Emergency and sequalae management of traumatic dental injuries: a systematic survey of clinical practice guidelines

Our research showed that the overall quality of CPGs in the field of dental trauma is suboptimal; only two out of ten CPGs were assessed as high quality. The domain with the highest score was Scope and Purpose (mean 78.0%), while Applicability obtained the lowest score (mean 15.3%). The AGREE II overall mean rate was 4.0 (SD 1.3). Only two CPGs were recommended without modifications by the reviewers.

The only study variable associated with the quality of the guidelines was the organization responsible for developing the guidelines, since the CPGs developed by governments were found to present the best quality. Finally, as expected, the domain that correlated best with a high-quality CPG was Rigour of development.

Our review showed that the two best-assessed domains were Scope and purpose and Clarity of presentation, consistent with other systematic reviews [30, 31].

Although the Scope and purpose domain passed the quality threshold, some guidelines failed to describe the health questions covered by the CPG. Well formulated study questions help directly the search for evidence, as well as the assessment of certainty; therefore, when choosing which questions to include, the objective and scope of the guide are being defined [32]. Since the recommendations arise from the answers to these questions, the object of the CPG should be clear, and consistent with the recommendations, in order to help the user to implement the most appropriate care for a given patient.

The Clarity of presentation domain presented the second-best evaluation, the main issues being ambiguity and the format in which the recommendations were presented. This is important for making the recommendation easier to implement [18].

As in our study, evidence shows that dental CPGs of different dental specialties tend to be of low quality, presenting important flaws in their development, especially related to Stakeholder involvement, poor Methodological rigour [10, 33, 34], and issues in the Applicability and the Editorial independence domains [12, 13].

Regarding the Stakeholder involvement domain, the views and preferences of the target population were not considered in formulating the recommendations, either because they were not included as members of the panel or because the study did not carry out a systematic search of the evidence. The principal justification for including patients’ values and preferences in guideline development is because recommendations that are in line with these might be more easily accepted, implemented and adhered to by those who will benefit from them [35]. Moreover, most CPGs should have stated the specialists or experts involved in their development. CPGs improve when specialists, methodologists and patients participate actively in guideline development [36, 37].

Rigour of development is regarded as the most important domain for assessing CPGs, since it appraises the process for gathering and synthesizing the evidence, and the methodology for formulating the recommendations. Although most of the CPGs reported carrying out a systematic search of the evidence, only a few assessed the strengths and limitations of the identified evidence. This assessment is critical, since most evidence supporting the recommendations comes from observational or animal studies. The certainty of the evidence in these cases is low or very low, which means there is uncertainty about whether the identified evidence is appropriate to formulate a recommendation (e.g., there is very little evidence or studies have significant limitations). Low or very low certainty of evidence determining a conditional or weak recommendation means that many individuals in this position might accept the suggested course of action, but an important amount would not [38].

Another important limitation in the methodological rigour of the CPGs was that the methodology for formulating the recommendations was not clearly described. Although most of the CPGs reported that the recommendations were formulated by consensus of the panel members, few provided information on the methodology, the factors considered, and the results of the deliberation process. One way to make this process more transparent is through the GRADE approach (Grading of Recommendation Assessment, Development and Evaluation). This methodology provides a structured process for determining the certainty of the evidence, making recommendations, and taking decisions. The GRADE approach does not only consider the quality of the evidence when formulating a recommendation, but also considers the benefit-risk balance, the patients’ values and preferences, the magnitude of the necessary resources and costs, as well as equity, acceptability, and implementation, among others. Evidence shows that the best quality CPGs are those based on evidence and used a transparent way to develop recommendations, like the GRADE methodology [12]. This is important given that poor quality guidelines may negatively influence patient care, or their applicability may be questionable [14, 15]. In our study, only one guideline used the GRADE approach to assess the certainty of evidence and in developing its recommendations, despite the fact that more than 90 health organizations around the world have endorsed this approach [39]. However, this deficiency is also observed in CPGs published for other areas of dentistry [11, 13, 40].

The Applicability domain is poorly reported in CPGs, not only in dental guidelines but also in other health fields [31]. This shows the importance of considering aspects such as implementation, organizational barriers and facilitators, and economic implications when developing future guidelines on TDIs. Inappropriate analysis of these factors can influence adherence to the guideline. When carrying out this analysis, the CPGs must consider the local facilitators and the barriers that may influence their applicability. According to Alonso-Coello et al., low scores in the applicability domain could result from the fact that the developers consider guideline development and guideline implementation as different activities [31].

The Editorial Independence domain was assessed as very low-quality because the CPGs did not declare possible intellectual and financial conflicts of interest. This is a generalized problem, in both dental and medical guidelines [30, 31] [41]. It is essential that both funding bodies and members of CPG development groups state their conflicts in detail, because they are used for decision-making in both insurance coverage and standards of care [42]. It is important to link the recommendations clearly to the evidence, and to exclude panelists with conflicts of interest, in order to avoid influence from external interests [41].

Concerning the factors associated with guideline quality, we observed that guidelines developed by Governments have higher scores than CPGs produced by scientific societies or hospitals, in agreement with the reports of other studies [31, 43]. This is attributable to the large amount of financial and human resources needed to properly develop a CPG [44].

The greatest strength of the present study was that CPGs were obtained by a systematic literature search that included developers’ websites and repositories of CPGs. AGREE II is the only reliable, validated instrument developed for comparing CPGs [18].