Cruz-Peralta, Agles¹

Language: English/Spanish [Versión en español]
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The exponential growth of scientific knowledge and technology makes it necessary for the dentist to use tools that facilitate decision-making; evidence-based clinical practice guidelines (CPG) are the most appropriate resource. CPGs, developed with methodological rigor, synthesize the relevant research, weigh the risks with the benefits, considering the costs and the patient's preference to issue recommendations applicable to a given context.¹

With the advent of evidence-based dentistry, it is clear that patients with the same clinical problems receive different treatments depending on the professional providing care, geographic location, socioeconomic environment, among many other factors, with negative consequences for the health of patients and the proper management of health care institutions. The use of CPGs addresses this problem, helping patients to receive a definitive diagnosis and management.

In Mexico, as a result of the National Development Plan 2006-2012, the development and validation of CPGs were initiated, and, to date, the National Center of Technological Excellence coordinates the sectoral integration of the Master Catalog of CPGs (see: http://cenetec-difusion.com/gpc-sns/?p=1227). To date, there is a repository of 472 GPC. The guides in the dental area are:

• 1. Diagnosis and anesthetic approach to symptomatic irreversible pulpitis in permanent tooth organs (year of publication 2013).
• 2. Timely diagnosis of dental malocclusions in children 4 to 11 years of age at the first level of care (2016).
• 3. Prevention, diagnosis, and treatment of odontogenic infections causing cervicofacial infections at the three levels of care (2011).
• 4. Prevention and diagnosis of dental caries in patients aged 6 to 16 years.
• 5. Prevention of dental caries through the application of dental pit and fissure sealants (2011).
• 6. Diagnosis and treatment of bacterial infections foci in the oral cavity (2011).
• 7. Dental restorations with amalgam, resin, and glass ionomer (2011).
• 8. Treatment of traumatic avulsion of permanent anterior teeth in patients 6 to 15 years of age in the first level of care (2014).

Ideally, guidelines should develop in the context in which they will use. However, it is a process that requires a multidisciplinary group working for an extended period and high economic costs. In these cases, it is more efficient to carry out a process of adaptation of existing guidelines and avoid unnecessary duplication of them. The method used for adaptation and adoption is relevant because it will preserve the validity and reliability of the original guideline.

For adapting CPG minimum of eight methods have been proposed:²

• 1. Systematic Guideline Review (SGR). Year 2006.
• 2. Royal College of Nursing (RCN). Year 2000.
• 3. Alberta Ambassador Program Adaptation Phase. Year 2006.
• 4. ADAPTE.
• 5. Adapted ADAPTE.
• 6. GRADE-ADOLOPMENT.
• 7. MAGIC.
• 8. RAPADAPTE.

Although with some variations, in general, the adaptation of CPG is carried out with the following steps: elaboration of PIPOH (Population, Intervention, Professionals, Outcome, and Healthcare) questions, identification of the priority topic, systematic search of CPGs, and selection by methodological quality and predefined criteria about local needs, analysis, and synthesis of information, adaptation or adoption of recommendations, identification of gaps in knowledge for future research, publication and implementation.³

The ADAPTE method is currently the best known and most widely used. It was developed between 2005 and 2007, updated in 2009, and proposes 24 steps for adaptation. In addition, the working group made its resources available internationally through the Guidelines International Network (GIN).²

In "Adapted ADAPTE" (Alexandria Center for Evidence-Based Clinical Practice Guidelines), between 2010 and 2015, it follows the steps of the original ADAPTE; however, it introduces changes to increase its efficiency and introduces the use of Appraisal of Guidelines for Research & Evaluation II (AGREE II: an instrument to assess the quality of the original CPG).⁴

The GRADE-ADOLOPMENT method was developed in 2016-2018 by members of the GRADE working group at McMaster University, Canada. Frequently existing CPGs do not present sufficient details of the judgments made to translate the evidence to recommendations and modifications made to allow implementation of patient care. They may also fail to cover all the relevant criteria for local decision-making. In consequence of these challenges, it was implemented a new methodology that combines three options: 1) adopting existing recommendations as they are; 2) adapting existing recommendations to their context; 3) developing de novo recommendations based on the synthesis of available evidence. This approach has two essential tools, the GRADE Evidence to Decision frameworks⁵ and Summary of Findings tables (SoF), available at https://isof.epistemonikos.org/#/.

This approach includes prioritizing the (health) problem, certainty and quality of evidence, patient values and preferences, resource use, costs, feasibility and acceptability issues, and potential impact on health equity.

The "Making GRADE the Irresistible Choice (MAGIC)" in 2014 developed a process for adaptation that consists of five steps (planning, initial assessment of recommendations, modification, publication, and evaluation). They simplify the process limiting the ADAPTE steps regarding the selection of the original CPG and emphasize transparency in the adaptation process using GRADE tools. It has a web platform (MAGIC app https://magicevidence.org/magicapp/) that provides tools to guide, organize (plan, assign tasks, instruments, etc.), present, and disseminate the guidelines.⁶

RAPADAPTE, developed in 2016, proposes a faster 12-step process focused on resource-poor health systems. The methodology was based on ADAPTE but added consultation of databases such as DynaMed and EBM Guidelines and several panels conducted via remote that included a large number of experts.⁷

This communication aims to motivate interest in Mexico concerning the need for updated dental clinical guidelines and to consider the adaptation process as an alternative

REFERENCES

1. Torres-Arreola LP, Peralta-Pedrero ML, Viniegra-Osorio A, Valenzuela-Flores AA, Echevarría-Zuno S, Sandoval-Castellanos FJ. Proyecto para el desarrollo de guías de práctica clínica en el Instituto Mexicano del Seguro Social. Rev Med Inst Mex Seguro Soc. 2010; 48 (6): 661-672.

2. Darzi A, Abou-Jaoude EA, Agarwald A, Lakis C, Wiercioch W, Santesso N et al. A methodological survey identified eight proposed frameworks for the adaptation of health related guidelines. J Clin Epidemiol. 2017; 86: 3-10.

3. Alva Diaz C, García-Mostajo JA, Gil-Olivares F, Timana R, Pimentel P, Canelo-Aybar C. Guías de práctica clínica: evolución, metodología de elaboración y definiciones actuales. Acta Médica Peruana. 2017; 34 (4): 317-322.

4. Brouwers MC, Kho ME, Browman GP et al. AGREE II: Advancing guideline development, reporting and evaluation in health care. CMAJ. 2010; 182 (18): E839-E842.

5. Alonso-Coello P, Schünemann HJ, Moberg J et al. Marcos GRADE de la evidencia a la decisión (EtD): un enfoque sistemático y transparente para tomar decisiones sanitarias bien informadas. 1: Introducción. Gac Sanit. 2018; 32 (2): 166.e1-166.e10.

6. Olav Vandvik P, Fog Heen A, Brandt L. Una nueva generación de guías de práctica clínica confiables a través de MAGIC. Rev Peru Med Exp Salud Pública. 2014; 31 (1): 118-126.

7. Alper BS, Tristan M, Ramirez-Morera A, Vreugdenhil MM, Van-Zuuren EJ, Fedorowicz Z. RAPADAPTE for rapid guideline development: high-quality clinical guidelines can be rapidly developed with limited resources. Int J Qual Health Care. 2016; 28 (3): 268-274.

AFFILIATIONS

¹ Facultad de Odontología de la Universidad Nacional Autónoma de México.

CORRESPONDENCE

Dr. Agles Cruz-Peralta. E-mail: wertsaco@gmail.com