Clinical practice guideline on emergency management of acute apical periodontitis (AAP) in adults

This guideline has been developed by the Canadian Collaboration on Clinical Practice Guidelines in Dentistry (CCCD) and was approved by the Council of the CCCD on 6 December 2002. The full version of the guideline is available online at www.cccd.ca, along with the methods used in its development. Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate oral healthcare for specific clinical circumstances. They should be used as an adjunct to sound clinical decision-making. CCCD guidelines are updated on a regular basis as new research information becomes available. The dentists' quick reference format as available on the CCCD website or in pdf format on the site is shown below. Goal This guideline is intended to aid clinicians in ensuring pain relief for people who have acute apical periodontitis (AAP). Definition AAP is a periapical inflammation resulting from an untreated, non-vital pulp. Exclusions The recommendations in this guideline do not apply to patients with swelling, periapical radiolucency nor systemic changes. This guideline has been developed by the Canadian Collaboration on Clinical Practice Guidelines in Dentistry (CCCD) and has been approved by the Council of the CCCD. The full version of the guideline will be available online at www.cccd.ca, along with the methods used in its development. Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate oral healthcare for specific clinical circumstances. They should be used as an adjunct to sound clinical decision-making. CCCD guidelines are updated on a regular basis as new research information becomes available. The dentists' quick reference format as available on the CCCD website or in pdf format on the site is shown below. Goal This guideline is intended to aid clinicians in ensuring pain relief for people who have acute apical abscesses (AAA). Definition AAA is a periapical inflammation resulting from an untreated, non-vital pulp. Clinical practice guidelines are commonly seen as a tool for helping to close the gap between research evidence and clinical practice.1 The role of these "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances"2 is not to limit or replace clinical judgment but to provide a comprehensive, critical summary of the research findings in the form of easily implemented recommendations for clinical care.3 Over the last decade there has been much interest in the development of guidelines, although the rigour of the development process and the quality of existing guidelines varies considerably.4 The development of practice guidelines is a complex task that requires many skills, including literature searching, appraisal of scientific evidence, expertise in group decision-making and the presentation of complex information in comprehensible forms.5 If guidelines are developed without the proper skills and resources, can they truly assist patients and practitioners in making the most appropriate decisions about healthcare? In order to improve patient care, should not clinical practice guidelines have to meet minimum quality criteria? An international group of researchers and policy-makers (the Appraisal of Guidelines Research and Evaluation (AGREE) collaboration; see www.agreecollaboration.org) is concerned with improving the quality and effectiveness of clinical practice guidelines. The AGREE collaboration have developed an instrument for assessing the key elements of guideline quality, with quality defined as, "confidence that the potential biases of guideline development have been addressed adequately and that the recommendations are both internally and externally valid, and are feasible for practice." The AGREE instrument consists of 23 key items that cover six domains (see below). Each item is scored from 1 (strongly disagree) to 4 (strongly agree). The instrument aims to assist policy-makers and healthcare providers decide which guidelines should be recommended for use in practice. It can also be used as a self-assessment tool for those involved in the process of developing or updating clinical guidelines. Currently there are many national and international organisations with the remit of guideline development. Within dentistry, one such is CCCD (see www.cccd.ca), established in 1999. Although it is involved in research to assess the best methods for disseminating, implementing and evaluating guidelines, its primary role is the development of clinical practice guidelines for the dental profession. The CCCD aims to produce "credible and useful" guidelines by using a development process that is both evidence-based and transparent. The first clinical practice guidelines undertaken by the CCCD, completed in 2002, provided recommendations on emergency management of AAP in adults. Subsequently, a clinical practice guideline on the emergency management of AAA has been completed. Summaries of both of these guidelines are presented (p. 7). This article considers the quality of the CCCD guidelines in light of the AGREE instrument criteria. For the AAP guidelines the clinical question addressed was, "In adult patients presenting with acute apical periodontitis resulting from a non-vital pulp, what is the effect on pain relief of various interventions? These interventions include systemic and local pharmacotherapeutics, local surgical measures, extraction, occlusal adjustment or watchful waiting." The clinical question for the AAA guidelines was identical apart from the patient group under consideration, ie, adults presenting with an AAA. The target population to be covered by both sets of guidelines are clearly described, with an outline of the clinical signs and symptoms characterising each condition. So that clinicians can quickly determine whether or not a guideline is relevant to them, the target users should be clearly defined. The CCCD guidelines are aimed at general dental practitioners, although this is not explicitly stated. Likewise, to enhance the validity of the guidelines for the target users, it is suggested that the guidelines are piloted prior to publication (see www.agreecollaboration.org). This process can identify skills required in the implementation of the recommendations, potential organisational barriers and, again, patients' views. Although extensive peer review of the CCCD draft guidelines was undertaken, there is no description of the guidelines being piloted by general dental practitioners. For both sets of guidelines, searches of Medline, EMbase and the Cochrane Central Register of Controlled Trials were undertaken from database inception through to August 2001 (for the AAP guidelines) or March 2002 (AAA guidelines). The search strategies used are presented in full. The systematic reviews undertaken were limited to published articles only, in either the French or English language. In the most recent set of guidelines (AAA) the reviewers recorded how many non-English or non-French language citations were identified so as to gauge the possible impact of limiting the review with regard to language of publication. Eighteen potentially relevant articles were identified but were not reviewed because of lack of resources for translation. Ideally systematic reviews should include both published and unpublished studies, irrespective of language, as there is good evidence of publication bias according to the results of a study. Studies with statistically significant findings are more likely to be submitted for publication,7 published in English-language journals8 and be published sooner9 than studies with more equivocal results. Resources do not always allow such a comprehensive review of the literature, however, and more recent research suggests that systematic reviews based on a search of English language literature only will often, but not always, produce results similar to those obtained through more comprehensive reviews.10 Egger et al suggest that financial and time constraints be considered when deciding the degree of comprehensiveness appropriate for a given review.10 The assessment of the quality of the individual studies included in a systematic review and a statement on how biases identified might affect the outcomes are essential in establishing the believability of a review's findings. Within the systematic reviews undertaken as part of the CCCD guideline development process, all studies included were assessed using the Jadad checklist 11 and the findings of the quality assessment clearly presented. The Jadad checklist is a widely used composite scale that focuses on the internal validity of the trial by examining randomisation, blinding and withdrawals. Each trial is given a score of 0–5, but it should be noted that scores reflect of the quality of the reporting more than the quality of the trial's methods. For example, a trial can gain points for simply describing the number of dropouts that occurred, irrespective of the number that dropped out, or whether analysis was carried out on an intent-to-treat basis or not. In addition, the scale makes no allowances for the fact that in certain circumstances blinding is not always possible, such as when examining the effectiveness of some surgical procedures. There has been much debate over the use of such composite scales for the assessment of randomised controlled trials (RCT), particularly as recent evidence showed that different scales can give conflicting results.12 The assessment of the individual components, without producing an overall summary score, may be preferable. Evidence tables containing summaries of all included trials (n=15 for the AAP guidelines; n= 8 for the AAA guidelines) were produced and meta-analysis of clinically homogeneous trials was undertaken. The findings of the systematic reviews were reviewed by the relevant CAG and evidence-based recommendations were developed by consensus within the group. The draft recommendations underwent thorough external review through a survey sent by post to Canadian dentists for whom the guidelines were thought relevant. The survey gathered information on practitioners' views about the need for a clinical practice guideline on the topic, the methods used in the development of the guidelines, the recommendations themselves and their impact. Twenty practitioners provided feedback for the AAP and the AAA guidelines. Based upon this feedback and comments from the CCCD Council the final recommendations (as illustrated in the summary document, p. 8) were produced. Both the draft recommendations and the final recommendations are published in the full document, allowing the reader to establish how the recommendations changed as a result of peer review. As mentioned previously, evidence tables are given providing summaries of trials included. However, AGREE suggest that there should be an explicit link between the recommendations and the evidence upon which they are based, with each recommendation being linked to the relevant references. The guidelines under review may have benefited from a clearer link between the recommendations and the supporting evidence. The recommendations were, however, graded according to the strength of the supporting evidence (see below). For clinical practice guidelines to be useful they need to incorporate current research. They must not be static documents but there should be a procedure for reviewing and updating the guidelines as appropriate. The CCCD CAG do have formal, standardised processes to ensure the guidelines are kept up-to-date, with new evidence evaluated within 5 years. The key recommendation relating to recognition is that it may be necessary to reschedule drainage because of patient/clinician factors and that, in these instances, analgesia and not antibiotic therapy should be initiated. This may prove the most difficult recommendation for which to achieve widespread acceptance in practice. The results from the dissemination of the guideline to volunteer practitioners (in the guideline's Appendix 3) do, however, contradict this. It is slightly disappointing that the evidence was not available to recommend one antibiotic in preference to another for more widespread infection but the recommendations overall appear to be appropriate, thorough and very relevant to general practice.