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An Audit on Oral Health Assessment in General Dental Practice

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AN AUDIT ON ORAL HEALTH RISK ASSESSMENT IN GENERAL DENTAL PRACTICE

S. Lee and D. Mavani

BACKGROUND

• The National Institute of Health and Clinical Excellence guidelines (NICE, 2004) published in
relation to routine dental recall intervals advises determination of oral health risk assessments
for individual patients.
• Carrying out a risk assessment for the four domains: caries, periodontal disease, tooth surface
loss and oral cancer can help clinicians make tailored decisions regarding management of
individual patients, while discussing the scores with patients can aid in education them about
their own oral health.
• However, working in general practice has identified inadequacies in clinical record keeping in this
regard.

AIMS

• This audit aims to establish whether:
1. A risk assessment of the four domains was routinely carried out and recorded in clinical records
2. The patients had an understanding about their own assessment scores

GUIDELINES

• The National Institute of Health and Clinical Excellence (2004) guidelines published in relation to
routine dental recall intervals advises determination of oral health risk assessments for individual
patients.
• Scottish Dental Clinical Effectiveness Programme (2012) and the Faculty of General Dental Practice
(2009) guidelines recommend recording of risk assessments in clinical records as good practice.

METHODOLOGY

• Initially, a pilot audit was completed across two general dental practices in North East London.
• Then, 1st cycle of the audit retrospectively analysed a random sample of 100 clinical records,
across the same two general dental practices, to determine if: caries, periodontal disease, tooth
surface loss and oral cancer risk assessments were recorded in the notes.
• This was followed by patient questionnaires to determine whether they were made aware of their
respective risk assessment scores.

RESULTS OF 1ST CYCLE

The data was collected from those 46 clinical notes where an overall risk assessment was recorded.
The table above on the right, shows the percentage of those notes that recorded each of the four
risk domains respectively.

ACTION PLAN

• After discussion at practice meetings, the following barriers were identified to recording of risk
assessment scores:
• Subjective assignment of risk categories
• Knowledge (Recording of BEWE)
• Habits of the dentist
• Time
• An evidence based index was created to help with quick, but, structured assignment of risk categories.
Practice meetings were then held to: increase awareness, introduce the index, educate and train the
staff for the same. Following implementation across the practices, the second cycle of the audit was
then carried out, on the ensuing 100 clinical records.

RISK ASSESSMENT INDEX & INFORMATION LEAFLET

The index below was designed for assignment
of a low, moderate or high risk category for the
four domains based on clinical factors as well
as patient factors:

The index was designed to contain basic
information on the reverse side to aid with
patient education regarding reduction of risk
for the four domains:

DISCUSSION

• Overall the intervention was successful across both practices. Although short of meeting 100%
recording of risk assessments, there has been a drastic improvement in recording from 46% to 84%
in a short span of time.
• There has been an improvement in the recording of each of the four domains with tooth surface loss
having the biggest improvement. However, it is still the least recorded and this needs to be addressed.
It is important for dentists to identify the cause of tooth surface loss, especially if intrinsic erosion is
involved as studies suggest links to oesophageal neoplasm.
• The index and leaflet was well received by the patients with generally positive responses. Feedback
from the staff regarding ease of use and practicality may help with further improvements.
• Although the intervention appears to have improved recording of risk assessments across the two
general dental practices, a larger sample size may have produced more representative data. This can
be considered for a re-audit in the future.

NEXT STEPS

• Inform the staff of the results during a practice meeting. While gathering feedback to identify any
issues identified during use of the index and if anything can be improved to help gain 100%
recording of oral health risk assessments.
• Display the index in the surgery to remind the dentist to conduct a risk assessment.
• Display information in the surgery on the BEWE scoring system and investigate if a pop up reminder
in the clinical notes software can be incorporated.
• Amend templates for patient notes to include oral health risk assessment domains.
• Re-audit in 6 months to determine if standards have been maintained / improved.

REFERENCES

1. National Institute of Health and Clinical Excellence. 2004. Dental recall – Recall interval between routine dental examinations. [Guidance 19]. [Online]. London: National Institute for
Health and Clinical Excellence. [Accessed 12 January 2017]. Available from: https://www.nice.org.uk/guidance/cg19
2. Faculty of General Dental Practice. 2009. Clinical Examination and Record Keeping. Good Practice Guidelines (2nd edition). London: Faculty of General Dental Practice.
3. Scottish Dental Clinical Effectiveness Programme. 2012. Oral Health Assessment and Review. [Online]. Dundee: Scottish Dental Clinical Effectiveness Programme. [Accessed 18 January
2017]. Available from: www.sdcep.org.uk/wp-content/uploads/2015/04/SDCEP-OHAR-Version-1.0.pdf
4. American Academy of Pediatric Dentistry. 2013. Guideline on caries-risk assessment and management for infants, children, and adolescents. Pediatric Dentistry. [Online]. 35(5), pp 157-
164. [Accessed 18 January 2017]. Available from: http://www.aapd.org/media/policies_guidelines/g_cariesriskassessment.pdf
5. Lang, N.P. and Tonetti, M.S. 2003. Periodontal risk assessment (PRA) for patients in supportive periodontal therapy (SPT). Oral health and preventive dentistry. [Online]. 1(1), pp7-16.
[Accessed 15 January 2017]. Available from: http://www.perio-tools.com/pdf/Lang_&_Tonetti_2003.pdf
6. Bartlett, D., Ganss, C. and Lussi, A. 2008. Basic Erosive Wear Examination (BEWE): a new scoring system for scientific and clinical needs. Clinical Oral Investigations. [Online]. 12(1), pp65-
68. [Accessed 17 January 2017]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2238785/
7. Kaidonis, J.A. 2012. Oral diagnosis and treatment planning: part 4. Non-carious tooth surface loss and assessment of risk. British Dental Journal. [Online]. 213(4), pp155-161. [Accessed 17
January 2017]. Available from: http://www.nature.com/bdj/journal/v213/n4/full/sj.bdj.2012.722.html
8. Department of Health. 2014. Delivering better oral health: an evidence-based toolkit for prevention. [Online]. London: Department of Health. [Accessed 18 January 2017]. Available
from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
9. Koshi, E., Rajesh, S., Koshi, P. and Arunima, P.R. 2012. Risk assessment for periodontal disease. Journal of Indian Society of Periodontology . [Online]. 16(3), pp324-328. [Accessed 17
January 2017]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3498698/

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