May 2019 Volume LIV Number 3


Evidence-Based Dentistry Update

September 2017 Volume LII Number 5

How the New Clinical Practice Guidelines are GRADED

Unlike school, there’s no pass/fail or curve for clinical guide- lines. Here at AAPD we grade tough. Our evidence-based dentistry workgroup members are trained to develop guidelines using stringent, methodologies, which means coins are tossed only if randomization is required. Guideline developers employ the GRADE (Grading of Rec- ommendations Assessment, Development and Evaluation) approach, a system for rating quality of evidence and strength of recommendations.

Each recommendation starts out as a clinical question or a PICO1, followed with outcomes ranked by importance. A search is conducted to find the best available evidence on the topic (ideally a systematic review.) Then, the evidence is reviewed, extracted, synthesized (quali- tatively or quantitatively) and finally graded.

Guideline recommendations will be marked as either STRONG or WEAK.

A strong recommendation implies in most situations that clini- cians should follow the suggested intervention.

A weak recommendation indicates that while the clinician may want to follow the suggested intervention, the panel recognizes that different choices may be appropriate for individual patients. 2

Next to the recommendation’s grade is listed the strength of evidence. Strength of evidence is based on the quality of the evidence informing the recommendations. While strong evidence often denotes a strong recommendation, on occasion a strong recommendation may be based on moderate or even low-quality evidence. For example, sealants are recommended for use in primary molars, despite the dearth of studies on the effect of sealants in the primary dentition.

"The sealant guideline panel recommends the use of sealants compared with nonuse in primary and permanent molars with both sound occlusal surfaces and noncavitated occlusal carious lesions in children and adolescents. (Strong recommendation, moderate-quality evidence.)"3

Strong recommendations based on lower-quality evidence are determined on a case-by-case basis and serve as examples of how the clinicians and their collective expertise are essential to guideline development.

For more information, please contact Senior Evidence-Based Dentistry Manager, Research and Policy Center Laurel Graham at

1Population, the Intervention (or exposure in the case of observation studies), the appropriate Control or Comparator, and the Outcomes of interest. Ann Intern Med. 1997 Sep 1;127(5):380- 7. Formulating questions and locating primary studies for inclusion in systematic reviews.
2Schünemann H, Brozek J, Guyatt G, Oxman A. Recommendations and their strength. Going from evidence to recommendations. GRADE Handbook. Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach. Updated October 2013. As accessed on April 25, 2017 from handbook.html.
3Pediatr Dent. 2016 Oct 15;38(5):120-136. Evidence-based Clinical Practice Guideline for the Use of Pit-and-Fissure Sealants.

The Dental Trauma Guide – Evidence-Based Treatment Guide

In 2005, researchers at the University Hospital of Copenhagen started the Dental Trauma Guide to capitalize on an extensive dental trauma injuries database they had collected. The extensive catalog of trauma data is used to produce prognosis estimates for different injuries, and allows comparison of competing treatments.

Due to a loss of funding the Dental Trauma Guide is now a membership-based website. For AAPD members, the fee (normally $25 per year) is a nominal $5.00 per user per year.

To subscribe :
• Visit
• Select the number of individual users that need to have access to the Dental Trauma Guide.
• You now have access to the unique services of the Dental Trauma Guide

Click here for a PDF version of this article.