Clinical audits

Academy Dental HospitalDecember 2015

Presented on Feb 2016

Audit

‘A quality improvement process that seeks to improve patient care and outcomes through

systematic review of care against explicit criteria and the implementation of change’

Aim and Objective: Improvement of quality of care provided.

Achieved by identifying less-than-adequate care and raising it to the standard of the agreed best

Audit Team Members Zahra Hassan Abdelaziz

Mustafa Aboulella Samah Abdulhalim

Zaynab Mohammed Elhabib Haifaa Mohammed Ibrahim

Hiba Amir Ibrahim Sid Ahmed Hussain

Nouran Najeeb Aya Khalid

Fatima Elmahgoub

Audit Topics1.The complications associated with root canal treatment

performed by 5th year Dental Students

2. Infection Control Methods in Academy Dental Hospital

3. The quality of periapical radiographs

Infection Control Audit

Background• Infection control refers to policies and procedures used to minimize the risk of spreading infections in hospitals and health care facilities.

ЖGoals of Infection Control:ЖProtect the patientЖProtect the health care worker, visitors, and others in the health care environment, and

ЖAccomplish the previous goals in a timely, efficient, and cost-effective manner, whenever possible.

Objectives•To identify if infection Control Methods

are adhered to

Results

Instrument Processing and Sterilisation

Yes No

Central Instrument Processing Area ✖

Utility gloves and long brushes are not provided for clinics

✖

Instrument Processing and Sterilisation

▪ 27% of clinics do not use wrap for sterilisation

▪ 73% do not store equipment properly after sterilisation

▪ Instruments were not checked for packaging before/after sterilisation

Clinical Personal

4 out of 8 dental assistants have received official dental training on instrument processing .

All clinical personal do not use PPE when cleaning environmental surfaces.

▪ CP do not wear protective clothing at all times

▪ Not all CP wear eye protection

▪ CP do not change masks between pts

▪ Not all CP change clothing before leaving the office

▪ Gloves are not provided in various sizes

Hand Hygiene

Yes NoAlcohol rubs ✖

Hand lotions ✖

Hand hygiene before/after each patient

✖

Protocols

▪ Infection control officers are present

▪ No evaluation of infection control protocol is done

▪ No written infection control protocol plan

▪ No HBV vaccination/records kept

▪ Sharp containers present BUT overfilled

▪ Extracted teeth were either discarded as medical waste or given to patients

Standard Precautions

▪ 60% of clinics did not clean blood/debris

▪ 53% of dental clinics did not clean/disinfect contact surface before patient care

▪ 20% of dental clinics did not change surface barriers between patients.

▪ Masks are not changed between patients

▪ Gloves are changed between patients

▪ Latex free products are not available, different glove sizes not available

▪ OMFS: sterile gloves are not used

Dental lab

Yes NoPPE used when handling items

✖

Impressions disinfected properly before being transported to lab

✖

Housekeeping

▪ Housekeeping surfaces are not cleaned on a routine basis but the correct cleaning products are used.

Recommendations

• Implementation of a standardised hospital control policy.• Training of all personal who are subject to occupational

exposure: dental health care professionals, dental nurses, students.

• Provision of antimicrobial handwash and lotions in all departments.

• Proper clearing of sharp containers.• Clear waste disposal policy; differentiation between clinical and

non-clinical waste

• Schedule for regular cleaning• Staff must use heavy-duty utility (puncture and chemical-

resistant) gloves, and wear eye protection/face shield and a mask

• Used dental instruments should be pre-cleaned by wiping at the chairside.

• A long-handled instrument brush should be supplied• Immunisation and maintain immunisation records• Exposure incident protocol• Re-audit in July

RadiographAudit

Background▪ Why audit radiographs?

There is a need to minimise or eliminate:▪ Radiographic examinations where the results are

unlikely to affect patient management and/or prognosis▪ Radiographic examination which are repeated

unnecessarily▪ Duplication of radiographic examinations which have

been done already▪ Inappropriate radiographic examinations▪ Avoidable lapses in quality assurance which impact on

patient dose and care

Objectives

▪ To identify the quality ratings of periapical radiographs taken at Academy Dental Hospital during the period of September - December 2015

Criteria/Standards

The NRPB suggests the following standards for subjective quality rating of radiographs:

▪ No less than 70% of dental images should have a rating of Excellent – No errors of patient preparation, exposure, positioning, processing or film handling.

▪ No more than 20% should have a rating of diagnostically acceptable – Some errors present, but do not detract from the diagnostic utility of the radiograph.

▪ No more than 10% should have a rating of Unacceptable - Errors which render the radiograph diagnostically unacceptable.

Results

Radiograph Quality

NRPB Standard

>70% Excellent

<20% Acceptable

<10% Unacceptable

Hospital Stats

11% Excellent

32% Acceptable

57% Unacceptable

Recommendations

• Appropriate training of the hospital’s staff• The use of collimation and thyroid collars• Receptor holders align the receptor precisely with the

collimated beam (parallel technqiue)• Personal dosimeters should be used by workers • Introduction of other intraoral radiographs: bitewing

radiographs• Radiographs should be documented correctly• Re-audit in July

Endodontic Complications

BackgroundThe aetiology and diagnosis of dental pain and diseases

are integral parts of endodontic practice. Endodontic procedures should be practised with the required level of

skill and on the basis of sound scientific knowledge.

According to the European Society of Endodontology, a competency-based approach to training implies that the quality and consistency of student performance are more important than simply the quantity of clinical exposure.

For root canal treatment, students should be competent to undertake the treatment of uncomplicated molar

teeth, and all students should gain adequate experience in the treatment of anterior, premolar and molar teeth in

both the pre-clinical and clinical environment.

Objectives• To identify the percentage of complications

encountered during endodontic treatment performed by 5th year dental students

• Ascertain that correct guidelines are followed when providing root canal treatment

Criteria/Standards• Quality guidelines for endodontic treatment: consensus report of the European Society of

Endodontology 2006

• European Society of Endodontology-Undergraduate Curriculum Guidelines for Endodontology 2013

Results

Access Cavity Preparation

molar premolar canine central lateral0

102030405060708090

79

45

15 18 18

Access Cavity

₰ Extension: Regarding the extension of access cavity walls, 31% were found to be overextended; the majority of overextension in anterior teeth was found in canines (40%), while in posterior teeth lower molars were more commonly overextended (35%)

₰ Deroofing: 88% of teeth were sufficiently de-roofed. Of those 12% which were not deroofed, the most commonly involved teeth were the molars (15 out of 64 teeth).

31%

66%

3%

Extension of Access Cavity Walls

OverextendedGoodUnder-extdended

154

21

Deroofing

Deroofing Yes Deroofing No

175

₰ Floor of Pulp Chamber: In 52% of cases, the floor of the pulp chamber was touched with the handpiece.

₰ Straight Line Access: Straight line access was present in 78% of cases. Where it was absent, molars were most commonly involved (48% of molars had no straight line access).

₰ Perforation: Only one documented case had a perforation in the access cavity, found in the furcal floor of a lower molar. 2% almost perforated.

molars premolars canines centrals laterals05

1015202530354045

Floor of Pulp Chamber

Touched Not touched

Absent SLA

SLA Present

Total number of

molars assessed

Upper molars 6 11 17 35%

Lower molars 31 31 62 50%

ObturationPosterior Teeth

0

10

20

30

40

50

60 Number of Teeth

Molar

Premolar

₰ Obturation length: 76% of cases had an acceptable obturation length. ₰ When examining each canal separately, 27% of teeth had at least one

canal that was overextended, 32% had at least one canal that was underextended, and 25% had at least one canal which was obturated at the radiographic apex.

57

20

24

19

Extension of Obturation

AcceptableOverextendedUnderextendedAt the radiographic apex

₰ The most commonly presenting problem in relation

to length, was underextension, which mostly affected the ML canal (24%).

₰ Voids: Voids were present in 72% of cases.

₰ Flaring: 56% of cases had acceptable flaring, while 44% did not. The teeth which had the least acceptable flaring were upper molars.

Present Absent0

10203040 34

1920

2

Voids

Molar Premolar

Upper molars

Lower molars

Upper premolars

Lower premolars

0 5 10 15 20 25 30 35

3

29

6

4

7

14

7

5

Flaring

Not acceptable Acceptable

Discussion and Recommendations

Case selectionFor root canal treatment, students should be competent to undertake the treatment of uncomplicated molar teeth, and all students should gain adequate experience in the treatment of anterior, premolar and molar teeth in both the pre-clinical and clinical environment. (European Society of Endodontology-Undergraduate Curriculum Guidelines for Endodontology 2013)

When selecting a case, the students should anticipate all the difficulties that may be encountered, and prepare for these ahead of time. The knowledge of one’s own clinical skills and limitations, plays an important role in case selection.

It is clear from our study, that many difficulties have been encountered, many complications have arisen throughout all stages of root canal treatment, some of which have been overcome.

Detailed assessment of cases prior to treatment, and implementation of the AAE Endodontic Case Difficulty Assessment Guidelines may warrant adequate provision of dental treatment, through the anticipation of expected difficulties and preparation through provision of adequate instrumentation, and the use of various techniques.

Access Cavity• Guidelines that should be followed when preparing an access cavity are as

follows (Pathways of the Pulp, 10th Edition, Stephen Cohen):• Visualization of the Likely Internal Anatomy• Preparation of the Access Cavity Through the Lingual and Occlusal Surfaces• Removal of All Defective Restorations and Caries Before Entry Into the Pulp

Chamber• Removal of Unsupported Tooth Structure• Creation of Access Cavity Walls That Do Not Restrict Straight- or Direct-line Passage

of Instruments to the Apical Foramen or Initial Canal Curvature• Delay of Dental Dam Placement Until Difficult Canals Have Been Located and

Confirmed• Location, Flaring, and Exploration of All Root Canal Orifices

• In our study, 31% of access cavities were overextended, while 3% were underextended. The remaining 66% were good. This could be improved through education by highlighting the precise location of the canals, as well as emphasizing removal of caries and infected dentine using excavators, and low speed handpieces instead of using high speed handpieces.

• 21 out of 175 teeth didn’t have satisfactory deroofing. The result of this is impeded access of instruments to the coronal 1/3 of the root. (Oxford Handbook of Clinical Dentistry, Laura Mitchell, 6th Edition)

• 52% had touched the floor of the pulp chamber with the handpiece. It should be emphasized that students should not search for the canals using the handpiece, and adequate endodontic explorers should be provided, to aid in location of the canals.

• Straight line access was least satisfactory in lower molars (50%). Straight line access could be carefully created in these cases using Gates-Glidden burs and NiTi orifice shapers. Students should be made aware of the use of various techniques available to help with such difficulties.

Recommendations• Introduction of various instruments such as pluggers, and replacement of

old damaged instruments such as excavators, and explorers.• Division of the students between teaching assistants to provide a more

concentrated learning experience and keep better track of their progress.• Presenting an ‘Introduction to Endodontics’ course to third year dental

students, helping them prepare for preclinical endodontics.• Posters identifying recent diagnostic terms, criteria of obturation,

different techniques to approach difficult cases, and handouts to highlight the importance of case selection.

• Students should practice using rotary endodontic instruments on extracted teeth, prior to working on patients.

Thanks!!