Clinical audit of orthodontic chart documentation by dental undergraduates.

INTRODUCTION: Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through the systematic review of care against explicit criteria and the implementation of change. The objective of this audit was to evaluate the quality of orthodontic chart documentation by dental undergraduates against established guidelines. MATERIALS AND METHODS: An audit checklist with 13 criteria for good documentation was adapted from guidelines proposed by the American Association of Orthodontists and British Orthodontic Society. Orthodontic chart documentation in 103 removable appliance therapy patients under 4th and 5th year dental undergraduates' care was retrieved from the electronic record of the University dental clinic and audited. The audit exercise explored in detail the thirteen criteria for good documentation and eight assessment attributes of the first criterion, namely, basic orthodontic examination. The level of compliance was measured as the percentage records meeting the criteria. The data were statistically analysed using SPSS 26.0 (SPSS, Inc., Chicago, IL, USA). RESULTS: There was no complete compliance for any of the criteria. Thirty-five (33.9%) patient charts reported basic orthodontic examination documentation adequately. Compliance was the highest for documentation of treatment modality (77.6%), appliance delivery encounters (77.6%), and appliance adjustment appointments (83.5%). About 51.4% of the 68 patient charts (treatment of 35 patients of the total 103 were in the progress stage) stated adequately the outcome of treatment. Only 22% of the 68 patient charts had the details for retention protocol. There was statistically significant difference in chart documentation between male and female students for basic orthodontic assessment and appliance delivery and patient instructions attributes. CONCLUSION: The clinical audit demonstrated poor compliance with the criteria for orthodontic chart documentation. The audit should be repeated after the provision of learning opportunities and self-critical analysis.

Shade selection practices amongst clinical dental students in South Western Nigeria

Objective: Shade selection is crucial in satisfying aesthetic demands of patients during cosmetic dental treatment. It is important to nurture and evaluate this act in students as future dental professionals. This study aimed to evaluate the understanding and practice of tooth shade matching amongst dental students. Methods: A descriptive cross-sectional study was carried out in South-Western Nigeria. A structured, self-administered questionnaire was given to clinical dental students to garner information on socio-demographics, knowledge and practice of shade selection. The resulting data were statistically tested using chi-square with p-value ≤ 0.05 indicating significant level. Results: There was 76.5% response rate to the questionnaires with the male subjects accounting for 52.3%. The mean age of participants was 24.2 ± 2.4 years. Majority (40.9%) did not know the ideal time required for shade selection. Most (57.9%) students used visual/manual method in shade selection but 63.6% of these did not know the name of the shade guide used. Majority (80.8%) select the shade before commencing restorative procedure. Less than half (36.4%) of participants performed tooth shade matching in 3 segments (from incisal-third to cervical-third) while 54.5% considered tooth shade as a single uniform colour. Most students, 67.4% had a fair knowledge of shade matching while 13.6% practiced good shade matching technique for restorations/prosthesis. There was a statistically significant difference (p=0.022) between shade selection practice and the clinical training levels of students. Conclusion: The dental students had a fair knowledge about the principles of shade selection but lack the clinical know-how

Clinical audit training improves undergraduates' performance in root canal therapy.

AIM: To evaluate the effectiveness of clinical audit-feedback cycle as an educational tool in improving the technical quality of root canal therapy (RCT) and compliance with record keeping performed by dental undergraduates. METHODS: Clinical audit learning was introduced in Year 3 of a 5-year curriculum for dental undergraduates. During classroom activities, students were briefed on clinical audit, selected their audit topics in groups of 5 or 6 students, and prepared and presented their audit protocols. One chosen topic was RCT, in which 3 different cohorts of Year 3 students conducted retrospective audits of patients' records in 2012, 2014 and 2015 for their compliance with recommended record keeping criteria and their performance in RCT. Students were trained by and calibrated against an endodontist (κ ≥ 0.8). After each audit, the findings were reported in class, and recommendations were made for improvement in performance of RCT and record keeping. Students' compliance with published guidelines was presented and their RCT performances in each year were compared using the chi-square test. RESULTS: Overall compliance with of record keeping guidelines was 44.1% in 2012, 79.6% in 2014 and 94.6% in 2015 (P = .001). In the 2012 audit, acceptable extension, condensation and the absence of mishap were observed in 72.4, 75.7% and 91.5%; in the 2014 audit, 95.1%, 64.8% and 51.4%; and in 2015 audit, 96.4%, 82.1% and 92.8% of cases, respectively. In 2015, 76.8% of root canal fillings met all 3 technical quality criteria when compared to 48.6% in 2014 and 44.7% in 2012 (P = .001). CONCLUSION: Clinical audit-feedback cycle is an effective educational tool for improving dental undergraduates' compliance with record keeping and performance in the technical quality of RCT.

A Retrospective Audit of Dental Treatment Provided to Special Needs Patients under General Anesthesia During a Ten-Year Period.

OBJECTIVE: The purpose of this study was to perform a comprehensive audit of dental treatment provided to special needs patients (SNP) under general anesthesia (GA) over a ten-year period. STUDY DESIGN: Special needs patients who received dental treatment under GA as an in-patient at Queen Mary Hospital, Hong Kong SAR during the time period January 2002 and December 2011 were included in the study. The study population was divided into three groups, based on age (<6years, 6-12 years, >12 years). One-way ANOVA was used to evaluate the effect of "age group" on duration of treatment, post-recovery time, treatment procedures and utilization of different restorative materials. Kappa statistics were used for intra-examiner reliability. RESULTS: A total of 275 patients (174 males and 101 females) were included in the study. The mean age of the patients at the time they received GA was 12.37±10.18 years. Dental procedures performed were mostly restorative in nature (47%). The >12 years group had significantly shorter treatment duration (p<0.05). No significant difference in post-operative recovery time was observed among the three age groups (p>0.05). The <6 years group received significantly less preventive, but more restorative procedures (p<0.05). Significantly fewer extractions were performed in the 6-12 years group (p<0.05). The use of composite restorations was significantly higher in the <6 years group; while amalgam restorations were more frequently used in the >12 years group (P<0.05). Stainless steel crowns were more frequently employed in SNP under 12 years of age (p<0.05). Intra-examiner reliability was good (k=0.94). CONCLUSIONS: Most of the dental procedures performed under GA on SNP were restorative procedures. For children less than 6 years of age, had longer treatment time under GA. Composite restorations and stainless steel crowns were more frequently used in the primary dentition and amalgam restorations were more frequently employed in the permanent dentition.

Inaccurate Dental Charting in an Audit of 1128 General Dental Practice Records.

Fourteen dentists at different practices in the UK assessed the dental charts of 1128 patients who were new to the dentist but not new to the practice; 44% of the dental charts were found to be inaccurate. Inaccuracy of the individual practice-based charts ranged between 16% for the best performing practices to 83% for the worst: 5% of dental charts had too many teeth charted and 5% had too few teeth charted; 13% of charts had missed amalgam restorations and 18% had missed tooth-coloured restorations; 5% of charts had amalgam restorations recorded but with the surfaces incorrect (eg an MO restoration charted but a DO restoration actually present); 9% of charts had tooth-coloured restoration surfaces incorrectly recorded. For 7.5% of charts, amalgams were charted but not actually present. Other inaccuracies were also noted. The authors reinforce the requirements of the GDC, the advice of defence organizations, and the forensic importance of accurate dental charts. Clinical relevance: Dental charting forms part of the patient's dental records, and the GDC requires dentists to maintain complete and accurate dental records.

Compliance with the guide for commissioning oral surgery: an audit and discussion.

Introduction The Guide for commissioning oral surgery and oral medicine published by NHS England (2015) prescribes the level of complexity of oral surgery and oral medicine investigations and procedures to be carried out within NHS services. These are categorised as Level 1, Level 2, Level 3A and Level 3B. An audit was designed to ascertain the level of oral surgery procedures performed by clinicians of varying experience and qualification working in a large oral surgery department within a major teaching hospital.Materials and methods Two audit cycles were conducted on retrospective case notes and radiographic review of 100 patient records undergoing dental extractions within the Department of Oral Surgery at King's College Dental Hospital. The set gold standard was: '100% of Level 1 procedures should be performed by dental undergraduates or discharged back to the referring general dental practitioner'. Data were collected and analysed on a Microsoft Excel spreadsheet. The results of the first audit cycle were presented to all clinicians within the department in a formal meeting, recommendations were made and an action plan implemented prior to undertaking a second cycle.Results The first cycle revealed that 25% of Level 1 procedures met the set gold standard, with Level 2 practitioners performing the majority of Level 1 and Level 2 procedures. The second cycle showed a marked improvement, with 66% of Level 1 procedures meeting the set gold standard.Conclusion Our audit demonstrates that whilst we were able to achieve an improvement with the set gold standard, several barriers still remain to ensure that patients are treated by the appropriate level of clinician in a secondary care setting. We have used this audit as a foundation upon which to discuss the challenges faced in implementation of the commissioning framework within both primary and secondary dental care and strategies to overcome these challenges, which are likely to be encountered in any NHS care setting in which oral surgery procedures are performed.

Improving patient safety through a clinical audit spiral: prevention of wrong tooth extraction in orthodontics.

Introduction With an increasing demand to improve patient safety within the NHS, it is important to ensure that measures are undertaken to continually improve patient care. Wrong site surgery has been defined as a 'never event'. This article highlights the importance of preventing wrong tooth extraction within orthodontics through an audit spiral over five years investigating the accuracy and clarity of orthodontic extraction letters at the University Dental Hospital of Manchester.Aims To examine compliance with the standards for accuracy and clarity of extraction letters and the incidence of wrong tooth extractions, and to increase awareness of the errors that can occur with extraction letters and of the current guidelines.Method A retrospective audit was conducted examining extraction letters sent to clinicians outside the department.Results It can be seen there has been no occurrence of a wrong site tooth extraction. The initial audit highlighted issues in conformity, with it falling below expected standards. Cycle two generally demonstrated a further reduction in compliance. Cycle three appeared to result in an increase in levels of compliance. Cycles 4 and 5 have demonstrated gradual improvements. However, it is noteworthy that in all cycles the audit standards were still not achieved, with the exception of no incidences of the incorrect tooth being extracted.Conclusion This audit spiral demonstrates the importance of long term re-audit to aim to achieve excellence in clinical care. There has been a gradual increase in standards through each audit.

Improving the quality of endodontic record keeping through clinical audit.

Introduction Record keeping is an essential part of day-to-day practice and plays an important role in treatment, audit and dento-legal procedures. Creating effective endodontic records is challenging due to the scope of information required for comprehensive notes. Two audits were performed to assess the standards of endodontic record keeping by dentists in a restorative dentistry department and students on an endodontic MSc course.Methods Fifty sets of departmental records and 10 sets of student records were retrospectively evaluated against the European Society of Endodontology 2006 guidelines. Results of the first cycle of both audits were presented to departmental staff and MSc students, alongside an educational session. Additionally, departmental guidelines, consent leaflets and endodontic record keeping forms were developed. Both audits were repeated using the same number of records, thus completing both audit cycles.Results The most commonly absent records included consent, anaesthetic details, rubber dam method, working length reference point, irrigation details and obturation technique. Almost all areas of record keeping improved following the second audit cycle, with some areas reaching 100% compliance when record keeping forms were used. Statistically significant improvements were seen in 24 of the 29 areas in the departmental audit and 14 of the 29 areas in the MSc audit (P = 0.05).Conclusions Significant improvements in endodontic record keeping can be achieved through the provision of education, departmental guidelines, consent leaflets and endodontic record keeping forms.

Gestión del fracaso del tratamiento dental / Management of dental treatment failure

Desde la Bioética y empleando los principios de la calidad en salud y de la seguridad del paciente, se listan los diferentes argumentos que apoyan la necesidad de implementar de forma sólida los procedimientos de supervisión y auditoría interna en el centro dental para identificar, prevenir y manejar los diferentes niveles de fracaso que se dan en el ámbito terapéutico de la Odontología. (AU)

From bioethics and employing principles of quality in health and patients safety, different arguments are listed that support the need to solidly implement supervision and internal auditing procedures in the dental center to identify prevent and manage the different levels of failure that occur in the therapeutic field of dentistry. (AU)

The Effect of a Radiation Positioning Stent (RPS) in the Reduction of Radiation Dosage to the Opposing Jaw and Maintenance of Mouth opening after Radiation Therapy.

The effect of a radiation positioning stent (RPS) in radiation dosage reduction to the opposing jaw and maintenance of mouth opening was audited. 55 Head and Neck cancer patients who received radiotherapy were reviewed. Radiation dosages at similar points in the primary/opposing jaws were measured along with the mouth opening. Results showed a significant reduction in the radiation dosage to the opposing jaw in patients given the RPS. Mouth opening was generally maintained in patients given the RPS (77.7% improvement in mouth opening) compared to patients without RPS. Patients undergoing radiotherapy who had an RPS showed a significant reduction in radiation dosage to the opposing jaw and maintained their mouth opening in the short-term.

Prospective audit of postoperative instructions to patients undergoing root canal treatment in the DDUH and re-audit following introduction of a written patient information sheet.

STATEMENT OF THE PROBLEM: Concerns were expressed that postoperative written instructions following endodontic treatment are not available in the Dublin Dental University Hospital. MATERIALS AND METHODS: Data was collected in three phases: retrospective analysis of clinical notes for evidence of the delivery of postoperative instructions; a randomly distributed questionnaire to patients undergoing root canal treatment prior to the introduction of a written postoperative advice sheet; and, another survey following introduction of the advice sheet. RESULTS: Some 56% of patients' charts documented that postoperative advice was given. Analysis of phase two revealed that patients were not consistently informed of any key postoperative messages. In phase 3 analysis, the proposed benchmarks were met in four out of six categories. CONCLUSIONS: Postoperative advice after root canal treatment in the DDUH is both poorly recorded and inconsistently delivered. A combination of oral postoperative instructions and written postoperative advice provided the most effective delivery of patient information.

A Clinical Audit of Escorts' Awareness And Patients' Safety Following Intravenous Sedation In Adult Oral Surgery.

AIM: To evaluate current level of safety under the care of an escort following intravenous sedation, post-sedation arrangements and to identify potential risk levels. BACKGROUND: Information and post-sedation arrangements are important to patients'safety following surgery but although there is a general consensus over what is recommended for patients and their escorts, there is little, if any, literature on the escorts' awareness of sedation and accordance to post-sedation arrangement and recommendations. METHOD: Escorts of 113 consecutive patients treated in oral surgery under sedation (midazolam) completed a questionnaire composed of 27 questions divided into seven sections including demographics, awareness of sedation, source of information and post-operative arrangement. From the data collected, two scores were calculated representative of the escorts' Safety and Reliability. Data were then analysed by ANOVA. RESULTS: Safety scores were statistically correlated with instruction source while Reliability correlated to a wider variety of parameters including gender, age as well as information source. CONCLUSION: Provision of clear written information to escorts is recommended as likely to improve patients' safety. Assessment of escorts' Safety and Reliability could provide a means for improving quality and safety of sedation service.

The State of UK Dental Anaesthesia: Results From The NAP5 Activity Survey. A national survey by the 5th National Audit Project of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland.

The National Health Service anaesthesia annual activity (2013) was recently reported by the Fifth National Audit Program of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland. Within a large dataset were 620 dental cases. Here, we describe this data subset. The estimated annual dental caseload was 111,600:60% were children (< 16 y), 38.5% adults (16 - 65y) and 1.5% the elderly (> 65y). Almost all were elective day procedures (97%) and ASA 1 or 2 patients (95%).The most senior anaesthetist present was a Consultant in 82% and a non-career grade doctor in 14%.Virtually all (98%) cases were conducted during GA. Propofol was used to induce anaesthesia in almost all adults compared with 60% of children. Propofol maintenance was used in 5% of both children and adults. Almost all adults received an opioid (including remifentanil) compared with only 40% of children. Thirty one per cent of children had a GA for a dental procedure without either opioid or LA supplementation. Approximately 50% of adults and 16% of children received a tracheal tube: 20% of children needed only anaesthesia by face mask. These data show that anaesthetists almost always use general anaesthesia for dental procedures and this exposes difficulties in training of anaesthetists in sedation techniques. Dentists, however, are well known to use sedation when operating alone and our report provides encouragement for a comprehensive survey of dental sedation and anaesthesia practice in both NHS and non-NHS hospitals and clinics in the UK.

Short Report. Audit of Conscious Sedation Provision in a Salaried Dental Service.

Clinical audit is a tool that may be used to improve the quality of care and outcomes for patients in a health care setting as well as a mechanism for clinicians to reflect on their performance. The audit described in this short report involved the collection and analysis of data related to the administration of 1,756 conscious sedations, categorised as standard techniques, by clinicians employed by an NHS Trust-based dental service during the year 2014. Data collected included gender, age and medical status of subject, the type of care delivered, the dose of drug administered and the quality of the achieved sedation and any sedation-related complications. This was the first time that a service-wide clinical audit had been undertaken with the objective of determining the safety and effectiveness of this aspect of care provision. Evaluation of the analysed data supported the perceived view that such care was being delivered satisfactorily. This on-going audit will collect data during year 2016 on the abandonment of clinical sessions, in which successful sedation had been achieved, due to the failure to obtain adequate local anaesthesia.

Prospective study on dental extractions carried out for paediatric patients under general anaesthetic in a district general hospital.

BACKGROUND: The first line approach to managing healthy anxious children requiring dental extractions should include behavioural management and treatment under local anaesthetic. This can be coupled with conscious sedation. AIM: To evaluate alternative methods attempted prior to treatment under general anaesthesia (GA), to establish the incidence of repeat GA procedures. METHOD: Paediatric cases requiring dental extractions under GA were audited from October 2014 - December 2014 in the Oral and Maxillofacial Department, Great Western Hospital, Swindon. RESULTS: 78 paediatric cases requiring dental extractions were carried out during the study period. 91% of referrals came from local general dental practitioners (GDPs). The indication for the GA was included in 59% of the referral letters. The number of teeth extracted per case ranged from 1 - 14. In 18% of cases treatment under local anaesthetic had been attempted previously. Conscious sedation had not been attempted in any of the cases. There were 5 cases (6.4%) of repeat general anaesthetic procedures. CONCLUSION: Local guidance regarding appropriate paediatric referrals should be distributed to primary care referrers. Treatment under conscious sedation should be considered for paediatric cases and an improved referral pathway to the community dental service should be developed. Preventative advice should be reinforced to the referrer and to the patient.