevotella intermedia have been found to colonise nearly all niches in the oral cavity, such as the tongue, the mucosa, the saliva and the tonsils (Beikler 2004). Translocation of these pathogens may occur rapidly and a recently instrumented deep pocket might be re‐colonised from remaining untreated pockets or from other intraoral niches before a less pathogenic ecosystem can be established.

Description of the intervention

Conventional treatment involves scaling and root planing (SRP), which is done at several appointments over a period of weeks. There is considerable evidence to support SRP as an effective procedure for the treatment of infectious periodontal diseases (Heitz‐Mayfield 2002; Van der Weijden 2002). However, based on the risk of re‐colonisation hypothesis, a full‐mouth disinfection (FMD) approach, which consists of SRP of all pockets in two visits within 24 hours, in combination with adjunctive chlorhexidine treatments of all oral niches, has been proposed (Quirynen 2006). This was first evaluated in a series of studies by the same research group (Bollen 1998; Mongardini 1999; Vandekerckhove 1996). A later report indicated that this full‐mouth treatment approach resulted in superior clinical outcomes and microbiological effects than conventional quadrant SRP (control), irrespective of the adjunctive use of chlorhexidine (Quirynen 2000). More recent studies from other research centres, however, failed to demonstrate an advantage of full‐mouth scaling within 24 hours versus the control regimen (Apatzidou 2004; Del Peloso 2008; Jervøe‐Storm 2006; Knöfler 2007; Koshy 2005; Loggner Graff 2009; Swierkot 2009; Wennström 2005; Zanatta 2006; Zijnge 2010).

How the intervention might work

It is thought that the comprehensive reduction of bacteria from several oral niches by application of antiseptics within 24 hours will reduce the re‐colonisation of already treated sites leading to reductions of probing pocket depth and bleeding on probing, and gains in clinical attachment.

Why it is important to do this review

This is an update of a Cochrane review published in 2008 (Eberhard 2008a). Three other systematic reviews (Eberhard 2008b; Farman 2008; Lang 2008) have been conducted to assess the evidence for full‐mouth treatment modalities. A review article was published by the advocates of the full‐mouth treatment concept (Teughels 2009), which disagreed with the results of these reviews. Our review update includes the most recent studies on this topic and ensures the evidence base for this important clinical question is up to date.

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Randomised controlled clinical trials (RCTs) with at least three months follow‐up.

Types of participants

People with a clinical diagnosis of chronic periodontitis based on the International Classification of Periodontal Diseases (Armitage 1999). We did not include studies of people with aggressive periodontitis. Studies including only participants with systemic disorders were also excluded, as were studies including participants taking antibiotics.

Types of interventions

Full‐mouth scaling (FMS), comprising scaling and root planing of all quadrants within 24 hours
Full‐mouth disinfection (FMD), comprising scaling and root planing of all quadrants within 24 hours along with adjunctive antiseptic treatments (such as chlorhexidine), which could include rinsing, pocket irrigation, spraying of the tonsils and tongue brushing
Quadrant scaling and root planing (control), comprising SRP of each quadrant at a separate session, each session separated by an interval of at least one week

The comparisons were: FMS versus control, FMD versus control and FMS versus FMD.

Types of outcome measures

Primary outcomes

Tooth loss
Change in probing pocket depth after three to four months and six to eight months

Secondary outcomes

Change in clinical attachment level after three to four months and six to eight months
Change in bleeding on probing after three to four months and six to eight months
Adverse events

Search methods for identification of studies

Electronic searches

For the identification of studies for this review, we developed detailed search strategies for each database searched. These were based on the search strategy developed for MEDLINE (OVID) (Appendix 1) but revised appropriately for each database. The search strategy used a combination of controlled vocabulary and free text terms.

We searched the following electronic databases:

The Cochrane Oral Health Group Trials Register (to 26 March 2015) (Appendix 2)
The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 2) (Appendix 3)
MEDLINE via OVID (1946 to 26 March 2015) (Appendix 1)
EMBASE via OVID (1980 to 26 March 2015) (Appendix 4)
CINAHL via EBSCO (1937 to 26 March 2015) (Appendix 5)

A filter to limit the search to RCTs was not used as the yield was low. There were no restrictions on language or date of publication in the searches of the electronic databases.

Searching other resources

Incomplete information and ambiguous data were researched further by contacting the author and/or researcher responsible for the study directly. For unpublished material, the conference proceedings of the International Association for Dental Research (IADR), American Academy of Periodontology (AAP) and European Federation of Periodontology (EFP) were searched up to February 2014. Relevant 'in press' manuscripts were sought from Journal of Clinical Periodontology, Journal of Periodontology, Journal of Dental Research and Journal of Periodontal Research and by contact with the journal editors.

The following journals were handsearched:

Journal of Periodontology (1980 to 5 February 2014)
Journal of Clinical Periodontology (1980 to 5 February 2014)
Journal of Periodontal Research (1980 to 5 February 2014)

We searched the following databases for ongoing trials (see Appendix 6 for the search strategy):

US National Institutes of Health Trials Register (http://clinicaltrials.gov) (to 26 March 2015)
The WHO Clinical Trials Registry Platform (http://apps.who.int/trialsearch/default.aspx) (to 26 March 2015)

Data collection and analysis

Selection of studies

Titles and abstracts were downloaded to EndNote 9 software. Two review authors (JE and SJ) carried out the selection of papers and decisions about eligibility independently, in duplicate. Any disagreements were resolved by discussion. Data extraction and data entry into a computer were carried out by four review authors (PS, HW, JE and SJ). We recorded reasons for studies that were rejected at full‐text stage in Characteristics of excluded studies tables.

Data extraction and management

We extracted the following data:

General study characteristics: year of the study, country of origin, authors, funding, university/private practice based
Specific trial characteristics: population, diagnosis of chronic periodontitis, gender, age, severity of periodontal disease, inclusion and exclusion criteria not already stated
Primary outcomes: probing depth (after three months if available, otherwise the nearest assessment time point evaluation)
Secondary outcomes: attachment level and bleeding on probing before and after different treatment modalities (after three months if available, otherwise the nearest assessment time point evaluation)

Assessment of risk of bias in included studies

The methodological quality of included studies was assessed mainly using the risk of bias components shown to affect study outcomes including method of randomisation, allocation concealment and blinding of examiners. Completeness of outcome reporting, selective outcome reporting and other potential threats to validity were also examined. Risk of bias was used in sensitivity analyses to test the robustness of the conclusions but was not used to exclude studies qualifying for the review. We used the definitions of risk of bias categories from the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) (see Appendix 7).

To examine overall risk of bias for each study, we used all the domains of risk of bias. If all domains were at low risk, the study was deemed to be at low risk of bias. If any domains had an unclear risk then the study was classed as having an unclear risk of bias; however, if one or more domains were assessed as being at a high risk of bias, then so was the study.

Measures of treatment effect

We used change scores for the secondary outcomes as this is how the data were generally presented in these trials. If only post scores or covariance adjusted means were presented, these were included and a subgroup analysis was conducted for the different outcome measures. For continuous outcomes, we used mean differences (MD) and 95% confidence intervals (CI) to summarise the data for each group. For dichotomous outcomes, the estimates of effect of an intervention were expressed as risk ratios together with 95% CI.

Unit of analysis issues

Whole mouth, single‐rooted teeth and multi‐rooted teeth outcomes were the basis for data analysis, and we calculated means for all the primary and secondary outcomes. We did not feel that trials with a split‐mouth or cross‐over design were appropriate for this review due to potential carryover effects.

Dealing with missing data

We calculated missing standard deviations using the methods in Higgins 2011.

Assessment of heterogeneity

Prior to each meta analysis, we assessed heterogeneity by inspection of a graphical display of the estimated treatment effects from trials, along with Cochran's test for heterogeneity, and I² statistics.

Assessment of reporting biases

We gave consideration to the different types of reporting bias that might have been present in this review. If there had been more than 10 studies included in a meta‐analysis, we would have created a funnel plot to detect possible publication bias, although an asymmetrical funnel plot may be due to other factors. However, no single comparison of the present review included more than 10 studies.

Data synthesis

Where there were studies of similar comparisons reporting the same outcome measures, we performed a meta‐analysis. We combined risk ratios for dichotomous data, and mean differences for continuous data, using the random‐effects model.

We categorised teeth into the following groups for the meta‐analysis, as these categories are thought to have clinical relevance: whole mouth (all teeth), teeth that had moderate pocket depth at baseline, teeth that had deep pocket depth at baseline. These analyses were repeated for single‐rooted and multi‐rooted teeth separately for all outcomes, and for two outcome assessment times: three to four months and six to eight months after treatment. Based on current treatment concepts we categorised the pocket depth of 4 to 6 mm as moderate and 7 mm or more as deep. This is described in more detail for each study in the results section.

Subgroup analysis and investigation of heterogeneity

We conducted subgroup analyses for different outcome measures (post, change, covariance adjusted). The following factors were recorded to assess the clinical heterogeneity of outcomes across studies:

Plaque levels
Time allowed for treatment
Age of patients
Initial probing depth
Smoking status
Risk of bias

There were insufficient studies in any one comparison to investigate any clinical heterogeneity.

Sensitivity analysis

We conducted sensitivity analyses by analysing only studies assessed as having low risk of bias, and by excluding unpublished literature.

Results

Description of studies

Results of the search

Two review authors (from JE, SJ and HV) screened 370 titles and abstracts and rejected 345. The full text was obtained for 25 potentially eligible articles. Of these, 10 studies (11 articles) were excluded and one, in Chinese, awaits assessment. We included 12 trials (reported in 13 articles) (Figure 1). The 12 included trials were Apatzidou 2004; Del Peloso 2008; Jervøe‐Storm 2006; Knöfler 2007; Koshy 2005; Mongardini 1999; Quirynen 2006; Swierkot 2009; Vandekerckhove 1996; Wennström 2005; Zanatta 2006; and Zijnge 2010. The Mongardini 1999 trial was reported in two articles; one of the articles (Quirynen 2000) included a third group (described as FRp group) that was not randomised and therefore is not part of this review.

Included studies

Design

Nine of the included studies were conducted in Europe, two in Brazil (Del Peloso 2008; Zanatta 2006) and one in Japan (Koshy 2005). They were all parallel group trials of between 3 and 12 months duration.

Participants

In total, 389 patients were treated in the 12 included studies. They were all adults with chronic periodontitis, aged 23 to 75 years (one study did not specify the age range (Jervøe‐Storm 2006)). Three of the studies involved non‐smokers (Del Peloso 2008; Koshy 2005; Zijnge 2010); seven studies involved a mix of smokers and non‐smokers; and two studies were unclear about smoking status (Knöfler 2007; Zanatta 2006). The number of patients enrolled in the included studies ranged from 10 to 85. Seven trials had no drop‐outs and the other trials had drop‐outs ranging from 3% to 18%.

Interventions

Four studies included more than one comparison. The comparisons included in the trials were:

FMS versus control (10 trials): Apatzidou 2004; Del Peloso 2008; Jervøe‐Storm 2006; Knöfler 2007; Koshy 2005; Quirynen 2006; Swierkot 2009; Wennström 2005; Zanatta 2006; Zijnge 2010
FMD versus control (6 trials): Koshy 2005; Mongardini 1999; Quirynen 2006; Swierkot 2009; Vandekerckhove 1996; Zanatta 2006
FMS versus FMD (4 trials): Koshy 2005; Quirynen 2006; Swierkot 2009; Zanatta 2006

Outcomes

None of the studies measured tooth loss.

Eight studies (Apatzidou 2004; Del Peloso 2008; Koshy 2005; Mongardini 1999; Swierkot 2009; Vandekerckhove 1996; Wennström 2005; Zijnge 2010) reported information about adverse events or patient‐reported outcomes (see Table 4).

1. Adverse events and patient‐reported outcomes.

Study	Outcome
Apatzidou 2004	Visual analogue scale (0 ‐ 10) of pain, percentage of patients taking analgesics, number of analgesics, body temperature (axilla) all recorded after 24 and 48 hours. Occurence of labial herpes or oral ulcers recorded after 2 weeks
Del Peloso 2008	Body temperature (axilla), visual analogue scale (0 ‐ 10) of pain, reports of analgesics, reports of oral ulcerations or other adverse effects
Jervøe‐Storm 2006	Not reported
Knöfler 2007	Not reported
Koshy 2005	Visual analogue scale (1 ‐ 10) of pain, number of painkillers, body temperature (axilla) all recorded after treatment same day and next day
Mongardini 1999	Visual analogue scale of pain on a 10 cm scale, number of analgesics, body temperature (axilla) all recorded same and next day. Occurence of labial herpes or oral ulcers recorded during the first week
Quirynen 2006	Not reported
Swierkot 2009	Adverse events or side effects (none reported)
Vandekerckhove 1996	Questionnaire of pain, number of analgesics, body temperature all recorded after the first session of treatment. Occurence of labial herpes
Wennström 2005	Overall degree of treatment discomfort on a 100 mm visual analogue scale
Zanatta 2006	Not reported
Zijnge 2010	Adverse events or severe side effects (none reported)

FMS versus control for the treatment of adult chronic periodontitis
Patient or population: adults with chronic periodontitis  Settings: university dental departments  Intervention: FMS versus control
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect  (95% CI)	No of Participants  (studies)	Quality of the evidence  (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	FMS versus control
Tooth loss						Not reported in any of the trials.
Change in PPD; single‐ and multi‐rooted teeth ‐ Whole mouth   Follow‐up: 3‐4 months	The mean change in PPD; single‐ and multi‐rooted teeth ‐ whole mouth ranged across control groups from  0.69 to 2.51 mm	The mean change in PPD; single‐ and multi‐rooted teeth ‐ whole mouth in the intervention groups was  0.01 higher   (0.17 lower to 0.19 higher)		82  (3 studies)	⊕⊕⊕⊝  low¹	Similar result was found for the longer follow‐up of 6 to 8 months. Subgroup analyses were undertaken for 1) single‐ and multi‐rooted teeth separately, and 2) for teeth with initial moderate (5‐6 mm) or high (> 6 mm) levels of PPD. There was no consistent evidence of a benefit for FMS.
Change in CAL; single‐ and multi‐rooted teeth ‐ Whole mouth   Follow‐up: 3‐4 months	The mean change in CAL; single‐ and multi‐rooted teeth ‐ whole mouth ranged across control groups from  0.81 to 1.87 mm	The mean change in CAL; single‐ and multi‐rooted teeth ‐ whole mouth in the intervention groups was 0.02 lower   (0.26 lower to 0.22 higher)		82  (3 studies)	⊕⊕⊕⊝  low¹	Similar result was found for the longer follow‐up of 6 to 8 months. Subgroup analyses were undertaken for 1) single‐ and multi‐rooted teeth separately, and 2) for teeth with initial moderate (5‐6 mm) or high (> 6 mm) levels of PPD. There was no consistent evidence of a benefit for FMS.
Change in BOP; single‐ and multi‐rooted teeth ‐ Whole mouth   Follow‐up: 3‐4 months	The mean change in BOP; single‐ and multi‐rooted teeth ‐ whole mouth ranged across control groups from  18 to 49.4 percent	The mean change in BOP; single‐ and multi‐rooted teeth ‐ whole mouth in the intervention groups was  2.86 lower   (7.65 lower to 1.93 higher)		120  (4 studies)	⊕⊕⊕⊝  low²	Similar result was found for the longer follow‐up of 6 to 8 months. Subgroup analyses were undertaken for 1) single‐ and multi‐rooted teeth separately, and 2) for teeth with initial moderate (5‐6 mm) or high (> 6 mm) levels of PPD. There was no consistent evidence of a benefit for FMS.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).  CI: confidence interval; FMS: full mouth scaling; PPD: probing pocket depth; CAL: clinical attachment level; BOP: bleeding on probing (BOP)
GRADE Working Group grades of evidence  High quality: Further research is very unlikely to change our confidence in the estimate of effect.  Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.  Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.  Very low quality: We are very uncertain about the estimate.

FMD versus control for the treatment of adult chronic periodontitis
Patient or population: adults with chronic periodontitis  Settings: university dental departments  Intervention: FMD versus control
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect  (95% CI)	No of Participants  (studies)	Quality of the evidence  (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	FMD versus control
Tooth loss						Not reported in any of the trials.
Change in PPD; single‐ and multi‐rooted teeth ‐ Whole mouth   Follow‐up: 3‐4 months	The mean change in PPD; single‐ and multi‐rooted teeth ‐ whole mouth ranged across control groups from  0.69 to 2.51 mm	The mean change in PPD; single‐ and multi‐rooted teeth ‐ whole mouth in the intervention groups was  0.13 higher   (0.09 lower to 0.34 higher)		44  (2 studies)	⊕⊕⊝⊝  low¹	Similar result was found for the longer follow‐up of 6 to 8 months. Subgroup analyses were undertaken for 1) single‐ and multi‐rooted teeth separately, and 2) for teeth with initial moderate (5‐6 mm) or high (> 6 mm) levels of PPD. There was no consistent evidence of a benefit for FMD.
Change in CAL; single‐ and multi‐rooted teeth ‐ Whole mouth   Follow‐up: 3‐4 months	The mean change in CAL; single‐ and multi‐rooted teeth ‐ whole mouth ranged across control groups from  0.81 to 1.87 mm	The mean change in CAL; single‐ and multi‐rooted teeth ‐ whole mouth in the intervention groups was  0.04 higher   (0.25 lower to 0.33 higher)		44  (2 studies)	⊕⊕⊝⊝  low¹	Similar result was found for the longer follow‐up of 6 to 8 months. Subgroup analyses were undertaken for 1) single‐ and multi‐rooted teeth separately, and 2) for teeth with initial moderate (5‐6 mm) or high (> 6 mm) levels of PPD. There was no consistent evidence of a benefit for FMD.
Change in BOP; single‐ and multi‐rooted teeth ‐ Whole mouth   probe  Follow‐up: 3‐4 months	The mean change in BOP; single‐ and multi‐rooted teeth ‐ whole mouth ranged across control groups from  18 to 31 percent	The mean change in BOP; single‐ and multi‐rooted teeth ‐ whole mouth in the intervention groups was  12.59 higher   (8.58 lower to 33.77 higher)		68  (3 studies)	⊕⊕⊕⊝  low²	Similar result was found for the longer follow‐up of 6 to 8 months. Subgroup analyses were undertaken for 1) single‐ and multi‐rooted teeth separately, and 2) for teeth with initial moderate (5‐6 mm) or high (> 6 mm) levels of PPD. There was no consistent evidence of a benefit for FMD.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).  CI: confidence interval; FMD: full mouth disinfection; PPD: probing pocket depth; CAL: clinical attachment level; BOP: bleeding on probing (BOP).
GRADE Working Group grades of evidence  High quality: Further research is very unlikely to change our confidence in the estimate of effect.  Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.  Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.  Very low quality: We are very uncertain about the estimate.

FMS versus FMD for the treatment of adult chronic periodontitis
Patient or population: adults with chronic periodontitis  Settings: university dental departments  Intervention: FMS versus FMD
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect  (95% CI)	No of Participants  (studies)	Quality of the evidence  (GRADE)	Comments
	Assumed risk	Corresponding risk
	FMD	FMS
Tooth loss						Not reported in any of the trials.
Change in PPD; single‐ and multi‐rooted teeth ‐ Whole mouth   probe  Follow‐up: 3‐4 months	The mean change in PPD; single‐ and multi‐rooted teeth ‐ whole mouth ranged across FMS groups from  0.69 to 2.58 mm	The mean change in PPD; single‐ and multi‐rooted teeth ‐ whole mouth in the intervention groups was  0.11 lower   (0.34 lower to 0.12 higher)		45  (2 studies)	⊕⊕⊝⊝  low¹	Similar result was found for the longer follow‐up of 6 to 8 months. Subgroup analyses were undertaken for 1) single‐ and multi‐rooted teeth separately, and 2) for teeth with initial moderate (5‐6 mm) or high (> 6 mm) levels of PPD.
Change in CAL; single‐ and multi‐rooted teeth ‐ Whole mouth   Follow‐up: 3‐4 months	The mean change in CAL; single‐ and multi‐rooted teeth ‐ whole mouth ranged across FMS groups from  0.56 ‐ 1.99 mm	The mean change in CAL; single‐ and multi‐rooted teeth ‐ whole‐mouth in the intervention groups was  0.25 lower   (0.42 lower to 0.07 lower)		45  (2 studies)	⊕⊕⊝⊝  low¹	The result for the 6 to 8 month follow‐up was not significant and did not indicate a benefit for FMS. Subgroup analyses were undertaken for 1) single‐ and multi‐rooted teeth separately, and 2) for teeth with initial moderate (5‐6 mm) or high (> 6 mm) levels of PPD. There was no consistent evidence of a benefit for either intervention
Change in BOP; single‐ and multi‐rooted teeth ‐ Whole mouth   probe  Follow‐up: 3‐4 months	The mean change in BOP; single‐ and multi‐rooted teeth ‐ whole mouth ranged across FMS groups from  22 to 23 percent	The mean change in BOP; single‐ and multi‐rooted teeth ‐ whole mouth in the intervention groups was  1.59 lower   (9.97 lower to 6.80 higher)		45  (2 studies)	⊕⊕⊕⊝  low¹	The result for the 6 to 8 month follow‐up had a smaller treatment effect and also did not indicate a benefit for either intervention. Subgroup analyses were undertaken for 1) single‐ and multi‐rooted teeth separately, and 2) for teeth with initial moderate (5‐6 mm) or high (> 6 mm) levels of PPD. There was no consistent evidence of a benefit for either intervention
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).  CI: confidence interval; FMD: full mouth disinfection; FMS: full mouth scaling; PPD: probing pocket depth; CAL: clinical attachment level; BOP: bleeding on probing (BOP)
GRADE Working Group grades of evidence  High quality: Further research is very unlikely to change our confidence in the estimate of effect.  Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.  Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.  Very low quality: We are very uncertain about the estimate.

Tooth type:   Single‐rooted,  Multi‐rooted,  or Both	Baseline pocket depth (mm)	Time   (Months)	Number of studies (Participants)	Mean difference   (Random‐effects meta‐analysis)	Heterogeneity   (P value; I²)
Both	5‐6	3/4	5 (149)	‐0.05 [‐0.19, 0.09]; (P = 0.46)	(P = 0.94); I² = 0%
Both	> 6	3/4	6 (165)	‐0.05 [‐0.31, 0.21]; (P = 0.69)	(P = 0.57); I² = 0%
Both	5‐6	6/8	3 (97)	‐0.13 [‐0.35, 0.08]; (P = 0.23)	(P = 0.91); I² = 0%
Both	> 6	6/8	3 (76)	0.00 [‐0.48, 0.48]; (P = 1.00)	(P = 0.81); I² = 0%
Single‐rooted	5‐6	3/4	1 (16)	0.63 [0.29, 0.97]; (P = 0.0002)	Not applicable
Single‐rooted	> 6	3/4	0 (0)	Not estimable	Not applicable
Single‐rooted	5‐6	6/8	3 (69)	0.16 [‐0.01, 0.32]; (P = 0.06)	(P = 0.89); I² = 0%
Single‐rooted	> 6	6/8	2 (53)	0.26 [‐0.21, 0.73]; (P = 0.27)	(P = 0.64); I² = 0%
Multi‐rooted	5‐6	3/4	1 (16)	1.00 [0.41, 1.59]; (P = 0.0008)	Not applicable
Multi‐rooted	> 6	3/4	0 (0)	Not estimable	Not applicable
Multi‐rooted	5‐6	6/8	3 (69)	0.21 [‐0.14, 0.55]; (P = 0.24)	(P = 0.06); I² = 64%
Multi‐rooted	> 6	6/8	2 (53)	0.18 [‐0.26, 0.62]; (P = 0.42)	(P = 0.42); I² = 0%

Tooth type:  Single‐rooted,  Multi‐rooted,  or Both	Baseline pocket depth (mm)	Time  (Months)	Number  of studies (Participants)	Mean difference  (Random‐effects meta‐analysis)	Heterogeneity  (P value; I²)
Both	5‐6	3/4	2 (61)	‐8.05 [‐30.25, 14.16];(P = 0.48)	(P = 0.02); I² = 80%
Both	> 6	3/4	3 (77)	‐0.33 [‐7.70, 7.04]; (P = 0.93)	(P = 0.51); I² = 0%
Both	5‐6	6/8	2 (57)	‐4.94 [‐16.59, 6.72]; (P = 0.41)	(P = 0.87); I² = 0%
Both	> 6	6/8	2 (36)	10.22 [‐0.59, 21.03]; (P = 0.06)	(P = 0.92); I² = 0%
Single‐rooted	5‐6	3/4	1 (16)	3.00 [‐2.43, 8.43]; (P = 0.28)	Not applicable
Single‐rooted	> 6	3/4	0 (0)	Not estimable	Not applicable
Single‐rooted	5‐6	6/8	2 (45)	‐3.06 [‐10.47, 4.35]; (P = 0.42)	(P = 0.27); I² = 18%
Single‐rooted	> 6	6/8	1 (29)	‐4.00 [‐20.17, 12.17];(P = 0.63)	Not applicable
Multi‐rooted	5‐6	3/4	1 (16)	7.00 [4.54, 9.46];(P < 0.00001)	Not applicable
Multi‐rooted	> 6	3/4	0 (0)	Not estimable	Not applicable
Multi‐rooted	5‐6	6/8	2 (45)	2.38 [‐2.95, 7.71]; (P = 0.38)	(P = 0.50); I² = 0%
Multi‐rooted	> 6	6/8	1 (29)	‐4.00 [‐23.29, 15.29];(P = 0.68)	Not applicable

Date	Event	Description
26 March 2015	New search has been performed	Search updated.
26 March 2015	New citation required but conclusions have not changed	Five new trials included, one new trial excluded and one study awaiting classification. Title changed from 'Full‐mouth disinfection for the treatment of adult chronic periodontitis' to 'Full‐mouth treatment modalities (within 24 hours) for chronic periodontitis in adults'.

Date	Event	Description
6 March 2012	Amended	Additional tables linked to text.
30 July 2008	Amended	Converted to new review format.

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Change in PPD: whole mouth, single‐rooted teeth and multi‐rooted teeth	6		Mean Difference (IV, Random, 95% CI)	Subtotals only
1.1 3/4 months	3	82	Mean Difference (IV, Random, 95% CI)	0.01 [‐0.17, 0.19]
1.2 6/8 months	4	117	Mean Difference (IV, Random, 95% CI)	0.03 [‐0.12, 0.17]
2 Change in CAL: whole mouth, single‐ and multi‐rooted teeth	6		Mean Difference (IV, Random, 95% CI)	Subtotals only
2.1 3/4 months	3	82	Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.26, 0.22]
2.2 6/8 months	4	117	Mean Difference (IV, Random, 95% CI)	0.05 [‐0.11, 0.22]
3 Change in BOP: whole mouth, single‐ and multi‐rooted teeth	7		Mean Difference (IV, Random, 95% CI)	Subtotals only
3.1 3/4 months	4	120	Mean Difference (IV, Random, 95% CI)	‐2.86 [‐7.65, 1.93]
3.2 6/8 months	4	117	Mean Difference (IV, Random, 95% CI)	1.98 [‐5.23, 9.20]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Change in PPD: whole mouth, single‐ and multi‐rooted teeth	3		Mean Difference (IV, Random, 95% CI)	Subtotals only
1.1 3/4 months	2	44	Mean Difference (IV, Random, 95% CI)	0.13 [‐0.09, 0.34]
1.2 6/8 months	2	40	Mean Difference (IV, Random, 95% CI)	0.14 [‐0.19, 0.46]
2 Change in CAL: whole mouth, single‐ and multi‐rooted teeth	3		Mean Difference (IV, Random, 95% CI)	Subtotals only
2.1 3/4 months	2	44	Mean Difference (IV, Random, 95% CI)	0.04 [‐0.25, 0.33]
2.2 6/8 months	2	40	Mean Difference (IV, Random, 95% CI)	0.03 [‐0.20, 0.26]
3 Change in BOP: whole mouth, single‐ and multi‐rooted teeth	4		Mean Difference (IV, Random, 95% CI)	Subtotals only
3.1 3/4 months	3	68	Mean Difference (IV, Random, 95% CI)	12.59 [‐8.58, 33.77]
3.2 6/8 months	3	64	Mean Difference (IV, Random, 95% CI)	12.56 [‐4.01, 29.13]

Methods	Study design: RCT with 2‐arm parallel design Recruitment period: Unclear Setting: University Dental Hospital, Scotland  Number of centres: One  Funding source: Unclear
Participants	Inclusion criteria: Diagnosis: Chronic periodontitis ‐ with PD of > 5 mm Exclusion criteria: Systemic disease or on antibiotics from 3 months before or during study. Age: 31 to 70 Gender: 17 F and 23 M  Smokers: 15  Number randomised: 40 (20/20), 2 Asian (1 in each group), 38 Caucasian  Number evaluated: 40 (20/20)
Interventions	Comparison: FMS vs control Test group: (FM‐SRP): FMS 2 sessions same day  Control group: (Q‐SRP): QRP 4 sessions ‐ 2‐weekly intervals  OHI before study start: Unknown  Instruments used: Hand and US instruments  Time per Q: 1 hour  Maintenance: At 7 weeks (FMS) or 13 weeks (QRP) and 6 months from baseline (both groups) Retreatment: None Duration of study: 6 months
Outcomes	Primary outcome: PPD (6 sites per tooth) Secondary outcomes: CAL/RAL, BOP (6 sites per tooth) Teeth: Whole‐mouth recordings with manual probe, moderate and deep PD at baseline Pocket depth at baseline: Moderate (> 5 and < 7 mm), deep (> 7 mm), for selected sites (deepest site per quadrant) Outcome time reported: 6‐month data used. Baseline, 6‐week re‐assessment after last instrumentation (FM‐SRP: 7 weeks; Q‐SRP: 13 weeks from baseline), 25 weeks. Computer‐assisted disk probe for selected sites  Other outcomes: MGI, PI, SUP (selected site clinical analysis = 1 deepest pocket per quadrant). Average pain VAS score (0 to 10), body temperature, number of analgesics, cold sores or oral ulcers
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"Subjects were randomised into two groups"
Allocation concealment (selection bias)	Unclear risk	Not mentioned
Incomplete outcome data (attrition bias)   All outcomes	Low risk	All patients completed study
Blinding of outcome assessment (detection bias)   All outcomes	High risk	"Clinical measurements were collected by a calibrated single examiner (D. A. A.) and unbiased data collection was assured by having no access to recordings of previous visits" Comment: Blinding at high risk of bias as the same person undertook the interventions and the outcome assessments
Selective reporting (reporting bias)	Low risk	Data reported on all primary and secondary outcomes
Other bias	Low risk	Baseline balance good for smokers and pocket depth. No apparent other biases

Methods	Study design: RCT with 3‐arm parallel design Recruitment period: unclear Setting: University Dental Clinic, Japan  Number of centres: One  Funding source: Grant from Scientific Society
Participants	Inclusion criteria: Diagnosis: Chronic periodontitis ‐ with PD of > 5mm. All patients were in good general health Exclusion criteria: SRP in past 6 months or on antibiotics from 6 months before or during study, smokers, pregnancy, allergic to iodine Age: 34 to 66 Gender: 23 F (FMD/FMS/control 8/7/8) and 13 M (4/5/4)  Smokers: 0  Number randomised: 36 all Japanese, 12 individuals in each group  Number evaluated: 36 (12/12/12)
Interventions	Comparison: FMS vs control: FMD vs control: FMS vs FMD Test group 1: (FMD + water): FMS 1 session US scaling with water (duration 2 to 2.5 hours) Test group 2: (FMD + povidone): FMS 1 session US scaling with 1% povidone iodine (duration 2‐2.5 hours), patients rinsing with 0.05% CHX twice a day for 1 month, tongue brushing Control group: (QMD): QRP 4 sessions US scaling with water ‐ 1‐week intervals (duration 40‐50 min each)  OHI before study start: Yes  Instruments used: US instruments  Time per Q: Unclear  Maintenance: Every month Retreatment: None Duration of study: 6 months
Outcomes	Primary outcome: PPD (6 sites per tooth) Secondary outcomes: RAL, BOP (6 sites per tooth). Manual probe with stent for all measurements Teeth: Whole‐mouth recordings (baseline, 1, 3 and 6 months). Data split in single‐/multi‐rooted teeth and initial moderate (PPD 5 to 6 mm) and deep pockets (PPD > 6 mm) Pocket depth at baseline: moderate (> 5 to < 7 mm), deep (> 7 mm) Outcome time reported: 6 months used.  Other outcomes: PI, average pain VAS score (0 to 10), body temperature, number of analgesics, microbiology
Notes	PAL is equal to RAL
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"They were then randomly allocated to three groups based on the treatment protocol and the examiner was blinded to the allocation. The random sequence was computer generated, with no stratification or balancing of factors"
Allocation concealment (selection bias)	Low risk	"The subjects chose a sequentially numbered opaque, sealed envelope, which enclosed the code for the treatment protocol they were to receive. The number of envelopes was same as the number of subjects"
Incomplete outcome data (attrition bias)   All outcomes	Low risk	All patients completed study
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	"The treatment groups were coded so that only the operator was aware of the protocol and the examiner remained blinded throughout the study"
Selective reporting (reporting bias)	Low risk	Data reported on all primary and secondary outcomes
Other bias	Low risk	Baseline balance good for pocket depth. No apparent other biases

Methods	Study design: RCT with 5‐arm parallel design (3 arms included) Recruitment period: unclear Setting: University Dental Hospital, Belgium  Number of centres: One  Funding Source: supported by University
Participants	Inclusion criteria: Diagnosis: Chronic periodontitis ‐ with PD of > 6 mm . All patients were in good general health Exclusion criteria: SRP in past 12 months or antibiotics from 4 months before or during study, compromised medical condition, pregnancy Age: 31 to 75. All Caucasian Gender: 19 F (FMS/FMD/control 10/4/5) and 24 M (4/10/10)  Smokers: 11 (3/3/5)  Number randomised: 85 in 5 arms  Number evaluated: 43 in 3 arms (14/14/15) (71 in 5 arms)
Interventions	Comparison: FMS vs control: FMD vs control: FMS vs FMD Test group 1: (FRp): 2 sessions scaling within 24 hours Test group 2: (FM‐CHX): 2 sessions scaling within 24 hours, after instrumentation: tongue brushing: CHX = 1%, 1 min; rinse: CHX = 0.2%, 2 x 1 min; spray pharynx: CHX = 0.2%; subgingival: CHX = 1%, 3 times within 10 min. Home: rinse CHX = 0.2%, 1 min, 2 x day, 2 months Control group: (NC): QRP 4 sessions scaling ‐ 2‐week intervals, no antiseptics  OHI before study start: No  Instruments used: Hand instruments  Time per Q: Unclear  Maintenance: 1, 2, 4 months Retreatment: None Duration of study: 8 months
Outcomes	Primary outcome: PPD (6 sites per tooth) Secondary outcomes: CAL (as sum of PPD and gingival recession), BOP (6 sites per tooth). Manual probe for all measurements Teeth: First quadrant recordings (baseline, 2, 4 and 8 months). Data split in single‐/multi‐rooted teeth and initial medium (PPD 4 to 5.5 mm) and deep pockets (PPD > 5 mm) Pocket depth at baseline: moderate (PPD 4.5 to 6.5 mm) and deep pockets (PPD > 7 mm) Outcome time reported: 4 months used, 1, 2, 4, 8 months measured  Other outcomes: SBI, PI, GR (6 sites per tooth)
Notes	Drop‐outs: 85 enrolled, 71 completed the study. Time point for drop‐outs unclear. Only 3 arms of trial included Authors could not provide data for 4 months evaluation on request
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"A clinician who was informed about the baseline clinical data (but not about the content of the treatment strategies) randomly  allocated (via a random‐number table) the consecutive participants (if fulfilling criteria) to one of the following groups"
Allocation concealment (selection bias)	Low risk	"A clinician who was informed about the baseline clinical data (but not about the content of the treatment strategies) randomly  allocated (via a random‐number table) the consecutive participants (if fulfilling criteria) to one of the following groups"
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	Drop‐outs 14/85; unclear reasons or timing of drop‐outs
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Treatment and examination by two independent persons
Selective reporting (reporting bias)	Low risk	Data reported on all primary and secondary outcomes
Other bias	Low risk	Baseline balance good for pocket depth and smoking. No apparent other biases

Study	Reason for exclusion
Bollen 1998	6 out of 16 patients suffering from aggressive periodontitis. Data not shown separately for aggressive and chronic periodontitis
Eren 2002	Patients in the intervention arm received FMS for 4 consecutive days (over 24 hours)
Jothi 2009	No QRP control group
Loggner Graff 2009	Retreatment of patients after 3 months in study prior to outcome assessment at 6 months
Meulman 2013	Data only available as figures. No reply from authors to request for supplemental data
Preus 2013	Participants in all arms received a chlorhexidine rinse
Quirynen 1995	2‐months data only
Serrano 2011	4 to 6 weeks data only
Tomasi 2006	18‐month evaluation after baseline but all patients had several retreatments. These were the same patients as Wennström 2005 but it was an observational follow‐up of the trial
Ushida 2008	Immunology study with no clinical data

PERMALINK

Full‐mouth treatment modalities (within 24 hours) for chronic periodontitis in adults

Joerg Eberhard

Sören Jepsen

Pia‐Merete Jervøe‐Storm

Ian Needleman

Helen V Worthington

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Plain language summary

Summary of findings

Background

Description of the condition

Description of the intervention

How the intervention might work

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Types of interventions

Types of outcome measures

Primary outcomes

Secondary outcomes

Search methods for identification of studies

Electronic searches

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Measures of treatment effect

Unit of analysis issues

Dealing with missing data

Assessment of heterogeneity

Assessment of reporting biases

Data synthesis

Subgroup analysis and investigation of heterogeneity

Sensitivity analysis

Results

Description of studies

Results of the search

1.

Included studies

Design

Participants

Interventions

Outcomes

1. Adverse events and patient‐reported outcomes.

Excluded studies

Risk of bias in included studies

2.

3.

Allocation

Blinding

Incomplete outcome data

Selective reporting

Other potential sources of bias

Overall risk of bias

Effects of interventions

Summary of findings for the main comparison. FMS versus control for the treatment of adult chronic periodontitis.

Summary of findings 2. FMD versus control for the treatment of adult chronic periodontitis.

Summary of findings 3. FMS versus FMD for the treatment of adult chronic periodontitis.

FMS versus control

Tooth loss

Change in probing pocket depth (PPD)

1.1. Analysis.

2. FMS versus control: change in PPD.

Single‐rooted teeth (Table 2)

Multi‐rooted teeth (Table 2)

Sensitivity analysis

Clinical attachment level (CAL)

1.2. Analysis.