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A clinical audit to assess periodontal record keeping standards, in line with the latest guidelines, carried out in four general dental practices in North East London.

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A clinical audit to assess periodontal record keeping standards, in line with the latest guidelines, carried out in four general dental practices in North East London
Monil Chohan (BDS), Yoshan Patel (BDS), Nikita Shah (BDS Hons), Rahul Swami (BDS) and Kunal Tibrewal (BDS)

If there is no record of it taking place, did it occur?
Periodontal disease is the most common chronic inflammatory disease affecting nearly 50 % of adults in the United Kingdom1. It is a major public health problem, causing: tooth loss, disability, masticatory dysfunction, aesthetic problems and poor nutritional status. Periodontitis also ‘compromises speech, reduces quality of life, and is an escalating burden to the healthcare economy.’2
Undiagnosed and untreated periodontal disease is one of the fastest expanding areas of complaints and litigation in dentistry. The DDU reported a total payout of almost £2.8 million in 2014 in relation to medico-legal cases involving periodontal disease3. In findings from 2014, it was noted by Dental Protection that the most common allegation with regards to periodontal disease was that the patient was unaware of its presence, or the consequences of the periodontal disease affecting the patient had not been explained by the treating dentist. It is not unusual for there to be differences of opinions and recollection between the patient and the dentist. Therefore, during an investigation the clinical records are important to establish which version of events is better supported by the contemporaneous notes.4 Not only do incomplete records make it more difficult to challenge the patient’s version of events, more significantly it makes it difficult to monitor the patients’ progress and thus appreciate a marked deterioration/change.
Comprehensive and well-documented periodontal records are essential for compliance with regulatory and dento-legal standards but more importantly, vital for diagnosis, appropriate treatment planning and monitoring. In March 2016, the British Society of Periodontology updated its evidence based guidelines, “Good Practitioner's Guide to Periodontology 2016”, on the use of the BPE5 and treatment provision required in relation to the management of periodontal disease.6


. This audit aimed to assess and improve the quality and content of clinical record keeping by dentists, with regards to examination, diagnosis, treatment planning and treatment of periodontal conditions, in line with current guidelines.
. To ensure the clinical records meet the standards and level of quality outlined by the latest guidelines and therefore meet the dento–legal standards10.



. To create a gold standard for clinical records based on the BSP guidelines, SDCEP and National Institute for Health and Care Excellence- Gingivitis and periodontitis Clinical Knowledge Summaries11.
. To investigate the standard of clinical record keeping for patients suffering from periodontal disease by comparing it to our gold standard.
. To investigate and create useful interventions to help improve any problem areas which are identified by our audit.
. To try and achieve our gold standard by the end of the re-audit.
1. Audit theme chosen
2.A Gold Standard was created using the latest guidelines to assess what information was important to attain and record in relation to patients suffering from periodontal disease.
3.Further to this, a pro forma was created to reflect the standard and used to collect the required data for analysis.
4.The standardised data-collection pro forma was made and used as clinical record review. Each set of notes was scored using the pro forma looking at the information in the clinical notes.
5.Retrospective data was collected from 200 patients
6.Results analysed, problem areas identified and staff meeting held to discuss these.
7.Strategies and interventions created and implemented to help improve the identified areas
8.A re- audit was carried out on 100 patients thereafter.

Gold Standard:
Guidelines indicate that the following should be recorded in the clinical notes when undertaking an oral health assessment on any patient, ( tailored to patients suffering from periodontal disease):
. Periodontal risk factors (Smoking status, Diabetes control) 6,7,10
. Evaluation of home Oral Hygiene Regime 10
. BPE screening 5,6,7,10
. Appropriate radiographic assessment and report 5,6,7,10
. Record of periodontal disease risk 10
. Correct diagnoses according to current classifications 6,10
. Appropriate record of discussions regarding the disease process, patient education 10,11
. Informed consent gained for further assessment and treatment, along with all treatment options, if required 10
. Further periodontal investigations for BPE score 1-4 (Plaque assessment, Bleeding score, 6PPC) 5,6,7,10
. Appropriate treatment and management of the periodontal disease 6,7,9
. Appropriate recall interval advised and noted 6,7,9,10

Discussion and Conslucion:
•A complete record of periodontal disease management , guided by current evidence, is essential in effectively providing appropriate dental care. Initial data collection in respect to periodontal disease assessment, diagnosis and treatment, unfortunately found that a majority of records in general practice were not in accordance with current guidelines. Our findings revealed areas consistently recorded and updated well were: Medical history, social history especially smoking status and BPE scores. Areas where development was needed, were in relation to recording: plaque assessment, complete diagnosis, patient discussion/education, 6PPC not being filled out completely, appropriate treatment options given and elected. After identifying the key weakness and discussing these with the dental team we created interventions and strategies to help improve these areas.
•We found the largest improvement at our re audit was in patient education, especially with relation to discussing the link between smoking and periodontal disease. This was aided by our record template and patient leaflet. Having the template for the discussion meant reduced time for typing notes, therefore was a successful intervention.
•We found the smallest improvement was for 6PPCs being filled out completely i.e. not just pocket depths being recorded. This was because we could not reduce the time taken to fill them out, and it was difficult to create an intervention for this however, the new guidelines state that only pocket depths 4mm + need to be noted, many clinicians still record all the depths due to habit. Perhaps regular team meetings and reminders will change practice over time. We found templates were the most easily adopted intervention however this was only true where computerised notes were concerned and limited when using paper notes.
•One thing we did not audit and would add to the next re audit would be assessing whether a periodontal risk assessment has been noted.
•It is important to note that individual feedback is necessary as it is likely every clinician will be carrying out their practices differently and therefore will require different interventions to improve their standards.
•We will aim to carry out a re-audit and identify the new problems + create new strategies if needed annually ensuring to keep up to date with latest guidelines.
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