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Systematic Review of Clinical Practice Guidelines for Traumatic Dental

Injuries

Article in Dental Traumatology · March 2023

DOI: 10.1111/edt.12838

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Received: 29 July 2022 | Revised: 4 March 2023 | Accepted: 7 March 2023

DOI: 10.1111/edt.12838

ORIGINAL ARTICLE

Systematic review of clinical practice guidelines for traumatic

dental injuries

Ankita Saikia1 | Sneha S. Patil1 | Muthu MS1,2 | Divyambika CV3 | Ram Sabarish4 |
Senthoor Pandian5 | Robert Anthonappa6 | Tarun Walia7 |
8
Moayad Jamal Saeed Al Shahwan
1
Department of Pediatric and Preventive Dentistry, Sri Ramachandra Faculty of Dental Sciences, Centre for Early Childhood Caries Research (CECCRe), Sri
Ramachandra Institute of Higher Education and Research (SRIHER), Porur, Chennai, 600116, India
2
Centre of Medical and Bio-­Allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates
3
Department of Oral Medicine and Radiology, Sri Ramachandra Faculty of Dental Sciences, Sri Ramachandra Institute of Higher Education and Research (DU),
Porur, Chennai, 600116, India
4
Department of Periodontology, Sri Ramachandra Faculty of Dental Sciences, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai,
600116, India
5
Specialist Oral and Maxillofacial Surgeon, Dentacare Centre, Abudhabi, United Arab Emirates
6
Dental School, Oral Developmental and Behavioural Sciences, The University of Western Australia, Sterling Highway, Perth, Western Australia, Australia
7
College of Dentistry, Ajman University, Ajman, United Arab Emirates
8
Centre of Medical and Bio-­allied Health Science Research (CMBHSR), College of Pharmacy and Health Sciences (COPHS), Ajman University, Ajman, United
Arab Emirates

Correspondence
Muthu MS, Department of Pediatric Abstract
Dentistry, Faculty of Dental Sciences,
Background/Aims: Traumatic dental injuries (TDI) are considered a public health
Centre for Early Childhood Caries
Research (CECCRe), Sri Ramachandra problem due to their high prevalence and associated physical, economic, psychologi-
Institute of Higher Education
cal and social consequences. Hence, good Clinical Practice Guidelines are essential to
and Research (SRIHER), Porur,
Chennai—­6 00116, India; Centre of achieving a favourable prognosis. The aim of this review was to appraise the existing
Medical and Bio-­Allied Health Sciences
Clinical Practice Guidelines (CPGs) on TDI using AGREE II and AGREE-­REX.
Research, Ajman University, United Arab
Emirates. Materials and Methods: A systematic search for existing guidelines on TDI was
Email: [email protected]
performed on PubMed, EMBASE, CINAHL, Cochrane Library, ProQuest, National
Institute for Health Care Excellence, BMJ Best Practice, Trip database, Guideline
International Network, Scottish Intercollegiate Guidelines Network, World Health
Organisation, Web of Science and ‘Ministry of Health worldwide’ databases. Four ap-
praisers independently appraised the included CPGs. The AGREE II tool was applied
to assess the methodological quality, while AGREE REX assessed the quality of rec-
ommendations of the included guidelines.
Results: Of the 7736 titles screened, three guidelines, namely the International
Association of Dental Traumatology Guidelines (IADT), and the Italian and Malaysian
guidelines, were included for the final analysis. These guidelines were published be-
tween 2019 and 2020. The AGREE II analysis demonstrated scores above 80% for the
IADT and Italian guidelines for the scope and purpose domain. Overall, the Malaysian
guidelines achieved the highest score for all domains. The AGREE REX analysis

© 2023 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Dental Traumatology. 2023;00:1–10.  wileyonlinelibrary.com/journal/edt | 1

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2 SAIKIA et al.

indicated variability in implementation across the nine items, with five that scored
above the midpoint of 4.0 on the response scale. Both the Italian and the IADT guide-
lines had a similar score for the values and preference domains (36.36%).
Conclusions: Several deficiencies exist in the methodological quality of existing CPGs
on TDI. Future guidelines should consider improvements for domains such as ‘rigour
of development’, ‘stakeholder involvement’ and ‘applicability’ to overcome the exist-
ing limitations.

KEYWORDS
AGREE II, clinical practices, dental trauma, guideline, recommendations, traumatic dental
injuries

1 | I NTRO D U C TI O N and reported over 50 guidelines to be of poor quality.19 A similar

study was conducted by London et al. 20 to assess the method-
1
Traumatic dental injuries (TDI) are common and occur most fre- ological rigour and transparency in CPGs of the American Dental
2,3
quently in children and young adults. TDIs are a major threat to Association (ADA). This review recommended improvement in do-
their health and are currently seen as a neglected public health prob- mains such as stakeholder involvement, rigour of development, ap-
lem.4 Reports about TDI in different countries show a wide variation plicability and editorial independence. 20 San Martin-­Galindo et al.
5–­10
in its prevalence. Accurate diagnosis, proper treatment plan- assessed the quality of European dental CPGs. The results revealed
ning and follow-­up are imperative to ensure a favourable outcome. critical variations across CPG recommendations, and they suggested
Dentists and other healthcare professionals need to use high-­quality the development of high quality dental CPGs and to investigate their
Clinical Practice Guidelines (CPGs) to provide evidence-­based care dissemination. 21
for their patients with TDI. The Institute of Medicine defines guide- Although a robust guideline on TDI ushers oral care profession-
lines as ‘systematically developed statements to assist practitioner als to provide the best possible care in an effective manner, a consci-
and patient decisions about appropriate health care for specific clin- entious quality assessment of CPGs is essential. Identifying possible
ical circumstances’.11 High-­quality CPGs are important to augment weaknesses and strengths may help to improve future guideline
healthcare quality to improve patient outcomes and to bridge gaps work in the field of TDI. The aim of this study was to appraise vari-
12
between stakeholders and patient choice. CPGs influence day-­ ous guidelines on TDI and to determine their methodological quality
to-­day clinical decisions, procedure protocols, the curriculum for using the instruments AGREE II and Appraisal of Guidelines Research
doctor training and health funding allocation by governments and and Evaluation—­Recommendation EXcellence (AGREE-­REX).
insurers. CPGs are tools for clinicians, policy makers and payers to
standardise health care thus closing the gap between what clinicians
do and what scientific evidence supports.13 Rigorously developed 2 | M E TH O D S
evidence-­based guidelines minimise the potential harms. The adop-
tion of low-­quality guidelines may result in widespread use of in- This systematic review of CPGs was developed in full compliance
effective treatments, inefficient practices and may ultimately harm with PRISMA (Preferred Reporting Items for Systematic Reviews
the patients.14–­16 Therefore, identifying and promoting high-­quality and Meta-­analyses). 22 The protocol of this review was registered in
guidelines is paramount for good practice. PROSPERO (Reg No. CRD42021259488). 23
In dentistry, the evaluation of guidelines using guideline as- Clinical Practice Guidelines with recommendations for the man-
sessment tools is in its infancy stage with only a few published ar- agement of TDI developed by national or international professional
ticles.17–­21 Arieta-­Miranda et al.,17 in their study on the quality of and government bodies or organisations were collated. To provide
currently available international orthodontic guidelines, reported an appraisal of the most recent guidelines, only those that were
significant variations and sub-­optimal quality level of CPGs. The published within the previous 5 years were included. The search
quality assessment of CPGs in the management of paediatric dental was carried out between December 2021 and February 2022.
emergencies applicable to the COVID-­19 pandemic was conducted The guidelines had to be published in English. Databases such as
by Tejani et al, using Appraisal of Guidelines Research and Evaluation PubMed, EMBASE, CINAHL, the Cochrane Library and ProQuest
II (AGREE II) tool. The reports revealed only one CPG which was were searched independently by two reviewers (AS and SP). Further
classified as ‘highly recommended’. They further recommended the searches were conducted in other guideline-­focused archives such as
use of appropriate methodologies during guideline development the National Institute for Health Care Excellence, BMJ Best Practice,
and their periodic updates.18 In 2011, Shah et al. evaluated the qual- Trip database, Guideline International Network (GIN), Scottish
ity of paediatric dentistry guidelines using the AGREE instrument Intercollegiate Guidelines Network, World Health Organization and
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SAIKIA et al. 3

Web of Science. Hand searches were done for the International tutorials (www.agree​trust.org) and read the user's manual. This was
Association of Dental Traumatology and the American Academy of followed by independent appraisal of all included guidelines using
Pediatric Dentistry. A further search was conducted in the ‘Ministry the AGREE II assessment tool.
of Health worldwide’ database listed under the Geneva Foundation The maximum possible score obtained by each domain was cal-
for Medical Education and Research (https://www.gfmer.ch/Medic​ culated by using the following formula:
al_searc​h/Minis​try_health.htm). Title and abstract screening of Maximum possible score
articles was performed by two authors (AS and SP). MeSH (med-
= 7 (strongly agree) × Y (items within domain) × 4 (appraisers).
ical subject headings) terms, guidelines, recommendations, clinical
practice guideline, TDI, traumatic dental injuries, tooth fracture The minimum possible score for each domain was obtained by
and Boolean operators were used to build the search strategy in the following formula:
the aforementioned databases. Full texts were retrieved whenever
Minimum possible score
eligible documents were identified. Any disagreements in inclusion
= 1 (strongly disagree) × Y (items within domain) × 4 (appraisers).
and exclusion were resolved by discussion between the reviewers,
and if required, arbitration with an experienced reviewer (MSM) was
sought. Guidelines not meeting the inclusion criteria were excluded, Using the above method, the scores for each of the six AGREE II
and the reasons are illustrated in the PRISMA flowchart (Figure 1). 22 domains were calculated independently by all four assessors. To cal-
The AGREE II tool from the AGREE Trust was adopted to com- culate the ‘obtained score’ for each domain, all four assessors scores
pare methodological quality of the included guidelines. The AGREE II were added for that particular domain.
tool has 23 items under 6 domains: Scope and Purpose, Stakeholder By using the formula, the overall domain score was calculated by:
Involvement, Rigor of Development, Clarity of Presentation,
Applicability and Editorial Independence. Each items are scored on Obtained score − Minimum possible score
× 100.
a 7-­point agreement scale, where 1 is ‘strongly disagree’ and 7 is Maximum possible score − Minimum possible score
‘strongly agree’. 23
Each guideline was independently rated by four assessors (MSM, The threshold quality for each domain was assessed. CPGs
DA, RS and SP). All four assessors completed the AGREE II online were considered as ‘high-­quality’ if the domain score was >70%,

F I G U R E 1 Prisma flow.
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4 SAIKIA et al.

‘moderate’ when 40% > 70% and ‘poor-­quality’ when the domain but a lower score (39.58%) for editorial independence. Furthermore,
20,23–­27
score was <40%. the scores for rigour of development were 42.18%. The Italian guide-
To ensure that guideline recommendations are of high quality lines scored highest for the editorial independence domain (89.58%)
and with clinical credibility, AGREE REX was used by four assessors but had the lowest score for applicability (18.75). All three guidelines
(MSM, DA, RS and SP). AGREE-­REX has 3 domains: clinical applica- were recommended with additional modification in one or more
bility (3 items), values and preferences (3 items) and implementabil- domains.
ity (2 items). All items were answered using a 7-­point response scale Using the AGREE-­REX tool, the variability in performance was
(1 [lowest quality] to 7 [highest quality]). A Consensus Approach observed across the nine items with five that scored above the mid-
was used to reach agreement with the AGREE-­REX item scores.18 dle point of 4.0 on the response scale. The suitability of use was
Maximum and minimum possible scores were calculated using the also assessed for all three domains. The Malaysian guidelines scored
formula below. highest for the clinical applicability (66.66%) and the implementabil-
ity domain (66.66%). The Italian and IADT guidelines had a similar
Maximum possible score = 7 (highest quality) × 3 (items) × 1 (appraiser)
score for the values and preference domain (36.36%). The IADT
guidelines scored significantly lower in the implementability domain
Minimum possible score = 1 (lowest quality) × 3 (items) × 1 (appraiser)
(8.33%).
The recently updated guidelines by the IADT address diagnosis,
To calculate the Consensus score, for each domain the following management and follow-­up instructions for all types of TDIs. These
formula was used. guidelines have several strengths and have been adapted by several
organisations and published in different languages across the globe.
Obtained consensus score − Minimum possible score
Consensus score = × 100. The IADT guidelines are easy to use, and the recommendations are
Maximum possible score − Minimum possible score
explicitly described. These are the only guidelines currently available
An AGREE-­REX overall score was calculated by adding all nine for international use with specific information on each type of tooth
item scores and using the formula above to scale the total as a per- injury such as crown fractures, crown-­root fractures and the various
centage. The threshold scores for AGREE REX were used to deter- luxation injuries. These guidelines provided specific recommenda-
mine the quality of recommendations. Also, overall domain score tions for each type of dental injuries and obtained a moderate score.
of >70% was categorised as high quality, <30% as ‘low quality’ and Overall, the guidelines obtained ‘Yes with modification’ with regard
30% > 70% as ‘moderate quality’. 28 to a recommendation for use.
Data analysis was conducted using Microsoft Excel, version 15, The primary focus of the Italian Guidelines was to provide
and SPSS Statistics, version 21. Descriptive analyses included the evidence-­based recommendations and indications on the prevention
means and standard deviations. and first aid for dental trauma in children, and a careful assessment
of the medico-­legal implications. Although the guidelines have been
developed for TDI in growing children (0–­18 years), the guidelines
3 | R E S U LT S development group included a multidisciplinary team and was de-
veloped according to the guidelines provided by the Italian National
The search yielded 7736 citations. After title and abstract screening Guideline Programme (Programma Nazionale per le Linee Guida,
and removal of duplicates, 10 guidelines which fulfilled the inclusion PNLG). The guidelines development also underwent a process
criteria underwent full-­text analysis. Seven papers were excluded, of consultation with experts from the Milan WHO Collaboration
and the reasons for exclusion are provided in Figure 1. Thus, three Centre for Epidemiology and Community Dentistry of Milan. These
guidelines published and updated between 2015 and 2020 by the guidelines enumerate 28 recommendations divided across four do-
International Association of Dental Traumatology (IADT), 29–­32 the mains. They have clearly defined the target group, objectives and
Italian Ministry of Health33 and the Malaysian Ministry of Health34 level of evidence. The recommendations have been formulated for
were included. The characteristics of the included guidelines are General Practitioners (GPs), paediatricians, maxillofacial surgeons,
outlined in Table 1. The AGREE II and AGREE REX domain scores for trauma surgeons, emergency room physicians, sports medicine prac-
each guideline are presented in Table 2. titioners, medico-­legal specialists, dentists, dental hygienists, nurs-
The AGREE II showed one or more domains with more than ing staff, school staff, sports centre workers and parents or carers.
70% scores across each included CPGs. Among the different guide- The guidelines developed by the Malaysian Ministry of Health
lines, scores were relatively high for the scope and purpose. In con- focuses on the management of avulsed permanent anterior tooth.
trast, all guidelines received low scores in the applicability domain. These guidelines provide specific algorithms for the management of
The Malaysian guidelines received the highest scores in the scope an avulsed permanent anterior tooth, with or without a mature root,
and purpose domain (91.66%), stakeholder involvement domain at the site of injury. These guidelines obtained the most favourable
(72.22%), rigour of development (73.95%) and the clarity of presen- AGREE II and AGREE-­REX ratings for domains such as the Clinical
tation domain (90.27%). The IADT guidelines received high scores Applicability and Implementability items. These guidelines have
for scope and purpose (83.33%) and clarity of presentation (81.94%), also provided explicit details on the guideline development process,
 TA B L E 1 Characteristics of the included guidelines.

Guideline Level of
organisation/ Year of Guideline review evidence
SAIKIA et al.

society Guideline name publication Target users Guideline writers process Evidence base included

IADT37–­40 International Association 2020 Paediatric dentists, general dentists, Experienced researchers IADT Board of Systematic High, moderate,
of Dental Traumatology health care workers and clinicians from Directors literature lower level of
guidelines for the various specialties and review evidence
management of traumatic the general dentistry
dental injuries: community
• General introduction
Fractures and
• Luxations
• Avulsion of permanent
teeth
• Injuries in the primary
dentition
Italy41 Italian guidelines for 2019 Dentists, paediatricians, surgeons, Multidisciplinary expert Specialists from Systematic I to VIa
the prevention and teachers, school and sport staff, team—­part of the Italian various fields literature
management of dental parents Ministry of Health review
trauma in children General Secretariat
and Milan WHO
Collaboration Centre
for Epidemiology and
Community Dentistry
of Milan
Oral Health Management of Avulsed 2019 Primary care providers—­Dental officers Paediatric Dental Internal and External Systematic US/Canadian
Programme Permanent Anterior Teeth Medical officers Allied health Specialists, Dental Reviewers—­ literature Preventive
(OHP), Professionals Public Health Paediatric Dental review Services Task
Ministry Specialists of related disciplines related Specialists, a Restorative Specialists, Force Level
of Health dental specialists (i.e. Paediatric Dental Specialist, Dental Consultant of Evidence
Malaysia 42 Dental Specialists, Orthodontists, Officers and a Dental Periodontologist, (2001)—­I to
Dental Public Health Specialists, Therapist from the Restorative IIIb
Oral and Maxillofacial Surgeons, Ministry of Health and Dental Specialist
Periodontologists, Restorative the Ministry of Higher
Dental Specialists) Related medical Education
specialists (i.e. Family Medicine
Specialists, Accident and Emergency
Physicians, and Anaesthetists)
a
I—­Evidence from several randomised controlled clinical trials, systematic reviews of randomised trials and/or international guidelines; II—­Evidence from one adequately designed randomised clinical
trial; III—­Evidence from non-­randomised cohort studies with concurrent or historical controls, or meta-­analyses including this type of studies; IV—­Evidence from retrospective case–­controlled studies, or
meta-­analyses including this type of studies; V—­Evidence from case series with no control group; VI—­Evidence based on the opinion of recognised experts or expert panels, as indicated in guidelines or
consensus conferences, based on the opinion of the panel.
b
I—­Evidence obtained from at least one properly designed randomised controlled trial; I-­1—­Evidence obtained from well-­designed controlled trials without randomisation; II-­2—­Evidence obtained from
well-­designed cohort or case–­control analytic studies, preferably from more than one centre or research group; II-­3—­Evidence obtained from multiple time series studies, with or without intervention.
|

Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence; III—­Opinions or respected
5

authorities, based on clinical experience; descriptive studies and case reports; or reports of expert committees.

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6 SAIKIA et al.

TA B L E 2 Overview of the final ‘Appraisal of Guidelines for Research and Evaluation’ (AGREE II) and ‘Recommendation EXcellence’
(AGREE-­REX) scores.

Domain/guideline IADT Italian Malaysian Mean ± SD

AGREE II
Scope and purpose 83.33 84.72 91.66 86.57 ± 4.46
Stakeholder involvement 56.94 65.27 72.22 64.81 ± 7.65
Rigour of development 42.18 55.2 73.95 57.11 ± 15.97
Clarity of presentation 81.94 58.33 90.27 76.84 ± 16.56
Applicability 40.62 18.75 71.87 43.74 ± 29.69
Editorial independence 39.58 89.58 75 68.05 ± 25.71
Overall assessment (out of 7) 5 4.75 6.25
Recommendation Yes with modification Yes Yes with modification
AGREE REX
Clinical applicability 55.55 44.4 66.66 55.54 ± 11.13
Values and preferences 36.36 36.36 44.44 39.05 ± 4.66
Implementability 8.33 25 66.66 33.33 ± 30.04

developer panel and level of evidence. The target population has in TDI reduces the level of evidence score. Hence, the evidence base
also been specified. Furthermore, both AGREE II and AGREE-­REX for most recommendations was primarily based on case reports,
assessment revealed several strengths in the fundamental steps case series and expert opinions.
taken into consideration during the development of recommenda- Despite the IADT guidelines being popular worldwide, low
tions for the Malaysian guidelines on avulsed permanent teeth. The AGREE II scores were observed in Editorial Independence (39.5%),
scores for ‘Values and Preferences’ were marginally lower when Rigour of Development (42.1%) and Applicability (40.6%). The pos-
compared to other domains. The lower score is due to a lack of fac- sible reasons for low AGREE II score for ‘Editorial Independence’
tors considered with regard to the acceptance of recommendations are due to the lack of mention of records for competing interests
by the patient or the local population as whole. The guideline de- of guideline development group members. The guidelines were
velopers also provided a ‘Dental Trauma Data Collection Form’. The reviewed by the IADT Board members, and no external reviewing
limitation of these otherwise robust guidelines is that they only ad- was sought by experts prior to publication. Detailed description on
dress avulsion of permanent anterior teeth and they do not cover procedures followed for updating the guideline has not been pro-
any other type of injury. vided by the IADT. The Rigour of Development also assesses the
congruency and clarity of evidence sources linked to each recom-
mendation. Though, the IADT provided the databases used for their
4 | DISCUSSION search, but the overall assessment revealed a lack of information
on systematic methods, specific search terms for all injury types,
The present systematic review was undertaken to evaluate the selection criteria used to search, strengths and limitations of evi-
quality of the existing CPGs on TDI using AGREE II and AGREE-­ dence and their explicit link to their recommendations. Similarly,
REX. The final search identified three eligible guidelines: the IADT the AGREE REX scores for Implementability (8.3%) were low for
guidelines, 29–­32 Italian guidelines33 and the guidelines by the these guidelines. This domain includes two items (Purpose and
Ministry of Malaysia.34 Despite the variables in the development Local Application and Adoption). The absence of specific goals in
process and evidence source, good consistency on TDI recom- the IADT guidelines contributes to this low score. Thus, the align-
mendations was observed. Overall, the assessment highlights the ment of guideline recommendations with the implementation goals
scope for improvement in domains such as rigour of development, of the guideline could not be assessed The developers also failed to
applicability and editorial independence in all included CPGs. Due provide anticipated impacts of recommendation adoption on indi-
to the heterogeneity observed (variations in each of the included viduals (e.g. patients, populations and target users), organisations
guidelines addressing various aspects of TDIs) across the included and/or systems. Although the IADT guideline developers have suc-
CPGs, a descriptive analysis was performed for each included guide- cessfully translated the guidelines into 19 different languages, there
line rather than comparative. Lower scores of the aforementioned is no mention of any alteration tailored for local adaptation in differ-
items of AGREE II and AGREE REX across the included guidelines ent countries. Nonetheless, the IADT provides standard ‘Save your
are attributed to inadequate reporting, documentation and not poor Tooth posters’ and ‘ToothSOS app’ for the emergency management
quality in methodological execution. In addition, the lack of system- of TDIs. This appraisal thus recommends strengthening the afore-
atic reviews or reduced possibilities of randomised controlled trials mentioned areas.
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SAIKIA et al. 7

The overall AGREE II assessment for the Italian guideline was the recommendations and whether each recommendation is linked
low (4.75). The assessment reported a low Applicability (18.7%) to a key evidence description/paragraph and/or reference list. The
score. The lack of information provided on facilitators and barriers, certainty of this evidence is thus crucial to determine the strength
tools, monitoring and/or auditing criteria contributed to the lower of the recommendation (e.g. strong or conditional) and, ultimately,
score for this domain. There was also a lower AGREE REX score for whether the intervention can be applied to patients24. The final
Implementability (25%) as a result of the lack of information pro- draft of CPGs must be peer-­reviewed by external experts prior to
vided on the purpose and local application and adoption. its publication. The purpose and intent of the external review (e.g. to
The score for the Malaysian guidelines for ‘Values and improve quality, gather feedback on draft recommendations, assess
Preferences’ was low when compared to other domains. The lower applicability and feasibility, disseminate evidence) must be disclosed
score is due to the lack of factors considered with regard to accep- in the CPG. Additionally, the methods undertaken by the external
tance of recommendations by the patient or the local population reviewers (e.g. rating scale, open-­ended questions) and the descrip-
as whole. The guideline developers have also provided a ‘Dental tion of the external reviewers (e.g. number, type of reviewers and
Trauma Data Collection Form’. The limitation of this otherwise ro- affiliations) also need to be reported. Lastly, it is critical to provide
bust guideline is that it caters only to avulsion of permanent anterior the procedure and the period for updating the guideline. 23,28
teeth and does not cover any other type of injury. The use of AGREE II and AGREE REX helps to enhance capacity
The array of shortcomings in CPGs can have serious clinical im- building in clinical research and among guideline developing commu-
plication. Low scores in Domain 3 indicate lack of evidence-­based nities. AGREE-­REX can be instrumental to assess gaps and shortcom-
recommendations. This can mislead the user and affect the overall ings in the development of guidelines that provide recommendations
outcome of the injured tooth. for the management of TDI. The significance of Patient and Public
The results of this appraisal can be used for future CPG devel- involvement in the guideline process has been emphasised in the G-­
opment, amendments and adaptation for the management of TDI. I-­N Public Toolkit.35 This toolkit aids to understand why and how the
Furthermore, higher levels of evidence sources should be generated patient or the public should be included as expert reviewers.12,35–­38
(wherever possible) considering each injury type to strengthen the The results of this review thus affirm the need for formal training of
development process of the CPGs. The use of specific ‘search terms’ guideline developers for robust CPGs. It is advisable to identify dental
and ‘search strategy’ for each type of dental injury is recommended, researchers trained and certified in the GIN network and in the guide-
and implementing their outcomes is essential. A separate search line development process and also the experienced members of GIN
strategy for all subtypes of TDI (e.g. crown fractures or crown-­root network to assist and support the guideline development process.35
fractures) needs to be carried out. If needed, the IADT can formulate Future research to be directed in identifying areas where ran-
multi-­country teams (each team assigned to carry out systematic domised control trials (RCTs) are possible. Wherever RCTs are not
reviews on each heading) with the capability to perform system- feasible planning high-­quality case–­control and cohort studies (if
atic reviews to execute in a time bound manner on various individ- possible multi centric) to develop higher quality of evidence per-
ual injuries such as crown fractures and root fractures before the taining to each injury types. For these studies, recently published
next scheduled revision of the existing CPGs that were published in ‘Dental trauma—­CORE outcome set’ can be used to standardise data
2020. The domain 3, ‘Methodological Rigor’ is the most important of collection.39,40 Hence, it is critical that clinicians are familiar with the
all domains. It determines the quality of evidence and the basis for steps involved in guideline development and evaluation methods to
recommendations in CPGs. Thus, future CPGs must use systematic identify, adopt and adapt CPGs for use in their daily practice. The
methods to search evidence and clearly describe the strengths and WHO also encourages the medical and dental community to use
limitations of the selected evidence. Criteria such as target popula- their leadership in clinical guideline development in alignment with
tion, study designs, comparisons, outcomes, language and context the planetary health into the clinical setting to sustainably transform
must be reported. Guideline developers must clearly elucidate the health care.41 Because CPGs can steer daily clinical practice and in-
methods used for formulating the recommendations while consider- stil evidence-­based management across the globe, regular quality
ing possible health benefits, side effects and risks. The recommen- assessment of CPGs by clinicians is pivotal to ensure the transpar-
dation development process and its outcomes must be described in ency and rigour of the CPGs development process.
detail including the technique (e.g. steps used in a modified Delphi The strengths of the current review are (1) the appraisal was
technique) and voting procedures considered. The study design(s) performed by a specialised clinical team of paediatric dentists, oral
included in the body of evidence is a critical factor that need to be radiologist, oral surgeon, periodontist, clinician researchers and
reported. The limitations of methodology in the included studies experts from universities in India, Australia and the United Arab
with regard to sampling, blinding, allocation concealment and an- Emirates, (2) the other advantages include the use of internation-
alytical methods, relevance of primary and secondary outcomes ally accepted, rigorously structured and validated CPGs appraisal
considered, consistency and direction of results across the studies tools such as the AGREE II and AGREE REX, (3) the appraisal of each
are essential in good CPGs. To highlight the congruency between CPGs by four appraisers including three clinical topic experts and
recommendations and evidence, the CPG must describe how the two members from the Guidelines International Network (GIN) who
guideline development group linked and used the evidence to form had undergone training in guideline development and had published
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8 SAIKIA et al.

previous similar studies regarding the management of cleft lip and revision of the manuscript; and approval of the manuscript. Robert
42
palate, and (4) the reviewers carried out a comprehensive search A involved in critical revision of the manuscript and approval of the
within several core databases as well as ministries of health and var- manuscript. Tarun W involved in critical revision of the manuscript
ious guideline related databases. and approval of the manuscript. Moayad JSAS involved in critical
Inclusion of only English-­language CPGs is a potential limitation. revision of the manuscript and approval of the manuscript.
As a result, the data for credibility and implementability of Non-­
English CPGs still remain obscure. The AGREE II instrument also AC K N O​W L E​D G E​M E N T S
has limitations such as a lack of comprehensive critical appraisal of The authors thank Dr Amit for his assistance on EMBASE search and
other important items such as risk of bias, precision, consistency, Dr Umesh for his guidance on statistics. No funding was received to
43
directness and publication bias. CPGs from the Ministry of Fuji conduct this review.
and the American Association of Endodontics (AAE) 44 were ex-
cluded as they were published in 2010 and 2013, respectively. The C O N F L I C T O F I N T E R E S T S TAT E M E N T
American Association of Pediatric Dentistry (AAPD) guidelines were The authors declare no conflict of interests.
not included as they endorse the IADT guidelines with no alter-
ation. Similarly, CPGs developed by private dental hospitals or non-­ DATA AVA I L A B I L I T Y S TAT E M E N T
established organisations were also excluded. Although, excluding The data that support the findings of this study are available from
CPGs beyond 5 years could be a possible limitation, as it may intro- the corresponding author upon reasonable request.
duce a selection bias, guideline programs endorse 3–­5 years as a rea-
sonable period after which guidelines should be reviewed.45 Hence, ORCID
this review included CPGs that were not older than 5 years. Sneha S. Patil https://orcid.org/0000-0001-6698-2711
Muthu MS https://orcid.org/0000-0002-5847-9662
Robert Anthonappa https://orcid.org/0000-0001-6278-9762
5 | CO N C LU S I O N Tarun Walia https://orcid.org/0000-0002-8144-7490

The appraisal of the included CPGs using AGREE II and AGREE-­REX REFERENCES
tools ascertained several gaps in their methodological quality. Scope 1. Chadwick BL, White DA, Morris AJ, Evans D, Pitts NB. Non-­
for improvement in areas such as ‘stakeholder involvement’, ‘rigour carious tooth conditions in children in the UK, 2003. Br Dent J.
2006;200:379–­8 4.
of development’, ‘applicability’ and ‘local adaptability’ is warranted
2. Hamilton FA, Hill FJ, Holloway PJ. An investigation of dento-­
when developing future CPGs for TDI. Despite these methodologi- alveolar trauma and its treatment in an adolescent population. Part
cal shortcomings, the consistency of recommendations across all in- 1: the prevalence and incidence of injuries and the extent and ade-
cluded guidelines makes them suitable for use in daily practice until quacy of treatment received. Br Dent J. 1997;182:91–­5.
3. Petersson EE, Andersson L, Sorensen S. Traumatic oral vs non-­oral
higher quality of evidence emerges in the field of dental traumatol-
injuries. Swed Dent J. 1997;21:55–­68.
ogy and vigorous guideline development process are adapted when 4. Sleet DA. The global challenge of child injury prevention. Int J
revising the existing CPGs. Environ Res Public Health. 2018;15:1921.
5. Glendor U. Epidemiology of traumatic dental injuries –­ a 12 year
review of the literature. Dent Traumatol. 2008;24:603–­11.
AU T H O R C O N T R I B U T I O N S
6. Kramer PF, Zembruski C, Ferreira SH, Feldens CA. Traumatic
Ankita S involved in conceptualization and design; development dental injuries in Brazilian preschool children. Dent Traumatol.
of the protocol; AGREE II and AGREE REX training; screening of 2003;19:299–­3 03.
titles, abstracts, full texts, data collection, data analysis, and inter- 7. Eyuboglu O, Yilmaz Y, Zehir C, Sahin H. A 6-­year investigation into
pretation; drafting and revising the manuscript, and agreement for types of dental trauma treated in a paediatric dentistry clinic in
eastern Anatolia region. Turkey Dent Traumatol. 2009;25:110–­4.
accountability. Sneha SP involved in development of the protocol;
8. Al-­Jundi SH. Dental emergencies presenting to a dental teaching
screening of titles, abstracts, and full texts; AGREE II and AGREE hospital due to complications from traumatic dental injuries. Dent
REX analysis and interpretation; and drafting the manuscript. MS Traumatol. 2002;18:181–­5.
Muthu involved in conceptualization and design; development of 9. Hargreaves JA, Cleaton-­Jones PE, Roberts GJ, Williams S, Matejka
JM. Trauma to primary teeth of south African pre-­school children.
the protocol; AGREE II and AGREE REX analysis and interpretation;
Endod Dent Traumatol. 1999;15:73–­6.
critical revision of the manuscript; approval of the manuscript; and 10. Borssén E, Holm AK. Treatment of traumatic dental injuries in a co-
agreement for accountability. Ram S involved in development of hort of 16-­year-­olds in northern Sweden. Endod Dent Traumatol.
the protocol; AGREE II and AGREE REX analysis and interpretation; 2000;16:276–­81.
11. Committee to Advise the Public Health Service on Clinical Practice
critical revision of the manuscript; and approval of the manuscript.
Guidelines, Institute of Medicine, Field MJ, Lohr KN. Clinical prac-
Divyambika CV involved in development of the protocol; AGREE II tice guidelines: directions of a new program. Washington, DC:
and AGREE REX analysis and interpretation; critical revision of the National Academy Press; 1990.
manuscript; and approval of the manuscript. Senthoor P involved 12. Institute of Medicine (US) Committee on Standards for Developing
Trustworthy Clinical Practice Guidelines. Clinical practice
in development of the protocol; prospero registration and critical
 |

16009657, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/edt.12838 by Muthu MS - Sri Ramachandra Institute Of , Wiley Online Library on [01/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
SAIKIA et al. 9

guidelines we can trust. Washington, DC: National Academies for the management of traumatic dental injuries: 3. Injuries in the
Press (US); 2011. primary dentition. Dent Traumatol. 2020;36:343–­59.
13. Field MJ, Lohr KN, editors. Guidelines for clinical practice: from de- 33. Cagetti MG, Marcoli PA, Berengo M, Cascone P, Cordone L,
velopment to use. Washington, DC: National Academy Press; 1992. Defabianis P, et al. Italian guidelines for the prevention and man-
14. Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: agement of dental trauma in children. Ital J Pediatr. 2019;45:157.
developing guidelines. BMJ. 1999;318:593–­6. 34. Oral Health Programme-­Ministry of Oral Health Malaysia.
15. Hurwitz B. Legal and political considerations of clinical practice Management of avulsed permanent anterior teeth. Ministry of Oral
guidelines. BMJ. 1999;318:661–­4. Health Malaysia [cited 2021 Dec 23]. Available from: https://www.
16. Feder G. Management of mild hypertension: which guidelines to moh.gov.my/moh/resou​rces/Pener​bitan/​CPG/Denta​l%20&%20Ora​
follow? BMJ. 1994;308:470–­1. l/CPG_Avuls​ed_Perma​nent_Anter​ior_Teeth_(Third_Ed)_2019_07042​
17. Arieta-­Miranda J, Alcaychahua AS, Santos GP, Sevillano MC, 021.pdf
Verástegui RL, Victorio DB, et al. Quality assessment of clinical 35. G-­I-­N Public Working Group. New digital guidelines international
practice guidelines for the management of paediatric dental emer- network (G-­I-­N) PUBLIC toolkit: patient and public involvement in
gencies applicable to the COVID-­19 pandemic, using the AGREE II guidelines. [cited 2022 Apr 18]. Available from: https://g-­i-­n.net/
instrument. A systematic review. Heliyon. 2020;6:e05612. new-­digit​al-­gin-­p ubli​c-­toolk​it-­p atie​nt-­and-­p ubli​c-­invol​vemen​t-­in-­
18. Tejani T, Mubeen S, Seehra J, Cobourne MT. An exploratory quality guide​lines/
assessment of orthodontic clinical guidelines using the AGREE II 36. Amer YS, Elzalabany MM, Omar TI, Ibrahim AG, Dowidar NL.
instrument. Eur J Orthod. 2017;39:654–­9. The ‘adapted ADAPTE’: an approach to improve utilization of the
19. Shah P, Moles DR, Parekh S, Ashley P, Siddik D. Evaluation of pe- ADAPTE guideline adaptation resource toolkit in the Alexandria
diatric dentistry guidelines using the AGREE instrument. Pediatr Center for Evidence-­Based Clinical Practice Guidelines. J Eval Clin
Dent. 2011;33:120–­9. Pract. 2015;21:1095–­106.
20. London SD, Chamut S, Fontelo P, Iafolla T, Dye BA. Assessment of 37. Schünemann HJ, Wiercioch W, Etxeandia I, Falavigna M, Santesso
the quality of current American dental association clinical practice N, Mustafa R, et al. Guidelines 2.0: systematic development of a
guidelines. JDR Clin Trans Res. 2022;2:23800844221083563. comprehensive checklist for a successful guideline enterprise.
21. San Martin-­Galindo L, Rodríguez-­Lozano FJ, Abalos-­L abruzzi C, CMAJ. 2014;186:E123–­42.
Niederman R. European fissure sealant guidelines: assessment 38. Brouwers MC, Kerkvliet K, Spithoff K, AGREE Next Steps
using AGREE II. Int J Dent Hyg. 2017;15:37–­45. Consortium. The AGREE reporting checklist: a tool to improve re-
22. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, porting of clinical practice guidelines. BMJ. 2016;352:i1152.
Mulrow CD, et al. The PRISMA 2020 statement: an updated guide- 39. Kenny KP, Day PF, Sharif MO, Parashos P, Lauridsen E, Feldens CA,
line for reporting systematic reviews. BMJ. 2021;372:n71. et al. What are the important outcomes in traumatic dental injuries?
23. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder An international approach to the development of a core outcome
G, et al. AGREE II: advancing guideline development, reporting, and set. Dent Traumatol. 2018;34:4–­11.
evaluation in health care. Prev Med. 2010;51:421–­4. 40. Sharif MO, Tejani-­Sharif A, Kenny K, Day PF. A systematic re-
24. Ciapponi A, Tapia-­López E, Virgilio S, Bardach A. The quality of clin- view of outcome measures used in clinical trials of treatment in-
ical practice guidelines for preoperative care using the AGREE II terventions following traumatic dental injuries. Dent Traumatol.
instrument: a systematic review. Syst Rev. 2020;9:159. 2015;31:422–­8.
25. Ghazal S, Ridha Z, D'Aguanno K, Nassim D, Quaiattini A, 41. Herrmann A, Lenzer B, Müller BS, Danquah I, Nadeau KC, Muche-­
Netchiporouk E, et al. Treatment guidelines for atopic dermatitis Borowski C, et al. Integrating planetary health into clinical guide-
since the approval of Dupilumab: a systematic review and quality lines to sustainably transform health care. Lancet Planet Health.
appraisal using AGREE-­II. Front Med (Lausanne). 2022;9:821871. 2022;6:e184–­5.
26. Lei R, Li Y, Zhou D, Hu X, Jiang X. Quality appraisal of clinical prac- 42. Saikia A, Muthu MS, Orenuga OO, Mossey P, Ousehal L, Yan S,
tice guidelines on physical restraints in ICU: a systematic review. et al. Systematic review of clinical practice guidelines for Oral
Ann Palliat Med. 2022;11:774–­83. health in children with cleft lip and palate. Cleft Palate Craniofac J.
27. Bargeri S, Iannicelli V, Castellini G, Cinquini M, Gianola S. AGREE 2022;59:800–­14.
II appraisals of clinical practice guidelines in rehabilitation showed 43. Ministry of Health: Shaping Fiji's Health. Clinical Practice guide-
poor reporting and moderate variability in quality ratings when line for the management of dental trauma. [cited 2021 Dec 23].
users apply different cuff-­offs: a methodological study. J Clin Available from: https://www.health.gov.fj/wp-­conte​nt/uploa​ds/​
Epidemiol. 2021;139:222–­31. 2014/05/Manag​ement​-­of-­Denta​l-­Trauma.doc.pdf
28. AGREE-­REX Research Team. The Appraisal of Guidelines Research 44. American Association of Endodontists. Guide to clinical endodon-
& Evaluation—­Recommendation EXcellence (AGREE-­REX). [cited tics. 6th ed. Chicago, IL: American Association of Endodontists;
2021 May 03]. Available from: https://www.agree​trust.org/wp-­ 2013.
conte​nt/uploa​ds/2019/04/AGREE​-­REX-­2019.pdf 45. Martínez García L, Arévalo-­Rodríguez I, Solà I, et al. Strategies for
29. Levin L, Day PF, Hicks L, O'Connell A, Fouad AF, Bourguignon C, monitoring and updating clinical practice guidelines: a systematic
et al. International Association of Dental Traumatology guidelines review. Implement Sci. 2012;7:109.
for the management of traumatic dental injuries: general introduc-
tion. Dent Traumatol. 2020;36:309–­13.
30. Fouad AF, Abbott PV, Tsilingaridis G, Cohenca N, Lauridsen E,
Bourguignon C, et al. International Association of Dental Traumatology
How to cite this article: Saikia A, Patil SS, MS M, CV D,
guidelines for the management of traumatic dental injuries: 2. Avulsion
of permanent teeth. Dent Traumatol. 2020;36:331–­42. Sabarish R, Pandian S, et al. Systematic review of clinical
31. Bourguignon C, Cohenca N, Lauridsen E, Flores MT, O'Connell AC, practice guidelines for traumatic dental injuries. Dental
Day PF, et al. International Association of Dental Traumatology Traumatology. 2023;00:1–10. https://doi.org/10.1111/
guidelines for the management of traumatic dental injuries: 1.
edt.12838
Fractures and luxations. Dent Traumatol. 2020;36:314–­3 0.
32. Day PF, Flores MT, O'Connell AC, Abbott PV, Tsilingaridis G, Fouad
AF, et al. International association of dental traumatology guidelines
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10 SAIKIA et al.

injuries)) OR (subluxation)) OR (concussion)) OR (intrusion)) OR (ex-

APPENDIX 1
trusion)) OR (avulsion)) OR (soft tissue injury)) OR (crown root frac-
ture)) OR (tooth)) OR (sports dental injuries)) OR (dento-­alveolar
Search strategy
trauma)) OR (exarticulation)) OR (chin injury)) OR (posterior teeth in-
(((((((((((((((((((((((((((((Traumatic Dental Injury) OR (TDI)) OR (dental in-
jury)) AND (Clinical Practice Guidelines)) OR (guidelines)) OR (CPGs))
juries)) OR (dental trauma))) OR (supporting structures))) OR (teeth))
OR (recommendations).
OR (crown fracture)) OR (fracture)) OR (root fracture)) OR (luxation

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