Clinical audits

Academy Dental Hospital

December 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 Topics
1.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.

Goals of Infection Control:

Protect the patient
Protect the health care worker, visitors, and others
in the health care environment, and
Accomplish 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
Central Instrument
Processing Area

Utility gloves and

long brushes are
not provided for
clinics

No

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

Hand Hygiene
Yes

No

Alcohol 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/record
s kept
Sharp containers
present BUT
overfilled
Extracted teeth
were either
discarded as
medical waste or

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

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

No

PPE 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

Radiograph
Audit

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/Standar
ds
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

Hospital Stats

>70% Excellent

11% Excellent

<20% Acceptable

32% Acceptable

<10%
Unacceptable

57% Unacceptable

Recommendations

 Appropriate training of the hospitals 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

Background
The 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

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

Access Cavity

90
8079
70
60
50
40
30
20
10
0
molar

45

premolar

15

18

18

canine

central

lateral

 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).

Extension of Access Cavity Walls

Deroofing
21

3%
66%

31%

Overextend
ed
Good

154

17
5

 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.

Floor of Pulp Chamber

45
40
35
30
25
20
15
10
5
0

Absent
SLA

molars

premolars canines
Touched

centrals

Not touched

laterals

Total
SLA
number
Present of molars
assessed

Upper
molars

11

17

35%

Lower
molars

31

31

62

50%

Obturation
Posterior Teeth
60

Number of Teeth

50
40

Mola
r

30
20
10
0

Premola
r

 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.
Extension of Obturation

The most commonly

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

Acceptable
Overextended

19

Underextended

57

24
20

At the radiographic
apex

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.
Voids

40
30
20
10
0

Flaring

34

5
4

Lower premolars

20

19
2

Present
Molar

Absent
Premolar

7
6

Upper premolars

14

Lower molars
Upper molars

3
0

29

7
5

Acceptable

10

15

20

25

Not acceptable

30

35

Discussion and
Recommendations

Case selection
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.
(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 ones 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 didnt 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, 6 th 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.

Thank
s!!