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A schema of school dental screening process
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Figure 1

A schema of school dental screening process

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Study flow diagram
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Figure 2

Study flow diagram

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study
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Figure 4

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Forest plot of comparison: 1 Traditional screening versus no screening, outcome: 1.1 Dental attendance
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Figure 5

Forest plot of comparison: 1 Traditional screening versus no screening, outcome: 1.1 Dental attendance

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Comparison 1 Traditional screening versus no screening, Outcome 1 Dental attendance.
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Analysis 1.1

Comparison 1 Traditional screening versus no screening, Outcome 1 Dental attendance.

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Comparison 2 Criteria‐based screening versus no screening, Outcome 1 Dental attendance.
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Analysis 2.1

Comparison 2 Criteria‐based screening versus no screening, Outcome 1 Dental attendance.

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Comparison 3 Criteria‐based versus traditional screening, Outcome 1 Dental attendance.
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Analysis 3.1

Comparison 3 Criteria‐based versus traditional screening, Outcome 1 Dental attendance.

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Comparison 4 Criteria‐based screening with specific referral versus criteria‐based screening with non‐specific referral, Outcome 1 Dental attendance.
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Analysis 4.1

Comparison 4 Criteria‐based screening with specific referral versus criteria‐based screening with non‐specific referral, Outcome 1 Dental attendance.

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Comparison 5 Traditional screening with motivation versus traditional screening alone, Outcome 1 Dental attendance.
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Analysis 5.1

Comparison 5 Traditional screening with motivation versus traditional screening alone, Outcome 1 Dental attendance.

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Summary of findings for the main comparison. Traditional screening compared to no screening for increasing dental attendance

Traditional screening compared to no screening for increasing dental attendance

Population: increasing dental attendance
Setting: primary and secondary school
Intervention: traditional screening
Comparison: no screening

Outcomes

Relative effect
(95% CI)

Anticipated absolute effects* (95% CI)

Number of participants (studies)

Certainty of the evidence
(GRADE)

What happens

Without no screening

With traditional screening

Difference

Dental attendance

Follow‐up: 3 to 4 months

Data not pooled

6281
(4 RCTs)

⊕⊝⊝⊝
VERY LOW 1 2

There was substantial heterogeneity, in part due to study design (3 cluster RCTs and 1 individual‐level RCT). Due to the inconsistency, we downgraded the evidence to 'very low certainty' and are unable to draw conclusions about this comparison.

*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio; OR: odds ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

1Praveen 2014 and Zarod 1992 trials have unclear selection bias, performance and detection bias. Downgraded by two levels

2 High heterogeneity (I2 = 91%). Downgraded by one level

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Summary of findings for the main comparison. Traditional screening compared to no screening for increasing dental attendance
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Summary of findings 2. Criteria‐based screening compared to no screening for increasing dental attendance

Criteria‐based screening compared to no screening for increasing dental attendance

Population: school children
Setting: primary and secondary schools
Intervention: criteria‐based screening
Comparison: no screening

Outcomes

Relative effect
(95% CI)

Anticipated absolute effects* (95% CI)

Number of participants (studies)

Certainty of the evidence
(GRADE)

Comment

With no screening

With criteria‐based screening

Difference

Dental attendance

Follow‐up: 3 to 4 months

RR 1.07
(0.99 to 1.16)

33.1%

35.5%
(32.8 to 38.1)

2.3% more
(0.3 fewer to 5 more)

4980
(2 RCTs)

⊕⊕⊝⊝
LOW 1

There is 7% relative increase in the dental attendance in criteria‐based screening group compared to no screening with 95% CI ranging from 1% decrease to 16% increase.

*The risk in the intervention group (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; RR: risk ratio; OR: odds ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

1Cunningham 2009 trial has wide CI ranging from no effect to favourable effect and ICC is borrowed from Milsom 2006 trial. Downgraded by 2 levels

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Summary of findings 2. Criteria‐based screening compared to no screening for increasing dental attendance
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Summary of findings 3. Criteria‐based screening compared to traditional screening for increasing dental attendance

Criteria‐based screening compared to traditional screening for increasing dental attendance

Population: school children
Setting: primary and secondary schools
Intervention: criteria‐based screening
Comparison: traditional screening

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Risk with traditional screening

Risk with criteria‐based screening

Dental attendance
follow‐up: range 3 months to 4 months

335 per 1000

338 per 1000
(315 to 362)

RR 1.01
(0.94 to 1.08)

5316
(2 RCTs)

⊕⊝⊝⊝
VERY LOW 1 2

There is 1% relative increase in the dental attendance in criteria‐based screening compared to traditional screening with 95% CI ranging from 6% decrease to 8% increase in the attendance

*The risk in the intervention group (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; RR: risk ratio; OR: odds ratio

GRADE Working Group grades of evidence
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect
Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

1 Results of both the trials are ranging from favouring traditional screening to no effect. Downgraded by two levels.

2 Wide 95% CI in Cunningham 2009 trial crossing the line of no effect. Downgraded by one level

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Summary of findings 3. Criteria‐based screening compared to traditional screening for increasing dental attendance
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Summary of findings 4. Criteria‐based screening with specific referral compared to criteria‐based screening with non‐specific referral for increasing dental attendance

Criteria‐based screening with specific referral compared to criteria‐based screening with non‐specific referral for increasing dental attendance

Population: school children
Setting: secondary school
Intervention: criteria‐based screening with specific referral
Comparison: criteria‐based screening with non‐specific referral

Outcomes

Relative effect
(95% CI)

Anticipated absolute effects* (95% CI)

Number of participants (studies)

Certainty of the evidence
(GRADE)

Comment

With criteria‐based screening with non‐specific referral

With criteria‐based screening with specific referral

Difference

Dental attendance at general dentist

Follow‐up: mean 8 months

RR 1.39
(1.09 to 1.77)

49.0%

68.1%
(53.4 to 86.7)

19.1% more
(4.4 more to 37.7 more)

201
(1 RCT)

⊕⊕⊝⊝
LOW 1

There is 39% relative increase in the attendance to general dentist in the specific referral group compared to non‐specific group, with 95% CI ranging from 9% to 77% increase in attendance.

Dental attendance at orthodontist

Follow‐up: mean 8 months

RR 1.90
(1.18 to 3.06)

19.4%

36.8%
(22.9 to 59.3)

17.4% more
(3.5 more to 39.9 more)

201
(1 RCT)

⊕⊕⊝⊝
LOW 1

There is 90% relative increase in the attendance to orthodontist in the specific referral group compared to the non‐specific group with 95% CI ranging from 18% to 206% increase in attendance.

*The risk in the intervention group (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; RR: risk ratio; OR: odds ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

1Burden 1994 is a single study of secondary school children (11 to 12 years) at unclear risk of selection bias. Downgraded by two levels

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Summary of findings 4. Criteria‐based screening with specific referral compared to criteria‐based screening with non‐specific referral for increasing dental attendance
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Summary of findings 5. Traditional screening with motivation compared to traditional screening for increasing dental attendance

Traditional screening with motivation compared to traditional screening for increasing dental attendance

Patient or population: school children
Setting: primary and secondary schools
Intervention: traditional screening with motivation
Comparison: traditional screening

Outcomes

Relative effect
(95% CI)

Anticipated absolute effects* (95% CI)

Number of participants (studies)

Certainty of the evidence
(GRADE)

What happens

Without traditional screening with motivation

With traditional screening with motivation

Difference

Dental attendance

Follow‐up: mean 3 months

RR 3.08
(2.57 to 3.71)

10.0%

30.9%
(25.8 to 37.2)

20.9% more
(15.7 more to 27.2 more)

2486
(1 RCT)

⊕⊕⊝⊝
LOW 1

There is 208% relative increase in the attendance of the motivation group compared to control group with 95% CI ranging from 157% to 271% increase in attendance.

*The risk in the intervention group (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; RR: risk ratio; OR: odds ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

1 Hebbal 2005 trial has unclear risk of selection bias and high risk of performance bias. Downgraded by two levels

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Summary of findings 5. Traditional screening with motivation compared to traditional screening for increasing dental attendance
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Table 1. Data adjusted to minimise clustering effect

Data values for total number and events to be divided by effect estimate across all studies

Effect estimate: 1 + (M − 1)ICC

M = average cluster size

ICC = 0.03 (borrowed from Milsom 2006)

Total number of

participants

(original)

Total number

of participants

(adjusted)

Events ‒ original

children attending

dental office)

Events ‒ adjusted

(children attending

dental office)

Cunningham 2009

1 + (15 − 1).03 = 1.42

Control arm

Traditional arm

Criteria‐based arm

819

1175

958

577

827

675

129

165

151

91

116

107

Milsom 2006

1 + (42 − 1).03 = 2.23

Control arm

Traditional arm

Criteria‐based arm

4226

4418

4087

1895

1981

1833

1624

1838

1695

728

824

760

Praveen 2014

1 + (8 − 1).03 = 1.21

Control arm

Intervention arm

300

300

248

248

80

54

67

45
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Table 1. Data adjusted to minimise clustering effect
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Comparison 1. Traditional screening versus no screening

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Dental attendance Show forest plot

4

Risk Ratio (IV, Random, 95% CI)

Subtotals only

1.1 Cluster RCT with ICC 0.03

3

5776

Risk Ratio (IV, Random, 95% CI)

1.10 [0.89, 1.35]

1.2 Individual‐level RCT

1

505

Risk Ratio (IV, Random, 95% CI)

1.74 [1.47, 2.05]
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Comparison 1. Traditional screening versus no screening
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Comparison 2. Criteria‐based screening versus no screening

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Dental attendance Show forest plot

2

4980

Risk Ratio (IV, Random, 95% CI)

1.07 [0.99, 1.16]
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Comparison 2. Criteria‐based screening versus no screening
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Comparison 3. Criteria‐based versus traditional screening

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Dental attendance Show forest plot

2

5316

Risk Ratio (IV, Random, 95% CI)

1.01 [0.94, 1.08]
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Comparison 3. Criteria‐based versus traditional screening
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Comparison 4. Criteria‐based screening with specific referral versus criteria‐based screening with non‐specific referral

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Dental attendance Show forest plot

1

402

Risk Ratio (IV, Random, 95% CI)

1.52 [1.15, 2.00]

1.1 Attending general dentist

1

201

Risk Ratio (IV, Random, 95% CI)

1.39 [1.09, 1.77]

1.2 Attending orthodontist

1

201

Risk Ratio (IV, Random, 95% CI)

1.90 [1.18, 3.06]
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Comparison 4. Criteria‐based screening with specific referral versus criteria‐based screening with non‐specific referral
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Comparison 5. Traditional screening with motivation versus traditional screening alone

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Dental attendance Show forest plot

1

2486

Risk Ratio (IV, Random, 95% CI)

3.08 [2.57, 3.71]
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Comparison 5. Traditional screening with motivation versus traditional screening alone
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