Expanding the Grading of Recommendations Assessment, Development, and Evaluation (Ex-GRADE) for Evidence-Based Clinical Recommendations: Validation Study

Linda Phi1, Reem Ajaj1, 2, Manisha H Ramchandani1, Xenia MC Brant1, 3, Oluwadayo Oluwadara1, Olga Polinovsky1, David Moradi1, Andre Barkhordarian1, Pathu Sriphanlop1, Margaret Ong1, Amy Giroux1, Justin Lee1, Muniza Siddiqui1, Nora Ghodousi1, Francesco Chiappelli1, 2, *
1 Division of Oral Biology & Medicine, UCLA School of Dentistry, Los Angeles, CA, USA
2 Division of Associated Clinical Specialties, UCLA, School of Dentistry, Los Angeles, CA, USA
3 Department of Endodontics and Research and Education Center, CEO IPSEMG, UFMG, Belo Horizonte MG, Brazil

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© Phi et al.; Licensee Bentham Open.

open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

* Address correspondence to this author at the Evidence-Based Study Group, Evidence-Based Decisions-Practice-Based Research Network (EBDPBRN. org) and Division of Oral Biology & Medicine, CHS 63-090, UCLA School of Dentistry, CHS 63-090, Los Angeles, CA 90095-1668; Tel: 310-794-6625; Fax: 310-794-7109; E-mail:


Clinicians use general practice guidelines as a source of support for their intervention, but how much confidence should they place on these recommendations? How much confidence should patients place on these recommendations? Various instruments are available to assess the quality of evidence of research, such as the revised Wong scale (R-Wong) which examines the quality of research design, methodology and data analysis, and the revision of the assessment of multiple systematic reviews (R-AMSTAR), which examines the quality of systematic reviews.

The Grading of Recommendation Assessment, Development, and Evaluation (GRADE) Working Group developed an instrument called the GRADE system in order to grade the quality of the evidence in studies and to evaluate the strength of recommendation of the intervention that is proposed in the published article. The GRADE looks at four factors to determine the quality of the evidence: study design, study quality, consistency, and directness. After combining the four components and assessing the grade of the evidence, the strength of recommendation of the intervention is established. The GRADE, however, only makes a qualitative assessment of the evidence and does not generate quantifiable data.

In this study, we have quantified both the grading of the quality of evidence and also the strength of recommendation of the original GRADE, hence expanding the GRADE. This expansion of the GRADE (Ex-GRADE) permits the creation of a new instrument that can produce tangible data and possibly bridge the gap between evidence-based research and evidence-based clinical practice.

Keywords: GRADE, AMSTAR, Revised AMSTAR, Wong scale, Systematic Review, Vaccination and Autism, Vaccination, Whitening, Bleaching, In-office Whitening, In-office Beaching, CPAP versus Oral Appliance, CPA, Sleep Apnea, Hypoxia, Evidence-Based Decision Making, Strength of Clinical Relevance, Quality of Evidence, Strength of Recommendation, Clinical Significance, Evidence-Based Clinical Practice, Evidence-Based Dentistry, Evidence-Based Medicine.