Commentary

Clinical practice guidelines have been defined as:

statements that include recommendations intended to optimise patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options. 4

The process for development of these type of guidelines have been developed in recent years and are clearly articulated in process manuals by well known evidence-based guideline developers such as NICE and SIGN. The SIGN process (http://www.sign.ac.uk/methodology/index.html) has eight key stages; topic selection, guideline development group formation, systematic literature review, formation and grading of recommendations and peer review, publication and dissemination, implementation and review. Over the past decade tools have also been developed for the appraisal of guidelines and the most methodologically robust is the Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument.

The AGREE instrument uses 23 questions to appraise five domains; scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability, editorial independence. As this guidance document is presented in a short journal article it perhaps suffers in comparison to recent caries guideline documents from SIGN5 and the Scottish Dental Clinical Effectiveness Programme,6 which are large stand-alone documents that enable the developers to cover in greater details elements assessed in the AGREE instrument.

However it is clear that the process undertaken for the development of this guidance document differs markedly from the approaches taken by SIGN and SDCEP. While the scope and purpose of this guideline is relatively clear, the extent of stakeholder involvement is unclear. Ideally the target populations' views and preferences should be sought and there is no indication that parents or older adolescents have been involved. The initial reviews1,2,3 on which the guideline is based have been carried out by academics and a wider group of dental professionals have been involved in the workshops, although these may not have been more broadly representative of the target users of the guidance. One of the three underlying reviews lacks details regarding the search strategies undertaken and provides a narrative summary of findings. It also does not mention a number of potential relevant systematic reviews.6,7,8,9 If the full range of review evidence available was not available for the workshop participants this could affect the recommendations made raising important questions about the rigour of the guidance development process. It is unclear whether there was any opportunity for any additional evidence to be introduced during the workshop sessions.

The recommendations regarding caries risk assessment are not directly linked with any evidence, and although there is a recommendation that multivariate tools were considered to be more effective a recent diagnostic systematic review of caries risk assessment tools10 found only low quality evidence to support available methods and highlighted an urgent need to improve study designs. No information on how the recommendations were formed in the workshops is presented in the paper so it is difficult to assess the validity of the process. One concern is the potential for key individuals to influence the content of the recommendations in open sessions.

An overall summary of the quality of evidence supporting 11 of the 22 recommendations was provided using the GRADE system (http://www.gradeworkinggroup.org/). The GRADE system has also been used to classify the strength of recommendation. GRADE classifies recommendations as strong or weak.9

Table 1
  • Strong recommendations mean that most informed patients would choose the recommended management and that clinicians can structure their interactions with patients accordingly

  • Weak recommendations mean that patients' choices will vary according to their values and preferences, and clinicians must ensure that patients' care is in keeping with their values and preferences

  • Strength of recommendation is determined by the balance between desirable and undesirable consequences of alternative management strategies, quality of evidence, variability in values and preferences and resource use.

While GRADE uses the word weak, a number of organisations prefer to use the term conditional instead and this approach has been taken by EAPD.

The recommendations themselves are wordy and could be considered ambiguous and this could affect its implementation. Key recommendations are not highlighted and this approach can be contrasted with the SIGN 138 guideline that has 21 recommendations and good practice points but only six key recommendations.

In terms of applying the guideline there is no discussion of facilitators and barriers to its adoption advice or tools to improve adoption such as monitoring or potential auditing criteria. Potential resource implications have also not been considered. The guidance has been developed by the EAPD and there is no indication of whether there has been any funding support from them or from any other body.

As noted in this issue's editorial, the process of evidence-based guideline development is a resource intensive process. The Guidelines International Network Group (http://www.g-i-n.net/) lists 15 caries guidelines that have been published since 2007, and the TRIP database (https://www.tripdatabase.com/) lists 325. Given these large numbers of guidelines the need for new guidance that has a less than robust development process is questionable. Particularly in light of a number of earlier guidelines that have called for higher quality primary research to address gaps highlighted in previous guidelines.