The Journal of EVIDENCE-BASED DENTAL PRACTICE ORIGINAL ARTICLE QUALITY APPRAISAL OF CLINICAL PRACTICE GUIDELINES ON PROVISION OF DENTAL SERVICES DURING THE FIRST MONTHS OF THE COVID-19 PANDEMIC NAIRA FIGUEIREDO DEANA a,b , CARLOS ZAROR a,b , ANDREA SEIFFERT a , YANELA ARAVENA-RIVAS b , PATRICIA MUÑOZ-MILLÁN a,b , GERARDO ESPINOZA-ESPINOZA b,c , PATRICIA PINEDA a,b, AND PABLO ALONSO-COELLO d,e a Department of Pediatric Dentistry and Orthodontics, Faculty of Dentistry, Universidad de La Frontera, Temuco, Chile b Center for Research in Epidemiology, Economics and Oral Public Health (CIEESPO), Faculty of Dentistry, Universidad de La Frontera, Temuco, Chile c Department of Public Health, Faculty of Medicine, Universidad de La Frontera, Temuco, Chile d Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau) e CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain ABSTRACT CORRESPONDING AUTHOR: Carlos Zaror, DDS, MSC, PhD, Department Objectives of Pediatric Dentistry and To evaluate the quality of clinical practice guidelines (CPGs) on dental services Orthodontics, Faculty of Dentistry, provision during the first months of the COVID-19 pandemic. Universidad de La Frontera, Manuel Materials and methods Montt #112, Temuco, Chile. Tel.:/Fax: We systematically searched in MEDLINE, EMBASE, LILACS, Epistemonikos, Trip +56-45-2325776. databases, websites of CPG developers, compilers of CPGs, scientific societies E-mail: carlos.zaror@ufrontera.cl and ministries of health to identify documents with recommendations intended to minimize the risk of COVID-19 transmission during dental care. Reviewers in- KEYWORDS dependently and in duplicate assessed the included CPGs using the AGREE II Practice guideline, Dental care, instrument. We calculated the standardized scores for the 6 domains and made COVID-19, Evidence-based dentistry a final recommendation about each CPG. The inter-appraiser agreement was as- sessed using the intraclass correlation coefficient (ICC). Results Twenty-three CPGs published were included. Most of the CPGs were from Amer- Received 20 February 2021; revised 5 ica (n = 15) and Europe (n = 6). The overall agreement between reviewers was July 2021; accepted 24 August 2021 very good (ICC = 0.93; 95%CI 0.87-0.95). The median score for each domain was the following: Scope and purpose 67% (IQR 20%); Stakeholder involvement 33% J Evid Base Dent Pract 2021: [101633] (IQR 14%); Rigour of development 13% (IQR 13%); Clarity of presentation 64% 1532-3382/$36.00 (IQR 31%); Applicability 19% (IQR 17%) and Editorial independence 8% (IQR 8%). © 2021 The Twenty two guidelines were not recommended by the reviewers. Only one of the Authors. Published by Elsevier Inc. CPGs was recommended with modifications. The median overall rate was 3 (IQR This is an open 1). All CPGs were classified as low quality. access article under the CC BY-NC-ND Conclusions license The overall quality of CPGs on dental services provision during the first months (http://creativecommons.org/licenses/by- of the COVID-19 pandemic was low, which makes its implementation difficult for nc-nd/4.0/) clinicians and policy makers. Therefore, it is critical that developers are trans- doi: https://doi.org/10.1016/ parent and forthcoming about the difficulties that have arisen during the CPG j.jebdp.2021.101633 development process. December 2021 1 The Journal of EVIDENCE-BASED DENTAL PRACTICE INTRODUCTION Analysis PRISMA tool.15 We published the protocol in Open Science Framework.16 B y the end of 2019, the new Severe Acute Respiratory Syndrome CoronaVirus2 (SARS-CoV-2) was reported in Wuhan China.1 This pathogen is the cause of the coronavirus Eligibility Criteria 2019 disease (COVID-19).2 In just a few months, COVID- We included documents in English, Spanish and Portuguese 19 had spread worldwide, becoming a major public health self-declared as a guideline, guidance providing recommen- problem and being categorised by The World Health Organ- dations for walk-in or emergency dental care in the context isation as a pandemic disease.3 of the COVID-19 pandemic. A document was also eligible if it was developed by regional, national, or local organiza- Epidemiological data show that all ages are suscepti- tions, a team of experts, by a panel of experts, or if it pro- ble to COVID-19. However, individuals with co-morbidities vided a list of authors/experts involved in the process. We are more likely to develop severe clinical symptoms.4 excluded Clinical Practice Guidelines developed exclusively Health workers are exposed to contaminated fluids/aerosols for special-care patients, guidelines developed outside of through close contact with SARS-CoV-2 infected patients’ the pandemic context, previous versions of the same guide- face, having an unprecedented occupational risk of morbid- line, letters to the editor, and conference summaries. ity and mortality.5 , 6 In the field of dentistry, treatments are de- livered in close proximity to the patient. Furthermore, dental Sources of Information workers are subject to frequent exposure to saliva, blood and We searched in MEDLINE, EMBASE, LILACS, Episte- other bodily fluids,7 contact with contaminated surfaces,7 , 8 monikos, and Trip databases up to August 10, 2020. This and frequent exposure to bioaerosols.7 , 9 , 10 Dentists are at a was complemented by a manual search of guideline devel- higher risk of infection, and of becoming potential carriers of opers’ websites, repositories, international dental scientific the disease.9 , 11 The use of the dental drill, ultrasonic scalers, societies, Ministries of Health worldwide and institutions re- and air/water syringes magnify the dissemination of saliva lated to COVID-19 management. This search was also up- droplets, blood and aerosol emissions, all facilitate environ- dated in August 2020. (Appendix S1). We also examined the ment, equipment, and surface contamination.12 As a result, reference lists of the selected CPGs to identify other guide- dental service providers may also be at a higher risk of cross lines that met the inclusion criteria. We did not limit the infection with patients.9 , 11 search by date, language or publication status. Currently, vaccines are being tested globally; nevertheless, The search strategy and databases used are listed in supple- it will take time until the majority of the population is pro- mentary material (Appendix S1). tected. Meanwhile, biosafety measures are fundamental to stop the spread and transmission of the disease. Therefore, Selection of Guidelines dental services must prioritize the patient’s protection and All references identified were extracted to an EndNote X9 reduce the coronavirus transmission risk, in both public and database to facilitate their management. private dental services, to ensure the health and safety of the dental staff and patients. Titles, abstracts and full texts were independently reviewed by 2 investigators (C.Z, G.E.E., N.F.D., P.M.M, P.P or Y.A.R) in To provide appropriate dental services, protocols and clinical a 3-step process. We resolved disagreements with the help practice guidelines (CPGs) focused on important biosafety of a third reviewer. In the case of several documents from a measures for a low-risk COVID-19 transmission environment single source, we included the most recent. have been developed. In order to provide the safest dental practice based on scientific evidence, CPGs should aim for Data Charting Process the best quality and be readily available,13 thus improving One reviewer (C.Z, G.E.E, N.F.D., P.M.M, P.P or Y.A.R) ex- the quality and results of medical services.14 Consequently, tracted the data and another reviewer checked all the ex- assessing the quality of CPGs developed during COVID-19 tracted information for accuracy. We extracted the following pandemic in the dental field is a critical task. In this study we information from each article using a previously piloted data assessed the quality of CPGs on dental services during the collection form: author, year, title, country, organization, lan- first months of the COVID-19 pandemic. guage, setting, and target population. MATERIAL AND METHODS Critical Appraisal of Individual Sources of Evidence Two researchers (A.S., C.Z., N.F.D., P.M.M or Y.A.R) indepen- Design dently rated the quality of each guideline using the online Systematic Evaluation of CPGs AGREE II tool (https://www.agreetrust.org/resource-centre/ For the development of this assessment we adhered to the agree-plus/). The AGREE II instrument17 includes 23 items Preferred Reporting Items of Systematic Reviews and Meta- divided into 6 domains: 1. Scope and purpose, refers to the 2 Volume 21, Number 4 The Journal of EVIDENCE-BASED DENTAL PRACTICE aim of the guidelines; 2. Stakeholder involvement, repre- in order to determine which domains influenced the over- sents the views of the intended users; 3.Rigor of develop- all quality of the CPG. Spearman’s correlation was classi- ment, reflects the quality of the CPG development process fied as: negligible (0.0-0.1), weak (0.1>ρ>0.39), moderate and its recommendations; 4. Clarity of presentation, refers (0.4<ρ<0.69), strong (0.7-0.89), and very strong (0.8-1.0).21 to the structure of the guidelines; 5. Applicability, shows the Data were analyzed with IBM SPSS v.27 software for Mac,22 barriers and facilitators for the implementation of the CPG, considering a significance threshold of 5%. also considering the financial implications to implement the recommendations; and 6. Editorial independence, illustrat- ing the transparency in the formulation of the guideline rec- RESULTS ommendations. Each of the 23 items is rated from 1 to 7 After excluding duplicates, the search initially yielded 1149 points in the Likert scale. The AGREE II instrument also in- references. Twelve documents were selected from databases cludes 2 overall quality appraisals for each CPG: an over- and 11 were identified through other sources. Finally, 23 doc- all score of 1 to 7, and whether the reviewer would recom- uments were included. Figure 1 shows the selection pro- mend using the CPG, assessing it as recommended, recom- cess flow chart. The agreement between reviewers during mended with modifications, or not recommended.17 all phases of the process was high (Kappa = 0.872). Of the CPGs included in the study, fifteen were from Amer- Synthesis of the Results ica, six from Europe, and one from Asia and Oceania. The de- The total AGREE II score was calculated by summing up the velopers were mainly Ministries or Health Departments and individual items included in a domain and by scaling the to- government agencies (n = 11), scientific societies and dental tal as a percentage of the maximum possible score for that colleges (n = 13). Following publication of an initial version domain.17 If discrepancies between reviewers were higher a total of 10 CPGs were subsequently updated. Main CPG than 3 points, or if the standard deviation (SD) in an item was characteristics are listed in Table 1 . greater than, or equal to 1.5 SD, the item of the guideline was reassessed by the reviewers and agreement was reached.18 Appraisal of CPGs The reviewers considered the overall quality of the CPGs and The overall agreement between the 2 reviewers with re- made a final recommendation about each guideline.18 We spect to the use of the AGREE II instrument was very good classified the CPG as high quality when at least 3 of the do- (ICC = 0.93; 95%CI 0.7-0.95). Table 2 shows the standardized mains showed a score of 60% or higher, including the rigor domain scores per CPG, as well as the overall recommenda- of development domain.17-19 tion. Of the 6 domains, 3 scored above 60% in at least one CPG: Scope and purpose in 16 CPGs (69.6%),23-38 Clarity of Data Analysis presentation in 15 CPGs (65.2%),23-32 , 35-37 and Stakeholder in- The intraclass coefficient with its 95% confidence interval volvement in 2 CPGs (8.7%).27 , 28 The domain with the highest (95% CI) as an indicator of overall agreement between re- score was Scope and Purpose (median 67.0%), and the one viewers for each of the 23 items of the AGREE II instrument with the lowest score was Editorial Independence (median was calculated. According to the scale proposed by Landis 8.0%). and Koch,20 the degree of agreement between 0.01 and 0.20 is slight, from 0.21 to 0.40 is fair, from 0.41 to 0.60 is moder- Scope and Purpose ate, from 0.61 to 0.80 is substantial and from 0.81 to 1.00 is The median score was 67.0% (IQR 20.0%). Of the 23 guide- very good. lines, 16 (69.6%)23-38 scored above 60% in this domain. The intended aim was well defined by the CPGs (65.2%) as was Shapiro-Wilk test was performed to analyze the normality the population (patients, public, etc.) for whom the guide- of the data. Given the skewed distribution of the AGREE II line was intended.23 , 24 , 26-34 , 36 , 37 , 39 However, some CPGs did scores, median and the interquartile range (IQR) were cal- not describe the specific health questions covered by the culated for each domain score for each CPG. We used non- guideline of the specific health issue (eg, recommendation parametric analysis and Mann-Whitney U or Kruskal-Wallis about Personal Protective Equipment, environmental infec- tests, with post-hoc test, to assess the association between tion control, procedural risk mitigation, etc.). total AGREE II score and the characteristics of the CPG such as region, presence of update, and CPGs develop- Stakeholder Involvement ment agencies, (Ministries or Health departments and gov- Median score was 33.0% (IQR 14.0%). Two of the CPGs ernment agencies vs scientific societies, dental colleges or (8.7%)27 , 28 scored above 60% in this domain. Scarcity of de- universities). tailed information about the guideline development group Spearman test was used to analyze the correlation between (discipline, institution, description of the role), as well as not the score obtained in the AGREE II domains and total score, taking into account the target users point of view (only 2 December 2021 3 The Journal of EVIDENCE-BASED DENTAL PRACTICE Table 1. General information of the clinical practice guidelines. Reference Guideline title Country Organization Language Date publication (P) Date of update (U) 41 COVID-19. Recomendaciones para Argentina Ministerio de Salud de Spanish P: 06/10/20 Odontología Argentina U: no 36 Manual de buenas prácticas en Brazil Conselho Federal de Spanish, P: 03/21/20 bioseguridad para ambientes Odontologia, ITI Brasil, ITI Portuguese U: 05/26/20 odontológicos México Faculdade ILAPEO, Consejo Mexicano de Rehabilitación Oral y Maxilofacial a.c., AMP, APP, Universidad de Concepción, Centro de Rehabilitación Oral Avanzada e Implantologiá-Facultad de Odontologiá 39 Orientação de biossegurança. Adequações Brazil Conselho Regional de Portuguese P: 04/20 técnicas em tempos de COVID-19 Odontologia de São Paulo U: No 23 Nota técnica GVIMS/GGTES/ANVISA n. Brazil Agência Nacional de Portuguese P:1/30/20 04/2020 Orientações para serviços de Vigilância Sanitária - U: 02/17/20 saúde: medidas de prevenção e controle ANVISA U: 03/21/20 que devem ser adotadas durante a U: 03/31/20 assistência aos casos suspeitos ou U: 05/08/20 confirmados de infeccção pelo novo coronaviŕus (SARS- CoV-2). 42 Nota técnica conjunta n°014/2020- Brazil Secretaria de Estado da Portuguese P:07/02/20 DAPS/DIVS/DIVE/SES/COMSES/SC Saúde de Santa Catarina U: no (02/07/2020). Coronavírus COVID-19: Recomendações ao atendimento odontológico do SUS em Santa Catarina 33 CDSS Alert – COVID-19 Pandemic: IPC Canada The College of Dental English P: 04/27/20 Interim Protocol Update “RE - OPEN Surgeons of Saskatchewan U: no SASKATCHEWAN” – A Summary for Dentists 40 Return to practice office manual. Adapting Canada Canadian Dental English P: 05/10/20 the dental office to the COVID-19 Pandemic Association U: no 32 Orientaciones para atención odontológica Chile Ministry of Health Spanish P: 05/18/20 en fase IV COVID-19 U: no 31 Lineamiento técnico para la prevención y Costa Ministerio de Salud Spanish P: 03/27/20 contención de COVID-19 para odontólogos Rica Pública de Costa Rica U: no y personal auxiliar de Costa Rica 44 Protocolo para atención odontológica en Ecuador Ministerio de Salud Pública Spanish P: 04/2020 emergencias y urgencias odontológicas U: no durante la emergencia sanitaria por COVID–19 35 Standard operating procedure. Transition to England National Health Services. English U: 06/04/20 recovery. A phased transition for dental NHS England practices toward the resumption of the full range of dental provision (continued on next page) 4 Volume 21, Number 4 The Journal of EVIDENCE-BASED DENTAL PRACTICE Table 1 (continued) Reference Guideline title Country Organization Language Date publication (P) Date of update (U) 34 COVID-19 guidance and standard England National Health Services. English P:04/15/20 operating procedure. For the provision of NHS England U:06/16/20 urgent dental care in primary care dental settings (from 8 June 2020) and designated urgent dental care provider sites 29 Protocolo de Bioseguridad Odontológica Colegio Estomatológico Spanish P: 05/2020 con énfasis en COVID-19 Guatemala de Guatemala U: no 43 A statutory body constituted under the India Dental Council of India English P: 05/07/20 dentists act, 1948 U: no 24 Guidelines for oral health services at New Ministry of Health English P: 03/31/20 COVID-19 Alert Level 1 Zealand U: 04/22/20 (Level 3) 11/05/20 (Level 2) 06/08/20 (Level 1) 06/23/20 (Level 1) 07/03/20 (Level 1) 38 Protocolo para atención Odontológica Paraguay Ministerio de Salud Spanish P: 04/14/20 durante la pandemia de SARS-CoV-2 en la U: no República del Paraguay 25 COVID-19: Procedimentos em clińicas, Portugal Ordem dos Médicos Portuguese P: 05/01/20 consultórios ou serviços de saúde oral dos Dentistas, Programa U: 07/27/20 cuidados de saúde primários, setor social e nacional de Promoção da privado Saude Oral, Programa Nacional de Prevenção e Controlo de Infeções e das Resistências aos Antimicrobianos 27 Resuming General Dental Services Scotland The Scottish Dental English P: 05/25/20 Following COVID-19 Shutdown. Clinical Effectiveness U: 06/12/20 A guide and implementation tools for Programme general dental practice. For Phases 2 and 3 of dental services remobilisation 26 Plan estratégico de acción para el periódo Spain Consejo de Dentistas de Spanish P: 04/13/20 de desescalada COVID-19 España U: 05/02/20 28 Implications of COVID-19 for the safe UK College of General English P: 06/16/20 management of general dental practice. A Dentistry U: no practical guide Faculty of General Dental Practice 30 Guidance for Dental Settings. Interim USA Centre for Disease Control English P: 06/17/20 Infection Prevention and Control Guidance and Prevention U: 08/04/20 for Dental Settings During the coronavirus disease 2019 (COVID-19) Pandemic 45 Return to Work Interim Guidance Toolkit USA American Dental English P: 05/07/20 Association U: 07/23/20 37 Ruta de atención para procedimientos de – Asociación English, P: 04/11/20 Odontología Pediatrica durante la etapa de Latinoamericana de Spanish, U: no confinamiento o cuarentena de la Odontopediatria. Portuguese pandemia COVID-19 December 2021 5 6 Volume 21, Number 4 The Journal of EVIDENCE-BASED DENTAL PRACTICE Table 2. Standardized scores across CPGs per domain (AGREE II). Reference Guide Title Scope Stakeholder Rigour of Clarity of Applicability Editorial Overall Overall Recom- Quality and involvement develop- presenta- indepen- rate mendation purpose ment tion dence 41 COVID-19. Recomendaciones para Odontología 22% 8% 6% 25% 0% 0% 2.0 Not Low recommended 36 Manual de buenas prácticas en bioseguridad para 78% 44% 5% 78% 10% 0% 3.0 Not Low ambientes odontológicos recommended 39 Orientação de biossegurança. Adequações 58% 33% 7% 64% 13% 8% 3.5 Not Low técnicas em tempos de COVID-19 recommended 23 Nota técnica GVIMS/GGTES/ANVISA n. 78% 47% 19% 64% 19% 8% 4.0 Not Low 04/2020Orientações para serviços de saúde: recommended medidas de prevenção e controle que devem ser adotadas durante a assistência aos casos suspeitos ou confirmados de infeccção pelo novo coronaviŕus (SARS- CoV-2). 42 Nota técnica conjunta 39% 19% 0% 44% 2% 0% 2.0 Not Low n°014/2020-DAPS/DIVS/DIVE/SES/COMSES/SC recommended (02/07/2020). Coronavírus COVID-19: Recomendações ao atendimento odontológico do SUS em Santa Catarina 33 CDSS Alert – COVID-19 Pandemic: IPC Interim 61% 31% 13% 44% 10% 8% 2.5 Not Low Protocol Update “RE - OPEN SASKATCHEWAN” – recommended A Summary for Dentists 40 Return to practice office manual. Adapting the 47% 33% 16% 61% 21% 0% 3.0 Not Low dental office to the COVID-19 Pandemic recommended 32 Orientaciones para atención odontológica en fase 72% 25% 6% 69% 2% 0% 2.5 Not Low IV COVID-19 recommended 31 Lineamiento técnico para la prevención y 64% 28% 8% 64% 8% 0% 2.5 Not Low contención de COVID-19 para odontólogos y recommended personal auxiliar de Costa Rica 44 Protocolo para atención odontológica en 58% 36% 16% 33% 21% 8% 3.5 Not Low emergencias y urgencias odontológicas durante la recommended emergencia sanitaria por COVID–19 (continued on next page) Table 2 (continued) Reference Guide Title Scope Stakeholder Rigour of Clarity of Applicability Editorial Overall Overall Recom- Quality and involvement develop- presenta- indepen- rate mendation purpose ment tion dence 35 Standard operating procedure. Transition to 81% 36% 9% 75% 29% 8% 3.5 Not Low recovery. A phased transition for dental practices recommended toward the resumption of the full range of dental provision 34 COVID-19 guidance and standard operating 78% 50% 11% 56% 19% 8% 3.5 Not Low procedure. For the provision of urgent dental care recommended in primary care dental settings (from 8 June 2020) and designated urgent dental care provider sites 29 Protocolo de Bioseguridad Odontológica con 81% 42% 22% 69% 23% 0% 3.5 Not Low énfasis en COVID-19 recommended 43 A statutory body constituted under the dentists 22% 28% 4% 50% 13% 4% 2.0 Not Low act, 1948 recommended 24 Guidelines for oral health services at COVID-19 67% 14% 21% 81% 10% 8% 3.0 Not Low Alert Level 1 recommended 38 Protocolo para atención Odontológica durante la 61% 33% 5% 25% 17% 0% 2.0 Not Low pandemia de SARS-CoV-2 em la República del recommended Paraguay 25 COVID-19: Procedimentos em clínicas, 61% 36% 7% 75% 19% 8% 3.0 Not Low The Journal of EVIDENCE-BASED DENTAL PRACTICE consultórios ou serviços de saúde oral dos recommended cuidados de saúde primários, setor social e privado 27 Resuming General Dental Services Following 89% 86% 51% 72% 31% 58% 4.5 Recommended Low COVID-19 Shutdown. with A guide and implementation tools for general modifications dental practice. For Phases 2 and 3 of dental services remobilization 26 Plan Estratégico de acción para el periodo de 83% 42% 21% 86% 29% 8% 4.0 Not Low desescalada COVID-19 recommended 28 Implications of COVID-19 for the safe management 83% 86% 27% 97% 40% 0% 4.0 Not Low December 2021 of general dental practice. A practical guide recommended (continued on next page) 7 8 Volume 21, Number 4 The Journal of EVIDENCE-BASED DENTAL PRACTICE Table 2 (continued) Reference Guide Title Scope Stakeholder Rigour of Clarity of Applicability Editorial Overall Overall Recom- Quality and involvement develop- presenta- indepen- rate mendation purpose ment tion dence 30 Guidance for Dental Settings. Interim Infection 72% 33% 17% 78% 29% 0% 4.0 Not Low Prevention and Control Guidance for Dental recommended Settings during the coronavirus disease 2019 (COVID-19) Pandemic 45 Return to Work Interim Guidance Toolkit 28% 19% 13% 36% 27% 33% 3.0 Not Low recommended 37 Ruta de atención para procedimientos de 78% 42% 16% 64% 19% 13% 3.0 Not Low Odontologiá Pediátrica durante la etapa de recommended confinamiento o cuarentena de la pandemia COVID-19 Mean 63.5% 37.0% 13.9% 61.4% 17.8% 7.8% 3.1 (SD) (19.8%) (18.6%) (10.6%) (19.4%) (10.2%) (13.1%) (0.73) Median 67.0% 33.0% 13.0% 64.0% 19.0% 8.0% 3.0 (IQR) (20.0%) (14.0%) (13.0%) (31.0%) (17.0%) (8.0%) (1.0) The Journal of EVIDENCE-BASED DENTAL PRACTICE Figure. 1. Flowchart of the included CPGs. CPGs considered this point)27 , 28 Most of the CPGs clearly (43.5%)25 , 31 , 32 , 35 , 36 , 38 , 39 , 41-43 of the guidelines scored below declared a target user (60.8%).23 , 25-30 , 33-38 , 40 10%. The CPGs developed during the first 8 months of the COVID-19 pandemic did not use systematic meth- Rigour of Development ods for the development of recommendations. Only 4 de- Median score was 13.0% (IQR 13.0%). In this domain no clared conducting a systematic search, or that the evidence guidelines were found that scored above 60% and 10 was provided by guideline panel members (17.4%).27-29 , 37 December 2021 9 The Journal of EVIDENCE-BASED DENTAL PRACTICE Four guidelines (17.4%)27 , 28 , 37 , 44 reported some information higher scores in the domains Scope and purpose, Stake- about selection criteria. holder involvement and Clarity of presentation. However, we did not find significant differences between guidelines de- Two CPGs (8.7%)27 , 28 declared assessing the body of the ev- veloped by Ministries or government agencies and scientific idence, but did not describe the methodology applied. In societies. (Table 3). most of the guidelines the description of the methods used to develop the recommendations, and the means by which A high significant correlation between the scores of AGREE panels reached their decisions was not clear. Only 6 CPGs II domains and the overall rate was observed, except for Ed- (26.1%)24 , 27 , 28 , 37 , 40 , 44 reported scarce information, of these 6, itorial Independence (r = 0.374; P = .078) (Appendix S2). 2 (8.7%)28 , 35 reported the use of a Delphi method for the de- velopment of recommendations. DISCUSSION Two guidelines reported an obvious relation between rec- ommendations and the supporting evidence (8.7%).27 , 30 Ten Main Findings guidelines noted this aspect for a subset of the recommen- This study showed a low quality for CPGs developed dur- dations (43.5%).23 , 24 , 26 , 28 , 29 , 34 , 35 , 37 , 44 , 45 One the 23 guide- ing the first 8 months of the pandemic aimed at minimizing lines (4.3%)27 reported some information regarding exter- the risk of contagion by COVID-19 during dental care. The nal peer review prior to publication. Considering the up- domain with the highest score was Scope and Purpose (me- dating process only one (4.3%)27 of the ten updated CPGs dian 67.0%), and the one with the lowest score was Editorial (43.5%)23-27 , 30 , 34-36 , 45 reported some information. Independence (median 8.0%). According to the AGREE II in- strument the median overall rate was 3.0 (IQR 1.0). Only one Clarity of Presentation of the CPGs was recommended with modifications by the The median score for this domain was 64.0% (IQR 31.0%). reviewers. Eight CPGs (34.8%)33 , 34 , 38 , 41-45 scored below 60% in this do- main. The majority of the guidelines presented specific and Our Results in the Context of Previous Research unambiguous recommendations (86.9%). In 8 of the guide- Although the domains “Scope and purpose” and “Clar- lines (34.8%)23 , 25 , 26 , 28 , 30 , 35 , 36 , 39 specifically listed the different ity of presentation” obtained a mean quality score of over treatment options and in 5 CPGs (21.7%)24-26 , 28 , 36 key recom- 60%, remaining domains presented an exceptionally poor mendations were easily identified.. report reflected in very low scores. The low score for the remaining domains, was also reported for other guidelines Applicability carried out in the context of the COVID-19 pandemic.46 , 47 Median score was 19.0% (IQR 17.0%). All of the guidelines Norris et al48 who evaluated WHO guidelines generated (100%) scored below 60% in the Applicability domain. Two during 4 previous emergencies related to recent infectious guidelines CPGs (8.7%)26 , 45 provided advice and/or tools on diseases (H1N1, H7N9 virus, MERS-CoV, and Ebola), con- how the recommendations could be implemented. cluded that few guidelines met international standards for reliable and evidence-based CPGs. Moreover, they pointed Editorial Independence out CPGs’ weaknesses, such as limited mention of system- For this domain, the median score was 8.0% (IQR 8.0%). Ten atic reviews, failure to perform external peer reviews, and of the CPGs (43.5%)28-32 , 36 , 38 , 40-42 obtained a score of 0.0%, incomplete information with regard to development meth- and all of the guidelines (100%) scored below 60%. ods.48 Similarly, these aspects were also observed in our study. In our research, only 2 guidelines27 , 28 presented a Overall Assessment score higher than 60% in at least 3 domains. Notwithstanding None of the 22 assessed guidelines was recommended by the above, whether performed during or outside a pandemic the reviewers. Only one of the CPGs (4.3%)27 was recom- context,46 , 47 , 49 the quality of the CPGs in the dental field mended with modifications. All the guidelines were classi- in general tend to be of substandard quality with AGREE II fied as low quality, since none scored ≥ 60% in at least 3 overall rate. domains, including the Rigour of Development. The “Stakeholder involvement” domain presented a low- The median overall rate was 3 (IQR 1), the highest score was quality score, namely as a result of poor information with re- 4.5,27 and the lowest was 2.38 , 41-43 gard to group participants developing the guide and the in- formation related to the target population. This was also ob- Association Between Agree II Score and served among guidelines developed during the COVID-1947 Characteristics of the CPG pandemic and outbreaks of other diseases.50 In a pandemic Updated CPGs scored significantly higher in the AGREE II context, where the rapid development of recommendations overall rate. CPGs developed in Europe showed significantly is needed, it is difficult to meet some of the aspects in this 10 Volume 21, Number 4 The Journal of EVIDENCE-BASED DENTAL PRACTICE Table 3. Median and interquartile range (IQR), in percentages (%) for the AGREE II domains according to prespecified predictors. Variables n Scope and Stakeholder Rigour of de- Clarity of Applicability Editorial in- Overall rate purpose involvement velopment presentation dependence Median (IQR) Median (IQR) Median (IQR) Median (IQR) Median (IQR) Median (IQR) Median (IQR) Update conducted Yes 10 78.0 (16.0) 39.0 (18.3) 15.0 (12.5) 75.00 (16.8) 23.0 (12.3) 8.0 (8.3) 3.5 (1.0) No 13 61.0 (32.0) 33.0 (12.3) 8.0 (10.5) 61.00 (28.0) 13.0 (16.0) 0.0 (8.0) 2.5 (1.5) P-value .057 .148 .186 .021∗ .067 .049∗ .015∗ Type of organization Scientific Societies, Dental 12 69.5 (32.8) 39.0 (12.0) 14.5 (14.8) 66.5 (24.5) 20.0 (15.5) 8.0 (11.8) 3.0 (0.88) Colleges or Universities Ministries or Health 11 67.0 (20.0) 33.0 (17.0) 9.0 (11.0) 64.0 (42.0) 17.0 (19.0) 0.0 (8.0) 3.0 (1.5) Departments and Government Agencies P-value .608 .151 .316 .316 .118 .260 .449 Region Asia 1 22.0 28.0 4.0 50.0 13.0 4.0 2.0 America 15 61.0 (31.0)† 33.0 (17.0)† 13.0 (10.0) 64.0 (33.0)† 17.0 (13.0) 0.0 (8.0) 3.0 (1.0) Europe 6 82.0 (10.8)† 46.0 (50.0)† 16.0 (24.5) 75.0 (20.8) † 29.0 (14.3) 8.0 (14.5) 3.8 (0.75) Oceania 1 67.0 14.0 21.0 81.0 10.0 8.0 3.00 P-value .027∗ .026∗ .138 .047∗ .057 .371 0.060 ∗ Statistically significant difference. † Statistically significant difference between Europe and America. domain. A contributing factor to the lower quality, may be It is possible that the low score in “Rigour of Development” that participation of all the relevant stakeholders is often not presented in the guidelines developed during the initial pe- feasible.51 riod of the COVID-19 pandemic, was related to the difficulty in obtaining reliable evidence, since very little information The domain “Rigour of Development” is usually consid- of the virus was available. Hence, studies currently available ered the main domain of evaluation in clinical guidelines, have important methodological limitations.53 For this rea- since it assesses the process used to gather and synthesize son, it is preferable to state that systematic reviews were not the evidence and methods to formulate the recommenda- used in the process, because none were available in the pe- tions.19 In our research, we pointed out that the guidelines riod in which the guideline was developed, rather than to developed in the initial months of the COVID-19 pandemic, directly omit the information.50 presented a poor report, with little information regarding the methods used for the synthesis of the evidence, or for Due to the COVID-19 health emergency, some medical the development of the recommendations. Very few CPGs CPGs carried out in the first months of the pandemic based related the recommendations to the supporting evidence. their recommendations in studies developed during the Furthermore, they did not report conducting external peer SARS outbreak in 2003.54 Even though, the use of indirect reviews prior to publication. This is also consistent with evidence based on other viral infections is controversial,55 guidelines developed in response to health emergencies for it must be determined a priori which indirect evidence will both disease outbreaks,48 , 50 and guidelines developed in be considered for the development of the CPG.56 For ex- times of the COVID-19 pandemic.46 , 47 , 52 ample, the World Health Organization (WHO) developed December 2021 11 The Journal of EVIDENCE-BASED DENTAL PRACTICE recommendations for its COVID-19 guidelines based on a financial and human, may possibly influence score qual- previously developed guideline for MERS, given that both ity of the guideline depending on the geographical area are betacoronaviruses.49 where they are developed. Therefore, adequate access to resources would allow CPG to be carried out in a shorter We consider that some of the recommendations made in the period. Most of the CPG included were developed by na- dental guidelines developed in these first months of the pan- tional organizations and only 3 have been developed by lo- demic, should have been supported by indirect evidence. cal organizations. This may be due to the fact that national For instance, the development of recommendations for re- organizations have greater resources (both financial and hu- ducing AGPs in dental practice should have been based on man) and, therefore, can provide a faster response during a indirect evidence of other types of coronaviruses. Recom- health emergency such as the COVID-19 pandemic. Another mendations based on indirect evidence could have posi- variable analyzed in the present study was the update of the tively influenced the quality assessment of the guidelines, guidelines. We verified that the updated CPGs presented a both for the “Rigour of Development” domain, as well as higher quality for the “Clarity of Presentation” and “Appli- for global quality. cability” domains. This finding underlines the concept that CPGs should incorporate the Grading of Recommenda- guidelines generated in the first stage of a health emergency tion Assessment, Development and Evaluation (GRADE) ap- are of lower quality. It further accentuates the importance of proach, since this provides a structured approach to deter- updating guidelines as new evidence comes to light. mine the certainty of the evidence, and to make recommen- dations and decisions.57 In our study, none of the guidelines used the GRADE approach to assess certainty of the evi- Strengths and Limitations dence or to develop the recommendations, as reported in The main strengths of this study are that the information re- studies that evaluated COVID-19 CPGs.46 garding development process of CPGs was obtained in a systematic search of the literature that included websites of The “Applicability” domain also rendered a very low-quality developers and repositories of CPG. In addition, the guide- score in our analysis, since the guidelines did not adequately lines were evaluated independently by 2 calibrated review- report the facilitators and obstacles to its application. This ers using a standardized tool. The AGREE II instrument is cur- was also reported in the study by Song et al58 for other rently the only validated and reliable instrument that enables guidelines related with COVID-19. The low score was also a quantitative comparison of CPGs, and is designed to help reported for dental guidelines carried out outside the pan- users to evaluate their methodological quality. demic context.49 Evidently, the report for this domain should be implemented generally in dental guidelines, not only for However, there are certain limitations in our study. Even those carried out during times of health emergencies. though, an extensive search including gray literature was carried out, it is possible that relevant guidelines in a lan- In this research, “Editorial Independence” was the one do- guage other than English, Spanish, or Portuguese were not main that presented the lowest quality, with a score of 0% in included. Furthermore, we only evaluated the latest version at least 10 guidelines. In medical guidelines carried out dur- available, and some information reported in previous ver- ing the current COVID-19 pandemic, this domain also pre- sions may provide additional information to those reported sented a low-quality score, with a score of 0% for most of in the latest version, not being reflected in our evaluation. these.54 , 58 In our study, the low score obtained for this do- However, we think that this is unlikely as typically updated main was the result of incomplete reports due to conflicts of versions tend to show higher scores, as our results showed. interest. This fact was also observed by Norris et al48 in the Finally, the instrument used for quality evaluation (AGREE evaluation of guidelines carried out for other infectious dis- II) was not developed to evaluate CPGs for periods when eases. Dental guidelines carried out outside the COVID-19 timely and prompt answers are needed.48 Some domains re- pandemic context also present a suboptimal score49 for this quire longer time for their development impacting the level domain, indicating the need to improve reporting on the in- of quality. fluence of the possible financial and institutional conflicts of interest. Implications for Practice and Research In reference to the variables that influence the quality of Developing trustworthy guidelines in a relatively short time- the guidelines, our analysis showed that the CPGs produced frame is a challenge, which has been evidenced in this study. in Europe had higher average scores compared to guide- Some domains that require more time to develop will al- lines developed in other continents. Mubeen et al49 found ways be susceptible to lower quality.50 However, guideline that the guidelines developed in Europe and North Amer- developers should establish methods to ensure the guide- ica presented better quality compared to guides developed line is conducted in a transparent and evidence-based man- in other countries. Access to the necessary resources both ner. Therefore, it is critical that developers are transparent 12 Volume 21, Number 4 The Journal of EVIDENCE-BASED DENTAL PRACTICE and forthcoming about the difficulties that have arisen dur- SOURCE OF FUNDING ing the CPG development process. This project was funded by a grant from Agencia Nacional The low-quality of CPGs on dental services during the de Investigación y Desarrollo (ANID), Chile [COVID0700]. COVID-19 pandemic may not achieve effective health out- comes, or might not appropriately consider the risks of using those recommendations in a specific scenario.19 This makes SUPPLEMENTARY MATERIALS their implementation difficult for clinicians and policy mak- Supplementary material associated with this article can be ers,59 and may interfere with patient adherence to the rec- found, in the online version, at doi:10.1016/j.jebdp.2021. ommendations.60 101633. Future research should be aimed at optimizing the de- velopment process of the CPGs and allow updating rec- REFERENCES ommendations as soon as relevant evidence becomes 1. World Health Organization (WHO). WHO statement regard- available. 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