كتاب
Fluoride for adults
- Methodology
A comprehensive search for guidelines was undertaken to identify the most relevant guidelines to consider for adaptation.
Inclusion/ exclusion criteria followed in the search and retrieval of guidelines to be adapted:
• Selecting only evidence-based guidelines (guideline must include a report on systematic literature searches and explicit links between individual recommendations and their supporting evidence).
• Selecting only national and/or international guidelines.
• Specific range of dates for publication (using Guidelines published or updated in 2015 and later).
• Selecting peer reviewed publications only
• Selecting guidelines written in English language
• Excluding guidelines written by a single author, not on behalf of an organization to be valid and comprehensive, a guideline ideally requires multidisciplinary input.
• Excluding guidelines published without references as the panel needs to know whether a thorough literature review was conducted and whether current evidence was used in the preparation of the recommendations.
The following characteristics of the retrieved guidelines were summarized in:
• Developing organization/authors
• Date of publication, posting, and release
• Country/language of publication
• Date of posting and/or release
• Dates of the search used by the source guideline developers.
All retrieved Guidelines were screened and appraised using AGREE II instrument (www.agreetrust.org) by at least three members. The panel decided on a cut-off point or ranked the guidelines (any guideline scoring above 50% on the rigor dimension was retained). The GDG decided to adapt the American Dental Association (ADA) guidelines on professionally applied and prescription-strength, home-use topical fluoride agents for caries prevention – 2013.4
➡️Evidence assessment
According to WHO Handbook for Guidelines, we used the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to assess the quality of a body of evidence, develop and report recommendations. GRADE methods are used by WHO because these represent internationally agreed standards for making transparent recommendations. Detailed GRADE information is available on the following site:
https://www.gradeworkinggroup.org/
Table 1 Quality and Significance of the four levels of evidence in GRADE:
|
Quality |
Definition
|
Implications |
|
High |
The guideline development group is very confident that the true effect lies close to that of the estimate of the effect. |
Further research is very unlikely to change confidence in the estimate of effect |
|
Moderate |
The guideline development group is 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 |
Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate |
|
Low |
Confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the true effect |
Further research is very likely to have an important impact on confidence in the estimate of effect and is unlikely to change the estimate |
|
Very Low |
The group has very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of the effect. |
Any estimate of effect is very uncertain |
Table 2: Factors that determine How to upgrade or downgrade the quality of evidence:
|
Downgrade in presence of |
Upgrade in presence of |
|
Study limitations -1 Serious limitations -2 Very serious limitations Consistency -1 Important inconsistency Directness -1 Some uncertainty -2 Major uncertainty Precision -1 Imprecise data Reporting bias -1 High probability of reporting bias |
Dose-response gradient +1 Evidence of a dose-response gradient Direction of plausible bias +1 All plausible confounders would have reduced the effect Magnitude of the effect +1 Strong, no plausible confounders, consistent and direct evidence +2 Very strong, no major threats to validity and direct evidence |
➡️The strength of recommendations:
The strength of a recommendation communicates the importance of adherence to the recommendation.
➡️Strong recommendations
With strong recommendations, the guideline communicates the message that the desirable effects of adherence to the recommendation outweigh the undesirable effects. This means that in most situations the recommendation can be adopted as policy.
➡️Conditional recommendations
These are made when there is greater uncertainty about the four factors above or if local adaptation has to account for a greater variety in values and preferences, or when resource use makes the intervention suitable for some, but not for other locations. This means that there is a need for substantial debate and involvement of stakeholders before this recommendation can be adopted as policy.
➡️Good practice recommendations:
Clinical opinion suggests this advice is well established or supported. No robust underpinning research evidence exists. Good practice points are primarily based on extrapolation from research on related topics and/or clinical consensus, expert opinion and precedent, and not on research appropriate for rating the certainty or quality of the evidence.
➡️When not to make recommendations:
When there is lack of evidence on the effectiveness of an intervention, it may be appropriate not to make a recommendation.
