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Screening and diagnosis of oral cancer: a critical quality appraisal of clinical guidelines

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Clinical Oral Investigations
Authors:
Meisser Madera at University of Cartagena
Meisser Madera
Juan Víctor Ariel Franco at Universitätsklinikum Düsseldorf
Juan Víctor Ariel Franco
Ivan Solà at Iberoamerican Cochrane Centre
Ivan Solà
Xavier Bonfill at IIB Sant Pau
Xavier Bonfill
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Objectives To assess the quality of clinical practice guidelines (CPGs) on screening and diagnosis of oral cancer and to describe the characteristics of their recommendations. Materials and methods We systematically searched EMBASE, MEDLINE, CPG’ websites, and dentistry and oncology scientific societies to identify CPGs that were related to screening and diagnosis of oral cancer. The quality of selected CPGs was independently assessed by four appraisers using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. The inter-appraiser agreement was assessed. We performed a descriptive analysis of the recommendations included in the selected CPGs. Results Eight CPGs were selected. The overall agreement among reviewers was considered very good (ICC: 0.823; 95% CI: 0.777–0.861). The median scores of the six AGREE II domains were as follows: “scope and purpose” 97.9% (IQR: 96.2–100.0%); “stakeholder involvement” 86.1% (IQR: 69.8–93.1%); “rigor of development” 75.3% (IQR: 64.2–94.3%); “clarity of presentation” 91.7% (IQR: 82.6–94.4%); “applicability” 53.1% (IQR: 19.3–74.2%); and “editorial independence” 83.3% (IQR: 67.2–93.8%). Four CPGs were assessed as “recommended”, four “recommended with modifications”, and none “not recommended”. Twenty-three recommendations were provided, mostly with a low or very low level of evidence. Conclusion The methodological quality of CPGs on screening and diagnosis of oral cancer is moderate. The “applicability” domain scored the lowest. Most recommendations were based on a low o very low level of evidence. Clinical relevance Greater efforts are needed to provide healthcare based on high-quality evidence-based CPGs in this field.
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ORIGINAL ARTICLE
Screening and diagnosis of oral cancer: a critical quality appraisal
of clinical guidelines
Meisser Madera
1,2,3
&Juan Franco
4
&Ivan Solà
1,3
&Xavier Bonfill
1,3,5
&Pablo Alonso-Coello
1,3,5
Received: 29 June 2018 /Accepted: 25 September 2018 / Published online: 3 October 2018
#Springer-Verlag GmbH Germany, part of Springer Nature 2018
Abstract
Objectives To assess the quality of clinical practice guidelines (CPGs) on screening and diagnosis of oral cancer and to describe
the characteristics of their recommendations.
Materials and methods We systematically searched EMBASE, MEDLINE, CPG’websites, and dentistry and oncology scien-
tific societies to identify CPGs that were related to screening and diagnosis of oral cancer. The quality of selected CPGs was
independently assessed by four appraisers using the Appraisal of Guidelines for Research and Evaluation II (AGREE II)
instrument. The inter-appraiser agreement was assessed. We performed a descriptive analysis of the recommendations included
in the selected CPGs.
Results Eight CPGs were selected. The overall agreement among reviewers was considered very good (ICC: 0.823; 95% CI:
0.777–0.861). The median scores of the six AGREE II domains were as follows: Bscope and purpose^97.9% (IQR: 96.2–
100.0%); Bstakeholder involvement^86.1% (IQR: 69.8–93.1%); Brigor of development^75.3% (IQR: 64.2–94.3%); Bclarity of
presentation^91.7% (IQR: 82.6–94.4%); Bapplicability^53.1% (IQR: 19.3–74.2%); and Beditorial independence^83.3% (IQR:
67.2–93.8%). Four CPGs were assessed as Brecommended^,fourBrecommended with modifications^, and none Bnot recom-
mended^. Twenty-three recommendations were provided, mostly with a low or very low level of evidence.
Conclusion The methodological quality of CPGs on screening and diagnosis of oral cancer is moderate. The Bapplicability^
domain scored the lowest. Most recommendations were based on a low o very low level of evidence.
Clinical relevance Greater efforts are needed to provide healthcare based on high-quality evidence-based CPGs in this field.
Keywords Oral cancer .Guidelines .Evidence-based medicine .Screening .Diagnosis
Introduction
Due to increasing pressure to provide evidence-based medical
care, the use of clinical practice guidelines (CPGs) has been
increasing worldwide over the last decade [1,2]. CPGs are a
summary of evidence-based recommendations that were
developed using systematic methods of literature review.
These are a very useful tool for the translation of research
evidence into practice [3]. By using CPGs based on the best
available evidence, healthcare professionals can be assisted in
minimizing inappropriate variation in clinical practice, im-
proving decision-making processes on the most suitable
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s00784-018-2668-7) contains supplementary
material, which is available to authorized users.
*Meisser Madera
mmaderaa@unicartagena.edu.co
1
Iberoamerican Cochrane Centre, Institute of Biomedical Research
Sant Pau, Barcelona, Spain
2
Department of Research, Faculty of Dentistry, University of
Cartagena, Campus de la Salud, Zaragocilla Cra. 50 # 29-11,
CP 130014 Cartagena, Colombia
3
Public Health and Clinical Epidemiology Service, Sant Pau Hospital,
Barcelona, Spain
4
Cochrane Argentina,Instituto Universitario Hospital Italiano, Buenos
Aires, Argentina
5
CIBER of Epidemiology and Public Health, Barcelona, Spain
Clinical Oral Investigations (2019) 23:2215–2226
https://doi.org/10.1007/s00784-018-2668-7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Evidence shows that CPGs across dental specialties tend to be assessed as low quality, primarily associated with a lack of methodological rigour of development [10,11] and problems in applicability [12,13], making their implementation unreliable and their use difficult for patients, clinicians, and policy-makers. Poor quality CPGs may negatively influence patient care or have debatable applicability [14,15]. ...
... CPGs with a score of 60% or higher in at least three domains, including Rigour of development, were classified as high-quality [10,11,13]. ...
... In our study, only one guideline used the GRADE approach to assess the certainty of evidence and in developing its recommendations, despite the fact that more than 90 health organizations around the world have endorsed this approach [39]. However, this deficiency is also observed in CPGs published for other areas of dentistry [11,13,40]. ...
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  • Sep 2023
  • BMC Oral Health
Background The prevalence and consequences of traumatic dental injuries (TDI) make them a public health problem. Trustworthy TDI clinical practice guidelines (CPGs) assist clinicians in determining a diagnosis and guide them to the most appropriate therapy. The aim of this systematic survey was to identify and evaluate the quality of CPGs for the diagnosis, emergency management, and follow-up of TDIs. Materials and methods A systematic search was carried out in MEDLINE, EMBASE, Epistemonikos, Trip database, CPG websites, and dental societies to identify documents providing recommendations for the emergency and sequelae management of TDIs. Reviewers assessed the included guidelines independently and in duplicate, using the AGREE II instrument. ANOVA or Student’s t-tests were used to determine the attributes of CPGs associated with the total score in AGREE II. Results Ten CPGs published between 2010 and 2020 were included, mostly from Europe (n = 6). The overall agreement between reviewers was very good (0.94; 95%CI 0.91–0.97). The mean scores (the higher the score, the better the domain assessment) per domain were as follows: Scope and purpose 78.0 ± 18.9%; stakeholder involvement 46.9 ± 29.6%; rigour of development 41.8 ± 26.7%; clarity of presentation 75.8 ± 17.6%; applicability 15.3 ± 18.8%; and editorial independence 41.7 ± 41.7%. The overall mean rate was 4 ± 1.3 out of a maximum score of 7. Two guidelines were recommended by the reviewers for use in practice and rated as high quality. CPGs developed by government organizations showed a significantly higher overall score. Conclusions The overall quality of CPGs on TDI was suboptimal. CPG developers should synthesize the evidence and formulate recommendations using high-quality methodologies and standards in a structured, transparent, and explicit way.
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... 18 Other comprehensive screening protocols are available specifically for dental clinicians (Table S1) 7,[19][20][21][22][23][24][25][26][27] or some specifically for nurses and other non-dental personnel, 28 but none address the broad range of criteria relevant to oral disorders [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29] or gives much attention to patient-reported outcomes or concerns. 30 The CODE index originated from epidemiological investigations as a screening protocol and ranked index for jaw movements, dentures, oral mucosa, teeth and periodontium among frail residents of care facilities. 7,31 The objectives were to provide dental professionals with a comprehensive set of criteria and clinical severity scores for each disorder. ...
... A review of medical records and discussion with the patient and caregivers provide an overview of physical and cognitive status and subjective patient-reported outcomes relating to general and oral health. 27,30,[50][51][52][53][54] The physical assessment includes the hands for osteoarthritis which complicates oral hygiene, particularly in older women. 55,56 ...
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Background: The Clinical Oral Disorder in Elders (CODE) index was proposed in 1999 to assess the oral health status and treatment needs of older people who typically were edentate or had few natural teeth. Since then, more people are retaining natural teeth into old age and have oral disorders similar to younger adults. In addition, there has been further guidance on screening for disease that includes changes to the clinical indicators of several oral disorders and greater sensitivity to people's concerns about their oral health and care needs. Methods: Experts in dental geriatrics assembled at a satellite symposium of the International Association of Dental Research in June 2019 to revise the objectives and content of the CODE index. Before the symposium, 139 registrants were asked for comments on the CODE index, and 11 content experts summarised current evidence and assembled reference lists of relevant information on each indicator. The reference lists provided the base for a narrative review of relevant evidence supplemented by reference tracking and direct searches of selected literature for additional evidence. Results: Analysis of the evidence by consensus of the experts produced the Clinical Oral Disorders in Adults Screening Protocol (CODA-SP). Conclusions: The CODA-SP encompasses multiple domains of physical and subjective indicators with weighted severity scores. Field tests are required now to validate its effectiveness and utility in oral healthcare services, outcomes and infrastructure.
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... Furthermore, the diagnosis may be delayed for misinterpretation of symptoms that may resemble odontogenic infection especially when occurring in dental area [10,11]. Although data from a systematic critical appraisal of clinical guidelines on screening and diagnosis of oral cancer reported that the majority of clinical recommendations were based on low level of evidence [12], many authors recommend an accurate screening of oral mucosa for all patients and especially for high-risk patients such as smokers, drinkers and patients with HIV [13,14]. Thereby, the oral mucosa of each patient should be carefully monitored during routine dental care. ...
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Article
Full-text available
Objectives To evaluate a tissue autofluorescence (AF) system as an aid for Dental Hygienist (DH) to screening oral mucosa alterations during supportive periodontal care (SPC). Materials and methods Two hundred patients in regular SPC with no previous oral mucosa lesions were enrolled. The oral cavity of each patient was examined by a DH without and with the AF system. Afterward, the patient was examined by a General Dentist (GD) by means of conventional visual inspection alone. The primary outcome was the sensitivity of AF system used by a DH. Furthermore, the specificity, predictive values and likelihood ratios were also evaluated. Receiver operating characteristic (ROC) curves were generated and area under ROC (AUROC) was estimated to overall evaluate the ability of DH to detect oral mucosa lesions with and without an AF system. Results After completion of intraoral screening, 111 and 66 oral mucosa alterations were detected by DH without and with the AF system. A total of 83 lesions were instead recorded by GD with conventional inspection. The sensitivity and specificity of AF system used by a DH were 61.5% and 90.6% while the conventional visual inspection showed a sensitivity of 81.3% and specificity of 97.6%. AUROC values of 0.760 and 0.894 were found for AF system and for conventional visual inspection respectively. Conclusions Whitin the limitations of present study, the results showed for DH an increase of specificity and a loss of sensitivity in detection of oral mucosa alterations using the AF system. Clinical relevance The use of AF system may be considered an aid for DH to improve screening of oral mucosal alterations during SPC.
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... There is evidence that most CPGs do not adhere to the best methodological design. 12,13 Furthermore, some countries adopt and/or adapt existing CPGs to their context, leading to a vast variability in CPG quality 14 . It would be expected that the recommendations would be consistent if the topics of these guidelines are similar, since they should follow the same methodological quality. ...
Consistency of recommendations of clinical practice guidelines in periodontology: a systematic review
Article
Full-text available
  • Mar 2023
  • Braz Oral Res
The aim of this systematic review was to evaluate the methodological quality and the consistency of recommendations of clinical practice guidelines (CPGs) in Periodontology. An electronic search was conducted in two databases, MEDLINE and EMBASE, eight CPGs databases, and home pages of scientific societies in Periodontology up to April 2022. Three reviewers independently assessed methodological quality using the AGREE II instrument. In addition, we evaluated the consistency of the recommendations. Eleven CPGs were included, and the topics developed focused on prevention, diagnosis, risk factors, surgical and non-surgical periodontal treatment, antimicrobial therapy, root coverage, and maintenance. We found that the AGREE domains 2 (Stakeholder involvement) and 5 (Applicability) obtained the lowest scores. Domains 1 (Scope and purpose), 3 (Rigor of development) and 4 (Clarity of presentation) obtained the highest scores among the evaluated CPGs. The clinical recommendations for treatment of periodontal diseases were mostly consistent. Overall, the quality of CPGs used in periodontics was high. There was consistency of recommendations in specific fields. These findings may help researchers to promote CPGs focused on different fields of periodontics that have not yet been developed. Furthermore, the clinician will be able to make better clinical decisions.
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... 10 Several nations and institutions have invested a lot of human and financial resources to develop and update CPGs for stroke management to improve patient outcomes, which contain recommendations on PSD management. 1 11 12 This approach can create a bridge between theoretical achievements and clinical practice and eventually accelerate the transition of the former into the latter. 13 Various studies have shown that CPGs can improve healthcare. 14 15 However, compared with physicians, nurses had a lower perception towards CPGs. ...
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... A study published in 2018 analyzed 89 CPGs on adult critical care, and reported a mean overall score of 83%, which was higher than this review [36]. The study by Madera et al. suggested that 50% of the eight adult CPGs on screening and diagnosis of oral cancer were assessed as "recommend" and the other 50% were assigned as "recommended with modifications" [37]. Compared with CPGs for adults, the quality of pediatric CPGs still needs to be improved. ...
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Full-text available
  • May 2021
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Critical quality appraisal and algorithm development of clinical practice guidelines for management of poststroke sensory loss: a systematic review
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Background: The relationship between sugar and health is affected by energy balance, macronutrient substitutions, and diet and lifestyle patterns. Several authoritative organizations have issued public health guidelines addressing dietary sugars. Purpose: To systematically review guidelines on sugar intake and assess consistency of recommendations, methodological quality of guidelines, and the quality of evidence supporting each recommendation. Data sources: MEDLINE, EMBASE, and Web of Science (1995 to September 2016); guideline registries; and gray literature (bibliographies, Google, and experts). Study selection: Guidelines addressing sugar intake that reported their methods of development and were published in English between 1995 and 2016. Data extraction: Three reviewers independently assessed guideline quality using the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II), instrument. To assess evidence quality, articles supporting recommendations were independently reviewed and their quality was determined by using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methods. Data synthesis: The search identified 9 guidelines that offered 12 recommendations. Each of the reviewed guidelines indicated a suggested decrease in the consumption of foods containing nonintrinsic sugars. The guidelines scored poorly on AGREE II criteria, specifically in rigor of development, applicability, and editorial independence. Seven recommendations provided nonquantitative guidance; 5 recommended less than 25% to less than 5% of total calories from nonintrinsic sugars. The recommendations were based on various health concerns, including nutrient displacement, dental caries, and weight gain. Quality of evidence supporting recommendations was low to very low. Limitation: The authors conducted the study independent of the funding source, which is primarily supported by the food and agriculture industry. Conclusion: Guidelines on dietary sugar do not meet criteria for trustworthy recommendations and are based on low-quality evidence. Public health officials (when promulgating these recommendations) and their public audience (when considering dietary behavior) should be aware of these limitations. Primary funding source: Technical Committee on Dietary Carbohydrates of the North American branch of the International Life Sciences Institute. (PROSPERO: CRD42015029182).
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GRADE Evidence to Decision (EtD) frameworks: A systematic and transparent approach to making well informed healthcare choices. 1: Introduction
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#### Summary points Healthcare decision making is complex. Decision-making processes and the factors (criteria) that decision makers should consider vary for different types of decisions, including clinical recommendations, coverage decisions, and health system or public health recommendations or decisions.1 2 3 4 However, some criteria are relevant for all of these decisions, including the anticipated effects of the options being considered, the certainty of the evidence for those effects (also referred to as quality of evidence or confidence in effect estimates), and the costs and feasibility of the options. Decision makers must make judgments about each relevant factor, informed by the best evidence that is available to them. Often, the processes that decision makers use, the criteria that they consider and the evidence that they …
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Heparin-induced thrombocytopenia: A critical appraisal of clinical practice guidelines with the AGREE II instrument
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Assessing the quality of dental clinical practice guidelines
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  • Oct 2017
  • J DENT
Objectives: The primary aim of this study was to evaluate the quality of published dental clinical guidelines using the AGREE II instrument. Methods: Online searching of a wide range of organisations (national and International) was undertaken to identify dental clinical practice guidelines published between 2000-2014. The quality of each included guideline was assessed in relation to the AGREE II instrument by four assessors independently. Inter-rater agreement was assessed. Descriptive statistics and both univariate and multivariate analyses were conducted. Results: 162 guidelines were identified. The overall mean quality score was 51.9% (SD 13.3). There was variation in the reporting quality of individual domains with both Applicability (20.4%) and Editorial Independence (34.25%) poorly reported. Variation between the overall quality scores for guidelines produced by different dental specialities was evident. The quality of guidelines improved per publication year (β=0.76, 95% CI: 0.26, 1.26, p=0.003). Guidelines based on formal evidence (β=19.94, 95% CI: 15.25, 24.64, p=0.001) achieved higher quality scores. Conclusion: Overall, the quality of clinical dental practice guidelines is suboptimal. There is variation in the overall quality, reporting of individual items and domains of the AGREE II instrument between different dental speciality clinical practice guidelines. Guidelines based on formal evidence achieved higher quality scores. Clinical significance: Clinicians should be aware of the variation in the quality of dental clinical guidelines in particular related to methodological rigour. The use of formal evidence may be a useful indicator of their quality prior to their implementation.
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Evidence-based clinical practice guideline for the evaluation of potentially malignant disorders in the oral cavity
Article
  • Oct 2017
  • J AM DENT ASSOC
Background An expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs and the Center for Evidence-Based Dentistry conducted a systematic review and formulated clinical recommendations to inform primary care clinicians about the potential use of adjuncts as triage tools for the evaluation of lesions, including potentially malignant disorders (PMDs), in the oral cavity. Types of Studies Reviewed This is an update of the ADA’s 2010 recommendations on the early diagnosis of PMDs and oral squamous cell carcinoma. The authors conducted a systematic search of the literature in MEDLINE and Embase via Ovid and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials and diagnostic test accuracy studies. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in the evidence and to move from the evidence to the decisions. Results The panel formulated 1 good practice statement and 6 clinical recommendations that concluded that no available adjuncts demonstrated sufficient diagnostic test accuracy to support their routine use as triage tools during the evaluation of lesions in the oral cavity. For patients seeking care for suspicious lesions, immediate performance of a biopsy or referral to a specialist remains the single most important recommendation for clinical practice. In exceptional cases, when patients decline a biopsy or live in rural areas with limited access to care, the panel suggested that cytologic testing may be used to initiate the diagnostic process until a biopsy can be performed (conditional recommendation, low-quality evidence). Conclusions and Practical Implications The authors urge clinicians to remain alert and take diligent action when they identify a PMD. The authors emphasize the need for counseling because patients may delay diagnosis because of anxiety and denial.
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Critical Evaluation of the Quality and Recommendations of Clinical Practice Guidelines for Nasopharyngeal Carcinoma
Article
  • Mar 2017
Background: Given the distinct biological characteristics and regional distribution of nasopharyngeal carcinoma (NPC) compared with other head and neck cancers, and uncertainties regarding therapeutic strategies, physicians require high-quality clinical practice guidelines (CPGs) to provide transparent recommendations for NPC treatment. This study aimed to critically appraise the quality of NPC CPGs and assess the consistency of their recommendations. Methods: We identified CPGs that provided recommendations on the diagnosis and management of NPC published up to December 2015. Four investigators independently appraised CPG quality using the Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument. Key recommendations by CPGs were also evaluated. Results: A total of 7 CPGs were eligible for this study: 5 produced by professional organizations or governmental agencies and 2 were developed based on expert consensus. Of the 6 AGREE II domains, the applicability domain scored consistently low across CPGs (range, 13.5%-30.2%); no CPG achieved a score of >50% in all 6 domains. The scope and purpose domain (≥73.6% for 4 CPGs) and editorial independence domain (≥75.0% for 6 CPGs) scored highest. Of the 23 AGREE II items, 9 scored less than half of the points available in all 7 CPGs. The recommendations by CPGs were consistent in general; heterogeneity mainly existed among recommended therapeutic strategies. Conclusions: Variation exists in NPC CPG development processes and recommendations. Increased efforts are required to make comprehensive resources available to guide healthcare providers and enhance delivery of high-quality, evidence-based care for NPC. International collaboration is necessary to enable the development of high-quality and regionally relevant CPGs for NPC. © 2017 National Comprehensive Cancer Network, Inc. All rights reserved.
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Cancer Statistics, 2017
Article
  • Dec 2016
Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data were collected by the National Center for Health Statistics. In 2017, 1,688,780 new cancer cases and 600,920 cancer deaths are projected to occur in the United States. For all sites combined, the cancer incidence rate is 20% higher in men than in women, while the cancer death rate is 40% higher. However, sex disparities vary by cancer type. For example, thyroid cancer incidence rates are 3-fold higher in women than in men (21 vs 7 per 100,000 population), despite equivalent death rates (0.5 per 100,000 population), largely reflecting sex differences in the "epidemic of diagnosis." Over the past decade of available data, the overall cancer incidence rate (2004-2013) was stable in women and declined by approximately 2% annually in men, while the cancer death rate (2005-2014) declined by about 1.5% annually in both men and women. From 1991 to 2014, the overall cancer death rate dropped 25%, translating to approximately 2,143,200 fewer cancer deaths than would have been expected if death rates had remained at their peak. Although the cancer death rate was 15% higher in blacks than in whites in 2014, increasing access to care as a result of the Patient Protection and Affordable Care Act may expedite the narrowing racial gap; from 2010 to 2015, the proportion of blacks who were uninsured halved, from 21% to 11%, as it did for Hispanics (31% to 16%). Gains in coverage for traditionally underserved Americans will facilitate the broader application of existing cancer control knowledge across every segment of the population. CA Cancer J Clin 2017. © 2017 American Cancer Society.
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