https://orcid.org/0000-0001-6633-6461
Figures
Abstract
Objectives
To review the content of recommendations within antenatal oral healthcare guidance documents and appraise the quality of their methodology to inform areas of development, clinical practice, and research focus.
Method
A systematic search of five electronic databases, Google search engine, and databases from relevant professional and guideline development groups published in English, developed countries, and between 2010 and 2020 was undertaken to identify guidance documents related to antenatal oral healthcare. Quality of documents was appraised using the Appraisal of Guidelines Research and Evaluation II tool, and a 3-step quality cut-off value was used. Inductive thematic analysis was employed to categories discreet recommendations into themes.
Results
Six guidelines and one consensus statement were analysed. Two documents developed within Australia scored ≥60% across five of the six domains of the quality appraisal tool and were recommended for use. Four documents (developed in the United States and Canada) were recommended for use with modifications, whilst one document (developed in Europe) was not recommended. A total of 98 discreet recommendations were identified and demonstrated considerable unanimity but differed in scope and level of information. The main content and number of recommendations were inductively categorised within the following clinical practice points: risk factor assessments (n = 2), screening and assessment (n = 10), pre-pregnancy care (referral, n = 1), antenatal care (health education and advice, n = 14; management of nausea and vomiting, n = 7; referral, n = 2), postnatal care (health education and advice, n = 1; anticipatory guidance, n = 6), documentation (n = 4), coordinated care (n = 4), capacity building (n = 6), and community engagement (n = 1).
Conclusion
The methodological rigour of included guidance documents revealed areas of strengths and limitations and posit areas for improvement. Further research could centre on adapting antenatal oral healthcare guidelines and consensus statements to local contexts. More high-quality studies examining interventions within antenatal oral healthcare are needed to support the development of recommendations.
Citation: Wilson A, Hoang H, Bridgman H, Crocombe L, Bettiol S (2022) Clinical practice guidelines and consensus statements for antenatal oral healthcare: An assessment of their methodological quality and content of recommendations. PLoS ONE 17(2): e0263444. https://doi.org/10.1371/journal.pone.0263444
Editor: Rohit Kunnath Menon, School of Dentistry, International Medical University, MALAYSIA
Received: April 26, 2021; Accepted: January 19, 2022; Published: February 3, 2022
Copyright: © 2022 Wilson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting information files.
Funding: The authors received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Oral health is a critical component of general health and wellbeing. Pregnancy signifies a unique and vulnerable period in a woman’s life and increases susceptibility to oral diseases such as periodontal disease and dental caries due to complex hormonal, behavioural, and physiologic changes [1]. Evidence has suggested an association between periodontal diseases and risk of adverse pregnancy outcomes during pregnancy, including preeclampsia, low-birthweight and preterm birth [2]. Other evidence has demonstrated the impact of poor oral health of women throughout the lifespan and that of their children, including the development of dental caries, impaired nutrition, increasing dental costs, and diminished quality of life [3]. These outcomes can be worse for women who are vulnerable, disadvantaged or Indigenous [1]. In light of the evidence, maintaining oral health during pregnancy has been continually recognised as a pressing public health concern worldwide [4], whilst oral healthcare topics relating to pregnancy have also been introduced into formal medical pedagogy [5], professional development training [6], and integrated primary healthcare models [7].
The role of antenatal care (ANC) providers in promoting oral health during pregnancy have emerged as a beneficial and cost-effective strategy to facilitate women accessing dental services and improving the oral health of women and their children [8]. As an umbrella term, ANC providers are healthcare professionals involved in antenatal care for women during pregnancy and include medical practitioners, obstetric specialists, midwives, nurses, and Indigenous healthcare workers. These providers are often the first point of contact for pregnant women and are well-placed to deliver oral health promotion and interventions prior to formal assessments by dental professionals.
Guidance documents, including clinical practice guidelines (CPGs) and consensus statements, can assist ANC providers and benefit women in promoting evidence-based practices. As defined by the Health and Medicine Division of the American National Academics (formerly the Institute of Medicine), CPGs are statements that “are informed by a systematic review of evidence and an assessment of the benefits and costs of alternative care options” [9]. In contrast, consensus statements are statements “developed by an independent panel of experts, usually multidisciplinary, convened to review the research literature for the purpose of advancing the understanding of an issue, procedure, or method” [10]. These terms are often used interchangeably and are both used to optimise patient care. Despite the existence of antenatal oral healthcare CPGs and consensus statements, considerable variation in rates of oral healthcare interventions exists among ANC providers who remain uncertain of their ability to implement recommendations [11–13]. It is possible that practice variation derives from discrepancies in recommendations, limited awareness of guideline existence and expert consensus, or differences in methodological quality during development [11, 14]. Moreover, it is often unknown whether recommendations are in accordance with best evidence and are suited to the local context [14]. This variation in the quality and content of CPGs and consensus statements addressing women’s oral health issues could result in conflicting recommendations making it challenging for ANC providers to deliver consistent quality health care.
Accordingly, evaluating the methodological quality and content of recommendations within guidance documents is imperative [15–17]. To our knowledge, a critical evaluation of antenatal CPGs and consensus statements for the management of oral health during pregnancy has not been previously conducted.
Therefore, the objectives of this systematic review were to:
- Review the content of eligible antenatal oral healthcare CPGs and consensus statements; and,
- Appraise the quality of methodology to inform areas of development, clinical practice, and research focus.
Materials and methods
The authors developed a detailed study protocol according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) [18]. The systematic review was reported according to the PRISMA statement [19].
Eligibility criteria
The eligibility criteria were predetermined by the authors. Guidance documents were included if they were: (1) written in English; (2) published in developed countries for comparison according to the Organisation for Economic Co-operation and Development (countries that are regarded as developed countries due to their high Human Development Index and very high-income economies; see S1 Table); (3) labelled as CPG, guideline, consensus statement, recommendation, guidance statement, position paper, or professional standard; (4) allocated either entirely to antenatal oral healthcare or contained a minimum of two explicit recommendations on antenatal oral health; (5) published or updated between 2010 and 2020 as guidelines published prior to 2010 could be considered out of date and not reflect contemporary practices; (6) obtained from original sources (de novo development); and (7) most updated document if multiple versions existed. Documents were excluded if published earlier than 2010 or within a developing or least developed country, written in languages other than English, adapted from other sourced CPGs and consensus statements, or did not meet the definitions of CPGs or consensus statements as previously defined [9, 10].
Search strategy
Three systematised search strategies were conducted to identify relevant guidelines and consensus statements between 16th October 2020 to 23rd October 2020. This approach involved only one reviewer (AW) due to the scope of the paper and resource constraints [20]. The three search strategies are outlined as follows:
- A systematic search was conducted within five electronic databases: MEDLINE via PubMed, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Library, Embase, and Scopus. Limiters by year (1st Jan 2010 to 31st Dec 2020) and language (English) were applied. MeSH terms including “pregnant women”, “prenatal care”, “oral health”, “practice guidelines”, “guidelines”, “consensus”, and “standard of care” and associated keywords were used.
- A similar guideline review [21] has demonstrated sourcing guidance documents from grey literature sources as effective. Thus, an internet web search (in the Google search engine) using the terms “oral health”, and “guideline”, in conjunction with interchangeable terms of “antenatal”, “prenatal”, “perinatal”, “pregnancy”, and “maternal” were comprehensively examined up to the first 150 results, as these were considered most relevant.
- Documents were purposively sought from prominent guideline development groups within eligible countries such as the Australian National Health and Medical Research Council (NHMRC), Guidelines International Network, Scottish Intercollegiate Guidelines Network, National Guideline Clearinghouse, and the National Institute of Health and Care Excellence. Databases of national and international professional societies related to the field of antenatal oral healthcare were also searched, such as the American College of Obstetricians and Gynaecologists, Royal College of Obstetricians and Gynaecologists, Royal College of Australian and New Zealand College of Obstetricians and Gynaecologists, and Society of Obstetricians and Gynaecologists of Canada, among others. The combined search term ‘pregnancy + oral health + guideline’ was used, and the first 20 results were examined for relevancy.
A secondary search using the Google search engine strategy to check for updated or additional sources was undertaken on 20th April 2021 by the first author (AW), but no additional CPGs or consensus statements were identified. However, a 2020 updated version of an Australian guideline was identified and replaced an existing 2019 version within our review [22]. Detailed search processes with results are outlined in the S1 Appendix.
Screening
Using EndNote X9.3.1 software (Clarivate Analytics, PA, USA), the first author (AW) conducted the literature searches, then screened potential results by title and abstract, retrieved the full-text document and excluded those that did not meet eligibility criteria. References from full-text documents were also cross-referenced by AW to assess for additional guidance documents. Results were periodically shared with the research team, and any disagreements were resolved by consensus via discussion among all five reviewers (AW, HH, HB, LC and SB). The reasons for excluding guidance documents were documented.
Data extraction
One reviewer (AW) independently reviewed the guidance documents and extracted characteristic information relating to: title, development organisation, country/region, publication year, guidance document type (for example, whether evidence-based or based on expert consensus) and number of references. The content of recommendations within the guidance documents was extracted according to a predetermined recommendation extraction form by the authors and was adapted from the matrix developed by Zhang et al. [23] (See S2 Appendix). The following information was extracted from each document: title, author, publication year, guidance document type, funding, methodology, and relevant recommendations. Recommendations concerning antenatal oral healthcare were systematically extracted for further analysis and were repetitively and recursively analysed. We employed a thematic analysis using an inductive approach and categorised discrete recommendations by themes [24]. All extracted data were checked for accuracy by a second, third and fourth reviewer at random (HH, HB and SB).
Quality appraisal
Three reviewers (HH, HB and SB) independently evaluated the quality of two or more guidance documents, and one reviewer (AW) independently evaluated the quality of all included guidance documents (until each document was appraised a minimum of twice). Disagreements were resolved through consensus discussion; when needed, a fifth reviewer (LC) participated in the discussion until agreement was achieved. We used the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool [16], a validated and widely adopted tool that appraises methodological rigour and guideline development transparency. The AGREE II tool includes 23 items on a seven-point Likert scale across six domains. Each domain captures a distinct facet of guideline quality: ‘Scope and Purpose’ (n = 3), ‘Stakeholder Involvement’ (n = 3), ‘Rigour of Development’ (n = 8), ‘Clarity of Presentation’ (n = 3), ‘Applicability’ (n = 4) and ‘Editorial Independence’ (n = 2). An overall score of each domain was calculated as a percentage as follows: [total actual domain score–minimum possible domain score]/[maximum possible domain score–minimum possible domain score] x 100. Comments regarding the justification of scores, strengths and limitations were recorded into a separate table.
In addition, the AGREE II tool also included two overall quality assessments for each document: a final quality score of 1 to 7 and whether we would recommend using the document, categorising it as ‘recommend’, ‘recommend with modifications’, or ‘not recommend’. However, the AGREE II tool does not report a threshold for domain score quality, making it challenging to distinguish between high-, medium- and low-quality guidance documents. Following the 3-step system used in a similar review [25], we modified this approach to determine both overall guideline quality and recommendations for clinical use. Documents were deemed high-quality (recommended) if most domain scores (at least five of six) were greater than 60%, whilst documents were deemed medium-quality (recommended with modifications) if most domain scores were between 30–60% or at least two domain scores were no less than 60%. Documents were deemed low-quality (not recommended) if most of the domain scores were less than 30%.
Statistical analysis
One reviewer (AW) performed statistical analyses using Stata version 17.0 (StataCorp, TX, USA). Descriptive statistics (mean, median, standard deviation [SD] and range) were calculated for each domain score. The intraclass coefficient (ICC) with its 95% confidence interval (95% CI) was calculated as an overall indicator of agreement on quality scores between reviewers. The degree of agreement between 0.01 and 0.20 is slight, from 0.21 to 0.40 is fair, from 0.41 and 0.60 is moderate, from 0.61 to 0.80 is substantial, and from 0.81 to 1.00 is almost perfect to perfect [26]. An independent t-test was undertaken to evaluate the differences between means of relevant variables, and p-values of 0.05 or less were considered significant.
Results
Search results
The search yielded 1,873 records after removing duplicates. After title and abstract screen, 26 records were obtained for full review; 19 were excluded based on: not satisfying our guidance document definitions (n = 5, factsheets [27–31]; n = 1, expert committee opinion [32]); published prior to 2010 (n = 2) [33, 34]; were not published in prespecified developed countries (n = 1, in Sri Lanka) [35]; provided a limited focus on antenatal oral healthcare (n = 1) [36]; were adapted from source CPGs or consensus statements included in our search (n = 8) [37–44]; or were not the latest version (n = 1) [45] (Fig 1). A final seven guidance documents (n = 6, CPGs; n = 1 consensus statement) met the eligibility criteria and were included in the review for analysis. Summary characteristics of included guidance documents are presented in Table 1.
Characteristics of included guidance documents
Guidance documents were identified and were published by the following organisations: American Academy of Pediatric Dentistry (AAPD) [47], Australian Government Department of Health (AGDH) [22], California Dental Association Foundation (CDAF) [48], European Federation of Periodontology (EFP) [51], National Aboriginal Community Controlled Health Organisation/The Royal Australian College of General Practitioners (NACCHO/RACGP) [46], Oral Health Care During Pregnancy Expert Workgroup (OHCDPEW) [49], and Perinatal Services British Columbia (PSBC) [50]. Six guidelines (AAPD, AGDH, CDAF, EFP, NACCHO/RACGP and PSBC) and one consensus statement (OHCDPEW) were included. These guidance documents were developed from three continents including North America (the United States [US] [n = 3, AAPD, CDAF and OHCDPEW] and Canada [n = 1, PSBC]), Australia (n = 2, AGDH and NACCHO/RACGP), and Europe (n = 1, EFP). Most documents were developed for implementation at a national level (n = 5, AAPD, AGDH, CDAF, NACCHO/RACGP and OHCDPEW), state or province levels (n = 1, PSBC) or international level (n = 1, EFP). The types of documents were based on expert consensus (n = 5, AAPD, CDAF, EFP, OHCDPEW and PSBC) or evidence-based methodology (n = 2, AGDH and NACCHO/RACGP). The number of references included within the guidance documents varied (range 3 to 249; AAPD, AGDH, CDAF, NACCHO/RACGP and PSBC). However, two documents (EFP and OHCDPEW) did not clearly provide references.
Most guidance documents were exclusively developed for antenatal oral healthcare and provided comprehensive recommendations (n = 4, AAPD, CDAF, EFP and OHCDPEW), while other documents were developed for general aspects of antenatal care and included a section or chapter of oral healthcare recommendations (n = 4, AGDH, NACCHO/RACGP and PSBC). External funding from academic institutions, government and non-government entities (n = 9, AGDH, CDAF, OHCDPEW, NACCHO/RACGP), and a consumer goods corporation (n = 1, EFP) were disclosed in several documents. Only two documents developed by the AGDH and NACCHO/RACGP provided a level of evidence and grading of recommendations using the NHMRC system [52].
Summary of recommendations
All relevant guidance document information and recommendations were extracted using the recommendation extraction form (S2 Appendix). A total of 98 discreet recommendations were identified. Of these 98 recommendations, two were based on the systematic assessment of evidence, and the remaining 96 were based on expert consensus. The two evidence-based recommendations are outlined in S2 Table. These recommendations received an overall grading of recommendation of ‘B’, indicating that the body of evidence can be trusted to guide practice in most situations. Overall, oral healthcare recommendations and management options demonstrated considerable unanimity but differed in scope and level of information. The main content and number of recommendations have been inductively categorised within the following clinical practice points: risk factor assessments (n = 2), screening and assessment (n = 10), pre-pregnancy care (referral, n = 1), antenatal care (health education and advice, n = 14; management of nausea and vomiting, n = 7; referral, n = 2), postnatal care (health education and advice, n = 1; anticipatory guidance, n = 6), documentation (n = 4), coordinated care (n = 4), capacity building (n = 6), and community engagement (n = 1), and are presented in Table 2.
Quality of included guidance documents
The overall agreement among reviewers of guidance documents against the AGREE II tool was almost perfect (overall ICC: 0.856; 95% CI: 0.710, 0.918), whilst the level of agreement between individual reviewers ranged from substantial to almost perfect (ICC: 0. 636–0.913). The ICC scores and their 95% CIs are reported in Table 3.
No documents scored ≥60% across all domains. Two documents scored ≥60% across five domains (n = 2, AGDH and NACCHO/RACGP), three documents scored between 30–60% across two or more domains (n = 4, AAPD, CDAF, OHCDPEW AND PSBC), whilst one document scored <60% across all domains (n = 1, EFP). The highest average domain score was ‘Scope and Purpose’ (79.3%, SD 19.4%), followed by ‘Clarity of Presentation’ (75.8%, SD 13.7%), ‘Stakeholder Involvement’ (59.9%, SD 23.5%), ‘Rigour of Development’ (49.8%, SD 39.9%), ‘Editorial Independence’ (30.9%, SD 40.1%), and ‘Applicability’ (27.9%, SD 20.2%). Notably, two evidence-based documents (46.2%, SD 23.9%; AGDH and NACCHO/RACGP) when compared to five documents based on expert consensus (82.5%, SD 17.1%; AAPD, CDAF, EFP, OHCDPEW and PSBC) scored significantly higher across domain scores (t[degrees of freedom] = t statistic, p = p-value: t[10] = 3, p = 0.013). However, no significant difference in domain scores were demonstrated when guidelines (56.0%, SD 23.6%; n = 5, AAPD, AGDH, CDAF, EFP, NACCHO/RACGP and PSBC) and consensus statement (41.7%, SD 22.7%; n = 1, OHCDPEW) were compared (t[10] = 1, p = 0.311). Guidance documents developed by the NACCHO/RACGP and the AGDH were deemed high-quality and recommended for use in clinical practice (n = 2), four documents were medium-quality and recommended with modifications (n = 5, AAPD, CDAF, OHCDPEW and PSBC), and one document (n = 1, EFP) was deemed low-quality and not recommended for use in clinical practice (See Table 4).
The standardised AGREE II domain scores of included guidance documents are presented as a forest plot (Fig 2), visually demonstrating areas of relative methodological strengths and weaknesses.
The strengths and limitations of included guidance documents based on the AGREE II criteria are summarised in Table 5 and are based on the consensus of our comments during the quality appraisal phase and highlight areas of potential improvement.
Discussion
To the best of our knowledge, this is the first study to critically evaluate the quality and content of antenatal CPGs and consensus statements relating to oral healthcare during pregnancy within developed countries. Seven antenatal oral healthcare guidance documents (six guidelines and one consensus statement) were identified and were appraised using the AGREE II tool. Our findings highlighted several areas for improvement and development, clinical practice, and research focus.
The guidance documents developed by AGDH and NACCHO/RACGP scored ≥60% across five domains of the AGREE II tool, were deemed high-quality and were recommended for use in clinical practice. We attributed this to the robust and transparent methods reported by the guideline developers. This finding was further supported when guidance documents based on evidence-based methodology (n = 2, AGDH and NACCHO/RACGP) demonstrated significantly higher quality scores across domains when compared to guidance documents based on expert consensus (n = 5, AAPD, CDAF, EFP, OHCDPEW and PSBC). None scored ≥60% across all domains, whilst four documents developed by APPD, CDAF, OHCDPEW and PSBC were deemed medium-quality and recommended with modifications and posited areas for improvement. One document (EFP) did not achieve our cut-off value of 60% within any domains, was deemed low-quality and was not recommended for use in clinical practice, suggesting significant room for improvement in its methodology. To illustrate, all documents demonstrated a need to improve their applicability (Domain 5), especially in areas concerning the discussion of facilitators and barriers to implementation, inclusion of quality measures and indicators to monitoring and clinical audit, and evidence of economic analysis. In another example, five documents (AAPD, CDAF, EFP, OHCDPEW and PSBC) did not indicate a disclosure of competing interests statements highlighting a need to improve their editorial independence (Domain 6). Four documents (AAPD, OHCDPEW, EFP and PSBC) also demonstrated deficiencies within stakeholder involvement (Domain 2), most notably in the lack of pregnant women involvement during development stages. Whilst three documents (EFP, OHCDPEW and PSBC) had significant gaps in their rigour of development (Domain 3), including lack of systematic literature search, quality assessment of the evidence, detailed discussion of benefits and risks in formulating recommendations, and reporting of review and update processes. Our lowest scoring domains of editorial independence (Domain 6) and applicability (Domain 5) align with findings from a systematic review of 42 appraisal studies, including 626 CPGs across several disciplines [53].
However, in spite of the variations in methodological rigour, the overall oral healthcare recommendations across guidance documents were consistent and included risk factor assessments, screening and assessment, pre-pregnancy care (referrals), antenatal care (health education and advice, management of nausea and vomiting, and referrals), postnatal care (health education and advice and anticipatory guidance), documentation, coordinated care, capacity building, and community engagement as it related to the management of oral health during pregnancy. Only recommendations for ANC providers to advise women to have an oral health check at the initial antenatal visit were supported by a level of evidence and grading of recommendations system [52]. Overall, it appears that the assessment of current evidence evaluating oral healthcare interventions provided by ANC providers is relatively scant within the literature. To illustrate, we could only easily locate four systematic reviews [13, 54–56] and one scoping review [57] relating to this topic published within the past decade. Therefore, more high-quality studies using rigorous methodologies are needed to support the development of recommendations concerning antenatal oral healthcare.
Our systematic assessment of antenatal oral healthcare guidance documents could be beneficial in supporting the decision to adopt or adapt guidance documents into clinical practice or within different local contexts. For guidance documents to be considered trustworthy and of high quality, the following criteria from the NHMRC Standards for Guidelines is suggested: (1) guidance documents should be relevant and useful for decision-making; (2) be transparent; (3) be overseen by a guideline development group; (4) identify and manage conflicts of interest; (5) be focused on health and related outcomes; (6) be evidence-informed; (7) make actionable recommendations; (8) be up-to-date; and (9) be accessible [52]. Based on these criteria and because of the high methodological rigour within the CPGs developed by AGDH and NACCHO/RACGP, we consider the adoption of their recommendations as appropriate and indicative of the best available evidence. The adaptation of CPGs and consensus statements has been acknowledged as a valid and less resource-intensive alternative to de novo development [58]. Within antenatal oral healthcare, several adapted guidelines have been published within the past ten years, particularly within the US [37–40, 42–44] and Canada [41]. Though beyond the scope of our systematic review, the option to adapt rather than develop guidance documents could prove particularly advantageous to developing and least developed countries and could implement existing formal adaptation methodologies and frameworks [59, 60]. Most notably, guidance adaptation and knowledge synthesis within antenatal oral healthcare, both within developed, developing and least developed countries, signifies a dearth of literature and suggests an area for future research.
Our critical appraisal of antenatal oral healthcare guidance documents further highlights the flexibility and diverse use of the AGREE II tool to evaluate methodological rigour appropriately and effectively. Within 2021, systematic reviews of pregnancy-related guidance documents using the AGREE II tool have included gestational weight management [61], gestational diabetes [62], use of complementary medicines and therapies in antenatal care [63], and prevention of preeclampsia [64], among other related topics. These reviews highlighted gaps in methodology and guideline development, consistencies and inconsistencies within recommendations and management options, and provided suggestions for improvements.
Strengths and limitations
This is the first systematic review to appraise guidance documents on antenatal oral healthcare and identify and synthesise the content of recommendations. Systematic methods in the review processes and quality appraisal were performed with the AGREE II tool, which remains a well-established and validated instrument. Our adapted version of the ‘recommendation matrix’ developed by Zhang et al. [23] proved a useful and systematic data extraction method. Overall, the findings of our review have the potential to provide pragmatic guidance on areas of antenatal oral healthcare, particularly as it pertains to the methodology of recommendation development, clinical practices of ANC providers, and the identification of gaps in areas requiring further research.
However, this systematic review had several limitations. The purposive search of guidance documents was limited to professional and guideline development groups within developed and English-speaking countries. Sources from less developed and non-English speaking countries were thus likely overlooked and could limit our findings’ generalisability and relevance to local contexts and healthcare systems. In addition, the AGREE II tool was originally designed to evaluate CPGs [16]. Despite opinions within the literature that consensus statements should be subjected to the same rigorous appraisal methods for their development as CPGs [65, 66], it may be important to consider this limitation when interpreting our findings for the consensus statement developed by the OHCDPEW [49]. Notwithstanding, the consensus statement developed by the OHCDPEW did not demonstrate a significant difference in quality when compared to the six eligible guidelines within our review, which may add some credence to the diverse application of the AGREE II tool.
As an inherent limitation when conducting a systematic review, a potential for reviewer bias exists. However, the level of agreement using the AGREE II tool was substantial to almost perfect among reviewers, suggesting that we were relatively unanimous in our interpretation of quality.
Conclusions
The methodological qualities of seven antenatal oral healthcare guidance documents within developed countries were appraised and revealed areas of strengths and limitations. Guidance documents developed by the AGDH and NACCHO/RACGP presented the highest methodological rigour, were developed using an evidence-based methodology and were recommended for use in clinical practice. The content of recommendations was relatively consistent but differed in scope and level of information. Further research could centre on adapting existing antenatal oral healthcare CPGs and consensus statements to local contexts. More high-quality studies examining interventions within antenatal oral healthcare are needed to support development of recommendations.
Supporting information
S1 Appendix. Detailed search strategy and results.
https://doi.org/10.1371/journal.pone.0263444.s001
(DOCX)
S2 Appendix. Recommendation extraction forms of included guidance documents.
https://doi.org/10.1371/journal.pone.0263444.s002
(DOCX)
S1 Table. List of organisations for economic co-operation and development member countries.
As of 10.2020.
https://doi.org/10.1371/journal.pone.0263444.s003
(DOCX)
S2 Table. Grading of recommendations in evidence-based guidelines (n = 2).
https://doi.org/10.1371/journal.pone.0263444.s004
(DOCX)
S1 File. List of relevant professional society websites.
https://doi.org/10.1371/journal.pone.0263444.s006
(DOCX)
References
- 1.
World Dental Federation. Oral Health Worldwide: A report by FDI World Dental Federation. Geneva: FDI World Dental Federation; 2015.
- 2. Daalderop LA, Wieland BV, Tomsin K, Reyes L, Kramer BW, Vanterpool SF, et al. Periodontal disease and pregnancy outcomes: Overview of systematic reviews. JDR Clin Trans Res. 2017;3(1):10–27. pmid:30370334
- 3. Finlayson TL, Gupta A, Ramos-Gomez FJ. Prenatal maternal factors, intergenerational transmission of disease, and child oral health outcomes. Dent Clin North Am. 2017;61(3):483–518. pmid:28577633
- 4.
United Nations. Transforming Our World: The 2030 Agenda for Sustainable Development 2015 [cited 2021 Jan 5]. https://sustainabledevelopment.un.org/post2015/transformingourworld.
- 5. George A, Kong AC, Villarosa A, Duff M, Sheehan A, Burns E, et al. Implementing and evaluating the effectiveness of an oral health module for the bachelor of midwifery program at an Australian university. Nurse Educ Today. 2020;90:104457. pmid:32388200
- 6. George A, Dahlen HG, Blinkhorn A, Ajwani S, Bhole S, Ellis S, et al. Evaluation of a midwifery initiated oral health-dental service program to improve oral health and birth outcomes for pregnant women: A multi-centre randomised controlled trial. Int J Nurs Stud. 2018;82:49–57. pmid:29605753
- 7.
Health Resources and Services Administration. Integration of Oral Health and Primary Care Practice. Rockville: US Department of Health and Human Services; 2014.
- 8. Azofeifa A, Yeung LF, Alverson CJ, Beltrán-Aguilar E. Oral health conditions and dental visits among pregnant and nonpregnant women of childbearing age in the United States, National Health and Nutrition Examination Survey, 1999–2004. Prev Chronic Dis. 2014;11:163. pmid:25232750
- 9.
Institute of Medicine (US), Committee on Standards for Developing Trustworthy Clinical Practice Guidelines, Graham R, Mancher M, Wolman DM, Greenfield S, et al. Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Press; 2011.
- 10.
Mosby’s Medical Dictionary. 10th ed: Elsevier; 2016.
- 11. Adeniyi A, Donnelly L, Janssen P, Jevitt C, von Bergman H, Brondani M. A qualitative study of health care providers’ views on integrating oral health into prenatal care. JDR Clin Trans Res. 2020 Sep 30: 2380084420961998. pmid:32996370
- 12. George A, Dahlen HG, Reath J, Ajwani S, Bhole S, Korda A, et al. What do antenatal care providers understand and do about oral health care during pregnancy: a cross-sectional survey in New South Wales, Australia. BMC Pregnancy Childbirth. 2016;16(1):382. pmid:27903257
- 13. Wilson A, Hoang H, Bridgman H, Bettiol S, Crocombe L. Factors influencing the provision of oral health care practices by antenatal care providers: A systematic review. J Womens Health (Larchmt). 2021 May 6. pmid:33960834
- 14. Francke AL, Smit MC, de Veer AJ, Mistiaen P. Factors influencing the implementation of clinical guidelines for health care professionals: a systematic meta-review. BMC Med Inform Decis Mak. 2008;8:38. pmid:18789150
- 15. Hoffmann-Eßer W, Siering U, Neugebauer EAM, Brockhaus AC, McGauran N, Eikermann M. Guideline appraisal with AGREE II: online survey of the potential influence of AGREE II items on overall assessment of guideline quality and recommendation for use. BMC Health Serv Res. 2018;18(1):143. pmid:29482555
- 16. Brouwers M, Kho M, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: Advancing guideline development, reporting and evaluation in healthcare. CMAJ. 2010;182(18):E839–42. pmid:20603348
- 17. Watine J, Friedberg B, Nagy E, Onody R, Oosterhuis W, Bunting PS, et al. Conflict between guideline methodologic quality and recommendation validity: A potential problem for practitioners. Clin Chem. 2006;52(1):65–72. pmid:16391328
- 18. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1. pmid:25554246
- 19. Moher D, Liberati A, Tetzlaff J, Altman DG, Group. TP. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med. 2009;6:e1000097. pmid:19621072
- 20. Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J. 2009;26(2):91–108. pmid:19490148
- 21. Coates D, Homer C, Wilson A, Deady L, Mason E, Foureur M, et al. Induction of labour indications and timing: A systematic analysis of clinical guidelines. Women Birth. 2020;33(3):219–30. pmid:31285166
- 22.
Australian Government Department of Health. Clinical Practice Guidelines: Pregnancy Care. Canberra: Australian Government; 2020.
- 23. Zhang M, Zhou Y, Zhong J, Wang K, Ding Y, Li L, et al. Quality appraisal of gestational diabetes mellitus guidelines with AGREE II: A systematic review. BMC Pregnancy Childbirth. 2019;19(1):478. pmid:31805878
- 24. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. pmid:32100154
- 25. Wang Y, Luo Q, Li Y, Wang H, Deng S, Wei S, et al. Quality Assessment of Clinical Practice Guidelines on the Treatment of Hepatocellular Carcinoma or Metastatic Liver Cancer. PLoS One. 2014;9(8):e103939. pmid:25105961
- 26. Landis JR, Koch GG. The Measurement of Observer Agreement for Categorical Data. Biom. 1977;33(1):159–74. pmid:843571
- 27.
Dental Health Services Victoria. Pregnancy and oral health: Caring for the oral health of your pregnant patients 2013 [cited 2020 October 19]. https://www.dhsv.org.au/__data/assets/pdf_file/0004/35293/GP-Fact-Sheet-_Oral-Health-and-Pregnancy.pdf.
- 28.
Oral Health Services Tasmania. Understanding pregnancy and oral health: Evidence based information for health professionals 2019 [cited 2020 October 19]. https://www.health.tas.gov.au/__data/assets/pdf_file/0018/381240/029_Health_Professionals_Information_Sheet_2019.pdf.
- 29.
National Health Service Health Scotland. Maternal and Early Years for Early Years Workers: How Can I Help Address Oral Health Problems in Pregnancy? 2013 [cited 2020 Oct 20]. http://www.maternal-and-early-years.org.uk/how-can-i-help-address-oral-health-problems-in-pregnancy.
- 30.
Ohio Department of Health. Oral health and pregnancy—Fact sheet for health care providers 2018 [cited 2020 October 19]. https://odh.ohio.gov/wps/wcm/connect/gov/ecafa826-9872-4734-9869-d96eec0120a0/Pregnancy+and+Oral+Health+Fact+Sheet+for+Healthcare+Providers.pdf?MOD=AJPERES&CONVERT_TO=%20url&CACHEID=ROOTWORKSPACE.Z18_M1HGGIK0N0JO00QO9DDDDM3000-ecafa826-9872-4734-9869-d96eec0120a0-mZDZ8nK.
- 31.
Maryland Department of Health. Oral health care during pregnancy: At-a-glance reference guide 2012 [cited 2020 October 19]. https://phpa.health.maryland.gov/oralhealth/docs1/pregnant_women_reference_guide.pdf.
- 32. American College of Obstetricians and Gynecologists. Committee Opinion No. 569: Oral health care during pregnancy and through the lifespan. Obstet Gynecol. 2013;122(2):417–22. pmid:23969828
- 33.
New York State Department of Health. Oral Health Care during Pregnancy and Early Childhood: Practice Guidelines. New York: New York State Department of Health; 2006.
- 34.
New Zealand College of Midwives. Consensus statement: Oral health guidelines 2008 [cited 2020 October 19]. https://www.midwife.org.nz/wp-content/uploads/2019/05/Oral-Health-Guidelines.pdf.
- 35.
Family Health Bureau, Ministry of Health Sri Lanka. Oral Health Care During Pregnancy: Practice Guidelines. Colombo: Family Health Bureau; 2009.
- 36.
The Management of Pregnancy Work Group. VA/DoD Clinical Practice Guideline for the Management of Pregnancy. Washington: US Department of Veteran Affairs, Department of Defense; 2018.
- 37.
Maryland Department of Health. Oral Health Care During Pregnancy: Practice Guidance for Maryland’s Prenatal and Dental Providers. Baltimore: Maryland Department of Health, Office of Oral Health; 2019.
- 38.
Massachusetts Department of Public Health. Oral Health Practice Guidelines for Pregnancy and Early Childhood. Boston: Massachusetts Department of Public Health; 2016.
- 39.
Michigan Department of Health and Human Services. During Pregnancy, the Mouth Matters: A Guide to Michigan Perinatal Oral Health. Lansing: Michigan Department of Health and Human Services; 2015.
- 40.
North Carolina Public Health. Oral Health Care During Pregnancy: North Carolina Collaborative Practice Framework. Raleigh: North Carolina Department of Health and Human Services; 2018.
- 41.
Saskatchewan Prevention Institute. Improving the Oral Health of Pregnant Women and Young Children: Opportunities for Oral Care and Prenatal Care Providers. A Saskatchewan Consensus Document. Saskatchewan: Saskatchewan Prevention Institute; 2014.
- 42.
South Carolina Oral Health Coalition. Oral Health Care for Pregnant Women. Columbia: South Carolina Department of Health and Environmental Control; 2017.
- 43.
Texas Department of State and Health Services. Oral Health Care During Pregnancy: Practice Guidance for Texas Prenatal and Dental Providers. Austin: Department of State Health Services, Oral Health Improvement Program; 2019.
- 44.
Virginia Department of Health. Oral Health During Pregnancy: Practice Guidance for Virginia’s Prenatal and Dental Providers. Richmond: Virginia Department of Health, Dental Health Program; 2019.
- 45. American Academy of Pediatric Dentistry. Guideline on Perinatal Oral Health Care. The Reference Manual of Pediatric Dentistry. 2011;36(6):14–5.
- 46.
National Aboriginal Community Controlled Health Organisation and The Royal Australian College of General Practitioners. National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. East Melbourne: RACGP; 2018.
- 47.
American Academy of Pediatric Dentistry. Guidelines on Perinatal and Infant Oral Health Care. The Reference Manual of Pediatric Dentistry. 2016:252–6.
- 48. California Dental Association Foundation. Oral health during pregnancy and early childhood: evidence-based guidelines for health professionals. J Calif Dent Assoc. 2010;38(6):391–440. pmid:20645626
- 49.
Oral Health Care During Pregnancy Expert Workgroup. Oral Health Care During Pregnancy: A National Consensus Statement. Washington: National Maternal and Childhood Oral Health Resource Center; 2012.
- 50.
Perinatal Services British Columbia. Provincial Perinatal Guidelines: Population and Public Health Prenatal Care Pathway. Vancouver: Perinatal Services BC; 2014.
- 51.
European Federation of Periodontology. Guidelines for Non-Dentistry Health Professionals. United Kingdom: EFP; 2020.
- 52.
National Health and Medical Research Council. Guidelines for Guidelines Handbook [cited 2021 Jan 5]. www.nhmrc.gov.au/guidelinesforguidelines.
- 53. Alonso-Coello P, Irfan A, Solà I, Gich I, Delgado-Noguera M, Rigau D, et al. The quality of clinical practice guidelines over the last two decades: A systematic review of guideline appraisal studies. Qual Saf Health Care. 2010;19(6):e58. pmid:21127089
- 54. Vamos CA, Thompson EL, Avendano M, Daley EM, Quinonez RB, Boggess K. Oral health promotion interventions during pregnancy: A systematic review. Community Dent Oral Epidemiol. 2015;43(5):385–96. pmid:25959402
- 55. George A, Shamim S, Johnson M, Dahlen H, Ajwani S, Bhole S, et al. How do dental and prenatal care practitioners perceive dental care during pregnancy? Current evidence and implications. Birth. 2012;39(3):238–47. pmid:23281906
- 56. Abou El Fadl R, Blair M, Hassounah S. Integrating maternal and children’s oral health promotion into nursing and midwifery practice: A systematic review. PLoS One. 2016;11(11):e0166760. pmid:27880790
- 57. Villarosa AC, Villarosa AR, Salamonson Y, Ramjan LM, Sousa MS, Srinivas R, et al. The role of indigenous health workers in promoting oral health during pregnancy: A scoping review. BMC Public Health. 2018;18(1):381. pmid:29558933
- 58. Fervers B, Burgers JS, Voellinger R, Brouwers M, Browman GP, Graham ID, et al. Guideline adaptation: An approach to enhance efficiency in guideline development and improve utilisation. BMJ Qual Saf. 2011;20(3):228. pmid:21209134
- 59. Wang Z, Norris SL, Bero L. The advantages and limitations of guideline adaptation frameworks. Implement Sci. 2018;13(1):72. pmid:29843737
- 60. Amer YS, Elzalabany MM, Omar TI, Ibrahim AG, Dowidar NL. The ’Adapted ADAPTE’: an approach to improve utilization of the ADAPTE guideline adaptation resource toolkit in the Alexandria Center for Evidence-Based Clinical Practice Guidelines. J Eval Clin Pract. 2015;21(6):1095–106. pmid:26662728
- 61. Connell G, Weis CA, Hollman H, Nissen K, Verville L, Cancelliere C. Physical activity throughout pregnancy: guideline critical appraisal and implementation tool. J Can Chiropr Assoc. 2021;65(1):50–8. pmid:34035540
- 62. Mustafa ST, Hofer OJ, Harding JE, Wall CR, Crowther CA. Dietary recommendations for women with gestational diabetes mellitus: a systematic review of clinical practice guidelines. Nutr Rev. 2021;79(9):988–1021. pmid:33677540
- 63. Ee C, Levett K, Smith C, Armour M, Dahlen HG, Chopra P, et al. Complementary medicines and therapies in clinical guidelines on pregnancy care: A systematic review. Women Birth. 2021. pmid:34419374
- 64. Ninan K, Morfaw F, Ali R, McDonald S. Prevention of preeclampsia with aspirin: a systematic review of guidelines and evaluation of recommendation evidence. J Obstet Gynaecol Can. 2021;43(5):676.
- 65. Williams G, Singer BJ, Ashford S, Brian H, Hastings-Ison T, Fheodoroff K, et al. A synthesis and appraisal of clinical practice guidelines, consensus statements and Cochrane systematic reviews for the management of focal spasticity in adults and children. Disabil Rehabil. 2020:1–11. pmid:32503375
- 66. Jacobs C, Graham ID, Makarski J, Chassé M, Fergusson D, Hutton B, et al. Clinical practice guidelines and consensus statements in oncology—An assessment of their methodological quality. PLoS One. 2014;9(10):e110469–e. pmid:25329669