Methodology

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About this guidance

Guidance development methodology

SDCEP uses a methodology for guidance development that aims to be transparent, systematic and to adhere as far as possible to international standards set out by the AGREE (Appraisal of Guidelines for Research and Evaluation) Collaboration (www.agreetrust.org). Details of the guidance development methodology used by SDCEP to produce this guidance are available at www.sdcep.org.uk/how-we-work/guidance-development-process.

SDCEP first published guidance entitled Prevention and Treatment of Periodontal Diseases in Primary Care in 2014. A full review of the topic was initiated in 2022 and this updated second edition of the guidance was developed following the NICE accredited methodology described in the SDCEP Guidance Development Process Manual (Version 2.0, February 2019). The specific details of the updating process is documented in the Prevention and Treatment of Periodontal Diseases in Primary Care Methodology (2024).

Prior to updating this guidance, SDCEP’s partner programme TRiaDS conducted two surveys to ascertain dentists’ attitudes towards the guidance and to obtain feedback on how they felt it could be improved. The findings of these surveys were considered during the development of the updated guidance.

Scope

The scope and aims of the guidance do not vary substantially from those of the first edition. The GDG agreed that the twenty clinical questions from the first edition of the guidance were applicable for the guidance update, with some edits made for clarity. Eight new clinical questions related to risk assessment and treatment planning, periodontitis and systemic conditions, management of furcations, periodontal maintenance, and management of patients with dental implants were added. The clinical questions covered by the guidance are listed below:

In patients accessing dental services, does conducting/recording a structured periodontal risk assessment, compared to no structured periodontal risk assessment, aid in the prediction of long-term outcomes of periodontal disease status such as attachment level, bone loss and tooth loss?
Does conducting/recording a structured periodontal risk assessment, compared to no structured periodontal risk assessment, influence the treatment (e.g. targeted risk factor control, oral hygiene instruction, individual recall intervals) provided by the dental team?
In patients who are at increased risk of periodontitis, does receiving information about their periodontal risk result in behaviour changes to reduce this risk, such as smoking cessation or improved oral hygiene?
In the general population, what are the self-care oral hygiene practices that constitute an effective regime to prevent plaque-induced gingivitis and periodontitis?
In patients accessing dental services, does the provision of oral hygiene instruction, compared to no instruction, result in improved clinical outcomes, such as plaque levels and gingival health?
In the general population, are rechargeable powered toothbrushes, compared to manual toothbrushes, more effective at reducing levels of plaque and gingivitis?
In the general population, is interdental cleaning in addition to toothbrushing, compared to toothbrushing alone, more effective at reducing plaque levels and gingivitis?
In the general population, are toothpastes that contain fluoride and another active ingredient, compared to toothpastes which only contain fluoride, more effective at reducing plaque levels and gingivitis?
In patients with a diagnosis of periodontal health, is supragingival professional mechanical plaque removal (PMPR) alone, compared to no supragingival PMPR, effective in preventing periodontal diseases (gingivitis/periodontitis)?
In patients with a diagnosis of gingivitis, is supragingival professional mechanical plaque removal (PMPR) and oral hygiene instruction (OHI) compared to no supragingival PMPR and OHI, effective in improving gingival health?
In patients with a diagnosis of periodontitis who also have a specific medical condition, does control of their periodontitis improve the control of their medical condition?
In patients with a diagnosis of periodontitis who are pregnant, does control of their periodontitis improve their pregnancy outcomes?
In patients with a diagnosis of periodontitis, is subgingival professional mechanical plaque removal (PMPR), compared to supragingival PMPR alone or no treatment, effective in stabilising their disease?
In patients with a diagnosis of periodontitis, is power driven professional mechanical plaque removal (PMPR), compared to hand PMPR, more effective in stabilising their disease?
In patients with a diagnosis of periodontitis, is full mouth professional mechanical plaque removal (PMPR) more effective than quadrant PMPR in stabilising their disease?
In patients with a diagnosis of periodontitis who have furcation involvement of multi-rooted teeth, is nonsurgical periodontal treatment, compared to surgical periodontal treatment, effective in promoting long-term tooth retention?
In patients with a diagnosis of periodontitis, does the use of local antimicrobial therapy (antiseptics or antibiotics), as an adjunct to professional mechanical plaque removal (PMPR), compared to PMPR alone, result in improvements in clinical parameters such as probing depth and clinical attachment level?
In patients with a diagnosis of periodontitis, does the use of systemic antibiotic therapy as an adjunct to professional mechanical plaque removal (PMPR), compared to PMPR alone, result in improvements in clinical outcomes such as probing depth and clinical attachment level?
In patients with a diagnosis of periodontitis, does the use of adjunctive host modulation therapy in conjunction with professional mechanical plaque removal (PMPR), compared to PMPR alone, result in improvements in clinical outcomes such as probing depth and clinical attachment level?
In patients with a diagnosis of periodontitis, what treatments are effective in reducing dentine sensitivity following professional mechanical plaque removal (PMPR)?
In a patient with a diagnosis of periodontitis, does supportive periodontal therapy, compared to no supportive periodontal therapy, maintain stability of the patient’s disease status?
In a patient with a diagnosis of periodontitis who is undergoing supportive periodontal therapy (SPT), is there evidence to inform which SPT care regime is most effective at maintaining the stabilisation of the patient’s disease status?
Is the risk of peri-implant disease higher in patients with a diagnosis of periodontitis before implant placement compared to patients with no previous periodontal disease?
In patients with a diagnosis of periodontitis who are considering dental implant(s), what interventions carried out before implant placement, compared to no interventions, reduce the risk of peri-implant disease?
In patients with dental implants, does implant-specific supportive therapy, compared to no therapy, reduce the risk of peri-implant disease?
In patients with peri-implant mucositis, is there evidence to support a specific intervention to recover peri-implant tissue health?
In patients with peri-implantitis, is there evidence to support a specific intervention to recover peri-implant tissue health?
In patients with peri-implant mucositis or peri-implantitis, does the use of antibiotic therapy as an adjunct to peri-implant therapy, compared to peri-implant therapy alone, result in improved peri-implant tissue health?

Evidence sources

For this guidance update, the BSP implementation of European S3 – level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice (BSP-S3) and the Delivering Better Oral Health toolkit (DBOH) were used as the basis for the SDCEP guidance recommendations.^{6, 7} The methodological quality of these guidelines was assessed using the AGREE II instrument (www.agreetrust.org). A summary of the evidence cited by these core guidelines, including an assessment of the evidence certainty, was presented to the GDG to inform and facilitate the review and updating and/or development of the recommendations in the guidance. This was supplemented by other relevant evidence identified. The process for the review/development of the recommendations followed the GRADE approach, with considered judgements based on the certainty of evidence, balance of risks, values and preferences, and the acceptability and feasibility of the treatment options. Decisions on the wording of the recommendations and their strength were reached by group consensus.

For clinical questions not covered by the BSP-S3 or DBOH guidelines, comprehensive literature searches of online databases, including MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, Epistemonikos and Database of Abstracts of Reviews of Effects, were performed as described below. Filters for systematic reviews were applied.

Questions(s)	Date of search	Databases and date limits
1-3	7 June 2022	Cochrane Database of Systematic Reviews (Issue 6, 2022); MEDLINE Ovid (1946 to 7 June 2022); EMBASE Ovid (1980 to 7 June 2022); Epistemonikos (whole database to 7 June 2022); Centre for Reviews and Dissemination database (1994 to March 2015)
16	8 June 2022	Cochrane Database of Systematic Reviews (Issue 6, 2022); MEDLINE Ovid (1946 to 8 June 2022); EMBASE Ovid (1980 to 8 June 2022); Epistemonikos (whole database to 8 June 2022); Centre for Reviews and Dissemination database (1994 to March 2015)
20	11 July 2022	Cochrane Database of Systematic Reviews (Issue 7, 2022); MEDLINE Ovid (1946 to 11 July 2022); EMBASE Ovid (1980 to 11 July 2022); Epistemonikos (whole database to 11 July 2022); Centre for Reviews and Dissemination database (1994 to March 2015)
24	18 November 2022	Cochrane Database of Systematic Reviews (Limit 2019-2022); MEDLINE Ovid (1946 to 17 November 2022); EMBASE Ovid (1974 to 17 Nov 2022); Epistemonikos (whole database to 17 Nov 2022); TRIP (Limit 2019-2022); Google Scholar; Centre for Reviews and Dissemination (whole database)
25	18 November 2022	Cochrane Database of Systematic Reviews (Limit 2019-2022); MEDLINE Ovid (1946 to 15 Nov 2022); EMBASE Ovid (1974 to 15 Nov 2022); Epistemonikos (whole database to 17 Nov 2022); TRIP (Limit 2019-2022); Google Scholar
26-28	6 January 2023	Cochrane Database of Systematic Reviews (Limit 2013-2023); MEDLINE Ovid (1946 to 5 Jan 2023); EMBASE Ovid (1974 to 5 Jan 2023); Epistemonikos (Limit 2013-2023); TRIP (Limit 2013-2023); Google Scholar (Limit 2013-2023); Centre for Reviews and Dissemination database (Limit 2013-2023);

Further details of these searches is provided in the Prevention and Treatment of Periodontal Diseases in Primary Care Methodology (2024).

Potentially eligible articles were identified independently by at least two reviewers from the list of titles and abstracts retrieved. A third reviewer was available to resolve any disagreement. An article was considered potentially eligible if it met both of the following criteria:

The article was a systematic review or a guideline. An article would be included as a systematic review, if it included a methods section, a search of one or more electronic databases and details of included studies. An article was included as a guideline if it made recommendations for clinical practice.
The article was relevant to the clinical question(s).

Additional manual searching of guideline repositories and other resources, and follow up of citations from relevant articles found through the systematic searching, was carried out. Other sources of evidence identified by GDG members were considered, taking relevance and methodological quality into account.

Evidence appraisal

Eligible systematic reviews and guidelines were appraised for their quality of development, evidence base and applicability to the clinical questions, with precedence given to the most recent articles. Systematic reviews were assessed for methodological quality using criteria informed by AMSTAR,¹³⁶ relevant information was extracted, and the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach used to assess and rate evidence certainty.

The synthesised evidence for each of these clinical questions was summarised and distributed to the GDG to inform and facilitate the development of the recommendations in the guidance as described above.

Consultation and peer review

Open consultation and targeted external peer review of a draft of the updated guidance was carried out in July and August 2023. End-users of the guidance, dentists, dental therapists and dental hygienists in Scotland, were notified that the consultation draft of the guidance was available on the SDCEP website and invited to comment. Individuals and bodies with specific interest in the management of patients with periodontal diseases, those involved in the organisation of dental services and education in the UK and patient interest groups were also informed of the consultation and invited to comment.

Targeted external peer review is a process that occurs in parallel with open consultation and is primarily a means of additional quality assurance. Peer reviewers, representing a range of expertise and experience in relevant dental fields and individuals with knowledge of guidance methodology, were asked to comment on the applicability and suitability of the guidance to the intended audience (mainly primary dental care in Scotland) and to indicate whether they thought the process used to develop the guidance was satisfactory. They were also asked to provide any other relevant feedback.

All consultee and peer reviewer comments were considered, and the guidance amended accordingly prior to publication.

Patient feedback on the content of patient information leaflets was obtained via a focus group.

Implementation

During the development of the first edition of the guidance, potential barriers to the implementation of this guidance were identified. These were reconsidered during the guidance updating. An Implementation Summary for this guidance is available. An assessment of the potential impact of this guidance on equality target groups was also conducted.

Sustainability

The environmental impact of the recommendations and advice was considered during the development of this guidance update. Details of the environmental sustainability considerations for this guidance are provided in a separate methodology document.

Updating

For this guidance, a further review of the topic will take place five years after publication of this edition, and if there are significant changes the guidance will be updated accordingly.