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.

The Use of Acupuncture in the Treatment of Temporomandibular Dysfunction – An Audit

Objective

Temporomandibular dysfunction often represents a major therapeutic problem in a dental practice. Evidence from clinical studies suggests that acupuncture may be useful in the treatment of temporomandibular dysfunction. However, most studies have been performed in university settings. The aims of this study were to determine if the results of acupuncture treatment of temporomandibular dysfunction in general dental practice are comparable to the results obtained in previous studies in university clinics, and whether the treatment approach differs from that used in previous studies.

Methods

The case reports submitted by 15 dentists applying for the diploma of the British Dental Acupuncture Society were combined into one audit. All dentists were informed before submitting the forms that the data might be used for scientific purposes. The criteria for Pain Syndrome Dysfunction were used as inclusion criteria. A visual analogue scale (VAS) was used to assess the pain intensity before and after acupuncture treatment. The acupuncture points and technique used were recorded for each treatment.

Results

A total number of 70 case reports were received. Ten patients were excluded, as they did not fulfil the criteria. The remaining 60 patients (50 female) fulfilled an average of 3.2 of the Pain Syndrome Dysfunction criteria, out of a possible five. Their mean age was 40.6 years (range 14–68). The average duration of temporomandibular dysfunction was 32 months (range 1–180). The patients received a mean of 3.4 treatments, each treatment lasting on average 12 minutes. The dentists used only manual stimulation, and mainly acupuncture points over the temporomandibular joint and in the masticatory muscles, points on the neck, and additional relaxing points. The mean pain scores were 7.35 (SD 1.52) before treatment and 2.67 (SD 0.58) after treatment (P<0.001). A beneficial effect was observed in 85% with an average reduction in the pain intensity of 75%.

Conclusion

This audit shows that the results of using acupuncture in the treatment of temporomandibular dysfunction in a general dental practice are comparable to those obtained in clinical studies in university settings. Also the therapeutic approach of using acupuncture is similar. Thus, acupuncture is a simple, relatively safe and potentially efficacious and useful technique in the management of temporomandibular dysfunction in a general dental practice.

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.

The Eurocleft Study: Intercenter Study of Treatment Outcome in Patients with Complete Cleft Lip and Palate. Part 5: Discussion and Conclusions

Objective

To review the lessons learned from a longitudinal intercenter comparison study.

Design

Longitudinal cohort study.

Setting

Multidisciplinary cleft services in Northern Europe.

Subjects

Individuals with repaired complete unilateral cleft lip and palate.

Main Outcomes Measures

The first four papers in this series report amount of treatment, cephalometric form, nasolabial appearance, dental arch relationship, patient/parent satisfaction. This paper considers the consistency of outcome at the five centers over time, and other relationships between outcomes.

Results

Some outcomes measured in childhood can be predictive over time. The amount of treatment does not correlate with the quality of clinical outcome.

Conclusions

Measurement of clinical outcome in childhood is an important and valid form of clinical audit. Intercenter studies are more informative than single center reports, and will have an important future role in cleft care.

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.

British Orthodontic Society national audit of temporary anchorage devices (TADs): report of the first thousand TADs placed

OBJECTIVE

To provide data from the British Orthodontic Society (BOS) national clinical audit on temporary anchorage device (TAD) use following the recommendations of the National Institute for Health and Clinical Excellence (NIHCE) Design and setting: The Audit commenced on 1 January 2008 and is still ongoing. This article reports the data for TADs placed from 1 January 2008 to 1 November 2013.

MATERIALS AND METHODS

Audit data was collected from participants using a system of both on-line data entry and hard copy forms. The criteria and standards for the audit were set following the NIHCE report in conjunction with the Development and Standards Committee of the BOS. Virtually all participants used the on-line data entry available on the BOS website. The data submitted was checked and entered manually into an Excel spreadsheet, and transferred to SPSS for analysis.

RESULTS

Written information and documented discussion of risks were provided in over 90% of TADs placed, but 17.4% were placed without a specific signed consent form. Temporary anchorage device failure rate was 24.2% overall. Among failed TADs, 93.1% were lost or removed due to excess mobility. Infection or inflammation resulting in loss or removal was reported in 6% of TADs.

CONCLUSIONS

The only audit standard that was met was failures due to infection of inflammation. The rest of the audit standards were not met. Recommendations are made to address these issues.

Non-vital bleaching PART 1: an audit of practice in the Belfast and Cork restorative departments prior to the release of the 2012 European Cosmetic Directive PART 2: an audit on the perceived clinical impact of the 2012 European Cosmetic Directive in the Belfast and Cork restorative departments

Intrinsic discolouration of teeth often requires bleaching to improve the aesthetics. There are three techniques available for non-vital bleaching: chairside; walking; and, inside/outside. Before the 2012 Cosmetic Directive was released, an audit of non-vital bleaching practice in the Belfast and Cork restorative departments was undertaken (Part 1). Results showed a variation in clinical procedures from the gold standard and therefore the latter was used to develop a clinical protocol and pro forma for use in the restorative departments. These were designed to be useful in the hospital and general dental practice settings, and should hopefully increase compliance with the gold standard and therefore improve both the consent process and record keeping. With the change in the European Cosmetic Directive Guidelines on October 31, 2012, dentists were confined to using a maximum of 6% hydrogen peroxide in tooth bleaching products provided the first application was by a dentist or under their direct supervision. A high proportion of audit responses in Part 1 involved concentrations of hydrogen peroxide, in both the walking and chairside techniques, that no longer complied with the new Directive. This suggested that the new Cosmetic Directive could significantly impact the practice of non-vital bleaching in the Belfast and Cork restorative departments. This in turn prompted an evaluation on the perceived clinical impact of the European Cosmetic Directive since its release in 2012 (Part 2). Surprisingly, clinicians found similar clinical outcomes following the restriction in the concentration of bleach, although 50% felt that more treatment visits were required to achieve an acceptable result. Moreover, the results of the audit revealed that clinicians were most concerned that the introduction of a ban on treating patients under 18 years of age might exacerbate psychological issues in this vulnerable age group if discoloured teeth were left untreated.

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.

A randomized controlled trial of cluster audit and feedback on the quality of dental sealant for rural schoolchildren

THE OBJECTIVE

To examine whether audit and feedback could improve the quality of the application of dental sealant in rural Thai school children.

RESEARCH DESIGN

A single blind, cluster randomized controlled trial was conducted.

CLINICAL SETTING

Hospital-based and school-based school sealant applied by dental nurses in Southern province of Thailand.

PARTICIPANTS

Dental nurses and school children who received dental sealant were involved.

INTERVENTION

The intervention consisted of confidential feedback of data and tailor-made problem-solving workshops.

MAIN OUTCOME MEASURES

Sealant quality was measured by sealant retention and caries on sealed surfaces at six-month after sealing. The teeth examinations were done among different groups of children prior and after the intervention.

RESULTS

After the intervention, the sealant retention rate increased dramatically in the intervention group, whereas in the control group the rate was similar to that found at baseline. The rate of caries after the intervention was stable in the intervention group and increased slightly in the control group. At the beginning of the study, the adjusted odds ratio of complete sealant retention between the intervention and control group was 0.47 which increased to 1.99 at the end of the study. However, no effect on caries on sealed surfaces was observed.

CONCLUSIONS

The intensive focus on actual problems during the audit and feedback improved the dental nurses' performance and the quality of the dental service, although it had no statistical impact on the incidence of caries.

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.

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.

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.

A retrospective audit of population service access trends for cleft lip and cleft palate patients

Population prevalence of orofacial clefts (OFCs) is well documented but the service utilisation patterns of these patients have received limited consideration.

OBJECTIVE

To analyse 10-year trends in the utilisation of subsidised OFC related services in Australia.

DESIGN

Retrospective audit of service utilisation and claims datasets.

METHODS

Using state-wide hospital admission data, all persons treated for Cleft Palate Only (CPO) and Cleft Lip Only (CLO) as their primary diagnosis from 1999 to 2009 in Western Australia were included in the data frameset. Additionally, National Medicare out-of-hospital claims from 2003 to 2013 were added to the data frameset. The socioeconomic status and accessibility to services were analysed as effectors of service-mix such as age group, gender and geographic location.

RESULTS

Of 721 in-hospital care episodes in Western Australia, 69% had CPO and 31% CLO as their principal diagnosis. Hospitalisations occurred from 0-69 years of age, but three quarters of all episodes occurred from 0-4 years of age (averaging one to two episodes per child). Whilst total hospitalisations were about four times higher for patients resident in high access areas, adjustment for population found the poorest 20% of the population having substantially lower hospital admission rates than the rest of the population. In Australia, claims for out-of-hospital cleft-related services varied between States. The overall pattern of out-of-hospital Medicare claims nationwide showed orthodontic services having the highest number of claims, followed by prosthodontic then oral surgical services.

CONCLUSION

These data provide a picture of diverse service utilisation and leads to some interesting conclusions about geographic and economic access as well as cost-shifts between State and Commonwealth.

Time trends and determinants of acute odontogenic maxillofacial infections in Lithuania: a retrospective national 2009-2013 treatment data audit

OBJECTIVES

To examine the distribution of treatment facilities accepting patients with acute odontogenic maxillofacial infections (AOMIs), time trends in incidence and relate these infections with a number of determinants.

METHODS

A national Lithuanian retrospective study gathered data on all patients treated in outpatient/inpatient treatment facilities. Adjusted Incidence Ratios (AIRs) of AOMIs were calculated separately for each type of infection and for each year. Administrative districts (ADs) were grouped into low, medium, and high thirds based on the regional determinants: socio-economic index (R-SEI), access to basic (R-BDCI) or specialized dental care (R-SDCI) and index of systemic diseases (R-ISD).

RESULTS

There were no statistically significant geographical differences in the distribution of TFs providing care for patients with AOMIs. Numbers of treatment facilities consistently increased from 2009 to 2013, but there was no consistent increase/decrease in the incidence of AOMIs (-1%). Regions with the highest R-SEI tended to have a higher incidence of AOMIs as compared to regions with medium or low R-SEI. When controlled for other determinants, lower R-BDCI/R-SDCI scores were associated with a higher incidence of AOMIs.

CONCLUSIONS

High annual incidences (-1% of a total population) were diagnosed and treated for AOMIs, but there was no consistent time trend for these infections.

Evidence Regarding Teaching and Assessment of Record-Keeping Skills in Training of Dental Students

The aim of this study was to assess the literature on teaching and assessing dental students' record-keeping skills prior to qualification to practice independently as a dentist. A systematic literature review was performed using Ovid MEDLINE and SCOPUS. Keywords used in the search included dental, record, audit, education, and assessment. Electronic search results were screened for publications that targeted undergraduate dental training, related to a record-keeping education intervention, and were published in English and available in full text. Six studies met the inclusion and exclusion criteria. Data extraction and quality assessment were performed, and research findings were compared across the included studies. These six articles addressed the techniques used to teach and assess record-keeping skills in a pre-qualification context. The techniques included supervisor audits, peer audits, lectures, tutorials, research assignments, case reports, record-keeping templates, and checklists of required record components. The use of record audit as part of teaching and evaluation dominated these articles; it was used as the assessment method in five of the six studies. All methods of record-keeping training in studies published to date were found effective in improving student record-keeping skills. However, there was insufficient evidence to determine whether certain methods were more effective than others.

Credibility and Confidence in Your Dental Laboratory Work-How Quality Assurance Systems Can Be Used in the Manufacturing of Individual Custom-Made Dental Devices

Manufacturing of custom-made dental devices such as removable dentures, fixed prosthodontics and orthodontics are subject to the requirements of the Medical Devices Directive (MDD). Many dental laboratories often enhance these requirements by implementing quality assurance procedures that then provide enhanced consistency. This paper provided a personal view of some of the systems currently being used in dental laboratories to provide a quality assured product and associated issues.

Reducing Harm in Healthcare Systems

An understanding of the importance of causation of medical errors is important for determining strategies to reduce the harm that they can cause to patients. This paper discusses how dentistry can learn from medicine as well as other industries when developing approaches designed to deal with the causes of errors, rather than their outcomes.

The Francis Report--dento-legal implications

This article explores the potential implications of the Francis Report for members of the dental team from a dento-legal perspective. It looks at the broad recommendations in light of the existing ethical environment in which dental registrants work and asks what is new and what the recommendations will actually mean for dental professionals in practical terms. Clinical Relevance: The fundamental recommendations of the Francis Report, namely, that those who provide care should put patients' interests first and be open about outcomes and performance, are not new concepts. A breach of these ethically based expectations may, however, create grounds for legal proceedings, which is clearly a significant point for all members of the dental team. It is therefore important to be aware of what is expected of those providing clinical care.

An audit into the reasons why treatment was not completed as planned under intravenous sedation in an adult oral surgery department, and the cost implications

This audit aimed to identify the prevalence of, and reasons for failed intravenous conscious sedation in an adult oral surgery department, to develop recommendations to reduce such failures and to identify any cost implications. Data were collected prospectively for three months for all intravenous sedation appointments in the Oral Surgery department. Data were collected for 109 sedation appointments of which 83 were successful (76%). The failure rate (24%) was higher than the acceptable departmental failure rate (10%), and included reasons for failure that should have been avoided by a thorough patient assessment prior to treatment. Of the 26 failures, the most common reasons for failure were: cancellation: 8 patients (30.8%), failure to attend: 6 patients (23.1%), excessively late arrival of patient: 4 patients (15.4%) and failure to cannulate: 3 patients (11.6%). When sedation was unsuccessful, 13 of the 26 patients (50%) had their treatment successfully completed under local anaesthesia alone, 10 patients (38%) were rebooked for sedation and 3 patient. (12%) were rebooked for a general anaesthetic. Identifying and correcting the reasons for failure can result in vast savings in appointment time, clinical resources and cost. That 13 patients subsequently had their treatment completed under local anaesthesia alone opens the debate on how rigorous the patient assessment and allocation of sedation appointments was, and the potential to achieve savings.

The development of a patient-centered measure of the process and outcome of combined orthodontic and orthognathic treatment

OBJECTIVE

The aim of this study was to develop a patient-based measure of the process and outcome of combined orthodontic and orthognathic care in the National Health Service in the UK.

DESIGN

Identification of relevant dimensions through qualitative methods, design of form, determination of psychometric properties of the scale, specific readability, reliability and validity.

SETTING

NHS hospitals in the South West Region.

SUBJECTS

The sample comprised patients who had received combined orthodontic and orthognathic treatment between 01 January 1998 and 31 December 2000. Twenty-six participants (a 25% response rate) took part in four focus group meetings. Thirty subjects (65% response rate) took part in a pilot study to test the properties of the questionnaire.

MAIN OUTCOME MEASURES

Six broad themes emerged from the focus groups. These formed the basis of the sections in the questionnaire.

RESULTS

The questionnaire developed had a Flesch reading ease score of 72.9 or US grade level 4 equivalent to aged 9-10 years. Test-retest reliability gave kappa values for most questions that exceeded 0.4. Criterion validity of the measure was established by comparing responses to the questionnaire over two periods with a telephone interview on a sample of 30 patients. Criterion related validity was poor for nine of the 16 items. By contrast the construct validity of the questionnaire was satisfactory.

CONCLUSION

A patient-based measure of the process and outcome of combined orthodontic and orthognathic treatment has been developed. This has sufficient validity and reliability for use in inter-center audit projects.

A 2-year outcome audit of a versatile orthodontic bone anchor

This study examined complications leading to, or possibly leading to, treatment failure, related to the use of the orthodontic bone anchor (OBA). The OBA is a potential means of providing absolute anchorage and consists of a base-plate fixed with mono-cortical screws, a neck piercing the soft tissues, and a coronal part with conventional orthodontic hooks, tubes or slots. The investigation took the form of a single centre prospective registry at a supra-regional teaching hospital. Eighteen patients (average age 21 years) had one to four OBAs placed between January 2000 and February 2002. Altogether 35 OBAs were placed. Follow-up took place until April 2004. Reasons for placing the OBAs were noted together with any associated complications during the follow-up period. Twenty-three OBAs have been removed so far, four prematurely (one of them before it was taken into use, due to a change of treatment plan enforced by loss of the contralateral OBA). Nineteen were removed as planned after completion of the intended tooth movements. Common (but minor) complications included granulations, acute gingivitis and gingival recession. Light mobility of the OBA was also noted in some cases, but without clinical repercussions. The OBA can be loaded directly, at the level of the orthodontic archwire or more occlusally. It can be placed at any site at the circumference of the jaws, given good quality and thickness of the bony wall. Conventional biomechanical techniques can be applied. However, the failure rate (premature loss of OBA) of 8.6% is considered high, and has necessitated changes in the hardware and protocol.

An audit of ‘early debond’ cases in the national outcomes audit of patients treated with upper and lower fixed appliances by Consultant Orthodontists in the UK

OBJECTIVE

To audit the outcomes of the 'early debond' cohort of the national outcomes audit carried out by the Consultant Orthodontic Group of the British Orthodontic Society.

DESIGN

Multi-centre, retrospective national audit.

STANDARDS

Seventy-five per cent of cases should exhibit a reduction in PAR greater than 70% with 3% or less with a PAR score reduction of less than 30% (i.e. worse/no different).

METHOD

Analysis of consecutively completed cases treated by upper and lower fixed appliances that were noted by the operator as having discontinued treatment early.

MAIN OUTCOME MEASURES

Incidence of early debond, PAR outcome.

RESULTS

The 'early debond' cohort constituted 11% of the total 823 patients and fell below previously published standards for orthodontic treatment outcomes. They were less likely to be in the 'greatly improved' category, more likely to be in the 'improved' category and only slightly more likely to be in the 'worse/no different' category. There was a 67% reduction in PAR and 50% exhibited a reduction in PAR greater than 70%, with 6.5% having a reduction in PAR score lower than 30%.

CONCLUSION

Discontinuation of orthodontic treatment is associated with a reduced level of treatment outcome.

Communicating prosthetic prescriptions from dental students to the dental laboratory: is the message getting through?

The aim of this research was to investigate the quality of written prosthetic prescriptions provided by fourth-year dental students to a commercially operated dental laboratory and to ascertain the contribution of interprofessional education to improving prescription quality. Based on guidelines established by the Medicines and Healthcare Products Regulatory Agency of the European Union (Medical Device Directive 93/42/EEC), an audit was conducted prior to and after an educational intervention was delivered by a dental technician to a dental student cohort at one Australian dental school. Prior to the intervention, thirty-nine dental prosthetic prescriptions were collected, analyzed, and audited to determine the clarity of written communication and instructions from dental student to dental technician. Following the intervention, a further forty prosthetic prescriptions were collected from the same cohort of students and were audited. The audit of the initial prescriptions showed that 85 percent (n=33) did not comply with the recommended conventions. After the intervention, the prescriptions that did not meet the guidelines had fallen to 30 percent (n=12) of the total. Improvements in prosthetic prescriptions submitted by these dental students to the commercial dental laboratory suggest there is an advantage to including a prosthetic prescription-writing module in dental school curricula.

An audit of antimicrobial prescribing in an acute dental care department

INTRODUCTION

Antimicrobial resistance is a growing problem that is likely to have a major negative impact on healthcare in the future. Dentists have a key role in ensuring that antimicrobials are prescribed correctly to reduce the emergence of resistant strains.

OBJECTIVE

To audit how appropriately antimicrobials were prescribed in the oral surgery acute dental department of Guy's Hospital in London, when compared to the standards set within the Faculty of General Dental Practice (UK) and Scottish Dental Clinical Effectiveness guidelines on antimicrobial prescribing in dentistry.

TARGET

100% compliance.

METHOD

A prospective audit consisting of two cycles (each including 60 patients) was carried out. Between each cycle, there was a two-month intervention period, which included extensive training and education of staff and students.

RESULTS

Cycle 1 showed that only 30% of prescriptions were appropriate and only 62% of practitioners were recording a diagnosis. After two months of intervention, cycle 2 was carried out; this showed a significant improvement, with 80% of prescriptions being appropriate and 100% of practitioners recording a diagnosis. The majority of inappropriate prescriptions in both cycles were for acute pulpitis without evidence of systemic involvement.

CONCLUSION

This audit has shown that clinical practice for antimicrobial prescribing did not follow the published guidelines. Following targeted interventions, a substantial improvement was made in the prescribing pattern. The target of 100% has not been reached, necessitating further intervention.

Post-operative complications following dental extractions at the School of Dentistry, University of Otago

OBJECTIVES

To determine the frequency and correlates associations of post-extraction complications at a dental school.

DESIGN

Retrospective review of patient records.

SETTING

Exodontia clinic at the School of Dentistry, University of Otago, Dunedin.

MAIN OUTCOME MEASURES

Provider characteristics, patient demographic characteristics, patient medical history, teeth extracted and occurrence of postoperative complications.

RESULTS

Of the 598 extractions (540 routine and 58 surgical) which were undertaken in the audit period, 74 (12.4%) resulted in post-operative complications. Dry socket and post-operative pain were the major complications. A higher complication rate was found among patients treated by fourth-year undergraduate students than among those treated by more senior students or staff. Post-operative complications were not significantly associated with patients' ethnicity or medical history.

CONCLUSION

The rate of postoperative complications at the Univeristy of Otago's Faculty of Dentistry is consistent with reports in existing literature and inversely associated with operators' experience.

Adults with intellectual disability: a mixed-methods investigation of their experiences of dental treatment under general anaesthetic

OBJECTIVES

This study aimed to explore the experiences of dental care under general anaesthesia in adults with an intellectual disability.

METHODS

The study used an explanatory mixed-methods design. In the initial quantitative phase of the study, a clinical audit of oral health services provided for adults with intellectual disabilities was carried out for individuals who underwent a general anaesthetic (GA) for dental treatment at Christchurch Hospital during a 5-year period. In a qualitative second phase, fifteen semi-structured interviews were carried out for 13 individuals with an intellectual disability to investigate the experience and perceptions of individuals with an intellectual disability (and caregivers and guardians) relating to their oral health care.

RESULTS

The majority of the treated patients lived in care, and many had severe medical problems. Most had both restorative treatment and tooth extractions carried out under GA. Their major concern was anxiety associated with the dental visits. Support people/ guardians shared this concern, and played a vital role in helping to manage this anxiety. Many of the latter had difficulty identifying dental problems in their charges, and they often relied on detection of changes in the individual's behaviour or demeanour. The time spent waiting in waiting rooms for treatment was a frequently reported cause of stress.

CONCLUSIONS

As a group, these individuals present challenges for the provision of oral health care, given their severe disability and medical conditions, and many require a high level of support for daily activities. When dental treatment is required, a GA is often necessary in order to carry it out. The management of anxiety was a key issue for the patient group and support people play a vital role in helping to manage this anxiety, and achieve a successful visit. There is potential to improve the service with a multidisciplinary approach to coordinate other health services during treatment episodes, reduced time spent in waiting rooms, and improved waiting room layout.

How good are our impressions? An audit of alginate impression quality in the production of removable prostheses

Impressions are taken regularly in practice giving vital information to the dental laboratory, but are there quality assurance systems in place to make sure that they are up to a sufficient standard? As dental professionals we have to appreciate that dental technicians can only work with the information given to them. This makes the skill of taking a good impression vital in order for us as clinicians to provide prostheses of good quality. This paper outlines an audit of alginate impressions and their quality in the making of removable prostheses.

CLINICAL RELEVANCE

To record the quality of impression taking, and how one's own ability to critique an impression may differ from that of our colleagues.

Lateral compression open cap splint with circummandibular wiring for management of pediatric mandibular fractures: a retrospective audit of 10 cases

INTRODUCTION

Mandibular fractures are relatively less frequent in children when compared to adults. Pediatric patients present a unique challenge to maxillofacial surgeons in terms of their treatment planning and in their functional needs. We currently describe our experience with lateral compression open cap splint with circummandibular wiring as a treatment modality which involves fewer risks in treating pediatric symphysis/parasymphysis/body mandibular fractures.

MATERIALS AND METHODS

A retrospective analysis of pediatric patients with mandibular symphysis/parasymphysis/body fractures operated from January 2007 to January 2012 was performed. Clinical photographs and orthopantomogram assessment at the time of presentation, after treatment, and at 6 months postoperatively were evaluated.

RESULTS

All the 10 patients were followed up until the period of 6 months, and none of them had any major complications. Postoperatively, there was satisfactory healing and union of fracture fragments in all the patients. Only one patient developed infection at submental region. The 6-month follow-up showed good occlusion, without interference in teeth eruption and no signs of temporomandibular joint problems.

CONCLUSIONS

Lateral compression open cap splints for treatment of pediatric mandibular symphysis/parasymphysis/body fractures are reliable treatment modalities with regard to occlusion-guided fracture reduction.

Clinical audit teaching in record-keeping for dental undergraduates at International Medical University, Kuala Lumpur, Malaysia

This study investigated the impact of clinical audit training on record-keeping behavior of dental students and students' perceptions of the clinical audit training. The training was delivered to Year 4 and Year 5 undergraduates at the School of Dentistry, International Medical University, Kuala Lumpur, Malaysia. It included a practical audit exercise on patient records. The results were presented by the undergraduates, and guidelines were framed from the recommendations proposed. Following this, an audit of Year 4 and Year 5 students' patient records before and after the audit training was carried out. A total of 100 records were audited against a predetermined set of criteria by two examiners. An email survey of the students was also conducted to explore their views of the audit training. Results showed statistically significant improvements in record-keeping following audit training. Responses to the email survey were analyzed qualitatively. Respondents reported that the audit training helped them to identify deficiencies in their record-keeping practice, increased their knowledge in record-keeping, and improved their record-keeping skills. Improvements in clinical audit teaching were also proposed.

Audit to assess the quality of communication between operators and technicians in a fixed prosthodontic laboratory: educational and training implications

OBJECTIVE

This audit aimed to assess the quality of communication between dental students/qualified dentists and dental technicians, increase the percentage of satisfactorily completed laboratory prescriptions and reduce the number of errors that can result from poor communication. A subsidiary aim was to educate students and staff in this respect.

METHOD

An audit of laboratory prescription completion was conducted within Dundee Dental Hospital. Four hundred and eighteen prescriptions for indirect fixed restorations completed by dental undergraduates and qualified staff were audited over a three month period (first audit cycle). Educational reminders on laboratory prescriptions were then provided to undergraduates and qualified staff, a further three hundred and twenty-two prescriptions were audited (second audit cycle) and compared with the first cycle.

RESULTS

Satisfactorily completed prescriptions increased from 28% to 43% following basic educational intervention. However, this percentage still signifies a poor level of completion and the need for improvement. Some aspects of the prescription were completed better than others, but overall the standard remained poor with a significant number failing to comply with guidelines set by the UK General Dental Council, the European Union's Medical Devices Directive and the British Society for Restorative Dentistry (BSRD).

CONCLUSION

Further undergraduate and staff training on laboratory prescription writing will be necessary through staff training events and developments in the undergraduate curriculum.

Patient safety in dental care: A challenging quality issue? An exploratory cohort study

OBJECTIVE

Little is known about patient safety in primary oral healthcare. The aim of this study was to describe and analyze patient safety incidents in primary oral health care.

MATERIALS AND METHODS

A random sample of 1000 patient records from 20 dental practices was reviewed retrospectively over 60 months. All adverse events (AEs) were noted: unintended events happening during treatment that resulted or could have resulted in harm to the patient.

RESULTS

A total of 46 (95% CI = 33-59) AEs was identified, of which 18 (95% CI = 10-26) were considered preventable. From these, 15 related to treatment, 10 to diagnostics and one to communication.

CONCLUSIONS

The low incidence of AEs and absence of major harm to patients suggests that primary oral care is safe for patients. However, the low quality of record keeping may imply underestimation.

An audit of orthodontic treatment eligibility among new patients referred to a Health Service Executive orthodontic referral centre

AIM

The aim of this audit was to evaluate orthodontic treatment eligibility among new patients referred for assessment from primary dental care clinics in the Health Service Executive (HSE) South region to a HSE orthodontic referral centre.

METHOD

A data collection form was designed and applied prospectively to consecutive new patient referrals who attended diagnostic clinics at the Orthodontic Unit, Cork University Dental School and Hospital, between October 2011 and February 2012. Orthodontic treatment eligibility was based on guidelines introduced by the HSE in 2007.

RESULTS

Data on 291 patients (147 males and 144 females) with a mean age of 11.6 years (SD +/- 2.4 years; range 8-19 years) were evaluated. Of the 83 (29%) patients eligible for orthodontic treatment under the guidelines, the most commonly diagnosed malocclusion traits were a crossbite with greater than 2 mm discrepancy between retruded contact position and intercuspal position (24 patients), followed by an overjet greater than 9 mm (21 patients).

CONCLUSIONS

A total of 29% of new patient referrals were deemed eligible for orthodontic treatment under HSE eligibility guidelines introduced in 2007. Reduction of new patient referrals not eligible for treatment, under these guidelines, is required to enable more efficient use of resources.

Audit of the Health Service Executive orthodontic referral pathway between 2009 and 2011 in the Dublin Mid-Leinster region

An audit was undertaken in 2009 to determine the success of the new national orthodontic referral protocol introduced to the Health Service Executive (HSE) in 2007 and operated in the Dublin Mid-Leinster HSE region. It was repeated in 2011 to determine if the HSE austerity measures have had a bearing on the orthodontic service performance in the Dublin Mid-Leinster HSE region. The audit also measured the success of referring practitioners in identifying the correct Index of Orthodontic Treatment Need (IOTN) classification of the patient. In the 2011 audit, the figures were broken down to identify the occlusal variables that caused dental practitioners most difficulties in identification. The audit demonstrates a good referral to assessment timeframe in 2009 (85-80% compliance for IOTN 5 and 4 within three to six months, respectively), which deteriorates significantly in 2011 (26-4% for IOTN 5 and 4 within three to six months, respectively). The ability of dentists to identify the correct IOTN classification was better in 2009 (60% correct) compared to 2011 (51% correct), but both figures fell below the audit standard of 75% of referrals with correct IOTN classifications. The IOTN occlusal dental health components most readily identified by referring practitioners and meeting audit standards were 5a (overjet >9mm), 5i (impacted teeth) and 5h (extensive hypodontia). The remaining occlusal dental health components in the HSE IOTN fell below the audit standard. The audit clearly identifies a requirement for a continued educational effort to maintain the HSE IOTN skill base in primary care, and a need for additional resources to manage the demand for orthodontic assessments.

Clinical record-keeping for monitoring treatment outcomes in implant dentistry: a case study

Sound clinical practice in implant dentistry depends upon defining the methodology that can successfully be used. This can be achieved by identifying literature relating to a specific technique prior to its use. However, clinical observations of outcomes within one's own practice are also very effective. This is particularly true as it becomes specific, by eliminating numerous confounding factors. Appropriate documentation, both clinical and radiographic, permits the practitioner to review clinical cases and establish the efficacy of the methodology used. This is most effective in terms of evaluating survival as well as determining aesthetic and functional outcomes. Software programs such as ImpDAT (Kea Software, Poecking, Germany) provide a platform that easily allows both accurate record-keeping and, importantly, retrieval of data for purposes of review and publication. This paper presents a case report that uses radiographic and photographic records to monitor the ongoing response of the patient to the specific treatment that was carried out; in this case, autogenous onlay bone grafts for the management of congenital partial anodontia.

North Cork HSE orthodontic treatment waiting list 2009-2010: retrospective audit of patient records

PURPOSE OF THE STUDY

To evaluate the case profile and verify the treatment eligibility (based on the modified IOTN) from written case records, of patients accepted for orthodontic treatment from the North Cork area of HSE South.

MATERIALS AND METHODS

A data collection form was designed and applied to the written case records of 200 consecutive patients accepted for orthodontic treatment in 2009/2010. Data relating to the IOTN (DHC and AC, where relevant) were provided by a calibrated examiner.

RESULTS

Based on the written case records, most (57%) of the treatment cohort were female and had an average age of 14 years and two months. The predominant malocclusion was Class II division 1 (40%). The prevalence of Class III malocclusion was high at 18%. A total of 61% of patients were in grade 5 and 36% in grade 4. The majority of patients in each of these grades fell into DHC 5a (32%), followed by 5i (24%) and 4d AC > 8 (16%).

CONCLUSIONS

Written case records conclude that patients accepted for orthodontic treatment from the North Cork area of HSE South were predominantly female. Class II division 1 malocclusion was the most common accepted for treatment. These records verify that those patients accepted for orthodontic treatment satisfy the eligibility criteria for HSE treatment.

An inhalation sedation patient profile at a specialist paediatric dentistry unit: a retrospective survey

AIM

To report on the characteristics, treatment, attendance, scheduling and duration of treatment sessions of child patients attending a specialist paediatric dental hospital service for inhalation sedation.

METHODS

A retrospective study was carried out of all 88 patient case notes of inhalation sedation recipients between September 2004 and March 2005. The recorded data included: child's age, gender and level of social deprivation together with the details of the treatment that was undertaken, the time between the first and current/last sedation appointment and the total number of appointments attended, cancelled and missed.

RESULTS

Twenty of the subjects were excluded giving a sample of 68; 51% male, mean age at start of treatment 9.8 years (range 4 to 15) and mean age at end of treatment 10.6 years (range 4 to 16). Of these children 35 (51%) were socially deprived. In respect to treatment, 29% had extractions, 22% endodontics, 81% restorations and 25% fissure sealants. In respect to the number of quadrants that had teeth requiring treatment; 26.5% had one, 25% two, 22% three and 26.5% four. The mean number of treatment sessions required was 4.4 with a mean duration between first and last appointments of 9.5 months (range 0.25 051). There were 27% of appointments cancelled, while 12% of patients failed to keep their appointments.

CONCLUSIONS

Although over half of the children treated under inhalation sedation came from socially deprived areas, attendance was reasonable and the majority required less than 5 appointments for treatment completion. The treatment provided was variable not only in respect to the procedures but also to the number of quadrants treated.